51
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Tamura M, Sato I, Maruyama T, Ohshima K, Mangin JF, Nitta M, Saito T, Yamada H, Minami S, Masamune K, Kawamata T, Iseki H, Muragaki Y. Integrated datasets of normalized brain with functional localization using intra-operative electrical stimulation. Int J Comput Assist Radiol Surg 2019; 14:2109-2122. [PMID: 30955195 DOI: 10.1007/s11548-019-01957-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 04/01/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE The purpose of this study was to transform brain mapping data into a digitized intra-operative MRI and integrated brain function dataset for predictive glioma surgery considering tumor resection volume, as well as the intra-operative and postoperative complication rates. METHODS Brain function data were transformed into digitized localizations on a normalized brain using a modified electric stimulus probe after brain mapping. This normalized brain image with functional information was then projected onto individual patient's brain images including predictive brain function data. RESULTS Log data were successfully acquired using a medical device integrated into intra-operative MR images, and digitized brain function was converted to a normalized brain data format in 13 cases. For the electrical stimulation positions in which patients showed speech arrest (SA), speech impairment (SI), motor and sensory responses during cortical mapping processes in awake craniotomy, the data were tagged, and the testing task and electric current for the stimulus were recorded. There were 13 SA, 7 SI, 8 motor and 4 sensory responses (32 responses) in total. After evaluation of transformation accuracy in 3 subjects, the first transformation from intra- to pre-operative MRI using non-rigid registration was calculated as 2.6 ± 1.5 and 2.1 ± 0.9 mm, examining neighboring sulci on the electro-stimulator position and the cortex surface near each tumor, respectively; the second transformation from pre-operative to normalized brain was 1.7 ± 0.8 and 1.4 ± 0.5 mm, respectively, representing acceptable accuracy. CONCLUSION This image integration and transformation method for brain normalization should facilitate practical intra-operative brain mapping. In the future, this method may be helpful for pre-operatively or intra-operatively predicting brain function.
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Affiliation(s)
- Manabu Tamura
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, 8-1 (TWIns) Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan. .,Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Ikuma Sato
- Faculty of System Information Science Engineering, Future University Hakodate, 116-2 Kamedanakano-cho, Hakodate City, Hokkaido, 041-8655, Japan
| | - Takashi Maruyama
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, 8-1 (TWIns) Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.,Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kazuma Ohshima
- Faculty of System Information Science Engineering, Future University Hakodate, 116-2 Kamedanakano-cho, Hakodate City, Hokkaido, 041-8655, Japan
| | - Jean-François Mangin
- The Computer Assisted Neuroimaging Laboratory, Neurospin, Biomedical Imaging Institute, CEA, Centre d'études de Saclay, 91191, Gif-Sur-Yvette, France
| | - Masayuki Nitta
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, 8-1 (TWIns) Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.,Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Taiichi Saito
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hiroyuki Yamada
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, 8-1 (TWIns) Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shinji Minami
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, 8-1 (TWIns) Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Ken Masamune
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, 8-1 (TWIns) Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hiroshi Iseki
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, 8-1 (TWIns) Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yoshihiro Muragaki
- Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, 8-1 (TWIns) Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.,Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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Poulen G, Gozé C, Rigau V, Duffau H. Huge heterogeneity in survival in a subset of adult patients with resected, wild-type isocitrate dehydrogenase status, WHO grade II astrocytomas. J Neurosurg 2019; 130:1289-1298. [PMID: 29676695 DOI: 10.3171/2017.10.jns171825] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/07/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE World Health Organization grade II gliomas are infiltrating tumors that inexorably progress to a higher grade of malignancy. However, the time to malignant transformation is quite unpredictable at the individual patient level. A wild-type isocitrate dehydrogenase (IDH-wt) molecular profile has been reported as a poor prognostic factor, with more rapid progression and a shorter survival compared with IDH-mutant tumors. Here, the oncological outcomes of a series of adult patients with IDH-wt, diffuse, WHO grade II astrocytomas (AII) who underwent resection without early adjuvant therapy were investigated. METHODS A retrospective review of patients extracted from a prospective database who underwent resection between 2007 and 2013 for histopathologically confirmed, IDH-wt, non-1p19q codeleted AII was performed. All patients had a minimum follow-up period of 2 years. Information regarding clinical, radiographic, and surgical results and survival were collected and analyzed. RESULTS Thirty-one consecutive patients (18 men and 13 women, median age 39.6 years) were included in this study. The preoperative median tumor volume was 54 cm3 (range 3.5-180 cm3). The median growth rate, measured as the velocity of diametric expansion, was 2.45 mm/year. The median residual volume after surgery was 4.2 cm3 (range 0-30 cm3) with a median volumetric extent of resection of 93.97% (8 patients had a total or supratotal resection). No patient experienced permanent neurological deficits after surgery, and all patients resumed a normal life. No immediate postoperative chemotherapy or radiation therapy was given. The median clinical follow-up duration from diagnosis was 74 months (range 27-157 months). In this follow-up period, 18 patients received delayed chemotherapy and/or radiotherapy for tumor progression. Five patients (16%) died at a median time from radiological diagnosis of 3.5 years (range 2.6-4.5 years). Survival from diagnosis was 77.27% at 5 years. None of the 21 patients with a long-term follow-up greater than 5 years have died. There were no significant differences between the clinical, radiological, or molecular characteristics of the survivors relative to the patients who died. CONCLUSIONS Huge heterogeneity in the survival data for a subset of 31 patients with resected IDH-wt AII tumors was observed. These findings suggest that IDH mutation status alone is not sufficient to predict risk of malignant transformation and survival at the individual level. Therefore, the therapeutic management of AII tumors, in particular the decision to administer early adjuvant chemotherapy and/or radiation therapy following surgery, should not solely rely on routine molecular markers.
