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Nico E, Adereti CO, Hackett AM, Bianconi A, Naik A, Eberle AT, Cifre Serra PJ, Koester SW, Malnik SL, Fox BM, Hartke JN, Winkler EA, Catapano JS, Lawton MT. Assessing the Relationship between Surgical Timing and Postoperative Seizure Outcomes in Cavernoma-Related Epilepsy: A Single-Institution Retrospective Analysis of 63 Patients with a Review of the Literature. Brain Sci 2024; 14:494. [PMID: 38790473 PMCID: PMC11120247 DOI: 10.3390/brainsci14050494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Patients with supratentorial cavernous malformations (SCMs) commonly present with seizures. First-line treatments for cavernoma-related epilepsy (CRE) include conservative management (antiepileptic drugs (AEDs)) and surgery. We compared seizure outcomes of CRE patients after early (≤6 months) vs. delayed (>6 months) surgery. Methods: We compared outcomes of CRE patients with SCMs surgically treated at our large-volume cerebrovascular center (1 January 2010-31 July 2020). Patients with 1 sporadic SCM and ≥1-year follow-up were included. Primary outcomes were International League Against Epilepsy (ILAE) class 1 seizure freedom and AED independence. Results: Of 63 CRE patients (26 women, 37 men; mean ± SD age, 36.1 ± 14.6 years), 48 (76%) vs. 15 (24%) underwent early (mean ± SD, 2.1 ± 1.7 months) vs. delayed (mean ± SD, 6.2 ± 7.1 years) surgery. Most (32 (67%)) with early surgery presented after 1 seizure; all with delayed surgery had ≥2 seizures. Seven (47%) with delayed surgery had drug-resistant epilepsy. At follow-up (mean ± SD, 5.4 ± 3.3 years), CRE patients with early surgery were more likely to have ILAE class 1 seizure freedom and AED independence than those with delayed surgery (92% (44/48) vs. 53% (8/15), p = 0.002; and 65% (31/48) vs. 33% (5/15), p = 0.03, respectively). Conclusions: Early CRE surgery demonstrated better seizure outcomes than delayed surgery. Multicenter prospective studies are needed to validate these findings.
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Affiliation(s)
- Elsa Nico
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Christopher O. Adereti
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Ashia M. Hackett
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Andrea Bianconi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Adam T. Eberle
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Pere J. Cifre Serra
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Stefan W. Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Samuel L. Malnik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Brandon M. Fox
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joelle N. Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ethan A. Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
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Freund BE, Feyissa AM, Khan A, Middlebrooks EH, Grewal SS, Sabsevitz D, Sherman WJ, Quiñones-Hinojosa A, Tatum WO. Early Postoperative Seizures Following Awake Craniotomy and Functional Brain Mapping for Lesionectomy. World Neurosurg 2024; 181:e732-e742. [PMID: 37898274 DOI: 10.1016/j.wneu.2023.10.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE Awake craniotomy with electrocorticography (ECoG) and direct electrical stimulation (DES) facilitates lesionectomy while avoiding adverse effects. Early postoperative seizures (EPS), occurring within 7 days following surgery, can lead to morbidity. However, risk factors for EPS after awake craniotomy including clinical and ECoG data are not well defined. METHODS We retrospectively studied the incidence and risk factors of EPS following awake craniotomy for lesionectomy, and report short-term outcomes between January 1, 2020, and December 31, 2022. RESULTS We included 138 patients (56 female) who underwent 142 awake craniotomies, average age was 50.78 ± 15.97 years. Eighty-eight (63.7%) patients had a preoperative history of tumor-related epilepsy treated with antiseizure medication (ASM), 12 (13.6%) with drug-resistance. All others (36.3%) received ASM prophylaxis with levetiracetam perioperatively and continued for 14 days. An equal number of cases (71) each utilized a novel circle grid or strip electrodes for ECoG. There were 31 (21.8%) cases of intraoperative seizures, 16 with EPS (11.3%). Acute abnormality on early postoperative neuroimaging (P = 0.01), subarachnoid hemorrhage (P = 0.01), young age (P = 0.01), and persistent postoperative neurologic deficits (P = 0.013) were associated with EPS. Acute abnormality on neuroimaging remained significant in multivariate analysis. Outcomes during hospitalization and early outpatient follow up were worse with EPS. CONCLUSIONS We report novel findings using ECoG and clinical features to predict EPS, including acute perioperative brain injury, persistent postoperative deficits and young age. Given worse outcomes with EPS, clinical indicators for EPS should alert clinicians of potential need for early postoperative EEG monitoring and perioperative ASM adjustment.
