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Eibl T, Schrey M, Rossmann J, Liebert A, Ritter L, Lange R, Steiner HH, Schebesch KM. Resection of meningiomas located in motor eloquent areas - comparative analysis of navigated transcranial magnetic stimulation and conventional neuronavigation. Neurol Res 2024:1-7. [PMID: 38953309 DOI: 10.1080/01616412.2024.2370731] [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: 02/11/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Navigated transcranial magnetic stimulation (nTMS) has been established as a preoperative diagnostic procedure in glioma surgery, increasing the extent of resection and preserving functional outcome. nTMS motor mapping for the resection of motor eloquent meningiomas has not been evaluated in a comparative analysis, yet. METHODS We conducted a retrospective matched-pair analysis for tumor location and size in meningioma patients with tumors located over or close to the primary motor cortex. Half of the study population received nTMS motor mapping preoperatively (nTMS-group). The primary endpoint were permanent surgery-related motor deficits. Additional factors associated with new motor deficits were evaluated apart from nTMS. RESULTS 62 patients (mean age 62 ± 15.8 years) were evaluated. 31 patients received preoperative nTMS motor mapping. In this group, motor thresholds (rMT) corresponded with tumor location and preoperative motor status, but could not predict motor outcome. No patient with preoperative intact motor function had a surgery-related permanent deficit in the nTMS group whereas four patients in the non-TMS group with preoperative intact motor status harbored from permanent deficits. 13 patients (21.3%) had a permanent motor deficit postoperatively with no difference between the nTMS and the non-TMS-group. Worsening in motor function was associated with higher patient age (p = 0.01) and contact to the superior sagittal sinus (p = 0.027). CONCLUSION nTMSmotor mapping did not lead to postoperative preservation in motorfunction. nTMS data corresponded well with the preoperative motorstatus and were associated with postoperative permanent deficits if tumors were located over the motor hotspot according to nTMS.
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Affiliation(s)
- Thomas Eibl
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Michael Schrey
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Jakob Rossmann
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Adrian Liebert
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Leonard Ritter
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Rüdiger Lange
- Department of Neurology, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
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Rammeloo E, Schouten JW, Krikour K, Bos EM, Berger MS, Nahed BV, Vincent AJPE, Gerritsen JKW. Preoperative assessment of eloquence in neurosurgery: a systematic review. J Neurooncol 2023; 165:413-430. [PMID: 38095774 DOI: 10.1007/s11060-023-04509-x] [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: 08/23/2023] [Accepted: 11/12/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Tumor location and eloquence are two crucial preoperative factors when deciding on the optimal treatment choice in glioma management. Consensus is currently lacking regarding the preoperative assessment and definition of eloquent areas. This systematic review aims to evaluate the existing definitions and assessment methods of eloquent areas that are used in current clinical practice. METHODS A computer-aided search of Embase, Medline (OvidSP), and Google Scholar was performed to identify relevant studies. This review includes articles describing preoperative definitions of eloquence in the study's Methods section. These definitions were compared and categorized by anatomical structure. Additionally, various techniques to preoperatively assess tumor eloquence were extracted, along with their benefits, drawbacks and ease of use. RESULTS This review covers 98 articles including 12,714 participants. Evaluation of these studies indicated considerable variability in defining eloquence. Categorization of these definitions yielded a list of 32 brain regions that were considered eloquent. The most commonly used methods to preoperatively determine tumor eloquence were anatomical classification systems and structural MRI, followed by DTI-FT, functional MRI and nTMS. CONCLUSIONS There were major differences in the definitions and assessment methods of eloquence, and none of them proved to be satisfactory to express eloquence as an objective, quantifiable, preoperative factor to use in glioma decision making. Therefore, we propose the development of a novel, objective, reliable, preoperative classification system to assess eloquence. This should in the future aid neurosurgeons in their preoperative decision making to facilitate personalized treatment paradigms and to improve surgical outcomes.