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Affiliation(s)
| | - Catherine Gozé
- 2Tumor Cellular and Tissular Biopathology Department, Gui de Chauliac Hospital, Montpellier University Medical Center; and
- 3National Institute for Health and Medical Research (INSERM), U1051 Laboratory, Team "Brain Plasticity, Stem Cells and Glial Tumors," Institute for Neurosciences of Montpellier, Montpellier University Medical Center, Montpellier, France
| | - Valérie Rigau
- 2Tumor Cellular and Tissular Biopathology Department, Gui de Chauliac Hospital, Montpellier University Medical Center; and
- 3National Institute for Health and Medical Research (INSERM), U1051 Laboratory, Team "Brain Plasticity, Stem Cells and Glial Tumors," Institute for Neurosciences of Montpellier, Montpellier University Medical Center, Montpellier, France
| | - Hugues Duffau
- 1Department of Neurosurgery and
- 3National Institute for Health and Medical Research (INSERM), U1051 Laboratory, Team "Brain Plasticity, Stem Cells and Glial Tumors," Institute for Neurosciences of Montpellier, Montpellier University Medical Center, Montpellier, France
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Zanello M, Goodden JR, Colle H, Wager M, Hamer PCDW, Smits A, Bello L, Tate M, Spena G, Bresson D, Capelle L, Robles SG, Sarubbo S, Rydenhag B, Martino J, Meyer B, Fontaine D, Reyns N, Schichor C, Metellus P, Colle D, Robert E, Noens B, Muller P, Rossi M, Nibali MC, Papagno C, Galbarritu L, de Gopegui ER, Chioffi F, Bucheli C, Krieg SM, Wostrack M, Yusupov N, Visser V, Baaijen JC, Roux A, Dezamis E, Mandonnet E, Corns R, Duffau H, Pallud J. Predictors of Epileptic Seizures and Ability to Work in Supratentorial Cavernous Angioma Located Within Eloquent Brain Areas. Neurosurgery 2019; 85:E702-E713. [DOI: 10.1093/neuros/nyz063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 02/10/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
BACKGROUND
The postoperative outcomes and the predictors of seizure control are poorly studied for supratentorial cavernous angiomas (CA) within or close to the eloquent brain area.
OBJECTIVE
To assess the predictors of preoperative seizure control, postoperative seizure control, and postoperative ability to work, and the safety of the surgery.
METHODS
Multicenter international retrospective cohort analysis of adult patients benefitting from a functional-based surgical resection with intraoperative functional brain mapping for a supratentorial CA within or close to eloquent brain areas.
RESULTS
A total of 109 patients (66.1% women; mean age 38.4 ± 12.5 yr), were studied. Age >38 yr (odds ratio [OR], 7.33; 95% confidence interval [CI], 1.53-35.19; P = .013) and time to surgery > 12 mo (OR, 18.21; 95% CI, 1.11-296.55; P = .042) are independent predictors of uncontrolled seizures at the time of surgery. Focal deficit (OR, 10.25; 95% CI, 3.16-33.28; P < .001) is an independent predictor of inability to work at the time of surgery. History of epileptic seizures at the time of surgery (OR, 7.61; 95% CI, 1.67-85.42; P = .003) and partial resection of the CA and/or of the hemosiderin rim (OR, 12.02; 95% CI, 3.01-48.13; P < .001) are independent predictors of uncontrolled seizures postoperatively. Inability to work at the time of surgery (OR, 19.54; 95% CI, 1.90-425.48; P = .050), Karnofsky Performance Status ≤ 70 (OR, 51.20; 95% CI, 1.20-2175.37; P = .039), uncontrolled seizures postoperatively (OR, 105.33; 95% CI, 4.32-2566.27; P = .004), and worsening of cognitive functions postoperatively (OR, 13.71; 95% CI, 1.06-176.66; P = .045) are independent predictors of inability to work postoperatively.
CONCLUSION
The functional-based resection using intraoperative functional brain mapping allows safe resection of CA and the peripheral hemosiderin rim located within or close to eloquent brain areas.
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Affiliation(s)
- Marc Zanello
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France
- Sorbonne Paris Cité, Paris Descartes University, Paris, France
- Inserm, U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - John R Goodden
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Henry Colle
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Michel Wager
- Department of Neurosurgery, La Milétrie University Hospital, Poitiers, France
| | | | - Anja Smits
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neuroscience, Neurology, Uppsala University, University Hospital, Uppsala, Sweden
| | - Lorenzo Bello
- NeuroOncological Surgery Unit, Humanitas Research Hospital, Milano, Italy
| | - Matthew Tate
- Departments of Neurological Surgery and Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Damien Bresson
- Department of Neurosurgery, Lariboisière Hospital, Paris, France
| | - Laurent Capelle
- Department of Neurosurgery, Pitié-Salpêtrière University Hospital, Paris, France
| | - Santiago Gil Robles
- Department of Neurosurgery, Hospital Universitario Quironsalud, Madrid, Spain
| | - Silvio Sarubbo
- Division of Neurosurgery, Structural and Functional Connectivity Lab Project, “S. Chiara” Hospital, APSS Trento, Italy
| | - Bertil Rydenhag
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Juan Martino
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla (HUMV) and Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Denys Fontaine
- Department of Neurosurgery, Nice University Hospital, Nice, France
| | - Nicolas Reyns
- Department of Neurosurgery, Roger-Salengro University Hospital, Lille, France
| | - Christian Schichor
- Neurosurgical Clinic, University of Munich - Campus Grosshadern, Munich, Germany
| | - Philippe Metellus
- Department of Neurosurgery, Clairval Private Hospital, Marseille, France
| | - David Colle
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Erik Robert
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Bonny Noens
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Peter Muller
- Department of Neurosurgery, St Lucas Hospital, Gand, Belgium
| | - Marco Rossi
- NeuroOncological Surgery Unit, Humanitas Research Hospital, Milano, Italy
| | - Marco Conti Nibali
- NeuroOncological Surgery Unit, Humanitas Research Hospital, Milano, Italy
| | - Costanza Papagno
- Center for Neurocognitive Rehabilitation (CeRiN), CIMeC, University of Trento, Trento, Italy
| | - Lara Galbarritu
- Neurosurgery, Cruces University Hospital, Barakaldo, Basque Country, Spain
| | | | - Franco Chioffi
- Division of Neurosurgery, Structural and Functional Connectivity Lab Project, “S. Chiara” Hospital, APSS Trento, Italy
| | - Carlos Bucheli
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla (HUMV) and Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Natan Yusupov
- Neurosurgical Clinic, University of Munich - Campus Grosshadern, Munich, Germany
| | - Victoria Visser
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, Netherlands
| | - Johannes C Baaijen
- Neurosurgical Center Amsterdam, VU University Medical Center, Amsterdam, Netherlands
| | - Alexandre Roux
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France
- Sorbonne Paris Cité, Paris Descartes University, Paris, France
- Inserm, U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France
- Sorbonne Paris Cité, Paris Descartes University, Paris, France
- Inserm, U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Emmanuel Mandonnet
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Robert Corns
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Hugues Duffau
- Neurosurgery Department, Hôpital Gui-de-Chauliac, Montpellier University Medical Center, Montpellier, France
| | - Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France
- Sorbonne Paris Cité, Paris Descartes University, Paris, France
- Inserm, U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
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Vanacôr C, Duffau H. Analysis of Legal, Cultural, and Socioeconomic Parameters in Low-Grade Glioma Management: Variability Across Countries and Implications for Awake Surgery. World Neurosurg 2018; 120:47-53. [DOI: 10.1016/j.wneu.2018.08.155] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/19/2018] [Accepted: 08/20/2018] [Indexed: 11/30/2022]
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Duffau H. Diffuse low-grade glioma, oncological outcome and quality of life: a surgical perspective. Curr Opin Oncol 2018; 30:383-389. [DOI: 10.1097/cco.0000000000000483] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Duffau H. Higher-Order Surgical Questions for Diffuse Low-Grade Gliomas: Supramaximal Resection, Neuroplasticity, and Screening. Neurosurg Clin N Am 2018; 30:119-128. [PMID: 30470399 DOI: 10.1016/j.nec.2018.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Diffuse low-grade glioma (DLGG) is a brain neoplasm that migrates within the connectome and that becomes malignant if left untreated. Early and maximal safe surgical resection by means of awake mapping enables a significant improvement of survival and quality of life. Supramaximal functional-based resection seems to prevent DLGG malignant transformation. Neuroplasticity is helpful to remove DLGG in eloquent areas. When radical excision cannot be achieved due to invasion of critical neural networks, cerebral remapping over time may lead to a reoperation with an optimized resection. To discover and treat DLGG earlier, a screening in the general population should be considered.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, CHU Montpellier, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier 34295, France; Team "Plasticity of Central Nervous System, Human Stem Cells and Glial Tumors", Institute for Neuroscience of Montpellier, INSERM U1051, Saint Eloi Hospital, Montpellier University Medical Center, Montpellier, France.