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Affiliation(s)
- Brin E Freund
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.
| | | | - Aafreen Khan
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Erik H Middlebrooks
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA; Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Sanjeet S Grewal
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - David Sabsevitz
- Department of Psychology and Psychiatry, Mayo Clinic, Jacksonville, Florida, USA
| | - Wendy J Sherman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
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Tuleasca C, Leroy HA, Strachowski O, Derre B, Maurage CA, Peciu-Florianu I, Reyns N. Combined use of intraoperative MRI and awake tailored microsurgical resection to respect functional neural networks: preliminary experience. Swiss Med Wkly 2023; 153:40072. [PMID: 37192405 DOI: 10.57187/smw.2023.40072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION The combined use of intraoperative MRI and awake surgery is a tailored microsurgical resection to respect functional neural networks (mainly the language and motor ones). Intraoperative MRI has been classically considered to increase the extent of resection for gliomas, thereby reducing neurological deficits. Herein, we evaluated the combined technique of awake microsurgical resection and intraoperative MRI for primary brain tumours (gliomas, metastasis) and epilepsy (cortical dysplasia, non-lesional, cavernomas). PATIENTS AND METHODS Eighteen patients were treated with the commonly used "asleep awake asleep" (AAA) approach at Lille University Hospital, France, from November 2016 until May 2020. The exact anatomical location was insular with various extensions, frontal, temporal or fronto-temporal in 8 (44.4%), parietal in 3 (16.7%), fronto-opercular in 4 (22.2%), Rolandic in two (11.1%), and the supplementary motor area (SMA) in one (5.6%). RESULTS The patients had a mean age of 38.4 years (median 37.1, range 20.8-66.9). The mean surgical duration was 4.1 hours (median 4.2, range 2.6-6.4) with a mean duration of intraoperative MRI of 28.8 minutes (median 25, range 13-55). Overall, 61% (11/18) of patients underwent further resection, while 39% had no additional resection after intraoperative MRI. The mean preoperative and postoperative tumour volumes of the primary brain tumours were 34.7 cc (median 10.7, range 0.534-130.25) and 3.5 cc (median 0.5, range 0-17.4), respectively. Moreover, the proportion of the initially resected tumour volume at the time of intraoperative MRI (expressed as 100% from preoperative volume) and the final resected tumour volume were statistically significant (p= 0.01, Mann-Whitney test). The tumour remnants were commonly found posterior (5/9) or anterior (2/9) insular and in proximity with the motor strip (1/9) or language areas (e.g. Broca, 1/9). Further resection was not required in seven patients because there were no remnants (3/7), cortical stimulation approaching eloquent areas (3/7) and non-lesional epilepsy (1/7). The mean overall follow-up period was 15.8 months (median 12, range 3-36). CONCLUSION The intraoperative MRI and awake microsurgical resection approach is feasible with extensive planning and multidisciplinary collaboration, as these methods are complementary and synergic rather than competitive to improve patient oncological outcomes and quality of life.
