Fall 2009

Case Study: Awake Language Mapping Facilitates Radical Resection of Insular Glioma

AC, age 32, was an otherwise healthy young woman when a seizure sent her to the emergency room. Physicians there noticed not only disruptions in the woman's language, but also that there was a potential glioma on her CT scan. Though AC's symptoms quickly subsided, a subsequent MRI revealed a large, insular tumor deep beneath the frontal temporal lobe. AC's physicians referred her to Mitchel Berger, M.D., director of the UCSF Brain Tumor Center.

"Most surgeons do not feel comfortable operating within the insular region, and therefore usually refer patients to the UCSF Brain Tumor Center," says Berger, who over the last 25 years has done more surgeries of this kind than anyone else in the world.

The UCSF Brain Tumor Center is the busiest such center in the country. Last year, surgeons performed some 840 procedures, while the Neuro-oncology group saw 237 new outpatients and did about 2,300 follow-up visits. The center is also the lead center in the Adult Brain Tumor Consortium and one of three Pediatric Brain Tumor Foundation Institutes.

The first step in treating AC fell to the neuroradiologists at the center. After another MRI to pinpoint the glioma, they used magnetoencephalography with diffusion tensor imaging to identify motor pathways in the brain's insular areas.

"Neuroradiologists here take advantage of outstanding imaging capabilities to reveal not just anatomy, but also physiological functions you can't see with simpler methods," says Berger. "This makes my job a lot easier."

Mapping, Surgery and Collaborative Follow-up

Surgery began with the patient fully anesthetized, so Berger could perform a craniotomy. The surgical team then awoke AC to conduct awake brain mapping. Berger stimulated her brain with a current that transiently provokes sensory and motor function while interrupting language function, which permits precise mapping of the eloquent cortex. The patient was then returned to sleep for resection of the tumor.

"The surgical field is always reminiscent of a minefield because we are working between areas that are functional versus those that are not, as well as between arteries and veins that supply very important areas," says Berger. "Using functional mapping, we have to walk through this minefield very carefully, so as not to injure any of the arteries or veins or the functional tissue. To do this, we create microscopic corridors that enable us to remove the tumor in pieces. It's tedious work, with the goal to remove as much tumor as we safely can."

Berger's study detailing techniques for safely removing such gliomas will be published in January 2010 in the Journal of Neurosurgery.

Although AC had some word-finding difficulties shortly after surgery, they cleared up quickly. The team continued to monitor her closely for a few days, but there was no follow-up therapy, just careful monitoring. The reason was simple: Radical resection (>95 percent) of these low-grade gliomas has achieved 98 percent survival rates 10 years out.

"The extent of resection clearly affects outcome," says Berger.

Today, AC remains tumor-free and seizure-free. A partnership between her referring physician and the Neuro-oncology team at the Brain Tumor Center coordinates her follow-up care.

"Absent complications, we encourage patients to be managed in their community," says Berger.

For more information, contact the Brain Tumor Center at (415) 353–7500.

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