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Sasaki T, Murakami K, Saito A, Haryu S, Kameyama M, Takahashi Y, Takamuro S, Kato N, Endo T. Usefulness of Transcranial Motor Evoked Potential in Clipping Surgery for Cerebral Aneurysms-Introduction of a New Protocol for Stable Monitoring. Neurol Med Chir (Tokyo) 2023; 63:409-419. [PMID: 37380449 PMCID: PMC10556210 DOI: 10.2176/jns-nmc.2023-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/17/2023] [Indexed: 06/30/2023] Open
Abstract
The usefulness of transcranial motor evoked potentials (Tc-MEPs) in clipping surgery has been reported. However, numerous false positive and false negative cases were reported. We report the usefulness of a new protocol compared with direct cortical MEP (Dc-MEP).Materials were 351 patients who underwent aneurysmal clipping under simultaneous monitoring of Tc- and Dc-MEPs. A total of 337 patients without hemiparesis and 14 with hemiparesis were separately analyzed. Intraoperative changes of Tc-MEP thresholds were examined in the first 50 patients without hemiparesis. The stimulation strength of Tc-MEP was set at +20% of the stimulation threshold. As thresholds changed intraoperatively, thresholds were examined every 10 min and changed stimulation strength.Stimulation thresholds of Tc-MEP were significantly decreased after craniotomy and significantly increased after CSF aspiration. The recording ratios of Tc- and Dc-MEPs were 98.8% and 90.5%, respectively. Out of 304 patients without MEP change, 5 patients developed transient or mild hemiparesis with infarction of the territory of the perforating artery arising from the posterior communicating artery. Out of 31 patients whose MEP transiently disappeared, 3 patients developed transient or mild hemiparesis. The other two patients without MEP recovery manifested persistent hemiparesis. In 14 patients with preoperative hemiparesis, 3 patients whose healthy/affected ratio of Tc-MEP was large developed severe persistent hemiparesis.We clarified the intraoperative changes of Tc-MEP thresholds for the first time. A new protocol of Tc-MEP that followed thresholds and changed stimulation strength to +20% of thresholds is useful for stable monitoring. The usefulness of Tc-MEP is the same as that or better than that of Dc-MEP.
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Affiliation(s)
- Tatsuya Sasaki
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
| | | | | | - Shinya Haryu
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
| | - Masayuki Kameyama
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
| | | | - Satoru Takamuro
- School of Medicine, Tohoku Medical and Pharmaceutical University
| | - Nana Kato
- School of Medicine, Tohoku Medical and Pharmaceutical University
| | - Toshiki Endo
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
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Wilkinson MF, Silvaggio J, Kaufmann A. Cathodal Genesis of Ipsilateral Hand (Crossover) Motor Evoked Potentials: Evidence from a Patient with Previous Stroke. Neurodiagn J 2023:1-7. [PMID: 36919532 DOI: 10.1080/21646821.2023.2178807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
A case is described where baseline transcranial electrical motor evoked potentials (TcMEP) and somatosensory evoked potentials (SSEP) results were unilaterally absent in a patient with previous hemispheric stroke undergoing a right-sided carotid endarterectomy. SSEP data confirmed right cortical pathology and excluded a technical rationale for absent motor evoked responses. Attempts at generating left-hand (contralateral) TcMEP from right cortical anodal stimulation failed despite high stimulus intensities. However, TcMEP responses from anodal stimulation of the right cortex were recorded from the right-hand (ipsilateral) which were attributed to "crossover." Ipsilateral TcMEP onset latencies derived from the stimulus-response data supports the idea that crossover is a product of cathodal stimulation initially acting on pericortical motor pathways.
