Summary
Surgical treatment of glial tumours arising in the insula is specially challenging due to the proximity of the internal capsule. Although small insular gliomas have been removed safely by a transylvian approach, in large dominant insular tumours only biopsy has been recommended to avoid postoperative deficits. Unfortunately that is a suboptimal form of treatment as low grade supratentorial gliomas should be removed radically to prevent tumour progression, malignization and to increase the recurrence-free-interval. Addition of radiotherapy to partial removal is associated with a much higher incidence of recurrences and early malignizations compared to radical removal and no radiotherapy.
Between 1st October 1989 and 1st September 1996 we treated twenty-three patients harbouring insular gliomas. To increase the radicality of the resection the surgical procedure was performed under local anaesthesia whenever possible, as general anaesthesia usually leads to more conservative resections. In 20/23 (86.9%) patients complete resection was accomplished, and subtotal in three (13.1%). The removed tumours were: two oligodendrogliomas, five grade I astrocytomas, nine grade II, four grade III and three grade IV.
Postoperative neurological deficits occurred in five patients. Four suffered a hemiparesis (that recovered in an average of 6 months) and one a motor dysphasia which took a week to recover. Two of the seventeen patients operated on for low grade insular gliomas underwent malignant change.
We conclude that complete surgical removal of insular gliomas should be considered and at least attempted in all cases.
Similar content being viewed by others
References
Afra D, Mueller W, Benoist G (1987) Supratentorial recurrence of gliomas. Results of reoperation on astrocytomas and oligodendrogliomas. Acta Neurochir (Wien) 84: 217–227
Ammirati MJ, Vick N, Liao N, Ciric I, Michael M (1987) Effect of the extent of surgical resection on survival and quality of life in patients with supratentorial glioblastomas and anaplastic astrocytomas. Neurosurgery 21: 201–209
Archer DP, Mc Kenna JMA, Morin L, Ravusin R (1988) Conscious-sedation analgesia during craniotomy for intractable epilepsy: a review of 354 cases. Can J Anaest 35: 338–344
Auer LM, van Velthoven V (1990) Intraoperative ultrasound (US) imaging. Comparison of pathomorphological findings in US and CT. Acta Neurochir (Wien) 104: 84–95
Berger MS, Cohen WA, Ojemann GA (1990) Correlation of motor cortex brain mapping data with magnetic resonance imaging. J Neurosurg 72: 383–387
Berger MS, Ghatan BS, Haglund MM, Dobbins J, Ojemann GA (1993) Low grade gliomas associated with intractable epilepsy: seizure outcome utilizing electrocorticography during tumour resection. J Neurosurg 79: 62–69
Berger MS, Kincaid J, Ojemann GA, Lettich BA (1989) Brainmapping techniques to maximize resection, safety and seizure control in children with brain tumors. Neurosurgery 25: 786–992
Berger MS, Ojemann GA (1992) Intraoperative brain mapping techniques in neuro-oncology. Stereotact Funct Neurosurg 58: 153–161
Berger MS, Ojemann GA, Lettich E (1990) Neurophysiological monitoring during astrocytoma surgery. Neurosurg Clin North Am 1: 65–80
Connelly A, Gadian DG, Kumar VJ, Harkness WFJ (1993) Epilepsy and tumors near the motor cortex: pre-operative identification of the motor strip using functional MRI. Epilepsia 34: 120–123
Chandler WF, Knake JE, McGillicudy JE, Lilleheii KO, Siver TM (1982) Intraoperative use of real-time ultrasonography in neurosurgery. J Neurosurg 57: 157–163
Ebeling U, Kothbauer K (1995) Circumscribed low grade astrocytomas in the dominant opercular and insular region: a pilot study. Acta Neurochir (Wien) 132: 66–74
Enzmann DR, Wheat R, Marshall WH, Bird R, Murphy-Irwin K, Karbon K, Hanbery J, Silverberg GD, Britt RH, Shuer L (1985) Tumours of the central nervous system studied by computed tomography and ultrasound. Radiology 154: 393–399
