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Staub-Bartelt F, Suresh Babu MP, Szelényi A, Rapp M, Sabel M. Establishment of Different Intraoperative Monitoring and Mapping Techniques and Their Impact on Survival, Extent of Resection, and Clinical Outcome in Patients with High-Grade Gliomas-A Series of 631 Patients in 14 Years. Cancers (Basel) 2024; 16:926. [PMID: 38473288 DOI: 10.3390/cancers16050926] [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: 12/12/2023] [Revised: 02/17/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND The resection of brain tumors can be critical concerning localization, but is a key point in treating gliomas. Intraoperative neuromonitoring (IONM), awake craniotomy, and mapping procedures have been incorporated over the years. Using these intraoperative techniques, the resection of eloquent-area tumors without increasing postoperative morbidity became possible. This study aims to analyze short-term and particularly long-term outcomes in patients diagnosed with high-grade glioma, who underwent surgical resection under various technical intraoperative settings over 14 years. METHODS A total of 1010 patients with high-grade glioma that underwent resection between 2004 and 2018 under different monitoring or mapping procedures were screened; 631 were considered eligible for further analyses. We analyzed the type of surgery (resection vs. biopsy) and type of IONM or mapping procedures that were performed. Furthermore, the impact on short-term (The National Institute of Health Stroke Scale, NIHSS; Karnofsky Performance Scale, KPS) and long-term (progression-free survival, PFS; overall survival, OS) outcomes was analyzed. Additionally, the localization, extent of resection (EOR), residual tumor volume (RTV), IDH status, and adjuvant therapy were approached. RESULTS In 481 patients, surgery, and in 150, biopsies were performed. The number of biopsies decreased significantly with the incorporation of awake surgeries with bipolar stimulation, IONM, and/or monopolar mapping (p < 0.001). PFS and OS were not significantly influenced by any intraoperative technical setting. EOR and RTV achieved under different operative techniques showed no statistical significance (p = 0.404 EOR, p = 0.186 RTV). CONCLUSION Based on the present analysis using data from 14 years and more than 600 patients, we observed that through the implementation of various monitoring and mapping techniques, a significant decrease in biopsies and an increase in the resection of eloquent tumors was achieved. With that, the operability of eloquent tumors without a negative influence on neurological outcomes is suggested by our data. However, a statistical effect of monitoring and mapping procedures on long-term outcomes such as PFS and OS could not be shown.
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Affiliation(s)
- Franziska Staub-Bartelt
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | | | - Andrea Szelényi
- Department of Neurosurgery, LMU University Hospital, LMU Munich, 80539 München, Germany
| | - Marion Rapp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Michael Sabel
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
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Fornia L, Leonetti A, Puglisi G, Rossi M, Viganò L, Della Santa B, Simone L, Bello L, Cerri G. The parietal architecture binding cognition to sensorimotor integration: a multimodal causal study. Brain 2024; 147:297-310. [PMID: 37715997 PMCID: PMC10766244 DOI: 10.1093/brain/awad316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/18/2023] [Accepted: 08/10/2023] [Indexed: 09/18/2023] Open
Abstract
Despite human's praxis abilities are unique among primates, comparative observations suggest that these cognitive motor skills could have emerged from exploitation and adaptation of phylogenetically older building blocks, namely the parieto-frontal networks subserving prehension and manipulation. Within this framework, investigating to which extent praxis and prehension-manipulation overlap and diverge within parieto-frontal circuits could help in understanding how human cognition shapes hand actions. This issue has never been investigated by combining lesion mapping and direct electrophysiological approaches in neurosurgical patients. To this purpose, 79 right-handed left-brain tumour patient candidates for awake neurosurgery were selected based on inclusion criteria. First, a lesion mapping was performed in the early postoperative phase to localize the regions associated with an impairment in praxis (imitation of meaningless and meaningful intransitive gestures) and visuo-guided prehension (reaching-to-grasping) abilities. Then, lesion results were anatomically matched with intraoperatively identified cortical and white matter regions, whose direct electrical stimulation impaired the Hand Manipulation Task. The lesion mapping analysis showed that prehension and praxis impairments occurring in the early postoperative phase were associated with specific parietal sectors. Dorso-mesial parietal resections, including the superior parietal lobe and precuneus, affected prehension performance, while resections involving rostral intraparietal and inferior parietal areas affected praxis abilities (covariate clusters, 5000 permutations, cluster-level family-wise error correction P < 0.05). The dorsal bank of the rostral intraparietal sulcus was associated with both prehension and praxis (overlap of non-covariate clusters). Within praxis results, while resection involving inferior parietal areas affected mainly the imitation of meaningful gestures, resection involving intraparietal areas affected both meaningless and meaningful gesture imitation. In parallel, the intraoperative electrical stimulation of the rostral intraparietal and the adjacent inferior parietal lobe with their surrounding white matter during the hand manipulation task evoked different motor impairments, i.e. the arrest and clumsy patterns, respectively. When integrating lesion mapping and intraoperative stimulation results, it emerges that imitation of praxis gestures first depends on the integrity of parietal areas within the dorso-ventral stream. Among these areas, the rostral intraparietal and the inferior parietal area play distinct roles in praxis and sensorimotor process controlling manipulation. Due to its visuo-motor 'attitude', the rostral intraparietal sulcus, putative human homologue of monkey anterior intraparietal, might enable the visuo-motor conversion of the observed gesture (direct pathway). Moreover, its functional interaction with the adjacent, phylogenetic more recent, inferior parietal areas might contribute to integrate the semantic-conceptual knowledge (indirect pathway) within the sensorimotor workflow, contributing to the cognitive upgrade of hand actions.
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Affiliation(s)
- Luca Fornia
- Department of Medical Biotechnology and Translational Medicine, MoCA Laboratory, Università degli Studi di Milano, Milano, 20122, Italy
| | - Antonella Leonetti
- Department of Oncology and Hemato-Oncology, Neurosurgical Oncology Unit, Università degli Studi di Milano, Milano, 20122, Italy
| | - Guglielmo Puglisi
- Department of Medical Biotechnology and Translational Medicine, MoCA Laboratory, Università degli Studi di Milano, Milano, 20122, Italy
| | - Marco Rossi
- Department of Medical Biotechnology and Translational Medicine, MoCA Laboratory, Università degli Studi di Milano, Milano, 20122, Italy
| | - Luca Viganò
- Department of Oncology and Hemato-Oncology, Neurosurgical Oncology Unit, Università degli Studi di Milano, Milano, 20122, Italy
| | - Bianca Della Santa
- Department of Medical Biotechnology and Translational Medicine, MoCA Laboratory, Università degli Studi di Milano, Milano, 20122, Italy
| | - Luciano Simone
- Department of Medicine and Surgery, Università Degli Studi di Parma, Parma, 43125, Italy
| | - Lorenzo Bello
- Department of Oncology and Hemato-Oncology, Neurosurgical Oncology Unit, Università degli Studi di Milano, Milano, 20122, Italy
| | - Gabriella Cerri
- Department of Medical Biotechnology and Translational Medicine, MoCA Laboratory, Università degli Studi di Milano, Milano, 20122, Italy
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Sala F. Intraoperative neurophysiology in pediatric neurosurgery: a historical perspective. Childs Nerv Syst 2023; 39:2929-2941. [PMID: 37776333 PMCID: PMC10613152 DOI: 10.1007/s00381-023-06155-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Intraoperative neurophysiology (ION) has been established over the past three decades as a valuable discipline to improve the safety of neurosurgical procedures with the main goal of reducing neurological morbidity. Neurosurgeons have substantially contributed to the development of this field not only by implementing the use and refinement of ION in the operating room but also by introducing novel techniques for both mapping and monitoring of neural pathways. METHODS This review provides a personal perspective on the evolution of ION in a variety of pediatric neurosurgical procedures: from brain tumor to brainstem surgery, from spinal cord tumor to tethered cord surgery. RESULTS AND DISCUSSION The contribution of pediatric neurosurgeons is highlighted showing how our discipline has played a crucial role in promoting ION at the turn of the century. Finally, a view on novel ION techniques and their potential implications for pediatric neurosurgery will provide insights into the future of ION, further supporting the view of a functional, rather than merely anatomical, approach to pediatric neurosurgery.
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Affiliation(s)
- Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy.
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Schlosser-Perrin F, Rossel O, Duffau H, Bonnetblanc F, Mandonnet E. How far does electrical stimulation activate white matter tracts? A computational modeling study. Clin Neurophysiol 2023; 153:68-78. [PMID: 37459667 DOI: 10.1016/j.clinph.2023.06.017] [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: 02/11/2023] [Revised: 06/08/2023] [Accepted: 06/16/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE The aim of this study was to model how the different parameters of electrical stimulation (intensity, pulse shape, probe geometry) influence the extent of white matter activation. METHODS The electrical potentials generated by the stimulating electrodes were determined by solving Laplace equation. The temporal evolution of membrane potentials at each nodes of Ranvier of an axon was then computed by solving the coupled system of differential equations describing membrane dynamics and cable propagation. RESULTS Regions of unilateral propagation were observed for monophasic pulses delivered with a bipolar probe aligned along the tract. For biphasic pulses, the largest activation areas and depths were found with a high inter-electrode-distance (IED) bipolar probe, oriented orthogonally to the tract. The smallest activation areas and depths were found for bipolar stimulations with the probe aligned parallel to the tract and low IED. For isotropic white matter regions, the activation area and depth were three times larger than for anisotropic white matter tracts. CONCLUSIONS Bipolar probes with biphasic pulses offer the greatest versatility: an orthogonal orientation acts as two monopolars (increased sensitivity when searching for a tract), whereas a parallel orientation corresponds to a single monopolar (increased specificity). Activation is more superficial when stimulating highly anisotropic tracts. SIGNIFICANCE This knowledge is essential for interpreting the behavorial effects of stimulation and the recordings of axono-cortical evoked potentials.
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Affiliation(s)
| | | | - Hugues Duffau
- Département de Neurochirurgie, Centre Hospitalier Universitaire de Montpellier Gui de Chauliac, Montpellier, France; Team "Neuroplasticity, Stem Cells and Glial Tumors", Institute of Functional Genomics, INSERM U-1191, University of Montpellier, 34090 Montpellier, France; Université de Montpellier, Montpellier, France
| | | | - Emmanuel Mandonnet
- Frontlab, Paris Brain Institute, CNRS UMR 7225, INSERM U1127, Paris, France; Department of Neurosurgery, Lariboisière Hospital, Paris, France; Université de Paris Cité, Paris, France.
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Ius T, Sabatino G, Panciani PP, Fontanella MM, Rudà R, Castellano A, Barbagallo GMV, Belotti F, Boccaletti R, Catapano G, Costantino G, Della Puppa A, Di Meco F, Gagliardi F, Garbossa D, Germanò AF, Iacoangeli M, Mortini P, Olivi A, Pessina F, Pignotti F, Pinna G, Raco A, Sala F, Signorelli F, Sarubbo S, Skrap M, Spena G, Somma T, Sturiale C, Angileri FF, Esposito V. Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review. J Neurooncol 2023; 162:267-293. [PMID: 36961622 PMCID: PMC10167129 DOI: 10.1007/s11060-023-04274-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/20/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. METHODS A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. RESULTS A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). CONCLUSIONS A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity.
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Affiliation(s)
- Tamara Ius
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Pier Paolo Panciani
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
| | - Marco Maria Fontanella
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
- Neurology Unit, Hospital of Castelfranco Veneto, 31033, Castelfranco Veneto, Italy
| | - Antonella Castellano
- Department of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe Maria Vincenzo Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico - San Marco" University Hospital, University of Catania, Catania, Italy
- Interdisciplinary Research Center On Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Francesco Belotti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe Catapano
- Division of Neurosurgery, Department of Neurological Sciences, Ospedale del Mare, Naples, Italy
| | | | - Alessandro Della Puppa
- Neurosurgical Clinical Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi Hospital, University of Florence, Florence, Italy
| | - Francesco Di Meco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Johns Hopkins Medical School, Baltimore, MD, USA
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Torino, Italy
| | | | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica Delle Marche, Azienda Ospedali Riuniti, Ancona, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | | | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Italy
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Italy
| | - Fabrizio Pignotti
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giampietro Pinna
- Unit of Neurosurgery, Department of Neurosciences, Hospital Trust of Verona, 37134, Verona, Italy
| | - Antonino Raco
- Division of Neurosurgery, Department of NESMOS, AOU Sant'Andrea, Sapienza University, Rome, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicines and Movement Sciences, Institute of Neurosurgery, University of Verona, 37134, Verona, Italy
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Neurosurgery Unit, University "Aldo Moro", 70124, Bari, Italy
| | - Silvio Sarubbo
- Department of Neurosurgery, Santa Chiara Hospital, Azienda Provinciale Per I Servizi Sanitari (APSS), Trento, Italy
| | - Miran Skrap
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | | | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | | | | | - Vincenzo Esposito
- Department of Neurosurgery "Giampaolo Cantore"-IRCSS Neuromed, Pozzilli, Italy
- Department of Human, Neurosciences-"Sapienza" University of Rome, Rome, Italy
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Mansouri A, Ibrahim S, Bello L, Martino J, Velasquez C. The current state of the art of primary motor mapping for tumor resection: A focused survey. Clin Neurol Neurosurg 2023; 229:107685. [PMID: 37105067 DOI: 10.1016/j.clineuro.2023.107685] [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: 12/22/2022] [Revised: 03/14/2023] [Accepted: 03/18/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Cortical and subcortical motor mapping has advanced the notion of maximal safe resection of intra-axial brain tumours, thereby preserving neurological functions as well as improving survival. Despite being an age-old and established neurosurgical procedure across the world, the strategy and techniques involved in motor mapping have a gamut of variation due to a lack of defined standard protocols. METHODS We disseminated a structured survey among focused group of neurosurgeons with established practices involving brain mapping. It consisted of 40 questions, split into five sections assessing the practice description, general approach for motor mapping, preference for asleep versus awake mapping, operative techniques and approach to representative tumor cases. Practice-patterns during primary motor mapping for brain tumours were analysed from responses of 51 neurosurgeons. RESULTS 60.8 % felt that any lesion even near (without infiltration) was suffice to define "involvement" of the cortical/subcortical motor pathways. 82.4 % felt that motor mapping was necessary for brain tumours involving motor pathways, irrespective of the tumor histology or patient age. 90.2 % opined that tumor location was the predominant factor affecting their choice between awake or asleep mapping. 31.4 % believed that all cases should be performed awake unless patient-related medical, psychological, or anaesthetic contraindications exist, whereas 45.1 % felt that all cases should be performed asleep unless language mapping is required. MRI, DTI-based tractography and intra-operative fluorescence were the most commonly employed surgical adjuncts. CONCLUSIONS The data from this survey may serve as a preliminary foundation for a more standardized approach to patient selection and the approach to motor mapping for brain tumors.
