Vascular Complications in Glioma Surgery: insights from a Case-Based Analysis

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This study presents a comprehensive case-based analysis of vascular injuries encountered during glioma surgery, focusing on their mechanisms, clinical impact, and preventive strategies. Methods We retrospectively reviewed intraoperative videos, surgical reports and charts of patients undergoing brain glioma surgery. Results We identified 4 possible scenarios: damage to capillaries arising from parent vessels; damage to “en passage” vessels; damage to large caliber vessels; damage to perforators. Conclusions Understanding the complex vascular anatomy surrounding gliomas, integrating advanced preoperative imaging, and adopting meticulous microsurgical techniques are essential to minimize ischemic morbidity. Ultimately, sound intraoperative judgment—prioritizing vascular preservation over radicality when planes are unfavorable—remains critical for optimizing functional outcomes. Glioma vessels perforators vascular damage Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Despite significant advancements in adjuvant therapies—including radiotherapy, chemotherapy, gene therapy, and immunotherapy—surgical resection remains the cornerstone of treatment for brain gliomas. The extent of tumor removal is a critical determinant of patient survival, often correlating with prolonged remission or improved disease control when integrated with multimodal treatment strategies[ 20 , 23 , 24 ]. High-grade gliomas (HGG), particularly glioblastomas, continue to carry a poor prognosis, with a two-year survival rate of approximately 26.5%. In contrast, patients with low-grade gliomas (LGG) demonstrate five-year survival rates between 58% and 72%[ 17 , 18 , 26 ]. In LGG, a more extensive resection has been shown to reduce malignant transformation and improve survival outcomes. Although prognosis for HGG remains unfavorable, recent evidence indicates that maximal safe resection can significantly enhance both overall survival and progression-free intervals[ 7 ]. Traditional glioma surgery, which focused on debulking rather than complete removal, inherently carried lower vascular risk. However, as the concept of “maximal safe resection” became established, surgeons began to work closer to eloquent regions, particularly in perisylvian, perirolandic, and insular territories. Modern techniques such as awake mapping, neuronavigation, intraoperative MRI, and real-time neurophysiological monitoring have substantially increased the achievable extent of resection. Yet, paradoxically, these advances also expose the surgeon to greater proximity to critical arteries and veins, raising the potential for ischemic events. The occurrence of vascular complications in glioma surgery reflects the delicate balance between oncological radicality and functional preservation. With modern surgical paradigms shifting toward maximal and even supramaximal resection, understanding the complex vascular anatomy surrounding gliomas has become increasingly crucial. Moreover, recent literature has highlighted that postoperative ischemic lesions are much more common than previously believed, especially when evaluated through DWI and ADC sequences[ 1 , 9 ]. This paper presents a comprehensive case-based analysis of vascular complications encountered during glioma surgery. Through the detection of DWI signal changes on postoperative MRI, we aimed to elucidate the mechanisms underlying arterial and venous injuries and outline technical strategies to prevent them. Materials and Methods A prospectively maintained database of adult patients (≥ 18 years) who underwent surgery for eloquent-area gliomas performed by the senior author (G.S.) between December 2020 and December 2025 was retrospectively analyzed to investigate the occurrence of diffusion-weighted imaging (DWI) signal changes on immediate postoperative MRI. The database is being examined with two primary objectives. First, an ongoing study aims to evaluate the correlation between postoperative DWI alterations and both short- and long-term neurological outcomes, assessing their predictive value. The second objective—representing the focus of the present study—is to analyze the intraoperative mechanisms underlying the development of postoperative DWI abnormalities. Inclusion criteria were as follow: Tumors infiltrating or adjacent to eloquent regions, specifically dominant perisylvian cortex (frontal and temporal opercula, supramarginal gyrus, angular gyrus); dominant middle and posterior temporal regions; selected nondominant temporal areas (mesial temporal region or corticospinal tract involvement); insula; sensory-motor cortex. Additional inclusion criteria required complete pre- and postoperative clinical and radiological data; availability of intraoperative videos and surgical reports; histopathological diagnosis classified according to the 2016 and 2021 WHO criteria[ 12 , 13 ]. Functional mapping and monitoring were performed in all cases (awake or asleep), individualized according to patient and tumor characteristics. Cortical and subcortical mapping included: Bipolar stimulation (250 Hz monophasic for motor mapping; 60 Hz biphasic for cognitive mapping); Monopolar stimulation for corticospinal tract localization (1 mA ≈ 1 mm distance rule); Continuous neurophysiological monitoring (EMG, EEG, ECoG, SSEPs, MEPs). Intraoperative language testing was conducted by a neuropsychologist in awake procedures. Early postoperative MRI included T1-weighted, T2-weighted, FLAIR, DWI, and post-contrast T1 sequences. Restricted diffusion was defined as hyperintensity on B1000 sequences; corresponding ADC reduction (rADC < 0.7 × 10⁻³ mm²/s compared with the contralateral hemisphere). These findings were considered consistent with cytotoxic edema due to acute ischemia, after exclusion of blood products. Diffusion abnormalities were classified into three patterns: Rim-shaped, Sector-shaped and Perforator-shaped (Fig. 1 ). Sector-shaped lesions were further subdivided into lesions having a clear vascular territory configuration (Fig. 1 C) or a more vague wedge-like configuration which is not always attributable to a specific vessel damage (Fig. 1 B). Rim-shaped alterations were only considered if they measured more then 3 mm in thickness. Since these images are difficult to correlate with specific arterial or venous injury, our analysis focused primarily on sector and perforator-shaped lesions through detailed review of surgical videos and intraoperative reports to determine the most likely underlying mechanisms. Data collection was approved by local IRB. Results A total of 136 patients met the inclusion criteria. Postoperative DWI demonstrated no diffusion abnormality in 94 patients (69.1%). In the 42 patients with postoperative DWI alterations, rim-shaped were present in 10 patients (7.3%) whereas sector- or perforator-shaped alterations in 32 patients (23.5%). Among sector-shaped lesions, wedge-like were present in 11 patients (10/ 32, 34.3%) whereas lesions resembling a frank vascular territory were present in 9 patients (28,1%). Perforators-shaped were recorded in 12 patients (37.5%). All these lesions patterns (sector-shaped and perforators-shaped) were predominantly observed in temporal and insular tumors (28/32 cases, 87.5%). Notably, perforator-shaped lesions were especially prevalent in insular tumors (8/12 cases, 66.6%). Further analyses regarding clinical findings, neurophysiological data, and long-term outcomes are part of an ongoing study and are beyond the scope of the present work. Review of operative videos and surgical reports indicated that an intraoperative clear vascular mechanism was detected for all vascular-like and perforator-shaped lesions and for part of the wedge-like lesions (4/11, 36.3%). In fact for these latter lesions it is sometimes difficult to recognize a direct lesion onto an arterial or venous structure (see discussion below). Based on these intraoperative evidences, we divided vascular mechanisms