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Affiliation(s)
- Constantin Tuleasca
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Henri-Arthur Leroy
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Ondine Strachowski
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Benoit Derre
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Claude-Alain Maurage
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Iulia Peciu-Florianu
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Nicolas Reyns
- Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
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Dammann P, Santos AN, Wan XY, Zhu Y, Sure U. Cavernous Malformations. Neurosurg Clin N Am 2022; 33:449-460. [DOI: 10.1016/j.nec.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rauschenbach L, Bartsch P, Santos AN, Lenkeit A, Darkwah Oppong M, Wrede KH, Jabbarli R, Chmielewski WX, Schmidt B, Quesada CM, Forsting M, Sure U, Dammann P. Quality of life and mood assessment in conservatively treated cavernous malformation-related epilepsy. Brain Behav 2022; 12:e2595. [PMID: 35470577 PMCID: PMC9226805 DOI: 10.1002/brb3.2595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/03/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To estimate the quality of life, anxiety, depression, and illness perception in patients with medically treated cerebral cavernous malformation (CCM) and associated epilepsy. METHODS Nonsurgically treated patients with CCM-related epilepsy (CRE) were included. Demographic, radiographic, and clinical features were assessed. All participants received established questionnaires (short-form 36 health survey, SF-36; hospital anxiety and depression score, HADS-A/D; visual analogue scale score, VAS) assessing the functional and psychosocial burden of disease. To some extent, calculated values were compared with reference values from population-based studies. Test results were related to seizure control. RESULTS A total of 37 patients were included. Mean age was 45.8 ± 14.4 years, and 54.1% were female. Diagnosis of CRE was significantly associated with attenuated quality of life and increased level of anxiety, affecting physical and psychosocial dimensions. The assessment of illness perception identified considerable burden. HADS was significantly associated with VAS and SF-36 component scores. Efficacy of antiepileptic medication had no restoring impact on quality of life, anxiety, depression, or illness perception. CONCLUSIONS CRE negatively influences quality of life and mood, independent of seizure control due to antiepileptic medication. Screening for functional and psychosocial deficits in clinical practice might be useful for assessing individual burden and allocating surgical or drug treatment.
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Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Pauline Bartsch
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Annika Lenkeit
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Witold X Chmielewski
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, Essen, Germany
| | - Carlos M Quesada
- Department of Neurology, Division of Epilepsy, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
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Dziedzic TA, Koczyk K, Nowak A, Maj E, Marchel A. Long-Term Management of Seizures after Surgical Treatment of Supratentorial Cavernous Malformations : A Retrospective Single Centre Study. J Korean Neurosurg Soc 2022; 65:415-421. [PMID: 35508959 PMCID: PMC9082132 DOI: 10.3340/jkns.2020.0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 07/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Seizure recurrence after the first-ever seizure in patients with a supratentorial cerebral cavernous malformation (CCM) is almost certain, so the diagnosis and treatment of epilepsy is justified. The optimal method of management of these patients is still a matter of debate. The aim of our study was to identify factors associated with postoperative seizure control and assess the surgical morbidity rate.
Methods We retrospectively analysed 45 consecutive patients with a supratentorial CCM and symptomatic epilepsy in a single centre. Pre- and postoperative epidemiological data, seizure-related patient histories, neuroimaging results, surgery details and outcomes were obtained from hospital medical records. Seizure outcomes were assessed at least 12 months after surgery.
Results Thirty-five patients (77.8%) were seizure free at the long-term follow-up (Engel class I); six (13,3%) had rare, nocturnal seizures (Engel class II); and four (8.9%) showed meaningful improvement (Engel class III). In 15 patients (33%) in the Engel I group; it was possible to discontinue antiepileptic medication. Although there was not statistical significance, our results suggest that patients can benefit from early surgery. No deaths occurred in our study, and mild postoperative neurologic deficits were observed in two patients (4%) at the long-term follow-up.
Conclusion Surgical resection of CCMs should be considered in all patients with a supratentorial malformation and epilepsy due to the favourable surgical results in terms of the epileptic seizure control rate and low postoperative morbidity risk, despite the use of different predictors for the seizure outcome.
