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Maldonado IL, Moritz-Gasser S, Duffau H. Does the left superior longitudinal fascicle subserve language semantics? A brain electrostimulation study. Brain Struct Funct 2011; 216:263-74. [PMID: 21538022 DOI: 10.1007/s00429-011-0309-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Accepted: 03/05/2011] [Indexed: 11/30/2022]
Abstract
Recent diffusion tensor imaging (DTI) tractography studies indicate that the supramarginal gyrus (SMG) represents a relay between frontal and temporal language sites. Some authors postulate that pathways connecting SMG to the posterior temporal lobe, i.e., the posterior part of the superior longitudinal fascicle (SLF) subserve semantic aspects of language. However, DTI provides only anatomic but not functional data. Therefore, it is impossible to conclude. Interestingly, intra-operative electrical mapping of cortical and subcortical language structures during tumor surgery is recognized as a reliable technique in functional neuroanatomy research. We mapped the underlying white matter of the SMG, especially the SLF, in 11 patients who underwent awake surgery for a glioma involving the left inferior parietal lobule. Using direct electrostimulation, we investigated the exact role of the SLF in language. Our findings indicate that the white matter under the inferior parietal lobule is highly involved in the dorsal phonological system. First, the SMG, connected to the ventral premotor cortex by horizontal fibers of the SLF, subserves articulatory processing, as demonstrated by dysarthria elicited by stimulation. Second, long arcuate fibers, found deeper in the white matter, subserve phonological processing, as supported by phonemic paraphasia induced by electrostimulation. Third, the most important result is that no semantic disturbances were elicited by stimulating the SLF, including its posterior part. Furthermore, no semantic disorders occurred postoperatively. Subcortical brain mapping by direct electrical stimulation does not provide arguments for a possible role of the left SLF in language semantic processing.
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Affiliation(s)
- Igor Lima Maldonado
- Department of Neurosurgery, Hôpital Gui de Chauliac, CHU Montpellier, 80 Av Augustin Fliche, 34295 Montpellier, France
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Maldonado IL, Moritz-Gasser S, Duffau H. Does the left superior longitudinal fascicle subserve language semantics? A brain electrostimulation study. Brain Struct Funct 2011. [DOI: 10.1007/s00429-011-0309-x (2011)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
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Elhawary H, Liu H, Patel P, Norton I, Rigolo L, Papademetris X, Hata N, Golby AJ. Intraoperative real-time querying of white matter tracts during frameless stereotactic neuronavigation. Neurosurgery 2011; 68:506-16; discussion 516. [PMID: 21135719 PMCID: PMC3121103 DOI: 10.1227/neu.0b013e3182036282] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Brain surgery faces important challenges when trying to achieve maximum tumor resection while avoiding postoperative neurological deficits. OBJECTIVE For surgeons to have optimal intraoperative information concerning white matter (WM) anatomy, we developed a platform that allows the intraoperative real-time querying of tractography data sets during frameless stereotactic neuronavigation. METHODS Structural magnetic resonance imaging, functional magnetic resonance imaging, and diffusion tensor imaging were performed on 5 patients before they underwent lesion resection using neuronavigation. During the procedure, the tracked surgical tool tip position was transferred from the navigation system to the 3-dimensional Slicer software package, which used this position to seed the WM tracts around the tool tip location, rendering a geometric visualization of these tracts on the preoperative images previously loaded onto the navigation system. The clinical feasibility of this approach was evaluated in 5 cases of lesion resection. In addition, system performance was evaluated by measuring the latency between surgical tool tracking and visualization of the seeded WM tracts. RESULTS Lesion resection was performed successfully in all 5 patients. The seeded WM tracts close to the lesion and other critical structures, as defined by the functional and structural images, were interactively visualized during the intervention to determine their spatial relationships relative to the lesion and critical cortical areas. Latency between tracking and visualization of tracts was less than a second for a fiducial radius size of 4 to 5 mm. CONCLUSION Interactive tractography can provide an intuitive way to inspect critical WM tracts in the vicinity of the surgical region, allowing the surgeon to have increased intraoperative WM information to execute the planned surgical resection.
