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Kram L, Neu B, Schroeder A, Wiestler B, Meyer B, Krieg SM, Ille S. Toward a systematic grading for the selection of patients to undergo awake surgery: identifying suitable predictor variables. Front Hum Neurosci 2024; 18:1365215. [PMID: 38756845 PMCID: PMC11096515 DOI: 10.3389/fnhum.2024.1365215] [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: 01/03/2024] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
Background Awake craniotomy is the standard of care for treating language eloquent gliomas. However, depending on preoperative functionality, it is not feasible in each patient and selection criteria are highly heterogeneous. Thus, this study aimed to identify broadly applicable predictor variables allowing for a more systematic and objective patient selection. Methods We performed post-hoc analyses of preoperative language status, patient and tumor characteristics including language eloquence of 96 glioma patients treated in a single neurosurgical center between 05/2018 and 01/2021. Multinomial logistic regression and stepwise variable selection were applied to identify significant predictors of awake surgery feasibility. Results Stepwise backward selection confirmed that a higher number of paraphasias, lower age, and high language eloquence level were suitable indicators for an awake surgery in our cohort. Subsequent descriptive and ROC-analyses indicated a cut-off at ≤54 years and a language eloquence level of at least 6 for awake surgeries, which require further validation. A high language eloquence, lower age, preexisting semantic and phonological aphasic symptoms have shown to be suitable predictors. Conclusion The combination of these factors may act as a basis for a systematic and standardized grading of patients' suitability for an awake craniotomy which is easily integrable into the preoperative workflow across neurosurgical centers.
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Affiliation(s)
- Leonie Kram
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - Beate Neu
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Benedikt Wiestler
- Section of Diagnostic and Interventional Neuroradiology, Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
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Ille S, Engel L, Kelm A, Meyer B, Krieg SM. Language-Eloquent White Matter Pathway Tractography and the Course of Language Function in Glioma Patients. Front Oncol 2018; 8:572. [PMID: 30574455 PMCID: PMC6291459 DOI: 10.3389/fonc.2018.00572] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/15/2018] [Indexed: 11/13/2022] Open
Abstract
Object: As various recent studies show, damage to white matter pathways leads to permanent functional deficits in a high percentage of patients. Particularly the subcortical language network is complex, and its visualization has a tremendous relevance for neurosurgeons. This pilot study aims to correlate language-eloquent white matter pathways with the course of language function after the resection of left-sided perisylvian gliomas. Methods: We included 10 patients who underwent resection of highly language-eloquent high- (9 pts) and low-grade gliomas (1 pts). We performed navigated repetitive transcranial magnetic stimulation (nrTMS)-based tractography via diffusion tensor imaging fiber trackings (DTI FT) preoperatively (PRE-1), postoperatively (POST-1), and at long-term follow up or tumor recurrence (PRE-2). We separately tracked the inferior fronto-occipital fascicle (IFOF), the frontal aslant tract (FAT), and the superior longitudinal (SLF), and arcuate fascicle (AF), and correlated the amount of visualized fibers to the patients' language function at each date. Results: The changes of nrTMS-based DTI FTs of single white matter pathways correlated with the according status of language function for any of the pathways in 80% of patients and in 19 of 30 (63%) single pathway comparisons between PRE-1 and POST-1. Between POST-1 and PRE-2 the nrTMS-based DTI FTs correlated with the status of language function for any of the pathways in all patients and in 24 of 30 (80%) single pathway comparisons. Single FT results correlated with the according status of language function at POST-1 in 60, 70, and 60% of cases, and with the according status of language function at PRE-2 in 60, 90, and 90% of cases for the tracking of the IFOF, FAT, and SLF/AF, respectively. Conclusion: By the present results we were able to show that nrTMS-based DTI FT of the IFOF, FAT, and SLF/AF mainly correlates with the according status of language function preoperatively, postoperatively, and at long-term follow up after the resection of left-sided perisylvian gliomas.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany.,TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
| | - Lara Engel
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany.,TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
| | - Anna Kelm
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany.,TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany.,TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
