insular anatomy after opening the temporal and fronto-parietal opercula
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Anatomia microchirurgica della regione temporo-silviana. Studio anatomico preoperatorio: Tips and Tricks Neurochirurgia - San Giovanni-Addolorata - Roma Massimiliano Neroni. Insular anatomy After opening the temporal and fronto-parietal opercula. - PowerPoint PPT PresentationTRANSCRIPT
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Anatomia microchirurgica della regione temporo-silviana.
Studio anatomico preoperatorio:Tips and Tricks
Neurochirurgia - San Giovanni-Addolorata - Roma
Massimiliano Neroni
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Insular anatomy After opening the temporal and fronto-parietal opercula
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Microsurgical anatomy of the Insular Lobe
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Sylvian fessure distal and prossimal division
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Vascular anatomy of the insula and LSAs
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Knownledge of the phylogenesis of the structures
Mesiobasal temporal Temporal pole
Amygdala Limbic Hippocampus Parahippocampus 2 layered structures (allocortex)
Cingulate GyrusFornix ParalimbicMammillary bodyCaudal Fronto-Orbital Gyrus (included Pars Orbitalis) INSULA3-5 layered structures (mesocortex)
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Preferential brain locations of LGG
Duffau H. and Capelle L. Cancer, 2004 Jun 15;100:2622-6
66% insular tumor are LGG
LGG are more likely located in “secondary” functional areas immediately near to the so called “eloquent areas”.
Insula is a part of the mesocortex with 3-5 neuronal layers(Paralymbic region: M.G. Yasargil et al: Microsurgery of Insular Gliomas)
LGGs show an affinity to phylogenetically more primitive zones. Fillimorf 1947 and then Yakovlev in 1959
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T2 sharp imaging on benign tumor
M.G.Yasargil,Ali F. Krisht, Ugur Ture, Ossama Al-Mefty and D.C.H.Yasargil Microsurgery of insular glioma Part III – Contemporary Neurosurgery 24;13:1-6
Y.A. Moshel, J.D.S. Marcus, E.C. Parker and P.J. Kelly Resection of insular gliomas: the importance of lenticulostriate artery position. Clinical article. JNS November 2008;109:5
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Lesion displacing LSAs medially often represent a sharp-well demarcated T2 MR images and LGGs histology.
On 429 Limbic-Paralimbic tumors 31/191 of the Insular Gliomas demostrated anaplastic grade (MG Yasargil Microsurgery of the insular gliomas on Cont. Neurosurg. VOL. 24,14:JUL 15.2002)
Tumor with moderate shift of the LSAs and T2 MR images showing a diffuse boundaries pattern are most likely HGG and aggressive surgery is often associated to permanent deficit.
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Y.A. Moshel, J.D.S. Marcus, E.C. Parker and P.J. Kelly Resection of insular gliomas: the importance of lenticulostriate artery position. Clinical article. JNS November 2008;109:5
- 50% patients underwent previous surgery in other institutions- 70% patients presenting with seizures- 20% with mild hemiparesis - 45% pure insular tumors (55% with opercular extension)- 20% High enhancing lesion with high grade tumor: had postop permanent deficit ((30% TGR)- 80% Low enhancing lesion were LGGs (70% TGR was achieved)-
- Opening the sylvian fessure at the sylvian center- Dethetering of M4-M5 vessels- Without metal retractors- Depending on the target: multiple vertical incision dividing the M2-M3 branches- If present opercular extension first approached - MEP and SEEP are strictly necessary only in the dominant hemisphere
Tumor approach
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Methodics & Tools
- MR- Functional MR- Intra-op Ultrasound- PET (tumor grade)- Intra-op vascular microdoppler- DS Angiography demonstrating the LSA displacement- Intra-op evoked potential recording (internal capsule)- Awake surgery preferred in the dominant hemisphere
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M.G. Yasargil lesionectomy for insular tumors
1) Removal of the central zone performing a longitudinal sulcus incision2) Debulking of infero-anterior zone3) Debulking of the inferior region4,5,6) Once obtained room enough: antero-superior, superior and posterior7) Removal of the region in the limen insula
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Fuctional MR demonstrating the tumor boundaries and the
Uditive area without pallido-capsular involvement
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Functional MR demonstating temporal opercular region tumor involvement and uditive area
to avoid during the tumor approach (no distraction of the opercula)
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Tractography of capsula interna axial view and
temporal opercular uditive area in right hemisphere
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MR Tractography recognizing tumor boundaries without involvement of the capsula interna
3D MR with surface imaging demonstraing no encasement of the putamen GP, NC and CI.
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Tumor LSAs medial displacementOpen biopsy: anaplastic glioma
QuickTime™ e undecompressore
sono necessari per visualizzare quest'immagine.
Anaplastic Astrocytoma: atypia, ipercellularity and mitosis (WHO III)