Surgery of Insular Diffuse Low-Grade Gliomas

  • Karine Michaud
  • Hugues DuffauEmail author


Diffuse low-grade glioma represents a premalignant neoplasm that has a propensity to involve the insula/paralimbic region for molecular, anatomical, and functional reasons. This tumor tends to affect young patients that present typically with few symptoms, most often epilepsy, but that exhibit neurocognitive deficits when screened appropriately by objective neuropsychological assessment. Because the natural history of this disease and the functional connectivity of this brain area are increasingly known, it has become clear that early and safe maximal surgical treatment is the best management in order to optimize not only survival but also quality of life of affected patients. We will here discuss insular gliomas as a specific pathologic entity; we will detail surgical techniques, by emphasizing the role of awake mapping; and we will report oncological as well as functional results of this therapeutic approach.


Low-grade gliomas Awake surgery Insular tumors Electrical mapping Outcome Survival Quality of life 


  1. 1.
    Duffau H. In: Duffau H, editor. Diffuse low-grade gliomas in adults: natural history, interaction with the brain, and new individualized therapeutic strategies. 2nd ed. London: Springer; 2017.CrossRefGoogle Scholar
  2. 2.
    Louis DN, Perry A, Reifenberger G, von Deimling A, Figarella-Branger D, Cavenee WK, et al. The 2016 World Health Organization classification of tumors of the central nervous system: a summary. Acta Neuropathol. 2016;131:803–20.CrossRefGoogle Scholar
  3. 3.
    Forst DA, Nahed BV, Loeffler JS, Batchelor TT. Low-grade gliomas. Oncoologist. 2014;19:403–13.CrossRefGoogle Scholar
  4. 4.
    Almairac F, Herbet G, Moritz-Gasser S, de Champfleur NM, Duffau H. The left inferior fronto-occipital fasciculus subserves language semantics: a multilevel lesion study. Brain Struct Funct. 2015;220:1983–95.CrossRefPubMedGoogle Scholar
  5. 5.
    Duffau H. A personal consecutive series of surgically treated 51 cases of insular WHO grade II glioma: advances and limitations. J Neurosurg. 2009;110:696–708.CrossRefPubMedGoogle Scholar
  6. 6.
    Pallud J, Varlet P, Devaux B, Geha S, Badoual M, Deroulers C, et al. Diffuse low-grade oligodendrogliomas extend beyond MRI-defined abnormalities. Neurology. 2010;74:1724–31.CrossRefPubMedGoogle Scholar
  7. 7.
    Pirzkall A, Nelson SJ, McKnight TR, Takahashi MM, Li X, Graves EE, et al. Metabolic imaging of low-grade gliomas with three-dimensional magnetic resonance spectroscopy. Int J Radiat Oncol Biol Phys. 2002;53:1254–64.CrossRefPubMedGoogle Scholar
  8. 8.
    Pallud J, Mandonnet E, Duffau H, Kujas M, Guillevin R, Galanaud D, et al. Prognostic value of initial magnetic resonance imaging growth rates for World Health Organization grade II gliomas. Ann Neurol. 2006;60:380–3.CrossRefPubMedGoogle Scholar
  9. 9.
    Pouratian N, Asthagiri A, Jagannathan J, Shaffrey ME, Schiff D. Surgery insight: the role of surgery in the management of low-grade gliomas. Nat Clin Pract Neurol. 2007;3:628–39.CrossRefPubMedGoogle Scholar
  10. 10.
    Sanai N, Polley MY, Berger MS. Insular glioma resection: assessment of patient morbidity, survival, and tumor progression. J Neurosurg. 2010;112:1–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Gozé C, Rigau V, Gibert L, Maudelonde T, Duffau H, et al. J Neuro-Oncol. 2009;91:1–5.CrossRefGoogle Scholar
  12. 12.
    Gozé C, Mansour L, Rigau V, Duffau H. Distinct IDH1/IDH2 mutation profiles in purely insular versus paralimbic WHO Grade II gliomas. J Neurosurg. 2013;118:866–72.CrossRefPubMedGoogle Scholar
  13. 13.
    Nieuwenhuys R. The insular cortex: a review. Prog Brain Res. 2012;195:123–63.CrossRefPubMedGoogle Scholar