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Treatment of cavernous malformations in supratentorial eloquent areas: experience after 10 years of patient-tailored surgical protocol. Acta Neurochir (Wien) 2018; 160:1963-1974. [PMID: 30091050 DOI: 10.1007/s00701-018-3644-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Eloquent area surgery has become safer with the development of intraoperative neurophysiological monitoring and brain mapping techniques. However, the usefulness of intraoperative electric brain stimulation techniques applied to the management and surgical treatment of cavernous malformations in supratentorial eloquent areas is still not proven. With this study, we aim to describe our experience with the use of a tailored functional approach to treat cavernous malformations in supratentorial eloquent areas. METHODS Twenty patients harboring cavernous malformations located in supratentorial eloquent areas were surgically treated. Individualized functional approach, using intraoperative brain mapping and/or neurophysiological monitoring, was utilized in each case. Eleven patients underwent surgery under awake conditions; meanwhile, nine patients underwent asleep surgery. RESULTS Total resection was achieved in 19 cases (95%). In one patient, the resection was not possible due to high motor functional parenchyma surrounding the lesion tested by direct cortical stimulation. Ten (50%) patients presented transient neurological worsening. All of them achieved total neurological recovery within the first year of follow-up. Among the patients who presented seizures, 85% achieved seizure-free status during follow-up. No major complications occurred. CONCLUSIONS Intraoperative electric brain stimulation techniques applied by a trained multidisciplinary team provide a valuable aid for the treatment of certain cavernous malformations. Our results suggest that tailored functional approach could help surgeons in adapting surgical strategies to prevent patients' permanent neurological damage.
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Albuquerque LAF, Pessoa FC, Diógenes GS, Borges FS, Araújo Filho SC. Awake craniotomy for a cavernous angioma in the Broca’s area. Neurosurg Focus 2018; 45:V4. [DOI: 10.3171/2018.10.focusvid.18240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cavernous angiomas constitute 5%–10% of cerebrovascular malformations and may cause seizure and neurological deficits from bleeding.4 The authors present a case of a 44-year-old man with a 3.5-year history of epilepsy without complete seizure control despite anticonvulsants. Brain MRI showed a 2.8 cm cavernous angioma at the left pars opercularis, also known as the Broca’s area.3 The patient underwent an awake craniotomy for intraoperative cortical–subcortical language and sensory-motor mapping for a complete resection of the cavernous angioma and the hemosiderin rim.1–6 The procedure was uneventful, and the patient evolved seizure free and with no deficits.The video can be found here: https://youtu.be/QajbLIsr_vg.
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Foster CH, Morone PJ, Cohen-Gadol A. Awake craniotomy in glioma surgery: is it necessary? J Neurosurg Sci 2018; 63:162-178. [PMID: 30259721 DOI: 10.23736/s0390-5616.18.04590-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The awake craniotomy has evolved from its humble beginnings in ancient cultures to become one of the most eloquent modern neurosurgical procedures. The development of intraoperative mapping techniques like direct electrostimulation of the cortex and subcortical white matter have further argued for its place in the neurosurgeon's armamentarium. Yet the suitability of the awake craniotomy with intraoperative functional mapping (ACWM) to optimize oncofunctional balance after peri-eloquent glioma resection continues to be a topic of active investigation as new methods of intraoperative monitoring and some unfavorable outcome data question its necessity. EVIDENCE ACQUISITION The neurosurgery and anesthesiology literatures were scoured for English-language studies that analyzed or reviewed the ACWM or its components as applied to glioma surgery via the PubMed, ClinicalKey, and OvidMEDLINE® databases or via direct online searches of journal archives. EVIDENCE SYNTHESIS Information on background, conceptualization, standard techniques, and outcomes of the ACWM were provided and compared. We parceled the procedure into its components and qualitatively described positive and negative outcome data for each. Findings were presented in the context of each study without attempt at quantitative analysis or reconciliation of heterogeneity between studies. Certain illustrative studies were highlighted throughout the review. Overarching conclusions were drawn based on level of evidence, expert opinion, and predominate concordance of data across studies in the literature. CONCLUSIONS Most investigators and studies agree that the ACWM is the best currently available approach to optimize oncofunctional balance in this difficult-to-treat patient population. This qualitative review synthesizes the most currently available data on the topic to provide contemporaneous insight into how and why the ACWM has become a favorite operation of neurosurgeons worldwide for the resection of gliomas from eloquent brain.