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Affiliation(s)
- Haytham Elhawary
- Surgical Planning Laboratory, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Haiying Liu
- Surgical Planning Laboratory, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Pratik Patel
- BrainLAB AG, Feldkirchen, Germany. http://www.brainlab.com
| | - Isaiah Norton
- Golby Laboratory, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Laura Rigolo
- Golby Laboratory, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Xenophon Papademetris
- Department of Diagnostic Radiology, Yale University of Medicine, and Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Nobuhiko Hata
- Surgical Planning Laboratory, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Alexandra J. Golby
- Surgical Planning Laboratory, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
- Golby Laboratory, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Spena G, Nava A, Cassini F, Pepoli A, Bruno M, D'Agata F, Cauda F, Sacco K, Duca S, Barletta L, Versari P. Preoperative and intraoperative brain mapping for the resection of eloquent-area tumors. A prospective analysis of methodology, correlation, and usefulness based on clinical outcomes. Acta Neurochir (Wien) 2010; 152:1835-46. [PMID: 20730457 DOI: 10.1007/s00701-010-0764-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 08/04/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Localization of brain function is a fundamental requisite for the resection of eloquent-area brain tumors. Preoperative functional neuroimaging and diffusion tensor imaging can display cortical functional organization and subcortical anatomy of major white matter bundles. Direct cortical and subcortical stimulation is widely used in routine practice, however, because of its ability to reveal tissue function in eloquent regions. The role and integration of these techniques is still a matter of debate. The objective of this study was to assess surgical and functional neurological outputs of awake surgery and intraoperative cortical and subcortical electrical stimulation (CSES) and to use CSES to examine the reliability of preoperative functional magnetic resonance (fMRI) and diffusion tensor imaging fiber tracking (DTI-FT) for surgical planning. PATIENTS AND METHODS We prospectively studied 27 patients with eloquent-area tumors who were selected to undergo awake surgery and direct brain mapping. All subjects underwent preoperative sensorimotor and language fMRI and DTI tractography of major white matter bundles. Intra- and postoperative complications, stimulation effects, extent of resection, and neurological outcome were determined. We topographically correlated intraoperatively identified sites (cortical and subcortical) with areas of fMRI activation and DTI tractography. RESULTS Total plus subtotal resection reached 88.8%. Twenty-one patients (77.7%) suffered transient postoperative worsening, but at 6 months follow-up only three (11.1%) patients had persistent neurological impairment. Sensorimotor cortex direct mapping correlated 92.3% with fMRI activation, while direct mapping of language cortex correlated 42.8%. DTI fiber tracking underestimated the presence of functional fibers surrounding or inside the tumor. CONCLUSION Preoperative brain mapping is useful when planning awake surgery to estimate the relationship between the tumor and functional brain regions. However, these techniques cannot directly lead the surgeon during resection. Intraoperative brain mapping is necessary for safe and maximal resection and to guarantee a satisfying neurological outcome. This multimodal approach is more aggressive, leads to better outcomes, and should be used routinely for resection of lesions in eloquent brain regions.
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Affiliation(s)
- Giannantonio Spena
- Division of Neurosurgery, Civil Hospital, via Venezia 16, 15100, Alessandria, Italy.
