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Dada A, Umbach G, Majumdar A, Kaur J, Oten S, Berger MS, Brang D, Hervey-Jumper SL. Somatosensory Mapping Using a Novel Sensory Discrimination Task: Technical Note. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01315. [PMID: 39248466 DOI: 10.1227/ons.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 07/23/2024] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Although diffuse gliomas in the primary somatosensory cortex (S1) are often considered resectable, gliomas in the primary motor cortex require motor mapping to preserve motor function. Recent evidence indicates that some somatosensory cortex neurons may trigger motor responses, necessitating refined somatosensory mapping techniques. METHODS Using piezoelectric tactile stimulators on patients' faces and hands, we delivered 25 Hz vibrations and prompted patients to discriminate between dermatomes. Testing included areas contralateral to tumor-infiltrated and to non-tumor-infiltrated cortical regions. Sensory thresholds were determined by reducing stimulus intensity based on performance. Intraoperatively, electrocorticography electrode arrays were used to map sensory responses, and postoperative assessments evaluated sensory outcomes. RESULTS The high-grade glioma case involved a 61-year-old man with right-sided weakness and numbness with a left parietal mass on MRI. Preoperative testing showed that the average vibratory detection threshold of the hand contralateral to the suspected tumor site was significantly higher than that of the hand contralateral to healthy cortex (P < .001). Intraoperative mapping confirmed the absence of functional involvement in cortical structures overlying the tumor. Postoperative imaging confirmed gross total resection, and sensory vibratory thresholds were normalized (P = .51). The low-grade glioma case included a 54-year-old man with a left parietal nonenhancing mass on MRI. No baseline sensory impairments were found on preoperative testing. Intraoperative mapping identified motor and sensory cortices, guiding tumor resection while preserving motor function. Postoperative MRI confirmed near-total resection, but new sensory impairments were noted in the hand and face contralateral to the resection site (P < .001). These deficits resolved by postoperative day 11, with no evidence of tumor progression on follow-up imaging. CONCLUSION The sensory discrimination task provides a quantifiable method for assessing sensory changes and functional outcomes related to glioma. This technique enhances our understanding of how glioma infiltration remodels sensory systems and affects clinical outcomes in patients.
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Affiliation(s)
- Abraham Dada
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Gray Umbach
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Areti Majumdar
- Department of Psychology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jasleen Kaur
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Sena Oten
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - David Brang
- Department of Psychology, University of Michigan, Ann Arbor, Michigan, USA
| | - Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
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Young JS, Morshed RA, Hervey-Jumper SL, Berger MS. The surgical management of diffuse gliomas: Current state of neurosurgical management and future directions. Neuro Oncol 2023; 25:2117-2133. [PMID: 37499054 PMCID: PMC10708937 DOI: 10.1093/neuonc/noad133] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Indexed: 07/29/2023] Open
Abstract
After recent updates to the World Health Organization pathological criteria for diagnosing and grading diffuse gliomas, all major North American and European neuro-oncology societies recommend a maximal safe resection as the initial management of a diffuse glioma. For neurosurgeons to achieve this goal, the surgical plan for both low- and high-grade gliomas should be to perform a supramaximal resection when feasible based on preoperative imaging and the patient's performance status, utilizing every intraoperative adjunct to minimize postoperative neurological deficits. While the surgical approach and technique can vary, every effort must be taken to identify and preserve functional cortical and subcortical regions. In this summary statement on the current state of the field, we describe the tools and technologies that facilitate the safe removal of diffuse gliomas and highlight intraoperative and postoperative management strategies to minimize complications for these patients. Moreover, we discuss how surgical resections can go beyond cytoreduction by facilitating biological discoveries and improving the local delivery of adjuvant chemo- and radiotherapies.
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Affiliation(s)
- Jacob S Young
- Department of Neurological Surgery, University of California, San Francisco, USA
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California, San Francisco, USA
| | | | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, USA
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3
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Hardigan AA, Jackson JD, Patel AP. Surgical Management and Advances in the Treatment of Glioma. Semin Neurol 2023; 43:810-824. [PMID: 37963582 PMCID: PMC11229982 DOI: 10.1055/s-0043-1776766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The care of patients with both high-grade glioma and low-grade glioma necessitates an interdisciplinary collaboration between neurosurgeons, neuro-oncologists, neurologists and other practitioners. In this review, we aim to detail the considerations, approaches and advances in the neurosurgical care of gliomas. We describe the impact of extent-of-resection in high-grade and low-grade glioma, with particular focus on primary and recurrent glioblastoma. We address advances in surgical methods and adjunct technologies such as intraoperative imaging and fluorescence guided surgery that maximize extent-of-resection while minimizing the potential for iatrogenic neurological deficits. Finally, we review surgically-mediated therapies other than resection and discuss the role of neurosurgery in emerging paradigm-shifts in inter-disciplinary glioma management such as serial tissue sampling and "window of opportunity trials".
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Affiliation(s)
- Andrew A Hardigan
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Joshua D Jackson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Anoop P Patel
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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Kokkinos V, Chatzisotiriou A, Seimenis I. Functional Magnetic Resonance Imaging and Diffusion Tensor Imaging-Tractography in Resective Brain Surgery: Lesion Coverage Strategies and Patient Outcomes. Brain Sci 2023; 13:1574. [PMID: 38002534 PMCID: PMC10670090 DOI: 10.3390/brainsci13111574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/04/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Diffusion tensor imaging (DTI)-tractography and functional magnetic resonance imaging (fMRI) have dynamically entered the presurgical evaluation context of brain surgery during the past decades, providing novel perspectives in surgical planning and lesion access approaches. However, their application in the presurgical setting requires significant time and effort and increased costs, thereby raising questions regarding efficiency and best use. In this work, we set out to evaluate DTI-tractography and combined fMRI/DTI-tractography during intra-operative neuronavigation in resective brain surgery using lesion-related preoperative neurological deficit (PND) outcomes as metrics. We retrospectively reviewed medical records of 252 consecutive patients admitted for brain surgery. Standard anatomical neuroimaging protocols were performed in 127 patients, 69 patients had additional DTI-tractography, and 56 had combined DTI-tractography/fMRI. fMRI procedures involved language, motor, somatic sensory, sensorimotor and visual mapping. DTI-tractography involved fiber tracking of the motor, sensory, language and visual pathways. At 1 month postoperatively, DTI-tractography patients were more likely to present either improvement or preservation of PNDs (p = 0.004 and p = 0.007, respectively). At 6 months, combined DTI-tractography/fMRI patients were more likely to experience complete PND resolution (p < 0.001). Low-grade lesion patients (N = 102) with combined DTI-tractography/fMRI were more likely to experience complete resolution of PNDs at 1 and 6 months (p = 0.001 and p < 0.001, respectively). High-grade lesion patients (N = 140) with combined DTI-tractography/fMRI were more likely to have PNDs resolved at 6 months (p = 0.005). Patients with motor symptoms (N = 80) were more likely to experience complete remission of PNDs at 6 months with DTI-tractography or combined DTI-tractography/fMRI (p = 0.008 and p = 0.004, respectively), without significant difference between the two imaging protocols (p = 1). Patients with sensory symptoms (N = 44) were more likely to experience complete PND remission at 6 months with combined DTI-tractography/fMRI (p = 0.004). The intraoperative neuroimaging modality did not have a significant effect in patients with preoperative seizures (N = 47). Lack of PND worsening was observed at 6 month follow-up in patients with combined DTI-tractography/fMRI. Our results strongly support the combined use of DTI-tractography and fMRI in patients undergoing resective brain surgery for improving their postoperative clinical profile.
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Affiliation(s)
- Vasileios Kokkinos
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02215, USA
| | | | - Ioannis Seimenis
- Department of Medicine, School of Health Sciences, Democritus University of Thrace, 387479 Alexandroupolis, Greece;
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Li Y, Hou Y, Li X, Li Q, Lu J, Tang J. Quantitative Validation of the Correlation Between Optimized Pyramidal Tract Delineation After Brain Shift Compensation and Direct Electrical Subcortical Stimulation During Brain Tumor Surgery. J Digit Imaging 2023; 36:1974-1986. [PMID: 37340196 PMCID: PMC10501987 DOI: 10.1007/s10278-023-00867-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/22/2023] Open
Abstract
It remains unclear whether tractography of pyramidal tracts is correlated with the intraoperative direct electrical subcortical stimulation (DESS), and brain shift further complicates the issue. The objective of this research is to quantitatively verify the correlation between optimized tractography (OT) of pyramidal tracts after brain shift compensation and DESS during brain tumor surgery. OT was performed for 20 patients with lesions in proximity to the pyramidal tracts based on preoperative diffusion-weighted magnetic resonance imaging. During surgery, tumor resection was guided by DESS. A total of 168 positive stimulation points and their corresponding stimulation intensity thresholds were recorded. Using the brain shift compensation algorithm based on hierarchical B-spline grids combined with a Gaussian resolution pyramid, we warped the preoperative pyramidal tract models and used receiver operating characteristic (ROC) curves to investigate the reliability of our brain shift compensation method based on anatomic landmarks. Additionally, the minimum distance between the DESS points and warped OT (wOT) model was measured and correlated with DESS intensity threshold. Brain shift compensation was achieved in all cases, and the area under the ROC curve was 0.96 in the registration accuracy analysis. The minimum distance between the DESS points and the wOT model was found to have a significantly high correlation with the DESS stimulation intensity threshold (r = 0.87, P < 0.001), with a linear regression coefficient of 0.96. Our OT method can provide comprehensive and accurate visualization of the pyramidal tracts for neurosurgical navigation and was quantitatively verified by intraoperative DESS after brain shift compensation.
