title: Surgical strategy for insular cavernomas.
abstract: OBJECTIVE
  Surgical treatment of cavernomas arising in the insula (especially in dominant cerebral hemisphere) is challenging in reason of the proximity to the internal capsule and lenticulostriate arteries. The advent of image guidance systems and intraoperative mapping of the subcortical language pathways has broadened the surgical indications for these lesions. In this work, we report four cases of insular cavernomas operated on, and we define a surgical strategy for these lesions.
  
  
  METHODS
  Between July 1997 and May 2007 in our department, four patients harboring an insular cavernoma were operated on by using image guidance system (neuronavigation in three cases, ultrasound in one case). Subcortical stimulations were used to preserve the functional language area in one case.
  
  
  RESULTS
  The image guidance system determined the exact planning of the approach and determination of the ideal trajectory of insular cortex dissection. In a case of a deep left insular cavernoma, the shortest approach to remove the cavernoma was stopped in per-operative time because subcortical stimulation produced a speech inhibition, justifying another insular corticotomy. No surgical complications occurred, and the postoperative course was uneventful in all patients.
  
  
  CONCLUSIONS
  As it has been proposed by many authors, image guidance system is recommended in surgery of insular cavernomas. When the lesion is located in the dominant hemisphere, intraoperative mapping of the subcortical language pathways is also indicated to preserve the language functional areas.
authors.affiliation: Department of Neurosurgery, University of Caen, France. prlleal@hotmail.com
authors.forename: Paulo Roberto Lacerda
authors.initials: PR
authors.lastname: Leal
authors.forename: Jean Pierre
authors.initials: JP
authors.lastname: Houtteville
authors.forename: Olivier
authors.initials: O
authors.lastname: Etard
authors.forename: Evelyne
authors.initials: E
authors.lastname: Emery
mesh_terms: D000328:Adult; D001932:Brain Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D002540:Cerebral Cortex / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D005260:Female; D020786:Hemangioma, Cavernous, Central Nervous System / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D038361:Neuronavigation / Q000379:methods*; D019635:Neurosurgical Procedures / Q000379:methods*; D014463:Ultrasonography; D014656:Vascular Surgical Procedures / Q000379:methods*