{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,15]],"date-time":"2026-02-15T21:21:06Z","timestamp":1771190466551,"version":"3.50.1"},"reference-count":55,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2022,10,14]],"date-time":"2022-10-14T00:00:00Z","timestamp":1665705600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001809","name":"National Natural Science Foundation of China","doi-asserted-by":"publisher","award":["81771792 and 82172028"],"award-info":[{"award-number":["81771792 and 82172028"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100009592","name":"Beijing Municipal Science and Technology Commission","doi-asserted-by":"publisher","award":["Z171100000117002"],"award-info":[{"award-number":["Z171100000117002"]}],"id":[{"id":"10.13039\/501100009592","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Surg."],"abstract":"<jats:sec><jats:title>Introduction<\/jats:title><jats:p>Insular gliomas have complex anatomy and microvascular supply that make resection difficult. Furthermore, resection of insular glioma is associated with a significant risk of postoperative ischemic complications. Thus, this study aimed to assess the incidence of ischemic complications related to insular glioma resection, determine its risk factors, and describe a single surgeon\u2019s experience of artery-preserving tumor resection.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We enrolled 75 consecutive patients with insular gliomas who underwent transcortical tumor resection. Preoperative and postoperative demographic, clinical, radiological [including diffusion-weighted imaging (DWI)], intraoperative neurophysiological data, and functional outcomes were analyzed. Motor evoked potentials (MEPs) and radiological characteristics like the relationship between the proximal segment of the lateral lenticulostriate arteries (LLSAs) and the tumor, the flat inner edge sign (the inner edge of the insular glioma is well-defined) or obscure inner edge sign, the distance between the lesion and posterior limb of the internal capsule and the invasion of the superior limiting sulcus by the tumor were analyzed. Strategies such as \u201cresidual triangle,\u201d \u201cbasal ganglia outline reappearance,\u201d and \u201csculpting\u201d technique were used to preserve the LLSAs and the main branches of M2 for maximal tumor resection according to the Berger\u2013Sinai classification.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Postoperative DWI showed acute ischemia in 44 patients (58.7%). Moreover, nine patients (12%) had developed new motor deficits, as determined by the treating neurosurgeons. The flat inner edge sign [odds ratio (OR), 0.144; 95% confidence interval (CI), 0.024\u20130.876) and MEPs (&amp;gt;50%) (OR, 18.182; 95% CI, 3.311\u2013100.00) were significantly associated with postoperative core ischemia, which affected the posterior limb of the internal capsule or corona radiata.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Insular glioma resection was associated with a high incidence of ischemia, as detected by DWI, as well as new motor deficits that were determined by the treating neurosurgeons. Insular glioma patients with obscure inner edge signs and intraoperative MEPs decline &amp;gt;50% had a higher risk of developing core ischemia. With our strategies, maximal safe resection of insular gliomas may be achieved.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fsurg.2022.956872","type":"journal-article","created":{"date-parts":[[2022,10,14]],"date-time":"2022-10-14T07:37:12Z","timestamp":1665733032000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":12,"title":["Incidence of ischemic complications and technical nuances of arteries preservation for insular gliomas resection"],"prefix":"10.3389","volume":"9","author":[{"given":"Zonggang","family":"Hou","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhenxing","family":"Huang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhenye","family":"Li","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhenghai","family":"Deng","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gen","family":"Li","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yaokai","family":"Xu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mingran","family":"Wang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shengjun","family":"Sun","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yazhuo","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hui","family":"Qiao","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jian","family":"Xie","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2022,10,14]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"2622","DOI":"10.1002\/cncr.20297","article-title":"Preferential