Localisation of motor areas in brain tumour patients: a comparison of preoperative [18F]FDG-PET and intraoperative cortical electrostimulation

SNMMI Procedure Standard/EANM Practice Guideline for Brain [18F]FDG PET Imaging, Version 2.0

PREAMBLEThe Society of Nuclear Medicine and Molecular Imaging (SNMMI) is an international scientific and professional organization founded in 1954 to promote the science, technology, and practical application of nuclear medicine. The European Association of Nuclear Medicine (EANM) is a professional nonprofit medical association that facilitates communication worldwide between individuals pursuing clinical and research excellence in nuclear medicine. The EANM was founded in 1985. The EANM was founded in 1985. SNMMI and EANM members are physicians, technologists, and scientists specializing in the research and practice of nuclear medicine.The SNMMI and EANM will periodically define new guidelines for nuclear medicine practice to help advance the science of nuclear medicine and to improve the quality of service to patients throughout the world. Existing practice guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.Each practice guideline, representing a policy statement by the SNMMI/EANM, has undergone a thorough consensus process in which it has been subjected to extensive review. The SNMMI and EANM recognize that the safe and effective use of diagnostic nuclear medicine imaging requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline by those entities not providing these services is not authorized.These guidelines are an educational tool designed to assist practitioners in providing appropriate care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, both the SNMMI and the EANM caution against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question.The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. Thus, there is no implication that an approach differing from the guidelines, standing alone, is below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the guidelines.The practice of medicine includes both the art and the science of the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment.Therefore, it should be recognized that adherence to these guidelines will not ensure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective.

EANM procedure guidelines for brain PET imaging using [18F]FDG, version 3

The present procedural guidelines summarize the current views of the EANM Neuro-Imaging Committee (NIC). The purpose of these guidelines is to assist nuclear medicine practitioners in making recommendations, performing, interpreting, and reporting results of [¹⁸F]FDG-PET imaging of the brain. The aim is to help achieve a high-quality standard of [¹⁸F]FDG brain imaging and to further increase the diagnostic impact of this technique in neurological, neurosurgical, and psychiatric practice. The present document replaces a former version of the guidelines that have been published in 2009. These new guidelines include an update in the light of advances in PET technology such as the introduction of digital PET and hybrid PET/MR systems, advances in individual PET semiquantitative analysis, and current broadening clinical indications (e.g., for encephalitis and brain lymphoma). Further insight has also become available about hyperglycemia effects in patients who undergo brain [¹⁸F]FDG-PET. Accordingly, the patient preparation procedure has been updated. Finally, most typical brain patterns of metabolic changes are summarized for neurodegenerative diseases. The present guidelines are specifically intended to present information related to the European practice. The information provided should be taken in the context of local conditions and regulations.

Brain activation patterns during visuomotor adaptation in motor experts and novices: An FDG PET study with unrestricted movements

BACKGROUND

Speed of performance improvements and the strength of memory consolidation in humans vary with movement expertise. Underlying neural mechanisms of behavioural differences between levels of movement expertise are so far unknown.

NEW METHOD

In this study, PET with [¹⁸F]fluorodeoxyglucose (FDG) was proposed as a powerful novel methodology to assess learning-related brain activity patterns during large non-restricted movements (ball throwing with a right hand). 24 male handball players ('Experts') and 24 male participants without handball experience ('Novices') performed visuomotor adaptations to prismatic glasses with or without strategic manoeuvres (i.e., explicit or implicit adaptation).

RESULTS

Regional changes in FDG uptake as a marker of neuronal activity, relative to a control condition, were assessed. Prismatic adaptation, in general, was associated with decreased occipital neuronal activity as a possible response to misleading visual information. In 'Experts', the adaptation was associated with altered neuronal activity in a network comprising the right parietal cortex and the left cerebellum. In 'Novices', implicit adaptation resulted in an activation of the middle frontal and inferior temporal gyrus.

COMPARISON WITH EXISTING METHODS

This study demonstrates the versatility of FDG PET for studying brain activations patterns in experimental settings with unrestricted movements that are not accessible by other techniques (e.g., fMRI or EEG).

CONCLUSIONS

Observed results are consistent with the involvement of different functional networks related to strategic manoeuvres and expertise levels. This strengthens the assumption of different mechanisms underlying behavioural changes associated with movement expertise. Furthermore, the present study underscores the value of FDG PET for studying brain activation patterns during unrestricted movements.