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Feigl GC, Ritz R, Moraes M, Klein J, Ramina K, Gharabaghi A, Krischek B, Danz S, Bornemann A, Liebsch M, Tatagiba MS. Resection of malignant brain tumors in eloquent cortical areas: a new multimodal approach combining 5-aminolevulinic acid and intraoperative monitoring. J Neurosurg 2010; 113:352-7. [PMID: 19911888 DOI: 10.3171/2009.10.jns09447] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Several studies have revealed that the gross-total resection (GTR) of malignant brain tumors has a significant influence on patient survival. Frequently, however, GTR cannot be achieved because the borders between healthy brain and diseased tissue are blurred in the infiltration zones of malignant brain tumors. Especially in eloquent cortical areas, resection is frequently stopped before total removal is achieved to avoid causing neurological deficits. Interestingly, 5-aminolevulinic acid (5-ALA) has been shown to help visualize tumor tissue intraoperatively and, thus, can significantly improve the possibility of achieving GTR of primary malignant brain tumors. The aim of this study was to go one step further and evaluate the utility and limitations of fluorescence-guided resections of primary malignant brain tumors in eloquent cortical areas in combination with intraoperative monitoring based on multimodal functional imaging data. METHODS Eighteen patients with primary malignant brain tumors in eloquent areas were included in this prospective study. Preoperative neuroradiological examinations included MR imaging with magnetization-prepared rapid gradient echo (MPRAGE), functional MR, and diffusion tensor imaging sequences to visualize functional areas and fiber tracts. Imaging data were analyzed offline, loaded into a neuronavigational system, and used intraoperatively during resections. All patients received 5-ALA 6 hours before surgery. Fluorescence-guided tumor resections were combined with intraoperative monitoring and cortical as well as subcortical stimulation to localize functional areas and fiber tracts during surgery. RESULTS Twenty-five procedures were performed in 18 consecutive patients. In 24% of all surgeries, resection was stopped because a functional area or cortical tract was identified in the resection area or because motor evoked potential amplitudes were reduced in an area where fluorescent tumor cells were still seen intraoperatively. Grosstotal resection could be achieved in 16 (64%) of the surgeries with preservation of all functional areas and fiber tracts. In 2 patients presurgical hemiparesis became accentuated postoperatively, and 1 of these patients also suffered from a new homonymous hemianopia following a second resection. CONCLUSIONS The authors' first results show that tumor resections with 5-ALA in combination with intraoperative cortical stimulation have the advantages of both methods and, thus, provide additional safety for the neurosurgeon during resections of primary malignant brain tumors in eloquent areas. Nonetheless, more cases and additional studies are necessary to further prove the advantages of this multimodal strategy.
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Affiliation(s)
- Guenther C Feigl
- Department of Neurosurgery, University of Tuebingen Medical Center, Tuebingen, Germany.
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De Benedictis A, Moritz-Gasser S, Duffau H. Awake Mapping Optimizes the Extent of Resection for Low-Grade Gliomas in Eloquent Areas. Neurosurgery 2010; 66:1074-84; discussion 1084. [PMID: 20386138 DOI: 10.1227/01.neu.0000369514.74284.78] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Abstract
BACKGROUND
Awake craniotomy with intraoperative electrical mapping is a reliable method to minimize the risk of permanent deficit during surgery for low-grade glioma located within eloquent areas classically considered inoperable. However, it could be argued that preservation of functional sites might lead to a lesser degree of tumor removal. To the best of our knowledge, the extent of resection has never been directly compared between traditional and awake procedures.
OBJECTIVE
We report for the first time a series of patients who underwent 2 consecutive surgeries without and with awake mapping.
METHODS
Nine patients underwent surgery for a low-grade glioma in functional sites under general anesthesia in other institutions. The resection was subtotal in 3 cases and partial in 6 cases. There was a postoperative worsening in 3 cases. We performed a second surgery in the awake condition with intraoperative electrostimulation. The resection was performed according to functional boundaries at both the cortical and subcortical levels.
RESULTS
Postoperative magnetic resonance imaging showed that the resection was complete in 5 cases and subtotal in 4 cases (no partial removal) and that it was improved in all cases compared with the first surgery (P = .04). There was no permanent neurological worsening. Three patients improved compared with the presurgical status. All patients returned to normal professional and social lives.
CONCLUSION
Our results demonstrate that awake surgery, known to preserve the quality of life in patients with low-grade glioma, is also able to significantly improve the extent of resection for lesions located in functional regions.
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Affiliation(s)
| | - Sylvie Moritz-Gasser
- Department of Neurosurgery, Hôpital Gui de Chauliac, CHU Montpellier, Montpellier, France
| | - Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, and Institut of Neuroscience of Montpellier, INSERM U583, Plasticity of Central Nervous System, Human Stem Cells and Glial Tumors, Hôpital Saint Eloi, CHU Montpellier, Montpellier, France
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Abstract
Surgery is the first treatment in neuro-oncology. However, brain gliomas are frequently located within eloquent areas. Therefore, in order to maximize the extent of resection while preserving cerebral functions, owing to major interindividual anatomo–functional variability across patients, functional mapping is now mandatory. Preoperative functional neuroimaging allows a better understanding of the individual organization of brain networks, leading to optimized surgical indications and planning. Intrasurgical cortical and subcortical stimulation, often carried out in awake patients, enables assessment of the performance of online anatomo–functional correlations, with increased resection according to functional boundaries. Postoperative functional neuroimaging following recovery, regularly carried out after active rehabilitation, provides information regarding cerebral plasticity over time, possibly opening the door to another surgery(ies). In summary, brain mapping allows surgical removal in eloquent areas classically considered as ‘inoperable’, and also preservation or even improvement of quality of life, while increasing median survival. The future persepctive is now to move towards dynamic therapeutic strategy based on a multiple-stage surgical approach, combined with (neo)adjuvant chemotherapy and/or radiotherapy. In addition, cerebral mapping enables a better knowledge of brain processing, especially concerning connectivity and plasticity, creating a link between neuro-oncology and cognitive neurosciences, and opening the concept of ‘functional neuro-oncology’.
