Letter to the Editor. Insular glioma surgery

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TO THE EDITOR: We read with great enthusiasm the review published by Hervey-Jumper and Berger on insular glioma surgery3 (Hervey-Jumper SL, Berger MS: Insular glioma surgery: an evolution of thought and practice. J Neurosurg 130:9–16, January 2019). The authors provide a comprehensive historical review about the anatomical and functional aspects of insular glioma surgery, its outcomes, and their personal expert view on the technical nuances, highlighting the role played by tumor histology and vascular injury in the outcome.

Our group supports the use of augmented reality (AR) combining morphological and functional information in insular glioma resection to improve the surgical planning, the intraoperative technical management, and to predict the functional outcome.

The insular arteries supply the insular cortex,1 extreme capsule and, rarely, the claustrum and external capsule. Although the preservation of the arteries of the insula in the dominant hemisphere is crucial (language-related tracts), the potential vascular relation with the corticospinal tract is paramount given the implications of a dense motor deficit in the adjuvant treatment and overall survival in patients with high-grade gliomas.3,4

We are aware of the limitations of microscope-navigated AR, in particular the intraoperative brain shift,2 the incomplete identification of the lenticulostriate arteries (LSAs) given the limitations of the 3D time-of-flight (TOF) MRI,7 and the variation in tractography processing algorithms.6 Therefore, AR is used as a surgical guide to increase awareness of the anatomical structures that is integrated with the intraoperative neuromonitoring (continuous motor evoked potentials provided by the subdural strip electrodes, cortical monopolar mapping, and continuous subcortical mapping with suction probe) and provisional diagnosis (intraoperative cytological smear). Conventional angiography,5 3D TOF MRI sequence,7 3D ultrasound,8 and micro-Doppler9 have also been described as useful for a better understanding of the vascular relations of the insular tumors with the M2/M3 branches and perforators, thereby assisting in prevention of vascular injuries. However, several limitations were pointed to regarding these methods, particularly the variability in number of LSAs identified by each method, thus reinforcing the role of a multimodality approach.

Hervey-Jumper and Berger3 recognize the relevance of these methods in assisting the resection and minimizing the postoperative morbidity, and they also recognize the role of the LSAs as the medial boundary of insular glioma resection. Our group supports the use of AR during the cortical window approach to provide a better understanding of the cortical, subcortical, and vascular functional anatomy in tailoring the surgical approach and the extent of resection.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Benet AHervey-Jumper SLSánchez JJLawton MTBerger MS: Surgical assessment of the insula. Part 1: surgical anatomy and morphometric analysis of the transsylvian and transcortical approaches to the insula. J Neurosurg 124:4694812016

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    • PubMed
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  • 2

    Gerard IJKersten-Oertel MPetrecca KSirhan DHall JACollins DL: Brain shift in neuronavigation of brain tumors: a review. Med Image Anal 35:4034202017

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    • PubMed
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    • Export Citation
  • 3

    Hervey-Jumper SLBerger MS: Insular glioma surgery: an evolution of thought and practice. J Neurosurg 130:9162019

  • 4

    Hervey-Jumper SLLi JOsorio JALau DMolinaro AMBenet ABerger MS: Surgical assessment of the insula. Part 2: validation of the Berger-Sanai zone classification system for predicting extent of glioma resection. J Neurosurg 124:4824882016

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    • Export Citation
  • 5

    Moshel YAMarcus JDParker ECKelly PJ: Resection of insular gliomas: the importance of lenticulostriate artery position. J Neurosurg 109:8258342008

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    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Pujol SWells WPierpaoli CBrun CGee JCheng G: The DTI challenge: toward standardized evaluation of diffusion tensor imaging tractography for neurosurgery. J Neuroimaging 25:8758822015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Saito RKumabe TInoue TTakada SYamashita YKanamori M: Magnetic resonance imaging for preoperative identification of the lenticulostriate arteries in insular glioma surgery. Technical note. J Neurosurg 111:2782812009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Šteňo AJezberová MHollý VTimárová GŠteňo J: Visualization of lenticulostriate arteries during insular low-grade glioma surgeries by navigated 3D ultrasound power Doppler: technical note. J Neurosurg 125:101610232016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Yaşargil MGKrisht AFTüre UAl-Mefty OYaşargil D: Microsurgery of insular gliomas: Part IV: Surgical treatment and outcome. Contemporary Neurosurg 24:182002

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INCLUDE WHEN CITING Published online August 30, 2019; DOI: 10.3171/2019.6.JNS19967.

Response

We appreciate the comments made by our colleagues in the UK and support AR as a strategy and as a useful adjunct to enhance the results of insular glioma surgery.

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Article Information

Correspondence Prajwal Ghimire: prajwal.ghimire@nhs.net.

INCLUDE WHEN CITING Published online August 30, 2019; DOI: 10.3171/2019.4.JNS19760.

Disclosures The authors report no conflict of interest.

© AANS, except where prohibited by US copyright law.

Headings

References

  • 1

    Benet AHervey-Jumper SLSánchez JJLawton MTBerger MS: Surgical assessment of the insula. Part 1: surgical anatomy and morphometric analysis of the transsylvian and transcortical approaches to the insula. J Neurosurg 124:4694812016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Gerard IJKersten-Oertel MPetrecca KSirhan DHall JACollins DL: Brain shift in neuronavigation of brain tumors: a review. Med Image Anal 35:4034202017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Hervey-Jumper SLBerger MS: Insular glioma surgery: an evolution of thought and practice. J Neurosurg 130:9162019

  • 4

    Hervey-Jumper SLLi JOsorio JALau DMolinaro AMBenet ABerger MS: Surgical assessment of the insula. Part 2: validation of the Berger-Sanai zone classification system for predicting extent of glioma resection. J Neurosurg 124:4824882016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Moshel YAMarcus JDParker ECKelly PJ: Resection of insular gliomas: the importance of lenticulostriate artery position. J Neurosurg 109:8258342008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Pujol SWells WPierpaoli CBrun CGee JCheng G: The DTI challenge: toward standardized evaluation of diffusion tensor imaging tractography for neurosurgery. J Neuroimaging 25:8758822015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Saito RKumabe TInoue TTakada SYamashita YKanamori M: Magnetic resonance imaging for preoperative identification of the lenticulostriate arteries in insular glioma surgery. Technical note. J Neurosurg 111:2782812009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Šteňo AJezberová MHollý VTimárová GŠteňo J: Visualization of lenticulostriate arteries during insular low-grade glioma surgeries by navigated 3D ultrasound power Doppler: technical note. J Neurosurg 125:101610232016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Yaşargil MGKrisht AFTüre UAl-Mefty OYaşargil D: Microsurgery of insular gliomas: Part IV: Surgical treatment and outcome. Contemporary Neurosurg 24:182002

    • Search Google Scholar
    • Export Citation

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