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Ganz JC. Cavernous malformations. PROGRESS IN BRAIN RESEARCH 2022; 268:115-132. [PMID: 35074077 DOI: 10.1016/bs.pbr.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cavernous malformations are relatively common intracerebral malformations of which we only became properly aware after the introduction of MRI. They may be sporadic or familial. Familial CMs may be multiple and new lesions appear over time requiring intermittent MR control. Many sporadic CMs have no symptoms. The commonest location is in the supratentorial cerebral parenchyma presenting with epilepsy. The best treatment is microsurgery. A small proportion are in the brainstem and may rebleed and even be lethal. Treatment includes microsurgery and radiosurgery. Microsurgery cures the patient but has substantial problems with complications, deterioration and partial removal. Radiosurgery has taken time to demonstrate that it can over 2 years substantially reduce the risk of rebleeds without the risks of microsurgery. Both methods have a part to play in the treatment.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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Ille S, Schroeder A, Hostettler IC, Wostrack M, Meyer B, Krieg SM. Impacting the Treatment of Highly Eloquent Supratentorial Cerebral Cavernous Malformations by Noninvasive Functional Mapping-An Observational Cohort Study. Oper Neurosurg (Hagerstown) 2021; 21:467-477. [PMID: 34624894 DOI: 10.1093/ons/opab318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/18/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) may cause cavernoma-related epilepsy (CRE) and intracranial hemorrhage (ICH). Functional mapping has shown its usefulness during the resection of eloquent lesions including the treatment of brain arteriovenous malformations. OBJECTIVE To evaluate the impact of noninvasive functional mapping on decision-making and resection of eloquently located CCM. METHODS Of 126 patients with intracranial cavernomas, we prospectively included 40 consecutive patients (31.7%) with highly eloquent CCM between 2012 and 2020. We performed functional mapping via navigated transcranial magnetic stimulation (nTMS) motor mapping in 30 cases and nTMS language mapping in 20 cases. Twenty patients suffered from CRE. CCM caused ICH in 18 cases. RESULTS We used functional mapping data including function-based tractography in all cases. Indication toward (31 cases) or against (9 cases) CCM resection was influenced by noninvasive functional mapping in 36 cases (90%). We resected CCMs in 24 cases, and 7 patients refused the recommendation for surgery. In 19 and 4 cases, we used additional intraoperative neuromonitoring and awake craniotomy, respectively. Patients suffered from transient postoperative motor or language deficits in 2 and 2 cases, respectively. No patient suffered from permanent deficits. After 1 yr of follow-up, anti-epileptic drugs could be discontinued in all patients who underwent surgery but 1 patient. CONCLUSION Surgery-related deficit rates are low even for highly eloquent CCM and seizure outcome is excellent. The present results show that noninvasive functional mapping and function-based tractography is a useful tool for the decision-making process and during microsurgical resection of eloquently located CCM.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Isabel C Hostettler
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
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Intraoperative brain mapping during awake surgery in symptomatic supratentorial cavernomas. ACTA ACUST UNITED AC 2021; 32:217-223. [PMID: 34493402 DOI: 10.1016/j.neucie.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Complete resection of symptomatic supratentorial cavernoma (SCA) and removal of the surrounding gliotic area is recommended to minimize the risk of persistent seizures or (re)bleeding. Surgery of SCA located in an eloquent area, can carry out severe postoperative neurological morbidity. We report a study aimed to assess feasibility, extent of resection and outcome after surgical removal of CA by cortico-subcortical intraoperative brain stimulation (ioBS) in the awake patient. METHODS Six patients diagnosed of symptomatic SCA located on an eloquent area and operated on while awake under local anaesthesia ioBS, were included. Preoperative planning included neuropsychologic assessment of language-related functions, sociocognitive functions and executive functions. Intraoperatively, we recorded the results achieved in the planned neuropsychological tasks when stimulation was applied (cortical and subcortical). Postoperative control 3D MRI was scheduled at 1 month after surgery to calculate extent of resection. Neuropsychological assessment at 6 months after surgery was performed in all cases. RESULTS Six patients (5 females, 1 male) aged 24-48 years were included in our study. Locations of the lesions were right insular (n=1), left insular (n=1), left temporo-insular (n=1), left temporal (n=2) and left frontal (n=1). In all patients, positive findings were obtained during ioBS. In 5 patients, complete surgical resection was achieved. Two patients had postoperative transient neurological deficits, one case of hemiparesis, one case of dysnomia, both cleared over a 6-month period. Clinical follow-up revealed that all patients experienced complete recovery from preoperative symptoms within a year and five patients with seizures showed marked improvement and eventually quit antiepileptic drugs. Neuropsychological assessment at 6 months provided normal results compared to preoperative baseline in all domains. CONCLUSIONS Our study suggests that ioBS in the awake surgery of symptomatic SCA located in eloquent areas, allows to increase the rate of complete resection, minimizing postoperative neurological and neuropsychological deficit, and improving postoperative seizures control.