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Affiliation(s)
- Ye Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China
| | - Yuanzheng Hou
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China
| | - Qiongge Li
- Department of Radiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China
| | - Jie Lu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China.
| | - Jie Tang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China.
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Ordonez-Rubiano EG, Johnson JM, Abdalá-Vargas N, Zorro OF, Marin-Munoz JH, Álvarez-Tobián R, Forlizzi V, Rangel CC, Luzzi S, Campero A, Patiño-Gómez JG, Baldoncini M. Preoperative tractography algorithm for safe resection of tumors located in the descending motor pathways zone. Surg Neurol Int 2023; 14:255. [PMID: 37560574 PMCID: PMC10408624 DOI: 10.25259/sni_230_2023] [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: 03/12/2023] [Accepted: 07/07/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Diffusion tensor imaging (DTI) tractography facilitates maximal safe resection and optimizes planning to avoid injury during subcortical dissection along descending motor pathways (DMPs). We provide an affordable, safe, and timely algorithm for preoperative DTI motor reconstruction for gliomas adjacent to DMPs. METHODS Preoperative DTI reconstructions were extracted from a prospectively acquired registry of glioma resections adjacent to DMPs. The surgeries were performed over a 7-year period. Demographic, clinical, and radiographic data were extracted from patients' electronic medical records. RESULTS Nineteen patients (12 male) underwent preoperative tractography between January 1, 2013, and May 31, 2020. The average age was 44.5 years (range, 19-81 years). A complete radiological resection was achieved in nine patients, a subtotal resection in five, a partial resection in three, and a biopsy in two. Histopathological diagnoses included 10 patients with high-grade glioma and nine with low-grade glioma. A total of 16 perirolandic locations (10 frontal and six frontoparietal) were recorded, as well as two in the insula and one in the basal ganglia. In 9 patients (47.3%), the lesion was in the dominant hemisphere. The median preoperative and postoperative Karnofsky Performance Scores were 78 and 80, respectively. Motor function was unchanged or improved over time in 15 cases (78.9%). CONCLUSION This protocol of DTI reconstruction for glioma removal near the DMP shows good results in low-term neurological functional outcomes.
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Affiliation(s)
- Edgar G. Ordonez-Rubiano
- Department of Neurosurgery, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
| | - Jason M. Johnson
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Nadin Abdalá-Vargas
- Department of Neurological Surgery, Hospital de San José - Sociedad de Cirugía de Bogotá, Colombia
| | - Oscar F. Zorro
- Department of Neurosurgery, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
| | - Jorge H. Marin-Munoz
- Department of Neurosurgery, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
| | - Ricardo Álvarez-Tobián
- Department of Diagnostic Imaging and Diagnostic Radiology, Fundación Universitaria de Ciencias de la Salud, Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Valeria Forlizzi
- Department of Anatomy, University of Buenos Aires, Buenos Aires, Argentina
| | - Carlos Castillo Rangel
- Department of Neurosurgery, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
| | - Sabino Luzzi
- Department of Neurosurgery, University of Pavia, Pavia, Italy
| | - Alvaro Campero
- Department of Neurosurgery, Hospital Padilla de Tucuman, Tucuman, Argentina
| | - Javier G. Patiño-Gómez
- Department of Neurosurgery, Hospital de San José - Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
| | - Matias Baldoncini
- Department of Neurosurgery, San Fernando Hospital, San Fernando, Argentina
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7
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Li Y, Guo J, Zhang K, Wei H, Fan J, Yu S, Li T, Yang X. Diffusion tensor imaging versus intraoperative subcortical mapping for glioma resection: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:154. [PMID: 37380888 PMCID: PMC10307847 DOI: 10.1007/s10143-023-02058-5] [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: 03/21/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023]
Abstract
Maintaining the integrity of crucial fiber tracts allows functional preservation and improved recovery in patients with glioma resection. Diffusion tensor imaging (DTI) and intraoperative subcortical mapping (ISM) are commonly required for pre- and intraoperative assessment of white matter fibers. This study investigated differences of clinical outcomes in glioma resection aided by DTI or ISM. A comprehensive literature retrieval of the PubMed and Embase databases identified several DTI or ISM studies in 2000-2022. Clinical data, including extent of resection (EOR) and postoperative neurological deficits, was collected and statistically analyzed. Heterogeneity was regressed by a random effect model and the Mann-Whitney U test was used to test statistical significance. Publication bias was assessed by Egger test. A total of 14 studies with a pooled cohort of 1837 patients were included. Patients undergoing DTI-navigated glioma surgery showed a higher rate of gross total resection (GTR) than ISM-assisted surgical resection (67.88%, [95% CI 0.55-0.79] vs. 45.73%, [95% CI 0.29-0.63], P = 0.032). The occurrence of early postoperative functional deficit (35.45%, [95% CI 0.13-0.61] vs. 35.60% [95% CI 0.20-0.53], P = 1.000), late postoperative functional deficit (6.00%, [95% CI 0.02-0.11] vs. 4.91% [95% CI 0.03-0.08], P = 1.000) and severe postoperative functional deficit (2.21%, [95% CI 0-0.08] vs. 5.93% [95% CI 0.01-0.16], P = 0.393) were similar between the DTI and ISM group, respectively. While DTI-navigation resulted in a higher rate of GTR, the occurrence of postoperative neurological deficits between DTI and ISM groups was comparable. Together, these data indicate that both techniques could safely facilitate glioma resection.
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Affiliation(s)
- Yiming Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiahe Guo
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Kai Zhang
- Institute for Intelligent Healthcare, Tsinghua University, Beijing, China
- Department of Neurosurgery, Tsinghua University Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Huijie Wei
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jikang Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shengping Yu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
| | - Xuejun Yang
- Institute for Intelligent Healthcare, Tsinghua University, Beijing, China.
- Department of Neurosurgery, Tsinghua University Beijing Tsinghua Changgung Hospital, Beijing, China.
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8
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Al-Adli NN, Young JS, Sibih YE, Berger MS. Technical Aspects of Motor and Language Mapping in Glioma Patients. Cancers (Basel) 2023; 15:cancers15072173. [PMID: 37046834 PMCID: PMC10093517 DOI: 10.3390/cancers15072173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023] Open
Abstract
Gliomas are infiltrative primary brain tumors that often invade functional cortical and subcortical regions, and they mandate individualized brain mapping strategies to avoid postoperative neurological deficits. It is well known that maximal safe resection significantly improves survival, while postoperative deficits minimize the benefits associated with aggressive resections and diminish patients’ quality of life. Although non-invasive imaging tools serve as useful adjuncts, intraoperative stimulation mapping (ISM) is the gold standard for identifying functional cortical and subcortical regions and minimizing morbidity during these challenging resections. Current mapping methods rely on the use of low-frequency and high-frequency stimulation, delivered with monopolar or bipolar probes either directly to the cortical surface or to the subcortical white matter structures. Stimulation effects can be monitored through patient responses during awake mapping procedures and/or with motor-evoked and somatosensory-evoked potentials in patients who are asleep. Depending on the patient’s preoperative status and tumor location and size, neurosurgeons may choose to employ these mapping methods during awake or asleep craniotomies, both of which have their own benefits and challenges. Regardless of which method is used, the goal of intraoperative stimulation is to identify areas of non-functional tissue that can be safely removed to facilitate an approach trajectory to the equator, or center, of the tumor. Recent technological advances have improved ISM’s utility in identifying subcortical structures and minimized the seizure risk associated with cortical stimulation. In this review, we summarize the salient technical aspects of which neurosurgeons should be aware in order to implement intraoperative stimulation mapping effectively and safely during glioma surgery.
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Affiliation(s)
- Nadeem N. Al-Adli
- Department of Neurological Surgery, University of California, San Francisco, CA 94131, USA
- School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Jacob S. Young
- Department of Neurological Surgery, University of California, San Francisco, CA 94131, USA
| | - Youssef E. Sibih
- School of Medicine, University of California, San Francisco, CA 94131, USA
| | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, CA 94131, USA
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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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Yang Z, Zhao C, Zong S, Piao J, Zhao Y, Chen X. A review on surgical treatment options in gliomas. Front Oncol 2023; 13:1088484. [PMID: 37007123 PMCID: PMC10061125 DOI: 10.3389/fonc.2023.1088484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/24/2023] [Indexed: 03/17/2023] Open
Abstract
Gliomas are one of the most common primary central nervous system tumors, and surgical treatment remains the principal role in the management of any grade of gliomas. In this study, based on the introduction of gliomas, we review the novel surgical techniques and technologies in support of the extent of resection to achieve long-term disease control and summarize the findings on how to keep the balance between cytoreduction and neurological morbidity from a list of literature searched. With modern neurosurgical techniques, gliomas resection can be safely performed with low morbidity and extraordinary long-term functional outcomes.
