LAUSR

BACKGROUND Perioperative cerebral infarction is a potential complication of glioma resection, of which insular tumors are at higher risk due to the proximity of middle cerebral artery branches, including the lateral lenticulostriates and long insular arteries. In the present report, three patients obtained three-dimensional rotational angiography, which was fused with magnetic resonance imaging (MRI) for frameless stereotactic navigation during dominant-hemisphere insular glioma resection. METHODS All patients obtained a preoperative catheter angiogram with a three-dimensional rotational acquisition of the ipsilateral internal carotid artery. The pixel-based axial three-dimensional angiography data, thin-cut structural MRI, tractography from diffusion tensor imaging, and expressive language activation from functional MRI were uploaded into the iPlan software (BrainLAB, Heimstetten, Germany) and fused. The target tumor, regional blood vessels, adjacent functional areas and their associated fiber tracts were segmented and overlaid on the appropriate MRI sequence. This image fusion was used preoperatively to visualize the relationship of the mass with the adjacent vasculature and intraoperatively for frameless stereotactic navigation to optimize preservation of arterial structures. RESULTS Three patients aged 27 to 60 years with excellent baseline functional status presented with seizures and were found to have a large dominant-hemisphere T2 hyperintense, non-enhancing insular mass. Surgical resection was performed using multimodality neuronavigation. None sustained a postoperative arterial infarction or a perioperative neurologic deficit. CONCLUSION Neuronavigation using a fusion of three-dimensional rotational angiography with MRI is a technique that can be employed for preoperative planning and during resection of insular gliomas to optimize preservation of adjacent arteries.