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Affiliation(s)
- Marshall F Wilkinson
- Section of Neurosurgery, University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Joseph Silvaggio
- Section of Neurosurgery, University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Anthony Kaufmann
- Section of Neurosurgery, University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba, Canada
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Silverstein JW, Shah HA, Unadkat P, Vilaysom S, Boockvar JA, Langer DJ, Ellis JA, D'Amico RS. Short and long-term prognostic value of intraoperative motor evoked potentials in brain tumor patients: a case series of 121 brain tumor patients. J Neurooncol 2023; 161:127-133. [PMID: 36629962 DOI: 10.1007/s11060-022-04229-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/24/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE Iatrogenic neurologic deficits adversely affect patient outcomes following brain tumor resection. Motor evoked potential (MEP) monitoring allows surgeons to assess the integrity of motor-eloquent areas in real-time during tumor resection to lessen the risk of iatrogenic insult. We retrospectively associate intraoperative transcranial and direct cortical MEPs (TC-MEPs, DC-MEPs) to early and late post-operative motor function to prognosticate short- and long-term motor recovery in brain tumor patients undergoing surgical resection in peri-eloquent regions. METHODS We reviewed 121 brain tumor patients undergoing craniotomies with DC-MEP and/or TC-MEP monitoring. Motor function scores were recorded at multiple time-points up to 1 year postoperatively. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated at each time point. RESULTS The sensitivity, specificity, PPV, and NPV of TC-MEP in the immediate postoperative period was 17.5%, 100%, 100%, and 69.4%, respectively. For DC-MEP monitoring, the respective values were 25.0%, 100%, 100%, and 68.8%. By discharge, sensitivity had increased for both TC-MEP and DC MEPs to 43.8%, and 50.0% respectively. Subset analysis on patients without tumor recurrence/progression at long term follow-up (n = 62 pts, 51.2%) found that all patients with stable monitoring maintained or improved from preoperative status. One patient with transient intraoperative TC-MEP loss and permanent DC-MEP loss suffered a permanent deficit. CONCLUSION Brain tumor patients who undergo surgery with intact MEP monitoring and experience new postoperative deficits likely suffer transient deficits that will improve over the postoperative course in the absence of disease progression.
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Affiliation(s)
- Justin W Silverstein
- Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Harshal A Shah
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, New York, NY, 11549, USA.
| | - Prashin Unadkat
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/ Northwell Health & The Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA
| | - Sabena Vilaysom
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, NY, USA
| | - John A Boockvar
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New York, NY, USA
| | - David J Langer
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New York, NY, USA
| | - Jason A Ellis
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New York, NY, USA
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Risk factors and prognostic implications of surgery-related strokes following resection of high-grade glioma. Sci Rep 2022; 12:22594. [PMID: 36585482 PMCID: PMC9803666 DOI: 10.1038/s41598-022-27127-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023] Open
Abstract
Surgery-related strokes are an important cause of morbidity following resection of high-grade glioma (HGG). We explored the incidence, risk factors and clinical consequences of intra-operative ischemic strokes in surgeries for resection of HGG. We retrospectively followed a cohort of 239 patients who underwent surgical resection of HGG between 2013 and 2017. Tumor types included both isocitrate dehydrogenase (IDH) wildtype glioblastoma and IDH-mutant WHO grade 4 astrocytoma. We analyzed pre- and post-operative demographic, clinical, radiological, anesthesiology and intraoperative neurophysiology data, including overall survival and functional outcomes. Acute ischemic strokes were seen on postoperative diffusion-weighted imaging (DWI) in 30 patients (12.5%), 13 of whom (43%) developed new neurological deficits. Infarcts were more common in insular (23%, p = 0.019) and temporal surgeries (57%, p = 0.01). Immediately after surgery, 35% of patients without infarcts and 57% of those with infarcts experienced motor deficits (p = 0.022). Six months later, rates of motor deficits decreased to 25% in the non-infarcts group and 37% in the infarcts group (p = 0.023 and 0.105, respectively) with a significantly lower Karnofsky-Performance Score (KPS, p = 0.001). Intra-operative language decline in awake procedures was a significant indicator of the occurrence of intra-operative stroke (p = 0.029). In conclusion, intraoperative ischemic events are more common in insular and temporal surgeries for resection of HGG and their intra-operative detection is limited. These strokes can impair motor and speech functions as well as patients' performance status.