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Affiliation(s)
- Alireza Mansouri
- Department of Neurosurgery, Penn State Health, Hershey, PA, United States
| | - Sufyan Ibrahim
- Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Lorenzo Bello
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Mi-lano, Milano, Italy
| | - Juan Martino
- Department of Neurological Surgery and Spine Unit, Hospital Universitario Marqués de Valdecilla & Instituto de Investigación Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
| | - Carlos Velasquez
- Department of Neurological Surgery and Spine Unit, Hospital Universitario Marqués de Valdecilla & Instituto de Investigación Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
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Review of Intraoperative Adjuncts for Maximal Safe Resection of Gliomas and Its Impact on Outcomes. Cancers (Basel) 2022; 14:cancers14225705. [PMID: 36428797 PMCID: PMC9688206 DOI: 10.3390/cancers14225705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/12/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
Maximal safe resection is the mainstay of treatment in the neurosurgical management of gliomas, and preserving functional integrity is linked to favorable outcomes. How these modalities differ in their effectiveness on the extent of resection (EOR), survival, and complications remains unknown. A systematic literature search was performed with the following inclusion criteria: published between 2005 and 2022, involving brain glioma surgery, and including one or a combination of intraoperative modalities: intraoperative magnetic resonance imaging (iMRI), awake/general anesthesia craniotomy mapping (AC/GA), fluorescence-guided imaging, or combined modalities. Of 525 articles, 464 were excluded and 61 articles were included, involving 5221 glioma patients, 7(11.4%) articles used iMRI, 21(36.8%) used cortical mapping, 15(24.5%) used 5-aminolevulinic acid (5-ALA) or fluorescein sodium, and 18(29.5%) used combined modalities. The heterogeneity in reporting the amount of surgical resection prevented further analysis. Progression-free survival/overall survival (PFS/OS) were reported in 18/61(29.5%) articles, while complications and permanent disability were reported in 38/61(62.2%) articles. The reviewed studies demonstrate that intraoperative adjuncts such as iMRI, AC/GA mapping, fluorescence-guided imaging, and a combination of these modalities improve EOR. However, PFS/OS were underreported. Combining multiple intraoperative modalities seems to have the highest effect compared to each adjunct alone.
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Plaha P, Camp S, Cook J, McCulloch P, Voets N, Ma R, Taphoorn MJB, Dirven L, Grech-Sollars M, Watts C, Bulbeck H, Jenkinson MD, Williams M, Lim A, Dixon L, Price SJ, Ashkan K, Apostolopoulos V, Barber VS, Taylor A, Nandi D. FUTURE-GB: functional and ultrasound-guided resection of glioblastoma - a two-stage randomised control trial. BMJ Open 2022; 12:e064823. [PMID: 36379652 PMCID: PMC9668053 DOI: 10.1136/bmjopen-2022-064823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Surgery remains the mainstay for treatment of primary glioblastoma, followed by radiotherapy and chemotherapy. Current standard of care during surgery involves the intraoperative use of image-guidance and 5-aminolevulinic acid (5-ALA). There are multiple other surgical adjuncts available to the neuro-oncology surgeon. However, access to, and usage of these varies widely in UK practice, with limited evidence of their use. The aim of this trial is to investigate whether the addition of diffusion tensor imaging (DTI) and intraoperative ultrasound (iUS) to the standard of care surgery (intraoperative neuronavigation and 5-ALA) impacts on deterioration free survival (DFS). METHODS AND ANALYSIS This is a two-stage, randomised control trial (RCT) consisting of an initial non-randomised cohort study based on the principles of the IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up) stage-IIb format, followed by a statistically powered randomised trial comparing the addition of DTI and iUS to the standard of care surgery. A total of 357 patients will be recruited for the RCT. The primary outcome is DFS, defined as the time to either 10-point deterioration in health-related quality of life scores from baseline, without subsequent reversal, progressive disease or death. ETHICS AND DISSEMINATION The trial was registered in the Integrated Research Application System (Ref: 264482) and approved by a UK research and ethics committee (Ref: 20/LO/0840). Results will be published in a peer-reviewed journal. Further dissemination to participants, patient groups and the wider medical community will use a range of approaches to maximise impact. TRIAL REGISTRATION NUMBER ISRCTN38834571.
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Affiliation(s)
- Puneet Plaha
- Department of Neursurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Sophie Camp
- Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan Cook
- Oxford Clinical Trials Research Unit & Surgical Intervention Trials Unit, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, Oxfordshire, UK
| | - Peter McCulloch
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Natalie Voets
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, Oxfordshire, UK
| | - Ruichong Ma
- Department of Neursurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Neurology, Haaglanden Medical Center Bronovo, Den Haag, Zuid-Holland, The Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Matthew Grech-Sollars
- Department of Computer Sciences, UCL, London, UK
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Colin Watts
- Institute of Cancer and Genomic Studies, University of Birmingham, Birmingham, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Michael D Jenkinson
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, Merseyside, UK
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Matthew Williams
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK
| | - Adrian Lim
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - Luke Dixon
- Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen John Price
- Neurosurgery Division, Department of Clinical Neurosciences, Cambridge University, Cambridge, UK
| | | | | | - Vicki S Barber
- Oxford Clinical Trials Research Unit & Surgical Intervention Trials Unit, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, Oxfordshire, UK
| | - Amy Taylor
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Dipankar Nandi
- Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Viganò L, Callipo V, Lamperti M, Rossi M, Conti Nibali M, Sciortino T, Gay L, Puglisi G, Leonetti A, Cerri G, Bello L. Transcranial versus direct electrical stimulation for intraoperative motor-evoked potential monitoring: Prognostic value comparison in asleep brain tumor surgery. Front Oncol 2022; 12:963669. [PMID: 36249008 PMCID: PMC9557724 DOI: 10.3389/fonc.2022.963669] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Safe resection of gliomas involving motor pathways in asleep-anesthesia requires the combination of brain mapping, to identify and spare essential motor sites, and continuous monitoring of motor-evoked potentials (MEPs), to detect possible vascular damage to the corticospinal tract (CST). MEP monitoring, according to intraoperative neurophysiology societies, is generally recommended by transcranial electrodes (TES), and no clear indications of direct cortical stimulation (DCS) or the preferential use of one of the two techniques based on the clinical context is available. The main aim of the study was to identify the best technique(s) based on different clinical conditions, evaluating the efficacy and prognostic value of both methodologies. Methods A retrospective series of patients with tumors involving the motor pathways who underwent surgical resection with the aid of brain mapping and combined MEP monitoring via TES and DCS was evaluated. Irreversible MEP amplitude reduction (>50% compared to baseline) was used as an intraoperative warning and correlated to the postoperative motor outcome. Selectivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed for both techniques. Results Four hundred sixty-two patients were retrospectively analyzed, and only 1.9% showed a long-term motor impairment. Both TES and DCS obtained high specificity and NPV for the acute and 1-month motor deficit. Sensitivity was rather low for the acute deficit but excellent considering the 1-month follow-up for both techniques. DCS was extremely reliable in predicting a postoperative motor decline (PPV of 100% and 90% for acute and long-term deficit, respectively). Conversely, TES produced a high number of false-positive results, especially for long-term deficits (65, 87.8% of all warnings) therefore obtaining poor PPV values (18% and 12% for acute and 1-month deficits, respectively). TES false-positive results were significantly associated with parietal tumors and lateral patient positioning. Conclusions Data support the use of mapping and combined monitoring via TES and DCS. The sole TES monitoring is reliable in most procedures but not in parietal tumors or those requiring lateral positioning. Although no indications are available in international guidelines, DCS should be recommended, particularly for cases approached by a lateral position.
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Affiliation(s)
- Luca Viganò
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, IRCCS Galeazzi-Sant'Ambrogio, Milano, Italy
- *Correspondence: Luca Viganò, ; Lorenzo Bello,
| | - Vincenzo Callipo
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, IRCCS Galeazzi-Sant'Ambrogio, Milano, Italy
| | - Marta Lamperti
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, IRCCS Galeazzi-Sant'Ambrogio, Milano, Italy
| | - Marco Rossi
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, IRCCS Galeazzi-Sant'Ambrogio, Milano, Italy
| | - Marco Conti Nibali
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, IRCCS Galeazzi-Sant'Ambrogio, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, IRCCS Galeazzi-Sant'Ambrogio, Milano, Italy
| | - Lorenzo Gay
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, IRCCS Galeazzi-Sant'Ambrogio, Milano, Italy
| | - Guglielmo Puglisi
- Motor, Cognition and Action Laboratory, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milano, Italy
| | - Antonella Leonetti
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, IRCCS Galeazzi-Sant'Ambrogio, Milano, Italy
| | - Gabriella Cerri
- Motor, Cognition and Action Laboratory, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, IRCCS Galeazzi-Sant'Ambrogio, Milano, Italy
- *Correspondence: Luca Viganò, ; Lorenzo Bello,
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10
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Carrabba G, Fiore G, Di Cristofori A, Bana C, Borellini L, Zarino B, Conte G, Triulzi F, Rocca A, Giussani C, Caroli M, Locatelli M, Bertani G. Diffusion tensor imaging, intra-operative neurophysiological monitoring and small craniotomy: Results in a consecutive series of 103 gliomas. Front Oncol 2022; 12:897147. [PMID: 36176387 PMCID: PMC9513471 DOI: 10.3389/fonc.2022.897147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
Diffusion tensor imaging (DTI) allows visualization of the main white matter tracts while intraoperative neurophysiological monitoring (IONM) represents the gold standard for surgical resection of gliomas. In recent years, the use of small craniotomies has gained popularity thanks to neuronavigation and to the low morbidity rates associated with shorter surgical procedures. The aim of this study was to review a series of patients operated for glioma using DTI, IONM, and tumor-targeted craniotomies. The retrospective analysis included patients with supratentorial glioma who met the following inclusion criteria: preoperative DTI, intraoperative IONM, tumor-targeted craniotomy, pre- and postoperative MRI, and complete clinical charts. The DTI was performed on a 3T scanner. The IONM included electroencephalography (EEG), transcranial (TC) and/or cortical motor-evoked potentials (MEP), electrocorticography (ECoG), and direct electrical stimulation (DES). Outcomes included postoperative neurological deficits, volumetric extent of resection (EOR), and overall survival (OS). One hundred and three patients (61 men, 42 women; mean age 54 ± 14 years) were included and presented the following WHO histologies: 65 grade IV, 19 grade III, and 19 grade II gliomas. After 3 months, only three patients had new neurological deficits. The median postoperative volume was 0cc (IQR 3). The median OS for grade IV gliomas was 15 months, while for low-grade gliomas it was not reached. In our experience, a small craniotomy and a tumor resection supported by IONM and DTI permitted to achieve satisfactory results in terms of neurological outcomes, EOR, and OS for glioma patients.
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Affiliation(s)
- Giorgio Carrabba
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
- *Correspondence: Giorgio Carrabba,
| | - Giorgio Fiore
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Andrea Di Cristofori
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
| | - Cristina Bana
- Neurophysiopathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
| | - Linda Borellini
- Neurophysiopathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
| | - Barbara Zarino
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giorgio Conte
- Neuroradiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Fabio Triulzi
- Neuroradiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Alessandra Rocca
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Carlo Giussani
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Manuela Caroli
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Marco Locatelli
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
- Department of Medical-Surgical Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Giulio Bertani
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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11
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Surgical Treatment of Glioblastoma: State-of-the-Art and Future Trends. J Clin Med 2022; 11:jcm11185354. [PMID: 36143001 PMCID: PMC9505564 DOI: 10.3390/jcm11185354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022] Open
Abstract
Glioblastoma (GBM) is a highly aggressive disease and is associated with poor prognosis despite treatment advances in recent years. Surgical resection of tumor remains the main therapeutic option when approaching these patients, especially when combined with adjuvant radiochemotherapy. In the present study, we conducted a comprehensive literature review on the state-of-the-art and future trends of the surgical treatment of GBM, emphasizing topics that have been the object of recent study.