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Affiliation(s)
- Emma Rammeloo
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Joost Willem Schouten
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Keghart Krikour
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Eelke Marijn Bos
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Mitchel Stuart Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Brian Vala Nahed
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Jasper Kees Wim Gerritsen
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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3
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Lucena O, Lavrador JP, Irzan H, Semedo C, Borges P, Vergani F, Granados A, Sparks R, Ashkan K, Ourselin S. Assessing informative tract segmentation and nTMS for pre-operative planning. J Neurosci Methods 2023; 396:109933. [PMID: 37524245 PMCID: PMC10861808 DOI: 10.1016/j.jneumeth.2023.109933] [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: 05/10/2023] [Revised: 07/15/2023] [Accepted: 07/28/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Deep learning-based (DL) methods are the best-performing methods for white matter tract segmentation in anatomically healthy subjects. However, tract annotations are variable or absent in clinical data and manual annotations are especially difficult in patients with tumors where normal anatomy may be distorted. Direct cortical and subcortical stimulation is the gold standard ground truth to determine the cortical and sub-cortical lo- cation of motor-eloquent areas intra-operatively. Nonetheless, this technique is invasive, prolongs the surgical procedure, and may cause patient fatigue. Navigated Transcranial Magnetic Stimulation (nTMS) has a well-established correlation to direct cortical stimulation for motor mapping and the added advantage of being able to be acquired pre-operatively. NEW METHOD In this work, we evaluate the feasibility of using nTMS motor responses as a method to assess corticospinal tract (CST) binary masks and estimated uncertainty generated by a DL-based tract segmentation in patients with diffuse gliomas. RESULTS Our results show CST binary masks have a high overlap coefficient (OC) with nTMS response masks. A strong negative correlation is found between estimated uncertainty and nTMS response mask distance to the CST binary mask. COMPARISON WITH EXISTING METHODS We compare our approach (UncSeg) with the state-of-the-art TractSeg in terms of OC between the CST binary masks and nTMS response masks. CONCLUSIONS In this study, we demonstrate that estimated uncertainty from UncSeg is a good measure of the agreement between the CST binary masks and nTMS response masks distance to the CST binary mask boundary.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Keyoumars Ashkan
- King's College London, London, UK; King's College Hospital Foundation Trust, London, UK
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Indharty RS, Japardi I, Irina RS, Tandean S, Siahaan AMP, Loe ML, Ivander A. Comparison of direct cortical stimulation and transcranial magnetic stimulation in brain tumor surgery: systematic review and meta analyses. J Neurooncol 2023; 163:505-514. [PMID: 37438656 PMCID: PMC10393852 DOI: 10.1007/s11060-023-04378-4] [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: 05/20/2023] [Accepted: 06/20/2023] [Indexed: 07/14/2023]
Abstract
INTRODUCTION Brain malignancy and, at the same time central nervous system malignancy are two of the most difficult problems in the oncology field of practice. Brain tumors located near or within eloquent areas may represent another challenge toward neurosurgeon treatment. As such, electrical stimulation, either directly or through other methods, may prove necessary as proper mapping of the eloquent area thus may create a proper resection guide. Minimal resection will hopefully preserve patient neurological function and ensure patient quality of life. METHODS This research is a systematic review and meta-analysis that aim to compare outcomes, primarily adverse event analysis, between direct cortical stimulation and transcortical magnetic stimulation. RESULTS Fourteen studies were identified between 2010 and the 2023 interval. While this number is sufficient, most studies were not randomized and were not accompanied by blinding. Meta-analysis was then applied as a hypothesis test, which showed that TMS were not inferior compared to DCS in terms of motoric and lingual outcome which were marked subjectively by diamond location and objectively through a p-value above 0.05. CONCLUSION TMS is a noninvasive imaging method for the evaluation of eloquent brain areas that is not inferior compared to the invasive gold-standard imaging method (DCS). However its role as adjuvant to DCS and alternative only when awake surgery is not available must be emphasized.
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Affiliation(s)
- Rr Suzy Indharty
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Dr. Mansyur St. No. 5, Padang Bulan, Medan Baru, Medan, Sumatera Utara, 20155, Indonesia.