into four main groups (see below): 1. damage to “en passage” vessels; 2. damage to large caliber vessels; 3. damage to capillaries arising from parent vessels; 4. damage to perforators. Discussion Vascular injuries during glioma surgery can be broadly categorized into arterial and venous types. Both can result in serious and sometimes catastrophic postoperative outcomes, although their clinical manifestations differ considerably. Injuries are often related to direct mechanical trauma, coagulation near the vessel wall, or traction leading to intimal tearing and subsequent thrombosis. Even without gross rupture, thermal or mechanical endothelial damage can provoke vasospasm or delayed occlusion, producing ischemic lesions hours after an apparently uneventful surgery. Thermal damage has to be regarded with great attention since the excessive use of bipolar cautery can provoke tissue lesions around the tumor cavity. The severity of this thermal injury could explain the difference between a rim-shaped lesion from a wedge-shaped one. Arterial damage typically leads to well-defined ischemic territories, following the vascular distribution of the affected artery. These infarctions are, most of the time, predictable in both extension and symptomatology. Conversely, venous injuries can result in far more unpredictable effects—ranging from minor, clinically silent edema to extensive hemispheric infarction. Due to their low-pressure system and thinner walls, veins are easily collapsed, thrombosed, or torn. Even slight compression by surgical retraction or coagulated debris can interrupt venous outflow, resulting in venous infarction and edema, often with delayed onset and variable clinical presentation. The severity of neurological deficits depends on multiple factors, including the size and location of the vessel, the eloquence of the affected brain area, and the availability of collateral circulation. For instance, the accidental occlusion of a small perforator supplying the internal capsule can have devastating consequences, while interruption of a non-dominant frontopolar terminal artery may have minimal impact. Similarly, the occlusion of large anastomotic veins, such as perirolandic or perisylvian veins, can lead to massive venous infarction. As a general rule, vessels supplying or draining brain tissue that is to be removed—for example, within the tumor mass—can be sacrificed safely. This is particularly true in high-grade gliomas, where “red veins” often appear on the tumor surface. These pathological veins show reversed or mixed flow patterns due to arteriovenous shunts within the tumor core and can be safely coagulated[ 15 ]. By contrast, “en passage” vessels—those that course through or along the tumor without supplying it—represent a major surgical challenge. Their preservation is critical, as they feed or drain otherwise healthy brain regions. Another key distinction exists between LGG and GBM in their relationship to vasculature. Low-grade gliomas usually respect the pial plane, preserving the integrity of vascular walls. In such cases, the subpial dissection technique allows surgeons to preserve vessels safely[ 16 ]. Conversely, glioblastomas often destroy the pial layer and infiltrate vessel walls, particularly arteries, making separation hazardous or impossible[ 25 ]. The advent of diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) mapping has profoundly improved our understanding of postoperative ischemic complications. Unlike conventional CT, which reveals infarction only several hours after onset, DWI can detect ischemic changes within minutes. This allows early differentiation between ischemic and hemorrhagic damage, aiding in postoperative evaluation. Several recent studies, using DWI-based methods, have demonstrated that postoperative ischemic lesions are significantly more common than previously recognized[ 2 , 4 , 21 ]. Although these techniques provide early detection, they cannot always clarify whether ischemia is arterial, venous, or secondary to retraction unless the lesion follows a distinct vascular territory pattern especially when a rim-shaped or a wedge-shaped lesion are implicated. 1. Damage to “en passage” vessels A frequent and challenging situation involves arteries or veins passing through or adjacent to the tumor that are mistakenly judged expendable. This typically occurs during lobectomies (such as anterior temporal or frontal lobectomy) or supratotal resections. These “en passage” vessels are often encountered in perisylvian, perirolandic, or parieto-temporo-occipital gliomas. Although their superficial position makes them accessible for direct control and subpial dissection, closure of any artery in these areas—especially in the dominant hemisphere—should be avoided. Occasionally, an “en passage” artery—such as a branch of the posterior cerebral artery—is discovered only late during resection, once the tumor core has been removed (Fig. 2 ). In those large volume tumors with deep operative fields, the risk of inadvertent vessel closure is high especially if the vessel is heavily stretched and encased by the tumor. When infiltration of the arterial wall is evident and safe separation impossible, partial tumor residue should be intentionally left to preserve vascular integrity and function. Reoperations pose additional risks, as scarring may tether arteries to dura or arachnoid, increasing the likelihood of tearing during exposure. In such cases, delicate dural opening or leaving small pieces of dura on the cortex if it does not detach, can prevent major complications. In Fig. 3 we show such a case of a left temporal glioma that relapsed 6 years later. During the opening of the dura, there was a tearing at the level of a posterior temporal artery. Due to the dominant location, an attempt to suture the hole was successfully done. 2. Damage to large caliber vessels Direct injury to large-caliber arteries (i.e. M2) is relatively uncommon, primarily thanks to the protective role of the pial and arachnoidal layers and the use of the subpial dissection technique. However, in certain contexts—particularly in high-grade gliomas—the situation can be far more complex. Glioblastomas and other aggressive gliomas often breach the leptomeningeal boundaries, infiltrating or tightly encasing major arteries and veins. In some cases (i.e. fronto-temporo-insular gliomas) if the tumor is soft and the interface between the neoplasm and vascular tissue remains discernible, it is possible to perform a complete resection while preserving arterial integrity. However, when the tumor exhibits a firm, fibrotic or calcified consistency and adheres intimately to the vessel wall, attempts to achieve total resection can easily lead to vascular rupture or thrombosis (Fig. 4 ). In these instances, intraoperative judgment is crucial. If blunt dissection fails to identify a safe plane between the artery and tumor, the surgeon should opt for leaving a minimal tumor residue rather than risking arterial damage. This approach is particularly valid when the vessel wall appears discolored, infiltrated, or stiffened—signs suggesting tumor invasion. Unfortunately, such invasion is often not predictable from preoperative imaging, even with advanced MRI techniques, and must be assessed intraoperatively. The management of large-caliber veins presents additional challenges. While high-grade gliomas frequently produce abnormal, pathologic veins—often referred to as “tumor veins”—that can be safely sacrificed due to their aberrant drainage patterns, the scenario is quite different in low-grade gliomas where preserving venous drainage is paramount, especially in eloquent or functionally critical areas. During dissection, every effort should be made to preserve large cortical and bridging veins, even if this means leaving small tumor remnants attached to them (Fig. 5 ). When veins appear to collapse toward the resection cavity at the end of tumor removal, it is advisable to support them with hemostatic materials, such as small Gelfoam fragments, to prevent kinking or compression within the cavity. 