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12
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Gallagher MJ, Lavrador JP, Coelho P, Mirallave-Pescador A, Bleil C, Gullan R, Ashkan K, Vergani F, Bhangoo R. Continuous Microdebrider-Based Dynamic Subcortical Motor Mapping: A Technical Advance in Tubular Retractor-Assisted Surgery. Oper Neurosurg (Hagerstown) 2022; 23:217-224. [PMID: 35972085 DOI: 10.1227/ons.0000000000000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/06/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Transsulcal minimally invasive parafasicular (TsMIP) approaches to brain tumor resection use tubular retractors to minimize iatrogenic brain injury. Dynamic cortical and subcortical continuous neurophysiological mapping facilitates safer resection of motor-eloquent tumors. OBJECTIVE To describe a new technique to address the challenge of combining TsMIP with tubular retractors and dynamic subcortical mapping using a single electrified stimulating microdebrider instrument. METHODS We adapted the NICO Myriad microdebrider with continuous monopolar stimulation electrification using high-frequency stimulation with the train-of-5 technique. We performed continuous subcortical mapping using this device and compared it with standard dynamic monopolar subcortical mapping using a suction stimulation device. We found no significant difference in recorded stimulation response. RESULTS Using a single operating instrument that provides synchronous tumor resection and monopolar subcortical mapping with the NICO Brainpath tubular retractor, we observed increased degrees of movement, faster surgical resection times with an enlarged working channel down the retractor, and improved safety because the stimulating probe sits 2 mm deep to the resection window. CONCLUSION We show that the adapted device is reliable and provides similar stimulation response as conventional subcortical mapping. We advocate the use of our adapted microdebrider in TsMIP tubular retractor approaches.
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Affiliation(s)
- Mathew J Gallagher
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Jose P Lavrador
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Pedro Coelho
- Neurophysiology Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Ana Mirallave-Pescador
- Neurophysiology Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Cristina Bleil
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Richard Gullan
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Keyoumars Ashkan
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Francesco Vergani
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Ranjeev Bhangoo
- Neurosurgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
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13
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Le Lann F, Cristante J, De Schlichting E, Quehan R, Réhault E, Lotterie JA, Roux FE. Variability of Intraoperative Electrostimulation Parameters in Conscious Individuals: Language Fasciculi. World Neurosurg 2022; 164:e194-e202. [PMID: 35472645 DOI: 10.1016/j.wneu.2022.04.066] [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: 02/17/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The authors analyzed the current-intensity thresholds for electrostimulation of language fasciculi and the possible consequences of threshold variability on brain mapping. METHODS A prospective protocol of subcortical electrostimulation was used in 50 patients undergoing brain mapping, directly stimulating presumed language fasciculi identified by diffusion tensor imaging. RESULTS The stimulation-intensity thresholds for identification of language fasciculi varied among patients (mean minimum current intensity of 4.4 mA, range = 1.5-10 mA, standard deviation = 1.1 mA), and 23% of fascicular interferences were detected only above 5 mA. Repeated stimulation of the same site with the same intensity led to different types of interferences in 20% of patients, and a higher current intensity led to changes in the type of response in 27%. The mean minimum stimulation intensities did not differ significantly between different fasciculi, between the different types of interference obtained, or with age, sex, or type of tumor. Positive results on cortical mapping were significantly associated with positive results on subcortical mapping (P < 0.001). Subcortical intensity thresholds were slightly lower than cortical ones (mean = 4.43 vs. 5.25 mA, P = 0.034). In 23 of 50 subcortical mappings, fascicular stimulation produced no language interference. CONCLUSIONS Individual variability of minimum stimulation-intensity thresholds for identification of language fasciculi is frequent. Nevertheless, even when a high current intensity was used, many stimulations on language fasciculi remained negative for various hypothetic reasons. Finding the optimal current intensity for identifying language fasciculi is of paramount importance to refine the clinical results and scientific data derived from brain mapping.
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Affiliation(s)
- Florian Le Lann
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; Université de Toulouse, UPS, Toulouse, France.
| | | | - Emmanuel De Schlichting
- Université Grenoble Alpes, Faculté de Médecine, Grenoble, France; Neurochirurgie, Centre Hospitalo-Universitaire de Grenoble, Toulouse, France
| | - Romain Quehan
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; Université de Toulouse, UPS, Toulouse, France
| | - Emilie Réhault
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
| | - Jean-Albert Lotterie
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; Université de Toulouse, UPS, Toulouse, France
| | - Franck-Emmanuel Roux
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; Université de Toulouse, UPS, Toulouse, France; Centre de Recherche Cerveau et Cognition (CNRS; CerCo), Toulouse, France
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14
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Current Status of Neuromodulation-Induced Cortical Prehabilitation and Considerations for Treatment Pathways in Lower-Grade Glioma Surgery. LIFE (BASEL, SWITZERLAND) 2022; 12:life12040466. [PMID: 35454957 PMCID: PMC9024440 DOI: 10.3390/life12040466] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/19/2022] [Accepted: 03/19/2022] [Indexed: 12/15/2022]
Abstract
The infiltrative character of supratentorial lower grade glioma makes it possible for eloquent neural pathways to remain within tumoural tissue, which renders complete surgical resection challenging. Neuromodulation-Induced Cortical Prehabilitation (NICP) is intended to reduce the likelihood of premeditated neurologic sequelae that otherwise would have resulted in extensive rehabilitation or permanent injury following surgery. This review aims to conceptualise current approaches involving Repetitive Transcranial Magnetic Stimulation (rTMS-NICP) and extraoperative Direct Cortical Stimulation (eDCS-NICP) for the purposes of inducing cortical reorganisation prior to surgery, with considerations derived from psychiatric, rehabilitative and electrophysiologic findings related to previous reports of prehabilitation. Despite the promise of reduced risk and incidence of neurologic injury in glioma surgery, the current data indicates a broad but compelling possibility of effective cortical prehabilitation relating to perisylvian cortex, though it remains an under-explored investigational tool. Preliminary findings may prove sufficient for the continued investigation of prehabilitation in small-volume lower-grade tumour or epilepsy patients. However, considering the very low number of peer-reviewed case reports, optimal stimulation parameters and duration of therapy necessary to catalyse functional reorganisation remain equivocal. The non-invasive nature and low risk profile of rTMS-NICP may permit larger sample sizes and control groups until such time that eDCS-NICP protocols can be further elucidated.
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15
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Seidel K, Szelényi A, Bello L. Intraoperative mapping and monitoring during brain tumor surgeries. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:133-149. [PMID: 35772883 DOI: 10.1016/b978-0-12-819826-1.00013-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Many different methodologies and paradigms are available to guide surgery of supratentorial tumors with the aim to preserve quality of life of the patients and to increase the extent of tumor resection. Neurophysiologic monitoring techniques (such as different evoked potentials) may help to continuously assess functional integrity of the observed systems and warn about vascular injury. For neurophysiologic mapping methods, the focus is not only to preserve cortical sites, but also to prevent injury to subcortical pathways. Therefore, cortical mapping is not enough but should be combined with subcortical mapping to identify tracts. This may be done by alternating resection and stimulation, or by continuous mapping via an electrified surgical tool such as a stimulating suction tip. Increasingly refined techniques are evolving to improve mapping of complex motor networks as well as language and higher cortical functions. Finally, in deciding between an awake vs asleep intraoperative setting, various factors need to be considered, such as the surgical goal, patient expectation and cooperation, treating team expertise, and neurooncologic aspects including histopathology. Therefore, the choice of protocol depends on the clinical context and the experience of the interdisciplinary team treating the patients.
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Affiliation(s)
- Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Andrea Szelényi
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Lorenzo Bello
- Department of Oncology and Hemato-Oncology, Neurosurgical Oncology Unit, Università degli Studi di Milano, Milan, Italy
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16
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Giampiccolo D, Nunes S, Cattaneo L, Sala F. Functional Approaches to the Surgery of Brain Gliomas. Adv Tech Stand Neurosurg 2022; 45:35-96. [PMID: 35976447 DOI: 10.1007/978-3-030-99166-1_2] [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] [Indexed: 06/15/2023]
Abstract
In the surgery of gliomas, recent years have witnessed unprecedented theoretical and technical development, which extensively increased indication to surgery. On one hand, it has been solidly demonstrated the impact of gross total resection on life expectancy. On the other hand, the paradigm shift from classical cortical localization of brain function towards connectomics caused by the resurgence of awake surgery and the advent of tractography has permitted safer surgeries focused on subcortical white matter tracts preservation and allowed for surgical resections within regions, such as Broca's area or the primary motor cortex, which were previously deemed inoperable. Furthermore, new asleep electrophysiological techniques have been developed whenever awake surgery is not an option, such as operating in situations of poor compliance (including paediatric patients) or pre-existing neurological deficits. One such strategy is the use of intraoperative neurophysiological monitoring (IONM), enabling the identification and preservation of functionally defined, but anatomically ambiguous, cortico-subcortical structures through mapping and monitoring techniques. These advances tie in with novel challenges, specifically risk prediction and the impact of neuroplasticity, the indication for tumour resection beyond visible borders, or supratotal resection, and most of all, a reappraisal of the importance of the right hemisphere from early psychosurgery to mapping and preservation of social behaviour, executive control, and decision making.Here we review current advances and future perspectives in a functional approach to glioma surgery.
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Affiliation(s)
- Davide Giampiccolo
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, University of Verona, Verona, Italy
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Institute of Neurosciences, Cleveland Clinic London, London, UK
| | - Sonia Nunes
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, University of Verona, Verona, Italy
| | - Luigi Cattaneo
- Center for Mind and Brain Sciences (CIMeC) and Center for Medical Sciences (CISMed), University of Trento, Trento, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, University of Verona, Verona, Italy.
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17
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MacDonald DB, Simon MV, Nuwer MR. Neurophysiology during epilepsy surgery. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:103-121. [PMID: 35772880 DOI: 10.1016/b978-0-12-819826-1.00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Intraoperative neuromonitoring (IONM) complements modern presurgical investigations by providing information about the epileptic focus as well as real-time identification of critical functional tissue and assessment of ongoing neural integrity during resective epilepsy surgery. This chapter summarizes current IONM methods for mapping the epileptic focus and for mapping and monitoring functionally important structures with direct brain stimulation and evoked potentials. These techniques include electrocorticography, computerized high-frequency oscillation mapping, single-pulse electric stimulation, cortical and subcortical motor evoked potentials, somatosensory evoked potentials, visual evoked potentials, and cortico-cortical evoked potentials. They may help to maximize epileptic tissue resection while avoiding permanent postoperative neurologic deficits.
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Affiliation(s)
| | - Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Marc R Nuwer
- Departments of Neurology and Clinical Neurophysiology, David Geffen School of Medicine, University of California Los Angeles, and Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
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18
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Fornia L, Rossi M, Rabuffetti M, Bellacicca A, Viganò L, Simone L, Howells H, Puglisi G, Leonetti A, Callipo V, Bello L, Cerri G. Motor impairment evoked by direct electrical stimulation of human parietal cortex during object manipulation. Neuroimage 2021; 248:118839. [PMID: 34963652 DOI: 10.1016/j.neuroimage.2021.118839] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/03/2021] [Accepted: 12/18/2021] [Indexed: 10/19/2022] Open
Abstract
In primates, the parietal cortex plays a crucial role in hand-object manipulation. However, its involvement in object manipulation and related hand-muscle control has never been investigated in humans with a direct and focal electrophysiological approach. To this aim, during awake surgery for brain tumors, we studied the impact of direct electrical stimulation (DES) of parietal lobe on hand-muscles during a hand-manipulation task (HMt). Results showed that DES applied to fingers-representation of postcentral gyrus (PCG) and anterior intraparietal cortex (aIPC) impaired HMt execution. Different types of EMG-interference patterns were observed ranging from a partial (task-clumsy) or complete (task-arrest) impairment of muscles activity. Within PCG both patterns coexisted along a medio (arrest)-lateral (clumsy) distribution, while aIPC hosted preferentially the task-arrest. The interference patterns were mainly associated to muscles suppression, more pronounced in aIPC with respect to PCG. Moreover, within PCG were observed patterns with different level of muscle recruitment, not reported in the aIPC. Overall, EMG-interference patterns and their probabilistic distribution suggested the presence of different functional parietal sectors, possibly playing different roles in hand-muscle control during manipulation. We hypothesized that task-arrest, compared to clumsy patterns, might suggest the existence of parietal sectors more closely implicated in shaping the motor output.
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Affiliation(s)
- Luca Fornia
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Italy; IRCCS Fondazione Don Carlo Gnocchi, Milano, Italy
| | - Marco Rossi
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Italy
| | | | - Andrea Bellacicca
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Italy
| | - Luca Viganò
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Italy
| | - Luciano Simone
- Cognition, Motion & Neuroscience, Center for Human Technologies, Istituto Italiano di Tecnologia, Genoa, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Italy
| | - Guglielmo Puglisi
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Italy
| | - Antonella Leonetti
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Italy
| | - Vincenzo Callipo
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Humanitas Research Hospital IRCSS, Rozzano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Italy
| | - Gabriella Cerri
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Humanitas Research Hospital IRCSS, Rozzano, Milano, Italy.