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Shoubash L, Baldauf J, Matthes M, Kirsch M, Rath M, Felbor U, Schroeder HWS. Long-term outcome and quality of life after CNS cavernoma resection: eloquent vs. non-eloquent areas. Neurosurg Rev 2021; 45:649-660. [PMID: 34164745 PMCID: PMC8827309 DOI: 10.1007/s10143-021-01572-8] [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: 01/28/2021] [Revised: 04/18/2021] [Accepted: 05/26/2021] [Indexed: 11/30/2022]
Abstract
The aim of this study is to analyze the long-term quality of life after surgery of cavernoma. A monocentric retrospective study was conducted on 69 patients with cavernoma treated microsurgically between 2000 and 2016. The eloquence was adopted from Spetzler-Martin definition. A most recent follow-up was elicited between 2017 and 2019, in which the quality of life (QoL) was evaluated with the Short Form-12 questionnaire (SF12). Forty-one lesions were in eloquent group (EG), 22 in non-eloquent group (NEG), 3 in orbit, and 3 in the spinal cord. Postoperative worsening of the modified Rankin scale (mRS) occurred in 19.5% of cases in EG versus 4.5% in NEG. After a mean follow-up of 6.5 years (SD 4.6), the neurological status was better or unchanged compared to baseline in 85.4% of EG and 100% of NEG. Regarding QoL assessment of 44 patients (EG n = 27, NEG n = 14) attended the last follow-up. Patients after eloquent cavernoma resection reported a non-inferior QoL in most SF12 domains (except for physical role) compared to NEG. However, they reported general health perception inferior to norms, which was affected by the limited physical and emotional roles. At a late follow-up, the surgical morbidity was transient in the NEG and mostly recovered in the EG. The QoL comparison between eloquent and non-eloquent cavernomas created interesting and new data after prolonged follow-up. These results add value for decision-making as well as patient counseling for future encountered cases. Preoperative evaluation of QoL is recommended for future studies to assess QoL dynamics.
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Affiliation(s)
- Loay Shoubash
- Department of Neurosurgery, University Medicine Greifswald, Ferdinand-Sauerbruch-Strasse, 17475, Greifswald, Germany.
| | - Jörg Baldauf
- Department of Neurosurgery, University Medicine Greifswald, Ferdinand-Sauerbruch-Strasse, 17475, Greifswald, Germany
| | - Marc Matthes
- Department of Neurosurgery, University Medicine Greifswald, Ferdinand-Sauerbruch-Strasse, 17475, Greifswald, Germany
| | - Michael Kirsch
- Department of Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Rath
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - Ute Felbor
- Department of Human Genetics, University Medicine Greifswald and Interfaculty Institute of Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Ferdinand-Sauerbruch-Strasse, 17475, Greifswald, Germany
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Sarubbo S, Annicchiarico L, Corsini F, Zigiotto L, Herbet G, Moritz-Gasser S, Dalpiaz C, Vitali L, Tate M, De Benedictis A, Amorosino G, Olivetti E, Rozzanigo U, Petralia B, Duffau H, Avesani P. Planning Brain Tumor Resection Using a Probabilistic Atlas of Cortical and Subcortical Structures Critical for Functional Processing: A Proof of Concept. Oper Neurosurg (Hagerstown) 2021; 20:E175-E183. [PMID: 33372966 DOI: 10.1093/ons/opaa396] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/13/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Functional preoperative planning for resection of intrinsic brain tumors in eloquent areas is still a challenge. Predicting subcortical functional framework is especially difficult. Direct electrical stimulation (DES) is the recommended technique for resection of these lesions. A reliable probabilistic atlas of the critical cortical epicenters and subcortical framework based on DES data was recently published. OBJECTIVE To propose a pipeline for the automated alignment of the corticosubcortical maps of this atlas with T1-weighted MRI. METHODS To test the alignment, we selected 10 patients who underwent resection of brain lesions by using DES. We aligned different cortical and subcortical functional maps to preoperative volumetric T1 MRIs (with/without gadolinium). For each patient we quantified the quality of the alignment, and we calculated the match between the location of the functional sites found at DES and the functional maps of the atlas. RESULTS We found an accurate brain extraction and alignment of the functional maps with both the T1 MRIs of each patient. The matching analysis between functional maps and functional responses collected during surgeries was 88% at cortical and, importantly, 100% at subcortical level, providing a further proof of the correct alignment. CONCLUSION We demonstrated quantitatively and qualitatively the reliability of this tool that may be used for presurgical planning, providing further functional information at the cortical level and a unique probabilistic prevision of distribution of the critical subcortical structures. Finally, this tool offers the chance for multimodal planning through integrating this functional information with other neuroradiological and neurophysiological techniques.
