A Journey into the Complexity of Temporo-Insular Gliomas: Case Report and Literature Review

Abstract

Introduction: Temporo-insular gliomas, rare brain tumors originating from glial cells, comprise about 30% of brain tumors and vary in aggressiveness from grade I to IV. Despite advancements in neuroimaging and surgical techniques, their management remains complex due to their location near critical cognitive areas. Techniques like awake craniotomy have improved outcomes, but tumor heterogeneity and proximity to vital structures pose challenges. Radiotherapy and chemotherapy offer benefits post-surgery, though issues like resistance and side effects persist. This article discusses a case report and literature review to deepen understanding of temporo-insular gliomas, focusing on advanced diagnostic and treatment approaches.

Materials and methods: A systematic review was conducted using PubMed, Embase, and Google Scholar, covering studies from 2019 to July 2024. Keywords included 'brain tumor', 'neurosurgery', and 'treatment'. Articles on glioma diagnosis, management, and outcomes were selected, excluding non-English studies, irrelevant reports, non-glioma research, and inaccessible texts.

Results: From 156 studies, 11 met inclusion criteria, highlighting advanced diagnostics, surgical strategies, and adjunct therapies for temporo-insular gliomas (TIGs). Gross total resection (GTR) was achieved in 39% of cases. Awake craniotomy enhanced functional outcomes, while temozolomide and radiotherapy improved survival. Challenges included ischemic complications and treatment resistance. Two patient cases underscored the complexity of TIG management and the importance of individualized approaches, achieving satisfactory resection with minimal deficits.

Conclusions: Temporo-insular gliomas (TIGs) necessitate a multidisciplinary strategy that integrates advanced imaging, meticulous surgical methods, and cutting-edge adjuvant therapies. Despite progress with techniques like awake craniotomy and the use of temozolomide improving patient outcomes, significant challenges persist in maintaining functional integrity and addressing treatment resistance. Ongoing research into targeted therapies, immunotherapies, and innovative technologies remains critical to advancing patient care and improving long-term prognosis.

Keywords: glioma; temporo-insular.

Figure 1

(A,B) (Axial views): Preoperative MRI scans depict a sizable temporo-insular lesion. The lesion exhibits hypointensity on T1-weighted sequences (A) and shows a ring-enhancing pattern on contrast-weighted sequences (B). A pronounced mass effect with a midline shift is also evident. (C) (Sagittal view): The lesion’s extent into the insular and temporal regions is clearly visualized, providing insight into its spatial involvement and proximity to critical structures. (D,E) (Postoperative axial and coronal views): Post-surgical imaging confirms gross total resection of the lesion. The images demonstrate resolution of the mass effect and midline shift, with preserved integrity of the surrounding brain tissue, emphasizing the surgical precision achieved.

Figure 2

(A) (Axial view): Preoperative MRI depicts a heterogeneously enhancing mass in the left temporo-insular region. The mass appears hypo-intense on T1-weighted sequences, with displacement of adjacent brain structures. (B) (Coronal view): The mass significantly involves the insular cortex and superior temporal gyrus, exerting a mild mass effect. (C) (Axial view): Further delineation reveals irregular tumor borders and peritumoral edema, with compression of the left lateral ventricle. (D–F) (Postoperative axial, coronal, and axial views): Post-surgical imaging demonstrates successful tumor resection. The images show resolution of the midline shift and a substantial reduction in mass effect, with no evidence of residual tumor. Preservation of surrounding brain structures is also evident.

Figure 3

Results of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram illustrating the study selection process for the literature review on temporo-insular gliomas.

Figure 4

Dissection of white fibers where the insular lobe (Blue arrow) can be seen (A). (B) The Arcuate Fasciculus (Blue arrow) is the part of the Superior Longitudinal Fasciculus that extends around the insula to connect the areas of language in the inferior frontal gyrus (Broca) and the superior temporal gyrus (Wernicke).

Figure 5

Axial section showing the relationship of the insular lobe (Blue arrow), temporal lobe, and vascular elements within Silvio’s valley (Yellow arrow).