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Affiliation(s)
- Zhongxi Yang
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Chen Zhao
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Shan Zong
- Department of Gynecology Oncology, The First Hospital of Jilin University, Jilin, China
| | - Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Yuhao Zhao
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
| | - Xuan Chen
- Department of Neurosurgery, The First Hospital of Jilin University, Jilin, China
- *Correspondence: Xuan Chen,
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Bonosi L, Marrone S, Benigno UE, Buscemi F, Musso S, Porzio M, Silven MP, Torregrossa F, Grasso G. Maximal Safe Resection in Glioblastoma Surgery: A Systematic Review of Advanced Intraoperative Image-Guided Techniques. Brain Sci 2023; 13:brainsci13020216. [PMID: 36831759 PMCID: PMC9954589 DOI: 10.3390/brainsci13020216] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/15/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
Glioblastoma multiforme (GBM) represents the most common and aggressive central nervous system tumor associated with a poor prognosis. The aim of this study was to depict the role of intraoperative imaging techniques in GBM surgery and how they can ensure the maximal extent of resection (EOR) while preserving the functional outcome. The authors conducted a systematic review following PRISMA guidelines on the PubMed/Medline and Scopus databases. A total of 1747 articles were identified for screening. Studies focusing on GBM-affected patients, and evaluations of EOR and functional outcomes with the aid of advanced image-guided techniques were included. The resulting studies were assessed for methodological quality using the Risk of Bias in Systematic Review tool. Open Science Framework registration DOI 10.17605/OSF.IO/3FDP9. Eighteen studies were eligible for this systematic review. Among the selected studies, eight analyzed Sodium Fluorescein, three analyzed 5-aminolevulinic acid, two evaluated IoMRI imaging, two evaluated IoUS, and three evaluated multiple intraoperative imaging techniques. A total of 1312 patients were assessed. Gross Total Resection was achieved in the 78.6% of the cases. Follow-up time ranged from 1 to 52 months. All studies assessed the functional outcome based on the Karnofsky Performance Status scale, while one used the Neurologic Assessment in Neuro-Oncology score. In 77.7% of the cases, the functional outcome improved or was stable over the pre-operative assessment. Combining multiple intraoperative imaging techniques could provide better results in GBM surgery than a single technique. However, despite good surgical outcomes, patients often present a neurocognitive decline leading to a marked deterioration of the quality of life. Advanced intraoperative image-guided techniques can allow a better understanding of the anatomo-functional relationships between the tumor and the surrounding brain, thus maximizing the EOR while preserving functional outcomes.
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12
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Zhang M, Xiao X, Gu G, Zhang P, Wu W, Wang Y, Pan C, Wang L, Li H, Wu Z, Zhang J, Zhang L. Role of neuronavigation in the surgical management of brainstem gliomas. Front Oncol 2023; 13:1159230. [PMID: 37205194 PMCID: PMC10185888 DOI: 10.3389/fonc.2023.1159230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/20/2023] [Indexed: 05/21/2023] Open
Abstract
Objective NeuroNavigation (NN) is a widely used intraoperative imaging guidance technique in neurosurgical operations; however, its value in brainstem glioma (BSG) surgery is inadequately reported and lacks objective proof. This study aims to investigate the applicational value of NN in BSG surgery. Method A retrospective analysis was performed on 155 patients with brainstem gliomas who received craniotomy from May 2019 to January 2022 at Beijing Tiantan Hospital. Eighty-four (54.2%) patients received surgery with NN. Preoperative and postoperative cranial nerve dysfunctions, muscle strength, and Karnofsky (KPS) were evaluated. Patients' radiological features, tumor volume, and extent of resection (EOR) were obtained from conventional MRI data. Patients' follow-up data were also collected. Comparative analyses on these variables were made between the NN group and the non-NN group. Result The usage of NN is independently related to a higher EOR in diffuse intrinsic pontine glioma (DIPG) (p=0.005) and non-DIPG group (p<0.001). It was observed that fewer patients in the NN group suffered from deterioration of KPS (p=0.032) and cranial nerve function (p=0.017) in non-DIPG group, and deterioration of muscle strength (p=0.040) and cranial nerve function (p=0.038) in DIPG group. Moreover, the usage of NN is an independent protective factor for the deterioration of KPS (p=0.04) and cranial nerve function (p=0.026) in non-DIPG patients and the deterioration of muscle strength (p=0.009) in DIPG patients. Furthermore, higher EOR subgroups were found to be independently related to better prognoses in DIPG patients (p=0.008). Conclusion NN has significant value in BSG surgery. With the assistance of NN, BSG surgery achieved higher EOR without deteriorating patients' functions. In addition, DIPG patients may benefit from the appropriate increase of EOR.
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Affiliation(s)
- Mingxin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiong Xiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guocan Gu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenhao Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Changcun Pan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Liwei Zhang,
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13
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Dmitriev AY, Dashyan VG. [Tractography in functional neuronavigation]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:12-18. [PMID: 37490660 DOI: 10.17116/jnevro202312307112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
The review addresses the combined use of tractography and neuronavigation. Fundamentals of diffusion tensor imaging are given, technical aspects of fiber tracking in general and in depicting separate subcortical tracts are described. Main advantages of the method and possible causes of errors are highlighted. Precision assessment of this technology is given by comparing with results of subcortical neurostimulation. Surgical tactics is described depending on distance between the tumor and subcortical pathways.
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Affiliation(s)
- A Yu Dmitriev
- Sklifosovsky Research Institute for Emergency, Moscow, Russia
- Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V G Dashyan
- Sklifosovsky Research Institute for Emergency, Moscow, Russia
- Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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14
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Sakata T, Tanikawa M, Yamada H, Fujinami R, Nishikawa Y, Yamada S, Mase M. Minimally invasive treatment for glioblastoma through endoscopic surgery including tumor embolization when necessary: a technical note. Front Neurol 2023; 14:1170045. [PMID: 37153685 PMCID: PMC10160401 DOI: 10.3389/fneur.2023.1170045] [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: 02/20/2023] [Accepted: 04/03/2023] [Indexed: 05/10/2023] Open
Abstract
Background Although there have been some reports on endoscopic glioblastoma surgery, the indication has been limited to deep-seated lesions, and the difficulty of hemostasis has been a concern. In that light, we attempted to establish an endoscopic procedure for excision of glioblastoma which could be applied even to hypervascular or superficial lesions, in combination with pre-operative endovascular tumor embolization. Methods Medical records of six consecutive glioblastoma patients who received exclusive endoscopic removal between September and November 2020 were analyzed. Preoperative tumor embolization was performed in cases with marked tumor stain and proper feeder arteries having an abnormal shape, for instance, tortuous or dilated, without passing through branches to the normal brain. Endoscopic tumor removal through a key-hole craniotomy was performed by using an inside-out excision for a deep-seated lesion, with the addition of an outside-in extirpation for a shallow portion when needed. Results Endoscopic removal was successfully performed in all six cases. Before resection, endovascular tumor embolization was performed in four cases with no resulting complications, including ischemia or brain swelling. Gross total resection was achieved in three cases, and near total resection in the other three cases. Intraoperative blood loss exceeded 1,000 ml in only one case, whose tumor showed a prominent tumor stain but no proper feeder artery for embolization. In all patients, a smooth transition to adjuvant therapy was possible with no surgical site infection. Conclusion Endoscopic removal for glioblastoma was considered to be a promising procedure with minimal invasiveness and a favorable impact on prognosis.
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15
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Duy Hung N, Duy Linh N, Ha Vi N, Van Anh NT, Dinh Hieu N, Dai Ha D, Minh Duc N. Predictive Value of Preoperative Diffusion Tensor Imaging for Evaluating Postoperative Outcomes of Supratentorial Glioma in the Motor Function Area. Ther Clin Risk Manag 2023; 19:269-278. [PMID: 36941979 PMCID: PMC10024488 DOI: 10.2147/tcrm.s402622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/06/2023] [Indexed: 03/17/2023] Open
Abstract
Objective This study aimed to assess the predictive value of preoperative diffusion tensor imaging (DTI) data for surgical outcomes of patients with supratentorial glioma in the motor function area. Patients and Methods This is a retrospective study of 43 patients receiving navigation-guided surgery for histopathologically demonstrated supratentorial glioma in the motor function area. All patients underwent preoperative 3 Tesla magnetic resonance imaging examinations with conventional and DTI sequences. Data on preoperative imaging and pre- and postoperative clinical characteristics of patients were retrospectively collected. Univariate and multivariate linear regressions were applied to analyze the relationships between preoperative parameters and pre- and postoperative muscle strength and the Karnofsky Performance Status (KPS) score. Results Fourteen patients had low-grade gliomas and 29 had high-grade gliomas. Although the corticospinal tract (CST) score did not differ significantly between tumor grades, edema and deviation were common in low-grade gliomas (64.3%), while destroyed and infiltrated lesions were common in high-grade gliomas (58.6%). Muscle strength improved after surgery in the deviated tract group (40%) more than in the infiltrated tract group (33.3%). Two independent indices, preoperative muscle strength (p = 0.000) and glioma-to-CST distance (p = 0.001), were linearly related to postoperative muscle strength. The preoperative KPS score was the only indicator that affected the postoperative KPS score (p = 0.000). Conclusion DTI should be considered in surgical management of supratentorial gliomas in the motor function area to determine the appropriate surgical strategy and predict the nature of the tumor and postoperative motor function.