3. Damage to Capillaries Arising from Parent Vessels Small capillaries branching from major arteries can sometimes inadvertently torn while detaching infiltrated cortex. These capillaries frequently supply the cortical areas infiltrated by the tumor and must be carefully recognized under high magnification. The safest technique involves gentle coagulation and division of these capillaries at a distance from their origin on the parent vessel. This situation is particularly common in gliomas of the medial frontal and parietal lobes (Fig. 6 )—where the pericallosal or calloso-marginal arteries give rise to cortical branches—or in insular gliomas, where capillaries arise from M3 branches of the middle cerebral artery. Large-volume tumors may stretch and thin the vessels, increasing the risk of tearing. When a capillary is torn at its origin, hemostasis should first be attempted using gentle compression with hemostatic agents (e.g., Gelfoam). If bleeding persists, low-intensity bipolar coagulation using fine tips (approximately 0.2 mm) can be employed to mold and seal the defect without compromising the parent vessel. To prevent such injuries, surgeons should carefully analyze preoperative angiographic sequences and integrate vascular data into neuronavigation systems. Early identification of the vessel course allows for preemptive planning and reduces the risk of unexpected tearing. 4. Damage to perforators The management of perforating arteries is among the most technically demanding aspects of glioma surgery, particularly in operations involving the insula and basal ganglia. During surgery of insular tumors, perforators may be encountered at different levels: at their cisternal origin (e.g., from the M1 segment of the MCA); within the anterior perforated substance or deep inside the basal ganglia or striatum; at the level of of M3 where typical long insular arteries (LIA) arise. At the cisternal level, these vessels can typically be preserved by maintaining meticulous respect for the arachnoid planes (Fig. 7 A). Several authors have emphasized the importance of identifying the lateral perforators of the MCA during insular glioma surgery, as these vessels define a virtual deep resection limit, serving as a natural anatomical boundary[ 10 , 11 ]. However, the situation becomes far more challenging when dealing with perforators embedded within the parenchyma. These intraparenchymal perforators are extremely delicate (Fig. 7 B); even minimal manipulation can lead to tearing or vasospasm. Consequently, surgeons should avoid exposing these vessels directly and should instead halt the resection once they reach the characteristic texture or color of the striatal tissue. Often, the appearance of tiny venous bleedings signals proximity to the lenticulostriate zone, serving as a warning to stop. Preoperative imaging, particularly high-resolution T2-weighted MRI, can provide valuable insights into the extent of vascular encasement and the degree of perforator involvement. By carefully reviewing these sequences, surgeons can anticipate the safe depth of resection and tailor their surgical trajectory accordingly. The long insular arteries (LIA) represent a particularly challenging subset. Small M2 branches supply the insular cortex, claustrum, and external capsule. About 80–90% of insular arteries are short, serving the insular cortex and extreme capsule. Roughly 10% are medium-length, supplying the claustrum and external capsule, while only 3–5% are long, extending to the corona radiata—mainly in the posterior insula[ 5 , 6 , 8 , 10 , 22 ]. These fine vessels are seldom visible on preoperative angiography due to cortical swelling caused by the infiltrating tumor. Once identified intraoperatively, they are extremely difficult to preserve, as they typically traverse tumor-infiltrated tissue. In many cases, their sacrifice is unavoidable if maximal resection is to be achieved. Some authors advocate a transopercular approach to minimize manipulation of the Sylvian vessels. While this method can reduce the risk of injury to large MCA branches [ 3 , 19 ], it remains uncertain whether it effectively spares the intraparenchymal course of the LIA, given their deep trajectory and intimate association with the infiltrated insular cortex [ 14 ] (Fig. 8 ). Conclusions Vascular complications during glioma surgery represent a complex interplay between anatomy, tumor biology, and surgical technique. Although advances in imaging, mapping, and microsurgical tools have significantly improved intraoperative safety, ischemic injuries remain a relevant source of morbidity. Modern neurosurgical treatment of these tumors needs to integrate a multimodal approach which comprises advanced preoperative planning and intraoperative technical and technological adjuncts. For the preoperative planning it is necessary to have an imaging integration, incorporating vascular sequences (TOF-MRA, CT angiography, DWI) into neuronavigation for better visualization of arteries, veins, and perforators. 3D reconstructions can help predict the course of “en passage” vessels relative to the tumor volume. Intraoperatively, it is safe to adopt an early vascular identification and respecting the arachnoid and pial planes. Techniques such as indocyanine green (ICG) angiography, micro-Doppler, and continuous neurophysiological monitoring (e.g., MEPs, SEPs) can provide real-time assessment of vessel patency and functional integrity. In the end, nothing can substitute a judicious decision-making such as do not insisting when the dissection plane is unfavorable in order not to destroy major arterial or venous structures. Declarations Funding : No funds, grants, or other support was received. Conflicts of interest : authors declare that they have not any conflict of interest. The authors have no relevant financial or non-financial interests to disclose. Availability of data and material : authors are available to share raw data in case of specific request. The latter has to be sent to corresponding author. Code availability : yes Authors' contributions : Conceptualization, G.S.; methodology, F.G., G.S.; validation, F.G., G.S.; formal analysis, F.G. and G.S..; data curation, F.G., and G.S.; writing—original draft preparation, F.G. and G.S.; writing—review and editing, G.S.; supervision, G.S.. All authors have read and agreed to the published version of the manuscript Ethics approval : data collection was approved by local IRB (code 2023-3.11-434) Consent to participate and publication : Informed consent was obtained from all subjects involved in the study. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9086442","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606649039,"identity":"dccbe9c8-1099-4be4-aee4-a2101693d74b","order_by":0,"name":"Francesco Guerrini","email":"data:image/png;base64,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","orcid":"","institution":"University of Pavia","correspondingAuthor":true,"prefix":"","firstName":"Francesco","middleName":"","lastName":"Guerrini","suffix":""},{"id":606649041,"identity":"a7a4942b-d3d4-4993-857d-8d23b6392346","order_by":1,"name":"Giannantonio Spena","email":"","orcid":"","institution":"Fondazione IRCCS Policlinico San Matteo","correspondingAuthor":false,"prefix":"","firstName":"Giannantonio","middleName":"","lastName":"Spena","suffix":""}],"badges":[],"createdAt":"2026-03-10 16:53:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9086442/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9086442/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104878982,"identity":"ec376ed3-8340-426c-800a-5086b40eba52","added_by":"auto","created_at":"2026-03-18 08:59:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":148093,"visible":true,"origin":"","legend":"\u003cp\u003eThis image shows the four most typical postoperative DWI alterations. A) rim-shaped. B) sector-shaped with a wedge conformation. C) sector-shaped with a vascular distribution. D) perforator-shaped lesion.