Insular glioma surgery planning [Neurosurgery Wiki]

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====== Insular glioma surgery planning ======

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===== Preoperative Planning =====
  * **High-resolution MRI** with [[DTI]] (tractography)
  * **[[Functional MRI]]** or **[[MEG]]** for eloquent cortex mapping
  * **[[Awake craniotomy]]** with **cortical and subcortical stimulation [[mapping]]** if tumor is near [[language]] or [[motor area]]s
  * **[[Neuronavigation]]** and intraoperative **[[ultrasound]] or MRI**

===== Preoperative assessment and selection of the approach =====
In preoperative [[planning]], in addition to structural MRI, functional MRI (fMRI) and diffusion tensor imaging (DTI) tractography can provide a three-dimensional anatomical perspective of the tumor and surrounding eloquent cortex and white matter tracts. On the cortical level, despite establishing the dominant hemisphere in terms of language function with the use of fMRI, identification of motor-, sensory-, or visual-related cortices within the frontal, parietal, and occipital lobes can be achieved. The relationship of the tumor to white matter tracts can be established with the use of DTI tractography. Despite technical advancements, both fMRI and DTI still present some drawbacks that make direct brain stimulation the gold standard in the intraoperative identification of eloquent regions at the cortical and subcortical levels. The limitations of MRI techniques are related to parenchymal invasion, pathological angiogenesis, and disturbed neurotransmitter concentrations due to glioma invasion
((Giussani C, Roux FE, Ojemann J, Sganzerla EP, Pirillo D, Papagno C. Is preoperative functional magnetic resonance imaging reliable for language areas mapping in brain tumor surgery? Review of language functional magnetic resonance imaging and direct cortical stimulation correlation studies. Neurosurgery. 2010 Jan;66(1):113-20. doi: 10.1227/01.NEU.0000360392.15450.C9. PMID: 19935438.))
((Przybylowski CJ, Hervey-Jumper SL, Sanai N. Surgical strategy for insular glioma. J Neurooncol. 2021 Feb;151(3):491-497. doi: 10.1007/s11060-020-03499-4. Epub 2021 Feb 21. PMID: 33611715; PMCID: PMC8012000.)).