  14. 14.
    Duffau H, Capelle L. Preferential brain locations of low-grade gliomas. Cancer. 2004;100:2622–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Kalani MY, Kalani MA, Gwinn R, Keogh B, Tse VC. Embryological development of the human insula and its implications for the spread and resection of insular gliomas. Neurosurg Focus. 2009;27(2):E2.CrossRefPubMedGoogle Scholar
  16. 16.
    Mandonnet E, Capelle L, Duffau H. Extension of paralimbic low grade glioma: toward an anatomical classification based on white matter invasion pattern. J Neuro-Oncol. 2006;78:179–85.CrossRefGoogle Scholar
  17. 17.
    Yasargil MG, von Ammon K, Cavazos E, Doczi T, Reeves JD, Roth P. Tumours of the limbic and paralimbic systems. Acta Neurochir. 1992;118:40–52.CrossRefPubMedGoogle Scholar
  18. 18.
    Hervey-Jumper SL, Li J, Osorio JA, Lau D, Molinaro AM, Benet A, et al. Surgical assessment of the insula. Part 2: validation of the Berger-Sanai zone classification system for predicting extent of glioma resection. J Neurosurg. 2016;124:482–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Duffau H, Mandonnet E. The “onco-functional balance” in surgery for diffuse low-grade glioma: integrating the extent of resection with quality of life. Acta Neurochir. 2013;155:951–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Michaud K, Duffau H. Surgery of insular and paralimbic diffuse low grade gliomas. J Neuro-Oncol. 2016;130:289–98.CrossRefGoogle Scholar
  21. 21.
    Rofes A, Mandonnet E, Godden J, Baron MH, Colle H, Darlix A, et al. Survey on current cognitive practices within the European Low-Grade Glioma Network: towards a European assessment protocol. Acta Neurochir. 2017;159:1167–78.CrossRefPubMedGoogle Scholar
  22. 22.
    Fernández Coello A, Moritz-Gasser S, Martino J, Martinoni M, Matsuda R, Duffau H. Selection of intraoperative tasks for awake mapping based on relationships between tumor location and functional networks. J Neurosurg. 2013;119:1380–94.CrossRefPubMedGoogle Scholar
  23. 23.
    Duffau H. A new concept of diffuse (low-grade) glioma surgery. Adv Tech Stand Neurosurg. 2012;38:3–27.CrossRefPubMedGoogle Scholar
  24. 24.
    Leclercq D, Duffau H, Delmaire C, Capelle L, Gatignol P, Ducros M, et al. Comparison of diffusion tensor imaging tractography of language tracts and intraoperative subcortical stimulations. J Neurosurg. 2010;112:503–11.CrossRefPubMedGoogle Scholar
  25. 25.
    Deras P, Moulinié G, Maldonado IL, Moritz-Gasser S, Duffau H, Bertram L. Intermittent general anesthesia with controlled ventilation for asleep-awake-asleep brain surgery: a prospective series of 140 gliomas in eloquent areas. Neurosurgery. 2012;71:764–71.CrossRefPubMedGoogle Scholar
  26. 26.
    Lang FF, Olansen NE, DeMonte F, Gokaslan ZL, Holland EC, Kalhorn C, et al. Surgical resection of intrinsic insular tumors: complication avoidance. J Neurosurg. 2001;95:638–50.CrossRefPubMedGoogle Scholar
  27. 27.
    Duffau H, Moritz-Gasser S, Gatignol P. Functional outcome after language mapping for insular World Health Organization grade II gliomas in the dominant hemisphere: experience with 24 patients. Neurosurg Focus. 2009;27:E7.CrossRefPubMedGoogle Scholar
  28. 28.
    Vanaclocha V, Saiz-Sapena N, Garcia-Casasola C. Surgical treatment of insular gliomas. Acta Neurochir. 1997;139:1126–35.CrossRefPubMedGoogle Scholar
  29. 29.
    Tate MC, Herbet G, Moritz-Gasser S, Tate JE, Duffau H. Probabilistic map of critical functional regions of the human cerebral cortex: Broca’s area revisited. Brain. 2014;137:2773–82.CrossRefPubMedGoogle Scholar
  30. 30.
    Duffau H, Capelle L, Lopes M, Faillot T, Sichez JP, Fohanno D. The insular lobe: physiopathological and surgical considerations. Neurosurgery. 2000;47:801–10.CrossRefPubMedGoogle Scholar