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Direct electrical stimulation as an input gate into brain functional networks: principles, advantages and limitations. Acta Neurochir (Wien) 2010; 152:185-93. [PMID: 19639247 DOI: 10.1007/s00701-009-0469-0] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 07/04/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND While the fundamental and clinical contribution of direct electrical stimulation (DES) of the brain is now well acknowledged, its advantages and limitations have not been re-evaluated for a long time. METHOD Here, we critically review exactly what DES can tell us about cerebral function. RESULTS First, we show that DES is highly sensitive for detecting the cortical and axonal eloquent structures. Moreover, DES also provides a unique opportunity to study brain connectivity, since each area responsive to stimulation is in fact an input gate into a large-scale network rather than an isolated discrete functional site. DES, however, also has a limitation: its specificity is suboptimal. Indeed, DES may lead to interpretations that a structure is crucial because of the induction of a transient functional response when stimulated, whereas (1) this effect is caused by the backward spreading of the electro-stimulation along the network to an essential area and/or (2) the stimulated region can be functionally compensated owing to long-term brain plasticity mechanisms. CONCLUSION In brief, although DES is still the gold standard for brain mapping, its combination with new methods such as perioperative neurofunctional imaging and biomathematical modeling is now mandatory, in order to clearly differentiate those networks that are actually indispensable to function from those that can be compensated.
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Kombos T, Süss O. Neurophysiological basis of direct cortical stimulation and applied neuroanatomy of the motor cortex: a review. Neurosurg Focus 2009; 27:E3. [DOI: 10.3171/2009.8.focus09141] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intraoperative electrical stimulation of the motor cortex is a sensitive method for intraoperative mapping and monitoring of this region. Two different stimulation techniques have been established, the bipolar and monopolar techniques. Controversy exists regarding the most suitable method. Both methods have advantages and disadvantages and different electrophysiological backgrounds. The present study is a review of the electrophysiological basis of direct cortical electrical stimulation of the motor cortex. Both methods are discussed and their field of application is presented.
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Kombos T, Süss O, Vajkoczy P. Subcortical mapping and monitoring during insular tumor surgery. Neurosurg Focus 2009; 27:E5. [DOI: 10.3171/2009.8.focus09140] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The treatment of insular tumors is controversial. Surgical treatment is associated with a higher morbidity rate than other therapies. The present work presents a new method in which the descending motor pathways are monitored during surgery for insular tumors.
Methods
Intraoperative monitoring was performed in a combination of 2 techniques. The motor cortex was stimulated with a transcranial electrical stimulus. In addition, direct subcortical stimulation was performed with an electrical anodal monopolar stimulus. Compound motor action potentials (CMAPs) were recorded from target muscles.
Results
Fifteen patients were included in this preliminary study. Following transcranial stimulation, CMAPs were recorded in all cases. Subcortical stimulation was successful in 12 cases. Significant CMAP alterations were recorded in 5 patients. There were no false-negative results in the series.
Conclusions
The technique presented here is a safe method. It allows a quantitative monitoring of motor function and functional mapping of the pyramidal tract during insular surgery.
