Trans-Sylvian Resection of Giant Left Insular Glioma: Operative Technique and Nuances

Background: Insular glioma was considered a nonsurgical entity due to resection-associated morbidities. The advancement in neurosurgical techniques and adjuncts used in the last two decades made the resection of insular gliomas simpler for neurosurgeons with the maximum extent of resection and acceptable morbidity rates. The complex anatomy of this region remains a challenge for neurosurgeons and requires expertise. The key factors to achieve complete resection in the insular region are the thorough knowledge of surgical anatomy and meticulous microsurgical techniques. Intraoperative adjuncts such as image guidance along with cortical and subcortical mapping assist in excellent outcomes. Objective: In this study, we describe the operative technique and application of trans-Sylvian approach to do the compartmental dissection done by the senior author, along with challenges faced, with the hope to highlight the efficacy of the approach to achieve maximal resection of this entity without compromising patient's safety. Materials and Methods: A 32-year-old right-handed gentleman presented with episodes of excessive salivation, tingling sensation on the right side of the body along with nausea that lasted for 15-20 s for the last 8 months and one episode of speech arrest without any loss of consciousness and motor or sensory deficit. CEMRI of the brain was suggestive of left insular glioma. The patient underwent left pterional craniotomy, and gross total resection of the tumor was done using compartmental dissection. Results: At follow-up after 1 month, the patient is seizure-free without any speech difficulty and motor or sensory deficit. Conclusion: Compartmental dissection of insular glioma is a safe and efficacious technique to achieve gross total resection of the tumor in this complex region without morbidity.