Annals of Medicine and Surgery 65 (2021) 102300 2049-0801/© 2021 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Case Report Adult Pilocytic Astrocytoma in the insula: Case report and review of the literature Baha’eddin A. Muhsen, MD, MRCSI, FEBNS a, * , Ansam Ghzawi b , Hasan Hashem e , Maher Elayyan a , Bayan Maraqa c , Mahmoud Al Masri d a Division of Neurosurgery, Department of Surgery, King Hussein Cancer Center, Amman, Jordan b Faculty of Medicine- Yarmouk University, Irbid, Jordan c Department of Pathology, King Hussein Cancer Center, Amman, Jordan d Department of Surgery, King Hussein Cancer Center, Amman, Jordan e Division of Pediatric Hematology Oncology, King Hussein Cancer Center, Amman, Jordan A R T I C L E INFO Keywords: Pilocytic Astrocytoma Adult Insular Microsurgery Outcomes ABSTRACT Introduction: and Importance: Adult Pilocytic Astrocytomas (APA) are infrequent low grade tumors. While supratentorial APA is considered rare, insular APA is extremely rare. Case presentation: We present a case of pure insular APA along with surgical outcomes. Tractography and functional MRI were obtained pre-operatively. The patient underwent neuro-navigation guided microsurgical resection with sub-cortical white matter mapping, utilizing Intra-operative MRI guidance. The Sylvain fssure was opened to secure the M3 branches, and near total resection was achieved. Clinical discussion: APA in the insula is a very rare presentation and is considered challenging. Its proximity to the middle cerebral and lenticulostriate arteries, motor areas, and language areas makes accessing and resecting the tumor challenging. A multidisciplinary approach by an experienced team is needed to plan the management of young adult patients and reach the best outcomes. Conclusion: Implementing microsurgical techniques, modern imaging modalities and intraoperative mapping helps to achieve maximal safe resection without risking functions. Introduction Adult Pilocytic astrocytomas (APA) are rare tumors. They are clas- sifed as Word Health Organization grade I gliomas [6]. PAs in general tend to be more prominent in children and adolescents. The incidence of PAs decreases signifcantly from 11.4% in children and adolescents to only 0.8% of CNS tumors in adults [7]. In addition, tumors location distribution seems to be related to the age of the patients. As it is more prominent to observe cerebellar presentations in pediatrics, in contrast to supratentorial location prominence in adults [10]. PAs present usu- ally manifest with a space-occupying lesion affecting the posterior fossa as obstructive hydrocephalus with clinical pictures of headache, vom- iting, nausea, and papilledema [9]. The excision of the tumor surgically is the treatment of choice aiming at tumor-free margins, with the least neurological insults. With recurrence, further resection surgically is mainly performed. APA in the cerebral hemispheres is very rare in the literature, insular location is even extremely rare. Surgical resection of insular tumors is challenging due to their proximity to the middle ce- rebral artery (MCA), lenticulostriate arteries (LSA), motor areas, and language areas. Herein, we present a rare case of adult pilocytic astro- cytoma presenting in the insula that have been managed at a cancer centre in Jordan and discuss it with the available literature. This case has been reported according to SCARE criteria for case reports [1]. Case report A 23 year-old right-handed male patient presented to the ER by his parents with severe progressive headache associated with short-term memory loss and refractory seizures (KPS 60). The patient is known to have epilepsy since the age of 3 years and has a history of left-sided Abbreviations: KPS, Karnofsky scale; MCA, middle cerebral artery; LSA, lenticulostriate arteries. * Corresponding author. Neurosurgical-Oncology and Skull Base Surgery, Department of Surgery, Division of Neurosurgery, King Hussein Cancer Center, 202 Queen Rania Al Abdullah St., P.O Box 1269, Amman, 11941, Jordan. E-mail addresses: BM.14911@khcc.jo, Bmuhsen08@gmail.com (B.A. Muhsen). Contents lists available at ScienceDirect Annals of Medicine and Surgery journal homepage: www.elsevier.com/locate/amsu https://doi.org/10.1016/j.amsu.2021.102300 Received 1 March 2021; Received in revised form 7 April 2021; Accepted 7 April 2021