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Affiliation(s)
- Nguyen Duy Hung
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Department of Radiology, Viet Duc Hospital, Hanoi, Vietnam
| | - Nguyen Duy Linh
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
- Department of Surgery, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Nguyen Ha Vi
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Thi Van Anh
- Department of Radiology, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Nguyen Dinh Hieu
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Department of Radiology, Ha Dong General Hospital, Ha Noi, Vietnam
| | - Duong Dai Ha
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
- Neurosurgery Center, Viet Duc Hospital, Hanoi, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
- Correspondence: Nguyen Minh Duc, Department of Radiology, Pham Ngoc Thach University of Medicine, 2 Duong Quang Trung Ward 12 District 10, Ho Chi Minh City, 700000, Vietnam, Email
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16
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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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17
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Wu A, Wu JY, Lim M. Updates in intraoperative strategies for enhancing intra-axial brain tumor control. Neuro Oncol 2022; 24:S33-S41. [PMID: 36322098 PMCID: PMC9629479 DOI: 10.1093/neuonc/noac170] [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] [Indexed: 11/06/2022] Open
Abstract
To ensure excellent postoperative clinical outcomes while preserving critical neurologic function, neurosurgeons who manage patients with intra-axial brain tumors can use intraoperative technologies and tools to achieve maximal safe resection. Neurosurgical oncology revolves around safe and optimal extent of resection, which further dictates subsequent treatment regimens and patient outcomes. Various methods can be adapted for treating both primary and secondary intra-axial brain lesions. We present a review of recent advances and published research centered on different innovative tools and techniques, including fluorescence-guided surgery, new methods of drug delivery, and minimally invasive procedural options.
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Affiliation(s)
- Adela Wu
- Department of Neurosurgery, Stanford Health Care, Stanford, California, USA
| | | | - Michael Lim
- Department of Neurosurgery, Stanford Health Care, Stanford, California, USA
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18
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Advanced Neuroimaging Approaches to Pediatric Brain Tumors. Cancers (Basel) 2022; 14:cancers14143401. [PMID: 35884462 PMCID: PMC9318188 DOI: 10.3390/cancers14143401] [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: 06/26/2022] [Accepted: 07/08/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary After leukemias, brain tumors are the most common cancers in children, and early, accurate diagnosis is critical to improve patient outcomes. Beyond the conventional imaging methods of computed tomography (CT) and magnetic resonance imaging (MRI), advanced neuroimaging techniques capable of both structural and functional imaging are moving to the forefront to improve the early detection and differential diagnosis of tumors of the central nervous system. Here, we review recent developments in neuroimaging techniques for pediatric brain tumors. Abstract Central nervous system tumors are the most common pediatric solid tumors; they are also the most lethal. Unlike adults, childhood brain tumors are mostly primary in origin and differ in type, location and molecular signature. Tumor characteristics (incidence, location, and type) vary with age. Children present with a variety of symptoms, making early accurate diagnosis challenging. Neuroimaging is key in the initial diagnosis and monitoring of pediatric brain tumors. Conventional anatomic imaging approaches (computed tomography (CT) and magnetic resonance imaging (MRI)) are useful for tumor detection but have limited utility differentiating tumor types and grades. Advanced MRI techniques (diffusion-weighed imaging, diffusion tensor imaging, functional MRI, arterial spin labeling perfusion imaging, MR spectroscopy, and MR elastography) provide additional and improved structural and functional information. Combined with positron emission tomography (PET) and single-photon emission CT (SPECT), advanced techniques provide functional information on tumor metabolism and physiology through the use of radiotracer probes. Radiomics and radiogenomics offer promising insight into the prediction of tumor subtype, post-treatment response to treatment, and prognostication. In this paper, a brief review of pediatric brain cancers, by type, is provided with a comprehensive description of advanced imaging techniques including clinical applications that are currently utilized for the assessment and evaluation of pediatric brain tumors.
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19
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Pradhan A, Mozaffari K, Ghodrati F, Everson RG, Yang I. Modern surgical management of incidental gliomas. J Neurooncol 2022; 159:81-94. [PMID: 35704158 PMCID: PMC9325816 DOI: 10.1007/s11060-022-04045-0] [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: 01/21/2022] [Accepted: 05/23/2022] [Indexed: 11/19/2022]
Abstract
Purpose Gliomas are the most common primary tumors of the central nervous system and are categorized by the World Health Organization into either low-grade (grades 1 and 2) or high-grade (grades 3 and 4) gliomas. A subset of patients with glioma may experience no tumor-related symptoms and be incidentally diagnosed. These incidental low-grade gliomas (iLGG) maintain controversial treatment course despite scientific advancements. Here we highlight the recent advancements in classification, neuroimaging, and surgical management of these tumors. Methods A review of the literature was performed. The authors created five subtopics of focus: histological criteria, diagnostic imaging, surgical advancements, correlation of surgical resection and survival outcomes, and clinical implications. Conclusions Alternating studies suggest that these tumors may experience higher mutational rates than their counterparts. Significant progress in management of gliomas, regardless of the grade, has been made through modern neurosurgical treatment modalities, diagnostic neuroimaging, and a better understanding of the genetic composition of these tumors. An optimal treatment approach for patients with newly diagnosed iLGG remains ill-defined despite multiple studies arguing in favor of safe maximal resection. Our review emphasizes the not so benign nature of incidental low grade glioma and further supports the need for future studies to evaluate survival outcomes following surgical resection.
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Affiliation(s)
- Anjali Pradhan
- Departments of Neurosurgery, University of California, Los Angeles, Los Angeles, USA.,David Geffen School of Medicine, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Khashayar Mozaffari
- Departments of Neurosurgery, University of California, Los Angeles, Los Angeles, USA
| | - Farinaz Ghodrati
- Departments of Neurosurgery, University of California, Los Angeles, Los Angeles, USA.,David Geffen School of Medicine, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Richard G Everson
- Departments of Neurosurgery, University of California, Los Angeles, Los Angeles, USA.,Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, USA.,The Lundquist Institute, University of California, Los Angeles, Los Angeles, USA.,Harbor-UCLA Medical Center, University of California, Los Angeles, Los Angeles, USA.,David Geffen School of Medicine, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Isaac Yang
- Departments of Neurosurgery, University of California, Los Angeles, Los Angeles, USA. .,Radiation Oncology, University of California, Los Angeles, Los Angeles, USA. .,Head and Neck Surgery, University of California, Los Angeles, Los Angeles, USA. .,Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, USA. .,The Lundquist Institute, University of California, Los Angeles, Los Angeles, USA. .,Harbor-UCLA Medical Center, University of California, Los Angeles, Los Angeles, USA. .,David Geffen School of Medicine, Los Angeles (UCLA), Los Angeles, CA, USA.
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20
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Bernstock JD, Gary SE, Klinger N, Valdes PA, Ibn Essayed W, Olsen HE, Chagoya G, Elsayed G, Yamashita D, Schuss P, Gessler FA, Peruzzi PP, Bag A, Friedman GK. Standard clinical approaches and emerging modalities for glioblastoma imaging. Neurooncol Adv 2022; 4:vdac080. [PMID: 35821676 PMCID: PMC9268747 DOI: 10.1093/noajnl/vdac080] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Glioblastoma (GBM) is the most common primary adult intracranial malignancy and carries a dismal prognosis despite an aggressive multimodal treatment regimen that consists of surgical resection, radiation, and adjuvant chemotherapy. Radiographic evaluation, largely informed by magnetic resonance imaging (MRI), is a critical component of initial diagnosis, surgical planning, and post-treatment monitoring. However, conventional MRI does not provide information regarding tumor microvasculature, necrosis, or neoangiogenesis. In addition, traditional MRI imaging can be further confounded by treatment-related effects such as pseudoprogression, radiation necrosis, and/or pseudoresponse(s) that preclude clinicians from making fully informed decisions when structuring a therapeutic approach. A myriad of novel imaging modalities have been developed to address these deficits. Herein, we provide a clinically oriented review of standard techniques for imaging GBM and highlight emerging technologies utilized in disease characterization and therapeutic development.
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Affiliation(s)
- Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Sam E Gary
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Neil Klinger
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Pablo A Valdes
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Hannah E Olsen
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Gustavo Chagoya
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Galal Elsayed
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Daisuke Yamashita
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Patrick Schuss
- Department of Neurosurgery, Unfallkrankenhaus Berlin , Berlin, Germany
| | | | - Pier Paolo Peruzzi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Asim Bag
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital , Memphis, TN USA
| | - Gregory K Friedman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham , Birmingham, AL, USA
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham , AL, USA
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21
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Manan AA, Yahya N, Idris Z, Manan HA. The Utilization of Diffusion Tensor Imaging as an Image-Guided Tool in Brain Tumor Resection Surgery: A Systematic Review. Cancers (Basel) 2022; 14:2466. [PMID: 35626069 PMCID: PMC9139820 DOI: 10.3390/cancers14102466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 02/04/2023] Open
Abstract
The diffusion tensor imaging technique has been recognized as a neuroimaging tool for in vivo visualization of white matter tracts. However, DTI is not a routine procedure for preoperative planning for brain tumor resection. Our study aimed to systematically evaluate the effectiveness of DTI and the outcomes of surgery. The electronic databases, PubMed/MEDLINE and Scopus, were searched for relevant studies. Studies were systematically reviewed based on the application of DTI in pre-surgical planning, modification of operative planning, re-evaluation of preoperative DTI data intraoperatively, and the outcome of surgery decisions. Seventeen studies were selected based on the inclusion and exclusion criteria. Most studies agreed that preoperative planning using DTI improves postoperative neuro-deficits, giving a greater resection yield and shortening the surgery time. The results also indicate that the re-evaluation of preoperative DTI intraoperatively assists in a better visualization of white matter tract shifts. Seven studies also suggested that DTI modified the surgical decision of the initial surgical approach and the rate of the GTR in tumor resection surgery. The utilization of DTI may give essential information on white matter tract pathways, for a better surgical approach, and eventually reduce the risk of neurologic deficits after surgery.
