• Johan Pallud, Marc Zanello, Alessandro Moiraghi, Sophie Peeters, Bénédicte Trancart, Myriam Edjlali, Catherine Oppenheim, Pascale Varlet, Fabrice Chrétien, Frédéric Dhermain, Alexandre Roux, and Edouard Dezamis.
• Department of Neurosurgery, GHU Paris-Sainte-Anne Hospital, Paris, France.
• Neurosurgery. 2021 Sep 15; 89 (4): 565-578.

BackgroundInsular diffuse glioma resection is at risk of vascular injury and of postoperative new neurocognitive deficits.ObjectiveTo assess safety and efficacy of surgical management of insular diffuse gliomas.MethodsObservational, retrospective, single-institution cohort analysis (2005-2019) of 149 adult patients surgically treated for an insular diffuse glioma: transcortical awake resection with intraoperative functional mapping (awake resection subgroup, n = 61), transcortical asleep resection without functional mapping (asleep resection subgroup, n = 50), and stereotactic biopsy (biopsy subgroup, n = 38). All cases were histopathologically assessed according to the 2016 World Health Organization classification and cIMPACT-NOW update 3.ResultsFollowing awake resection, 3/61 patients had permanent motor deficit, seizure control rates improved (89% vs 69% preoperatively, P = .034), and neurocognitive performance improved from 5% to 24% in tested domains, despite adjuvant oncological treatments. Resection rates were higher in the awake resection subgroup (median 94%) than in the asleep resection subgroup (median 46%; P < .001). There was more gross total resection (25% vs 12%) and less partial resection (34% vs 80%) in the awake resection subgroup than in the asleep resection subgroup (P < .001). Karnofsky Performance Status score <70 (adjusted hazard ratio [aHR] 2.74, P = .031), awake resection (aHR 0.21, P = .031), isocitrate dehydrogenase (IDH)-mutant grade 2 astrocytoma (aHR 5.17, P = .003), IDH-mutant grade 3 astrocytoma (aHR 6.11, P < .001), IDH-mutant grade 4 astrocytoma (aHR 13.36, P = .008), and IDH-wild-type glioblastoma (aHR 21.84, P < .001) were independent predictors of overall survival.ConclusionAwake surgery preserving the brain connectivity is safe, allows larger resections for insular diffuse gliomas than asleep resection, and positively impacts overall survival.© Congress of Neurological Surgeons 2021.

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