Regional neuronal activity in patients with relapsing remitting multiple sclerosis

OBJECTIVES

Although interferon-beta is an established drug for relapsing remitting multiple sclerosis (RRMS), its impact on neuronal activity is not well understood.

METHODS

We investigated 15 patients with RRMS by [¹⁸ F]fluorodeoxyglucose positron emission tomography (FDG-PET) to assess cerebral metabolic rate of glucose (CMR_glc ) before interferon-beta therapy. Further, we performed clinical and neuropsychological investigations. In nine patients, these investigations were repeated after 6 months of therapy. Ten healthy controls were also studied.

RESULTS

We found no significant differences in absolute CMR_glc between patients and controls, or in patients before and during treatment. However, during treatment, relative regional glucose metabolism (rCMRl_glc ) was decreased in cerebellum and increased in parts of left inferior parietal, temporo-occipital, frontal cortical areas, left striatum and right insula. In untreated patients, higher fatigue was associated with lower rCMRl_glc in portions of left posterior cingulate cortex, and higher depression was associated with lower rCMRl_glc within the left superior temporal sulcus. In the pooled sample, higher depression was associated with higher rCMRl_glc in parts of the right precuneus.

CONCLUSIONS

Our results indicate effects of IFN-beta treatment on cerebellar, cortical and subcortical neuronal function. Moreover, more severe fatigue and depression in untreated patients seem to be associated with reduced neuronal activity in left posterior cingulate cortex and left superior temporal cortex, respectively.

FDG Whole-Body PET/MRI in Oncology: a Systematic Review

The recent advance in hybrid imaging techniques enables offering simultaneous positron emission tomography (PET)/magnetic resonance imaging (MRI) in various clinical fields. ¹⁸F-fluorodeoxyglucose (FDG) PET has been widely used for diagnosis and evaluation of oncologic patients. The growing evidence from research and clinical experiences demonstrated that PET/MRI with FDG can provide comparable or superior diagnostic performance more than conventional radiological imaging such as computed tomography (CT), MRI or PET/CT in various cancers. Combined analysis using structural information and functional/molecular information of tumors can draw additional diagnostic information based on PET/MRI. Further studies including determination of the diagnostic efficacy, optimizing the examination protocol, and analysis of the hybrid imaging results is necessary for extending the FDG PET/MRI application in clinical oncology.

The use of fluorine-18 fluorodeoxyglucose positron emission tomography for imaging human motor neuronal activation in the brain

The present study aimed to visualize human motor neuronal activation in the brain using fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET), and to develop an FDG-PET procedure for imaging neuronal activation. A male volunteer underwent 20 min periods of rest and motor activation, whilst being assessed using FDG-PET on two consecutive days. The motor task, which involved repetitively grasping and releasing the right hand, was performed during the initial 5 min of the activation period. Subtraction of the rest period signal from the activation PET images was performed using the subtraction ictal single-photon emission computed tomography co-registered to magnetic resonance imaging method. The subtracted image detected activation of the contralateral (left) primary motor cortex, supplementary motor area, and ipsilateral (right) cerebellum. In the present study, FDG-PET detected significantly increased motor-associated activation of the brain in a subject performing a motor task.

Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period

OBJECT

Awake craniotomy is currently a useful surgical approach to help identify and preserve functional areas during cortical and subcortical tumor resections. Methodologies have evolved over time to maximize patient safety and minimize morbidity using this technique. The goal of this study is to analyze a single surgeon's experience and the evolving methodology of awake language and sensorimotor mapping for glioma surgery.

METHODS

The authors retrospectively studied patients undergoing awake brain tumor surgery between 1986 and 2014. Operations for the initial 248 patients (1986–1997) were completed at the University of Washington, and the subsequent surgeries in 611 patients (1997–2014) were completed at the University of California, San Francisco. Perioperative risk factors and complications were assessed using the latter 611 cases.