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Affiliation(s)
- Aiman Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Malaysia;
| | - Noorazrul Yahya
- Diagnostic Imaging and Radiotherapy, Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300, Malaysia;
| | - Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Penang 16150, Malaysia;
| | - Hanani Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Malaysia;
- Department of Radiology and Intervensy, Hospital Pakar Kanak-Kanak (HPKK), Universiti Kebangsaan Malaysia, Jalan Yaakob Latiff, Kuala Lumpur 56000, Malaysia
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22
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Abstract
Gliomas are the most common intrinsic brain tumor in adults. Although maximal tumor resection improves survival, this must be balanced with preservation of neurologic function. Technological advancements have greatly expanded our ability to safely maximize tumor resection and design innovative therapeutic trials that take advantage of intracavitary delivery of therapeutic agents after resection. In this article, we review the role of surgical intervention for both low-grade and high-grade gliomas and the innovations that are driving and expanding the role of surgery in this therapeutically challenging group of malignancies.
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Affiliation(s)
- Dana Mitchell
- Department of Pediatrics, Indiana University, Herman B. Wells Center for Pediatric Research 1044 W Walnut St, Indianapolis, IN 46202, USA
| | - Jack M Shireman
- Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue CSC K3/803, Madison, WI 53792, USA
| | - Mahua Dey
- Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue CSC K3/803, Madison, WI 53792, USA.
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23
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Carrete LR, Young JS, Cha S. Advanced Imaging Techniques for Newly Diagnosed and Recurrent Gliomas. Front Neurosci 2022; 16:787755. [PMID: 35281485 PMCID: PMC8904563 DOI: 10.3389/fnins.2022.787755] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/19/2022] [Indexed: 12/12/2022] Open
Abstract
Management of gliomas following initial diagnosis requires thoughtful presurgical planning followed by regular imaging to monitor treatment response and survey for new tumor growth. Traditional MR imaging modalities such as T1 post-contrast and T2-weighted sequences have long been a staple of tumor diagnosis, surgical planning, and post-treatment surveillance. While these sequences remain integral in the management of gliomas, advances in imaging techniques have allowed for a more detailed characterization of tumor characteristics. Advanced MR sequences such as perfusion, diffusion, and susceptibility weighted imaging, as well as PET scans have emerged as valuable tools to inform clinical decision making and provide a non-invasive way to help distinguish between tumor recurrence and pseudoprogression. Furthermore, these advances in imaging have extended to the operating room and assist in making surgical resections safer. Nevertheless, surgery, chemotherapy, and radiation treatment continue to make the interpretation of MR changes difficult for glioma patients. As analytics and machine learning techniques improve, radiomics offers the potential to be more quantitative and personalized in the interpretation of imaging data for gliomas. In this review, we describe the role of these newer imaging modalities during the different stages of management for patients with gliomas, focusing on the pre-operative, post-operative, and surveillance periods. Finally, we discuss radiomics as a means of promoting personalized patient care in the future.
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Affiliation(s)
- Luis R. Carrete
- University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Jacob S. Young
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Jacob S. Young,
| | - Soonmee Cha
- Department of Radiology, University of California, San Francisco, San Francisco, CA, United States
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Greisman JD, Dadario NB, Park J, Silverstein JW, D'Amico RS. Subcortical Stimulation in Brain Tumor Surgery: A closer look beneath the surface. World Neurosurg 2022; 161:55-63. [PMID: 35149248 DOI: 10.1016/j.wneu.2022.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Maximizing a patient's onco-functional balance is the central tenet of brain tumor surgery. As a result, numerous surgical adjuncts have been developed to facilitate identification of the tumor-brain interface and preservation of functional anatomy. Among these, intraoperative neurophysiologic monitoring (IONM) with direct cortical and subcortical stimulation remains the gold standard for real time, functional mapping of motor and language activity. However, stimulation techniques are not standardized and vary significantly across institutions. This is particularly true with subcortical stimulation for mapping of motor function. METHODS We review the state of subcortical IONM and mapping techniques. Historical and predicate literature were reviewed as well as new and emerging techniques. We discuss their evolution, clinical utility, and limitations to direct future research and application. RESULTS We evaluate and discuss the background and current clinical use of direct cortical and subcortical stimulation techniques and protocols and identify current trends and limitations. We focus specifically on methods of subcortical stimulation given the heterogeneity in the published literature. We also suggest directions to optimize the clinical utility of these tools. CONCLUSION Despite significant heterogeneity in published techniques, trends support the use of the Taniguchi method for subcortical stimulation. Novel dynamic stimulation techniques may improve accuracy. Prospective studies to define standardized guidelines are needed.
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Affiliation(s)
- Jacob D Greisman
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Nicholas B Dadario
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Jung Park
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA; Neuro Protective Solutions, New York, New York, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA.
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Li Y, Hou Y, Li Q, Tang J, Lu J. Optimized Tractography Mapping and Quantitative Evaluation of Pyramidal Tracts for Surgical Resection of Insular Gliomas: a Correlative Study with Diffusion Tensor Imaging–Derived Metrics and Patient Motor Strength. J Digit Imaging 2022; 35:356-364. [PMID: 35064370 PMCID: PMC8921407 DOI: 10.1007/s10278-021-00578-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 11/25/2022] Open
Abstract
We investigate the correlation between diffusion tensor imaging (DTI)-derived metric statistics and motor strength grade of insular glioma patients after optimizing the pyramidal tract (PT) delineation. Motor strength grades of 45 insular glioma patients were assessed. All the patients underwent structural and diffusion MRI examination before and after surgery. We co-registered pre- and post-op datasets, and a two-tensor unscented Kalman filter (UKF) algorithm was employed to delineate bilateral PTs after DWI pre-processing. The tractography results were voxelized, and their labelmaps were cropped according to the location of frontal and insular parts of the lesion. Both the whole and cropped labelmaps were used as regions of interest to analyze fractional anisotropy (FA) and Trace statistics; hence, their ratios were calculated (lesional side tract/contralateral normal tract). The combination of DWI pre-processing and two-tensor UKF algorithm successfully delineated bilateral PTs of all the patients. It effectively accomplished both full fiber delineation within the edema and an extensive lateral fanning that had a favorable correspondence to the bilateral motor cortices. Before surgery, correlations were found between patients' motor strength grades and ratios of PT volume and FA standard deviation (SD). Nearly 3 months after surgery, correlations were found between motor strength grades and the ratios of metric statistics as follows: whole PT volume, whole mean FA, and FA SD. We substantiated the correlation between DTI-derived metric statistics and motor strength grades of insular glioma patients. Moreover, we posed a workflow for comprehensive pre- and post-op DTI quantitative research of glioma patients.
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Affiliation(s)
- Ye Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China
| | - Yuanzheng Hou
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China
| | - Qiongge Li
- Department of Radiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China
| | - Jie Tang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China.
| | - Jie Lu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100853, China.
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Yu S, Guo J, Li Y, Zhang K, Li J, Liu P, Ming H, Guo Y. Advanced modalities and surgical theories in glioma resection: A narrative review. GLIOMA 2022. [DOI: 10.4103/glioma.glioma_14_22] [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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27
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Kakhkharov RA, Kadyrov SU, Ogurtsova AA, Baev AA, Pronin IN, Konovalov AN. [Surgical treatment of hemispheric and subcortical gliomas adjacent to corticospinal tract in children using MR tractography and intraoperative electrophysiological monitoring]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:16-24. [PMID: 36534620 DOI: 10.17116/neiro20228606116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Difficult total resection of supratentorial gliomas adjacent to the corticospinal tract (CST) is due to the high risk of its injury and disability of patients. The main methods for preventing intraoperative CST damage are preoperative MR tractography and intraoperative electrophysiological monitoring. The problem of total resection of gliomas adjacent to the CST with preservation of high functional status is difficult due to immaturity and plasticity of brain structures in children. Moreover, the advantages of MR tractography combined with intraoperative monitoring have not been described. The authors present surgical treatment of supratentorial gliomas adjacent to the CST at different anatomical levels. Patients underwent preoperative and postoperative MR tractography and intraoperative electrophysiological monitoring. MR tractography provided preoperative data on CST lesion. Intraoperative monitoring made it possible to identify and preserve CST in the depth of surgical wound. MR tractography and intraoperative electrophysiological monitoring increase resection quality in patients with hemispheric and subcortical gliomas without postoperative functional deterioration.
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Affiliation(s)
| | | | | | - A A Baev
- Burdenko Neurosurgical Center, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
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28
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Dmitriev AY, Dashyan VG. [Intraoperative brain shift in neuronavigation. Causes, clinical significance and solution of the problem]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:119-124. [PMID: 35412721 DOI: 10.17116/neiro202286021119] [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: 06/14/2023]
Abstract
Intraoperative brain shift is the main cause of inaccurate navigation. This limits the use of both conventional and functional neuronavigation. Causes of brain shift are divided into surgical, pathophysiological and metabolic ones. Brain shift is usually unidirectional and directed towards gravitation. Brain dislocation depends on lesion size and its location. Shift is minimal in patients with tumors <20 ml and skull base neoplasms. Small craniotomy, retractor-free surgery and no ventriculostomy are valuable to reduce brain shift. Brain dislocation increases during surgery that's why marking of eloquent lesions at the beginning of surgery and primary resection near subcortical tracts minimize the risk of damage to conduction pathways. Augmented reality and manual shift of marked objects are the cornerstones of linear correction of brain shift in modern navigation systems. In case of nonlinear brain shift, sonography and intraoperative magnetic resonance imaging can clarify location of surgical target and cerebral structures.
