title: Surgical treatment of insular tumours with tractography, functional magnetic resonance imaging, transcranial electrical stimulation and direct subcortical stimulation support.
abstract: OBJECTIVE
  Surgical treatment of insular tumours carries significant risks of limb paresis or speech disturbances due to their localization. The development of intraoperative neuromonitoring techniques that involve evoked motor potentials induced via both direct and transcranial cortical electrical stimulation as well as direct subcortical white matter stimulation, intraoperative application of preoperative tractography and functional magnetic resonance imaging (fMRI) in conjunction with neuronavigation resulted in significant reduction of postoperative disabilities that enabled widening of indications for surgical treatment. The aim of this study was to present the authors' own experience with surgical treatment of insular gliomas.
  
  
  METHODS
  Our cohort comprises 30 patients with insular gliomas treated at the Department of Neurosurgery in Sosnowiec. Clinical symptoms included sensorimotor partial seizures in 86.6%; generalized seizures in 23.3%; persistent headaches in 16.6% and hemiparesis in 6.6%. All the patients were operated on with intraoperative neuromonitoring that included transcranial cortical stimulation, direct subcortical white matter stimulation as well as tractography and fMRI concurrently with neuronavigation. The analysis in-cluded postoperative neurological evaluation along with the assessment of the radicalism of resection evaluated based on postoperative MRI.
  
  
  RESULTS
  Postoperatively, four patients had permanent hemiparesis (13.3%); importantly, two out of those patients had preoperative deficits (6.6%). Persistent speech disturbances were present in four patients (13.3%). Partial sensorimotor seizures were noted in two patients (6.6%). Seizures in the other patients receded. Intraoperative transcranial electrical stimulation as well as direct subcortical white matter stimulation along with tractography (DTI) and fMRI facilitated gross total resection of insular gliomas in 53.5%, subtotal in 13.3% and partial resection in 33.1%.
  
  
  CONCLUSIONS
  Implementation of TES, direct subcortical white master stimulation, DTI and fMRI into the management protocol of the surgical treatment of insular tumours resulted in total and subtotal resections in 66% of cases with permanent motor disability in 6.6% of patients. Poor prognosis for independent living after surgery mainly affects patients with WHO grade III or IV.
authors.affiliation: dr n. med. Michał Tymowski, Katedra i Oddział Kliniczny Neurochirurgii, Śląski Uniwersytet Medyczny, Sosnowiec.
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Majchrzak
authors.forename: Barbara
authors.initials: B
authors.lastname: Bobek-Billewicz
authors.forename: Michał
authors.initials: M
authors.lastname: Tymowski
authors.forename: Piotr
authors.initials: P
authors.lastname: Adamczyk
authors.forename: Hneryk
authors.initials: H
authors.lastname: Majchrzak
authors.forename: Piotr
authors.initials: P
authors.lastname: Ladziński
mesh_terms: D000328:Adult; D000368:Aged; D001921:Brain / Q000473:pathology / Q000601:surgery; D001932:Brain Neoplasms / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D003131:Combined Modality Therapy; D056324:Diffusion Tensor Imaging / Q000379:methods*; D004599:Electric Stimulation Therapy / Q000379:methods*; D004567:Electrodes, Implanted; D005260:Female; D005910:Glioma / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D009367:Neoplasm Staging; D019635:Neurosurgical Procedures / Q000379:methods; D011044:Poland; D016896:Treatment Outcome