Bilateral Trans-Sulcal and Interhemispheric Approaches for Butterfly Glioblastoma: 2-Dimensional Operative Video.

Butterfly glioblastoma (bGB) poses significant surgical challenges, yet recent findings have highlighted the potential of surgical decompression in extending patient survival.1-10 The selection of a surgical strategy for bGB varies across studies. Generally, the side with a larger tumor volume is a preferred approach route, and the nondominant hemisphere is preferred when both tumors are similar in size. The contralateral tumor is removed via the resection cavity of the ipsilateral side,11 with successful utilization of endoscopic-assisted techniques.8 In the case of deep-seated bGB covered with a thick intact brain, accessing the tumor requires creating an invasive corridor, therefore minimizing the damage to the intact brain is ideal. A man in his 70s presented the new-onset seizure. Preoperatively, the patient exhibited a Karnofsky performance status of 50% without any motor deficits, and magnetic resonance imaging demonstrated a deep-seated anterior bGB with a larger tumor volume on the left dominant side. Imaging showed the tumor located just beneath the bilateral superior frontal sulci. Therefore we used these sulci to access the tumor with the minimum cut of the intact brain while preserving the frontal aslant tracts and used bilateral interhemispheric approaches to protect the cingulate bundles. We conducted the same technique for another deep-seated anterior bGB case, both resulting in postoperative Karnofsky performance status improvements (Video 1). Tailoring the surgical approach to the unique characteristics of each bGB case is important. The patients consented to the procedure and the publication of their images.

Wide Dissection Trans-Sulcal Approach for Resection of Deep Intra-Axial Lesions in Eloquent Brain Areas.

Introduction: Resection of intra-axial tumors (IaT) in eloquent brain regions risks major postoperative neurological deficits. Awake craniotomy is often used to navigate these areas; however, some patients are ineligible for awake procedures. The trans-sulcal approach (TScal) was introduced to reduce parenchymal trauma during tumor resection. We report our experiences utilizing TScal for resection of deep IaT located in eloquent areas. Materials and Methods: This is a single-center retrospective analysis of patients who underwent IaT resection in eloquent areas via TScal from January 2013 to April 2021. Seventeen cases were reviewed, and relevant data was collected. Fluorescence-guided surgery with 5-aminolevulinic acid (ALA) and intraoperative ultrasound was performed in some cases. Results: Seventeen patients (10 males, 7 females) averaging 61.2 years-old (range, 21-76) were included in this study. Average length of stay was 4.8 days, and only 2 patients (11.8%) required hospital readmission within 30 days. Gross total resection (GTR) was achieved in 15 patients (88.2%), while subtotal resection occurred in 2 patients (11.8%). Eleven patients (64.7%) reported full resolution of symptoms, 4 patients (23.5%) reported deficit improvement, and 2 patients (11.8%) experienced no change from their preoperative deficits. No patient developed new permanent deficits postoperatively. Discussion: GTR, preoperative deficit reduction, and complications were comparable to awake craniotomy and other TScal studies. Ancillary intraoperative techniques, such as brain mapping, 5-ALA and intraoperative ultrasound, are afforded by TScal to improve resection rates and overall outcomes. Conclusions: TScal can be an option for patients with deep lesions in eloquent areas who are not candidates for awake surgeries.

Surgical management of meningioma of the trigone area of the lateral ventricle.

OBJECTIVE: Lateral ventricular trigone meningioma is relatively rare and surgical resection is the main treatment strategy. It is a challenge to achieve total resection without any complication. We analyzed a series of cases using literature review. METHODS: Retrospective data was collected on patients who underwent surgical treatment for trigone meningioma at our department from 2007 to 2012. RESULTS: Forty-three patients were included (12 men, 31 women). The average age was 42.8 years old. The symptoms depended on tumor size and location; 38 had prominent symptoms. The preoperative neuroimaging help assess the entity, size, location, and blood supply of the tumor. All lesions were resected using the trans-sulcal temporal or parietal approach, with intraoperative ultrasound assistance. Total resection was achieved in all patients. Thirty-six patients had a ventricular drain, which was removed 1 to 14 days later. Of the patients having prominent symptoms, 31 had relief soon after the operation, the other 7 patients improved to some extent at long-term follow-up. Two patients developed intraoperative distant epidural hematoma, which was confirmed by ultrasound, and underwent hematoma evacuation immediately. Two patients were reoperated for extensive intracranial hypertension. Three patients developed localized hydrocephalus and 2 of those underwent ventriculoperitoneal shunt several months later and 1 patient had spontaneous relief. One patient had grade II meningioma and 2 had grade III; they underwent adjuvant radiotherapy. The follow-up period ranged from 2 to 71 months, with no recurrence. CONCLUSIONS: Surgical resection, using the trans-sulcal approach with intraoperative ultrasound assistance, can achieve a high rate of total resection and a low rate of complication, promising a good prognosis. The management technique and the perioperative treatment have to be individualized.