brain locations of low-grade gliomas","volume":"100","author":"Duffau","year":"2004","journal-title":"Cancer"},{"key":"B2","doi-asserted-by":"publisher","first-page":"801","DOI":"10.3171\/2012.12.jns12125","article-title":"Postoperative ischemic changes following resection of newly diagnosed and recurrent gliomas and their clinical relevance","volume":"118","author":"Gempt","year":"2013","journal-title":"J Neurosurg"},{"key":"B3","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1007\/s00701-018-3717-3","article-title":"Hotspots of small strokes in glioma surgery: an overlooked risk?","volume":"161","author":"Loit","year":"2019","journal-title":"Acta Neurochir"},{"key":"B4","doi-asserted-by":"publisher","first-page":"263","DOI":"10.3171\/jns.2007.106.2.263","article-title":"Ischemic complications associated with resection of opercular glioma","volume":"106","author":"Kumabe","year":"2007","journal-title":"J Neurosurg"},{"key":"B5","doi-asserted-by":"publisher","first-page":"1991","DOI":"10.1007\/s00701-014-2167-9","article-title":"Microanatomical study of the insular perforating arteries","volume":"156","author":"Delion","year":"2014","journal-title":"Acta Neurochir"},{"key":"B6","doi-asserted-by":"publisher","first-page":"321","DOI":"10.2176\/nmc.cr2012-0361","article-title":"Preservation of the long insular artery to prevent postoperative motor deficits after resection of insulo-opercular glioma: technical case reports","volume":"54","author":"Iwasaki","year":"2014","journal-title":"Neurol Med Chir"},{"key":"B7","doi-asserted-by":"publisher","first-page":"176","DOI":"10.1227\/01.neu.0000163603.70972.ab","article-title":"Surgical resection of intrinsic insular tumors","volume":"57","author":"Hentschel","year":"2005","journal-title":"Neurosurgery"},{"key":"B8","doi-asserted-by":"publisher","first-page":"825","DOI":"10.3171\/jns\/2008\/109\/11\/0825","article-title":"Resection of insular gliomas: the importance of lenticulostriate artery position","volume":"109","author":"Moshel","year":"2008","journal-title":"J Neurosurg"},{"key":"B9","doi-asserted-by":"publisher","first-page":"2559","DOI":"10.1200\/JCO.2011.38.4818","article-title":"Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis","volume":"30","author":"De Witt Hamer","year":"2012","journal-title":"J Clin Oncol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"793","DOI":"10.1007\/s10143-021-01602-5","article-title":"Anatomical aspects of the insula, opercula and peri-insular white matter for a transcortical approach to insular glioma resection","volume":"45","author":"Dziedzic","year":"2021","journal-title":"Neurosurg Rev"},{"key":"B11","doi-asserted-by":"publisher","first-page":"491","DOI":"10.1007\/s11060-020-03499-4","article-title":"Surgical strategy for insular glioma","volume":"151","author":"Przybylowski","year":"2021","journal-title":"J Neurooncol"},{"key":"B12","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3171\/2009.6.jns0952","article-title":"Insular glioma resection: assessment of patient morbidity, survival, and tumor progression","volume":"112","author":"Sanai","year":"2010","journal-title":"J Neurosurg"},{"key":"B13","doi-asserted-by":"publisher","first-page":"59","DOI":"10.1007\/s11060-020-03390-2","article-title":"Transcortical approach for insular gliomas: a series of 253 patients","volume":"147","author":"Li","year":"2020","journal-title":"J Neurooncol"},{"key":"B14","doi-asserted-by":"publisher","first-page":"3093","DOI":"10.1007\/s00701-021-04806-2","article-title":"Complication avoidance: resection of the insular glioma complicated by iatrogenic injury to the lenticulostriate artery","volume":"163","author":"Pitskhelauri","year":"2021","journal-title":"Acta Neurochir"},{"key":"B15","doi-asserted-by":"publisher","first-page":"E6","DOI":"10.3171\/2012.12.FOCUS12342","article-title":"Technical nuances for surgery of insular gliomas: lessons learned","volume":"34","author":"Rey-Dios","year":"2013","journal-title":"Neurosurg