الفهرس 
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Abstract
Surgery of supratentorial LGGs remains a great challenge for neurosurgeons, because it usually affects young adults and its tendency to grow near eloquent areas of the brain; and usually those patients presents with minimal neurological manifestations. Hence, the traditional management of such cases was wait-and-see policy, or just biopsy to obtain histopathological specimen; and to receive adjuvant treatment.
The new WHO 2016 classification of brain tumours have changed the concept of considering diffuse LGG as a benign disease; because of its infilterative nature. The parameters of categorisation now depends on genetics, as well as histogenesis.
Recent observational studies revealed that on performing safe maximal resection of such lesions improved the PFS, the OS and QoL when compared to wait and see policy. Early aggressive management not only improved the life expectancy and quality of life; but also delayed malignant transformation of such cases.
The contemporary techniques in management of cerebral LGGs aims towards maximal safe resection. Preoperative advanced imaging is useful to localize eloquent areas and language areas, evaluate involvement of corticospinal tracts and to plan surgery for such cases. The use of awake craniotomies, electrophysiological monitoring, neuronavigation and ultrasound guided resection in such cases have improved the outcome of surgery. These techniques have showed significant improvement in the extent of resection, increase in OS rate, increase in PFS rate with improvement of QoL.
Between 2017 and 2018, 20 consecutive patients suffering from supratentorial LGGs underwent surgery to evaluate these contemporary techniques in performing safe maximal resection. The study took place in hospitals of Alexandria, Egypt.
from those 20 patients; 17 were males and 3 were females with mean age 36.45±10.38 years. 18 patients were right handed and 2 were left handed. All patients had standard neurological examination and the mean preoperative KPS was 76±5.98. All the 20 patients had standard MRI brain with contrast and MR spectroscopy; of these patients 16 had performed DTI, 14 performed fMRI and 2 performed perfusion MRI.
According to site of lesion; 10 cases were frontal, 6 parietal, 2 temporal and 2 insular. 13 cases were left and 7 were on the right side. 4 cases had preoperative vasogenic oedema.
The main presenting symptom was epilepsy, which was in 16 cases; headache in 4 cases; hemiparesis in 4 cases and dysphasia in 3 cases.
11 cases underwent awake craniotomies, 12 cases underwent electrophysiological monitoring (7 of them were in adjunction with awake surgeries), in 6 cases IOUS were used, 1 case with the use of neuronavigation; and conventional microsurgery was performed in 3 cases.
Intraoperative events occurred in 3 cases of awake craniotomies, 1 case of left insular glioma had speech deterioration which did not resolve in 5 minutes and resection was not completed, 1 case with intraoperative seizure and 1 case with left frontal glioma right lower limb monoparesis III occurred which led to discontinuing of resection. The mean operative time was 4.68±0.52.
In the immediate neurological evaluation, all cases were fully conscious; 11 cases had additional deficits, 5 cases with denovo hemiparesis, 1 case with denovo right lower limb monoparesis and 1 case with dysphasia; 4 cases with preoperative hemiparesis had mild deterioration in their motor weakness.
In the early neurological follow up period after 3 days; 5 cases only remained with motor deficit, 4 of them with preoperative weakness and 1 with the right lower limb monoparesis. The 5 cases showed improvement but did not recover completely.
Early follow up MRI brain with contrast was done in all cases, and GTR was achieved in 12 cases and STR was achieved in 8 cases.
Histopathological verifications of the studied cases revealed, 8 cases with fibrillary astrocytoma, 6 cases diffuse astrocytoma, 1 case of gangilioglioma. Unfortunately, 3 cases were found as HGG, were 2 cases with anaplastic astrocytoma III and 1 case with anaplastic oligodendroglioma.
The mean hospital stay was 8.45±2.06 days. 1 case had superficial wound infection which was successfully managed with dressings and antiobiotics, and 1 case with UTI.
6 cases received adjuvant therapy, the 3 cases of HGG and 3 cases of LGG because with immunohistochemistry staining KI 67 was > 5%. 2 cases were recommended for further follow up.
All cases had controlled seizures on late follow up, patient with right lower limb monoparesis recovered completely with physiotherapy.
Late follow up MRI brain with contrast revealed no recurrence in cases of GTR and stationary course in cases of STR.