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Awake craniotomy and intraoperative magnetic resonance imaging: patient selection, preparation, and technique. Top Magn Reson Imaging 2009; 19:191-6. [PMID: 19148035 DOI: 10.1097/rmr.0b013e3181963b46] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Intraoperative magnetic resonance imaging (iMRI) has been reported to augment radical brain tumor resection. "Awake craniotomy" is a technique to conserve function during brain tumor surgery. We report on the combination of these 2 techniques, with special emphasis on potential adverse effects, caveats, and patient preparation. METHODS Thirty-four patients had 38 awake craniotomies with cortical stimulation within an integrated MRI-operating room with a 1.5-T unit. Thirty-two lesions were left hemispheric, 6 on the right side. RESULTS Preparation for iMRI per patient amounted to 20 to 25 minutes, in addition to scan time. The procedure was well tolerated by all patients. Thirty-two stated that they would undergo this procedure again, if necessary. Four underwent a second "awake" surgery in the iMRI for recurrent disease. Intraoperative MRI had no adverse effect, such as seizures. Cortical stimulation could be performed without restrictions outside the 5-gauss line. CONCLUSIONS The combination of iMRI and awake craniotomy is demanding but well tolerated by patients. Careful preoperative evaluation is essential to ensure compliance. There is no adverse effect through iMRI on the awake patient or the results of cortical stimulation. Since the introduction of the iMRI in our department in 2005, all awake craniotomies were done in this setting. The implementation of these 2 techniques into our procedures is demanding, and necessitates thorough preparation but has broadened our basis for surgical decision making. However, to substantiate our positive perception, more clinical data are being compiled.
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Robles SG, Gatignol P, Lehéricy S, Duffau H. Long-term brain plasticity allowing a multistage surgical approach to World Health Organization Grade II gliomas in eloquent areas. J Neurosurg 2008; 109:615-24. [PMID: 18826347 DOI: 10.3171/jns/2008/109/10/0615] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although the goal of surgery for World Health Organization Grade II gliomas is maximal extent of resection, complete tumor removal is not always possible when the glioma involves eloquent areas. The authors propose a multistage surgical approach to highly crucial areas that are classically considered inoperable, enabling optimization of the extent of resection while avoiding permanent cognitive deficits due to induced functional reshaping in the interim between the 2 consecutive operations. To demonstrate such plasticity, the authors used a combination of sequential functional MR imaging and intraoperative electrical stimulation mapping before and during surgeries spaced by several years in 2 patients who each underwent 2 separate resections of Grade II gliomas located in the left dominant premotor area. During several years of follow-up after the first procedure, both patients had unremarkable examination results and normal socioprofessional lives. There was no malignant transformation. Based on their experience with these cases, the authors suggest that in cases of incomplete glioma removal, a second operation before anaplasia should be considered, made possible by brain reorganization after the first operation.
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Affiliation(s)
- Santiago Gil Robles
- Department of Neurosurgery, Hôpital Gui de Chauliac, Centre Hospitalier Universitaire de Montpellier, France
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63
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Duffau H, Peggy Gatignol ST, Mandonnet E, Capelle L, Taillandier L. Intraoperative subcortical stimulation mapping of language pathways in a consecutive series of 115 patients with Grade II glioma in the left dominant hemisphere. J Neurosurg 2008; 109:461-71. [PMID: 18759577 DOI: 10.3171/jns/2008/109/9/0461] [Citation(s) in RCA: 343] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECT Despite better knowledge of cortical language organization, its subcortical anatomofunctional connectivity remains poorly understood. The authors used intraoperative subcortical stimulation in awake patients undergoing operation for a glioma in the left dominant hemisphere to map the language pathways and to determine the contribution of such a method to surgical results. METHODS One hundred fifteen patients harboring a World Health Organization Grade II glioma within language areas underwent operation after induction of local anesthesia, using direct electrical stimulation to perform online cortical and subcortical language mapping throughout the resection. RESULTS After detection of cortical language sites, the authors identified 1 or several of the following subcortical language pathways in all patients: 1) arcuate fasciculus, eliciting phonemic paraphasia when stimulated; 2) inferior frontooccipital fasciculus, generating semantic paraphasia when stimulated; 3) subcallosal fasciculus, inducing transcortical motor aphasia during stimulation; 4) frontoparietal phonological loop, eliciting speech apraxia during stimulation; and 5) fibers coming from the ventral premotor cortex, inducing anarthria when stimulated. These structures were preserved, representing the limits of the resection. Despite a transient immediate postoperative worsening, all but 2 patients (98%) returned to baseline or better. On control MR imaging, 83% of resections were total or subtotal. CONCLUSIONS These results represent the largest experience with human subcortical language mapping ever reported. The use of intraoperative cortical and subcortical stimulation gives a unique opportunity to perform an accurate and reliable real-time anatomofunctional study of language connectivity. Such knowledge of the individual organization of language networks enables practitioners to optimize the benefit-to-risk ratio of surgery for Grade II glioma within the left dominant hemisphere.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier, Paris, France.