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Intraoperative linguistic performance during awake brain surgery predicts postoperative linguistic deficits. J Neurooncol 2018; 139:215-223. [PMID: 29637508 PMCID: PMC6061224 DOI: 10.1007/s11060-018-2863-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/04/2018] [Indexed: 11/20/2022]
Abstract
Introduction Awake craniotomy pursues a balance between extensive tumor resection and preservation of postoperative language function. A dilemma exists in patients whose tumor resection is restricted due to signs of language impairment observed during awake craniotomy. In order to determine the degree to which recovery of language function caused by tumor resection can be achieved by spontaneous neuroplasticity, the change in postoperative language function was compared to quantified intraoperative linguistic performance. Methods The modified, short-form Boston Diagnostic Aphasia Examination (sfBDAE) was used to assess pre- and postoperative language functions; visual object naming (DO 80) and semantic-association (Pyramid and Palm Tree Test, PPTT) tests assessed intraoperative linguistic performance. DO 80 and PPTT were performed alternatively during subcortical functional monitoring while performing tumor resection and sfBDAE was assessed 1-week postoperatively. Results Most patients with observed language impairment during awake surgery showed improved language function postoperatively. Both intraoperative DO 80 and PPTT showed significant correlation to postoperative sfBDAE domain scores (p < 0.05), with a higher correlation observed with PPTT. A linear regression model showed that only PPTT predicted the postoperative sfBDAE domain scores with the adjusted R2 ranging from 0.51 to 0.89 (all p < 0.01). Receiver operating characteristic analysis showed a cutoff value of PPTT that yielded a sensitivity of 80% and specificity of 100%. Conclusion PPTT may be a feasible tool for intraoperative linguistic evaluation that can predict postoperative language outcomes. Further studies are needed to determine the extent of tumor resection that optimizes the postoperative language following neuroplasticity.
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Kelm A, Sollmann N, Ille S, Meyer B, Ringel F, Krieg SM. Resection of Gliomas with and without Neuropsychological Support during Awake Craniotomy-Effects on Surgery and Clinical Outcome. Front Oncol 2017; 7:176. [PMID: 28868255 PMCID: PMC5563316 DOI: 10.3389/fonc.2017.00176] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/02/2017] [Indexed: 01/14/2023] Open
Abstract
Background During awake craniotomy for tumor resection, a neuropsychologist (NP) is regarded as a highly valuable partner for neurosurgeons. However, some centers do not routinely involve an NP, and data to support the high influence of the NP on the perioperative course of patients are mostly lacking. Objective The aim of this study was to investigate whether there is a difference in clinical outcomes between patients who underwent awake craniotomy with and without the attendance of an NP. Methods Our analysis included 61 patients, all operated on for resection of a presumably language-eloquent glioma during an awake procedure. Of these 61 cases, 47 surgeries were done with neuropsychological support (NP group), whereas 14 surgeries were performed without an NP (non-NP group) due to a language barrier between the NP and the patient. For these patients, neuropsychological assessment was provided by a bilingual resident. Results Both groups were highly comparable regarding age, gender, preoperative language function, and tumor grades (glioma WHO grades 1–4). Gross total resection (GTR) was achieved more frequently in the NP group (NP vs. non-NP: 61.7 vs. 28.6%, P = 0.04), which also had shorter durations of surgery (NP vs. non-NP: 240.7 ± 45.7 vs. 286.6 ± 54.8 min, P < 0.01). Furthermore, the rate of unexpected tumor residuals (estimation of the intraoperative extent of resection vs. postoperative imaging) was lower in the NP group (NP vs. non-NP: 19.1 vs. 42.9%, P = 0.09), but no difference was observed in terms of permanent surgery-related language deterioration (NP vs. non-NP: 6.4 vs. 14.3%, P = 0.48). Conclusion We need professional neuropsychological evaluation during awake craniotomies for removal of presumably language-eloquent gliomas. Although these procedures are routinely carried out with an NP, this is one of the first studies to provide data supporting the NP’s crucial role. Despite the small group size, our study shows statistically significant results, with higher rates of GTR and shorter durations of surgery among patients of the NP group. Moreover, our data emphasize the common problem of language barriers between the surgical and neuropsychological team and patients requiring awake tumor resection.
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Affiliation(s)
- Anna Kelm
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Nico Sollmann
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Florian Ringel
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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