| | - Iskandar Japardi
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Dr. Mansyur St. No. 5, Padang Bulan, Medan Baru, Medan, Sumatera Utara, 20155, Indonesia
| | - Rr Sinta Irina
- Anesthesiology and Intensive Care Study Program, Universitas Sumatera Utara, Medan, Indonesia
| | - Steven Tandean
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Dr. Mansyur St. No. 5, Padang Bulan, Medan Baru, Medan, Sumatera Utara, 20155, Indonesia
| | - Andre Marolop Pangihutan Siahaan
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Dr. Mansyur St. No. 5, Padang Bulan, Medan Baru, Medan, Sumatera Utara, 20155, Indonesia
| | - Michael Lumintang Loe
- Department of Neurosurgery, Faculty of Medicine, University of Palangka Raya, Palangkaraya, Indonesia
- Department of Neurosurgery, Siloam Hospital, Medan, Indonesia
| | - Alvin Ivander
- Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
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Maiuri F, Corvino S. Meningiomas of the rolandic region: risk factors for motor deficit and role of intra-operative monitoring. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05630-6. [PMID: 37277557 DOI: 10.1007/s00701-023-05630-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/12/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Meningiomas of the rolandic region are associated to high risk of postoperative motor deficits. This study discusses the factors affecting motor outcome and recurrences from the analysis of a monoinstitutional case series and eight studies from a literature review. METHODS Data of 75 patients who underwent surgery for meningioma of the rolandic region were retrospectively reviewed. The analyzed factors included tumor location and size, clinical presentation, magnetic resonance imaging (MRI) and surgical findings, brain-tumor interface, extent of resection, postoperative outcome and recurrence. Eight studies from literature on rolandic meningiomas treated with or without intraoperative monitoring (IOM) were reviewed with the aim to define the impact of IOM on the extent of resection and motor outcome. RESULTS Among the 75 patients of the personal series, the meningioma was on the brain convexity in 34 (46%), at the parasagittal region in 28 (37%) and at the falx in 13 (17%). The brain-tumor interface was preserved in 53 cases (71%) at MRI and in 56 (75%) at surgical exploration. Simpson grade I resection was obtained in 43% of patients, grade II in 33%, grade III in 15% and grade IV in 9%. The motor function worsened postoperatively in 9 among 32 cases with preoperative deficit (28%) and in 5 among 43 with no preoperative deficit (11.5%); definitive motor deficit was evidenced in overall series at follow-up in 7 (9.3%). Patients with meningioma with lost arachnoid interface had significant higher rates of worsened postoperative motor deficit (p = 0.01) and seizures (p = 0.033). Recurrence occurred in 8 patients (11%). The analysis of the 8 reviewed studies (4 with and 4 without IOM) shows in the group without IOM higher rates of Simpson grades I and II resection (p = 0.02) and lower rates of grades IV resection (p = 0.002); no significant differences in postoperative immediate and long-term motor deficits were evidenced between the two groups. CONCLUSIONS Data from literature review show that the use of IOM does not affect the postoperative motor deficit Therefore, its role in rolandic meningiomas resection remains to be determined and will be defined in further studies.
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Affiliation(s)
- Francesco Maiuri
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, University of Naples "Federico II", School of Medicine, Via Pansini, 5, 80131, Naples, Italy.
| | - Sergio Corvino
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, University of Naples "Federico II", School of Medicine, Via Pansini, 5, 80131, Naples, Italy
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Li S, Mu Y, Rao Y, Sun C, Li X, Liu H, Yu X, Yan X, Ding Y, Wang Y, Fei Z. Preoperative individual-target transcranial magnetic stimulation demonstrates an effect comparable to intraoperative direct electrical stimulation in language-eloquent glioma mapping and improves postsurgical outcome: A retrospective fiber-tracking and electromagnetic simulation study. Front Oncol 2023; 13:1089787. [PMID: 36816968 PMCID: PMC9936080 DOI: 10.3389/fonc.2023.1089787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Background Efforts to resection of glioma lesions located in brain-eloquent areas must balance the extent of resection (EOR) and functional preservation. Currently, intraoperative direct electrical stimulation (DES) is the gold standard for achieving the maximum EOR while preserving as much functionality as possible. However, intraoperative DES inevitably involves risks of infection and epilepsy. The aim of this study was to verify the reliability of individual-target transcranial magnetic stimulation (IT-TMS) in preoperative mapping relative to DES and evaluate its effectiveness based on postsurgical outcomes. Methods Sixteen language-eloquent glioma patients were enrolled. Nine of them underwent preoperative nTMS mapping (n=9, nTMS group), and the other seven were assigned to the non-nTMS group and did not undergo preoperative nTMS mapping (n=7). Before surgery, online IT-TMS was performed during a language task in the nTMS group. Sites in the cortex at which this task was disturbed in three consecutive trials were recorded and regarded as positive and designated nTMS hotspots (HSnTMS). Both groups then underwent awake surgery and intraoperative DES mapping. DES hotspots (HSDES) were also determined in a manner analogous to HSnTMS. The spatial distribution of HSnTMS and HSDES in the nTMS group was recorded, registered in a single brain template, and compared. The center of gravity (CoG) of HSnTMS (HSnTMS-CoG)-based and HSDES-CoG-based diffusion tensor imaging-fiber tracking (DTI-FT) was performed. The electromagnetic simulation was conducted, and the values were then compared between the nTMS and DES groups, as were the Western Aphasia Battery (WAB) scale and fiber-tracking values. Results HSnTMS and HSDES showed similar distributions (mean distance 6.32 ± 2.6 mm, distance range 2.2-9.3 mm, 95% CI 3.9-8.7 mm). A higher fractional anisotropy (FA) value in nTMS mapping (P=0.0373) and an analogous fiber tract length (P=0.2290) were observed. A similar distribution of the electric field within the brain tissues induced by nTMS and DES was noted. Compared with the non-nTMS group, the integration of nTMS led to a significant improvement in language performance (WAB scores averaging 78.4 in the nTMS group compared with 59.5 in the non-nTMS group, P=0.0321 < 0.05) as well as in brain-structure preservation (FA value, P=0.0156; tract length, P=0.0166). Conclusion Preoperative IT-TMS provides data equally crucial to DES and thus facilitates precise brain mapping and the preservation of linguistic function.