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Affiliation(s)
- Silvio Sarubbo
- Department of Neurosurgery, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy.,Structural and Functional Connectivity Lab Project, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Luciano Annicchiarico
- Department of Neurosurgery, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy.,Structural and Functional Connectivity Lab Project, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Francesco Corsini
- Department of Neurosurgery, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy.,Structural and Functional Connectivity Lab Project, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Luca Zigiotto
- Department of Neurosurgery, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy.,Structural and Functional Connectivity Lab Project, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Guillaume Herbet
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,National Institute for Health and Medical Research (INSERM), NSERM U1191, Institute of Functional Genomics, University of Montpellier, Montpellier, France
| | - Sylvie Moritz-Gasser
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,National Institute for Health and Medical Research (INSERM), NSERM U1191, Institute of Functional Genomics, University of Montpellier, Montpellier, France
| | - Chiara Dalpiaz
- Department of Anesthesiology and Intensive Care, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Luca Vitali
- Department of Anesthesiology and Intensive Care, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Matthew Tate
- Departments of Neurosurgery and Neurology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Alessandro De Benedictis
- Neurosurgery Unit, Department of Neuroscience, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Gabriele Amorosino
- Neuroinformatics Laboratory (NiLab), Bruno Kessler Foundation (FBK), Trento, Italy.,Center for Mind/Brain Sciences - CIMeC, University of Trento, Rovereto, Italy
| | - Emanuele Olivetti
- Neuroinformatics Laboratory (NiLab), Bruno Kessler Foundation (FBK), Trento, Italy.,Center for Mind/Brain Sciences - CIMeC, University of Trento, Rovereto, Italy
| | - Umberto Rozzanigo
- Department of Radiology, Division of Neuroradiology, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Benedetto Petralia
- Department of Radiology, Division of Neuroradiology, "S. Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,National Institute for Health and Medical Research (INSERM), NSERM U1191, Institute of Functional Genomics, University of Montpellier, Montpellier, France
| | - Paolo Avesani
- Neuroinformatics Laboratory (NiLab), Bruno Kessler Foundation (FBK), Trento, Italy.,Center for Mind/Brain Sciences - CIMeC, University of Trento, Rovereto, Italy
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12
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Prat-Acín R, Galeano-Senabre I, López-Ruiz P, García-Sánchez D, Ayuso-Sacido A, Espert-Tortajada R. Intraoperative brain mapping during awake surgery in symptomatic supratentorial cavernomas. Neurocirugia (Astur) 2020; 32:S1130-1473(20)30105-6. [PMID: 33060022 DOI: 10.1016/j.neucir.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Complete resection of symptomatic supratentorial cavernoma (SCA) and removal of the surrounding gliotic area is recommended to minimize the risk of persistent seizures or (re)bleeding. Surgery of SCA located in an eloquent area, can carry out severe postoperative neurological morbidity. We report a study aimed to assess feasibility, extent of resection and outcome after surgical removal of CA by cortico-subcortical intraoperative brain stimulation (ioBS) in the awake patient. METHODS Six patients diagnosed of symptomatic SCA located on an eloquent area and operated on while awake under local anaesthesia ioBS, were included. Preoperative planning included neuropsychologic assessment of language-related functions, sociocognitive functions and executive functions. Intraoperatively, we recorded the results achieved in the planned neuropsychological tasks when stimulation was applied (cortical and subcortical). Postoperative control 3D MRI was scheduled at 1 month after surgery to calculate extent of resection. Neuropsychological assessment at 6 months after surgery was performed in all cases. RESULTS Six patients (5 females, 1 male) aged 24-48 years were included in our study. Locations of the lesions were right insular (n=1), left insular (n=1), left temporo-insular (n=1), left temporal (n=2) and left frontal (n=1). In all patients, positive findings were obtained during ioBS. In 5 patients, complete surgical resection was achieved. Two patients had postoperative transient neurological deficits, one case of hemiparesis, one case of dysnomia, both cleared over a 6-month period. Clinical follow-up revealed that all patients experienced complete recovery from preoperative symptoms within a year and five patients with seizures showed marked improvement and eventually quit antiepileptic drugs. Neuropsychological assessment at 6 months provided normal results compared to preoperative baseline in all domains. CONCLUSIONS Our study suggests that ioBS in the awake surgery of symptomatic SCA located in eloquent areas, allows to increase the rate of complete resection, minimizing postoperative neurological and neuropsychological deficit, and improving postoperative seizures control.
