Method for temporal keyhole lobectomies in resection of low- and high-grade gliomas

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The purpose of this study was to describe a method of resecting temporal gliomas through a keyhole lobectomy and to share the results of using this technique.


The authors performed a retrospective review of data obtained in all patients in whom the senior author performed resection of temporal gliomas between 2012 and 2015. The authors describe their technique for resecting dominant and nondominant gliomas, using both awake and asleep keyhole craniotomy techniques.


Fifty-two patients were included in the study. Twenty-six patients (50%) had not received prior surgery. Seventeen patients (33%) were diagnosed with WHO Grade II/III tumors, and 35 patients (67%) were diagnosed with a glioblastoma. Thirty tumors were left sided (58%). Thirty procedures (58%) were performed while the patient was awake. The median extent of resection was 95%, and at least 90% of the tumor was resected in 35 cases (67%). Five of 49 patients (10%) with clinical follow-up experienced permanent deficits, including 3 patients (6%) with hydrocephalus requiring placement of a ventriculoperitoneal shunt and 2 patients (4%) with weakness. Three patients experienced early postoperative anomia, but no patients had a new speech deficit at clinical follow-up.


The authors provide their experience using a keyhole lobectomy for resecting temporal gliomas. Their data demonstrate the feasibility of using less invasive techniques to safely and aggressively treat these tumors.

ABBREVIATIONS DTI = diffusion tensor imaging; EOR = extent of resection; IFOF = inferior frontooccipital fasciculus; POD = postoperative day; SLF = superior longitudinal fasciculus; STG = superior temporal gyrus.

Article Information

Correspondence Michael E. Sughrue, Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd., Ste. 4000, Oklahoma City, OK 73104. email:

INCLUDE WHEN CITING Published online July 7, 2017; DOI: 10.3171/2016.12.JNS162168.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



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    Surgical planning. Using DTI preoperatively, the craniotomy was planned with respect to the white matter anatomy. A: Sagittal MR image showing the superior planned disconnection, represented by a pink dashed line; this was made below the sylvian fissure with avoidance of the inferior longitudinal fasciculus in green. B: Axial MR image showing the posterior planned disconnection, represented by a pink dashed line. This disconnection was planned anterior to the tracts lying posterior to the tumor and lateral to the tracts lying medial of the tumor. C: Using the trajectories of the planned surgical disconnections from A and B (represented by a pink dashed line), the craniotomy was positioned to allow access to the anterior temporal pole and inferior temporal boundary. The craniotomy site is illustrated with a light blue circle. White asterisk = tumor location. SS = straight sinus.

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    Positioning of craniotomy relative to surrounding structures. The white dashed circle represents bone flap relative to the planned surgical disconnections. The bone flap allowed access to the anterior portion of the STG. The inferior border of the craniotomy was at the middle portion of the middle temporal gyrus (MTG). Care was taken so that the craniotomy was anterior and inferior to the path of the SLF, represented by orange. ITG = inferior temporal gyrus; PCG = postcentral gyrus; PRG = precentral gyrus; SF = sylvian fissure; SMG = supramarginal gyrus. Pink = STG; blue = MTG; green = ITG.

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    Skin incision and craniotomy illustration. Left: Relative size of skin incision is shown with a white dashed line. Superficial mapping of the temporal lobe with a marker is designated with a pink arrow. Right: Example of craniotomy with bone flap. The bone flap is next to a ruler for comparison. Centimeter marks are illustrated on the ruler with black lines. The craniotomy measures roughly 3 cm.

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    Illustrative case of the temporal keyhole method used in a patient with a right temporal glioblastoma. Contrast-enhanced T1-weighted MR images show the axial (A) and coronal (B) views of a ring-enhancing lesion. T1-weighted FLAIR axial (C) and contrast-enhanced T1-weighted MR coronal (D) images illustrate postoperative resection.

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    Repeat craniotomy after initial resection. Left: Primary question mark incision (blue dotted line). A complex incision and craniotomy may limit subsequent craniotomies due to scarring of the dura and vascular issues related to wound healing. Repeat incisions within the gray area may heal poorly due to vascular supply. A repeat “T” incision (red dotted line) is possible but may also heal poorly. Right: Temporal keyhole lobectomy incision (blue dotted line). A smaller incision is less limiting on repeat craniotomies for recurrent tumors (green dotted lines).





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