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Affiliation(s)
- Sanzhong Li
- Department of Neurosurgery, Xijing Hospital, Air Force Medical University, Xi’an, Shaanxi, China,*Correspondence: Sanzhong Li, ; Zhou Fei,
| | - Yunfeng Mu
- Department of Gynecological Oncology, Shaanxi Provincial Cancer Hospital, Xi’an, China
| | - Yang Rao
- Shaanxi Brain Modulation and Scientific Research Center, Xi'an, Shaanxi, China
| | - Chuanzhu Sun
- Shaanxi Brain Modulation and Scientific Research Center, Xi'an, Shaanxi, China
| | - Xiang Li
- Shaanxi Brain Modulation and Scientific Research Center, Xi'an, Shaanxi, China,The Key Laboratory of Biomedical Information Engineering of Ministry of Education, Institute of Health and Rehabilitation Science, School of Life Science and Technology, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Huan Liu
- School of Mathematics and Statistics, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Xun Yu
- Product Department, Solide Brain Medical Technology, Ltd., Xi’an, Shaanxi, China
| | - Xiao Yan
- Shaanxi Brain Modulation and Scientific Research Center, Xi'an, Shaanxi, China
| | - Yunxia Ding
- Shaanxi Brain Modulation and Scientific Research Center, Xi'an, Shaanxi, China
| | - Yangtao Wang
- Shaanxi Brain Modulation and Scientific Research Center, Xi'an, Shaanxi, China
| | - Zhou Fei
- Department of Neurosurgery, Xijing Hospital, Air Force Medical University, Xi’an, Shaanxi, China,*Correspondence: Sanzhong Li, ; Zhou Fei,
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Presurgical Executive Functioning in Low-Grade Glioma Patients Cannot Be Topographically Mapped. Cancers (Basel) 2023; 15:cancers15030807. [PMID: 36765764 PMCID: PMC9913560 DOI: 10.3390/cancers15030807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
Executive dysfunctions have a high prevalence in low-grade glioma patients and may be the result of structural disconnections of particular subcortical tracts and/or networks. However, little research has focused on preoperative low-grade glioma patients. The frontotemporoparietal network has been closely linked to executive functions and is substantiated by the superior longitudinal fasciculus. The aim of this study was to investigate their role in executive functions in low-grade glioma patients. Patients from two neurological centers were included with IDH-mutated low-grade gliomas. The sets of preoperative predictors were (i) distance between the tumor and superior longitudinal fasciculus, (ii) structural integrity of the superior longitudinal fasciculus, (iii) overlap between tumor and cortical networks, and (iv) white matter disconnection of the same networks. Linear regression and random forest analyses were performed. The group of 156 patients demonstrated significantly lower performance than normative samples and had a higher prevalence of executive impairments. However, both regression and random forest analyses did not demonstrate significant results, meaning that neither structural, cortical network overlap, nor network disconnection predictors explained executive performance. Overall, our null results indicate that there is no straightforward topographical explanation of executive performance in low-grade glioma patients. We extensively discuss possible explanations, including plasticity-induced network-level equipotentiality. Finally, we stress the need for the development of novel methods to unveil the complex and interacting mechanisms that cause executive deficits in low-grade glioma patients.
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Assessing the feasibility of mapping the tibialis anterior muscle with navigated transcranial magnetic stimulation in neuro-oncologic patients. Sci Rep 2022; 12:18719. [PMID: 36333400 PMCID: PMC9636142 DOI: 10.1038/s41598-022-23444-x] [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: 08/11/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Mapping the lower extremity with navigated transcranial magnetic stimulation (nTMS) still remains challenging for the investigator. Clinical factors influencing leg mapping with nTMS have not been fully investigated yet. The aim of the study was to identify factors which influence the possibility of eliciting motor evoked potentials (MEPs) from the tibialis anterior muscle (TA). Patient records, imaging, nTMS examinations and tractography were retrospectively evaluated. 48 nTMS examinations were performed in 46 brain tumor patients. Reproducible MEPs were recorded in 20 patients (41.67%). Younger age (p = 0.044) and absence of perifocal edema (p = 0.035, Cramer's V = 0.34, OR = 0.22, 95% CI = 0.06-0.81) facilitated mapping the TA muscle. Leg motor deficit (p = 0.49, Cramer's V = 0.12, OR = 0.53, 95%CI = 0.12-2.36), tumor entity (p = 0.36, Cramer's V = 0.22), tumor location (p = 0.52, Cramer's V = 0.26) and stimulation intensity (p = 0.158) were no significant factors. The distance between the tumor and the pyramidal tract was higher (p = 0.005) in patients with successful mapping of the TA. The possibility to stimulate the leg motor area was associated with no postoperative aggravation of motor deficits in general (p = 0.005, Cramer's V = 0.45, OR = 0.63, 95%CI = 0.46-0.85) but could not serve as a specific predictor of postoperative lower extremity function. In conclusion, successful mapping of the TA muscle for neurosurgical planning is influenced by young patient age, absence of edema and greater distance to the CST, whereas tumor entity and stimulation intensity were non-significant.