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19
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Aaronson DM, Martinez Del Campo E, Boerger TF, Conway B, Cornell S, Tate M, Mueller WM, Chang EF, Krucoff MO. Understanding Variable Motor Responses to Direct Electrical Stimulation of the Human Motor Cortex During Brain Surgery. Front Surg 2021; 8:730367. [PMID: 34660677 PMCID: PMC8517489 DOI: 10.3389/fsurg.2021.730367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
Direct electrical stimulation of the brain is the gold standard technique used to define functional-anatomical relationships during neurosurgical procedures. Areas that respond to stimulation are considered “critical nodes” of circuits that must remain intact for the subject to maintain the ability to perform certain functions, like moving and speaking. Despite its routine use, the neurophysiology underlying downstream motor responses to electrical stimulation of the brain, such as muscle contraction or movement arrest, is poorly understood. Furthermore, varying and sometimes counterintuitive responses can be seen depending on how and where the stimulation is applied, even within the human primary motor cortex. Therefore, here we review relevant neuroanatomy of the human motor system, provide a brief historical perspective on electrical brain stimulation, explore mechanistic variations in stimulation applications, examine neurophysiological properties of different parts of the motor system, and suggest areas of future research that can promote a better understanding of the interaction between electrical stimulation of the brain and its function.
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Affiliation(s)
- Daniel M Aaronson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Timothy F Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Brian Conway
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Sarah Cornell
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Matthew Tate
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Wade M Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Edward F Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, United States
| | - Max O Krucoff
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Biomedical Engineering, Marquette University, Milwaukee, WI, United States
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20
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Paldor I, Doron O, Peso D, Jubran M, Sviri GE. Intraoperative neuromonitoring during resection of cranial meningiomas and its effect on the surgical workflow. Neurosurg Rev 2021; 45:1481-1490. [PMID: 34632555 DOI: 10.1007/s10143-021-01667-2] [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: 08/05/2021] [Revised: 09/15/2021] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Resection of meningiomas adjacent to the central sulcus entails a high rate of morbidity. Explored for intra-axial lesion resection, intraoperative neuromonitoring intraoperative neuromonitoring (IONM) has been shown to decrease neurological deficits. The use of IONM is relatively uncommon and is not considered routine practice in the removal of extra-axial lesions. We sought to characterize IONM's impact on the surgical workflow in supratentorial meningiomas. METHODS We retrospectively analyzed a prospectively collected database, searching cases in which IONM was used for resection of meningioma between 2017 and 2020. We classified the IONM effect on surgical workflow into 5 distinct categories of workflow changes (WFC). RESULTS Forty cases of meningiomas with IONM use were identified. In 1 case (class 1 WFC), the operation was stopped due to IONM input. In 5 cases (class 2 WFC), the tumor was incompletely resected due to input from the IONM. In 14 cases (35%), IONM leads to an alteration of the resection process (alteration of approach, class 3 WFC). In 4 cases (10%), anesthesia care was modified based on IONM input (class 4 WFC). In 16 cases, no changes were made (class 5 WFC). In all patients in whom a change was made (24 cases, WFC 1-4), only 8.3% suffered a temporary deficit, and there were no permanent deficits, whereas when no change was made, there were 18.75% temporary deficit and 6.25% permanent deficit. CONCLUSION IONM has an impact during resection of meningiomas in eloquent areas and may guide the surgical technique, approach to tumor resection, and extent of resection.
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Affiliation(s)
- Iddo Paldor
- The Neurosurgery Department, Rambam (Maimonides) Health Care Campus, Haifa, Israel
- The Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Omer Doron
- The Neurosurgery Department, Rambam (Maimonides) Health Care Campus, Haifa, Israel
- Biomedical Engineering department, The Iby and Aladar, Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Dana Peso
- The Neurosurgery Department, Rambam (Maimonides) Health Care Campus, Haifa, Israel
| | - Muna Jubran
- Surgical Monitoring Services, Beit Shemesh, Israel
| | - Gill E Sviri
- The Neurosurgery Department, Rambam (Maimonides) Health Care Campus, Haifa, Israel
- The Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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21
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Viganò L, Howells H, Rossi M, Rabuffetti M, Puglisi G, Leonetti A, Bellacicca A, Conti Nibali M, Gay L, Sciortino T, Cerri G, Bello L, Fornia L. Stimulation of frontal pathways disrupts hand muscle control during object manipulation. Brain 2021; 145:1535-1550. [PMID: 34623420 PMCID: PMC9128819 DOI: 10.1093/brain/awab379] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/20/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
The activity of frontal motor areas during hand-object interaction is coordinated by dense communication along specific white matter pathways. This architecture allows the continuous shaping of voluntary motor output and, despite extensively investigated in non-human primate studies, remains poorly understood in humans. Disclosure of this system is crucial for predicting and treatment of motor deficits after brain lesions. For this purpose, we investigated the effect of direct electrical stimulation on white matter pathways within the frontal lobe on hand-object manipulation. This was tested in thirty-four patients (15 left hemisphere, mean age 42 years, 17 male, 15 with tractography) undergoing awake neurosurgery for frontal lobe tumour removal with the aid of the brain mapping technique. The stimulation outcome was quantified based on hand-muscle activity required by task execution. The white matter pathways responsive to stimulation with an interference on muscles were identified by means of probabilistic density estimation of stimulated sites, tract-based lesion-symptom (disconnectome) analysis and diffusion tractography on the single patient level. Finally, we assessed the effect of permanent tracts disconnection on motor outcome in the immediate postoperative period using a multivariate lesion-symptom mapping approach. The analysis showed that stimulation disrupted hand-muscle activity during task execution in 66 sites within the white matter below dorsal and ventral premotor regions. Two different EMG interference patterns associated with different structural architectures emerged: 1) an arrest pattern, characterised by complete impairment of muscle activity associated with an abrupt task interruption, occurred when stimulating a white matter area below the dorsal premotor region. Local mid-U-shaped fibres, superior fronto-striatal, corticospinal and dorsal fronto-parietal fibres intersected with this region. 2) a clumsy pattern, characterised by partial disruption of muscle activity associated with movement slowdown and/or uncoordinated finger movements, occurred when stimulating a white matter area below the ventral premotor region. Ventral fronto-parietal and inferior fronto-striatal tracts intersected with this region. Finally, only resections partially including the dorsal white matter region surrounding the supplementary motor area were associated with transient upper-limb deficit (p = 0.05; 5000 permutations). Overall, the results identify two distinct frontal white matter regions possibly mediating different aspects of hand-object interaction via distinct sets of structural connectivity. We suggest the dorsal region, associated with arrest pattern and post-operative immediate motor deficits, to be functionally proximal to motor output implementation, while the ventral region may be involved in sensorimotor integration required for task execution.
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Affiliation(s)
- Luca Viganò
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano
| | - Henrietta Howells
- MoCA Laboratory, Department of Medical Biotechnology and Translational Medicine, Universita`degli Studi di Milano
| | - Marco Rossi
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano
| | - Marco Rabuffetti
- Biomedical Technology Department, IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano.,MoCA Laboratory, Department of Medical Biotechnology and Translational Medicine, Universita`degli Studi di Milano
| | - Antonella Leonetti
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano
| | - Andrea Bellacicca
- MoCA Laboratory, Department of Medical Biotechnology and Translational Medicine, Universita`degli Studi di Milano
| | - Marco Conti Nibali
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano
| | - Lorenzo Gay
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano
| | - Tommaso Sciortino
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano
| | - Gabriella Cerri
- MoCA Laboratory, Department of Medical Biotechnology and Translational Medicine, Universita`degli Studi di Milano
| | - Lorenzo Bello
- Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano
| | - Luca Fornia
- MoCA Laboratory, Department of Medical Biotechnology and Translational Medicine, Universita`degli Studi di Milano
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22
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Targeting Primary Motor Cortex (M1) Functional Components in M1 Gliomas Enhances Safe Resection and Reveals M1 Plasticity Potentials. Cancers (Basel) 2021; 13:cancers13153808. [PMID: 34359709 PMCID: PMC8345096 DOI: 10.3390/cancers13153808] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/13/2021] [Accepted: 07/21/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Primary-Motor-Cortex (M1) hosts two functional components, at its posterior and anterior borders, the first being faster and more excitable than the second. Our study reports a novel technique for the on-line identification of these functional components during M1 tumors resection. It reports for the first time the potential plastic reorganization of M1 and specifically how its functional organization is affected by a growing tumor and correlated to clinical, tumor-related factors and patient motor functional performance. It also shows for the first time that detecting the M1 functional architecture and targeting the two M1 functional components facilitates tumor resection, increasing the rate of complete tumor removal, while maintaining the patient’s functional motor capacity. Abstract Primary-Motor-Cortex (M1) hosts two functional components, at its posterior and anterior borders, being the first faster and more excitable. We developed a mapping-technique for M1 components identification and determined their functional cortical-subcortical architecture in M1 gliomas and the impact of their identification on tumor resection and motor performance. A novel advanced mapping technique was used in 102 tumors within M1 or CorticoSpinal-Tract to identify M1-two components. High-Frequency-stimulation (2–5 pulses) with an on-line qualitative and quantitative analysis of motor responses was used; the two components’ cortical/subcortical spatial distribution correlated to clinical, tumor-related factor and patients’ motor outcome; a cohort treated with standard-mapping was used for comparison. The two functional components were always identified on-line; in tumors not affecting M1, its functional segregation was preserved. In M1 tumors, two architectures, both preserving the two components, were disclosed: in 50%, a normal cortical/subcortical architecture emerged, while 50% revealed a distorted architecture with loss of anatomical reference and somatotopy, not associated with tumor histo-molecular features or volume, but with a previous treatment. Motor performance was maintained, suggesting functional compensation. By preserving the highest and resecting the lowest excitability component, the complete-resection increased with low morbidity. The real-time identification of two M1 functional components and the preservation of the highest excitability one increases safe resection, revealing M1 plasticity potentials.
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23
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Voets NL, Pretorius P, Birch MD, Apostolopoulos V, Stacey R, Plaha P. Diffusion tractography for awake craniotomy: accuracy and factors affecting specificity. J Neurooncol 2021; 153:547-557. [PMID: 34196915 PMCID: PMC8280000 DOI: 10.1007/s11060-021-03795-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/22/2021] [Indexed: 11/30/2022]
Abstract
Introduction Despite evidence of correspondence with intraoperative stimulation, there remains limited data on MRI diffusion tractography (DT)’s sensitivity to predict morbidity after neurosurgical oncology treatment. Our aims were: (1) evaluate DT against subcortical stimulation mapping and performance changes during and after awake neurosurgery; (2) evaluate utility of early post-operative DT to predict recovery from post-surgical deficits. Methods We retrospectively reviewed our first 100 awake neurosurgery procedures using DT- neuronavigation. Intra-operative stimulation and performance outcomes were assessed to classify DT predictions for sensitivity and specificity calculations. Post-operative DT data, available in 51 patients, were inspected for tract damage. Results 91 adult brain tumor patients (mean 49.2 years, 43 women) underwent 100 awake surgeries with subcortical stimulation between 2014 and 2019. Sensitivity and specificity of pre-operative DT predictions were 92.2% and 69.2%, varying among tracts. Post-operative deficits occurred after 41 procedures (39%), but were prolonged (> 3 months) in only 4 patients (4%). Post-operative DT in general confirmed surgical preservation of tracts. Post-operative DT anticipated complete recovery in a patient with supplementary motor area syndrome, and indicated infarct-related damage to corticospinal fibers associated with delayed, partial recovery in a second patient. Conclusions Pre-operative DT provided very accurate predictions of the spatial location of tracts in relation to a tumor. As expected, however, the presence of a tract did not inform its functional status, resulting in variable DT specificity among individual tracts. While prolonged deficits were rare, DT in the immediate post-operative period offered additional potential to monitor neurological deficits and anticipate recovery potential. Supplementary Information The online version contains supplementary material available at 10.1007/s11060-021-03795-7.
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Affiliation(s)
- Natalie L Voets
- Department of Neurosurgery, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, West Wing, L3, Oxford, Oxfordshire, OX3 9DU, UK
| | - Pieter Pretorius
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Martin D Birch
- Nuffield Department of Anaesthesia, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Vasileios Apostolopoulos
- Department of Neurosurgery, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, West Wing, L3, Oxford, Oxfordshire, OX3 9DU, UK
| | - Richard Stacey
- Department of Neurosurgery, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, West Wing, L3, Oxford, Oxfordshire, OX3 9DU, UK
| | - Puneet Plaha
- Department of Neurosurgery, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, West Wing, L3, Oxford, Oxfordshire, OX3 9DU, UK. .,Nuffield Department of Surgery, University of Oxford, Oxford, Oxfordshire, UK.