\u003c/p\u003e","description":"","filename":"001.png","url":"https://assets-eu.researchsquare.com/files/rs-9086442/v1/5590fdc20ba81b7ca19767ea.png"},{"id":104878820,"identity":"8ff63a49-35f9-46d7-812d-61d942fd04fd","added_by":"auto","created_at":"2026-03-18 08:58:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":311210,"visible":true,"origin":"","legend":"\u003cp\u003eA) Preoperative contrast-enhanced MRI demonstrating a large glioblastoma multiforme infiltrating the right temporo-parietal region. B) Postoperative MRI showing complete resection of the tumor. C) Postoperative diffusion-weighted imaging MRI demonstrating a large ischemic stroke involving the right occipital lobe.\u003c/p\u003e\n\u003cp\u003eD) Six months control MRI: No relapse is evident but encephalomalacia.\u003c/p\u003e","description":"","filename":"002.png","url":"https://assets-eu.researchsquare.com/files/rs-9086442/v1/4c153bbb51b6ebd77ce6642b.png"},{"id":104878962,"identity":"2e3b23cc-a251-4eb3-aa73-a225af973c05","added_by":"auto","created_at":"2026-03-18 08:59:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":392309,"visible":true,"origin":"","legend":"\u003cp\u003eA) Intraoperative photograph demonstrating the placement of a prolene 8-0 suture onto a branch of the left posterior temporal artery that was injured during the opening of the dura mater. The patient underwent surgery six years prior for a low-grade glioma in the left temporal lobe. At relapse, an awake procedure was performed for resection. The extensive scar tissue was the cause of the vessel’s lesion. B) Indocynine green demonstrated the efficacy of the vessel at the conclusion of the suture. C) and D) depict the postoperative FLAIR and ADC sequences, respectively, indicating the absence of ischemic damage.\u003c/p\u003e","description":"","filename":"003.png","url":"https://assets-eu.researchsquare.com/files/rs-9086442/v1/975f450f3e55536b75620e34.png"},{"id":104878963,"identity":"f87966f1-114a-4fef-b46d-cf744a8de84e","added_by":"auto","created_at":"2026-03-18 08:59:19","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":497850,"visible":true,"origin":"","legend":"\u003cp\u003eA) Preoperative contrast-enhanced MRI image demonstrating a large insular glioblastoma. B) Intraoperatively, the tumor exhibited a component firmly adherent to the middle cerebral artery (MCA). After skeletonization of the MCA, a residual mass was left in place (green arrow). C) Postoperative MRI image illustrating the complete resection of the tumor, with a calcified residue adhering to the MCA (D), green arrow. E and F) Despite all the efforts excessive manipulation of these arteries provoked DWI ischemic signal on postoperative MRI.\u003c/p\u003e","description":"","filename":"004.png","url":"https://assets-eu.researchsquare.com/files/rs-9086442/v1/f16501ca23713e76438f8f55.png"},{"id":104878884,"identity":"b6ae0d21-bf9e-4b08-a1f7-070337a69f0f","added_by":"auto","created_at":"2026-03-18 08:59:02","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":833244,"visible":true,"origin":"","legend":"\u003cp\u003eA) intraoperative picture showing a tumor infiltrating the left middle and inferior temporal gyri. The vein of Labbé and some tributary cross the temporal lobe. B) at the end of the resection the vein is completely preserved.\u003c/p\u003e","description":"","filename":"005.png","url":"https://assets-eu.researchsquare.com/files/rs-9086442/v1/6901d4de26af2d1e26bdbaf2.png"},{"id":104878964,"identity":"695bdfbb-33ae-4c81-863c-bdd192abfafd","added_by":"auto","created_at":"2026-03-18 08:59:20","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":435485,"visible":true,"origin":"","legend":"\u003cp\u003eA) - Preoperative FLAIR coronal section of a large low-grade glioma involving the cingular gyrus and the corpus callosum. B) - Intraoperative image. The two green arrows indicate the location where two capillaries were gently coagulated and excised. C - Postoperative FLAIR demonstrating complete resection.\u003c/p\u003e","description":"","filename":"006.png","url":"https://assets-eu.researchsquare.com/files/rs-9086442/v1/2abc1c2824a2747882b28a21.png"},{"id":104878967,"identity":"968c9b20-0c0d-4f26-8749-1cf08b640bb8","added_by":"auto","created_at":"2026-03-18 08:59:22","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":486607,"visible":true,"origin":"","legend":"\u003cp\u003eA) Intraoperative view showing the right M1 segment during microsurgical resection of an insular glioma. The green arrow identifies the first perforating arteries arising from M1 and directed toward the anterior perforated substance. In this setting, these perforators can be clearly visualized and preserved. B) The blue arrow indicates a long insular artery (LIA) originating from M3 and traversing the insula. In this scenario, preservation of such perforators is considerably more challenging.\u003c/p\u003e","description":"","filename":"007.png","url":"https://assets-eu.researchsquare.com/files/rs-9086442/v1/08bef77ba879b51904b7a74c.png"},{"id":104878818,"identity":"b051e75e-af16-4818-ae33-cdf853f5dca4","added_by":"auto","created_at":"2026-03-18 08:58:34","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":326265,"visible":true,"origin":"","legend":"\u003cp\u003eA) This schematic depiction demonstrates the typical anatomical distribution of the lenticulostriate arteries (LSAs) and long insular arteries (LIAs). (B) When the LIAs are incorporated within the tumor, their preservation becomes technically challenging, regardless of the surgical approach employed (i.e., transsylvian or transopercular).\u003c/p\u003e","description":"","filename":"008.png","url":"https://assets-eu.researchsquare.com/files/rs-9086442/v1/2f14fad11e37c20c05de1653.png"},{"id":105037225,"identity":"1a0520a9-4868-4221-95a0-196c1db4afba","added_by":"auto","created_at":"2026-03-20 07:38:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3793430,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9086442/v1/17ff2185-fe76-42e3-82c6-ad833c02a52a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Vascular Complications in Glioma Surgery: insights from a Case-Based Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDespite significant advancements in adjuvant therapies\u0026mdash;including radiotherapy, chemotherapy, gene therapy, and immunotherapy\u0026mdash;surgical resection remains the cornerstone of treatment for brain gliomas. The extent of tumor removal is a critical determinant of patient survival, often correlating with prolonged remission or improved disease control when integrated with multimodal treatment strategies[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHigh-grade gliomas (HGG), particularly glioblastomas, continue to carry a poor prognosis, with a two-year survival rate of approximately 26.5%. In contrast, patients with low-grade gliomas (LGG) demonstrate five-year survival rates between 58% and 72%[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In LGG, a more extensive resection has been shown to reduce malignant transformation and improve survival outcomes. Although prognosis for HGG remains unfavorable, recent evidence indicates that maximal safe resection can significantly enhance both overall survival and progression-free intervals[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTraditional glioma surgery, which focused on debulking rather than complete removal, inherently carried lower vascular risk. However, as the concept of \u0026ldquo;maximal safe resection\u0026rdquo; became established, surgeons began to work closer to eloquent regions, particularly in perisylvian, perirolandic, and insular territories. Modern techniques such as awake mapping, neuronavigation, intraoperative MRI, and real-time neurophysiological monitoring have substantially increased the achievable extent of resection. Yet, paradoxically, these advances also expose the surgeon to greater proximity to critical arteries and veins, raising the potential for ischemic events.