Combined Transcortical-Transsylvian Approach: A Way to Beat the Burdensome Large Insular Glioma

Abstract Background: Exploration of the benefits of the Combined transsylvian-transcortical approach to resect large insular glio-mas which are challenging tumors due to their relations to elo-quent areas and important vascular structures. Aim of Study: Determine thae anatomical landmark for op-timum resection of large and challenging insular gliomas. Patients and Methods: We prospectively studied 75 pa-tients with insular gliomas operated upon in the period from June 2017 till February 2019. All the patients had full neurolog-ical examination then they underwent preoperative MRI, MRA and MRV using 1.5 Tesla MRI-Systemto determine the location of the tumor and further classification of each lesion according to topographic zones of the insula which were postulated by Sanai andcolleagues. Results: This prospective study was conducted upon 75 patients who have large insular gliomas. All patients were oper-ated upon via a Combined transsylvian-transcortical approach either by awake surgery or ordinary surgery but with previously performed functional MRI. Male patients were 45 (60%) while female patients were 30 patients (40%). The age of the patient ranged from 20 to 59 (mean 39.96 years). In 60% of cases, tumors occupied more than 2 insular zones. Gross total resection was achieved in 48 cases (64%) while postoperative residual was only in 27 patients (36%). The pathology was astrocytoma grade 2 in 52 (70%), grade 3 in 10 (13%) and GBM in 13 (17%) patients. Conclusions: Combined transsylvian-transcortical ap-proach provides multiple surgical strategies for resection of insular gliomas by preparing the neurosurgeons with a dynamic surgical view that can be tailored according to different ana-tomical variabilities.