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Weiss Lucas C, Faymonville AM, Loução R, Schroeter C, Nettekoven C, Oros-Peusquens AM, Langen KJ, Shah NJ, Stoffels G, Neuschmelting V, Blau T, Neuschmelting H, Hellmich M, Kocher M, Grefkes C, Goldbrunner R. Surgery of Motor Eloquent Glioblastoma Guided by TMS-Informed Tractography: Driving Resection Completeness Towards Prolonged Survival. Front Oncol 2022; 12:874631. [PMID: 35692752 PMCID: PMC9186060 DOI: 10.3389/fonc.2022.874631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/21/2022] [Indexed: 12/13/2022] Open
Abstract
Background Surgical treatment of patients with glioblastoma affecting motor eloquent brain regions remains critically discussed given the risk–benefit dilemma of prolonging survival at the cost of motor-functional damage. Tractography informed by navigated transcranial magnetic stimulation (nTMS-informed tractography, TIT) provides a rather robust estimate of the individual location of the corticospinal tract (CST), a highly vulnerable structure with poor functional reorganisation potential. We hypothesised that by a more comprehensive, individualised surgical decision-making using TIT, tumours in close relationship to the CST can be resected with at least equal probability of gross total resection (GTR) than less eloquently located tumours without causing significantly more gross motor function harm. Moreover, we explored whether the completeness of TIT-aided resection translates to longer survival. Methods A total of 61 patients (median age 63 years, m = 34) with primary glioblastoma neighbouring or involving the CST were operated on between 2010 and 2015. TIT was performed to inform surgical planning in 35 of the patients (group T; vs. 26 control patients). To achieve largely unconfounded group comparisons for each co-primary outcome (i.e., gross-motor functional worsening, GTR, survival), (i) uni- and multivariate regression analyses were performed to identify features of optimal outcome prediction; (ii), optimal propensity score matching (PSM) was applied to balance those features pairwise across groups, followed by (iii) pairwise group comparison. Results Patients in group T featured a significantly higher lesion-CST overlap compared to controls (8.7 ± 10.7% vs. 3.8 ± 5.7%; p = 0.022). The frequency of gross motor worsening was higher in group T, albeit non-significant (n = 5/35 vs. n = 0/26; p = 0.108). PSM-based paired-sample comparison, controlling for the confounders of preoperative tumour volume and vicinity to the delicate vasculature of the insula, showed higher GTR rates in group T (77% vs. 69%; p = 0.025), particularly in patients with a priori intended GTR (87% vs. 78%; p = 0.003). This translates into a prolonged PFS in the same PSM subgroup (8.9 vs. 5.8 months; p = 0.03), with GTR representing the strongest predictor of PFS (p = 0.001) and OS (p = 0.0003) overall. Conclusion The benefit of TIT-aided GTR appears to overcome the drawbacks of potentially elevated motor functional risk in motor eloquent tumour localisation, leading to prolonged survival of patients with primary glioblastoma close to the CST.