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Affiliation(s)
- Chase H Foster
- Department of Neurological Surgery, George Washington University Hospital, Washington D.C., USA -
| | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Aaron Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
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Abstract
Focal epilepsy originating from the insular cortex is rare. One reason is the small amount of cortical tissue compared with other lobes of the brain. However, the incidence of insular epilepsy might be underestimated because of diagnostic difficulties. The semiology and the surface EEG are often not meaningful or even misleading, and elaborated imaging might be necessary. The close connections of the insular cortex with other potentially epileptogenic areas, such as the temporal lobe or frontal/central cortex, is increasingly recognized as possible reason for failure of epilepsy surgery for temporal or extratemporal seizures. Therefore, some centers consider invasive EEG recording of the insular cortex not only in case of insular epilepsy but also in other focal epilepsies with nonconclusive results from the presurgical work-up. The surgical approach to and resection of insular cortex is challenging because of its deep location and proximity to highly eloquent brain structures. Over the last decades, technical adjuncts like navigation tools, electrophysiological monitoring and intraoperative imaging have improved the outcome after surgery. Nevertheless, there is still a considerable rate of postoperative transient or permanent deficits, in some cases as unavoidable and calculated deficits. In most of the recent series, seizure outcome was favorable and comparable with extratemporal epilepsy surgery or even better. Up to now, the data volume concerning long-term follow-up is limited. This review focusses on the surgical challenges of resections to treat insular epilepsy, on prognostic factors concerning seizure outcome, on postoperative deficits and complications. Moreover, less invasive surgical techniques to treat epilepsy in this highly eloquent area are summarized.
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Awake Surgery for Gliomas within the Right Inferior Parietal Lobule: New Insights into the Functional Connectivity Gained from Stimulation Mapping and Surgical Implications. World Neurosurg 2018; 112:e393-e406. [DOI: 10.1016/j.wneu.2018.01.053] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 01/07/2018] [Accepted: 01/11/2018] [Indexed: 11/30/2022]
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Eseonu CI, Rincon-Torroella J, ReFaey K, Lee YM, Nangiana J, Vivas-Buitrago T, Quiñones-Hinojosa A. Awake Craniotomy vs Craniotomy Under General Anesthesia for Perirolandic Gliomas: Evaluating Perioperative Complications and Extent of Resection. Neurosurgery 2018; 81:481-489. [PMID: 28327900 DOI: 10.1093/neuros/nyx023] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/07/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND A craniotomy with direct cortical/subcortical stimulation either awake or under general anesthesia (GA) present 2 approaches for removing eloquent region tumors. With a reported higher prevalence of intraoperative seizures occurring during awake resections of perirolandic lesions, oftentimes, surgery under GA is chosen for these lesions. OBJECTIVE To evaluate a single-surgeon's experience with awake craniotomies (AC) vs surgery under GA for resecting perirolandic, eloquent, motor-region gliomas. METHODS Between 2005 and 2015, a retrospective analysis of 27 patients with perirolandic, eloquent, motor-area gliomas that underwent an AC were case-control matched with 31 patients who underwent surgery under GA for gliomas in the same location. All patients underwent direct brain stimulation with neuromonitoring and perioperative risk factors, extent of resection, complications, and discharge status were assessed. RESULTS The postoperative Karnofsky Performance Score (KPS) was significantly lower for the GA patients at 81.1 compared to the AC patients at 93.3 ( P = .040). The extent of resection for GA patients was 79.6% while the AC patients had an 86.3% resection ( P = .136). There were significantly more 100% total resections in the AC patients 25.9% compared to the GA group (6.5%; P = .041). Patients in the GA group had a longer mean length of hospitalization of 7.9 days compared to the AC group at 4.2 days ( P = .049). CONCLUSION We show that AC can be performed with more frequent total resections, better postoperative KPS, shorter hospitalizations, as well as similar perioperative complication rates compared to surgery under GA for perirolandic, eloquent motor-region glioma.
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Affiliation(s)
- Chikezie I Eseonu
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Jordina Rincon-Torroella
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Karim ReFaey
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Young M Lee
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Jasvinder Nangiana
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Tito Vivas-Buitrago
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
| | - Alfredo Quiñones-Hinojosa
- Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland
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Abstract
INTRODUCTION Radical glioma resection improves overall survival, both in low-grade and high-grade glial tumors. However, preservation of the quality of life is also crucial. Areas covered: Due to the diffuse feature of gliomas, which invade the central nervous system, and due to considerable variations of brain organization among patients, an individual cerebral mapping is mandatory to solve the classical dilemma between the oncological and functional issues. Because functional neuroimaging is not reliable enough, intraoperative electrical stimulation, especially in awake patients benefiting from a real-time cognitive monitoring, is the best way to increase the extent of resection while sparing eloquent neural networks. Expert commentary: Here, we propose a paradigmatic shift from image-guided resection to functional mapping-guided resection, based on the study of the dynamic distribution of delocalized cortico-subcortical circuits at the individual level, i.e., the investigation of brain connectomics and neuroplastic potential. This surgical philosophy results in an improvement of both oncological outcomes and quality of life. This highlights the need to reinforce the link between glioma surgery and cognitive neurosciences.
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Affiliation(s)
| | - Hugues Duffau
- b Department of Neurosurgery , Gui de Chauliac Hospital, Montpellier University Medical Center , Montpellier , France.,c National Institute for Health and Medical Research (INSERM), U1051 Laboratory, Team "Brain Plasticity, Stem Cells and Glial Tumors", Institute for Neurosciences of Montpellier , Montpellier University Medical Center , Montpellier , France
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Technical Aspects of Awake Craniotomy with Mapping for Brain Tumors in a Limited Resource Setting. World Neurosurg 2018; 113:67-72. [PMID: 29452315 DOI: 10.1016/j.wneu.2018.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 02/01/2018] [Accepted: 02/02/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Brain tumor surgery near or within eloquent regions is increasingly common and is associated with a high risk of neurologic injury. Awake craniotomy with mapping has been shown to be a valid method to preserve neurologic function and increase the extent of resection. However, the technique used varies greatly among centers. Most count on professionals such as neuropsychologists, speech therapists, neurophysiologists, or neurologists to help in intraoperative patient evaluation. We describe our technique with the sole participation of neurosurgeons and anesthesiologists. METHODS A retrospective review of 19 patients who underwent awake craniotomies for brain tumors between January 2013 and February 2017 at a tertiary university hospital was performed. We sought to identify and describe the most critical stages involved in this surgery as well as show the complications associated with our technique. RESULTS Preoperative preparation, positioning, anesthesia, brain mapping, resection, and management of seizures and pain were stages deemed relevant to the accomplishment of an awake craniotomy. Sixteen percent of the patients developed new postoperative deficit. Seizures occurred in 24%. None led to awake craniotomy failure. CONCLUSIONS We provide a thorough description of the technique used in awake craniotomies with mapping used in our institution, where the intraoperative patient evaluation is carried out solely by neurosurgeons and anesthesiologists. The absence of other specialized personnel and equipment does not necessarily preclude successful mapping during awake craniotomy. We hope to provide helpful information for those who wish to offer function-guided tumor resection in their own centers.