\u003c/p\u003e \u003cp\u003eThe occurrence of vascular complications in glioma surgery reflects the delicate balance between oncological radicality and functional preservation. With modern surgical paradigms shifting toward maximal and even supramaximal resection, understanding the complex vascular anatomy surrounding gliomas has become increasingly crucial. Moreover, recent literature has highlighted that postoperative ischemic lesions are much more common than previously believed, especially when evaluated through DWI and ADC sequences[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis paper presents a comprehensive case-based analysis of vascular complications encountered during glioma surgery. Through the detection of DWI signal changes on postoperative MRI, we aimed to elucidate the mechanisms underlying arterial and venous injuries and outline technical strategies to prevent them.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA prospectively maintained database of adult patients (\u0026ge;\u0026thinsp;18 years) who underwent surgery for eloquent-area gliomas performed by the senior author (G.S.) between December 2020 and December 2025 was retrospectively analyzed to investigate the occurrence of diffusion-weighted imaging (DWI) signal changes on immediate postoperative MRI.\u003c/p\u003e \u003cp\u003eThe database is being examined with two primary objectives. First, an ongoing study aims to evaluate the correlation between postoperative DWI alterations and both short- and long-term neurological outcomes, assessing their predictive value. The second objective\u0026mdash;representing the focus of the present study\u0026mdash;is to analyze the intraoperative mechanisms underlying the development of postoperative DWI abnormalities. Inclusion criteria were as follow: Tumors infiltrating or adjacent to eloquent regions, specifically dominant perisylvian cortex (frontal and temporal opercula, supramarginal gyrus, angular gyrus); dominant middle and posterior temporal regions; selected nondominant temporal areas (mesial temporal region or corticospinal tract involvement); insula; sensory-motor cortex. Additional inclusion criteria required complete pre- and postoperative clinical and radiological data; availability of intraoperative videos and surgical reports; histopathological diagnosis classified according to the 2016 and 2021 WHO criteria[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFunctional mapping and monitoring were performed in all cases (awake or asleep), individualized according to patient and tumor characteristics. Cortical and subcortical mapping included: Bipolar stimulation (250 Hz monophasic for motor mapping; 60 Hz biphasic for cognitive mapping); Monopolar stimulation for corticospinal tract localization (1 mA\u0026thinsp;\u0026asymp;\u0026thinsp;1 mm distance rule); Continuous neurophysiological monitoring (EMG, EEG, ECoG, SSEPs, MEPs). Intraoperative language testing was conducted by a neuropsychologist in awake procedures.\u003c/p\u003e \u003cp\u003eEarly postoperative MRI included T1-weighted, T2-weighted, FLAIR, DWI, and post-contrast T1 sequences. Restricted diffusion was defined as hyperintensity on B1000 sequences; corresponding ADC reduction (rADC\u0026thinsp;\u0026lt;\u0026thinsp;0.7 \u0026times; 10⁻\u0026sup3; mm\u0026sup2;/s compared with the contralateral hemisphere). These findings were considered consistent with cytotoxic edema due to acute ischemia, after exclusion of blood products. Diffusion abnormalities were classified into three patterns: Rim-shaped, Sector-shaped and Perforator-shaped (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Sector-shaped lesions were further subdivided into lesions having a clear vascular territory configuration (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC) or a more vague wedge-like configuration which is not always attributable to a specific vessel damage (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Rim-shaped alterations were only considered if they measured more then 3 mm in thickness. Since these images are difficult to correlate with specific arterial or venous injury, our analysis focused primarily on sector and perforator-shaped lesions through detailed review of surgical videos and intraoperative reports to determine the most likely underlying mechanisms.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eData collection was approved by local IRB.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 136 patients met the inclusion criteria. Postoperative DWI demonstrated no diffusion abnormality in 94 patients (69.1%). In the 42 patients with postoperative DWI alterations, rim-shaped were present in 10 patients (7.3%) whereas sector- or perforator-shaped alterations in 32 patients (23.5%). Among sector-shaped lesions, wedge-like were present in 11 patients (10/ 32, 34.3%) whereas lesions resembling a frank vascular territory were present in 9 patients (28,1%). Perforators-shaped were recorded in 12 patients (37.5%). All these lesions patterns (sector-shaped and perforators-shaped) were predominantly observed in temporal and insular tumors (28/32 cases, 87.5%). Notably, perforator-shaped lesions were especially prevalent in insular tumors (8/12 cases, 66.6%). Further analyses regarding clinical findings, neurophysiological data, and long-term outcomes are part of an ongoing study and are beyond the scope of the present work.\u003c/p\u003e \u003cp\u003eReview of operative videos and surgical reports indicated that an intraoperative clear vascular mechanism was detected for all vascular-like and perforator-shaped lesions and for part of the wedge-like lesions (4/11, 36.3%). In fact for these latter lesions it is sometimes difficult to recognize a direct lesion onto an arterial or venous structure (see discussion below).\u003c/p\u003e \u003cp\u003eBased on these intraoperative evidences, we divided vascular mechanisms into four main groups (see below): 1. damage to \u0026ldquo;en passage\u0026rdquo; vessels; 2. damage to large caliber vessels; 3. damage to capillaries arising from parent vessels; 4. damage to perforators.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eVascular injuries during glioma surgery can be broadly categorized into arterial and venous types. Both can result in serious and sometimes catastrophic postoperative outcomes, although their clinical manifestations differ considerably. Injuries are often related to direct mechanical trauma, coagulation near the vessel wall, or traction leading to intimal tearing and subsequent thrombosis. Even without gross rupture, thermal or mechanical endothelial damage can provoke vasospasm or delayed occlusion, producing ischemic lesions hours after an apparently uneventful surgery. Thermal damage has to be regarded with great attention since the excessive use of bipolar cautery can provoke tissue lesions around the tumor cavity. The severity of this thermal injury could explain the difference between a rim-shaped lesion from a wedge-shaped one.\u003c/p\u003e \u003cp\u003eArterial damage typically leads to well-defined ischemic territories, following the vascular distribution of the affected artery. These infarctions are, most of the time, predictable in both extension and symptomatology. Conversely, venous injuries can result in far more unpredictable effects\u0026mdash;ranging from minor, clinically silent edema to extensive hemispheric infarction. Due to their low-pressure system and thinner walls, veins are easily collapsed, thrombosed, or torn. Even slight compression by surgical retraction or coagulated debris can interrupt venous outflow, resulting in venous infarction and edema, often with delayed onset and variable clinical presentation.\u003c/p\u003e \u003cp\u003eThe severity of neurological deficits depends on multiple factors, including the size and location of the vessel, the eloquence of the affected brain area, and the availability of collateral circulation. For instance, the accidental occlusion of a small perforator supplying the internal capsule can have devastating consequences, while interruption of a non-dominant frontopolar terminal artery may have minimal impact. Similarly, the occlusion of large anastomotic veins, such as perirolandic or perisylvian veins, can lead to massive venous infarction.