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Affiliation(s)
- Ricardo Prat-Acín
- Servicio de Neurocirugía. Hospital Universitario I Politècnic La Fe, Valencia, Spain; Unidad Mixta Nanomedicina y Sensores: Fundación Hospital La Fe, Universidad Politécnica de Valencia, Spain.
| | - Inma Galeano-Senabre
- Servicio de Neurocirugía. Hospital Universitario I Politècnic La Fe, Valencia, Spain; Unidad Mixta Nanomedicina y Sensores: Fundación Hospital La Fe, Universidad Politécnica de Valencia, Spain
| | | | - Daniel García-Sánchez
- Servicio de Neurocirugía. Hospital Universitario I Politècnic La Fe, Valencia, Spain
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13
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La Rocca G, Ius T, Mazzucchi E, Simboli GA, Altieri R, Garbossa D, Acampora A, Auricchio AM, Vincitorio F, Cofano F, Vercelli G, Della Pepa GM, Pignotti F, Albanese A, Marchese E, Sabatino G. Trans-sulcal versus trans-parenchymal approach in supratentorial cavernomas. A multicentric experience. Clin Neurol Neurosurg 2020; 197:106180. [PMID: 32877767 DOI: 10.1016/j.clineuro.2020.106180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/06/2020] [Accepted: 08/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Cavernous malformations (CM) are low-flow vascular lesions that can cause significant symptoms and neurological deficits. Different intraoperative surgical approaches have been developed. Aim of the present investigation is the comparison between the trans-sulcal approach (TS) and the trans-parenchymal neuronavigation-assisted approach (TPN) in a surgical series from two neurosurgical centers. The technique and clinical outcomes are discussed, with a specific focus on seizure outcome. PATIENTS AND METHODS Clinical and radiological data from two neurosurgical centers ("A. Gemelli" Hospital in Rome and A.O.U. Città della Salute e della Scienza in Turin) were retrospectively reviewed in order to evaluate the different outcome of TS and TPN approach for cavernous malformation treatment. RESULTS A total of 177 patients underwent surgical intervention for supratentorial CM, 130 patients with TPN approach and 47 with TS approach. TS approach was associated with higher rate of seizure in early post-operative period both in epileptic patients (p < 0,001) and in patients without history of seizures before surgery (p = 0,002). Moreover, length of incision (p < 0,001), area of craniotomy (p < 0,001) and corticectomy (p < 0,001) were bigger in TS than in TPN approach. Brain contusion (p < 0,001) and fluid collection (p < 0,001) were more likely to be discovered after TS approach. CONCLUSIONS TPN is a valuable approach for resection of CM. Minor complications are significantly lower in TPN approach when compared with TS approach. In addition, it is associated with lower rate of early post-operative seizure and shorter length of stay.
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Affiliation(s)
- G La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy; Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - T Ius
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia, University Hospital, Udine, Italy
| | - E Mazzucchi
- Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy.