Focus"},{"key":"B16","doi-asserted-by":"publisher","first-page":"707","DOI":"10.1016\/j.clinph.2019.02.010","article-title":"Prediction of postoperative motor deficits using motor evoked potential deterioration duration in intracranial aneurysm surgery","volume":"130","author":"Li","year":"2019","journal-title":"Clin Neurophysiol"},{"key":"B17","doi-asserted-by":"publisher","first-page":"293","DOI":"10.1007\/s10143-019-01077-5","article-title":"A prediction of postoperative neurological deficits following intracranial aneurysm surgery using somatosensory evoked potential deterioration duration","volume":"43","author":"Wang","year":"2020","journal-title":"Neurosurg Rev"},{"key":"B18","doi-asserted-by":"publisher","first-page":"829","DOI":"10.3171\/2013.5.jns121981","article-title":"Postoperative ischemic changes after glioma resection identified by diffusion-weighted magnetic resonance imaging and their association with intraoperative motor evoked potentials","volume":"119","author":"Gempt","year":"2013","journal-title":"J Neurosurg"},{"key":"B19","doi-asserted-by":"publisher","first-page":"987","DOI":"10.1056\/NEJMoa043330","article-title":"Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma","volume":"352","author":"Stupp","year":"2005","journal-title":"N Engl J Med"},{"key":"B20","doi-asserted-by":"publisher","first-page":"469","DOI":"10.3171\/2014.12.JNS142182","article-title":"Surgical assessment of the insula. Part 1: surgical anatomy and morphometric analysis of the transsylvian and transcortical approaches to the insula","volume":"124","author":"Benet","year":"2016","journal-title":"J Neurosurg"},{"key":"B21","doi-asserted-by":"publisher","first-page":"E7","DOI":"10.3171\/2009.5.FOCUS0938","article-title":"Functional outcome after language mapping for insular World Health Organization grade II gliomas in the dominant hemisphere: experience with 24 patients","volume":"27","author":"Duffau","year":"2009","journal-title":"Neurosurg Focus"},{"key":"B22","doi-asserted-by":"publisher","first-page":"891","DOI":"10.3171\/jns.2004.100.5.0891","article-title":"Microsurgical anatomy of the insula and the sylvian fissure","volume":"100","author":"Tanriover","year":"2004","journal-title":"J Neurosurg"},{"key":"B23","doi-asserted-by":"publisher","first-page":"482","DOI":"10.3171\/2015.4.JNS1521","article-title":"Surgical assessment of the insula. Part 2: validation of the Berger-Sanai zone classification system for predicting extent of glioma resection","volume":"124","author":"Hervey-Jumper","year":"2016","journal-title":"J Neurosurg"},{"key":"B24","doi-asserted-by":"publisher","first-page":"676","DOI":"10.3171\/jns.2000.92.4.0676","article-title":"Arteries of the insula","volume":"92","author":"T\u00fcre","year":"2000","journal-title":"J Neurosurg"},{"key":"B25","doi-asserted-by":"publisher","first-page":"986","DOI":"10.1161\/01.STR.0000163087.66828.e9","article-title":"A digital map of middle cerebral artery infarcts associated with middle cerebral artery trunk and branch occlusion","volume":"36","author":"Phan","year":"2005","journal-title":"Stroke"},{"key":"B26","doi-asserted-by":"publisher","first-page":"153","DOI":"10.3171\/2019.10.jns192301","article-title":"Incidence and impact of stroke following surgery for low-grade gliomas","volume":"134","author":"Berger","year":"2019","journal-title":"J Neurosurg"},{"key":"B27","doi-asserted-by":"publisher","first-page":"1731","DOI":"10.3171\/2018.12.Jns183075","article-title":"Surgical morbidity of transsylvian versus transcortical approaches to insular gliomas","volume":"132","author":"Przybylowski","year":"2019","journal-title":"J Neurosurg"},{"key":"B28","doi-asserted-by":"publisher","first-page":"265","DOI":"10.1016\/j.wneu.2017.04.002","article-title":"Volumetric analysis of extent of resection, survival, and surgical outcomes for insular gliomas","volume":"103","author":"Eseonu","year":"2017","journal-title":"World Neurosurg"},{"key":"B29","doi-asserted-by":"publisher","first-page":"1081","DOI":"10.1227\/NEU.0b013e31823f5be5","article-title":"Surgery of insular nonenhancing gliomas: volumetric analysis of tumoral resection, clinical outcome, and survival in a consecutive series of 66 cases","volume":"70","author":"Skrap","year":"2012","journal-title":"Neurosurgery"},{"key":"B30","doi-asserted-by":"publisher","first-page":"706","DOI":"10.3171\/2018.4.jns18424","article-title":"Transcortical