Burr Hole Microsurgical Transsylvian Approach for Insular Gliomas

BACKGROUND AND OBJECTIVES: Resection of insular gliomas remains challenging because of their deep-seated location and proximity to eloquent neurovascular structures. Although the transsylvian approach through a standard pterional craniotomy is widely used, we present a minimally invasive alternative using a single burr hole technique. METHODS: A prospective analysis was performed on 6 patients who underwent burr hole surgery for insular gliomas using a technique termed burr hole microsurgery. RESULTS: In 6 patients, resection of insular tumors was performed using a 14-mm burr hole approach. A transsylvian corridor with preservation of the superficial middle cerebral veins was used in all cases. The most common clinical presentation was epileptic seizures, observed in 2 patients (33%). Tumors were predominantly located in the right hemisphere (83%, n = 5). Histopathological analysis revealed 3 isocitrate dehydrogenase (IDH)-wildtype glioblastomas (50%), one IDH-mutant World Health Organization grade III astrocytoma (17%), one ganglioglioma (17%), and one IDH-mutant diffuse World Health Organization grade II glioma (17%). Gross total resection (extension of resection >90%) was achieved in all patients (100%). One patient (17%) developed hemiplegia in the early postoperative period (24 hours). The mean preoperative tumor volume was 16.7 cm3 (range, 7.47-27.6 cm3), and the mean operative time was 101 minutes (range, 75-135 minutes). CONCLUSION: The Burr hole transsylvian approach achieves >90% extension of resection in insula gliomas and represents a viable surgical strategy, with preliminary results indicating an acceptable safety profile.