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Wilkinson MF, Chowdhury T, Kaufmann AM. A novel method for quantitative evaluation of motor evoked potential monitoring during cerebrovascular surgeries. J Clin Neurosci 2022; 98:29-36. [DOI: 10.1016/j.jocn.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/08/2021] [Accepted: 01/22/2022] [Indexed: 11/29/2022]
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Schiavao LJV, Neville Ribeiro I, Yukie Hayashi C, Gadelha Figueiredo E, Russowsky Brunoni A, Jacobsen Teixeira M, Pokorny G, Silva Paiva W. Assessing the Capabilities of Transcranial Magnetic Stimulation (TMS) to Aid in the Removal of Brain Tumors Affecting the Motor Cortex: A Systematic Review. Neuropsychiatr Dis Treat 2022; 18:1219-1235. [PMID: 35734549 PMCID: PMC9208734 DOI: 10.2147/ndt.s359855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The brain tumor is frequently related to severe motor impairment and impacts the quality of life. The corticospinal tract can sometimes be affected depending on the type and size of the neoplasm, so different tools can evaluate motor function and connections. It is essential to organize surgical procedures and plan the approach. Functional motor status is mapped before, during, and after surgery. Studying corticospinal tract status can help map the functional areas, predict postoperative outcomes, and help the decision, reducing neurological deficits, aiming to preserve functional networks, using the concepts of white matters localization and fibbers connections. Nowadays, there are new techniques that provide functional information regarding the motor cortex, such as transcranial magnetic stimulation (TMS), direct cortical stimulation (DCS), and navigated TMS (nTMS). These tools can be used to plan a customized surgical strategy and the role of motor evoked potentials (MEPs) is well described during intra-operative, using intraoperative neuromonitoring. MEPs can help to localize primary motor areas and delineate the cut-off point of resection in real-time, using direct stimulation. In the post-operative, the MEP has increased your function as a predictive marker of permanent or transitory neurological lesion marker. METHODS Systematic review performed in MEDLINE via PUBMED, EMBASE, and SCOPUS databases regarding the post-operative assessment of MEP in patients with brain tumors. The search strategy included the following terms: (("Evoked Potentials, Motor"[Mesh]) AND "Neoplasms"[Mesh]) AND "Transcranial Magnetic Stimulation"[Mesh] AND "Brain Tumor"[Mesh]), the analysis followed the PRISMA guidelines for systematic reviews, the review spanned until 06/04/2021, inclusion criteria were studies presenting confirmed diagnosis of brain tumor (primary or metastatic), patients >18 y/o, using TMS, Navigated TMS, and/or Evoked Potentials as tools in preoperative planning or at the intra-operative helping the evaluation of the neurological status of the motor cortex, articles published in peer-reviewed journals, and written in English or Portuguese. RESULTS A total of 38 studies were selected for this review, of which 14 investigated the potential of nTMS to predict the occurrence of motor deficits, while 25 of the articles investigated the capabilities of the nTMS technique in performing pre/intraoperative neuro mapping of the motor cortex. CONCLUSION Further studies regarding motor function assessment are needed and standardized protocols for MEPs also need to be defined.
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Affiliation(s)
- Lucas Jose Vaz Schiavao
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil.,Neurology, Instituto do Câncer do Estado de São Paulo - ICESP, São Paulo, Brazil
| | - Iuri Neville Ribeiro
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil.,Neurology, Instituto do Câncer do Estado de São Paulo - ICESP, São Paulo, Brazil
| | - Cintya Yukie Hayashi
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | - Eberval Gadelha Figueiredo
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | - Andre Russowsky Brunoni
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | | | - Wellingson Silva Paiva
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
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Jamaludin MR, Lai KW, Chuah JH, Zaki MA, Hum YC, Tee YK, Mohd Salim MI, Saw LB. Transcranial Electrical Motor Evoked Potential in Predicting Positive Functional Outcome of Patients after Decompressive Spine Surgery: Review on Challenges and Recommendations towards Objective Interpretation. Behav Neurol 2021; 2021:2684855. [PMID: 34777631 PMCID: PMC8580690 DOI: 10.1155/2021/2684855] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/18/2021] [Indexed: 11/18/2022] Open
Abstract
Spine surgeries impose risk to the spine's surrounding anatomical and physiological structures especially the spinal cord and the nerve roots. Intraoperative neuromonitoring (IONM) is a technology developed to monitor the integrity of the spinal cord and the nerve roots via the surgery. Transcranial motor evoked potential (TcMEP) (one of the IONM modalities) is adopted to monitor the integrity of the motor pathway of the spinal cord and the motor nerve roots. Recent research suggested that the IONM is conducive as a prognostic tool towards the patient's functional outcome. This paper summarizes the researches of IONM being adopted as a prognostic tool. In addition, this paper highlights the problems associated with the signal parameters as the improvement criteria in the previous researches. Lastly, we review the challenges of TcMEP to achieve a prognostic tool focusing on the factors that could interfere with the generation of a stable TcMEP response. The final section will discuss recommendations for IONM technology to achieve an objective prognostic tool.