  31. 31.
    Rey-Dios R, Cohen-Gadol AA. Technical nuances for surgery of insular gliomas: lessons learned. Neurosurg Focus. 2013;34(2):E6.CrossRefPubMedGoogle Scholar
  32. 32.
    Carrabba G, Mandonnet E, Fava E, Capelle L, Gaini SM, Duffau H, et al. Transient inhibition of motor function induced by the cavitron ultrasonic surgical aspirator during brain mapping. Neurosurgery. 2008;63:E178–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Duffau H. Stimulation mapping of white matter tracts to study brain functional connectivity. Nat Rev Neurol. 2015;11:255–65.CrossRefPubMedGoogle Scholar
  34. 34.
    Neuloh G, Pechstein U, Schramm J. Motor tract monitoring during insular glioma surgery. J Neurosurg. 2007;106:582–92.CrossRefPubMedGoogle Scholar
  35. 35.
    Schucht P, Moritz-Gasser S, Herbet G, Raabe A, Duffau H. Subcortical electrostimulation to identify network subserving motor control. Hum Brain Mapp. 2013;34:3023–30.CrossRefPubMedGoogle Scholar
  36. 36.
    Moritz-Gasser S, Herbet G, Duffau H. Mapping the connectivity underlying multimodal (verbal and non-verbal) semantic processing: a brain electrostimulation study. Neuropsychologia. 2013;51:1814–22.CrossRefPubMedGoogle Scholar
  37. 37.
    Herbet G, Moritz-Gasser S, Duffau H. Direct evidence for the contributive role of the right inferior fronto-occipital fasciculus in non-verbal semantic cognition. Brain Struct Funct. 2017;222:1597–610.CrossRefPubMedGoogle Scholar
  38. 38.
    Martino J, Taillandier L, Moritz-Gasser S, Gatignol P, Duffau H. Re-operation is a safe and effective therapeutic strategy in recurrent WHO grade II gliomas within eloquent areas. Acta Neurochir. 2009;151:427–36.CrossRefPubMedGoogle Scholar
  39. 39.
    Schmidt MH, Berger MS, Lamborn KR, Aldape K, McDermott MW, Prados MD, et al. Repeated operations for infiltrative low-grade gliomas without intervening therapy. J Neurosurg. 2003;98:1165–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Ius T, Pauletto G, Cesselli D, Isola M, Turella L, Budai R, et al. Second surgery in insular low-grade gliomas. Biomed Res Int. 2015;2015:497610.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Duffau H. The huge plastic potential of adult brain and the role of connectomics: new insights provided by serial mappings in glioma surgery. Cortex. 2014;58:325–37.CrossRefPubMedGoogle Scholar
  42. 42.
    Eseonu CI, ReFaey K, Garcia O, Raghuraman G, Quinones-Hinojosa A. Volumetric analysis of extent of resection, survival, and surgical outcomes for insular gliomas. World Neurosurg. 2017;103:265–74.CrossRefPubMedGoogle Scholar
  43. 43.
    Wu AS, Witgert ME, Lang FF, Xiao L, Bekele BN, Meyers CA, et al. Neurocognitive function before and after surgery for insular gliomas. J Neurosurg. 2011;115:1115–25.CrossRefPubMedGoogle Scholar
  44. 44.
    Ius T, Pauletto G, Isola M, Gregoraci G, Budai R, Lettieri C, et al. Surgery for insular low-grade glioma: predictors of postoperative seizure outcome. J Neurosurg. 2014;120:12–23.CrossRefPubMedGoogle Scholar
  45. 45.
    Ghareeb F, Duffau H. Intractable epilepsy in paralimbic World Health Organization Grade II gliomas: should the hippocampus be resected when not invaded by the tumor? J Neurosurg. 2012;116:1226–34.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NeurosurgeryEnfant-Jésus Hospital, CHU de Québec, Laval UniversityQuébecCanada
  2. 2.Department of NeurosurgeryGui de Chauliac Hospital, Montpellier University Medical CenterMontpellierFrance
  3. 3.Team “Plasticity of Central Nervous System, Stem Cells and Glial Tumors,” National Institute for Health and Medical Research (INSERM), U1051 Laboratory, Institute for Neurosciences of MontpellierMontpellier University Medical CenterMontpellierFrance

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