RESULTS

The median patient age was 42 years (range 13–84 years). Sixty percent of patients had Karnofsky Performance Status (KPS) scores of 90–100, and 40% had KPS scores less than 80. Fifty-five percent of patients underwent surgery for high-grade gliomas, 42% for low-grade gliomas, 1% for metastatic lesions, and 2% for other lesions (cortical dysplasia, encephalitis, necrosis, abscess, and hemangioma). The majority of patients were in American Society of Anesthesiologists (ASA) Class 1 or 2 (mild systemic disease); however, patients with severe systemic disease were not excluded from awake brain tumor surgery and represented 15% of study participants. Laryngeal mask airway was used in 8 patients (1%) and was most commonly used for large vascular tumors with more than 2 cm of mass effect. The most common sedation regimen was propofol plus remifentanil (54%); however, 42% of patients required an adjustment to the initial sedation regimen before skin incision due to patient intolerance. Mannitol was used in 54% of cases. Twelve percent of patients were active smokers at the time of surgery, which did not impact completion of the intraoperative mapping procedure. Stimulation-induced seizures occurred in 3% of patients and were rapidly terminated with ice-cold Ringer's solution. Preoperative seizure history and tumor location were associated with an increased incidence of stimulation-induced seizures. Mapping was aborted in 3 cases (0.5%) due to intraoperative seizures (2 cases) and patient emotional intolerance (1 case). The overall perioperative complication rate was 10%.

CONCLUSIONS

Based on the current best practice described here and developed from multiple regimens used over a 27-year period, it is concluded that awake brain tumor surgery can be safely performed with extremely low complication and failure rates regardless of ASA classification; body mass index; smoking status; psychiatric or emotional history; seizure frequency and duration; and tumor site, size, and pathology.

Electroacupuncture stimulation at sub-specific acupoint and non-acupoint induced distinct brain glucose metabolism change in migraineurs: a PET-CT study

BACKGROUND

Acupuncture has analgesic effect to most pain conditions. Many neuroimaging studies were conducted to explore acupoint specificity in pain and other condition, but till now there is still discrepancy. Based on our previous finding, this study investigated the brain metabolism changes of acupuncture analgesia induced by sub-specific acupoint and non-acupoint stimulation.

METHODS

30 migraineurs were included and randomly assigned to 3 groups: Acupuncture Group (AG), Sham Acupuncture Group (SAG) and Migraine Group (MG). In AG, a combination sub-specific points of Shaoyang meridians, Luxi (TE19), San Yangluo (TE8), and Xi Yangguan (GB33) has been stimulated with electroacupuncture, while non-acupoints for SAG were used and MG received no treatment. Positron emission tomography with computed tomography (PET-CT) was used to identify differences in brain glucose metabolism between groups.

RESULTS

In the AG, brain glucose metabolism increase compared with the MG was observed in the middle frontal gyrus, postcentral gyrus, the precuneus, parahippocampus, cerebellum and middle cingulate cortex (MCC), and decrease were observed in the left hemisphere of Middle Temporal Cortex (MTC).In the SAG, compared with MG, glucose metabolism increased in the poster cingulate cortex (PCC), insula, inferior temporal gyrus, MTC, superior temporal gyrus, postcentral gyrus, fusiform, inferior parietal lobe, superior parietal lobe, supramarginal gyrus, middle occipital lobe, angular and precuneus; while, decreased in cerebellum, parahippocampus.

CONCLUSIONS

Acupuncture stimulation at both sub-specific acupoint and non-acupoint yields ameliorating effect to migraine pain, but with evidently differed central mechanism as measured by PET-CT. The pattern of brain glucose metabolism change in acupoint is pertinent and targeted, while in non-acupoint that was disordered and randomized. These finding may provide new perspectives into the validation of acupoint specificity, optimizing acupuncture analgesia and revealing central mechanism of acupuncture analgesia by neuroimaging measurement.

TRIAL REGISTRATION

This trial was registered in the Chinese Clinical Trial Registry, with registration no. ChiCTR-TRC-11001813.

