Thalamic glioma surgery

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Thalamic Glioma Surgery is a highly specialized and challenging neurosurgical procedure, as the thalamus is a deep-seated brain structure crucial for sensory and motor signal relay and is closely associated with essential neural pathways.

Tumor Grade: High-grade gliomas (e.g., glioblastomas) may require surgery primarily for diagnosis or symptom relief. Low-grade gliomas may benefit from maximal safe resection.

Symptoms: Neurological deficits, hydrocephalus, or intractable symptoms caused by mass effect may necessitate surgical intervention.

Histopathological Diagnosis: Often required for treatment planning, especially if radiological findings are inconclusive.

Thalamic glioma surgery approaches

Advanced Imaging: MRI with tractography to map corticospinal and sensory pathways. Functional MRI for eloquent cortex identification. Contrast-enhanced MRI or MR spectroscopy for tumor characterization. Neuro-navigation: Essential for precise targeting, given the small margin for error. Intraoperative Monitoring: Continuous neurophysiological monitoring (e.g., motor evoked potentials) to minimize functional damage.

4. Surgical Goals Maximal Safe Resection: Limited by proximity to critical structures. Debulking: To reduce mass effect and relieve symptoms. Biopsy: In cases where gross total resection is unsafe. Hydrocephalus Management: Placement of external ventricular drains (EVD) or ventriculoperitoneal (VP) shunts if needed.

5. Risks and Complications Neurological Deficits: Hemiparesis, sensory loss, or aphasia due to damage to critical pathways. Hydrocephalus: Postoperative, requiring cerebrospinal fluid diversion. Hemorrhage: A significant risk due to the vascularity of the region. Seizures: May occur due to cortical irritation or surgery.

6. Postoperative Care Neurocritical Care: Monitoring for swelling, hemorrhage, or worsening neurological deficits. Radiotherapy/Chemotherapy: Post-surgical adjuvant treatments, especially for high-grade gliomas. Rehabilitation: Intensive physical, occupational, and speech therapy, if deficits occur.

7. Innovations in Thalamic Glioma Surgery Awake Surgery: Used in select cases to preserve function during resection. Intraoperative MRI/CT: For real-time tumor visualization. Laser Interstitial Thermal Therapy (LITT): Minimally invasive option for certain thalamic tumors. Artificial Intelligence: To enhance preoperative planning and intraoperative decision-making. Prognostic Considerations Low-grade Gliomas: Generally have a better prognosis, with surgery aimed at long-term disease control. High-grade Gliomas: Carry a poorer prognosis despite multimodal treatment; focus is on quality of life.

From May 2011 to Aug 2015, 49 patients with thalamic gliomas underwent microsurgical resection, and received chemotherapy and radiotherapy postoperatively. The postoperative symptoms and complications were documented, and the overall survival (OS) and the progression-free survival (PFS) data were collected. The prognostic factors were evaluated by univariate and multivariate analyses. Finally, there was no perioperative death. Twenty cases, 24 cases and 5 cases were achieved subtotal resection (>90%), partial resection (70-90%) and less than partial resection (<70%) respectively. All patients' pathological diagnosis was confirmed. The symptoms were improved in 32 cases, unchanged in 11 cases, and worsen in 6 cases. Postoperative complications were absent in 9 cases. The 6-month, 12-month, and 24-month OS were 71.4%, 38.9%, and 12.1% respectively; corresponding PFS were 66.6%, 27.1%, and 10.2% respectively. The median OS time and PFS time were 9.0 months (95% CI 6.9-11.1) and 9.0 months (95% CI 6.6-11.4) respectively. Multivariate analysis revealed extent of resection were independent prognostic factors for OS (p < .05), patients with postoperative adjuvant chemotherapy and radiotherapy had a significant prolonged OS (p < .001) and PFS (p < .001). The study shows that the short-term efficacy of microsurgery for high-grade thalamic gliomas is satisfactory. Microsurgery can effectively alleviate patients' symptoms and improve life quality. Postoperative adjuvant chemotherapy and radiotherapy are helpful for prolonging the survival time ¹⁾.

Through retrospective data collection, Briggs et al., described a small case series undergoing awake contralateral, transcallosal approach surgery for deep-seated brain tumors affecting the basal ganglia. They described the patient cohort, report on patient outcomes, and described the surgical technique.

Four patients underwent awake contralateral, transcallosal surgery for glioblastoma invading the basal ganglia. All four patients demonstrated hemibody weakness contralateral to the side of their tumor, with three patients confined to wheelchairs at presentation. Ages ranged from 25-64 years. Tumor volumes ranged from 14-93 cm3. Greater than 50% resection of each tumor was achieved during surgery. In two cases, approximately 90% resection was achieved. Motor strength improved in one patient who presented with hemiplegia. Two patients required ventriculoperitoneal shunting for complications related to hydrocephalus. When writing this manuscript, two of our patients were still alive, functional, and free of tumor progression.

They presented results attempting to resect large gliomas infiltrating the basal ganglia in four patients. This technique combined a contralateral, transcallosal approach with awake neuromonitoring. The results suggest it is possible to remove these tumors with reasonable outcomes ²⁾.