title: Application of Awake Craniotomy and Intraoperative Brain Mapping for Surgical Resection of Insular Gliomas of the Dominant Hemisphere.
abstract: BACKGROUND
  Radical resection of dominant insular gliomas is difficult because of their close vicinity with internal capsule, basal ganglia, and speech centers. Brain mapping techniques can be used to maximize the extent of tumor removal and to minimize postoperative morbidities by precise localization of eloquent cortical and subcortical areas.
  
  
  METHODS
  Patients with newly diagnosed gliomas of dominant insula were enrolled. The exclusion criteria were severe cognitive disturbances, communication difficulty, age greater than 75 years, severe obesity, difficult airways for intubation and severe cardiopulmonary diseases. All were evaluated preoperatively with contrast-enhanced brain magnetic resonance imaging (MRI), functional brain MRI, and diffusion tensor tractography of language and motor systems. All underwent awake craniotomy with the same anesthesiology protocol. Intraoperative monitoring included continuous motor-evoked potential, electromyography, electrocorticography, direct electrical stimulation of cortex, and subcortical tracts. The patients were followed with serial neurologic examination and imaging.
  
  
  RESULTS
  Ten patients were enrolled (4 men, 6 women) with a mean age of 43.6 years. Seven patients suffered from low-grade glioma, and 3 patients had high-grade glioma. The most common clinical presentation was seizure followed by speech disturbance, hemiparesis, and memory loss. Extent of tumor resection ranged from 73% to 100%. No mortality or new major postoperative neurologic deficit was encountered. Seizure control improved in three fourths of patients with medical refractory epilepsy. In one patient with speech disorder at presentation, the speech problem became worse after surgery.
  
  
  CONCLUSIONS
  Brain mapping during awake craniotomy helps to maximize extent of tumor resection while preserving neurologic function in patients with dominant insular lobe glioma.
authors.affiliation: Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Electronic address: alimohamadi59@gmail.com.
authors.forename: Maysam
authors.initials: M
authors.lastname: Alimohamadi
authors.affiliation: Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Shirani
authors.affiliation: Department of Anesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Reza
authors.initials: R
authors.lastname: Shariat Moharari
authors.affiliation: Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Pour-Rashidi
authors.affiliation: Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Mehdi
authors.initials: M
authors.lastname: Ketabchi
authors.affiliation: Department of Anesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Mohammadreza
authors.initials: M
authors.lastname: Khajavi
authors.affiliation: Department of Neurology, Neuromonitoring Subgroup, Milad Hospital, Tehran, Iran.
authors.forename: Mohamadali
authors.initials: M
authors.lastname: Arami
authors.affiliation: Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Abbas
authors.initials: A
authors.lastname: Amirjamshidi
mesh_terms: D000328:Adult; D000368:Aged; D001931:Brain Mapping; D001932:Brain Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D002540:Cerebral Cortex / Q000000981:diagnostic imaging; D003399:Craniotomy / Q000379:methods*; D004292:Dominance, Cerebral; D004558:Electric Stimulation; D004576:Electromyography; D019054:Evoked Potentials, Motor / Q000502:physiology; D005260:Female; D005910:Glioma / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D014851:Wakefulness
keywords: Awake craniotomy; Brain mapping; Cortical stimulation; Glioma; Insula; Insular glioma