Standard craniotomy under general anesthesia with bridging vein-guided tailored transcortical resection for medial frontal glioma involving the cingulate gyrus: A case report.

内容摘要

Gliomas of the medial frontal lobe extending into the gyrus cinguli represent a challenging neurosurgical entity because of their deep location, complex vascular anatomy, and proximity to functionally significant cortical and subcortical structures. Awake craniotomy with functional mapping, diffusion tensor imaging (DTI)-based planning, neuronavigation, and cortical/subcortical stimulation represents an important contemporary strategy for maximal safe glioma resection, particularly for tumors located within or near eloquent networks. However, in carefully selected cases, standard microsurgical craniotomy under general anesthesia may remain a valuable option when detailed anatomical and venous assessment identifies a safe operative corridor. Dense frontal bridging veins draining into the superior sagittal sinus may limit standard interhemispheric approaches and influence the selection of an alternative transcortical route. We report the case of a 31-year-old right-handed woman presenting with progressive headache, seizures, and urinary incontinence. Preoperative magnetic resonance imaging revealed a large intra-axial tumor of the right medial frontal lobe with extension toward the anterior cingulate gyrus and partial involvement of the corpus callosum. Neuropsychological assessment demonstrated moderate frontal-subcortical cognitive impairment. Preoperative venous imaging identified multiple frontal bridging veins draining into the superior sagittal sinus, which made the interhemispheric surgical corridor potentially unsafe. A tailored transcortical approach through the superior frontal gyrus was therefore selected. The procedure was performed under general anesthesia without awake mapping, DTI-based tractography, neuronavigation, or intraoperative cortical/subcortical stimulation. Tumor resection was performed using a three-trajectory strategy with early identification of the pericallosal-callosomarginal arterial complex according to the vessel-first principle, while minimizing brain retraction and preserving bridging veins. The component of the tumor tightly adherent to the cingulate cortex was intentionally left to preserve functionally significant structures. Near-total resection was achieved without new permanent neurological deficits, and postoperative neuropsychological changes were transient with subsequent recovery. This case does not propose an alternative to awake mapping or modern functional adjuncts in glioma surgery. Rather, it illustrates that standard microsurgical craniotomy under general anesthesia may retain clinical value in carefully selected medial frontal gliomas involving the cingulate gyrus, particularly when bridging venous anatomy makes an interhemispheric corridor potentially unsafe. Careful anatomical planning, preservation of bridging veins, early arterial identification, minimization of brain retraction, and function-oriented resection may allow safe tumor removal in selected cases.