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24
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Riva M, Hiepe P, Frommert M, Divenuto I, Gay LG, Sciortino T, Nibali MC, Rossi M, Pessina F, Bello L. Intraoperative Computed Tomography and Finite Element Modelling for Multimodal Image Fusion in Brain Surgery. Oper Neurosurg (Hagerstown) 2021; 18:531-541. [PMID: 31342073 DOI: 10.1093/ons/opz196] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/16/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND intraoperative computer tomography (iCT) and advanced image fusion algorithms could improve the management of brainshift and the navigation accuracy. OBJECTIVE To evaluate the performance of an iCT-based fusion algorithm using clinical data. METHODS Ten patients with brain tumors were enrolled; preoperative MRI was acquired. The iCT was applied at the end of microsurgical resection. Elastic image fusion of the preoperative MRI to iCT data was performed by deformable fusion employing a biomechanical simulation based on a finite element model. Fusion accuracy was evaluated: the target registration error (TRE, mm) was measured for rigid and elastic fusion (Rf and Ef) and anatomical landmark pairs were divided into test and control structures according to distinct involvement by the brainshift. Intraoperative points describing the stereotactic position of the brain were also acquired and a qualitative evaluation of the adaptive morphing of the preoperative MRI was performed by 5 observers. RESULTS The mean TRE for control and test structures with Rf was 1.81 ± 1.52 and 5.53 ± 2.46 mm, respectively. No significant change was observed applying Ef to control structures; the test structures showed reduced TRE values of 3.34 ± 2.10 mm after Ef (P < .001). A 32% average gain (range 9%-54%) in accuracy of image registration was recorded. The morphed MRI showed robust matching with iCT scans and intraoperative stereotactic points. CONCLUSIONS The evaluated method increased the registration accuracy of preoperative MRI and iCT data. The iCT-based non-linear morphing of the preoperative MRI can potentially enhance the consistency of neuronavigation intraoperatively.
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Affiliation(s)
- Marco Riva
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy.,Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | | | | | - Ignazio Divenuto
- Unit of Neuroradiology, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Lorenzo G Gay
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Tommaso Sciortino
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Marco Conti Nibali
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Marco Rossi
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Federico Pessina
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Lorenzo Bello
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy.,Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Milan, Italy
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25
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Keeble H, Lavrador JP, Pereira N, Lente K, Brogna C, Gullan R, Bhangoo R, Vergani F, Ashkan K. Electromagnetic Navigation Systems and Intraoperative Neuromonitoring: Reliability and Feasibility Study. Oper Neurosurg (Hagerstown) 2021; 20:373-382. [PMID: 33432974 DOI: 10.1093/ons/opaa407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND A recent influx of intraoperative technology is being used in neurosurgery, but few reports investigate the accuracy and safety of these technologies when used simultaneously. OBJECTIVE To assess the ability to use an electromagnetic navigation system alongside multimodal intraoperative neurophysiological monitoring (IONM). METHODS Single-institution prospective cohort study of patients requiring craniotomy for brain tumor resection operated using an electromagnetic navigation system (AxiEM, Medtronic®). motor evoked potentials, somatosensory evoked potentials (SSEPs), electroencephalography, and electromyography were recorded and analyzed with AxiEM on (with/without filters) and off. The neurological outcomes of the patients were recorded. RESULTS A total of 15 patients were included (8 males/7 females, mean age 52.13 yr). Even though the raw acquisition is affected by the electromagnetic field (particularly SSEPs), no significant difference was detected in the morphology, amplitude, and latency of the different monitoring modalities (AxiEM off vs on) after the appropriate software filter application. Adjustments to the frequency of SSEP stimulation and number of averages, and reductions to the low-pass filters were applied. Notch filters were used appropriately and changes to the physical setup of the IONM and electromagnetic navigation system equipment reduced noise. Postoperatively, none of the patients developed new focal deficits; 7 patients showed improvement in their motor deficit (4 recovered fully). CONCLUSION The information provided by the IONM in intracranial neurosurgery patients whilst also using electromagnetic navigation systems is reliable for monitoring, mapping, and detecting intraoperative complications, provided that the appropriate software filters and tools are applied.
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Affiliation(s)
| | - José Pedro Lavrador
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | | | | | - Christian Brogna
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | - Richard Gullan
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | - Ranjeev Bhangoo
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | - Francesco Vergani
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | - Keyoumars Ashkan
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
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26
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Rossi M, Puglisi G, Conti Nibali M, Viganò L, Sciortino T, Gay L, Leonetti A, Zito P, Riva M, Bello L. Asleep or awake motor mapping for resection of perirolandic glioma in the nondominant hemisphere? Development and validation of a multimodal score to tailor the surgical strategy. J Neurosurg 2021; 136:16-29. [PMID: 34144525 DOI: 10.3171/2020.11.jns202715] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Resection of glioma in the nondominant hemisphere involving the motor areas and pathways requires the use of brain-mapping techniques to spare essential sites subserving motor control. No clear indications are available for performing motor mapping under either awake or asleep conditions or for the best mapping paradigm (e.g., resting or active, high-frequency [HF] or low-frequency [LF] stimulation) that provides the best oncological and functional outcomes when tailored to the clinical context. This work aimed to identify clinical and imaging factors that influence surgical strategy (asleep motor mapping vs awake motor mapping) and that are associated with the best functional and oncological outcomes and to design a "motor mapping score" for guiding tumor resection in this area. METHODS The authors evaluated a retrospective series of patients with nondominant-hemisphere glioma-located or infiltrating within 2 cm anteriorly or posteriorly to the central sulcus and affecting the primary motor cortex, its fibers, and/or the praxis network-who underwent operations with asleep (HF monopolar probe) or awake (LF and HF probes) motor mapping. Clinical and imaging variables were used to design a motor mapping score. A prospective series of patients was used to validate this motor mapping score. RESULTS One hundred thirty-five patients were retrospectively analyzed: 69 underwent operations with asleep (HF stimulation) motor mapping, and 66 underwent awake (LF and HF stimulation and praxis task evaluation) motor mapping. Previous motor (strength) deficit, previous treatment (surgery/radiotherapy), tumor volume > 30 cm3, and tumor involvement of the praxis network (on MRI) were identified and used to design the mapping score. Motor deficit, previous treatment, and location within or close to the central sulcus favor use of asleep motor mapping; large tumor volume and involvement of the praxis network favor use of awake motor mapping. The motor mapping score was validated in a prospective series of 52 patients-35 underwent operations with awake motor mapping and 17 with asleep motor mapping on the basis of the score indications-who had a low rate of postoperative motor-praxis deficit (3%) and a high extent of resection (median 97%; complete resection in > 70% of patients). CONCLUSIONS Extensive resection of tumor involving the eloquent areas for motor control is feasible, and when an appropriate mapping strategy is applied, the incidence of postoperative motor-praxis deficit is low. Asleep (HF stimulation) motor mapping is preferable for lesions close to or involving the central sulcus and/or in patients with preoperative strength deficit and/or history of previous treatment. When a patient has no motor deficit or previous treatment and has a lesion (> 30 cm3) involving the praxis network, awake mapping is preferable.
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Affiliation(s)
- Marco Rossi
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Guglielmo Puglisi
- 2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and.,3Neurosurgical Oncology Unit, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano
| | - Marco Conti Nibali
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Luca Viganò
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Tommaso Sciortino
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Lorenzo Gay
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Antonella Leonetti
- 2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and.,3Neurosurgical Oncology Unit, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano
| | - Paola Zito
- 4Department of Anesthesia and Intensive Care, Humanitas Research Hospital, IRCCS, Rozzano, Italy
| | - Marco Riva
- 2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and.,3Neurosurgical Oncology Unit, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano
| | - Lorenzo Bello
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
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27
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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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28
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Improved potential quality of intraoperative transcranial motor-evoked potentials by navigated electrode placement compared to the conventional ten-twenty system. Neurosurg Rev 2021; 45:585-593. [PMID: 34043110 PMCID: PMC8827394 DOI: 10.1007/s10143-021-01568-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/08/2021] [Accepted: 05/17/2021] [Indexed: 11/08/2022]
Abstract
Intraoperative neurophysiological monitoring of transcranial motor-evoked potentials (tcMEPs) may fail to produce a serviceable signal due to displacements by mass lesions. We hypothesize that navigated placement of stimulation electrodes yields superior potential quality for tcMEPs compared to the conventional 10–20 placement. We prospectively included patients undergoing elective cranial surgery with intraoperative monitoring of tcMEPs. In addition to electrode placement as per the 10–20 system, an electrode pair was placed at a location corresponding to the hand knob area of the primary motor cortex (M1) for every patient, localized by a navigation system during surgical setup. Twenty-five patients undergoing elective navigated surgery for intracranial tumors (n = 23; 92%) or vascular lesions (n = 2; 8%) under intraoperative monitoring of tcMEPs were included between June and August 2019 at our department. Stimulation and recording of tcMEPs was successful in every case for the navigated electrode pair, while stimulation by 10–20 electrodes did not yield baseline tcMEPs in two cases (8%) with anatomical displacement of the M1. While there was no significant difference between baseline amplitudes, mean potential quality decreased significantly by 88.3 µV (− 13.5%) for the 10–20 electrodes (p = 0.004) after durotomy, unlike for the navigated electrodes (− 28.6 µV [− 3.1%]; p = 0.055). For patients with an anatomically displaced M1, the navigated tcMEPs declined significantly less after durotomy (− 3.6% vs. 10–20: − 23.3%; p = 0.038). Navigated placement of tcMEP electrodes accounts for interindividual anatomical variance and pathological dislocation of the M1, yielding more consistent potentials and reliable potential quality.
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Rossi M, Gay L, Ambrogi F, Conti Nibali M, Sciortino T, Puglisi G, Leonetti A, Mocellini C, Caroli M, Cordera S, Simonelli M, Pessina F, Navarria P, Pace A, Soffietti R, Rudà R, Riva M, Bello L. Association of supratotal resection with progression-free survival, malignant transformation, and overall survival in lower-grade gliomas. Neuro Oncol 2021; 23:812-826. [PMID: 33049063 DOI: 10.1093/neuonc/noaa225] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Supratotal resection is advocated in lower-grade gliomas (LGGs) based on theoretical advantages but with limited verification of functional risk and data on oncological outcomes. We assessed the association of supratotal resection in molecularly defined LGGs with oncological outcomes. METHODS Included were 460 presumptive LGGs; 404 resected; 347 were LGGs, 319 isocitrate dehydrogenase (IDH)-mutated, 28 wildtype. All patients had clinical, imaging, and molecular data. Resection aimed at supratotal resection without any patient or tumor a priori selection. The association of extent of resection (EOR), categorized on volumetric fluid attenuated inversion recovery images as residual tumor volume, along with postsurgical management with progression-free survival (PFS), malignant (M)PFS, and overall survival (OS) assessed by univariate, multivariate, and propensity score analysis. The study mainly focused on IDH-mutated LGGs, the "typical LGGs." RESULTS Median follow-up was 6.8 years (interquartile range, 5-8). Out of 319 IDH-mutated LGGs, 190 (59.6%) progressed, median PFS: 4.7 years (95% CI: 4-5.3). Total and supratotal resection obtained in 39% and 35% of patients with IDH1-mutated tumors. In IDH-mutated tumors, most patients in the partial/subtotal group progressed, 82.4% in total, only 6 (5.4%) in supratotal. Median PFS was 29 months (95% CI: 25-36) in subtotal, 46 months (95% CI: 38-48) in total, while at 92 months, PFS in supratotal was 94.0%. There was no association with molecular subtypes and grade. At random forest analysis, PFS strongly associated with EOR, radiotherapy, and previous treatment. In the propensity score analysis, EOR associated with PFS (hazard ratio, 0.03; 95% CI: 0.01-0.13). MPFS occurred in 32.1% of subtotal total groups; 1 event in supratotal. EOR, grade III, previous treatment correlated to MPFS. At random forest analysis, OS associated with EOR as well. CONCLUSIONS Supratotal resection strongly associated with PFS, MPFS, and OS in LGGs, regardless of molecular subtypes and grade, right from the beginning of clinical presentation.
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Affiliation(s)
- Marco Rossi
- Neurosurgical Oncology Unit, Dept of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Neurosurgical Oncology Unit, Milano, Italy
| | - Lorenzo Gay
- Neurosurgical Oncology Unit, Dept of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Neurosurgical Oncology Unit, Milano, Italy
| | - Federico Ambrogi
- Laboratory of Medical Statistics, Biometry and Epidemiology "G.A.Maccararo," Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Marco Conti Nibali
- Neurosurgical Oncology Unit, Dept of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Neurosurgical Oncology Unit, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgical Oncology Unit, Dept of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Neurosurgical Oncology Unit, Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgical Oncology Unit, Dept of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Neurosurgical Oncology Unit, Milano, Italy
| | - Antonella Leonetti
- Neurosurgical Oncology Unit, Dept of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Neurosurgical Oncology Unit, Milano, Italy
| | - Cristina Mocellini
- Neuro-oncologia, Divisione di Neurologia, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Manuela Caroli
- Neurochirurgia, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Susanna Cordera
- Neuro-oncologia, Divisione di Neurologia, Ospedale Regionale Parini, Aosta, Italy
| | - Matteo Simonelli
- Humanitas Cancer Center, Humanitas Research Hospital, IRCCS, Rozzano, Italy
| | - Federico Pessina
- Humanitas Cancer Center, Humanitas Research Hospital, IRCCS, Rozzano, Italy
| | - Piera Navarria
- Humanitas Cancer Center, Humanitas Research Hospital, IRCCS, Rozzano, Italy
| | - Andrea Pace
- Neuro-Oncologia, Istituto Nazionale Tumori Regina Elena, Roma, Italy
| | - Riccardo Soffietti
- Neuro-Oncologia, Città della Salute e della Scienza, Università di Torino, Torino, Italy
| | - Roberta Rudà
- Neuro-Oncologia, Città della Salute e della Scienza, Università di Torino, Torino, Italy
| | - Marco Riva
- Neurosurgical Oncology Unit, Dept of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Neurosurgical Oncology Unit, Milano, Italy
| | - Lorenzo Bello
- Neurosurgical Oncology Unit, Dept of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Neurosurgical Oncology Unit, Milano, Italy
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De Witt Hamer PC, Klein M, Hervey-Jumper SL, Wefel JS, Berger MS. Functional Outcomes and Health-Related Quality of Life Following Glioma Surgery. Neurosurgery 2021; 88:720-732. [PMID: 33517431 PMCID: PMC7955971 DOI: 10.1093/neuros/nyaa365] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/25/2020] [Indexed: 12/19/2022] Open
Abstract
Functional outcome following glioma surgery is defined as how the patient functions or feels. Functional outcome is a coprimary end point of surgery in patients with diffuse glioma, together with oncological outcome. In this review, we structure the functional outcome measurements following glioma surgery as reported in the last 5 yr. We review various perspectives on functional outcome of glioma surgery with available measures, and offer suggestions for their use. From the recent neurosurgical literature, 160 publications were retrieved fulfilling the selection criteria. In these publications, neurological outcomes were reported most often, followed by activities of daily living, seizure outcomes, neurocognitive outcomes, and health-related quality of life or well-being. In more than a quarter of these publications functional outcome was not reported. A minimum essential consensus set of functional outcome measurements would benefit comparison across neurosurgical reports. The consensus set should be based on a combination of clinician- and patient-reported outcomes, assessed at a predefined time before and after surgery. The selected measurements should have psychometric properties supporting the intended use including validity-related evidence, reliability, and sensitivity to detect meaningful change with minimal burden to ensure compliance. We circulate a short survey as a start towards reporting guidelines. Many questions remain to better understand, report, and improve functional outcome following glioma surgery.