\u003c/p\u003e \u003cp\u003eAs a general rule, vessels supplying or draining brain tissue that is to be removed\u0026mdash;for example, within the tumor mass\u0026mdash;can be sacrificed safely. This is particularly true in high-grade gliomas, where \u0026ldquo;red veins\u0026rdquo; often appear on the tumor surface. These pathological veins show reversed or mixed flow patterns due to arteriovenous shunts within the tumor core and can be safely coagulated[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBy contrast, \u0026ldquo;en passage\u0026rdquo; vessels\u0026mdash;those that course through or along the tumor without supplying it\u0026mdash;represent a major surgical challenge. Their preservation is critical, as they feed or drain otherwise healthy brain regions.\u003c/p\u003e \u003cp\u003eAnother key distinction exists between LGG and GBM in their relationship to vasculature. Low-grade gliomas usually respect the pial plane, preserving the integrity of vascular walls. In such cases, the subpial dissection technique allows surgeons to preserve vessels safely[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Conversely, glioblastomas often destroy the pial layer and infiltrate vessel walls, particularly arteries, making separation hazardous or impossible[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe advent of diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) mapping has profoundly improved our understanding of postoperative ischemic complications. Unlike conventional CT, which reveals infarction only several hours after onset, DWI can detect ischemic changes within minutes. This allows early differentiation between ischemic and hemorrhagic damage, aiding in postoperative evaluation.\u003c/p\u003e \u003cp\u003eSeveral recent studies, using DWI-based methods, have demonstrated that postoperative ischemic lesions are significantly more common than previously recognized[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although these techniques provide early detection, they cannot always clarify whether ischemia is arterial, venous, or secondary to retraction unless the lesion follows a distinct vascular territory pattern especially when a rim-shaped or a wedge-shaped lesion are implicated.\u003c/p\u003e \u003cp\u003e \u003cem\u003e1. Damage to \u0026ldquo;en passage\u0026rdquo; vessels\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA frequent and challenging situation involves arteries or veins passing through or adjacent to the tumor that are mistakenly judged expendable. This typically occurs during lobectomies (such as anterior temporal or frontal lobectomy) or supratotal resections.\u003c/p\u003e \u003cp\u003eThese \u0026ldquo;en passage\u0026rdquo; vessels are often encountered in perisylvian, perirolandic, or parieto-temporo-occipital gliomas. Although their superficial position makes them accessible for direct control and subpial dissection, closure of any artery in these areas\u0026mdash;especially in the dominant hemisphere\u0026mdash;should be avoided.\u003c/p\u003e \u003cp\u003eOccasionally, an \u0026ldquo;en passage\u0026rdquo; artery\u0026mdash;such as a branch of the posterior cerebral artery\u0026mdash;is discovered only late during resection, once the tumor core has been removed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In those large volume tumors with deep operative fields, the risk of inadvertent vessel closure is high especially if the vessel is heavily stretched and encased by the tumor. When infiltration of the arterial wall is evident and safe separation impossible, partial tumor residue should be intentionally left to preserve vascular integrity and function.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eReoperations pose additional risks, as scarring may tether arteries to dura or arachnoid, increasing the likelihood of tearing during exposure. In such cases, delicate dural opening or leaving small pieces of dura on the cortex if it does not detach, can prevent major complications. In Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e we show such a case of a left temporal glioma that relapsed 6 years later. During the opening of the dura, there was a tearing at the level of a posterior temporal artery. Due to the dominant location, an attempt to suture the hole was successfully done.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e2. Damage to large caliber vessels\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDirect injury to large-caliber arteries (i.e. M2) is relatively uncommon, primarily thanks to the protective role of the pial and arachnoidal layers and the use of the subpial dissection technique. However, in certain contexts\u0026mdash;particularly in high-grade gliomas\u0026mdash;the situation can be far more complex. Glioblastomas and other aggressive gliomas often breach the leptomeningeal boundaries, infiltrating or tightly encasing major arteries and veins.\u003c/p\u003e \u003cp\u003eIn some cases (i.e. fronto-temporo-insular gliomas) if the tumor is soft and the interface between the neoplasm and vascular tissue remains discernible, it is possible to perform a complete resection while preserving arterial integrity. However, when the tumor exhibits a firm, fibrotic or calcified consistency and adheres intimately to the vessel wall, attempts to achieve total resection can easily lead to vascular rupture or thrombosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn these instances, intraoperative judgment is crucial. If blunt dissection fails to identify a safe plane between the artery and tumor, the surgeon should opt for leaving a minimal tumor residue rather than risking arterial damage. This approach is particularly valid when the vessel wall appears discolored, infiltrated, or stiffened\u0026mdash;signs suggesting tumor invasion. Unfortunately, such invasion is often not predictable from preoperative imaging, even with advanced MRI techniques, and must be assessed intraoperatively.\u003c/p\u003e \u003cp\u003eThe management of large-caliber veins presents additional challenges. While high-grade gliomas frequently produce abnormal, pathologic veins\u0026mdash;often referred to as \u0026ldquo;tumor veins\u0026rdquo;\u0026mdash;that can be safely sacrificed due to their aberrant drainage patterns, the scenario is quite different in low-grade gliomas where preserving venous drainage is paramount, especially in eloquent or functionally critical areas. During dissection, every effort should be made to preserve large cortical and bridging veins, even if this means leaving small tumor remnants attached to them (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). When veins appear to collapse toward the resection cavity at the end of tumor removal, it is advisable to support them with hemostatic materials, such as small Gelfoam fragments, to prevent kinking or compression within the cavity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e3. Damage to Capillaries Arising from Parent Vessels\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSmall capillaries branching from major arteries can sometimes inadvertently torn while detaching infiltrated cortex. These capillaries frequently supply the cortical areas infiltrated by the tumor and must be carefully recognized under high magnification. The safest technique involves gentle coagulation and division of these capillaries at a distance from their origin on the parent vessel.\u003c/p\u003e \u003cp\u003eThis situation is particularly common in gliomas of the medial frontal and parietal lobes (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u0026mdash;where the pericallosal or calloso-marginal arteries give rise to cortical branches\u0026mdash;or in insular gliomas, where capillaries arise from M3 branches of the middle cerebral artery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eLarge-volume tumors may stretch and thin the vessels, increasing the risk of tearing. When a capillary is torn at its origin, hemostasis should first be attempted using gentle compression with hemostatic agents (e.g., Gelfoam). If bleeding persists, low-intensity bipolar coagulation using fine tips (approximately 0.2 mm) can be employed to mold and seal the defect without compromising the parent vessel.