PPubMed5 Aug 2022Cited 12×

Avoiding vascular complications in insular glioma surgery – A microsurgical anatomy study and critical reflections regarding intraoperative findings

Gustavo Rassier Isolan, Viviane Buffon, Igor Maldonado, Jander Moreira Monteiro, Kaan Yağmurlu, Carmen Austrália Paredes Marcondes Ribas, Rafael Roesler, Osvaldo Malafaia

Abstract

The M2 segment originates in the limen insulae, where the main bifurcation of the middle cerebral artery occurs or, in some cases, trifurcation. Distally to the curve, the upper and lower trunks launch branches that run through the insula to the periinsular sulcus where the M3 segment begins. These branches are called “arterial trunks”, from which the cortical arteries originate. The branches of the M2 segment can originate, in addition to the superior and inferior trunks, the intermediate trunk, the early branches, or even the accessory middle cerebral artery. The branches of the superior tru

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Detailed cadaveric and clinical study identifies lenticulostriate artery involvement and imaging markers to reduce vascular complications in insular glioma surgery.

What’s new

i.Performed microsurgical cadaveric dissections of 20 insular hemispheres with colored silicone perfusion.
ii.Reported lenticulostriate artery involvement in 13 of 52 insular glioma patients.
iii.Introduced MRI-based OC‑IR (Porto Alegre) line to predict LSTa involvement.
iv.Provided surgical reflections on transsylvian vs transcortical approaches and intraoperative mapping to prevent vascular injury.

How they did it

The insular vascularization was examined using ×3 to ×40 magnification in 20 cadaveric cerebral hemispheres with arteries and veins perfused with colored silicone. Clinical observations from 52 patients were reviewed to assess lenticulostriate artery involvement and correlate pre‑operative MRI findings with intra‑operative outcomes.

What they found

Lenticulostriate arteries were involved by the tumor in 13 of 52 patients (25%).
No involvement was found in 39 patients, allowing more aggressive resection.
Cadaveric study examined 20 hemispheres, revealing that 80‑90% of insular arteries are short, 10% medium, and 3‑5% long.
Average time for wide sylvian fissure dissection was about 1 hour.
Coagulation of insular veins can lead to venous infarction in 30% of patients.

Caveats

✕Study is a case series (level 3 evidence) with a limited sample size of 52 patients.
✕Intra‑operative identification of LSTa remains necessary; pre‑operative imaging predictions are not definitive.
✕Swollen tumor gyri prevent individualization of anatomical structures, limiting anatomical guidance.
✕No pre‑operative tool predicts sylvian fissure adhesion difficulty.

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