Role of surgical resection in low- and high-grade gliomas

OPINION STATEMENT

Central nervous system tumors are a major cause of morbidity and mortality in the United States. Outside of brain metastasis, low- and high-grade gliomas are the most common intrinsic brain tumors. Low-grade gliomas have a 5- and 10-year survival rate of 97 % and 91 %, respectively, when extent of resection is greater than 90 %. High-grade gliomas are extremely aggressive with the vast majority of patients experiencing recurrence and a median survival of 1 to 3 years. Survival of patients with both low- and high-grade gliomas is enhanced with maximal tumor resection. The pursuit of more aggressive extent of resection must be balanced with preservation of functional pathways. Several innovations in neurosurgical oncology have expanded our understanding of individualized patient neuroanatomy, physiology, and function. Emerging imaging technologies as well as intraoperative techniques have expanded our ability to resect maximal amounts of tumor while preserving essential function. Stimulation mapping of language and motor pathways is well-established for the safe resection of intrinsic brain lesions. Additional techniques including neuro-navigation, fluorescence-guided microsurgery using 5-aminolevulinic acid, intraoperative magnetic resonance imaging, and high-frequency ultrasonography can all be used to improve extent of resection in glioma patients.

Intraoperative cortico–subcortical stimulations in surgery of low-grade gliomas

In order to increase the impact of surgery on the natural history of low-grade glioma, resection should be of maximum importance. Nevertheless, since low-grade gliomas are frequently located in eloquent structures, function needs to be preserved. Therefore, studying the functional organization of the brain is mandatory for each patient due to the inter-individual anatomofunctional variability, increased in tumors due to cerebral plasticity. This strategy enables performance of a resection according to functional boundaries. However, preoperative neurofunctional imaging only allows the study of the gray matter. Consequently, since low-grade glioma invades cortical and subcortical structures and shows an infiltrative progression along the fibers, the goal of this review is to focus on the techniques able to map both cortical and subcortical regions. In addition to diffusion tensor imaging, which gives only anatomical information and still needs to be validated, intraoperative direct cortico-subcortical electrostimulation is the sole current method allowing a reliable study of the individual anatomofunctional connectivity, concerning sensorimotor, language and other cognitive functions. Its actual contribution is detailed, both in clinical issues, especially the improvement of the benefit/risk ratio of low-grade glioma resection, and in fundamental applications--namely, a new door to the connectionism and cerebral plasticity.

Magnetoencephalographic imaging of resting-state functional connectivity predicts postsurgical neurological outcome in brain gliomas

BACKGROUND

The removal of brain tumors in perieloquent or eloquent cortex risks causing new neurological deficits in patients. The assessment of the functionality of perilesional tissue is essential to avoid postoperative neurological morbidity.

OBJECTIVE

To evaluate preoperative magnetoencephalography-based functional connectivity as a predictor of short- and medium-term neurological outcome after removal of gliomas in perieloquent and eloquent areas.

METHODS

Resting-state whole-brain magnetoencephalography recordings were obtained from 79 consecutive subjects with focal brain gliomas near or within motor, sensory, or language areas. Neural activity was estimated using adaptive spatial filtering. The mean imaginary coherence between voxels in and around brain tumors was compared with contralesional voxels and used as an index of their functional connectivity with the rest of the brain. The connectivity values of the tissue resected during surgery were correlated with the early (1 week postoperatively) and medium-term (6 months postoperatively) neurological morbidity.

RESULTS

Patients undergoing resection of tumors with decreased functional connectivity had a 29% rate of a new neurological deficit 1 week after surgery and a 0% rate at 6-month follow-up. Patients undergoing resection of tumors with increased functional connectivity had a 60% rate of a new deficit at 1 week and a 25% rate at 6 months.

CONCLUSION

Magnetoencephalography connectivity analysis gives a valuable preoperative evaluation of the functionality of the tissue surrounding tumors in perieloquent and eloquent areas. These data may be used to optimize preoperative patient counseling and surgical strategy.

Validation of functional motor and language MRI with direct cortical stimulation

BACKGROUND

Functional magnetic resonance imaging (fMRI) is a widely available method and is therefore progressively utilized in neurosurgical practice. This study was carried out to determine fMRI sensitivity and specificity and to emphasize the threshold dependence of fMRI data.

METHODS

A total of 17 consecutive patients, scheduled for surgery on intracerebral lesions near eloquent brain areas, underwent preoperative motor (N = 12) and language (N = 5) fMRI. Functional data were analyzed with SPM software and displayed on a neuronavigation system for intraoperative guidance. High-risk maps for motor and language deficits obtained from direct electric cortical stimulation (DECS) were used for validation of functional activated areas. In a first analysis step, sensitivity and specificity were calculated in terms of a side-by-side correlation. The next step, the threshold dependence of fMRI data sensitivity and specificity, was estimated according to four statistical thresholds (p1 < 0.05, p2 < 0.0005, p3 < 0.00001, p4 < 0.0000001).