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Affiliation(s)
- Carolin Weiss Lucas
- Department of General Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andrea Maria Faymonville
- Department of General Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Department of Neurosurgery, University Hospital Mannheim, Mannheim, Germany
| | - Ricardo Loução
- Department of General Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Department of Stereotaxy and Functional Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Institute of Neuroscience and Medicine (INM-4), Forschungszentrum Julich, Juelich, Germany
| | - Catharina Schroeter
- Department of General Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Charlotte Nettekoven
- Department of General Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Karl Josef Langen
- Institute of Neuroscience and Medicine (INM-4), Forschungszentrum Julich, Juelich, Germany
| | - N Jon Shah
- Institute of Neuroscience and Medicine (INM-4), Forschungszentrum Julich, Juelich, Germany.,JARA - BRAIN - Translational Medicine, Aachen, Germany.,Department of Neurology, RWTH Aachen University, Aachen, Germany
| | - Gabriele Stoffels
- Institute of Neuroscience and Medicine (INM-4), Forschungszentrum Julich, Juelich, Germany
| | - Volker Neuschmelting
- Department of General Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Tobias Blau
- Department of Neurology, RWTH Aachen University, Aachen, Germany.,Institute of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Hannah Neuschmelting
- Institute of Pathology and Neuropathology, University Hospital Essen, Essen, Germany
| | - Martin Hellmich
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Martin Kocher
- Department of General Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Department of Stereotaxy and Functional Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Institute of Neuroscience and Medicine (INM-4), Forschungszentrum Julich, Juelich, Germany
| | - Christian Grefkes
- Institute of Neuroscience and Medicine (INM-4), Forschungszentrum Julich, Juelich, Germany.,Institute for Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of General Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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10
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Orillac C, Orringer DA. In Reply: Fluorescence Guidance and Intraoperative Adjuvants to Maximize Extent of Resection. Neurosurgery 2022; 90:e139. [PMID: 35238813 PMCID: PMC9514724 DOI: 10.1227/neu.0000000000001917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 12/19/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Cordelia Orillac
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
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Rahman R, Rahman S, Al-Salihi MM, Sarwar ASM, Rahman MM, Habib R, Hoq MZ. Letter: Fluorescence Guidance and Intraoperative Adjuvants to Maximize Extent of Resection. Neurosurgery 2022; 90:e137-e138. [PMID: 35238808 DOI: 10.1227/neu.0000000000001916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/19/2021] [Indexed: 01/09/2023] Open
Affiliation(s)
- Raphia Rahman
- Department of Osteopathic Medicine, Rowan School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Sabrina Rahman
- Department of Public Health, Independent University-Bangladesh, Dhaka, Bangladesh
| | | | | | - Md Moshiur Rahman
- Department of Neurosurgery, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
| | | | - Md Ziaul Hoq
- Department of Pediatric Neurosurgery, NINS, Bangladesh
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Schuermann M, Dzierma Y, Nuesken F, Oertel J, Rübe C, Melchior P. Automatic Radiotherapy Planning for Glioblastoma Radiotherapy With Sparing of the Hippocampus and nTMS-Defined Motor Cortex. Front Neurol 2022; 12:787140. [PMID: 35095732 PMCID: PMC8795623 DOI: 10.3389/fneur.2021.787140] [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: 10/15/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundNavigated transcranial magnetic stimulation (nTMS) of the motor cortex has been successfully implemented into radiotherapy planning by a number of studies. Furthermore, the hippocampus has been identified as a radiation-sensitive structure meriting particular sparing in radiotherapy. This study assesses the joint protection of these two eloquent brain regions for the treatment of glioblastoma (GBM), with particular emphasis on the use of automatic planning.Patients and MethodsPatients with motor-eloquent brain glioblastoma who underwent surgical resection after nTMS mapping of the motor cortex and adjuvant radiotherapy were retrospectively evaluated. The radiotherapy treatment plans were retrieved, and the nTMS-defined motor cortex and hippocampus contours were added. Four additional treatment plans were created for each patient: two manual plans aimed to reduce the dose to the motor cortex and hippocampus by manual inverse planning. The second pair of re-optimized plans was created by the Auto-Planning algorithm. The optimized plans were compared with the “Original” plan regarding plan quality, planning target volume (PTV) coverage, and sparing of organs at risk (OAR).ResultsA total of 50 plans were analyzed. All plans were clinically acceptable with no differences in the PTV coverage and plan quality metrics. The OARs were preserved in all plans; however, overall the sparing was significantly improved by Auto-Planning. Motor cortex protection was feasible and significant, amounting to a reduction in the mean dose by >6 Gy. The dose to the motor cortex outside the PTV was reduced by >12 Gy (mean dose) and >5 Gy (maximum dose). The hippocampi were significantly improved (reduction in mean dose: ipsilateral >6 Gy, contralateral >4.6 Gy; reduction in maximum dose: ipsilateral >5 Gy, contralateral >5 Gy). While the dose reduction using Auto-Planning was generally better than by manual optimization, the radiated total monitor units were significantly increased.ConclusionConsiderable dose sparing of the nTMS-motor cortex and hippocampus could be achieved with no disadvantages in plan quality. Auto-Planning could further contribute to better protection of OAR. Whether the improved dosimetric protection of functional areas can translate into improved quality of life and motor or cognitive performance of the patients can only be decided by future studies.