insular glioma resection: clinical outcome and predictors","volume":"131","author":"Hameed","year":"2018","journal-title":"J Neurosurg"},{"key":"B31","doi-asserted-by":"publisher","first-page":"e563","DOI":"10.1016\/j.wneu.2019.08.071","article-title":"Transopercular resection of IDH-mutated insular glioma: a critical appraisal of an initial experience","volume":"132","author":"Mandonnet","year":"2019","journal-title":"World Neurosurg"},{"key":"B32","doi-asserted-by":"publisher","first-page":"6994","DOI":"10.1038\/s41598-021-86165-7","article-title":"Microsurgical resection of fronto-temporo-insular gliomas in the non-dominant hemisphere, under general anesthesia using adjunct intraoperative MRI and no cortical and subcortical mapping: a series of 20 consecutive patients","volume":"11","author":"Leroy","year":"2021","journal-title":"Sci Rep"},{"key":"B33","doi-asserted-by":"publisher","first-page":"1279","DOI":"10.1007\/s00701-020-04643-9","article-title":"Insular lobe surgery and cognitive impairment in gliomas operated with intraoperative neurophysiological monitoring","volume":"163","author":"Zarino","year":"2021","journal-title":"Acta Neurochir"},{"key":"B34","doi-asserted-by":"publisher","first-page":"565","DOI":"10.1093\/neuros\/nyab254","article-title":"Surgery of insular diffuse gliomas\u2014part 1: transcortical awake resection is safe and independently improves overall survival","volume":"89","author":"Pallud","year":"2021","journal-title":"Neurosurgery"},{"key":"B35","doi-asserted-by":"publisher","first-page":"629166","DOI":"10.3389\/fonc.2021.629166","article-title":"Challenging giant insular gliomas with brain mapping: evaluation of neurosurgical, neurological, neuropsychological, and quality of life results in a large mono-institutional series","volume":"11","author":"Rossi","year":"2021","journal-title":"Front Oncol"},{"key":"B36","doi-asserted-by":"publisher","first-page":"904","DOI":"10.4103\/0028-3886.325334","article-title":"Avoiding complications in surgical resection of insular gliomas\u2014single surgeon experience","volume":"69","author":"Panigrahi","year":"2021","journal-title":"Neurol India"},{"key":"B37","doi-asserted-by":"publisher","first-page":"824003","DOI":"10.3389\/fsurg.2021.824003","article-title":"Awake surgery for left posterior insular low-grade glioma through the parietorolandic operculum: the need to preserve the functional connectivity. A case series","volume":"8","author":"Duffau","year":"2021","journal-title":"Front Surg"},{"key":"B38","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1007\/BF01400725","article-title":"Tumours of the limbic and paralimbic systems","volume":"118","author":"Yasargil","year":"1992","journal-title":"Acta Neurochir"},{"key":"B39","doi-asserted-by":"publisher","first-page":"276","DOI":"10.4103\/1793-5482.175626","article-title":"Indocyanine green as an adjunct for resection of insular gliomas","volume":"11","author":"Shah","year":"2016","journal-title":"Asian J Neurosurg"},{"key":"B40","doi-asserted-by":"publisher","first-page":"1016","DOI":"10.3171\/2015.10.JNS151907","article-title":"Visualization of lenticulostriate arteries during insular low-grade glioma surgeries by navigated 3D ultrasound power Doppler: technical note","volume":"125","author":"Steno","year":"2016","journal-title":"J Neurosurg"},{"key":"B41","doi-asserted-by":"publisher","first-page":"392","DOI":"10.1016\/S1470-2045(06)70665-9","article-title":"Fluorescence-guided surgery with 5-aminolevulinic acid for resection of malignant glioma: a randomised controlled multicentre phase III trial","volume":"7","author":"Stummer","year":"2006","journal-title":"Lancet Oncol"},{"key":"B42","doi-asserted-by":"publisher","first-page":"E4","DOI":"10.3171\/2015.11.FOCUS15542","article-title":"Factors triggering an additional resection and determining residual tumor volume on intraoperative MRI: analysis from a prospective single-center registry of supratentorial gliomas","volume":"40","author":"Scherer","year":"2016","journal-title":"Neurosurg Focus"},{"key":"B43","doi-asserted-by":"publisher","first-page":"1124","DOI":"10.3171\/2014.7.jns13899","article-title":"Practical surgical indicators to identify candidates for radical resection of insulo-opercular gliomas","volume":"121","author":"Kawaguchi","year":"2014","journal-title":"J