RESULTS

Both functional imaging and DECS revealed definite results for the investigated areas in all patients. Calculation of sensitivity and specificity resulted in 100 % and 68 % for the motor group and a sensitivity of 75 % and specificity of 68 % for the language group at the fixed threshold analysis. Threshold-dependent analysis of the obtained data revealed a sensitivity/specificity relationship from 100 %/0 % at threshold (p1), 100 %/5 % at (p2), 74 %/9 % at (p3), and 37 %/36 % at (p4) for the motor group. Evaluation of threshold-dependent sensitivity and specificity for the language group resulted in 78 %/51 % at threshold (p1), 67 %/75 % at (p2), 50 %/78 % at (p3), and 33 %/89 % at (p4).

CONCLUSIONS

The present findings on the threshold dependence of fMRI data demonstrate why individualized thresholds should be obtained in case of fMRI evaluation. Although the results are satisfying in most cases, fMRI is apparently not sufficient for critical intraoperative decision-making.

EANM procedure guidelines for PET brain imaging using [18F]FDG, version 2

These guidelines summarize the current views of the European Association of Nuclear Medicine Neuroimaging Committee (ENC). The purpose of the guidelines is to assist nuclear medicine practitioners in making recommendations, performing, interpreting, and reporting the results of fluorine-18 fluoro-2-deoxyglucose ([(18)F]FDG) PET imaging of the brain. The aim is to help achieve a high standard of FDG imaging, which will increase the diagnostic impact of this technique in neurological and psychiatric practice. The present document replaces a former version of the guidelines that were published in 2002 [1] and includes an update in the light of advances in PET technology, the introduction of hybrid PET/CT systems and the broadening clinical indications for FDG brain imaging. These guidelines are intended to present information specifically adapted for European practice. The information provided should be taken in the context of local conditions and regulations.

Resting functional connectivity in patients with brain tumors in eloquent areas

OBJECTIVE

Resection of brain tumors adjacent to eloquent areas represents a challenge in neurosurgery. If maximal resection is desired without inducing postoperative neurological deficits, a detailed knowledge of the functional topography in and around the tumor is crucial. The aim of the present work is to evaluate the value of preoperative magnetoencephalography (MEG) imaging of functional connectivity to predict the results of intraoperative electrical stimulation (IES) mapping, the clinical gold standard for neurosurgical localization of functional areas.

METHODS

Resting-state whole-cortex MEG recordings were obtained from 57 consecutive subjects with focal brain tumors near or within motor, sensory, or language areas. Neural activity was estimated using adaptive spatial filtering algorithms, and the mean imaginary coherence between the rest of the brain and voxels in and around brain tumors were compared to the mean imaginary coherence between the rest of the brain and contralesional voxels as an index of functional connectivity. IES mapping was performed in all subjects. The cortical connectivity pattern near the tumor was compared to the IES results.

RESULTS

Maps with decreased resting-state functional connectivity in the entire tumor area had a negative predictive value of 100% for absence of eloquent cortex during IES. Maps showing increased resting-state functional connectivity within the tumor area had a positive predictive value of 64% for finding language, motor, or sensory cortical sites during IES mapping.

INTERPRETATION

Preoperative resting state MEG connectivity analysis is a useful noninvasive tool to evaluate the functionality of the tissue surrounding tumors within eloquent areas, and could potentially contribute to surgical planning and patient counseling.

ASSOCIATION OF SURGICALLY ACQUIRED MOTOR AND LANGUAGE DEFICITS ON OVERALL SURVIVAL AFTER RESECTION OF GLIOBLASTOMA MULTIFORME

OBJECTIVE

Balancing the benefits of extensive tumor resection with the consequence of potential postoperative deficits remains a challenge in malignant astrocytoma surgery. Although studies have suggested that increasing extent of resection may benefit survival, the effect of new postoperative deficits on survival remains unclear. We set out to determine whether new-onset postoperative motor or speech deficits were associated with survival in our institutional experience with glioblastoma multiforme (GBM).