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65
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Cochereau J, Deverdun J, Herbet G, Charroud C, Boyer A, Moritz-Gasser S, Le Bars E, Molino F, Bonafé A, Menjot de Champfleur N, Duffau H. Comparison between resting state fMRI networks and responsive cortical stimulations in glioma patients. Hum Brain Mapp 2018; 37:3721-3732. [PMID: 27246771 DOI: 10.1002/hbm.23270] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 05/01/2016] [Accepted: 05/17/2016] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To validate the functional relevance of resting state networks (RSNs) by means of a comparison of resting state connectivity (RSC) between language regions elicited by direct cortical stimulation versus RSC between random regions; and to evaluate the accuracy of resting state fMRI in surgical planning by assessing the overlap between RSNs and intraoperative functional mapping results. METHODS Sensorimotor and language eloquent sites were identified by direct electrical cortical stimulation in 98 patients with a diffuse low-grade glioma. A seed to voxel analysis with inter-language stimulation point connectivity versus inter-random ROIs connectivity was performed (19 patients). An independant component analysis (ICA) was also applied to rsfMRI data. Language and sensorimotor components were selected over 20 independent components and compared to the corresponding stimulation points and resected cortex masks (31 and 90 patients, respectively). RESULTS Mean connectivity value between language seeds was significantly higher than the one between random seeds (0.68 ± 0.39 and 0.12 ± 0.21 respectively, P < 10-10 ). 96 ± 11% of sensorimotor stimulation points were located within 10 mm from sensorimotor ICA maps versus 92 ± 21% for language. 3.1 and 15% of resected cortex overlapped sensorimotor and language networks, respectively. Mean sensorimotor stimulation points and resected cortex z-scores were 2.0 ± 1.2 and -0.050 ± 0.60, respectively (P < 10-10 ). Mean language stimulation points and resected cortex z-scores were 1.6 ± 1.9 and 0.68 ± 0.91, respectively, P < 0.005. CONCLUSION The significantly higher RSC between language seeds than between random seeds validated the functional relevance of RSC. ICA partly succeeded to distinguish eloquent versus surgically removable areas and may be possibly used as a complementary tool to intraoperative mapping. Hum Brain Mapp 37:3721-3732, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jérôme Cochereau
- Department of Neurosurgery, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Unité I2FH, Institut d'Imagerie Fonctionnelle Humaine, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", INSERM U1051, Institute of Neurosciences of Montpellier, Montpellier, France.,Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Jérémy Deverdun
- Unité I2FH, Institut d'Imagerie Fonctionnelle Humaine, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Institut de Génomique Fonctionnelle, Unité UMR 5203 - INSERM U661 - Université Montpellier II - Université Montpellier I, France.,Laboratoire Charles Coulomb, Unité CNRS UMR 5221 - Université Montpellier II, Montpellier, France
| | - Guillaume Herbet
- Department of Neurosurgery, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", INSERM U1051, Institute of Neurosciences of Montpellier, Montpellier, France
| | - Céline Charroud
- Unité I2FH, Institut d'Imagerie Fonctionnelle Humaine, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Anthony Boyer
- Unité I2FH, Institut d'Imagerie Fonctionnelle Humaine, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,University of Montpellier 2, LIRMM laboratory, DEMAR Team, CNRS, INRIA, Montpellier, 34095, France
| | - Sylvie Moritz-Gasser
- Department of Neurosurgery, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", INSERM U1051, Institute of Neurosciences of Montpellier, Montpellier, France
| | - Emmanuelle Le Bars
- Unité I2FH, Institut d'Imagerie Fonctionnelle Humaine, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Laboratoire Charles Coulomb, Unité CNRS UMR 5221 - Université Montpellier II, Montpellier, France
| | - François Molino
- Institut de Génomique Fonctionnelle, Unité UMR 5203 - INSERM U661 - Université Montpellier II - Université Montpellier I, France.,Laboratoire Charles Coulomb, Unité CNRS UMR 5221 - Université Montpellier II, Montpellier, France
| | - Alain Bonafé
- Unité I2FH, Institut d'Imagerie Fonctionnelle Humaine, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", INSERM U1051, Institute of Neurosciences of Montpellier, Montpellier, France.,Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Nicolas Menjot de Champfleur
- Unité I2FH, Institut d'Imagerie Fonctionnelle Humaine, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", INSERM U1051, Institute of Neurosciences of Montpellier, Montpellier, France.,Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Laboratoire Charles Coulomb, Unité CNRS UMR 5221 - Université Montpellier II, Montpellier, France
| | - Hugues Duffau
- Department of Neurosurgery, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", INSERM U1051, Institute of Neurosciences of Montpellier, Montpellier, France
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Mandonnet E, Duffau H. An attempt to conceptualize the individual onco-functional balance: Why a standardized treatment is an illusion for diffuse low-grade glioma patients. Crit Rev Oncol Hematol 2017; 122:83-91. [PMID: 29458793 DOI: 10.1016/j.critrevonc.2017.12.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 11/19/2017] [Accepted: 12/12/2017] [Indexed: 12/15/2022] Open
Abstract
In the era of evidence-based medicine, clinicians aim to establish standards of care from randomized studies. Following, personalized medicine has emerged, as new individualized biomarkers could help to predict sensitivity to specific treatment. In this paper, we show that, for diffuse low-grade glioma, some specificities - dual goal of both survival and functional gain, long duration of the disease with multistep treatments, multiparametric evaluation of the onco-functional balance of each treatment modality - call for a change of paradigm. After summarizing how to weight the benefits and risks of surgery, chemotherapy and radiotherapy, we show that the overall efficacy of a treatment modality cannot be assessed per se, as it depends on its integration in the whole sequence. Then, we revisit the notion of personalized medicine: instead of decision-making based solely on molecular profile, we plead for a recursive algorithm, allowing a dynamic evaluation of the onco-functional balance, integrating many individual characteristics of the patient's tumor and brain function.
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Affiliation(s)
- Emmanuel Mandonnet
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France; University Paris 7, Paris, France; Institut du Cerveau de la Moelle (ICM), Paris, France.
| | - Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier Medical University Center, Montpellier, France; Institute of Neuroscience of Montpellier, INSERM U1051, Montpellier, France; University of Montpellier, Montpellier, France
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67
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Duffau H. Awake mapping is not an additional surgical technique but an alternative philosophy in the management of low-grade glioma patients. Neurosurg Rev 2017; 41:689-691. [PMID: 29236183 DOI: 10.1007/s10143-017-0937-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 12/06/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80, Avenue Augustin Fliche, 34295, Montpellier, France. .,Institute for Neuroscience of Montpellier, INSERM U1051, Team "Plasticity of Central Nervous System, Human Stem Cells and Glial Tumors," Saint Eloi Hospital, Montpellier University Medical Center, Montpellier, France.