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Affiliation(s)
- Philip C De Witt Hamer
- Correspondence: Philip C. De Witt Hamer, MD, PhD, Amsterdam UMC, Vrije Universiteit, Department of Neurosurgery, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands.
| | - Martin Klein
- Amsterdam UMC, Vrije Universiteit, Department of Medical Psychology, Neuroscience Campus, Amsterdam, Netherlands
| | - Shawn L Hervey-Jumper
- University of California San Francisco, Department of Neurological Surgery, San Francisco, California
| | - Jeffrey S Wefel
- University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology and Department of Radiation Oncology, Houston, Texas
| | - Mitchel S Berger
- University of California San Francisco, Department of Neurological Surgery, San Francisco, California
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Rossi M, Sciortino T, Conti Nibali M, Gay L, Viganò L, Puglisi G, Leonetti A, Howells H, Fornia L, Cerri G, Riva M, Bello L. Clinical Pearls and Methods for Intraoperative Motor Mapping. Neurosurgery 2021; 88:457-467. [PMID: 33476393 PMCID: PMC7884143 DOI: 10.1093/neuros/nyaa359] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/26/2020] [Indexed: 12/13/2022] Open
Abstract
Resection of brain tumors involving motor areas and pathways requires the identification and preservation of various cortical and subcortical structures involved in motor control at the time of the procedure, in order to maintain the patient's full motor capacities. The use of brain mapping techniques has now been integrated into clinical practice for many years, as they help the surgeon to identify the neural structures involved in motor functions. A common definition of motor function, as well as knowledge of its neural organization, has been continuously evolving, underlining the need for implementing intraoperative strategies at the time of the procedure. Similarly, mapping strategies have been subjected to continuous changes, enhancing the likelihood of preservation of full motor capacities. As a general rule, the motor mapping strategy should be as flexible as possible and adapted strictly to the individual patient and clinical context of the tumor. In this work, we present an overview of current knowledge of motor organization, indications for motor mapping, available motor mapping, and monitoring strategies, as well as their advantages and limitations. The use of motor mapping improves resection and outcomes in patients harboring tumors involving motor areas and pathways, and should be considered the gold standard in the resection of this type of tumor.
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Affiliation(s)
- Marco Rossi
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Marco Conti Nibali
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Gay
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Luca Viganò
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Antonella Leonetti
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Luca Fornia
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Gabriella Cerri
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Marco Riva
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
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Intraoperative mapping of pre-central motor cortex and subcortex: a proposal for supplemental cortical and novel subcortical maps to Penfield's motor homunculus. Brain Struct Funct 2021; 226:1601-1611. [PMID: 33871691 PMCID: PMC8096772 DOI: 10.1007/s00429-021-02274-z] [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: 12/05/2020] [Accepted: 04/09/2021] [Indexed: 12/17/2022]
Abstract
Penfield’s motor homunculus describes a caricaturised yet useful representation of the map of various body parts on the pre-central cortex. We propose a supplemental map of the clinically represented areas of human body in pre-central cortex and a novel subcortical corticospinal tract map. We believe this knowledge is essential for safe surgery in patients with eloquent brain lesions. A single-institution retrospective cohort study of patients who underwent craniotomy for motor eloquent lesions with intraoperative motor neuromonitoring (cortical and subcortical) between 2015 and 2020 was performed. All positive cortical and subcortical stimulation points were taken into account and cartographic maps were produced to demonstrate cortical and subcortical areas of motor representation and their configuration. A literature review in PubMed was performed. One hundred and eighty consecutive patients (58.4% male, 41.6% female) were included in the study with 81.6% asleep and 18.4% awake craniotomies for motor eloquent lesions (gliomas 80.7%, metastases 13.8%) with intraoperative cortical and subcortical motor mapping. Based on the data, we propose a supplemental clinical cortical and a novel subcortical motor map to the original Penfield’s motor homunculus, including demonstration of localisation of intercostal muscles both in the cortex and subcortex which has not been previously described. The supplementary clinical cortical and novel subcortical motor maps of the homunculus presented here have been derived from a large cohort of patients undergoing direct cortical and subcortical brain mapping. The information will have direct relevance for improving the safety and outcome of patients undergoing resection of motor eloquent brain lesions.
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Distinct Functional and Structural Connectivity of the Human Hand-Knob Supported by Intraoperative Findings. J Neurosci 2021; 41:4223-4233. [PMID: 33827936 DOI: 10.1523/jneurosci.1574-20.2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 01/02/2021] [Accepted: 01/10/2021] [Indexed: 12/15/2022] Open
Abstract
Fine motor skills rely on the control of hand muscles exerted by a region of primary motor cortex (M1) that has been extensively investigated in monkeys. Although neuroimaging enables the exploration of this system also in humans, indirect measurements of brain activity prevent causal definitions of hand motor representations, which can be achieved using data obtained during brain mapping in tumor patients. High-frequency direct electrical stimulation delivered at rest (HF-DES-Rest) on the hand-knob region of the precentral gyrus has identified two sectors showing differences in cortical excitability. Using quantitative analysis of motor output elicited with HF DES-Rest, we characterized two sectors based on their excitability, higher in the posterior and lower in the anterior sector. We studied whether the different cortical excitability of these two regions reflected differences in functional connectivity (FC) and structural connectivity (SC). Using healthy adults from the Human Connectome Project (HCP), we computed FC and SC of the anterior and the posterior hand-knob sectors identified within a large cohort of patients. The comparison of FC of the two seeds showed that the anterior hand-knob, relative to the posterior hand-knob, showed stronger functional connections with a bilateral set of parietofrontal areas responsible for integrating perceptual and cognitive hand-related sensorimotor processes necessary for goal-related actions. This was reflected in different patterns of SC between the two sectors. Our results suggest that the human hand-knob is a functionally and structurally heterogeneous region organized along a motor-cognitive gradient.SIGNIFICANCE STATEMENT The capability to perform complex manipulative tasks is one of the major characteristics of primates and relies on the fine control of hand muscles exerted by a highly specialized region of the precentral gyrus, often termed the "hand-knob" sector. Using intraoperative brain mapping, we identify two hand-knob sectors (posterior and anterior) characterized by differences in cortical excitability. Based on resting-state functional connectivity (FC) and tractography in healthy subjects, we show that posterior and anterior hand-knob sectors differ in their functional connectivity (FC) and structural connectivity (SC) with frontoparietal regions. Thus, anteroposterior differences in cortical excitability are paralleled by differences in FC and SC that likely reflect a motor (posterior) to cognitive (anterior) organization of this cortical region.
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Staub-Bartelt F, Hofmann BB, Rapp M, Hänggi D, Kamp MA, Sabel M. Direct Cortical Stimulation in Neurosurgical Emergencies: Single-Center Experience in 2 Patients. World Neurosurg 2021; 150:147-152. [PMID: 33819710 DOI: 10.1016/j.wneu.2021.03.118] [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: 01/14/2021] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) is widely used for elective resection of eloquently located brain tumors to increase safety and extent of resection. Owing to the need for specially trained personnel for IONM and the sophisticated, time-consuming technical setup, standard IONM is usually not suitable for emergency situations. We report the use of a device that can be operated by the neurosurgeon autonomously for monopolar brain mapping in 2 emergency cases. METHODS Both patients were initially scheduled for elective neurosurgery under IONM. Acute neurological deterioration in both cases led to emergency surgery. For monopolar cortical/subcortical stimulation, a standard monopolar probe was connected to a new device enabling electromyography real-time tracking of 8 muscles. Preoperative application of subdermal electromyography needles and intraoperative handling of the device were performed by the neurosurgeons independently. RESULTS Cortical mapping of the motor cortex was performed in both patients with a threshold of 4 mA in case 1 and 14 mA in case 2. Gross total resection with residual tumor volume of <2 mL in case 1 and subtotal resection with residual tumor volume of 4.2 mL in case 2 were achieved under use of the new device without any new neurological deficit. Grade IV glioblastoma was diagnosed in both patients. CONCLUSIONS We demonstrate the feasibility of monopolar stimulation in 2 patients undergoing emergency neurosurgery using a device autonomously operated by the surgeon. Owing to fast setup and nondemanding handling, monopolar stimulation could be used during emergency neurosurgery to extend resection with preservation of neurological function in both cases.
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Affiliation(s)
| | | | - Marion Rapp
- Department of Neurosurgery, University Hospital Düsseldorf, Düsseldorf, Germany; Centre of Neurooncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marcel Alexander Kamp
- Department of Neurosurgery, University Hospital Düsseldorf, Düsseldorf, Germany; Department of Neurosurgery, University Hospital Jena, Jena, Germany
| | - Michael Sabel
- Department of Neurosurgery, University Hospital Düsseldorf, Düsseldorf, Germany; Centre of Neurooncology, University Hospital Düsseldorf, Düsseldorf, Germany
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Rossi M, Gay L, Conti Nibali M, Sciortino T, Ambrogi F, Leonetti A, Puglisi G, Howells H, Zito P, Villa F, Ciroi G, Riva M, Bello L. Challenging Giant Insular Gliomas With Brain Mapping: Evaluation of Neurosurgical, Neurological, Neuropsychological, and Quality of Life Results in a Large Mono-Institutional Series. Front Oncol 2021; 11:629166. [PMID: 33828981 PMCID: PMC8019925 DOI: 10.3389/fonc.2021.629166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/01/2021] [Indexed: 01/23/2023] Open
Abstract
Objective Giant insular tumors are commonly not amenable to complete resection and are associated with a high postoperative morbidity rate. Transcortical approach and brain mapping techniques allow to identify peri-insular functional networks and, with neurophysiological monitoring, to reduce vascular-associated insults. Cognitive functions to be mapped are still under debate, and the analysis of the functional risk of surgery is currently limited to neurological examination. This work aimed to investigate the neurosurgical outcome (extent of resection, EOR) and functional impact of giant insular gliomas resection, focusing on neuropsychological and Quality of Life (QoL) outcomes. Methods In our retrospective analysis, we included all patients admitted in a five-year period with a radiological diagnosis of giant insular glioma. A transcortical approach was adopted in all cases. Resections were pursued up to functional boundaries defined intraoperatively by brain mapping techniques. We examined clinical, radiological, and intra-operative factors possibly affecting EOR and postoperative neurological, neuropsychological, and Quality of Life (QoL) outcomes. Results We finally enrolled 95 patients in the analysis. Mean EOR was 92.3%. A Gross Total Resection (GTR) was obtained in 70 cases (73.7%). Five patients reported permanent morbidity (aphasia in 3, 3.2%, and superior quadrantanopia in 2, 2.1%). Suboptimal EOR associated with poor seizures control postoperatively. Extensive intraoperative mapping (inclusive of cognitive, visual, and haptic functions) decreased long-term neurological, neuropsychological, and QoL morbidity and increased EOR. Tumor infiltration of deep perforators (vessels arising either medial to lenticulostriate arteries through the anterior perforated substance or from the anterior choroidal artery) associated with a higher chance of postoperative ischemia in consonant areas, with the persistence of new-onset motor deficits 1-month post-op, and with minor EOR. Ischemic insults in eloquent sites represented the leading factor for long-term neurological and neuropsychological morbidity. Conclusion In giant insular gliomas, the use of a transcortical approach with extensive brain mapping under awake anesthesia ensures broad insular exposure and extension of the surgical resection preserving patients’ functional integrity. The relation between tumor mass and deep perforators predicts perioperative ischemic insults, the most relevant risk factor for long-term and permanent postoperative morbidity.
