What question did this study set out to answer?

This study aims to evaluate the safety and effectiveness of the transcortical approach for resection of insular gliomas, focusing on surgical and functional outcomes.

May 11, 2026

Maximum safe resection of insular gliomas: update on surgical outcomes from 500 cases

Key Points

This study aims to evaluate the safety and effectiveness of the transcortical approach for resection of insular gliomas, focusing on surgical and functional outcomes.
Retrospective analysis of 502 low-grade and high-grade insular gliomas in 394 patients from September 1997 to December 2022.
Tumors classified by Berger-Sanai zone; MRI segmentation used to assess extent of resection (EOR).
Outcomes analyzed for morbidity, progression-free survival, and overall survival using Kaplan-Meier and Cox regression analyses.
Grade 2 gliomas were significantly larger than grade 4 IDH-wildtype gliomas (43 cm3 vs 17.5 cm3, p < 0.001).
Permanent motor and language deficits were observed in < 4% of newly diagnosed grade 2 tumors, with transient deficits in 9.5% and 20% respectively.
EOR > 88.6% correlated with improved progression-free and overall survival for newly diagnosed IDH-wildtype glioblastoma.

Abstract

OBJECTIVE: Insular gliomas present a unique surgical challenge due to their location near critical vascular structures and proximity to functional brain regions. While different surgical approaches to insular tumors exist, language and motor stimulation mapping are critical for a transcortical approach. The aim of this study was to determine if the transcortical approach to resection of insular gliomas remains a safe and effective strategy by assessing tumor characteristics, surgical outcomes, and postoperative functional outcomes in patients with newly diagnosed or recurrent tumors. METHODS: This retrospective analysis included 502 newly diagnosed and recurrent low-grade gliomas (LGGs) and high-grade gliomas (HGGs) of the insula (in 394 unique patients) resected between September 1997 and December 2022 at a single center. Tumors were classified based on the Berger-Sanai zone schema, and contrast-enhancing and non-contrast-enhancing tumor volumes were manually segmented on MRI and used to calculate the extent of resection (EOR). Patient morbidity was assessed at multiple time points from the initial presentation to at least 6 months of follow-up. Progression-free survival (PFS) and overall survival (OS) were compared between subgroups using unadjusted and propensity score-adjusted Kaplan-Meir and Cox regression analyses. RESULTS: Overall, 316 (165 LGG, 151 HGG) newly diagnosed and 186 (69 LGG, 117 HGG) recurrent cases were included. Grade 2 gliomas were typically larger than grade 4 IDH-wildtype gliomas (43 cm3 vs 17.5 cm3, p 88.6% was associated with improved PFS and OS for patients with newly diagnosed IDH-wildtype glioblastoma. Overall, surgical and medical complications occurred in < 3% of cases. Finally, new permanent arm or leg weakness was significantly associated with worse OS in multivariable analyses (HR 2.06, 95% CI 1.14-3.74; p = 0.017). CONCLUSIONS: Maximum safe resection using a transcortical approach and cortical and subcortical mapping continues to be a robust surgical strategy with low surgical morbidity for patients with newly diagnosed and recurrent insular gliomas.

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