Right Cingulate Glioblastoma
Published:
Right middle cingulate contrast enhancing mass with surrounding edema
HISTORY:
79 year old male who presents with a history, symptoms and radiographic findings consistent with a right middle cingulate mass. The neurological exam revealed sluggish train of thought with slow answering despite being oriented, subtle social and emotional apathy and slight weakness on left leg with clumsiness mostly affecting walk with spared strength in simple movements.
DIAGNOSTIC STUDY:
MRI brain showed right cingulate enhancing mass with MRI spectroscopy compatible with malignant glioma tumor. Vasogenic edema spread up to superior frontal gyrus (F1) from superior border of caudate nucleus.
SURGICAL APPROACH:
Interhemispheric ipsilateral transcingulate
POSITIONING:
A Mayfield head clamp was applied. The patient was placed in the latero-supine position with the head tilted with the right side down. All pressure points were well-padded. The hair was clipped over the planned incision. Pre-prepping was done with chlorhexidine solution. The electrophysiology monitoring team inserted needles in their proper locations and baseline SSEPs and motor evoked potentials were obtained. The patient underwent co-registration of the preoperative stereotactic MRI with his surface landmarks. The planned craniotomy was outlined right parasagittal slightly crossing the midline.
OPERATIVE TECHNIQUE:
The area was prepped and draped in the standard sterile fashion. A S-shaped coronal incision following previous surgical incision (for skin lesion) was planned and infiltrated with lidocaine and opened sharply using a #21 scalpel blade. Periosteum was preserved and cut separately for later closure.
Right parasagittal craniotomy was performed using an electric high speed drill. The bone flap was uplifted utilizing a combination of #3 Penfield and Adson periosteal elevator with special care for the midline sagital sinus. The dura was noted to be intact. The bone dust was irrigated and suctioned clean. A small C-shaped durotomy with base towards the midline was performed and the dura was lifted with tenting sutures.
The operating microscope was then draped and brought into the operative field. Careful dissection of the interhemispheric fissure was carried out anteriorly and posteriorly and down to the pericallosal cistern, letting the right medial cortical surface lower by gravity. Cottonoids were placed on bridging cortical veins, the sagittal sinus and keeping and, the medial surface of the superior frontal gyrus keeping them moist throughout the procedure. With the aid of the neuronavigational probe, the limits of the tumor in the medial surface were identified. Microdissection technique was used further to expose the cingulate sulcus and separate the callosomarginal artery cutting multiple arachnoid adhesions. Under blue light and guided with 5-ALA the medial surface of the tumor was visualized. A small corticectomy and tissue sample were centered at the most fluorescent spot for intraoperative biopsy that confirmed high grade glioma.
The lesion was noted to be grayish in color with soft consistency and ill-defined planes. Using a combination 7-French suction, bipolar electrocautery, as well as micro-scissors a plane was developed around the lesion in its superior, medial border following the cingulate sulcus and 5-ALA signal. Microdissection continued around the lesion following the plane and using the neuronavigational probe and the 5-ALA signal to carefully guide the volumetric resection.
The tumor specimen was sent to pathology. Before hemostasis was performed, vasospasm affecting a small segment of the callosomarginal artery was noted and treated with irrigation of diluted nimodipin and body-temperature saline, resolving completely in few minutes. The surgical bed was subsequently irrigated until clear hemostasis was achieved utilizing a combination of bipolar electrocautery and oxidized cellulose absorbable hemostat (Surgicel).
The dura was subsequently closed with running non-absorbable braided 4-0 silk suture. The bone was secured in place utilizing plates and screws. Periostium and subcutaneous layer were sutured with simple inverted knots of 2-0 synthetic absorbable suture (Polysorb). The skin was then closed with an intradermal running absorbable suture 3-0 (Monosyn). A small silicon Blake drainage was placed in the subperiosteal space. A sterile head dressing was placed over the closed wound.
Neurophysiological monitoring remained stable throughout the entire case. All sponge counts and instrument counts were correct at the end of the case times two. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
POSTOPERATIVE EVOLUTION:
The patient awaken with no complications and with subjective improvement of both leg clumsiness and slow thought. The walking pattern improved and the patient was socially more responsive as noted by his family. Postoperative MRI showed gross total resection with no complications. Discharge was given at postoperative day 5 with appointments for oncological follow up.
POSTOPERATIVE HISTOLOGICAL DIAGNOSIS:
Glioblastoma WHO IV
NUANCES AND DECISION STRATEGY
- Planning the position to open the interhemispheric fissure with the help of gravity - ipsilateral side down
- Plan the craniotomy according to the anatomy of cortical bridging veins
- Protect bridging veins and sagittal sinus with moisted cottonoids and avoid tension that occludes them
- Dissect the interhemispheric fissure down to the pericallosal cistern to accomplish a wide and relaxed exposure
- Spare superior frontal gyrus and avoid retractors or pressure on the medial surface to avoid supplementary motor area syndrome.
- Dissect in advance the callosomarginal artery from the sulcus and medial surface to be removed to avoid stroke
- If vasospasm is noted, take time to resolve it with body-temperature saline irrigation and even with nimodipin or papaverin soaked cottonoids
- 5 ALA guided resection - high suspicion of malignant glioma - specially useful in the interface with healthy tissue
- Intraoperative neurophysiology - motor evoked potentials - to spare corticospinal tract in the depth of the surgical bed