Recovery of long-term paresis following resection of WHO grade II gliomas infiltrating the pyramidal pathway

Recent publications had reported high rates of preoperative neurological impairments in WHO grade II gliomas (GIIG) that significantly affect the quality of life. Consequently, one step further in the analysis of surgical outcome in GIIG is to evaluate if surgery is capable to improve preoperative deficits. Here are reported two cases of GIIG infiltrating the primary motor cortex and pyramidal pathway that had a long-term paresis before surgery. Both patients were operated with intraoperative electrical stimulation mapping, with identification and preservation of the primary motor cortex and pyramidal tract. Despite the long-lasting paresis, both cases had a significant improvement of motor function after surgery. Knowledge of this potential recovery before surgery is of major significance for planning the surgical strategy in GIIG. Two possible predictors of motor recovery were analyzed: 1) reconstruction of the corticospinal tract with diffusion tensor imaging tractography is indicative of anatomo-functional integrity, despite tract deviation and infiltration; 2) intraoperative identification of motor response by electrostimulation confirms the presence of an intact peritumoral tract. Thus, resection should stop at this boundary even in cases of long lasting preoperative hemiplegia.