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64
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Carrabba G, Mandonnet E, Fava E, Capelle L, Gaini SM, Duffau H, Bello L. TRANSIENT INHIBITION OF MOTOR FUNCTION INDUCED BY THE CAVITRON ULTRASONIC SURGICAL ASPIRATOR DURING BRAIN MAPPING. Neurosurgery 2008; 63:E178-9; discussion E179. [DOI: 10.1227/01.neu.0000335087.85470.18] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
OBJECTIVE
We report, for the first time, the occurrence of interference between a Cavitron ultrasonic surgical aspirator (CUSA) and intraoperative brain mapping performed by direct electrical stimulation (DES).
METHODS
Intraoperative polygraphic recordings (electrocorticogram and electromyogram) were gathered from a 44-year-old patient harboring a recurrent Grade II oligoastrocytoma operated on with the aid of a CUSA and DES.
RESULTS
Simultaneous use of CUSA and DES at the subcortical level in proximity to the corticospinal tract brought about the abolition of previously evident motor responses. This abolition was fully reversible after the CUSA was turned off. An analogous pattern of motor response inhibition was evident when the DES was applied cortically and the CUSA was used subcortically close to motor pathways. Interestingly, the authors had already observed a similar phenomenon in many patients when the CUSA was used for resection of lesions located within or in proximity to subcortical language pathways. In this setting, the CUSA induced transient speech disturbances that were confirmed afterwards by the DES. This interference with language and motor mapping might be interpreted as a transitory inhibition of axonal conduction.
CONCLUSION
The clinical significance of this interference is relevant when the CUSA and DES are used simultaneously for motor mapping because the CUSA can decrease the sensitivity of the brain mapping technique. Further studies will be required to determine the neurophysiological mechanism underlying this interference.
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Affiliation(s)
- Giorgio Carrabba
- Department of Neurosurgery, University of Milan, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy
| | - Emmanuel Mandonnet
- Department of Neurosurgery, University of Paris, Hôpital Lariboisière, Paris, France
| | - Enrica Fava
- Department of Neurosurgery, University of Milan, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy
| | - Laurent Capelle
- Department of Neurosurgery, University of Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Sergio M. Gaini
- Department of Neurosurgery, University of Milan, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy
| | - Hugues Duffau
- Department of Neurosurgery, University of Montpellier, Hopital Gui de Chauliac, Montpellier, France
| | - Lorenzo Bello
- Department of Neurosurgery, University of Milan, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy
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65
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Carrabba G, Mandonnet E, Fava E, Capelle L, Gaini SM, Duffau H, Bello L. TRANSIENT INHIBITION OF MOTOR FUNCTION INDUCED BY THE CAVITRON ULTRASONIC SURGICAL ASPIRATOR DURING BRAIN MAPPING. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000313112.49285.47] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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66
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Duffau H. Intraoperative neurophysiology during surgery for cerebral tumors. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1567-4231(07)08035-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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67
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Abstract
Brain plasticity is the potential of the nervous system to reshape itself during ontogeny, learning or following injuries. The first part of this article reviews the pathophysiological mechanisms underlying plasticity at different functional levels. Such plastic potential means that the anatomo-functional organization of the brain in humans, both physiological and pathological, has flexibility. Patterns of reorganization may differ according to the time-course of cerebral damage, with better functional compensation in more slowly growing lesions. The second part of this review analyzes the interactions between tumor growth and brain reshaping, using non-invasive (neuroimaging) and invasive (electrophysiological) methods of functional mapping. Finally, the therapeutic implications provided by a greater understanding of these mechanisms of cerebral redistribution are explored from a surgical point of view. Enhanced preoperative prediction of an individual's potential for reorganization might be integrated into surgical planning and preserving quality of life through tailored rehabilitation programmes to optimize functional recovery following resection of a brain tumor.