METHODS

We retrospectively reviewed records of all patients (age range, 18–70 years; Karnofsky Performance Scale score, 80–100) who had undergone GBM resection between 1996 and 2006 at a single institution. Survival was compared between patients who had experienced surgically acquired motor or language deficits versus those who did not experience these deficits.

RESULTS

Three hundred six consecutive patients (age, 54 ± 11 years; median Karnofsky Performance Scale score, 80) underwent primary GBM resection. Nineteen patients (6%) developed surgically acquired motor deficits and 15 (5%) developed surgically acquired language deficits. Median survival was decreased in patients who acquired language deficits (9.6 months; P &lt; 0.05) or motor deficits (9.0 months; P &lt; 0.05) versus patients without surgically acquired deficits (12.8 months). Two-year survival was 8% and 0% for patients with surgically acquired motor or language deficits, respectively, versus 23% for patients without new-onset deficits.

CONCLUSION

In our experience, the development of new perioperative motor or language deficits was associated with decreased overall survival despite similar extent of resection and adjuvant therapy. Although it is well known that surgically induced neurological deficits affect quality of life, our results suggest that these surgical morbidities may also affect survival. Care should be taken to avoid surgically induced deficits in the management of GBM.

CLINICAL EVALUATION AND FOLLOW-UP OUTCOME OF DIFFUSION TENSOR IMAGING-BASED FUNCTIONAL NEURONAVIGATION

OBJECTIVE

To evaluate diffusion tensor imaging (DTI)-based functional neuronavigation in surgery of cerebral gliomas with pyramidal tract (PT) involvement with respect to both perioperative assessment and follow-up outcome.

METHODS

A prospective, randomized controlled study was conducted between 2001 and 2005. A consecutive series of 238 eligible patients with initial imaging diagnosis of cerebral gliomas involving PTs were randomized into study (n = 118) and control (n = 120) groups. The study cases underwent DTI and three-dimensional magnetic resonance imaging scans. The maps of fractional anisotropy were calculated for PT mapping. Both three-dimensional magnetic resonance imaging data sets and fractional anisotropy maps were integrated by rigid registration, after which the tumor and adjacent PT were segmented and reconstructed for presurgical planning and intraoperative guidance. The control cases were operated on using routine neuronavigation.

RESULTS

There was a trend for high-grade gliomas (HGGs) in the study group to be more likely to achieve gross total resection (74.4 versus 33.3%, P &lt; 0.001). There was no significant difference of low-grade gliomas resection between the two groups. Postoperative motor deterioration occurred in 32.8% of control cases, whereas it occurred in only 15.3% of the study cases (P &lt; 0.001). The 6-month Karnofsky Performance Scale score of study cases was significantly higher than that of control cases (86 ± 20 versus 74 ± 28 overall, P &lt; 0.001; 93 ± 10 versus 86 ± 17 for low-grade gliomas, P = 0.013; and 77 ± 27 versus 53 ± 32 for HGGs, P = 0.001). For 81 HGGs, the median survival of study cases was 21.2 months (95% confidence interval, 14.1–28.3 mo) compared with 14.0 months (95% confidence interval, 10.2–17.8 mo) of control cases (P = 0.048). The estimated hazard ratio for the effect of DTI-based functional neuronavigation was 0.570, representing a 43.0% reduction in the risk of death.

CONCLUSION

DTI-based functional neuronavigation contributes to maximal safe resection of cerebral gliomas with PT involvement, thereby decreasing postoperative motor deficits for both HGGs and low-grade gliomas while increasing high-quality survival for HGGs.

Functional brain mapping and its applications to neurosurgery

Functional brain mapping may be useful for both preoperative planning and intraoperative neurosurgical decision making. "Gold standard" functional studies such as direct electrical stimulation and recording are complemented by newer, less invasive techniques such as functional magnetic resonance imaging. Less invasive techniques allow more areas of the brain to be mapped in more subjects (including healthy subjects) more often (including pre- and postoperatively). Expansion of the armamentarium of tools allows convergent evidence from multiple brain mapping techniques to bear on pre- and intraoperative decision making. Functional imaging techniques are used to map motor, sensory, language, and memory areas in neurosurgical patients with conditions as diverse as brain tumors, vascular lesions, and epilepsy. In the future, coregistration of high resolution anatomic and physiological data from multiple complementary sources will be used to plan more neurosurgical procedures, including minimally invasive procedures. Along the way, new insights on fundamental processes such as the biology of tumors and brain plasticity are likely to be revealed.