Firsching R, King N, Börner U, Sanker P (1992) Lesions of the sensori-motor region: somatosensory evoked potentials and ultrasound guided surgery. Acta Neurochir (Wien) 118: 87–90
King RB, Schell GR (1987) Cortical localization and monitoring during cerebral operations. J Neurosurg 67: 210–219
Kitahara M (1988) Clinical analysis of glioma: low grade astrocytoma. Springer, Berlin Heidelberg New York Tokyo, pp 173–186
Laws ER, Tayler WF, Clifton MB, Okazaki H (1984) Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres. J Neurosurg 61: 665–673
Le Roux PD, Berger MS, Haglund MM, Pichler WH, Ojemann GA (1991) Resection of instrinsic tumours from nondominant face motor cortex using stimulation mapping: report of two cases. Surg Neurol 36: 44–48
Leuders H, Lesser RP, Hahn J, Dinner DS, Klem G (1983) Cortical somatosensory evoked potentials in reponse to hand stimulation. J Neurosurg 58: 885–894
McCormack BC, Miller DC, Budzilovich GN, Voorhees GJ, Ransohoff J (1992) Treatment and survival of low-grade astrocytoma in adults 1977–1988. Neurosurgery 31: 636–642
Obana WG, Laxer KD, Cogen PH, Walker JA, Davis RL, Barbaro NM (1992) Resection of dominant opercular gliosis in refractory partial epilepsy. J Neurosurg 77: 632–639
Ojemann GA (1979) Individual variability in cortical localization of language. J Neurosurg 50: 164–169
Ojemann GA, Ojemann J, Lettich E, Berger MS (1989) Cortical language localization in left, dominant hemisphere. J Neurosurg 71: 316–326
Philippon JH, Clemenceau SH, Fauchon FH, Foncin JF (1993) Supratentorial low-grade astrocytomas in adults. Neurosurgery 32: 554–559
Pia HW (1986) Microsurgery of gliomas. Acta Neurochir (Wien) 80: 1–11
Rooper SN, Lévesque MF, Sutherling WW, Engel J (1993) Surgical treament of partial epilepsy arising from the insular cortex. J Neurosurg 79: 266–269
Rostomily RC, Berger MS, Ojemann GA, Lettich E (1991) Postoperative deficits and functional recovery following removal of tumours involving the dominant hemisphere supplementary motor area. J Neurosurg 75: 62–68
Schatz CR, Kreth FW, Faist M, Warnke PC, Volk B, Ostertag CB (1994) Interstitial 125-iodine radiosurgery of low-grade gliomas of the insula of Reil. Acta Neurochir (Wien) 130: 80–89
Steiger HJ, Markwalder RV, Seiler RW, Ebeling U, Reulen HJ (1990) Early prognosis of supratentorial Grade 2 astrocytoma in adult patients after resection or stereotactic biopsy. Acta Neurochir (Wien) 106: 99–105
Suzuki A, Nobwyuki Y (1992) Intraoperative localization of the central sucus by cortical somatosensory evoked potentials in brain tumor. J Neurosurg 76: 867–870
Valk PE, Jagust WJ, Derenzo SE, Huesman RH, Geyer AB, Budinger TF (1990) Clinical evaluation of a high resolution (2.6-mm) positron emission tomography. Radiology 176: 783–790
van Velthofen V, Auer LM (1990) Practical application of intraoperative ultrasound imaging. Acta Neurochir (Wien) 105: 5–13
Vanaclocha V, Saiz-Sapena N, Monedero P (1997) Craniotomy under local anaesthesia and sedation for the removal of brain tumours within or adjacent to eloquent areas. Neurocirugía 8: 95–103
Walsh AR, Schmidt RH, Marsch HT (1992) Cortical mapping and local anaesthetic resection as an aid to surgery of low and intermediate grade gliomas. Br J Neurosurg 6: 119–124
Weingart J, Olivi A, Brem H (1991) Supratentorial low-grade astrocytomas in adults. Neurosurg Quaterly 1: 141–160
Wüllenweber R, Kuhlendahl H, Miltz H (1973) Astrocytomas of the cerebral hemispheres. In: Kuhlendahl H, Hensell V (eds) Modern aspects of neurosurgery, vol 3. Excerpta Medica, Amsterdam, pp 100–107
Yaşargil MG, von Ammon K, Cavazos E, Doczi T, Reeves JD, Roth P (1992) Tumour of the limbic and paralimbic systems. Acta Neurochir (Wien) 118: 40–52
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Vanaclocha, V., Sáiz-Sapena, N. & García-Casasola, C. Surgical treatment of insular gliomas. Acta neurochir 139, 1126–1135 (1997). https://doi.org/10.1007/BF01410972
Issue Date:
DOI: https://doi.org/10.1007/BF01410972