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Gliomas of the Cingulate Gyrus: Surgical Management and Functional Outcome

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Neurosurg Focus 27 (2):E9, 2009 Gliomas of the cingulate gyrus: surgical management and functional outcome MAREC VON LEHE , M.D., AN D JOHANNES SCHRA mm , M.D. Neurochirurgische Klinik, Universitätsklinik Bonn, Germany Object. In this paper, the authors’ goal was to summarize their experience with the surgical treatment of gliomas arising from the cingulate gyrus. Methods. The authors analyzed preoperative data, surgical strategies, complications, and functional outcome in a series of 34 patients (mean age 42 years, range 12–69 years; 14 females) who underwent 38 operations between May 2001 and November 2008. Results. In 7 cases (18%) the tumor was located in the posterior (parietal) part of the cingulate gyrus, and in 31 (82%) the tumor was in the anterior (frontal) part. In 10 cases (26%) the glioma was solely located in the cingulate gyrus, and in 28 cases (74%) the tumor extended to the supracingular frontal/parietal cortex. Most cases (23 [61%]) had seizures as the presenting symptom, 8 patients (24%) suffered from a hemiparesis/hemihypesthesia, and 4 pa- tients (12%) had aphasic symptoms. The authors chose an interhemispheric approach for tumor resection in 11 (29%) and a transcortical approach in 27 (71%) cases; intraoperative electrophysiological monitoring was applied in 23 (61%) and neuronavigation in 15 (39%) cases. A > 90% resection was achieved in 32 (84%) and > 70% in another 5 (13%) cases. Tumors were classified as low-grade gliomas in 11 cases (29%). A glioblastoma multiforme (WHO Grade IV, 10 cases [26%]) and oligoastrocytoma (WHO Grade III, 9 cases [24%]) were the most frequent histopathological results. Postoperatively, patients in 13 cases suffered from a transient supplementary motor area syndrome (34%), all of whom had tumors in the anterior cingulate gyrus. In the early postoperative period (30 days) a new deficit occurred in 5 cases (13%, mild motor deficits or aphasic symptoms). One patient had a major bleeding episode 2 days after surgery and was in a persistent vegetative state. Conclusions. Gliomas arising from the cingulate gyrus are rare. A gross-total resection is often possible and acceptably safe; intraoperative monitoring and neuronavigation are helpful adjuncts. In case of resection of gliomas arising from the anterior cingulate gyrus a supplementary motor area syndrome has to be considered, particularly when the tumor extends to the supracingular cortex. (DOI: 10.3171/2009.6.FOCUS09104) KEY WOR D S • cingulate gyrus • glioma • outcome HE cingulate gyrus surrounds the corpus callosum ropsychological findings,2,21 functional and diffusion ten- in a belt-shaped manner at the mesial aspect of the sor imaging,1,10 lesion studies,3,11 and electrophysiological cerebral hemispheres. It is divided into anterior stimulation studies with implanted electrodes.5,18,22 For T(frontal lobe) and posterior (parietal lobe) portions in the an excellent review of data regarding the complex func- area of the central sulcus. The rostral part surrounds the tional role of the cingulate gyrus and the surrounding genu of the corpus callosum and ends in the subcallosal structures of the frontal lobe, see Rushworth et al.15 cortex; it continues posteriorly around the splenium of the The literature concerning surgical intervention in the corpus callosum to become the parahippocampal gyrus at cingulate gyrus mostly comprises data about functional the level of the cingulate isthmus. The adjacent areas of (stereotactic) neurosurgery for intractable pain,25 depres- the hemisphere comprise the mesial and hemispheric sur- sion,19 or compulsive disorders.14 Additionally, there are face of F1 with the SMA, the paracentral lobule, and the a few small series or case reports about focal epilepsy precuneus in the parietal lobe (we summarized the areas arising from neoplastic and other lesions of the cingu- adjacent to the cingulate gyrus at the interhemispheric late gyrus and surgical treatment for seizure control.8,12,26 surface as “supracingular”). The largest series so far for surgical management of tu- Functionally, the cingulate gyrus is part of the limbic mors arising from the cingulate gyrus was presented by system with extensive connectivity to different anatomi- Yaşargil et al. in 1996.24 A recent study summarized data cal and functional areas. In the last decade many studies in patients with intermediate gliomas (WHO Grades II were published concerning the cingulate area and neu- and III) arising from the anterior cingulate gyrus.20 Tak- en together, little is known about functional outcome af- Abbreviations used in this paper: F1 = superior frontal gyrus; ter resection in this circumscribed area. In this study we GBM = glioblastoma multiforme; GTR = gross-total resection; report on a homogeneous group of patients, examine the KPS = Karnofsky Performance Scale; SMA = supplementary motor risks of tumor removal, and balance different factors for area. postoperative deficits. Neurosurg Focus / Volume 27 / August 2009 1 Unauthenticated | Downloaded 09/28/21 06:51 AM UTC M. von Lehe and J. Schramm TABLE 1: Presenting symptoms according to site and extent of the glioma and tumor grade* No. of Patients (%) Sporadic Refractory KPS Score Seizures Epilepsy HP Aphasia <80 Site & Type Overall Total (17 cases) (6 cases) (6 cases) (4 cases) (6 cases) anterior cingulate gyrus 31 (81.6) pure 7 (22.6) 4 1 0 0 0 ext supracingular 24 (77.4) 11 4 4 3 5 posterior cingulate gyrus 7 (18.4) pure 3 (42.9) 1 1 1 ext supracingular† 4 (57.1) 1 1 1 1 tumor grade (WHO) LGG 11 (28.9) 4 6 0 1 0 HGG 27 (71.1) 13 0 6 3 6 * ext = extended; HGG = high-grade glioma (WHO Grades III and IV); HP = hemiparesis; LGG= low-grade glioma (WHO Grades I and II). † One patient had temporomesial infiltration. Methods Radiological and Histopathological Data Patients and Clinical Data All patients underwent at least 1 MR imaging study preoperatively for evaluation of tumor location and infil- Between May 2001 and November 2008, we oper- tration in surrounding areas. The degree of resection was ated on 996 patients for supratentorial glial tumors in the measured according to postoperative CT/MR imaging in Department of Neurosurgery at the University of Bonn 26 cases and according to the surgeons’ impressions in (1072 resections total). The data of 38 consecutive opera- 12 cases. All histopathological diagnoses were made at tions (3.5% of all resections) in 34 patients harboring a the Department of Neuropathology/German Brain Tumor glioma arising from the cingulate gyrus were identified Reference Center at the University of Bonn based on the by a review of patients’ charts, surgery reports, and MR WHO criteria.6 imaging. The mean age of the included patients was 42 years (range 12–69 years); 14 (41%) were female. Right- Statistical Analysis sided resections were performed in 12 cases (32%). We excluded patients with tumors primarily arising from F1 Dichotomous discrete variables were analyzed using and reaching the roof of the lateral ventricle and the su- the chi-square test or Fisher exact test. A probability level pracingular aspect of the frontal lobe. of 0.05 was accepted for the indication of statistical sig- Preoperative and postoperative data were collected nificance in double-sided testing. Commercially available through a chart review and analyzed using a computer- software was used for statistical analysis (version 17.0, ized data bank. We included the age of the patients, pre- SPSS, Inc.). senting signs and symptoms, site of resection, postopera- Results tive deficits, local and systemic complications, pre- and postoperative KPS scores (10–100), and changes in KPS Clinical Data score after surgery until discharge or during the 30-day The common presenting symptoms were seizures (23 postoperative period. cases [61%]; Table 1). In addition to 6 cases (16%) with long-lasting refractory epilepsy, we found 17 cases (45%) Surgical Management in which the patients had a recent onset of seizures; in 1 We routinely recommended a tumor resection for sus- patient the seizures were combined with dysphasic symp- pected gliomas if a complete resection was possible or at toms. In 6 cases (16%) the patients had a hemiparesis, and least a meaningful cytoreduction seemed feasible (defined in 3 cases the patients had left-sided gliomas combined as > 70%). As in a recent study we defined tumor resections with dysphasic symptoms (overall 4 cases of patients with as > 90% (no or only minimal residual tumor), 90–70%, dysphasia [11%]). Patients in 2 cases (5%) presented with a and partial.17 Operative details comprised side and extent hemihypesthesia (tumor located in the posterior cingulate of surgery (pure cingulate resection or extending to adja- gyrus). In most patients it took a few days (up to 1 month) cent regions) and the approach to the tumor. In case of in- from the first presenting symptoms until CT/MR imag- volvement of the central area or the motor tract we routine- ing. In cases of refractory epilepsy the mean duration was ly used electrophysiological monitoring (continuous motor 12 years (range 3–28 years). The tumor was found inci- and somatosensory evoked potential recording and phase dentally in 3 patients (MR imaging for chronic earache/ reversal); in some cases neuronavigation was applied. deafness, after a minor trauma, or migraine, respectively). 2 Neurosurg Focus / Volume 27 / August 2009 Unauthenticated | Downloaded 09/28/21 06:51 AM UTC Gliomas of the cingulate gyrus Fig. 1. Contrast-enhanced sagittal T1-weighted (A) and coronal FLAIR (B) MR images obtained preoperatively. Contrast- enhanced T1-weighted (C) and coronal FLAIR (D) MR images obtained postoperatively. These images show an oligoastrocy- toma (WHO Grade III) in the left anterior cingulate gyrus with a large cyst and frontomesial and insular infiltration. This patient presented with hemiparesis and aphasia. One patient had acute bleeding of a GBM in the anterior of the cingulate gyrus (31 cases [82%]), and in 7 cases cingulate gyrus with occlusion of the ipsilateral Monro (18%) the tumor was solely located in the anterior cingu- foramen and progressive loss of consciousness.
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