New concepts in surgery of WHO grade II gliomas: functional brain mapping, connectionism and plasticity – a review

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.

Diffusion tensor tractography in patients with cerebral tumors: A helpful technique for neurosurgical planning and postoperative assessment

OBJECTIVE

To demonstrate the role of diffusion tensor tractography (DTT) in preoperative mapping of eloquent tracts in relation to cerebral tumors and to determine whether it is helpful for neurosurgical planning and postoperative assessment.

METHODS AND MATERIALS

Sixteen patients with brain tumors underwent diffusion tensor imaging (DTI). The pyramidal tract, corpus callosum and optic radiation were reconstructed and the exact location of a lesion with respect to these tracts was observed to design a reasonable surgical plan for preserving vital tracts while maximizing tumor resection. After surgery, DTI was performed again and these tracts were evaluated to investigate the surgical outcomes. Twenty-four patients with suspicion of pyramidal tract involvement were also evaluated as a control group.

RESULTS

The relationship between tracts and tumors was classified as three types: type I is simple displacement, type II is displacement with disruption and type III is simple disruption. Twelve cases involved in pyramidal tract (DTT group), one was type I with reduction of displacement after surgery, nine were type II with reduction of displacement and other two were type III without any improvement. The extent of tumor resection (p = 0.045) and postoperative improvement of locomotive function (p = 0.015) of DTT group were significantly higher than those of control group. Corpus callosum was involved in seven cases, three were type II with reduction of displacement and four were type III without any improvement. Optic radiation was involved in three cases, all were type I with reduction of displacement.

CONCLUSION

DTT allowed for visualization of the exact location of tumors relevant to eloquent tracts and was found to be beneficial in the neurosurgical planning and postoperative assessment.

Preoperative mapping of cortical motor function: prospective comparison of functional magnetic resonance imaging and [15O]-H2O-positron emission tomography in the same co-ordinate system

BACKGROUND

Two of the most widely accepted approaches to map eloquent cortical areas preoperatively are positron emission tomography (PET) and functional magnetic resonance imaging (fMRI). As yet, no study has compared these two modalities within the same frame of reference in tumour patients.

AIM

We employed [15O]-H2O-PET and fMRI in patients undergoing presurgical evaluation and compared the results with those obtained by direct electrical cortical stimulation (DECS).

METHODS

Twenty-five patients with tumours of different aetiology near the central region were investigated. fMRI and PET were processed using the same methods, i.e. statistical parametric mapping (SPM) without anatomical normalization, and transformed into the same frame of reference.

RESULTS

fMRI activity was found in more cranial and lateral sections, i.e. closer to the brain surface, in comparison with PET, which demonstrated parenchymal activation. The mean localization difference between fMRI and PET was 8.1 +/- 4.6 mm (range, 2-18 mm). fMRI and [15O]-H2O-PET could reliably identify the central sulcus, as demonstrated by DECS.

CONCLUSIONS

fMRI and [15O]-H2O-PET demonstrate comparable results and are sensitive and reliable tools to map the central region, especially in cases of infiltrating brain tumours. However, fMRI is more prone to artefacts, such as the visualization of draining veins, which may explain the more cranial and lateral activation visualized by fMRI, whereas PET depicts capillary perfusion changes and therefore shows activation closer to the parenchyma.

Preoperative motor system brain mapping using positron emission tomography and statistical parametric mapping: hints on cortical reorganisation

OBJECTIVES

This study investigated the applicability of statistical parametric mapping (SPM) for analysing individual preoperative brain mapping studies in patients with cerebral mass lesions for neurosurgical planning. The study further investigated if hints on functional reorganisation processes can be found.

METHODS

Nine adult patients with cerebral mass lesions underwent activation [(15)O]water-PET under stimulation by finger (n=9) and foot (n=4) movement. Individual SPM-t-maps were computed without anatomical normalisation and coregistered to the individual magnetic resonance imaging. Relative cerebral blood flow change maps were calculated for comparison.