Neurosurg"},{"key":"B44","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1016\/j.wneu.2018.05.226","article-title":"Hammock middle cerebral artery and delayed infarction in lenticulostriate artery after staged resection of giant insular glioma","volume":"117","author":"Hirono","year":"2018","journal-title":"World Neurosurg"},{"key":"B45","doi-asserted-by":"publisher","first-page":"16","DOI":"10.4103\/ajns.AJNS_146_18","article-title":"Preservation of the lenticulostriate arteries during insular glioma resection","volume":"15","author":"Ghali","year":"2020","journal-title":"Asian J Neurosurg"},{"key":"B46","doi-asserted-by":"publisher","first-page":"1173","DOI":"10.3171\/2017.1.jns161278","article-title":"Surgical strategy to avoid ischemic complications of the pyramidal tract in resective epilepsy surgery of the insula: technical case report","volume":"128","author":"Ikegaya","year":"2018","journal-title":"J Neurosurg"},{"key":"B47","doi-asserted-by":"publisher","first-page":"209","DOI":"10.3171\/2018.3.jns172516","article-title":"Evaluation of the extent of resection and detection of ischemic lesions with intraoperative MRI in glioma surgery: is intraoperative MRI superior to early postoperative MRI?","volume":"131","author":"Masuda","year":"2018","journal-title":"J Neurosurg"},{"key":"B48","doi-asserted-by":"publisher","first-page":"675","DOI":"10.3171\/jns.2006.105.5.675","article-title":"Monitoring of muscle motor evoked potentials during cerebral aneurysm surgery: intraoperative changes and postoperative outcome","volume":"105","author":"Szel\u00e9nyi","year":"2006","journal-title":"J Neurosurg"},{"key":"B49","doi-asserted-by":"publisher","first-page":"829","DOI":"10.1016\/j.wneu.2017.04.071","article-title":"The diagnostic accuracy of evoked potential monitoring techniques during intracranial aneurysm surgery for predicting postoperative ischemic damage: a systematic review and meta-analysis","volume":"103","author":"Thomas","year":"2017","journal-title":"World Neurosurg"},{"key":"B50","doi-asserted-by":"publisher","first-page":"383","DOI":"10.1016\/j.neucli.2007.09.002","article-title":"Stroke prevention during surgery for deep-seated gliomas","volume":"37","author":"Neuloh","year":"2007","journal-title":"Neurophysiol Clin"},{"key":"B51","doi-asserted-by":"publisher","first-page":"2869","DOI":"10.1007\/s10143-022-01803-6","article-title":"False-positive results in transcranial motor evoked potentials for outcome prognostication during surgery for supratentorial lesions","volume":"45","author":"Abboud","year":"2022","journal-title":"Neurosurg Rev"},{"key":"B52","doi-asserted-by":"publisher","first-page":"98","DOI":"10.3340\/jkns.2014.56.2.98","article-title":"Intraoperative monitoring of motor-evoked potentials for supratentorial tumor surgery","volume":"56","author":"Lee","year":"2014","journal-title":"J Korean Neurosurg Soc"},{"key":"B53","doi-asserted-by":"publisher","first-page":"575","DOI":"10.1007\/s00701-011-1216-x","article-title":"Awake surgery for incidental WHO grade II gliomas involving eloquent areas","volume":"154","author":"Duffau","year":"2012","journal-title":"Acta Neurochir"},{"key":"B54","doi-asserted-by":"publisher","first-page":"97","DOI":"10.1007\/s11060-020-03494-9","article-title":"Effects of supra-total resection in neurocognitive and oncological outcome of high-grade gliomas comparing asleep and awake surgery","volume":"148","author":"Zigiotto","year":"2020","journal-title":"J Neurooncol"},{"key":"B55","doi-asserted-by":"publisher","first-page":"1","DOI":"10.3171\/2022.1.JNS212257","article-title":"Network-level prediction of set-shifting deterioration after lower-grade glioma resection","author":"Mrah","year":"2022","journal-title":"J Neurosurg"}],"container-title":["Frontiers in Surgery"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2022.956872\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,10,14]],"date-time":"2022-10-14T07:37:16Z","timestamp":1665733036000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2022.956872\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,10,14]]},"references-count":55,"alternative-id":["10.3389\/fsurg.2022.956872"],"URL":"https:\/\/doi.org\/10.3389\/fsurg.2022.956872","relation":{},"ISSN":["2296-875X"],"issn-type":[{"value":"2296-875X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,10,14]]},"article-number":"956872"}}