title: Safe Resection of Gliomas of the Dominant Angular Gyrus Availing of Preoperative FMRI and Intraoperative DTI: Preliminary Series and Surgical Technique.
abstract: OBJECTIVE
  Language dysfunction, visual deficit, numeracy impairment, and Gerstmann syndrome often occur in the cortical area; furthermore, the subcortical white matter is the inviolable limit of "functional neurosurgery." Preoperative functional magnetic resonance imaging (fMRI) and tractography are capable of providing the data required for safe "surgical planning" at both the cortical and subcortical levels.
  
  
  METHODS
  We report our experience regarding high-grade gliomas affecting the dominant angular gyrus (AG), supramarginal gyrus (SMG), intraparietal sulcus (IPS), and their respective subcortical areas using intraoperative MRI and diffusion tensor imaging (DTI). Retrospectively, we reviewed a consecutive series of 27 patients operated in a BrainSuite for high-grade intraparenchymal tumors of the left posterior temporoparietal junction. We included tumors involving the dominant AG, SMG, and/or IPS and the subcortical course of arcuate fasciculus (AF) and all the patients who underwent preoperative fMRI and DTI to localize the AF and the eloquent cortical areas. Just after craniotomy, new volumetric MRI and DTI verified and corrected possible brain shift. After the gross total resection was carried out, and before approaching the residual mass close to the white matter tract, an intraoperative MRI was again performed.
  
  
  RESULTS
  We operated on 27 patients, 15 males and 12 females, whose diagnosis was always high-grade glioma. During the preoperative neurologic examination, 6 patients were asymptomatic; 3 presented a Gerstmann syndrome; 16 showed dysphasic disturbances, 6 of which were associated with visual field deficits; and 2 showed weakness of the right limb.
  
  
  CONCLUSIONS
  Our results suggest that this approach is completely safe and effective as an alternative to awake surgery.
authors.affiliation: Institute of Neurosurgery, S. Andrea Hospital, "La Sapienza" University of Rome, Italy. Electronic address: gdandrea2002@yahoo.it.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: D'Andrea
authors.affiliation: Institute of Neurosurgery, S. Andrea Hospital, "La Sapienza" University of Rome, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Familiari
authors.affiliation: Institute of Anesthesiology, S. Andrea Hospital, "La Sapienza" University of Rome, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Di Lauro
authors.affiliation: Institute of Neurosurgery, S. Andrea Hospital, "La Sapienza" University of Rome, Italy.
authors.forename: Albina
authors.initials: A
authors.lastname: Angelini
authors.affiliation: Institute of Neurosurgery, S. Andrea Hospital, "La Sapienza" University of Rome, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Sessa
mesh_terms: D000328:Adult; D000368:Aged; D001932:Brain Neoplasms / Q000601:surgery*; D002540:Cerebral Cortex / Q000601:surgery*; D003399:Craniotomy; D056324:Diffusion Tensor Imaging; D005260:Female; D005910:Glioma / Q000601:surgery*; D006801:Humans; D007432:Intraoperative Period; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome; D066127:White Matter / Q000601:surgery
keywords: Dominant angular gyrus; Glioma; Intraoperative DTI