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Affiliation(s)
- Marco Rossi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Lorenzo Gay
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Marco Conti Nibali
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Federico Ambrogi
- Laboratory of Medical Statistics, Biometry, and Epidemiology "G.A. Maccararo," Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Antonella Leonetti
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Laboratorio Interdisciplinare di Tecnologie Avanzate (LITA), Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Laboratorio Interdisciplinare di Tecnologie Avanzate (LITA), Milano, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Laboratorio Interdisciplinare di Tecnologie Avanzate (LITA), Milano, Italy
| | - Paola Zito
- Department of Anesthesia and Intensive Care, Humanitas Research Hospital, IRCCS, Milano, Italy
| | - Federico Villa
- Department of Anesthesia and Intensive Care, Humanitas Research Hospital, IRCCS, Milano, Italy
| | - Gjulio Ciroi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Marco Riva
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
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Fornia L, Rossi M, Rabuffetti M, Leonetti A, Puglisi G, Viganò L, Simone L, Howells H, Bellacicca A, Bello L, Cerri G. Direct Electrical Stimulation of Premotor Areas: Different Effects on Hand Muscle Activity during Object Manipulation. Cereb Cortex 2021; 30:391-405. [PMID: 31504261 PMCID: PMC7029688 DOI: 10.1093/cercor/bhz139] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 12/25/2022] Open
Abstract
Dorsal and ventral premotor (dPM and vPM) areas are crucial in control of hand muscles during object manipulation, although their respective role in humans is still debated. In patients undergoing awake surgery for brain tumors, we studied the effect of direct electrical stimulation (DES) of the premotor cortex on the execution of a hand manipulation task (HMt). A quantitative analysis of the activity of extrinsic and intrinsic hand muscles recorded during and in absence of DES was performed. Results showed that DES applied to premotor areas significantly impaired HMt execution, affecting task-related muscle activity with specific features related to the stimulated area. Stimulation of dorsal vPM induced both a complete task arrest and clumsy task execution, characterized by general muscle suppression. Stimulation of ventrocaudal dPM evoked a complete task arrest mainly due to a dysfunctional recruitment of hand muscles engaged in task execution. These results suggest that vPM and dPM contribute differently to the control of hand muscles during object manipulation. Stimulation of both areas showed a significant impact on motor output, although the different effects suggest a stronger relationship of dPM with the corticomotoneuronal circuit promoting muscle recruitment and a role for vPM in supporting sensorimotor integration.
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Affiliation(s)
- Luca Fornia
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
| | - Marco Rossi
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
| | - Marco Rabuffetti
- Biomedical Technology Department, IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milano, Italy
| | - Antonella Leonetti
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
| | - Guglielmo Puglisi
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
| | - Luca Viganò
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
| | - Luciano Simone
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
| | - Andrea Bellacicca
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
| | - Lorenzo Bello
- Unit of Neurosurgical Oncology, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
| | - Gabriella Cerri
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Humanitas Reasearch Hospital, IRCCS, Milano, Italy
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Negative motor responses to direct electrical stimulation: Behavioral assessment hides different effects on muscles. Cortex 2021; 137:194-204. [PMID: 33640851 DOI: 10.1016/j.cortex.2021.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/11/2020] [Accepted: 01/19/2021] [Indexed: 11/22/2022]
Abstract
A negative motor response (NMR) is defined as the inability to continue voluntary movements without losing consciousness when direct electrical stimulation (DES) is applied during awake neurosurgery. While visual inspection is most commonly used to define an NMR, the actual effect of stimulation on muscle activity has been neglected by recent neurosurgical literature. We show that behavioral assessment of NMRs hides different site-dependent effects on muscles as revealed by electromyography (EMG), describing ten cases of brain tumor patients undergoing awake neurosurgery while performing a hand-object manipulation task. DES-induced NMRs were assessed behaviorally and related to the underlying electromyographic recording. Quantitative analysis of motor unit recruitment and regularity between phasic muscle contractions was computed. We show that similar NMRs classified based on behavioral criteria can be associated with suppression, increased recruitment or mixed effects on ongoing hand muscles. In some cases, suppression of hand muscle activity is associated with involuntary recruitment of muscles not involved in the task. Interestingly, stimulation of behaviorally defined "negative areas" across the frontal and parietal lobes elicits different electromyographic patterns, depending on the stimulation site. This study provides novel preliminary background as to the heterogeneous profile of muscle activity during NMRs. In fact, EMG monitoring paired with behavioral assessment can distinguish between NMRs that, despite similarity on behavioral inspection, are different in their related EMG, possibly underlying different neural substrates. The identification of different circuits hidden in similar NMRs may become relevant when planning the extension of resection.
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Giampiccolo D, Parisi C, Meneghelli P, Tramontano V, Basaldella F, Pasetto M, Pinna G, Cattaneo L, Sala F. Long-term motor deficit in brain tumour surgery with preserved intra-operative motor-evoked potentials. Brain Commun 2021; 3:fcaa226. [PMID: 33615216 PMCID: PMC7884605 DOI: 10.1093/braincomms/fcaa226] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/29/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
Muscle motor-evoked potentials are commonly monitored during brain tumour surgery in motor areas, as these are assumed to reflect the integrity of descending motor pathways, including the corticospinal tract. However, while the loss of muscle motor-evoked potentials at the end of surgery is associated with long-term motor deficits (muscle motor-evoked potential-related deficits), there is increasing evidence that motor deficit can occur despite no change in muscle motor-evoked potentials (muscle motor-evoked potential-unrelated deficits), particularly after surgery of non-primary regions involved in motor control. In this study, we aimed to investigate the incidence of muscle motor-evoked potential-unrelated deficits and to identify the associated brain regions. We retrospectively reviewed 125 consecutive patients who underwent surgery for peri-Rolandic lesions using intra-operative neurophysiological monitoring. Intraoperative changes in muscle motor-evoked potentials were correlated with motor outcome, assessed by the Medical Research Council scale. We performed voxel–lesion–symptom mapping to identify which resected regions were associated with short- and long-term muscle motor-evoked potential-associated motor deficits. Muscle motor-evoked potentials reductions significantly predicted long-term motor deficits. However, in more than half of the patients who experienced long-term deficits (12/22 patients), no muscle motor-evoked potential reduction was reported during surgery. Lesion analysis showed that muscle motor-evoked potential-related long-term motor deficits were associated with direct or ischaemic damage to the corticospinal tract, whereas muscle motor-evoked potential-unrelated deficits occurred when supplementary motor areas were resected in conjunction with dorsal premotor regions and the anterior cingulate. Our results indicate that long-term motor deficits unrelated to the corticospinal tract can occur more often than currently reported. As these deficits cannot be predicted by muscle motor-evoked potentials, a combination of awake and/or novel asleep techniques other than muscle motor-evoked potentials monitoring should be implemented.
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Affiliation(s)
- Davide Giampiccolo
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Cristiano Parisi
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Pietro Meneghelli
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Vincenzo Tramontano
- Division of Neurology and Intraoperative Neurophysiology Unit, University Hospital, Verona, Italy
| | - Federica Basaldella
- Division of Neurology and Intraoperative Neurophysiology Unit, University Hospital, Verona, Italy
| | - Marco Pasetto
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Giampietro Pinna
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Luigi Cattaneo
- CIMEC-Center for Mind/Brain Sciences, University of Trento, Trento, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
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Riva M, Lopci E, Gay LG, Nibali MC, Rossi M, Sciortino T, Castellano A, Bello L. Advancing Imaging to Enhance Surgery: From Image to Information Guidance. Neurosurg Clin N Am 2021; 32:31-46. [PMID: 33223024 DOI: 10.1016/j.nec.2020.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Conventional magnetic resonance imaging (cMRI) has an established role as a crucial disease parameter in the multidisciplinary management of glioblastoma, guiding diagnosis, treatment planning, assessment, and follow-up. Yet, cMRI cannot provide adequate information regarding tissue heterogeneity and the infiltrative extent beyond the contrast enhancement. Advanced magnetic resonance imaging and PET and newer analytical methods are transforming images into data (radiomics) and providing noninvasive biomarkers of molecular features (radiogenomics), conveying enhanced information for improving decision making in surgery. This review analyzes the shift from image guidance to information guidance that is relevant for the surgical treatment of glioblastoma.
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Affiliation(s)
- Marco Riva
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Via Festa del Perdono 7, Milan 20122, Italy; IRCCS Istituto Ortopedico Galeazzi, U.O. Neurochirurgia Oncologica, Milan, Italy.
| | - Egesta Lopci
- Unit of Nuclear Medicine, Humanitas Clinical and Research Center - IRCCS, Via Manzoni 56, Rozzano, Milan 20089, Italy. https://twitter.com/LopciEgesta
| | - Lorenzo G Gay
- IRCCS Istituto Ortopedico Galeazzi, U.O. Neurochirurgia Oncologica, Milan, Italy; Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy
| | - Marco Conti Nibali
- IRCCS Istituto Ortopedico Galeazzi, U.O. Neurochirurgia Oncologica, Milan, Italy; Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy. https://twitter.com/dr_mcn
| | - Marco Rossi
- IRCCS Istituto Ortopedico Galeazzi, U.O. Neurochirurgia Oncologica, Milan, Italy; Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy
| | - Tommaso Sciortino
- IRCCS Istituto Ortopedico Galeazzi, U.O. Neurochirurgia Oncologica, Milan, Italy; Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy
| | - Antonella Castellano
- Neuroradiology Unit and CERMAC, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan 20123, Italy. https://twitter.com/antocastella
| | - Lorenzo Bello
- IRCCS Istituto Ortopedico Galeazzi, U.O. Neurochirurgia Oncologica, Milan, Italy; Department of Oncology and Hemato-Oncology, Via Festa del Perdono 7, Milan 20122, Italy
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Abstract
Intraoperative functional mapping of tumor and peri-tumor tissue is a well-established technique for avoiding permanent neurologic deficits and maximizing extent of resection. Motor, language, and other cognitive domains may be assessed with intraoperative tasks. This article describes techniques used for motor and language mapping including awake mapping considerations in addition to less traditional intraoperative testing paradigms for cognition. It also discusses complications associated with mapping and insights into complication avoidance.
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Kosyrkova AV, Goryainov SA, Ogurtsova AA, Okhlopkov VA, Kravchuk AD, Batalov AI, Afandiev RM, Bayev AA, Pogosbekyan EL, Pronin IN, Zakharova NE, Danilov GV, Strunina YV, Potapov AA. [Comparative analysis of mono- and bipolar pyramidal tract mapping in patients with supratentorial tumors adjacent to motor areas: comparison of data at 64 stimulation points]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:29-40. [PMID: 33095531 DOI: 10.17116/neiro20208405129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare monopolar and bipolar mapping in point-by-point fashion by using of threshold amperage, frequency of positive motor responses and the number of muscles involved in response. MATERIAL AND METHODS A prospective non-randomized study included 14 patients with supratentorial tumors who underwent surgery in 2018-2019. All neoplasms were localized within 2 cm from the motor cortex and pyramidal tract. Age of patients ranged from 25 to 74 years. There were 9 women and 5 men. Eight patients had malignant glioma (grade III - 4, grade IV - 4), 6 patients - meningioma. Motor functions were assessed in all patients before and after surgery (1, 7 days and 3 months later) by using of a 5-point scale. In addition to routine neurophysiological monitoring, comparative mono- and bipolar mapping of the pyramidal tract within the bed of excised tumor was carried out at the end of surgery. The points of motor responses were marked. Comparative analysis of mono- and bipolar stimulation at identical points included threshold amperage, frequency of positive motor responses and the number of muscles involved in response (leg, forearm, hand, facial muscles). Brain MRI was performed in early postoperative period for assessment of resection quality. RESULTS There were 64 points of motor responses in 14 patients. The number of these points ranged from 2 to 8 per a patient (mean 5 points). Motor responses were recorded in 57 points during monopolar and bipolar stimulation, in other 7 points - only during monopolar stimulation. Amperage of monopolar stimulation was 3-15 mA, bipolar stimulation - 2.5-25 mA. Threshold amperage (7.37 mA for monopolar stimulation and 8.88 mA for bipolar stimulation; p=0.12), frequency of positive motor responses and the number of muscles involved in response (p=0.1 and p=0.73) were similar. Seven (50%) patients had neurological deterioration in early postoperative period (4 patients with glial tumors and 3 patients with meningiomas). At the same time, only 2 patients (14.3%) had persistent neurological deficit (both patients with infiltrative meningioma). According to postoperative MRI in T1+C mode, resection volume was 100% in 1 patient with contrast-enhanced glioma and 94% in another one. According to FLAIR MRI data, resection volume exceeded 70% in 2 patients with non-enhancing glioma and less than 70% in 2 patients. Meningioma resection volume was estimated according to postoperative T1+C MRI data and made up over 90% in 4 patients. CONCLUSION Monopolar stimulation is a reliable method of pyramidal tract identification in supratentorial brain tumor surgery.