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68
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Ghinda DC, Wu JS, Duncan NW, Northoff G. How much is enough-Can resting state fMRI provide a demarcation for neurosurgical resection in glioma? Neurosci Biobehav Rev 2017; 84:245-261. [PMID: 29198588 DOI: 10.1016/j.neubiorev.2017.11.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/20/2017] [Accepted: 11/27/2017] [Indexed: 01/09/2023]
Abstract
This study represents a systematic review of the insights provided by resting state functional MRI (rs-fMRI) use in the glioma population. Following PRISMA guidelines, 45 studies were included in the review and were classified in glioma-related neuronal changes (n=28) and eloquent area localization (n=17). Despite the heterogeneous nature of the studies, there is considerable evidence of diffuse functional reorganization occurring in the setting of gliomas with local and interhemispheric functional connectivity alterations involving different functional networks. The studies showed evidence of decreased long distance functional connectivity and increased global local efficiency occurring in the setting of gliomas. The tumour grade seems to correlate with distinct functional connectivity changes. Overall, there is a potential clinical utility of rs-fMRI for identifying the functional brain network disruptions occurring in the setting of gliomas. Further studies utilizing standardized analytical methods are required to elucidate the mechanism through which gliomas induce global changes in brain connectivity.
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Affiliation(s)
- Diana C Ghinda
- Ottawa Hospital Research Institute, University of Ottawa, Division of Neurosurgery, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada; Mind, Brain Imaging and Neuroethics, Canada Research Chair, EJLB-Michael Smith Chair for Neuroscience and Mental Health, Royal Ottawa Mental Health Centre, University of Ottawa Institute of Mental Health Research, 1145 Carling Avenue, Rm. 6435, Ottawa, ON, K1Z 7K4, Canada.
| | - Jin-Song Wu
- Glioma Surgery Division, Department of Neurological Surgery, Huashan Hospital, Fudan University, 518 Wuzhong E Rd, Shanghai, China.
| | - Niall W Duncan
- Brain and Consciousness Research Center, Taipei Medical University-Shuang Ho Hospital, 250 Wu-Xing Street, Taipei, 11031, Taiwan.
| | - Georg Northoff
- Mind, Brain Imaging and Neuroethics, Canada Research Chair, EJLB-Michael Smith Chair for Neuroscience and Mental Health, Royal Ottawa Mental Health Centre, University of Ottawa Institute of Mental Health Research, 1145 Carling Avenue, Rm. 6435, Ottawa, ON, K1Z 7K4, Canada; Mental Health Center/7th Hospital, Zhejiang University School of Medicine, 305 Tianmu Road, Hangzhou, Zhejiang Province, 310013, China.
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69
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Proposition de dépistage des gliomes diffus de bas grade dans la population de 20 à 40 ans. Presse Med 2017; 46:911-920. [DOI: 10.1016/j.lpm.2017.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/17/2017] [Accepted: 07/12/2017] [Indexed: 12/30/2022] Open
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70
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Boissonneau S, Duffau H. Identifying clinical risk in low grade gliomas and appropriate treatment strategies, with special emphasis on the role of surgery. Expert Rev Anticancer Ther 2017; 17:703-716. [PMID: 28608763 DOI: 10.1080/14737140.2017.1342537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Diffuse low-grade glioma (DLGG) is a chronic tumoral disease that ineluctably grows, migrates along white matter pathways, and progresses to a higher grade of malignancy. Areas covered: To determine the best individualized treatment attitude for each DLGG patient, and to redefine it over the years, i.e. to optimize the 'onco-functional balance' of serial and multimodal therapies, the understanding of the natural history of this chronic disease is crucial but not sufficient. A paradigmatic shift is to tailor the individual management according to the dynamic relationships between DLGG course and neural remodeling. In this spirit, a better knowledge of brain plasticity in a connectomal account of cerebral processing has enabled a dramatic improvement of both oncological and functional outcomes in DLGG patients, by increasing overall survival while preserving (or even improving) the quality of life. Expert commentary: Here, we propose an individualized and recursive therapeutic strategy in DLGG, leading to the concept of a 'personalized functional neuro-oncology', by emphasizing the role of early and maximal safe surgical resection(s) reliably achieved using intraoperative mapping of cortico-subcortical networks in awake patients.
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Affiliation(s)
| | - Hugues Duffau
- b Department of Neurosurgery , Gui de Chauliac Hospital, Montpellier University Medical Center , Montpellier , France.,c Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors," INSERM U1051, Institute for Neurosciences of Montpellier , Montpellier University Medical Center , Montpellier , France
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71
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Fontaine D, Almairac F. Pain during awake craniotomy for brain tumor resection. Incidence, causes, consequences and management. Neurochirurgie 2017; 63:204-207. [DOI: 10.1016/j.neuchi.2016.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/01/2016] [Accepted: 08/22/2016] [Indexed: 10/20/2022]
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Abstract
For a long time, although the functional anatomy of human cortex has extensively been studied, subcortical white matter tracts have received little consideration. Recent advances in tractography have opened the door to a non-invasive investigation of the subcortical fibers in vivo. However, this method cannot study directly the function of the bundles. Interestingly, for the first time in the history of cognitive neurosciences, direct axonal electrostimulation (DES) mapping of the neural pathways offers the unique opportunity to investigate the function of the connectomal anatomy. Indeed, this technique is able to perform real-time anatomo-functional correlations in awake patients who undergo brain surgery, especially at the level of the subcortical fibers. Here, the aim is to review original data issued from DES of myelinated tracts in adults, with regard to the functional connectivity mediating the sensorimotor, visuo-spatial, language, cognitive and emotional functions, as well as the interactions between these different sub-networks, leading ultimately to explore consciousness. Therefore, axonal stimulation is a valuable tool in the field of connectomics, that is, the map of neural connections, in order to switch from the traditional localizationist view of brain processing to a networking model in which cerebral functions are underpinned by the dynamic interactions of large-scale distributed and parallel sub-circuits. Such connectomal account should integrate the anatomic constraint represented by the subcortical fascicles. Indeed, post-lesional neuroplasticity is possible only on the condition that the white matter fibers are preserved, to allow communication and temporal synchronization among delocalized inter-connected networks.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80 Av Augustin Fliche, 34295 Montpellier, France.,National Institute for Health and Medical Research (INSERM), U1051 Laboratory, Team "Brain Plasticity, Stem Cells and Glial Tumors", Institute for Neurosciences of Montpellier, Montpellier University Medical Center, 34091 Montpellier, France
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73
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Freyschlag CF, Kerschbaumer J, Eisner W, Pinggera D, Brawanski KR, Petr O, Bauer M, Grams AE, Bodner T, Seiz M, Thomé C. Optical Neuronavigation without Rigid Head Fixation During Awake Surgery. World Neurosurg 2016; 97:669-673. [PMID: 27989983 DOI: 10.1016/j.wneu.2016.10.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Optical neuronavigation without rigid pin fixation of the head may lead to inaccurate results because of the patient's movements during awake surgery. In this study, we report our results using a skull-mounted reference array for optical tracking in patients undergoing awake craniotomy for eloquent gliomas. METHODS Between March 2013 and December 2014, 18 consecutive patients (10 men, 8 women) with frontotemporal (n = 16) or frontoparietal (perirolandic; n = 2) lesions underwent awake craniotomy without rigid pin fixation. All patients had a skull-mounted reference array for optical tracking placed on the forehead. Accuracy of navigation was determined with pointer tip deviation measurements on superficial and bony anatomic structures. Good accuracy was defined as a tip deviation <2 mm. RESULTS Gross total resection (>98%) was achieved in 7 patients (38%); >90% of tumor was resected in 8 patients (44%). In 3 patients, only subtotal resection or biopsy was performed secondary to stimulation results. In all patients, good accuracy of the optical neuronavigation system could be demonstrated without intraoperative peculiarities or complications. The reference array had to be repositioned because of loosening in 1 patient. Neuronavigation could be reliably applied to support stimulation-based resection. CONCLUSIONS A skull-mounted reference array is a simple and safe method for optical neuronavigation tracking without rigid pin fixation of the patient's head.