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Affiliation(s)
- Michaela Schuermann
- Department of Radiotherapy and Radiation Oncology, Saarland University Hospital, Homburg, Germany
- *Correspondence: Michaela Schuermann
| | - Yvonne Dzierma
- Department of Radiotherapy and Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | - Frank Nuesken
- Department of Radiotherapy and Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | - Joachim Oertel
- Faculty of Medicine, Saarland University, Saarbrücken, Germany
- Department of Neurosurgery, Saarland University Hospital, Homburg, Germany
| | - Christian Rübe
- Department of Radiotherapy and Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | - Patrick Melchior
- Department of Radiotherapy and Radiation Oncology, Saarland University Hospital, Homburg, Germany
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TMS Seeded Diffusion Tensor Imaging Tractography Predicts Permanent Neurological Deficits. Cancers (Basel) 2022; 14:cancers14020340. [PMID: 35053503 PMCID: PMC8774180 DOI: 10.3390/cancers14020340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/01/2022] [Accepted: 01/06/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary For brain tumor patients, surgeons must resect as much of the tumor as possible while preserving the patient’s function and quality of life. This requires preoperative imaging that accurately identifies important parts of the brain. Transcranial magnetic stimulation is a way of preoperatively finding the areas of the brain connected to motor function. However, few studies have investigated the accuracy and clinical relevance of the data. In this study, we examine the functional outcomes of patients who had TMS points resected and patients who did not. We aim to address key technical barriers to performing this analysis. We also aim to discern the appropriate role of TMS tractography in preoperative diagnostic imaging. Insights gained from this study can be used to select the right patients and plan for the optimal surgeries. Abstract Surgeons must optimize the onco-functional balance by maximizing the extent of resection and minimizing postoperative neurological morbidity. Optimal patient selection and surgical planning requires preoperative identification of nonresectable structures. Transcranial magnetic stimulation is a method of noninvasively mapping the cortical representations of the speech and motor systems. Despite recent promising data, its clinical relevance and appropriate role in a comprehensive mapping approach remains unknown. In this study, we aim to provide direct evidence regarding the clinical utility of transcranial magnetic stimulation by interrogating the eloquence of TMS points. Forty-two glioma patients were included in this retrospective study. We collected motor function outcomes 3 months postoperatively. We overlayed the postoperative MRI onto the preoperative MRI to visualize preoperative TMS points in the context of the surgical cavity. We then generated diffusion tensor imaging tractography to identify meaningful subsets of TMS points. We correlated the resection of preoperative imaging features with clinical outcomes. The resection of TMS-positive points was significantly predictive of permanent deficits (p = 0.05). However, four out of eight patients had TMS-positive points resected without a permanent deficit. DTI tractography at a 75% FA threshold identified which TMS points are essential and which are amenable to surgical resection. TMS combined with DTI tractography shows a significant prediction of postoperative neurological deficits with both a high positive predictive value and negative predictive value.
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Schiavao LJV, Neville Ribeiro I, Yukie Hayashi C, Gadelha Figueiredo E, Russowsky Brunoni A, Jacobsen Teixeira M, Pokorny G, Silva Paiva W. Assessing the Capabilities of Transcranial Magnetic Stimulation (TMS) to Aid in the Removal of Brain Tumors Affecting the Motor Cortex: A Systematic Review. Neuropsychiatr Dis Treat 2022; 18:1219-1235. [PMID: 35734549 PMCID: PMC9208734 DOI: 10.2147/ndt.s359855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The brain tumor is frequently related to severe motor impairment and impacts the quality of life. The corticospinal tract can sometimes be affected depending on the type and size of the neoplasm, so different tools can evaluate motor function and connections. It is essential to organize surgical procedures and plan the approach. Functional motor status is mapped before, during, and after surgery. Studying corticospinal tract status can help map the functional areas, predict postoperative outcomes, and help the decision, reducing neurological deficits, aiming to preserve functional networks, using the concepts of white matters localization and fibbers connections. Nowadays, there are new techniques that provide functional information regarding the motor cortex, such as transcranial magnetic stimulation (TMS), direct cortical stimulation (DCS), and navigated TMS (nTMS). These tools can be used to plan a customized surgical strategy and the role of motor evoked potentials (MEPs) is well described during intra-operative, using intraoperative neuromonitoring. MEPs can help to localize primary motor areas and delineate the cut-off point of resection in real-time, using direct stimulation. In the post-operative, the MEP has increased your function as a predictive marker of permanent or transitory neurological lesion marker. METHODS Systematic review performed in MEDLINE via PUBMED, EMBASE, and SCOPUS databases regarding the post-operative assessment of MEP in patients with brain tumors. The search strategy included the following terms: (("Evoked Potentials, Motor"[Mesh]) AND "Neoplasms"[Mesh]) AND "Transcranial Magnetic Stimulation"[Mesh] AND "Brain Tumor"[Mesh]), the analysis followed the PRISMA guidelines for systematic reviews, the review spanned until 06/04/2021, inclusion criteria were studies presenting confirmed diagnosis of brain tumor (primary or metastatic), patients >18 y/o, using TMS, Navigated TMS, and/or Evoked Potentials as tools in preoperative planning or at the intra-operative helping the evaluation of the neurological status of the motor cortex, articles published in peer-reviewed journals, and written in English or Portuguese. RESULTS A total of 38 studies were selected for this review, of which 14 investigated the potential of nTMS to predict the occurrence of motor deficits, while 25 of the articles investigated the capabilities of the nTMS technique in performing pre/intraoperative neuro mapping of the motor cortex. CONCLUSION Further studies regarding motor function assessment are needed and standardized protocols for MEPs also need to be defined.