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Affiliation(s)
| | | | | | | | | | - A I Batalov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A A Bayev
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - G V Danilov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A A Potapov
- Burdenko Neurosurgical Center, Moscow, Russia
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Conti Nibali M, Leonetti A, Puglisi G, Rossi M, Sciortino T, Gay LG, Arcidiacono UA, Howells H, Viganò L, Zito PC, Riva M, Bello L. Preserving Visual Functions During Gliomas Resection: Feasibility and Efficacy of a Novel Intraoperative Task for Awake Brain Surgery. Front Oncol 2020; 10:1485. [PMID: 32983985 PMCID: PMC7492569 DOI: 10.3389/fonc.2020.01485] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/13/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: The intraoperative identification and preservation of optic radiations (OR) during tumor resection requires the patient to be awake. Different tasks are used. However, they do not grant the maintenance of foveal vision during all testing, limiting the ability to constantly monitor the peripheral vision and to inform about the portion of the peripheral field that is encountered. Although hemianopia can be prevented, quadrantanopia cannot be properly avoided. To overcome these limitations, we developed an intra-operative Visual field Task (iVT) to monitor the foveal vision, alerting about the likelihood of injuring the OR during task administration, and to inform about the portion of the peripheral field that is explored. Data on feasibility and efficacy in preventing visual field deficits are reported, comparing the outcome with the standard available task (Double-Picture-Naming-Task, DPNT). Methods: Patients with a temporal and/or parietal lobe tumor in close morphological relationship with the OR, or where the resection can involve the OR at any extent, without pre-operative visual-field deficits (Humphrey) were enrolled. Fifty-four patients were submitted to iVT, 38 to DPNT during awake surgery with brain mapping neurophysiological techniques. Feasibility was assessed as ease of administration, training and mapping time, and ability to alert about the loss of foveal vision. Type and location of evoked interferences were registered. Functional outcome was evaluated by manual and Humphrey test; extent of resection was recorded. Tractography was performed in a sample of patients to compare patient anatomy with intraoperative stimulation site(s). Results: The test was easy to administer and detected the loss of foveal vision in all cases. Stimulation induced visual-field interferences, detected in all patients, classified as detection or discrimination errors. Detection was mostly observed in temporal tumors, discrimination in temporo-parietal ones. Immediate visual disturbances in DPNT group were registered in 84 vs. 24% of iVT group. At 1-month Humphrey evaluation, 26% of iVT vs. 63% of DPNT had quadrantanopia (32% symptomatic); 10% of DPNT had hemianopia. EOR was similar. Detection errors were induced for stimulation of OR; discrimination also for other visual processing tract (ILF). Conclusion: iVT was feasible and sensitive to preserve the functional integrity of the OR.
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Affiliation(s)
- Marco Conti Nibali
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Antonella Leonetti
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Milano, Italy
| | - Marco Rossi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Gabriel Gay
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Umberto Aldo Arcidiacono
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Milano, Italy
| | - Luca Viganò
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano, Milano, Italy
| | - Paola Cosma Zito
- Department of Anesthesia and Intensive Care, Humanitas Research Hospital, IRCCS, Rozzano, Italy
| | - Marco Riva
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
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Optimizing the onco-functional balance in supratentorial brain tumour surgery: A single institution's initial experience with intraoperative cortico-subcortical mapping and monitoring in Singapore. J Clin Neurosci 2020; 79:224-230. [PMID: 33070901 DOI: 10.1016/j.jocn.2020.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 06/04/2020] [Accepted: 07/11/2020] [Indexed: 11/23/2022]
Abstract
Intraoperative cortical mapping provides functional information that permits the safe and maximal resection of supratentorial lesions infiltrating the so-called eloquent cortex or subcortical white matter tracts. Primary and secondary brain tumours located in eloquent cortex can render surgical treatment ineffective if it results in new or worsening neurology. A cohort of forty-six consecutive patients with supratentorial tumours of variable pathology involving eloquent cortical regions and aided with intraoperative neurophysiology were included for retrospective analysis at a single-centre tertiary institution. Intraoperative neurophysiological data has been related to immediate post-operative neurologic status as well as 3-month follow-up in patients that underwent awake or asleep surgical resection. Patients that experienced new or worsening neurologic symptoms post-operatively demonstrated a high incidence of recovery at 3-months. Those without new neurologic symptoms post-operatively demonstrated little to no worsening at 3-months. Our study explored the extent to which cortical mapping permitted safe surgical resection whilst preserving neurologic function. To the authors' knowledge this is the first documented case series in Singapore that has incorporated a systematic and individually tailored multimodal workflow to cortico-subcortical mapping and monitoring for the safe resection of infiltrative lesions of the supratentorial region.
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Howells H, Puglisi G, Leonetti A, Vigano L, Fornia L, Simone L, Forkel SJ, Rossi M, Riva M, Cerri G, Bello L. The role of left fronto-parietal tracts in hand selection: Evidence from neurosurgery. Cortex 2020; 128:297-311. [DOI: 10.1016/j.cortex.2020.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/07/2020] [Accepted: 03/12/2020] [Indexed: 10/24/2022]
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Rech F, Wassermann D, Duffau H. New insights into the neural foundations mediating movement/language interactions gained from intrasurgical direct electrostimulations. Brain Cogn 2020; 142:105583. [DOI: 10.1016/j.bandc.2020.105583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
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Suarez-Meade P, Marenco-Hillembrand L, Prevatt C, Murguia-Fuentes R, Mohamed A, Alsaeed T, Lehrer EJ, Brigham T, Ruiz-Garcia H, Sabsevitz D, Middlebrooks EH, Bechtle PS, Quinones-Hinojosa A, Chaichana KL. Awake vs. asleep motor mapping for glioma resection: a systematic review and meta-analysis. Acta Neurochir (Wien) 2020; 162:1709-1720. [PMID: 32388682 DOI: 10.1007/s00701-020-04357-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/16/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Intraoperative stimulation (IS) mapping has become the preferred standard treatment for eloquent tumors as it permits a more accurate identification of functional areas, allowing surgeons to achieve higher extents of resection (EOR) and decrease postoperative morbidity. For lesions adjacent to the perirolandic area and descending motor tracts, mapping can be done with both awake craniotomy (AC) and under general anesthesia (GA). OBJECTIVE We aimed to determine which anesthetic protocol-AC vs. GA-provides better patient outcomes by comparing EOR and postoperative morbidity for surgeries using IS mapping in gliomas located near or in motor areas of the brain. METHODS A systematic literature search was carried out to identify relevant studies from 1983 to 2019. Seven databases were screened. A total of 2351 glioma patients from 17 studies were analyzed. RESULTS A random-effects meta-analysis revealed a trend towards a higher mean EOR in AC [90.1% (95% C.I. 85.8-93.8)] than with GA [81.7% (95% C.I. 72.4-89.7)] (p = 0.06). Neurological deficits were divided by timing and severity for analysis. There was no significant difference in early neurological deficits [20.9% (95% C.I. 4.1-45.0) vs. 25.4% (95% C.I. 13.6-39.2)] (p = 0.74), late neurological deficits [17.1% (95% C.I. 0.0-50.0) vs. 3.8% (95% C.I. 1.1-7.6)] (p = 0.06), or in non-severe [28.4% (95% C.I. 0.0-88.5) vs. 20.1% (95% C.I. 7.1-32.2)] (p = 0.72), and severe morbidity [2.6% (95% C.I. 0.0-15.5) vs. 4.5% (95% C.I. 1.1-9.6)] (p = 0.89) between patients who underwent AC versus GA, respectively. CONCLUSION Mapping during resection of gliomas located in or near the perirolandic area and descending motor tracts can be safely carried out with both AC and GA.
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Affiliation(s)
- Paola Suarez-Meade
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Lina Marenco-Hillembrand
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Calder Prevatt
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Ricardo Murguia-Fuentes
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Alea Mohamed
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Thannon Alsaeed
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tara Brigham
- Mayo Clinic Libraries, Mayo Clinic, Jacksonville, FL, USA
| | - Henry Ruiz-Garcia
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - David Sabsevitz
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Perry S Bechtle
- Anesthesiology Department, Mayo Clinic, Jacksonville, FL, USA
| | | | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Intraoperative neuromonitoring predicts motor recovery in a long-term hemiplegic patient with a Rolandic metastasis. Clin Neurophysiol 2020; 131:2276-2278. [PMID: 32738787 DOI: 10.1016/j.clinph.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/22/2022]
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Lavrador JP, Ghimire P, Brogna C, Furlanetti L, Patel S, Gullan R, Ashkan K, Bhangoo R, Vergani F. Pre- and Intraoperative Mapping for Tumors in the Primary Motor Cortex: Decision-Making Process in Surgical Resection. J Neurol Surg A Cent Eur Neurosurg 2020; 82:333-343. [PMID: 32438419 DOI: 10.1055/s-0040-1709729] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Lesions within the primary motor cortex (M1) and the corticospinal tract (CST) represent a significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centered treatment plan. METHODS Patients with lesions within the M1 and CST with preoperative cortical and subcortical mapping (navigated transcranial magnetic stimulation [nTMS] and tractography), intraoperative mapping, and intraoperative provisional histologic information (smear with and without 5-aminolevulinic acid [5-ALA]) were included. This independently acquired information was integrated in a decision-making process model to determine the intraoperative extent of resection. RESULTS A total of 10 patients (6 patients with metastatic precentral tumor; 1 patient with grade III and 2 patients with grade IV gliomas; 1 patient with precentral cavernoma) were included in the study. Most of the patients (60%) had a preoperative motor deficit. The nTMS documented M1 invasion in all cases, and in eight patients, the lesions were embedded within the CST. Overall, 70% of patients underwent gross total resection; 20% of patients underwent near-total resection of the lesions. In only one patient was no surgical resection possible after both preoperative and intraoperative mapping. Overall, 70% of patients remained stable postoperatively, and previous motor weakness improved in 20%. CONCLUSION The independently acquired anatomical (anatomical MRI) and functional (nTMS and tractography) tests in patients with CST lesions provide a useful guide for resection. The inclusion of histologic information (smear with or without 5-ALA) further allows the surgical team to balance the potential functional risks within the global treatment plan. Therefore, the patient is kept at the center of the informed decision-making process.
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Affiliation(s)
- José Pedro Lavrador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Prajwal Ghimire
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Christian Brogna
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Luciano Furlanetti
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sabina Patel
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Richard Gullan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ranjeev Bhangoo
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Francesco Vergani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
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Visagan R, Lavrador JP, Acharya S, Pereira N, Bodi I, Ashkan K, Bhangoo R, Vergani F. Reliability of Intraoperative Monitoring in Patients with a Preexisting Motor Deficit: Case Report and Literature Review. J Neurol Surg A Cent Eur Neurosurg 2020; 82:387-391. [PMID: 32221963 DOI: 10.1055/s-0039-1698396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of intraoperative monitoring (IOM) in glioma surgery is a widely adopted and clinically validated adjunct to define safe zones of resection for the neurosurgeon. However, the role of IOM in cases of a significant preexisting motor deficit is questionable. CASE DESCRIPTION We describe a case of a 25-year-old with a recurrent presentation of a left paracentral glioblastoma, admitted with intratumoral hemorrhage and subsequent acute severe right-sided weakness. The patient underwent a redo left parietal craniotomy and 5-aminolevulinic acid-guided resection with IOM. The severity of the weakness was not reflected by the pre- and intraoperative cortical motor evoked potentials (MEPs) that were reassuring. The patient's hemiparesis recovered to full power postoperatively. CONCLUSIONS Preoperative weakness is traditionally accepted as a relative contraindication to IOM and therefore its usefulness is questioned in this context. Our case challenges this assumption. We present the clinical course, review the cranial and spinal literature including the reliability of IOM in cases of preoperative motor deficit, and discuss the need for tailor-made IOM strategies.
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Affiliation(s)
- Ravindran Visagan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust Denmark Hill, London, United Kingdom
| | - José Pedro Lavrador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust Denmark Hill, London, United Kingdom
| | - Shami Acharya
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust Denmark Hill, London, United Kingdom
| | - Noemia Pereira
- Department of Clinical Neurophysiology, Inomed Neurocare, London, UK
| | - Istvan Bodi
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust Denmark Hill, London, United Kingdom
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust Denmark Hill, London, United Kingdom
| | - Ranjeev Bhangoo
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust Denmark Hill, London, United Kingdom
| | - F Vergani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust Denmark Hill, London, United Kingdom
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The role of tailored intraoperative neurophysiological monitoring in glioma surgery: a single institute experience. J Neurooncol 2020; 146:459-467. [PMID: 32020476 DOI: 10.1007/s11060-019-03347-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Glioma surgery near the functional area is still a dilemma. Intraoperative neurophysiologic monitoring (IONM) and functional mapping can play a role to maximize the extent of resection (EOR), while minimizing the risk of sequelae. We herein review the utility of tailored intraoperative mapping and monitoring in patients undergoing glioma surgery in our institute. METHODS Patients were divided into two groups on the basis of application tailored IONM (group A, 2013-2017, n = 53) or not (group B, 2008-2012, n = 49) between January 2008 and December 2017. The setup, tailored IONM protocols, surgery, and clinical results of all patients with eloquent glioma were analyzed with the EOR, functionality scores, overall survival (OS) and progression-free survival (PFS) retrospectively. RESULTS The 102 patients were considered eligible for analysis. High grade and low grade gliomas accounted for 73 (72%) and 29 (28%) cases, respectively. There was a positive association between the application of neuromonitor and post-operative functional preservation, but no significant statistical differences over the EOR, OS and PFS between the two groups. CONCLUSIONS In our experience, tailored intraoperative functional mapping provides an effective neurological function preservation. Routine implementation of neurophysiological monitoring with adequate pre-operative planning and intraoperative teamwork in eloquent glioma can get more satisfied functional preservation. Due to the maturation and experience of our IONM team may also be the variation factor, prospective studies with a more prominent sample and proper multivariate analysis will be expected to determine the real benefit.
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