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Affiliation(s)
- A Yu Dmitriev
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V G Dashyan
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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29
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Haddad AF, Young JS, Morshed RA, Josephson SA, Cha S, Berger MS. Pseudo-insular glioma syndrome: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21481. [PMID: 35854917 PMCID: PMC9281470 DOI: 10.3171/case21481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/20/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Lower-grade insular gliomas often appear as expansile and infiltrative masses on magnetic resonance imaging (MRI). However, there are nonneoplastic lesions of the insula, such as demyelinating disease and vasculopathies, that can mimic insular gliomas. OBSERVATIONS The authors report two patients who presented with headaches and were found to have mass lesions concerning for lower-grade insular glioma based on MRI obtained at initial presentation. However, on the immediate preoperative MRI obtained a few weeks later, both patients had spontaneous and complete resolution of the insular lesions. LESSONS Tumor mimics should always be in the differential diagnosis of brain masses, including those involving the insula. The immediate preoperative MRI (within 24–48 hours of surgery) must be compared carefully with the initial presentation MRI to assess interval change that suggests tumor mimics to avoid unnecessary surgical intervention.
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Affiliation(s)
| | | | | | | | - Soonmee Cha
- Radiology, University of California, San Francisco, San Francisco, California
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30
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Yeh FC, Irimia A, Bastos DCDA, Golby AJ. Tractography methods and findings in brain tumors and traumatic brain injury. Neuroimage 2021; 245:118651. [PMID: 34673247 PMCID: PMC8859988 DOI: 10.1016/j.neuroimage.2021.118651] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 10/05/2021] [Accepted: 10/11/2021] [Indexed: 12/31/2022] Open
Abstract
White matter fiber tracking using diffusion magnetic resonance imaging (dMRI) provides a noninvasive approach to map brain connections, but improving anatomical accuracy has been a significant challenge since the birth of tractography methods. Utilizing tractography in brain studies therefore requires understanding of its technical limitations to avoid shortcomings and pitfalls. This review explores tractography limitations and how different white matter pathways pose different challenges to fiber tracking methodologies. We summarize the pros and cons of commonly-used methods, aiming to inform how tractography and its related analysis may lead to questionable results. Extending these experiences, we review the clinical utilization of tractography in patients with brain tumors and traumatic brain injury, starting from tensor-based tractography to more advanced methods. We discuss current limitations and highlight novel approaches in the context of these two conditions to inform future tractography developments.
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Affiliation(s)
- Fang-Cheng Yeh
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | - Andrei Irimia
- Ethel Percy Andrus Gerontology Center, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA; Corwin D. Denney Research Center, Department of Biomedical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, California, USA
| | | | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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31
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Wu C, Ferreira F, Fox M, Harel N, Hattangadi-Gluth J, Horn A, Jbabdi S, Kahan J, Oswal A, Sheth SA, Tie Y, Vakharia V, Zrinzo L, Akram H. Clinical applications of magnetic resonance imaging based functional and structural connectivity. Neuroimage 2021; 244:118649. [PMID: 34648960 DOI: 10.1016/j.neuroimage.2021.118649] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/24/2021] [Accepted: 10/10/2021] [Indexed: 12/23/2022] Open
Abstract
Advances in computational neuroimaging techniques have expanded the armamentarium of imaging tools available for clinical applications in clinical neuroscience. Non-invasive, in vivo brain MRI structural and functional network mapping has been used to identify therapeutic targets, define eloquent brain regions to preserve, and gain insight into pathological processes and treatments as well as prognostic biomarkers. These tools have the real potential to inform patient-specific treatment strategies. Nevertheless, a realistic appraisal of clinical utility is needed that balances the growing excitement and interest in the field with important limitations associated with these techniques. Quality of the raw data, minutiae of the processing methodology, and the statistical models applied can all impact on the results and their interpretation. A lack of standardization in data acquisition and processing has also resulted in issues with reproducibility. This limitation has had a direct impact on the reliability of these tools and ultimately, confidence in their clinical use. Advances in MRI technology and computational power as well as automation and standardization of processing methods, including machine learning approaches, may help address some of these issues and make these tools more reliable in clinical use. In this review, we will highlight the current clinical uses of MRI connectomics in the diagnosis and treatment of neurological disorders; balancing emerging applications and technologies with limitations of connectivity analytic approaches to present an encompassing and appropriate perspective.
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Affiliation(s)
- Chengyuan Wu
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, 909 Walnut Street, Third Floor, Philadelphia, PA 19107, USA; Jefferson Integrated Magnetic Resonance Imaging Center, Department of Radiology, Thomas Jefferson University, 909 Walnut Street, First Floor, Philadelphia, PA 19107, USA.
| | - Francisca Ferreira
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, 33 Queen Square, London WC1N 3BG, UK; Unit of Functional Neurosurgery, UCL Queen Square Institute of Neurology, 33 Queen Square, London WC1N 3BG, UK.
| | - Michael Fox
- Center for Brain Circuit Therapeutics, Departments of Neurology, Psychiatry, Radiology, and Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Noam Harel
- Center for Magnetic Resonance Research, University of Minnesota, 2021 Sixth Street S.E., Minneapolis, MN 55455, USA.
| | - Jona Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, Center for Precision Radiation Medicine, University of California, San Diego, 3855 Health Sciences Drive, La Jolla, CA 92037, USA.
| | - Andreas Horn
- Neurology Department, Movement Disorders and Neuromodulation Section, Charité - University Medicine Berlin, Charitéplatz 1, D-10117, Berlin, Germany.
| | - Saad Jbabdi
- Wellcome Centre for Integrative Neuroimaging, Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
| | - Joshua Kahan
- Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA.
| | - Ashwini Oswal
- Medical Research Council Brain Network Dynamics Unit, University of Oxford, Mansfield Rd, Oxford OX1 3TH, UK.
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge, Ninth Floor, Houston, TX 77030, USA.
| | - Yanmei Tie
- Center for Brain Circuit Therapeutics, Departments of Neurology, Psychiatry, Radiology, and Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Vejay Vakharia
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, 33 Queen Square, London WC1N 3BG, UK.
| | - Ludvic Zrinzo
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, 33 Queen Square, London WC1N 3BG, UK; Unit of Functional Neurosurgery, UCL Queen Square Institute of Neurology, 33 Queen Square, London WC1N 3BG, UK.
| | - Harith Akram
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, 33 Queen Square, London WC1N 3BG, UK; Unit of Functional Neurosurgery, UCL Queen Square Institute of Neurology, 33 Queen Square, London WC1N 3BG, UK.
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Richards TJ, Anderson KL, Anderson JS. "Fully automated segmentation of the corticospinal tract using the TractSeg algorithm in patients with brain tumors". Clin Neurol Neurosurg 2021; 210:107001. [PMID: 34749021 DOI: 10.1016/j.clineuro.2021.107001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Tractography has been used to define the presurgical location of white matter tracts, but this is subjective and time-intensive, making incorporation to imaging workflow at scale problematic. The objective is to validate a fully automated pipeline using the TractSeg algorithm (Wasserthal et al. NeuroImage 2018;183:239-253) to segment the corticospinal tract in patients with brain tumors adjacent to the corticospinal tract. METHODS The process of importing a structural MPRAGE sequence and raw diffusion weighted images from PACS, executing the TractSeg algorithm, overlaying the resulting bilateral corticospinal tracts on the MPRAGE image, and exporting this composite image to PACS was automated. This procedure was used to segment the corticospinal tract in 28 patients with brain masses adjacent to or displacing the corticospinal tract. These segmentations were compared with both manual deterministic tractography performed with DSI Studio using seeds placed in the pons and an automated tractography method in DSI Studio. RESULTS The automated algorithm was able to segment the bilateral corticospinal tracts in all 28 patients whereas the manual reference method and DSI Studio based automated tractography were unsuccessful in 2 and 1 patients, respectively. In all cases, the TractSeg segmentations very closely matched the manual segmentations. Also, TractSeg appeared to include larger portions of the lateral corticospinal tract fibers than the other 2 methods. CONCLUSION The TractSeg algorithm demonstrated robust performance in segmenting the corticospinal tract in patients with brain tumors adjacent to this tract. The algorithm is fast to perform and has great potential for optimizing and streamlining neurosurgical planning.
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Affiliation(s)
- Tyler J Richards
- University of Utah School of Medicine, Department of Radiology and Imaging Sciences, 30 North 1900 East #1A071, Salt Lake City, UT 84132-2140, USA.
| | - Keri L Anderson
- University of Utah School of Computing, Department of Computer Science, Merrill Engineering, 50 Central Campus Dr, Salt Lake City, UT 84112, USA.
| | - Jeffrey S Anderson
- University of Utah School of Medicine, Department of Radiology and Imaging Sciences, 30 North 1900 East #1A071, Salt Lake City, UT 84132-2140, USA.