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Affiliation(s)
- H Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, CHU de Montpellier, Montpellier Cedex, France
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68
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Benzagmout M, Gatignol P, Duffau H. Resection of World Health Organization Grade II gliomas involving Broca's area: methodological and functional considerations. Neurosurgery 2007; 61:741-52; discussion 752-3. [PMID: 17986935 DOI: 10.1227/01.neu.0000298902.69473.77] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Advances in functional mapping have enabled us to extend the indications of surgery for low-grade gliomas (LGGs) within eloquent regions. However, to our knowledge, no study has been specifically dedicated to the resection of LGGs within Broca's area. We report the first surgical series of LGGs involving this area by focusing on methodological and functional considerations. METHODS Seven patients harboring an LGG in Broca's area (revealed by partial seizures) had a language functional magnetic resonance imaging scan and then underwent operation while awake using intrasurgical electrical mapping. RESULTS The neurological examination was normal in all patients despite mild language disturbances shown using the Boston Diagnosis Aphasia Examination. Both pre- and intraoperative cortical mapping found language reorganization with recruitment of the ventral and dorsal premotor cortices, orbitofrontal cortex, and insula, whereas no or few language sites were detected within Broca's area. Subcortically, electrostimulation allowed the identification and preservation of four structures still functional, including the arcuate fasciculus, fronto-occipital fasciculus, fibers from the ventral premotor cortex, and head of the caudate. Postoperatively, after transient language worsening, all patients recovered and returned to a normal socioprofessional life. The resection was total in three cases, subtotal in three, and partial in one patient (operated twice). CONCLUSION Our results indicate that, in patients with no aphasia despite LGGs within Broca's area, thanks to brain plasticity, the tumor can be removed while involving this "unresectable" structure without inducing sequelae and even improving the quality of life when intractable epilepsy is relieved on the condition that subcortical language connectivity is preserved.
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Contribution of cortical and subcortical electrostimulation in brain glioma surgery: Methodological and functional considerations. Neurophysiol Clin 2007; 37:373-82. [DOI: 10.1016/j.neucli.2007.09.003] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Accepted: 09/09/2007] [Indexed: 11/19/2022] Open
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Bello L, Gallucci M, Fava M, Carrabba G, Giussani C, Acerbi F, Baratta P, Songa V, Conte V, Branca V, Stocchetti N, Papagno C, Gaini SM. INTRAOPERATIVE SUBCORTICAL LANGUAGETRACT MAPPING GUIDES SURGICAL REMOVALOF GLIOMAS INVOLVING SPEECH AREAS. Neurosurgery 2007; 60:67-80; discussion 80-2. [PMID: 17228254 DOI: 10.1227/01.neu.0000249206.58601.de] [Citation(s) in RCA: 209] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Subcortical stimulation can be used to identify functional language tracts during resection of gliomas located close to or within language areas or pathways. The objective of the present study was to investigate the feasibility of the routine use of subcortical stimulation for identification of language tracts in a large series of patients with gliomas and to determine the influence that subcortical language tract identification exerted on the extent of surgery and on the appearance of immediate and definitive postoperative deficits.
METHODS
Subcortical stimulation for language tract identification was systematically used during surgical removal of 88 gliomas (44 high-grade and 44 low-grade gliomas) involving language pathways. Procedures were performed during asleep/awake craniotomy. Subcortical stimulation was continuously alternated with surgical resection in a back-and-forth fashion. Language performances were tested by neuropsychological language evaluation preoperatively and at 3, 30, and 90 days after surgery.
RESULTS
Language tracts were identified in 59% of patients, with differences according to tumor location but not according to histological grade. Language tract identification influenced the ability to reach a complete tumor removal in low-grade gliomas, in which tracts were documented inside the peripheral mass of the tumor. Identification of language tracts was associated with a higher occurrence of transient postoperative deficits (67.3% of cases), but a low occurrence of definitive morbidity (2.3% of cases). A pattern of typical language disturbances related to the phonological and semantic system can be identified according to tumor location, with preservation being important for the maintenance of language integrity.
CONCLUSION
Our study supports the routine use of subcortical stimulation for language tract identification as a reliable tool for guiding surgical removal of gliomas in or in close proximity to language areas or pathways.
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Affiliation(s)
- Lorenzo Bello
- Department of Neurological Sciences, University of Milan, Milan, Italy.