\u003c/p\u003e \u003cp\u003eTo prevent such injuries, surgeons should carefully analyze preoperative angiographic sequences and integrate vascular data into neuronavigation systems. Early identification of the vessel course allows for preemptive planning and reduces the risk of unexpected tearing.\u003c/p\u003e \u003cp\u003e \u003cem\u003e4. Damage to perforators\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe management of perforating arteries is among the most technically demanding aspects of glioma surgery, particularly in operations involving the insula and basal ganglia. During surgery of insular tumors, perforators may be encountered at different levels: at their cisternal origin (e.g., from the M1 segment of the MCA); within the anterior perforated substance or deep inside the basal ganglia or striatum; at the level of of M3 where typical long insular arteries (LIA) arise.\u003c/p\u003e \u003cp\u003eAt the cisternal level, these vessels can typically be preserved by maintaining meticulous respect for the arachnoid planes (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eA). Several authors have emphasized the importance of identifying the lateral perforators of the MCA during insular glioma surgery, as these vessels define a virtual deep resection limit, serving as a natural anatomical boundary[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHowever, the situation becomes far more challenging when dealing with perforators embedded within the parenchyma. These intraparenchymal perforators are extremely delicate (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eB); even minimal manipulation can lead to tearing or vasospasm. Consequently, surgeons should avoid exposing these vessels directly and should instead halt the resection once they reach the characteristic texture or color of the striatal tissue. Often, the appearance of tiny venous bleedings signals proximity to the lenticulostriate zone, serving as a warning to stop.\u003c/p\u003e \u003cp\u003ePreoperative imaging, particularly high-resolution T2-weighted MRI, can provide valuable insights into the extent of vascular encasement and the degree of perforator involvement. By carefully reviewing these sequences, surgeons can anticipate the safe depth of resection and tailor their surgical trajectory accordingly.\u003c/p\u003e \u003cp\u003eThe long insular arteries (LIA) represent a particularly challenging subset. Small M2 branches supply the insular cortex, claustrum, and external capsule. About 80\u0026ndash;90% of insular arteries are short, serving the insular cortex and extreme capsule. Roughly 10% are medium-length, supplying the claustrum and external capsule, while only 3\u0026ndash;5% are long, extending to the corona radiata\u0026mdash;mainly in the posterior insula[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese fine vessels are seldom visible on preoperative angiography due to cortical swelling caused by the infiltrating tumor. Once identified intraoperatively, they are extremely difficult to preserve, as they typically traverse tumor-infiltrated tissue. In many cases, their sacrifice is unavoidable if maximal resection is to be achieved. Some authors advocate a transopercular approach to minimize manipulation of the Sylvian vessels. While this method can reduce the risk of injury to large MCA branches [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], it remains uncertain whether it effectively spares the intraparenchymal course of the LIA, given their deep trajectory and intimate association with the infiltrated insular cortex [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eVascular complications during glioma surgery represent a complex interplay between anatomy, tumor biology, and surgical technique. Although advances in imaging, mapping, and microsurgical tools have significantly improved intraoperative safety, ischemic injuries remain a relevant source of morbidity.\u003c/p\u003e \u003cp\u003eModern neurosurgical treatment of these tumors needs to integrate a multimodal approach which comprises advanced preoperative planning and intraoperative technical and technological adjuncts.\u003c/p\u003e \u003cp\u003eFor the preoperative planning it is necessary to have an imaging integration, incorporating vascular sequences (TOF-MRA, CT angiography, DWI) into neuronavigation for better visualization of arteries, veins, and perforators. 3D reconstructions can help predict the course of \u0026ldquo;en passage\u0026rdquo; vessels relative to the tumor volume.\u003c/p\u003e \u003cp\u003eIntraoperatively, it is safe to adopt an early vascular identification and respecting the arachnoid and pial planes.\u003c/p\u003e \u003cp\u003eTechniques such as indocyanine green (ICG) angiography, micro-Doppler, and continuous neurophysiological monitoring (e.g., MEPs, SEPs) can provide real-time assessment of vessel patency and functional integrity.\u003c/p\u003e \u003cp\u003eIn the end, nothing can substitute a judicious decision-making such as do not insisting when the dissection plane is unfavorable in order not to destroy major arterial or venous structures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e: No funds, grants, or other support was received.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConflicts of interest\u003c/em\u003e: authors declare that they have not any conflict of interest. The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and material\u003c/em\u003e: authors are available to share raw data in case of specific request. The latter has to be sent to corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCode availability\u003c/em\u003e: yes\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e: Conceptualization, G.S.; methodology, F.G., G.S.; validation, F.G., G.S.; formal analysis, F.G. and G.S..; data curation, F.G., and G.S.; writing—original draft preparation, F.G. and G.S.; writing—review and editing, G.S.; supervision, G.S.. All authors have read and agreed to the published version of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval\u003c/em\u003e: data collection was approved by local IRB (code 2023-3.11-434)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent to participate and publication\u003c/em\u003e: Informed consent was obtained from all subjects involved in the study. In some cases, patient consent was waived due to death\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBerger A, Tzarfati GG, Serafimova M, Valdes P, Meller A, Korn A, Kahana Levy N, Aviram D, Ram Z, Grossman R (2022) Risk factors and prognostic implications of surgery-related strokes following resection of high-grade glioma. Sci Rep 12(1):22594\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBukhari SS, Saeed F, Tahir I, Kazmi M, Angez M, Khalid MU, Nasir R, Jawed A, Enam SA (2023) Predicting clinical outcomes of post-operative focal neurological deficits after glioma resection based on MRI characteristics: A retrospective chart review. