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Delayed Deep White Matter Ischemia After Resection of Gliomas by Awake Surgery
Takahiro Tsuchiya1, Masamichi Takahashi1, Makoto Ohno1
1Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, Tokyo, Japan.
Background And Objectives:
Deep white matter (DWM) is perfused by the medullary arteries from the cortex, and ischemia sometimes occurs after glioma resection. However, the clinical significance of postoperative medullary artery-related ischemia has not been well studied. We retrospectively reviewed cases of delayed DWM ischemia after awake craniotomy to elucidate the clinical characteristics, mechanisms, and management of delayed ischemia.
Methods:
We identified 4 cases of intra-axial brain tumors, mainly gliomas, that underwent tumor resection by awake craniotomy at our hospital and developed DWM ischemic symptoms after surgery, despite no worsening of neurological symptoms at the end of surgery.
Results:
Four patients (3 men and 1 woman) presented with glioblastoma, oligodendroglioma, astrocytoma, and brain metastasis. The median age at surgery was 47.5 years (41-73 years). The tumors were located in the watershed area in the frontal lobe (n = 2) and the parietal lobe (n = 2), all of which were left-sided (n = 4). DWM ischemic symptoms, such as motor dysfunction, aphasia, dysarthria, and dysgraphia, developed at an average of 24 hours (14-48 hours) after resection by awake craniotomy. All 4 patients showed symptom improvement within a week after surgery and completely recovered within a month.
Conclusion:
DWM ischemia is caused by sacrifice of the medullary artery, which feeds the tumor and adjacent brain tissue during tumor resection, and should be considered when delayed aphasia or paralysis occurs postoperatively. These symptoms are often transient and recovery usually occurs. Tumors located in the frontal or parietal lobes, particularly in the watershed area, should be carefully monitored for postoperative ischemia.
Insights
Delayed deep white matter ischemia can occur after glioma surgery due to medullary artery sacrifice. Symptoms like aphasia and paralysis often resolve within a month, especially for tumors in the frontal or parietal lobes.
Area of Science:
- Neurosurgery
- Neurology
- Vascular Neurology
Background:
- Deep white matter (DWM) relies on medullary arteries for blood supply.
- Ischemia in DWM can occur post-glioma resection, but its clinical significance is understudied.
- Awake craniotomy for glioma removal poses a risk for DWM ischemia.
Purpose of the Study:
- To investigate the clinical characteristics, mechanisms, and management of delayed DWM ischemia after awake craniotomy.
- To understand the impact of medullary artery sacrifice during glioma resection.
- To identify risk factors and predict outcomes for DWM ischemia.
Main Methods:
- Retrospective review of 4 patients with intra-axial brain tumors (gliomas) undergoing awake craniotomy.
- Analysis of cases with delayed DWM ischemic symptoms post-surgery.
- Evaluation of clinical presentation, tumor location, and post-operative recovery.
Main Results:
- Four patients (3 male, 1 female; median age 47.5) with gliomas in the frontal/parietal lobes developed DWM ischemia.
- Symptoms (motor dysfunction, aphasia, dysarthria, dysgraphia) appeared ~24 hours post-surgery.
- All patients improved within a week and recovered fully within a month.
Conclusions:
- DWM ischemia results from medullary artery sacrifice during tumor resection.
- Delayed aphasia or paralysis post-glioma surgery warrants consideration of DWM ischemia.
- Transient DWM ischemia is common, with good prognosis; frontal/parietal watershed tumors require monitoring.