| | - G A Simboli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - R Altieri
- Division of Neurosurgery, Department of Neurosciences, Policlinico "G.Rodolico" University Hospital, Catania, Italy
| | - D Garbossa
- Neurosurgery Unit, Department of Neurosciences, University of Turin, Turin, Italy
| | - A Acampora
- Institute of Hygiene and Epidemiology, Catholic University, Rome, Italy
| | - A M Auricchio
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - F Vincitorio
- Neurosurgery Unit, Department of Neurosciences, University of Turin, Turin, Italy
| | - F Cofano
- Neurosurgery Unit, Department of Neurosciences, University of Turin, Turin, Italy
| | - G Vercelli
- Neurosurgery Unit, Department of Neurosciences, University of Turin, Turin, Italy
| | - G M Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - F Pignotti
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy; Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - A Albanese
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - E Marchese
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - G Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy; Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
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14
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Abstract
Surgical removal of accessible lesions is the only direct therapeutic approach for cerebral cavernous malformations (CCMs). The approach should be carefully evaluated according to clinical, anatomical, and neuroradiological assessment in order to both select the patient and avoid complications. In selected cases, a quantitative anatomical study with a preoperative simulation of surgery could be used to plan the operation. Neuronavigation, ultrasound, and neurophysiologic monitoring are generally required respectively to locate the CCMs and to avoid critical areas. The chapter describes all the possible surgical approaches for supratentorial, infratentorial, deep seated and brain stem CCMs. In any case before performing surgery, the physicians should always consider the benign nature of the lesions and the absolute necessity to avoid not only neurological deficits, but also a neuropsychological impairment that could affect the quality of life of the patients.
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15
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Stimulation-related intraoperative seizures during awake surgery: a review of available evidences. Neurosurg Rev 2019; 43:87-93. [PMID: 31797239 DOI: 10.1007/s10143-019-01214-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/08/2019] [Accepted: 11/13/2019] [Indexed: 01/01/2023]
Abstract
Awake surgery is a well-defined procedure with a very low morbidity. In particular, stimulation-related intraoperative seizure (IOS) is a commonly discussed and serious complication associated with awake surgery. Here, we reviewed the literature on awake surgery and IOS and sought to obtain evidences on the predictive factors of IOS and on the effect of IOS on postoperative outcomes. We conducted a comprehensive search of the Embase, MEDLINE, and Cochrane Central Register of Controlled Trials databases to identify potentially relevant articles from 2000 to 2019. We used combinations of the following search terms: "intraoperative seizure awake craniotomy," "awake surgery seizures," and pertinent associations; the search was restricted to publications in English and only to papers published in the last 20 years. The search returned 141 articles, including 39 papers that reported the IOS rate during awake craniotomy. The reported IOS rates ranged between 0 and 24% (mean, 7.7%). Only few studies have assessed the relationships between awake surgery and IOS, and hence, drawing clear conclusions is difficult. Nevertheless, IOS does not cause permanent and severe postoperative deficits, but can affect the patient's status perioperatively and the hospitalization duration. Anterior tumor location is an important perioperative factor associated with high IOS risk, whereas having seizures at tumor diagnosis does not seem to influence. However, the role of antiepileptic drug administration and prophylaxis remains unclear. In conclusion, given the difficulty in identifying predictors of IOS, we believe that prompt action at onset and awareness of appropriate management methods are vital.
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16
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Risk factors for intraoperative stimulation-related seizures during awake surgery: an analysis of 109 consecutive patients. J Neurooncol 2019; 145:295-300. [PMID: 31552589 DOI: 10.1007/s11060-019-03295-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 09/16/2019] [Indexed: 01/03/2023]
Abstract
INTRODUCTION During surgery for lesions in eloquent areas the goal is to achieve the widest resection possible, without loss of neurological function. Intraoperative seizures may lead to abandonment of the procedure or damages to the patient. Awareness regarding the predictors of IOS would help the surgeon. The aim of this retrospective study was to identify the factors associated with the occurrence of IOS in patients who underwent awake surgery for removal of gliomas in eloquent areas. METHODS This was a retrospective analysis of prospectively collected data of 109 patients who underwent awake craniotomy between January 2010 and December 2017 for removal of gliomas. IOS were defined as tonic-clonic seizures or loss of consciousness resulting in communication difficulties with the patient occurring during cortical and subcortical mapping. RESULTS A total of 109 patients were included in this study and IOS occurred in 9 (8.2%) patients. Demographic and clinical factors were comparable between patients with and without IOS. In the IOS group, 7 (77.8%) patients had seizures preoperatively and 4 (57.1%) were on more than one perioperative antiepileptic drugs (AED). CONCLUSIONS The current series add some hints to the poorly studied IOS risk during awake surgery. The risk of IOS appears to be relatively higher in patients with anteriorly located tumors and in patients operated without intraoperative brain activity monitoring and different patterns of stimulation for language and sensory-motor mapping. Further studies are needed to clarify the role of intraoperative techniques.
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