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Affiliation(s)
- Mohd Redzuan Jamaludin
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Khin Wee Lai
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Joon Huang Chuah
- Department of Electrical Engineering, Faculty of Engineering, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Muhammad Afiq Zaki
- Center of Environmental Health and Safety, Faculty of Health Sciences, Universiti Teknologi Mara Selangor, Puncak Alam Campus, 42300 Bandar Puncak Alam, Selangor Darul Ehsan, Malaysia
| | - Yan Chai Hum
- Centre for Healthcare Science & Technology, Department of Mechatronics and Biomedical Engineering, Lee Kong Chian Faculty of Engineering and Science, Universiti Tunku Abdul Rahman, Malaysia
| | - Yee Kai Tee
- Centre for Healthcare Science & Technology, Department of Mechatronics and Biomedical Engineering, Lee Kong Chian Faculty of Engineering and Science, Universiti Tunku Abdul Rahman, Malaysia
| | - Maheza Irna Mohd Salim
- Bioinspired Device and Tissue Engineering Research Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, 81300 Skudai, Johor, Malaysia
| | - Lim Beng Saw
- Department of Orthopaedic Surgery, Sunway Medical Centre, Malaysia
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Transcranial versus Direct Cortical Stimulation for Motor-Evoked Potentials during Resection of Supratentorial Tumors under General Anesthesia (The TRANSEKT-Trial): Study Protocol for a Randomized Controlled Trial. Biomedicines 2021; 9:biomedicines9101490. [PMID: 34680607 PMCID: PMC8533079 DOI: 10.3390/biomedicines9101490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/08/2021] [Accepted: 10/14/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Monitoring of motor function during surgery for supratentorial tumors under general anesthesia applies either transcranial electrical stimulation (TES) or direct cortical stimulation (DCS) to elicit motor-evoked potentials. To date, there is no guideline that favor one method over the other. Therefore, we designed this randomized study to compare between both methods regarding the prediction of postoperative motor deficits and extent of tumor resection. Methods: This is a multicenter (six centers in Germany and one in Switzerland), double blind, parallel group, exploratory, randomized controlled clinical trial. Patients without or with mild paresis, who are scheduled for surgical resection of motor-eloquent brain tumors under general anesthesia will be randomized to surgical resection under TES or surgical resection under DCS. The primary endpoint is sensitivity and specificity in prognosis of motor function 7 days after surgery. The main secondary endpoint is the extent of tumor resection. The study is planned to include 120 patients within 2 years. Discussion: The present exploratory study should compare TES and DCS regarding sensitivity and specificity in predicting postoperative motor deficit and extent of tumor resection to calculate the required number of patients in a confirmatory trial to test the superiority of one method over the other.
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Asimakidou E, Abut PA, Raabe A, Seidel K. Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review. Cancers (Basel) 2021; 13:2803. [PMID: 34199853 PMCID: PMC8200078 DOI: 10.3390/cancers13112803] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 12/31/2022] Open
Abstract
During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined.
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Affiliation(s)
- Evridiki Asimakidou
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Pablo Alvarez Abut
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
- Department of Neurosurgery, Clínica 25 de Mayo, 7600 Mar del Plata, Argentina
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
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Berger A, Tzarfati G, Costa M, Serafimova M, Korn A, Vendrov I, Alfasi T, Krill D, Aviram D, Ben Moshe S, Kashanian A, Ram Z, Grossman R. Incidence and impact of stroke following surgery for low-grade gliomas. J Neurosurg 2019; 134:153-161. [PMID: 31881532 DOI: 10.3171/2019.10.jns192301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ischemic complications are a common cause of neurological deficits following low-grade glioma (LGG) surgeries. In this study, the authors evaluated the incidence, risk factors, and long-term implications of intraoperative ischemic events. METHODS The authors retrospectively evaluated patients who had undergone resection of an LGG between 2013 and 2017. Analysis included pre- and postoperative demographic, clinical, radiological, and anesthetic data, as well as intraoperative neurophysiology data, overall survival, and functional and neurocognitive outcomes. RESULTS Among the 82 patients included in the study, postoperative diffusion-weighted imaging showed evidence of acute ischemic strokes in 19 patients (23%), 13 of whom (68%) developed new neurological deficits. Infarcts were more common in recurrent and insular surgeries (p < 0.05). Survival was similar between the patients with and without infarcts. Immediately after surgery, 27% of the patients without infarcts and 58% of those with infarcts experienced motor deficits (p = 0.024), decreasing to 16% (p = 0.082) and 37% (p = 0.024), respectively, at 1 year. Neurocognitive functions before and 3 months after surgery were generally stable for the two groups, with the exception of a decline in verbal rhyming ability among patients with infarcts. Confusion during awake craniotomy was a strong predictor of the occurrence of an ischemic stroke. Mean arterial pressure at the beginning of surgery was significantly lower in the infarct group. CONCLUSIONS Recurrent surgeries and insular tumor locations are risk factors for intraoperative strokes. Although they do not affect survival, these strokes negatively affect patient activity and performance status, mainly during the first 3 postoperative months, with gradual functional improvement over 1 year. Several intraoperative parameters may suggest the impending development of an infarct.
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