Clinical Scorecard: Evaluation of Perforating Arteries Surrounding Amygdala Glioblastoma Prior to Surgery Utilizing Intra-Arterial CT Angiography and High-Resolution CT with MR Tractography: A Case Study

At a Glance

Key Highlights

• Glioblastomas in medial temporal region may involve perforating arteries from anterior choroidal and lenticulostriate arteries supplying the pyramidal tract.
• Ultra-high-resolution intra-arterial CT angiography (UHR-IA-CTA) combined with gadolinium-enhanced MRI and diffusion tensor imaging enables detailed visualization of tumor-vascular relationships.
• Accurate identification of PT-LSAs and PT-AchoAs allowed determination of feasibility for maximal safe tumor resection with preservation of critical motor pathways.

Guideline-Based Recommendations

Diagnosis

• Use gadolinium-enhanced T1-weighted MRI to identify tumor extent and enhancement patterns.
• Perform digital subtraction angiography (DSA) to assess tumor vascular supply and arterial anatomy.
• Employ ultra-high-resolution intra-arterial CT angiography (UHR-IA-CTA) fused with MR tractography to visualize small perforating arteries supplying the pyramidal tract.

Management

• Plan maximal safe resection based on detailed anatomical relationship between tumor and PT-supplying perforating arteries.
• Use intraoperative motor evoked potential monitoring to preserve motor function during tumor resection.
• Consider careful dissection along tumor borders when perforating arteries are displaced but not encased.

Monitoring & Follow-up

• Postoperative MRI to confirm extent of resection and identify ischemic complications.
• Neurological assessment focusing on motor and sensory function, including aphasia and visual field deficits.

Risks

• Potential ischemic injury to internal capsule and pyramidal tract from damage to perforating arteries.
• Postoperative neurological deficits such as hemianopsia and transient aphasia.

Patient & Prescribing Data

60-year-old male with left medial temporal glioblastoma presenting with sensory aphasia

Maximal safe resection was feasible after confirming tumor displacement but not encasement of PT-LSAs and PT-AchoAs; postoperative improvement in aphasia with minor visual field deficit noted.

Clinical Best Practices

• Integrate ultra-high-resolution intra-arterial CTA with MR tractography for preoperative vascular and tract mapping in medial temporal gliomas.
• Use fusion imaging techniques to delineate spatial relationships between tumor, perforating arteries, and pyramidal tract.
• Employ continuous intraoperative motor evoked potential monitoring to minimize motor pathway injury.
• Perform careful surgical dissection respecting the displacement of critical perforating arteries to maximize resection while preserving neurological function.

References

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