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Drakopoulos F, Tsolakis C, Angelopoulos A, Liu Y, Yao C, Kavazidi KR, Foroglou N, Fedorov A, Frisken S, Kikinis R, Golby A, Chrisochoides N. Adaptive Physics-Based Non-Rigid Registration for Immersive Image-Guided Neuronavigation Systems. Front Digit Health 2021; 2:613608. [PMID: 34713074 PMCID: PMC8521897 DOI: 10.3389/fdgth.2020.613608] [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: 10/02/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022] Open
Abstract
Objective: In image-guided neurosurgery, co-registered preoperative anatomical, functional, and diffusion tensor imaging can be used to facilitate a safe resection of brain tumors in eloquent areas of the brain. However, the brain deforms during surgery, particularly in the presence of tumor resection. Non-Rigid Registration (NRR) of the preoperative image data can be used to create a registered image that captures the deformation in the intraoperative image while maintaining the quality of the preoperative image. Using clinical data, this paper reports the results of a comparison of the accuracy and performance among several non-rigid registration methods for handling brain deformation. A new adaptive method that automatically removes mesh elements in the area of the resected tumor, thereby handling deformation in the presence of resection is presented. To improve the user experience, we also present a new way of using mixed reality with ultrasound, MRI, and CT. Materials and methods: This study focuses on 30 glioma surgeries performed at two different hospitals, many of which involved the resection of significant tumor volumes. An Adaptive Physics-Based Non-Rigid Registration method (A-PBNRR) registers preoperative and intraoperative MRI for each patient. The results are compared with three other readily available registration methods: a rigid registration implemented in 3D Slicer v4.4.0; a B-Spline non-rigid registration implemented in 3D Slicer v4.4.0; and PBNRR implemented in ITKv4.7.0, upon which A-PBNRR was based. Three measures were employed to facilitate a comprehensive evaluation of the registration accuracy: (i) visual assessment, (ii) a Hausdorff Distance-based metric, and (iii) a landmark-based approach using anatomical points identified by a neurosurgeon. Results: The A-PBNRR using multi-tissue mesh adaptation improved the accuracy of deformable registration by more than five times compared to rigid and traditional physics based non-rigid registration, and four times compared to B-Spline interpolation methods which are part of ITK and 3D Slicer. Performance analysis showed that A-PBNRR could be applied, on average, in <2 min, achieving desirable speed for use in a clinical setting. Conclusions: The A-PBNRR method performed significantly better than other readily available registration methods at modeling deformation in the presence of resection. Both the registration accuracy and performance proved sufficient to be of clinical value in the operating room. A-PBNRR, coupled with the mixed reality system, presents a powerful and affordable solution compared to current neuronavigation systems.
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Affiliation(s)
- Fotis Drakopoulos
- Center for Real-Time Computing, Old Dominion University, Norfolk, VA, United States
| | - Christos Tsolakis
- Center for Real-Time Computing, Old Dominion University, Norfolk, VA, United States.,Department of Computer Science, Old Dominion University, Norfolk, VA, United States
| | - Angelos Angelopoulos
- Center for Real-Time Computing, Old Dominion University, Norfolk, VA, United States.,Department of Computer Science, Old Dominion University, Norfolk, VA, United States
| | - Yixun Liu
- Center for Real-Time Computing, Old Dominion University, Norfolk, VA, United States
| | - Chengjun Yao
- Department of Neurosurgery, Huashan Hospital, Shanghai, China
| | | | - Nikolaos Foroglou
- Department of Neurosurgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andrey Fedorov
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Sarah Frisken
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Ron Kikinis
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Alexandra Golby
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Nikos Chrisochoides
- Center for Real-Time Computing, Old Dominion University, Norfolk, VA, United States.,Department of Computer Science, Old Dominion University, Norfolk, VA, United States
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Morales H. Current and Future Challenges of Functional MRI and Diffusion Tractography in the Surgical Setting: From Eloquent Brain Mapping to Neural Plasticity. Semin Ultrasound CT MR 2021; 42:474-489. [PMID: 34537116 DOI: 10.1053/j.sult.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Decades ago, Spetzler (1986) and Sawaya (1998) provided a rough brain segmentation of the eloquent areas of the brain, aimed to help surgical decisions in cases of vascular malformations and tumors, respectively. Currently in clinical use, their criteria are in need of revision. Defining functions (eg, sensorimotor, language and visual) that should be preserved during surgery seems a straightforward task. In practice, locating the specific areas that could cause a permanent vs transient deficit is not an easy task. This is particularly true for the associative cortex and cognitive domains such as language. The old model, with Broca's and Wernicke's areas at the forefront, has been superseded by a dual-stream model of parallel language processing; named ventral and dorsal pathways. This complicated network of cortical hubs and subcortical white matter pathways needing preservation during surgery is a work in progress. Preserving not only cortical regions but most importantly preserving the connections, or white matter fiber bundles, of core regions in the brain is the new paradigm. For instance, the arcuate fascicululs and inferior fronto-occipital fasciculus are key components of the dorsal and ventral language pathways, respectively; and their damage result in permanent language deficits. Interestedly, the damage of the temporal portions of these bundles -where there is a crossroad with other multiple bundles-, appears to be more important (permanent) than the damage of the frontal portions - where plasticity and contralateral activation could help. Although intraoperative direct cortical and subcortical stimulation have contributed largely, advanced MR techniques such as functional MRI (fMRI) and diffusion tractography (DT), are at the epi-center of our current understanding. Nevertheless, these techniques posse important challenges: such as neurovascular uncoupling or venous bias on fMRI; and appropriate anatomical validation or accurate representation of crossing fibers on DT. These limitations should be well understood and taken into account in clinical practice. Unifying multidisciplinary research and clinical efforts is desirable, so these techniques could contribute more efficiently not only to locate eloquent areas but to improve outcomes and our understanding of neural plasticity. Finally, although there are constant anatomical and functional regions at the individual level, there is a known variability at the inter-individual level. This concept should strengthen the importance of a personalized approach when evaluating these regions on fMRI and DT. It should strengthen the importance of personalized treatments as well, aimed to meet tailored needs and expectations.
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Affiliation(s)
- Humberto Morales
- Section of Neuroradiology, University of Cincinnati Medical Center, Cincinnati, OH.
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35
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Chakravarthi SS, Fukui MB, Monroy-Sosa A, Gonen L, Epping A, Jennings JE, Mena LPDSR, Khalili S, Singh M, Celix JM, Kura B, Kojis N, Rovin RA, Kassam AB. The Role of 3D Tractography in Skull Base Surgery: Technological Advances, Feasibility, and Early Clinical Assessment with Anterior Skull Base Meningiomas. J Neurol Surg B Skull Base 2021; 82:576-592. [PMID: 34513565 DOI: 10.1055/s-0040-1713775] [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: 02/04/2020] [Accepted: 04/25/2020] [Indexed: 10/23/2022] Open
Abstract
Objective The aim of this study is to determine feasibility of incorporating three-dimensional (3D) tractography into routine skull base surgery planning and analyze our early clinical experience in a subset of anterior cranial base meningiomas (ACM). Methods Ninety-nine skull base endonasal and transcranial procedures were planned in 94 patients and retrospectively reviewed with a further analysis of the ACM subset. Main Outcome Measures (1) Automated generation of 3D tractography; (2) co-registration 3D tractography with computed tomography (CT), CT angiography (CTA), and magnetic resonance imaging (MRI); and (3) demonstration of real-time manipulation of 3D tractography intraoperatively. ACM subset: (1) pre- and postoperative cranial nerve function, (2) qualitative assessment of white matter tract preservation, and (3) frontal lobe fluid-attenuated inversion recovery (FLAIR) signal abnormality. Results Automated 3D tractography, with MRI, CT, and CTA overlay, was produced in all cases and was available intraoperatively. ACM subset : 8 (44%) procedures were performed via a ventral endoscopic endonasal approach (EEA) corridor and 12 (56%) via a dorsal anteromedial (DAM) transcranial corridor. Four cases (olfactory groove meningiomas) were managed with a combined, staged approach using ventral EEA and dorsal transcranial corridors. Average tumor volume reduction was 90.3 ± 15.0. Average FLAIR signal change was -30.9% ± 58.6. 11/12 (92%) patients (DAM subgroup) demonstrated preservation of, or improvement in, inferior fronto-occipital fasciculus volume. Functional cranial nerve recovery was 89% (all cases). Conclusion It is feasible to incorporate 3D tractography into the skull base surgical armamentarium. The utility of this tool in improving outcomes will require further study.