RESULTS

The spatial relation between the sensorimotor cortex and the lesion could be determined in all cases. Additional activations covered the ipsilateral sensorimotor cortex and the bilateral cerebellum, premotor cortices and supplementary motor areas. Patients with motor symptoms of the stimulated hand (paresis, focal seizures) activated the ipsilateral premotor cortices and contralateral cerebellum more often than patients without motor symptoms. The SPM results for p<0.005 and cerebral blood flow change maps showed considerably overlapping motor area activations. For p<0.001, SPM missed three sensorimotor cortex activations depicted by cerebral blood flow change maps and by SPM for p<0.005 in typical localisation. SPM analyses showed less activations probably unrelated to task performance.

CONCLUSION

It is concluded that SPM provides an efficient method for analysing individual preoperative PET activation studies. Activations of the ipsilateral premotor cortices and contralateral cerebellum may indicate an enhanced recruitment of ipsilateral motor pathways evoked by functional reorganisation processes. However, this changed activation pattern was not necessarily associated with a better neurological status.

Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients

OBJECT

Although a growing number of authors currently advocate surgery to treat low-grade gliomas, controversy still persists, especially because of the risk of inducing neurological sequelae when the tumor is located within eloquent brain areas. Many researchers performing preoperative neurofunctional imaging and intraoperative electrophysiological methods have recently reported on the usefulness of cortical functional mapping. Despite the frequent involvement of subcortical structures by these gliomas, very few investigators have specifically raised the subject of fiber tracking. The authors in this report describe the importance of mapping cortical and subcortical functional regions by using intraoperative real-time direct electrical stimulations during resection of low-grade gliomas.

METHODS

Between 1996 and 2001, 103 patients harboring a corticosubcortical low-grade glioma in an eloquent area, with no or only mild deficit, had undergone surgery during which intraoperative electrical mapping of functional cortical sites and subcortical pathways was performed throughout the procedure. Both eloquent cortical areas and corresponding white fibers were systematically detected and preserved, thus defining the resection boundaries. Despite an 80% rate of immediate postoperative neurological worsening, 94% of patients recovered their preoperative status within 3 months--10% even improved--and then returned to a normal socioprofessional life. Eighty percent of resections were classified as total or subtotal based on control magnetic resonance images.

CONCLUSIONS

The use of functional mapping of the white matter together with cortical mapping allowed the authors to optimize the benefit/risk ratio of surgery of low-grade glioma invading eloquent regions. Given that preoperative fiber tracking with the aid of neuroimaging is not yet validated, we used intraoperative real-time cortical and subcortical stimulations as a valuable adjunct to the other mapping methods.

Metabolic and electrophysiological validation of functional MRI

OBJECTIVES

Although functional MRI is widely used for preoperative planning and intraoperative neuronavigation, its accuracy to depict the site of neuronal activity is not exactly known. Experience with methods that may validate fMRI data and the results obtained when coregistering fMRI with different preoperative and intraoperative mapping modalities including metabolically based (18)F-fluorodeoxyglucose PET, electrophysiologcally based transcranial magnetic stimulation (TMS), and direct electrical cortical stimulation (DECS) are described.

METHODS

Fifty patients were included. PET was performed in 30, TMS in 10, and DECS in 41 patients. After coregistration using a frameless stereotactic system, results were grouped into overlapping (<1 cm distance), neighbouring (<2 cm), or contradictory (>2 cm).

RESULTS

Comparing fMRI with PET, 18 overlapping, seven neighbouring, and one contradictory result were obtained. In four patients no comparison was possible (because of motion artefacts, low signal to noise ratio, and unusual high tumour metabolism in PET). The comparison of TMS and fMRI showed seven overlapping and three neighbouring results. In three patients no DECS results could be obtained. Of the remaining 38 patients, fMRI hand motor tasks were compared with DECS results of the upper limb muscles in 36 patients, and fMRI foot motor tasks were compared with DECS results of the lower limb on 13 occasions. Of those 49 studies, overlapping results were obtained in 31 patients, and neighbouring in 14. On four occasions fMRI did not show functional information (because of motion artefacts and low signal to noise).

CONCLUSIONS

All validation techniques have intrinsic limitations that restrict their spatial resolution. However, of 50 investigated patients, there was only one in whom results contradictory to fMRI were obtained. Although it is not thought that fMRI can replace the intraoperatively updated functional information (DECS), it is concluded that fMRI is an important adjunct in the preoperative assessment of patients with tumours in the vicinity of the central region.