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Affiliation(s)
- Lucas Jose Vaz Schiavao
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil.,Neurology, Instituto do Câncer do Estado de São Paulo - ICESP, São Paulo, Brazil
| | - Iuri Neville Ribeiro
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil.,Neurology, Instituto do Câncer do Estado de São Paulo - ICESP, São Paulo, Brazil
| | - Cintya Yukie Hayashi
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | - Eberval Gadelha Figueiredo
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | - Andre Russowsky Brunoni
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
| | | | - Wellingson Silva Paiva
- Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo- FMUSP - University of São Paulo, São Paulo, Brazil
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Dzierma Y, Schuermann M, Melchior P, Nuesken F, Oertel J, Rübe C, Hendrix P. Optimizing Adjuvant Stereotactic Radiotherapy of Motor-Eloquent Brain Metastases: Sparing the nTMS-Defined Motor Cortex and the Hippocampus. Front Oncol 2021; 11:628007. [PMID: 33718201 PMCID: PMC7953904 DOI: 10.3389/fonc.2021.628007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/06/2021] [Indexed: 12/25/2022] Open
Abstract
Brain metastases can effectively be treated with surgical resection and adjuvant stereotactic radiotherapy (SRT). Navigated transcranial magnetic stimulation (nTMS) has been used to non-invasively map the motor cortex prior to surgery of motor eloquent brain lesions. To date, few studies have reported the integration of such motor maps into radiotherapy planning. The hippocampus has been identified as an additional critical structure of radiation-induced deficits. The aim of this study is to assess the feasibility of selective dose reduction to both the nTMS-based motor cortex and the hippocampi in SRT of motor-eloquent brain metastases. Patients with motor-eloquent brain metastases undergoing surgical resection and adjuvant SRT between 07/2014 and 12/2018 were retrospectively analyzed. The radiotherapy treatment plans were retrieved from the treatment planning system (“original” plan). For each case, two intensity-modulated treatment plans were created: the “motor” plan aimed to reduce the dose to the motor cortex, the “motor & hipp” plan additionally reduce the dose to the hippocampus. The optimized plans were compared with the “original” plan regarding plan quality, planning target volume (PTV) coverage, and sparing of organs at risk (OAR). 69 plans were analyzed, all of which were clinically acceptable with no significant differences for PTV coverage. All OAR were protected according to standard protocols. Sparing of the nTMS motor map was feasible: mean dose 9.66 ± 5.97 Gy (original) to 6.32 ± 3.60 Gy (motor) and 6.49 ± 3.78 Gy (motor & hipp), p<0.001. In the “motor & hipp” plan, dose to the ipsilateral hippocampi could be significantly reduced (max 1.78 ± 1.44 Gy vs 2.49 ± 1.87 Gy in “original”, p = 0.003; mean 1.01 ± 0.92 Gy vs. 1.32 ± 1.07 Gy in “original”, p = 0.007). The study confirms the results from previous studies that inclusion of nTMS motor information into radiotherapy treatment planning is possible with a relatively straightforward workflow and can achieve reduced doses to the nTMS-defined motor area without compromising PTV coverage. Furthermore, we demonstrate the feasibility of selective dose reduction to the hippocampus at the same time. The clinical significance of these optimized plans yet remains to be determined. However, with no apparent disadvantages these optimized plans call for further and broader exploration.
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Affiliation(s)
- Yvonne Dzierma
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Michaela Schuermann
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Patrick Melchior
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Frank Nuesken
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Centre and Saarland University Faculty of Medicine, Homburg, Germany
| | - Christian Rübe
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Philipp Hendrix
- Department of Neurosurgery, Saarland University Medical Centre and Saarland University Faculty of Medicine, Homburg, Germany
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Berger M. Progress on glioma surgery and multimodal treatments. GLIOMA 2021. [DOI: 10.4103/glioma.glioma_9_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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