title: Surgery of insular and paralimbic diffuse low-grade gliomas: technical considerations.
abstract: Once considered a "no man's land" especially when invaded by a diffuse low grade glioma (DLGG), the insula remains to this day a surgical challenge. Surgery for insular DLGG involves consideration of its hidden location under the potentially eloquent operculae, the proximity to vascular tree and high density of functions not only in the insular cortex but also in the white fiber pathways passing under the insular lobe. The natural history of DLGG and the potential benefits and consequences of the surgical approach also need a close look. In the last decade, a better knowledge of the functional anatomy and connectivity of this region, as well as an improvement in surgical techniques as direct stimulation mapping, combined with an increasing literature showing a favorable impact of maximal resection for DLGG, were deciding factors in the paradigmatic shift from expectative treatment to early surgical management. Here, our goal is to discuss the structural and functional aspects of the insula, the specificities of insular and paralimbic DLGG by emphasizing the technical considerations of surgery in this region, as well as its oncological and functional outcomes. In summary, this new strategy based upon early maximal safe surgical resection showed both oncological benefit and preservation of quality of life-or even an improvement thanks to epilepsy relief.
authors.affiliation: Department of Neurosurgery, Enfant-Jésus Hospital, CHU de Québec, Laval University, 1401 18e rue, Québec, QC, Canada.
authors.forename: Karine
authors.initials: K
authors.lastname: Michaud
authors.affiliation: Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80 Av Augustin Fliche, 34295, Montpellier, France. h-duffau@chu-montpellier.fr.|Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors," National Institute for Health and Medical Research (INSERM), U1051 Laboratory, Institute for Neurosciences of Montpellier, Montpellier University Medical Center, 34091, Montpellier, France. h-duffau@chu-montpellier.fr.
authors.forename: Hugues
authors.initials: H
authors.lastname: Duffau
mesh_terms: D001932:Brain Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D002540:Cerebral Cortex / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D005910:Glioma / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging; D060787:Neoplasm Grading; D019635:Neurosurgical Procedures; D016896:Treatment Outcome
keywords: Awake mapping; Diffuse low-grade glioma; Functional outcome; Insular lobe; Oncological outcome; Surgery