Transsylvian Insular Glioma Surgery

Currently, there is a unanimous opinion that the first line of the treatment of insular gliomas is microsurgical removal.^1-3 At the same time, surgery of insular glial tumors remains a challenge because of the complex anatomy of the insular region. Among the most crucial anatomical structures are branches of the middle cerebral artery (MCA), lenticulostriate arteries (LSAs), and corticospinal tract.⁴ Surgery of the insular glioma becomes much more complicated in cases when the tumor extends to the anterior perforated substance, which, according to our data, occurs in 29,1% of cases.⁵ We present a 33-year-old woman with a history of generalized seizures (Video1). Magnetic resonance imaging scan revealed a left insular lobe tumor with tumor expansion to the anterior perforated substance and mesial temporal lobe. Given the large size of the tumor and the patient's symptoms, the decision was made in favor of surgery. The video demonstrates the technique of a Sylvian fissure dissection, manipulations with MCA branches and LSA, removal of the tumor from the region of the anterior perforated substance, and a discussion of surgical nuances and safety aspects. The most challenging part of the operation was to identify and protect the LSAs.⁶ Advanced microsurgical techniques, and the correct patient selection for surgical treatment, are cornerstones for a successful outcome and provide an acceptable frequency of postoperative neurologic deficits in patients who undergo surgery of insular gliomas through the transsylvian approach.