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Surgical management of thalamic gliomas: case selection, technical considerations, and review of literature

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Abstract

This study aimed to identify (1) the thalamic gliomas suitable for surgical resection and (2) the appropriate surgical approach based on their location and the displacement of the posterior limb of the internal capsule (PLIC). A retrospective study over a 5-year period (from 2006 to 2010) was performed in 41 patients with thalamic gliomas. The mean age of these patients was 20.4 years (range, 2–65 years). Twenty (49 %) tumors were thalamic, 19 (46 %) were thalamopeduncular, and 2 (5 %) were bilateral. The PLIC, based on T2-weighted magnetic resonance axial sections, was displaced anterolaterally in 23 (56 %) cases and laterally in 6 (14 %) cases. It was involved by lesion in eight (20 %) cases and could not be identified in four (10 %) cases. Resection, favored in patients with well-defined, contrast-enhancing lesions, was performed in 34 (83 %) cases, while a biopsy was resorted to in 7 (17 %) cases. A gross total resection or near total resection (>90 %) could be achieved in 26 (63 %) cases. The middle temporal gyrus approach, used when the PLIC was displaced anterolaterally, was the commonly used approach (63.5 %). Common pathologies were pilocytic astrocytoma (58 %) in children and grade III/IV astrocytomas (86 %) in adults. Preoperative motor deficits improved in 64 % of the patients with pilocytic lesions as compared to 0 % in patients with grade III/IV lesions (P value, 0.001). Postoperatively, two patients (5 %) had marginal worsening of motor power, two patients developed visual field defects, and one patient developed a third nerve paresis. Radical resection of thalamic gliomas is a useful treatment modality in a select subset of patients and is the treatment of choice for pilocytic astrocytomas. Tailoring the surgical approach, depending on the relative position of the PLIC, has an important bearing on outcome.

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Authors and Affiliations

  1. Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India

    Narayanam Anantha Sai Kiran, Sumit Thakar, Ravi Dadlani, Dilip Mohan, Sunil Valentine Furtado, Saritha Aryan & Alangar S. Hegde

  2. Department of Neuropathology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, 560066, India

    Nandita Ghosal

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  1. Narayanam Anantha Sai Kiran
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Comments

Hussam Metwali, Hannover, Germany

Thalamic glioma is quite a difficult and challenging entity of supratentorial gliomas. Because of its deep location, the surgeon has to go through and circumvent many vital structures. In this article, the authors described their experience with 41 cases of thalamic gliomas with different grades. The selection of the surgical approach was based on the location of the internal capsule and the tumor extension. The authors have also adapted the middle temporal gyrus approach to access the majority of the cases due to the anterolateral displacement of the posterior limb of the internal capsule. The authors have also mentioned the other approaches they used.

On the other side, our practice is different. Thalamic glioma constitutes a good example of functional glioma surgery, in which not only tumor resection but also preservation of function is our aim. Apart from the conventional anatomical MRI, come the preoperative DTI with color orientation maps and fiber tracking as well as the functional MRI in consideration. The choice of the appropriate surgical approach in our institute depends on the concordance of many variables including the tumor extension, the location of the tumor in the thalamus, the location of the pyramidal tracts, the location of the optic radiation, the location of the fornix and its insertion point into the corpus callosum, the location of the venous point (point of joining of the thalamostriate vein and the septal vein into the great cerebral veins), the anterior communicating artery complex and dominance, tentorial steep and the location of vein of Galen, and cerebral dominance and location of the speech areas. We use, depending the previously mentioned variables, the transcallosal approaches (ipsilateral or contralateral), the translamina terminalis approach, the pterional approach, the transsulcal approach (ipsilateral or contralateral), the supracerebellar infratentorial approach, and the occipital transtentorial approach. Since 2007, surgery of thalamic gliomas is usually performed under intraoperative MRI control. It allows us to access the amount of resection. It also provides the possibility of new fiber tracking and readjusting of the neuronavigator accordingly. The surgery is also performed under continuous monitoring of the somatosensory evoked potentials and the motor evoked potential (MEP). Surgery could be also assisted with 5-ALA, 5-ALA endoscopy, or conventional endoscopy.

Identification of the pyramidal tract in case of edema is not a big problem. The point here is to analyze and understand the color orientation maps and to compare them to the constructed fiber tracts. This improves the accuracy of fiber tracking. Infiltrated or destructed tracts can be predicted clinically or by MEP. Color orientation maps are also very helpful.

The middle temporal gyrus approach to thalamic glioma is a not commonly used approach in our practice. It can cause direct trauma to the visual tract as well as injury of the speech center in the dominant hemisphere.

This difference in practice and the availability of technology are not negative issues in the presented article. The authors have honestly described their methodology and its limitations. The authors have invested a lot of time and effort to establish this work. Congratulations.

Walter Stummer, Münster, Germany

The authors present an impressive series of patients operated on for thalamopeduncular tumors. They carefully analyze the location of the posterior limb of the internal capsule and identify those patients with anterior or anterolateral displacement of this structure as suitable candidates for the approach used in the majority of their cases through the middle temporal gyrus. Their reported results in these demanding tumors are intriguing.

This work nicely expands the past experience of surgery for these challenging lesions and presents an additional option for individual planning of an appropriate surgical strategy. It must be remembered, however, that other approaches may be feasible, depending on individual anatomic considerations.

The authors use intraoperative ultrasound as a method for intraoperative tumor location and for assessment of radicality. They do not use neuronavigation, nor do they integrate tractography for identification of the optical tract or the pyramidal tract, respectively. They also do not use subcortical stimulation or language mapping in left temporal approaches, not out of conviction but due to limitations of their resources. Such technology would serve to further enhance safety and radicality of surgery in this sensitive area. Nevertheless, the authors demonstrate good results in difficult tumors to be possible even if technology is not perfect.

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Sai Kiran, N.A., Thakar, S., Dadlani, R. et al. Surgical management of thalamic gliomas: case selection, technical considerations, and review of literature. Neurosurg Rev 36, 383–393 (2013). https://doi.org/10.1007/s10143-013-0452-3

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