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21203/rs.3.rs-2616875/v1\u003c/span\u003e\u003cspan address=\"10.21203/rs.3.rs-2616875/v1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuffau H (2022) Awake Mapping With Transopercular Approach in Right Insular\u0026ndash;Centered Low-Grade Gliomas Improves Neurological Outcomes and Return to Work. Neurosurgery 91(1):182\u0026ndash;190\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGempt J, F\u0026ouml;rschler A, Buchmann N, Pape H, Ryang Y-M, Krieg SM, Zimmer C, Meyer B, Ringel F (2013) Postoperative ischemic changes following resection of newly diagnosed and recurrent gliomas and their clinical relevance: Clinical article. JNS 118(4):801\u0026ndash;808\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuerrini F, Custodi VM, Giuri A et al (2024) Predicting Extent of Resection and Neurological Outcome for Insular Gliomas: An Analysis of Two Available Classifications. Cancers 16(24):4137\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHervey-Jumper SL, Li J, Osorio JA, Lau D, Molinaro AM, Benet A, Berger MS (2016) Surgical assessment of the insula. Part 2: validation of the Berger-Sanai zone classification system for predicting extent of glioma resection. JNS 124(2):482\u0026ndash;488\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHervey-Jumper SL, Zhang Y, Phillips JJ et al (2023) Interactive Effects of Molecular, Therapeutic, and Patient Factors on Outcome of Diffuse Low-Grade Glioma. JCO 41(11):2029\u0026ndash;2042\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsolan GR, Buffon V, Maldonado I, Monteiro JM, Yağmurlu K, Ribas CAPM, Roesler R, Malafaia O (2022) Avoiding vascular complications in insular glioma surgery \u0026ndash; A microsurgical anatomy study and critical reflections regarding intraoperative findings. Front Surg 9:906466\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJakola AS, Berntsen EM, Christensen P, Gulati S, Unsg\u0026aring;rd G, Kvistad KA, Solheim O (2014) Surgically Acquired Deficits and Diffusion Weighted MRI Changes after Glioma Resection - A Matched Case-Control Study with Blinded Neuroradiological Assessment. PLoS ONE 9(7):e101805\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawaguchi T, Kumabe T, Saito R, Kanamori M, Iwasaki M, Yamashita Y, Sonoda Y, Tominaga T (2014) Practical surgical indicators to identify candidates for radical resection of insulo-opercular gliomas: Clinical article. JNS 121(5):1124\u0026ndash;1132\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLang FF, Olansen NE, DeMonte F, Gokaslan ZL, Holland EC, Kalhorn C, Sawaya R (2001) Surgical resection of intrinsic insular tumors: complication avoidance. J Neurosurg 95(4):638\u0026ndash;650\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLouis DN, Perry A, Reifenberger G, Von Deimling A, Figarella-Branger D, Cavenee WK, Ohgaki H, Wiestler OD, Kleihues P, Ellison DW (2016) The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol 131(6):803\u0026ndash;820\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLouis DN, Perry A, Wesseling P et al (2021) The 2021 WHO Classification of Tumors of the Central Nervous System: a summary. Neurooncology 23(8):1231\u0026ndash;1251\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMandonnet V, Rheault F, Barberis M, Prevost C, Letrange S, Poisson I, Froelich S, Mandonnet E (2024) Mini-strokes within Broca-caudate connections during left insular glioma awake surgery cause transient severe naming deficits. Acta Neurochir 166(1):507\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMariani L, Schroth G, Wielepp JP, Haldemann A, Seiler RW (2001) Intratumoral Arteriovenous Shunting in Malignant Gliomas. Neurosurgery 48(2):353\u0026ndash;358\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra A, Shetty P, Singh V, Moiyadi A (2020) Microsurgical subpial resections for diffuse gliomas\u0026mdash;old wine in a new bottle. Acta Neurochir 162(12):3031\u0026ndash;3035\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarita Y, Shibui S, On Behalf of the Committee of Brain Tumor Registry of Japan Supported by the Japan Neurosurgical Society (2015) Trends and Outcomes in the Treatment of Gliomas Based on Data during 2001\u0026ndash;2004 from the Brain Tumor Registry of Japan. Neurol Med Chir(Tokyo) 55(4):286\u0026ndash;295\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eP\u0026ouml;hlmann J, Weller M, Marcellusi A, Grabe-Heyne K, Krott-Coi L, Rabar S, Pollock RF (2024) High costs, low quality of life, reduced survival, and room for improving treatment: an analysis of burden and unmet needs in glioma. Front Oncol 14:1368606\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrzybylowski CJ, Hervey-Jumper SL, Sanai N (2021) Surgical strategy for insular glioma. J Neurooncol 151(3):491\u0026ndash;497\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoder C, Stummer W, Coburger J et al (2023) Intraoperative MRI-Guided Resection Is Not Superior to 5-Aminolevulinic Acid Guidance in Newly Diagnosed Glioblastoma: A Prospective Controlled Multicenter Clinical Trial. JCO 41(36):5512\u0026ndash;5523\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrand PS, Berntsen EM, Fyllingen EH, Sagberg LM, Reinertsen I, Gulati S, Bouget D, Solheim O (2021) Brain infarctions after glioma surgery: prevalence, radiological characteristics and risk factors. Acta Neurochir 163(11):3097\u0026ndash;3108\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTamura A, Kasai T, Akazawa K, Nagakane Y, Yoshida T, Fujiwara Y, Kuriyama N, Yamada K, Mizuno T, Nakagawa M (2014) Long Insular Artery Infarction: Characteristics of a Previously Unrecognized Entity. AJNR Am J Neuroradiol 35(3):466\u0026ndash;471\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeller M, Van Den Bent M, Preusser M et al (2021) EANO guidelines on the diagnosis and treatment of diffuse gliomas of adulthood. Nat Rev Clin Oncol 18(3):170\u0026ndash;186\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWen PY, Weller M, Lee EQ et al (2020) Glioblastoma in adults: a Society for Neuro-Oncology (SNO) and European Society of Neuro-Oncology (EANO) consensus review on current management and future directions. Neurooncology 22(8):1073\u0026ndash;1113\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYasargil MG, Adamson TE, Cravens GF, Johnson RJ, Lang A (2013) Microneurosurgery, Volume IV A: CNS Tumors: Surgical Anatomy, Neuropathology, Neuroradiology, Neurophysiology, Clinical Considerations, Operability, Treatment Options, 1. Auflage. Thieme, Stuttgart\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan Y, Shi Q, Li M, Nagamuthu C, Andres E, Davis FG (2016) Canadian brain cancer survival rates by tumour type and region: 1992\u0026ndash;2008. Can J Public Health 107(1):e37\u0026ndash;e42\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Glioma, vessels, perforators, vascular damage","lastPublishedDoi":"10.21203/rs.3.rs-9086442/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9086442/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe modern paradigm of maximal safe resection has improved oncological outcomes but has also increased the risk of vascular complications due to closer dissection near eloquent and vascular-rich brain regions. This study presents a comprehensive case-based analysis of vascular injuries encountered during glioma surgery, focusing on their mechanisms, clinical impact, and preventive strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe retrospectively reviewed intraoperative videos, surgical reports and charts of patients undergoing brain glioma surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe identified 4 possible scenarios: damage to capillaries arising from parent vessels; damage to “en passage” vessels; damage to large caliber vessels; damage to perforators.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnderstanding the complex vascular anatomy surrounding gliomas, integrating advanced preoperative imaging, and adopting meticulous microsurgical techniques are essential to minimize ischemic morbidity. Ultimately, sound intraoperative judgment—prioritizing vascular preservation over radicality when planes are unfavorable—remains critical for optimizing functional outcomes.\u003c/p\u003e","manuscriptTitle":"Vascular Complications in Glioma Surgery: insights from a Case-Based Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:57:11","doi":"10.21203/rs.3.rs-9086442/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"646425cc-3a96-4581-b9bf-20d8538aa500","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-18T08:58:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 08:57:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9086442","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9086442","identity":"rs-9086442","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}