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Affiliation(s)
| | | | - Wilhelm Eisner
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Ondra Petr
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Marlies Bauer
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Astrid E Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Bodner
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marcel Seiz
- Department of Neurosurgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
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74
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Awake surgery for hemispheric low-grade gliomas: oncological, functional and methodological differences between pediatric and adult populations. Childs Nerv Syst 2016; 32:1861-74. [PMID: 27659829 DOI: 10.1007/s00381-016-3069-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 03/14/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Brain mapping through a direct cortical and subcortical electrical stimulation during an awake craniotomy has gained an increasing popularity as a powerful tool to prevent neurological deficit while increasing extent of resection of hemispheric diffuse low-grade gliomas in adults. However, few case reports or very limited series of awake surgery in children are currently available in the literature. METHODS In this paper, we review the oncological and functional differences between pediatric and adult populations, and the methodological specificities that may limit the use of awake mapping in pediatric low-grade glioma surgery. RESULTS This could be explained by the fact that pediatric low-grade gliomas have a different epidemiology and biologic behavior in comparison to adults, with pilocytic astrocytomas (WHO grade I glioma) as the most frequent histotype, and with WHO grade II gliomas less prone to anaplastic transformation than their adult counterparts. In addition, aside from the issue of poor collaboration of younger children under 10 years of age, some anatomical and functional peculiarities of children developing brain (cortical and subcortical myelination, maturation of neural networks and of specialized cortical areas) can influence direct electrical stimulation methodology and sensitivity, limiting its use in children. CONCLUSIONS Therefore, even though awake procedure with cortical and axonal stimulation mapping can be adapted in a specific subgroup of children with a diffuse glioma from the age of 10 years, only few pediatric patients are nonetheless candidates for awake brain surgery.
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Spena G, Schucht P, Seidel K, Rutten GJ, Freyschlag CF, D'Agata F, Costi E, Zappa F, Fontanella M, Fontaine D, Almairac F, Cavallo M, De Bonis P, Conesa G, Foroglou N, Gil-Robles S, Mandonnet E, Martino J, Picht T, Viegas C, Wager M, Pallud J. Brain tumors in eloquent areas: A European multicenter survey of intraoperative mapping techniques, intraoperative seizures occurrence, and antiepileptic drug prophylaxis. Neurosurg Rev 2016; 40:287-298. [PMID: 27481498 DOI: 10.1007/s10143-016-0771-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/05/2016] [Accepted: 07/25/2016] [Indexed: 01/08/2023]
Abstract
Intraoperative mapping and monitoring techniques for eloquent area tumors are routinely used world wide. Very few data are available regarding mapping and monitoring methods and preferences, intraoperative seizures occurrence and perioperative antiepileptic drug management. A questionnaire was sent to 20 European centers with experience in intraoperative mapping or neurophysiological monitoring for the treatment of eloquent area tumors. Fifteen centers returned the completed questionnaires. Data was available on 2098 patients. 863 patients (41.1%) were operated on through awake surgery and intraoperative mapping, while 1235 patients (58.8%) received asleep surgery and intraoperative electrophysiological monitoring or mapping. There was great heterogeneity between centers with some totally AW oriented (up to 100%) and other almost totally ASL oriented (up to 92%) (31% SD). For awake surgery, 79.9% centers preferred an asleep-awake-asleep anesthesia protocol. Only 53.3% of the centers used ECoG or transcutaneous EEG. The incidence of intraoperative seizures varied significantly between centers, ranging from 2.5% to 54% (p < 0.001). It there appears to be a statistically significant link between the mastery of mapping technique and the risk of intraoperative seizures. Moreover, history of preoperative seizures can significantly increase the risk of intraoperative seizures (p < 0.001). Intraoperative seizures occurrence was similar in patients with or without perioperative drugs (12% vs. 12%, p = 0.2). This is the first European survey to assess intraoperative functional mapping and monitoring protocols and the management of peri- and intraoperative seizures. This data can help identify specific aspects that need to be investigated in prospective and controlled studies.
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Affiliation(s)
- Giannantonio Spena
- Clinic of Neurosurgery, Spedali Civili di Brescia, Scala 7, Piano 3°, Piazzale Spedali Civili 1, 25121, Brescia, Italy.