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Spena G, Gatignol P, Capelle L, Duffau H. Superior longitudinal fasciculus subserves vestibular network in humans. Neuroreport 2006; 17:1403-6. [PMID: 16932147 DOI: 10.1097/01.wnr.0000223385.49919.61] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vestibular function is known to be represented in a large-scale network within the brain. Although much is known about the topography of this cortical network, the subcortical anatomo-functional connectivity has received less attention. We present three patients operated on while conscious for cerebral low-grade gliomas, in which we elicited vestibular symptoms during subcortical stimulation. Anatomo-functional correlations between postoperative imaging and intraoperative findings suggest the involvement of the superior longitudinal fasciculus in the spreading of the vestibular symptoms. We argue that this fasciculus plays a major role in the functional connectivity of the areas involved in the complex multimodal network that controls vestibular function.
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Affiliation(s)
- Giannantonio Spena
- Department of Neurosurgery, University of Genova, San Martino Hospital, San Martino, Genova, Italy
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Duffau H. Brain plasticity: From pathophysiological mechanisms to therapeutic applications. J Clin Neurosci 2006; 13:885-97. [PMID: 17049865 DOI: 10.1016/j.jocn.2005.11.045] [Citation(s) in RCA: 220] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Accepted: 11/10/2005] [Indexed: 11/30/2022]
Abstract
Cerebral plasticity, which is the dynamic potential of the brain to reorganize itself during ontogeny, learning, or following damage, has been widely studied in the last decade, in vitro, in animals, and also in humans since the development of functional neuroimaging. In the first part of this review, the main hypotheses about the pathophysiological mechanisms underlying plasticity are presented. At a microscopic level, modulations of synaptic efficacy, unmasking of latent connections, phenotypic modifications and neurogenesis have been identified. At a macroscopic level, diaschisis, functional redundancies, sensory substitution and morphological changes have been described. In the second part, the behavioral consequences of such cerebral phenomena in physiology, namely the "natural" plasticity, are analyzed in humans. The review concludes on the therapeutic implications provided by a better understanding of these mechanisms of brain reshaping. Indeed, this plastic potential might be 'guided' in neurological diseases, using rehabilitation, pharmacological drugs, transcranial magnetic stimulation, neurosurgical methods, and even new techniques of brain-computer interface - in order to improve the quality of life of patients with damaged nervous systems.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Inserm U678, Hôpital Gui de Chaulic, CHU de Montpellier, 80 avenue Augustin Fliche, 34295 Montpellier, Cedex 5, France.
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Duffau H. New concepts in surgery of WHO grade II gliomas: functional brain mapping, connectionism and plasticity – a review. J Neurooncol 2006; 79:77-115. [PMID: 16607477 DOI: 10.1007/s11060-005-9109-6] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 12/21/2005] [Indexed: 10/24/2022]
Abstract
Despite a recent literature supporting the impact of surgery on the natural history of low-grade glioma (LGG), the indications of resection still remain a matter of debate, especially because of the frequent location of these tumors within eloquent brain areas - thus with a risk to induce a permanent postoperative deficit. Therefore, since the antagonist nature of this surgery is to perform the most extensive glioma removal possible, while preserving the function and the quality of life, new concepts were recently applied to LGG resection in order to optimize the benefit/risk ratio of the surgery.First, due to the development of functional mapping methods, namely perioperative neurofunctional imaging and intrasurgical direct electrical stimulation, the study of cortical functional organization is currently possible for each patient - in addition to an extensive neuropsychological assessment. Such knowledge is essential because of the inter-individual anatomo-functional variability, increased in tumors due to cerebral plasticity phenomena. Thus, brain mapping enables to envision and perform a resection according to individual functional boundaries.Second, since LGG invades not only cortical but also subcortical structures, and shows an infiltrative progression along the white matter tracts, new techniques of anatomical tracking and functional mapping of the subcortical white matter pathways were also used with the goal to study the individual effective connectivity - which needs imperatively to be preserved during the resection.Third, the better understanding of brain plasticity mechanisms, induced both by the slow-growing LGG and by the surgery itself, were equally studied in each patient and applied to the surgical strategy by incorporating individual dynamic potential of reorganization into the operative planning. The integration of these new concepts of individual functional mapping, connectivity and plastic potential to the surgery of LGG has allowed an extent of surgical indications, an optimization of the quality of resection (neuro-oncological benefit), and a minimization of the risk of sequelae (benefit on the quality of life). In addition, such a strategy has also fundamental applications, since it represents a new door to the connectionism and cerebral plasticity.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, UMR-S678 Inserm, Hôpital Salpêtrière, Paris, France
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