| | | | | | | | | | | | - Emanule Costi
- Clinic of Neurosurgery, Spedali Civili di Brescia, Scala 7, Piano 3°, Piazzale Spedali Civili 1, 25121, Brescia, Italy
| | - Francesca Zappa
- Clinic of Neurosurgery, Spedali Civili di Brescia, Scala 7, Piano 3°, Piazzale Spedali Civili 1, 25121, Brescia, Italy
| | - Marco Fontanella
- Clinic of Neurosurgery, Spedali Civili di Brescia, Scala 7, Piano 3°, Piazzale Spedali Civili 1, 25121, Brescia, Italy
| | - Denys Fontaine
- Neurosurgery, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Fabien Almairac
- Neurosurgery, Centre Hospitalier Universitaire de Nice, Nice, France
| | | | | | | | - Nicholas Foroglou
- Neurosurgery, AHEPA University Hospital of Thessaloniki, Thessaloniki, Greece
| | | | | | - Juan Martino
- Neurosurgery, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Thomas Picht
- Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Michel Wager
- Neurosurgery, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Johan Pallud
- Neurosurgery, Centre Hospitalier Sainte-Anne and Paris Descartes University, Paris, France
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Roux FE, Durand JB, Djidjeli I, Moyse E, Giussani C. Variability of intraoperative electrostimulation parameters in conscious individuals: language cortex. J Neurosurg 2016; 126:1641-1652. [PMID: 27419823 DOI: 10.3171/2016.4.jns152434] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Electrostimulation in awake brain mapping is widely used to guide tumor removal, but methodologies can differ substantially across institutions. The authors studied electrostimulation brain mapping data to characterize the variability of the current intensity threshold across patients and the effect of its variations on the number, type, and surface area of the essential language areas detected. METHODS Over 7 years, the authors prospectively studied 100 adult patients who were undergoing intraoperative brain mapping during resection of left hemisphere tumors. In all 100 cases, the same protocol of electrostimulation brain mapping (a controlled naming task-bipolar stimulation with biphasic square wave pulses of 1-msec duration and 60-Hz trains, maximum train duration 6 sec) and electrocorticography was used to detect essential language areas. RESULTS The minimum positive thresholds of stimulation varied from patient to patient; the mean minimum intensity required to detect interference was 4.46 mA (range 1.5-9 mA), and in a substantial proportion of sites (13.5%) interference was detected only at intensities above 6 mA. The threshold varied within a given patient for different naming areas in 22% of cases. Stimulation of the same naming area with greater intensities led to slight changes in the type of response in 19% of cases and different types of responses in 4.5%. Naming sites detected were located in subcentimeter cortical areas (50% were less than 20 mm2), but their extent varied with the intensity of stimulation. During a brain mapping session, the same intensity of stimulation reproduced the same type of interference in 94% of the cases. There was no statistically significant difference between the mean stimulation intensities required to produce interfereince in the left inferior frontal lobe (Broca's area), the supramarginal gyri, and the posterior temporal region. CONCLUSIONS Intrasubject and intersubject variations of the minimum thresholds of positive naming areas and changes in the type of response and in the size of these areas according to the intensity used may limit the interpretation of data from electrostimulation in awake brain mapping. To optimize the identification of language areas during electrostimulation brain mapping, it is important to use different intensities of stimulation at the maximum possible currents, avoiding afterdischarges. This could refine the clinical results and scientific data derived from these mapping sessions.
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Affiliation(s)
- Franck-Emmanuel Roux
- Pôle Neuroscience (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse.,Centre de Recherche Cerveau et Cognition (CNRS; CerCo), Toulouse, France; and
| | | | - Imène Djidjeli
- Pôle Neuroscience (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse.,Centre de Recherche Cerveau et Cognition (CNRS; CerCo), Toulouse, France; and
| | - Emmanuel Moyse
- Pôle Neuroscience (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse.,Université de Toulouse, UPS
| | - Carlo Giussani
- Neurosurgery, Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Ospedale San, Gerardo, Monza, Italy
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Templer JW, Gavvala JR, Tate MC, Schuele SU. Reexamining the Value of Intraoperative Electrocorticography During Awake Craniotomy. World Neurosurg 2016; 91:655. [DOI: 10.1016/j.wneu.2015.10.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 10/24/2015] [Indexed: 11/26/2022]
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78
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Awake Craniotomy: First-Year Experiences and Patient Perception. World Neurosurg 2016; 90:588-596.e2. [DOI: 10.1016/j.wneu.2016.02.051] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 02/06/2016] [Accepted: 02/09/2016] [Indexed: 12/22/2022]
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79
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Stevanovic A, Rossaint R, Veldeman M, Bilotta F, Coburn M. Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0156448. [PMID: 27228013 PMCID: PMC4882028 DOI: 10.1371/journal.pone.0156448] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 05/13/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Awake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques. METHODS Two authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI]. RESULTS We have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1-3], 8% [95%CI:6-11], 17% [95%CI:12-23] and 2% [95%CI:2-3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36-2.69], 1.01 [95%CI:0.52-1.88] for seizures, 1.66 [95%CI:1.35-3.70] for new neurological dysfunction and 2.17 [95%CI:1.22-3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies. CONCLUSION SAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.
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Affiliation(s)
- Ana Stevanovic
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, University of Rome “La Sapienza”, Rome, Italy
| | - Mark Coburn
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- * E-mail:
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Proposal of an optimized strategy for intraoperative testing of speech and language during awake mapping. Neurosurg Rev 2016; 40:29-35. [DOI: 10.1007/s10143-016-0723-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 11/15/2015] [Accepted: 01/25/2016] [Indexed: 01/21/2023]
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Preoperative Quantitative MR Tractography Compared with Visual Tract Evaluation in Patients with Neuropathologically Confirmed Gliomas Grades II and III: A Prospective Cohort Study. Radiol Res Pract 2016; 2016:7671854. [PMID: 27190647 PMCID: PMC4852118 DOI: 10.1155/2016/7671854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/23/2016] [Indexed: 12/22/2022] Open
Abstract
Background and Purpose. Low-grade gliomas show infiltrative growth in white matter tracts. Diffusion tensor tractography can noninvasively assess white matter tracts. The aim was to preoperatively assess tumor growth in white matter tracts using quantitative MR tractography (3T). The hypothesis was that suspected infiltrated tracts would have altered diffusional properties in infiltrated tract segments compared to noninfiltrated tracts. Materials and Methods. Forty-eight patients with suspected low-grade glioma were included after written informed consent and underwent preoperative diffusion tensor imaging in this prospective review-board approved study. Major white matter tracts in both hemispheres were tracked, segmented, and visually assessed for tumor involvement in thirty-four patients with gliomas grade II or III (astrocytomas or oligodendrogliomas) on postoperative neuropathological evaluation. Relative fractional anisotropy (rFA) and mean diffusivity (rMD) in tract segments were calculated and compared with visual evaluation and neuropathological diagnosis. Results. Tract segment infiltration on visual evaluation was associated with a lower rFA and high rMD in a majority of evaluated tract segments (89% and 78%, resp.). Grade II and grade III gliomas had similar infiltrating behavior. Conclusion. Quantitative MR tractography corresponds to visual evaluation of suspected tract infiltration. It may be useful for an objective preoperative evaluation of tract segment involvement.
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Electrocorticography Is Not Necessary During Awake Brain Surgery for Gliomas. World Neurosurg 2016; 91:656-7. [PMID: 27001242 DOI: 10.1016/j.wneu.2016.03.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 01/01/2023]
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