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Affiliation(s)
- Srikant S Chakravarthi
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Melanie B Fukui
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Alejandro Monroy-Sosa
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Lior Gonen
- Department of Neurosurgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Austin Epping
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Jonathan E Jennings
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Laila Perez de San Roman Mena
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Sammy Khalili
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Maharaj Singh
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Juanita M Celix
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Bhavani Kura
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Nathaniel Kojis
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Richard A Rovin
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
| | - Amin B Kassam
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, United States
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Petrovic BD, Burman D, Chowdhry S, Bailes JE, Meyer J. Pictorial essay: How co-registered BOLD fMRI and DTI data can improve diffusion tensor tractography. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Skyrman S, Lai M, Edström E, Burström G, Förander P, Homan R, Kor F, Holthuizen R, Hendriks BHW, Persson O, Elmi-Terander A. Augmented reality navigation for cranial biopsy and external ventricular drain insertion. Neurosurg Focus 2021; 51:E7. [PMID: 34333469 DOI: 10.3171/2021.5.focus20813] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 05/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the accuracy (deviation from the target or intended path) and efficacy (insertion time) of an augmented reality surgical navigation (ARSN) system for insertion of biopsy needles and external ventricular drains (EVDs), two common neurosurgical procedures that require high precision. METHODS The hybrid operating room-based ARSN system, comprising a robotic C-arm with intraoperative cone-beam CT (CBCT) and integrated video tracking of the patient and instruments using nonobtrusive adhesive optical markers, was used. A 3D-printed skull phantom with a realistic gelatinous brain model containing air-filled ventricles and 2-mm spherical biopsy targets was obtained. After initial CBCT acquisition for target registration and planning, ARSN was used for 30 cranial biopsies and 10 EVD insertions. Needle positions were verified by CBCT. RESULTS The mean accuracy of the biopsy needle insertions (n = 30) was 0.8 mm ± 0.43 mm. The median path length was 39 mm (range 16-104 mm) and did not correlate to accuracy (p = 0.15). The median device insertion time was 149 seconds (range 87-233 seconds). The mean accuracy for the EVD insertions (n = 10) was 2.9 mm ± 0.8 mm at the tip with a 0.7° ± 0.5° angular deviation compared with the planned path, and the median insertion time was 188 seconds (range 135-400 seconds). CONCLUSIONS This study demonstrated that ARSN can be used for navigation of percutaneous cranial biopsies and EVDs with high accuracy and efficacy.
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Affiliation(s)
- Simon Skyrman
- 1Department of Neurosurgery, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Marco Lai
- 2Philips Research, High Tech Campus 34, Eindhoven.,3Eindhoven University of Technology (TU/e), Eindhoven
| | - Erik Edström
- 1Department of Neurosurgery, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gustav Burström
- 1Department of Neurosurgery, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Petter Förander
- 1Department of Neurosurgery, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Flip Kor
- 5Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | | | - Benno H W Hendriks
- 2Philips Research, High Tech Campus 34, Eindhoven.,5Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Oscar Persson
- 1Department of Neurosurgery, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Adrian Elmi-Terander
- 1Department of Neurosurgery, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Yang JYM, Yeh CH, Poupon C, Calamante F. Diffusion MRI tractography for neurosurgery: the basics, current state, technical reliability and challenges. Phys Med Biol 2021; 66. [PMID: 34157706 DOI: 10.1088/1361-6560/ac0d90] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/22/2021] [Indexed: 01/20/2023]
Abstract
Diffusion magnetic resonance imaging (dMRI) tractography is currently the only imaging technique that allows for non-invasive delineation and visualisation of white matter (WM) tractsin vivo,prompting rapid advances in related fields of brain MRI research in recent years. One of its major clinical applications is for pre-surgical planning and intraoperative image guidance in neurosurgery, where knowledge about the location of WM tracts nearby the surgical target can be helpful to guide surgical resection and optimise post-surgical outcomes. Surgical injuries to these WM tracts can lead to permanent neurological and functional deficits, making the accuracy of tractography reconstructions paramount. The quality of dMRI tractography is influenced by many modifiable factors, ranging from MRI data acquisition through to the post-processing of tractography output, with the potential of error propagation based on decisions made at each and subsequent processing steps. Research over the last 25 years has significantly improved the anatomical accuracy of tractography. An updated review about tractography methodology in the context of neurosurgery is now timely given the thriving research activities in dMRI, to ensure more appropriate applications in the clinical neurosurgical realm. This article aims to review the dMRI physics, and tractography methodologies, highlighting recent advances to provide the key concepts of tractography-informed neurosurgery, with a focus on the general considerations, the current state of practice, technical challenges, potential advances, and future demands to this field.
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Affiliation(s)
- Joseph Yuan-Mou Yang
- Department of Neurosurgery, The Royal Children's Hospital, Melbourne, Australia.,Neuroscience Research, Murdoch Children's Research Institute, Melbourne, Australia.,Developmental Imaging, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Chun-Hung Yeh
- Institute for Radiological Research, Chang Gung University and Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Child and Adolescent Psychiatry, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Cyril Poupon
- NeuroSpin, Frédéric Joliot Life Sciences Institute, CEA, CNRS, Paris-Saclay University, Gif-sur-Yvette, France
| | - Fernando Calamante
- The University of Sydney, Sydney Imaging, Sydney, Australia.,The University of Sydney, School of Biomedical Engineering, Sydney, Australia
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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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Ibrahim O, Hafez MA, Haleem HA, El Maghraby H. Recent Advances in the Treatment of Gliomas: The Multimodal Care Therapy. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Glioblastoma (GBM) is the most devastating primary malignancy of the central nervous system in adults. At present, standard treatment consists of maximal safe surgical resection followed by radiotherapy (60 Gray) with concomitant daily temozolomide chemotherapy. Low-grade gliomas constitute approximately 15% of the nearly primary brain tumors diagnosed in adults each year. Extent of tumor resection has become a strong predictor of patient outcomes, alongside patient age, performance status, tumor histology, and molecular genetics (isocitrate dehydrogenase-1 and 1p/19q codeletion status). Over the past two decades, surgeons have emphasized the importance of maximizing extent of resection and its impact on overall survival, progression-free survival, and time to malignant transformation.
AIM: We aimed to present recent advances in the treatment of gliomas.
METHODS: This is a prospective analysis of 50 patients diagnosed with gliomas which are enrolled in a joint supervision between Kasr Al Aini Hospital, Cairo University, Egypt, and Coventry University Hospitals, England.
RESULTS: The study included 50 patients, 31 males and 19 females, ages ranged from 21 to 75 years (mean age 47.5 years). Gross total resection was achieved in 28 patients (56%). The most common surgical complication in our series was post-operative transient weakness in 4 patients (8%). Mean true survival of low-grade glioma patients was 40.5 months while the mean true survival for anaplastic astrocytoma (Grade 3) patients was 38 months and that of GBM (Grade 4) patients was 18.8 months.
CONCLUSION: Despite persistent limitations in the quality of data, mounting evidence suggests that more extensive surgical resection is associated with longer life expectancy for both low- and high-grade gliomas.
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Gogos AJ, Young JS, Morshed RA, Avalos LN, Noss RS, Villanueva-Meyer JE, Hervey-Jumper SL, Berger MS. Triple motor mapping: transcranial, bipolar, and monopolar mapping for supratentorial glioma resection adjacent to motor pathways. J Neurosurg 2021; 134:1728-1737. [PMID: 32502996 DOI: 10.3171/2020.3.jns193434] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Maximal safe resection of gliomas near motor pathways is facilitated by intraoperative mapping. The authors and other groups have described the use of bipolar or monopolar direct stimulation to identify functional tissue, as well as transcranial or transcortical motor evoked potentials (MEPs) to monitor motor pathways. Here, the authors describe their initial experience using all 3 modalities to identify, monitor, and preserve cortical and subcortical motor systems during glioma surgery. METHODS Intraoperative mapping data were extracted from a prospective registry of glioma resections near motor pathways. Additional demographic, clinical, pathological, and imaging data were extracted from the electronic medical record. All patients with new or worsened postoperative motor deficits were followed for at least 6 months. RESULTS Between January 2018 and August 2019, 59 operations were performed in 58 patients. Overall, patients in 6 cases (10.2%) had new or worse immediate postoperative deficits. Patients with temporary deficits all had at least Medical Research Council grade 4/5 power. Only 2 patients (3.4%) had permanently worsened deficits after 6 months, both of which were associated with diffusion restriction consistent with ischemia within the corticospinal tract. One patient's deficit improved to 4/5 and the other to 4/5 proximally and 3/5 distally in the lower limb, allowing ambulation following rehabilitation. Subcortical motor pathways were identified in 51 cases (86.4%) with monopolar high-frequency stimulation, but only in 6 patients using bipolar stimulation. Transcranial or cortical MEPs were diminished in only 6 cases, 3 of which had new or worsened deficits, with 1 permanent deficit. Insula location (p = 0.001) and reduction in MEPs (p = 0.01) were the only univariate predictors of new or worsened postoperative deficits. Insula location was the only predictor of permanent deficits (p = 0.046). The median extent of resection was 98.0%. CONCLUSIONS Asleep triple motor mapping is safe and resulted in a low rate of deficits without compromising the extent of resection.
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Affiliation(s)
| | | | | | | | - Roger S Noss
- 3Neuromonitoring Service, University of California, San Francisco, California
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Hoch MJ, Bruno M, Pacione D, Lui YW, Fieremans E, Shepherd TM. Simultaneous Multislice for Accelerating Diffusion MRI in Clinical Neuroradiology Protocols. AJNR Am J Neuroradiol 2021; 42:1437-1443. [PMID: 33985946 DOI: 10.3174/ajnr.a7140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/04/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND PURPOSE Diffusion MR imaging sequences essential for clinical neuroradiology imaging protocols may be accelerated with simultaneous multislice acquisitions. We tested whether simultaneous multislice-accelerated diffusion data were clinically equivalent to standard acquisitions. MATERIALS AND METHODS In this retrospective study, clinical diffusion sequences obtained before and after implementation of 2-slice simultaneous multislice acceleration and an altered diffusion gradient sampling scheme using the same 3T MRI scanner and 20-channel coil (n = 25 per group) were independently and blindly evaluated by 2 neuroradiologists for perceived quality, artifacts, and overall diagnostic utility. Diffusion tractography was performed in 13 patients both with and without 2-slice simultaneous multislice acceleration (b = 0, 1000, 2000 s/mm2; 60 directions). The corticospinal tract and arcuate fasciculus ipsilateral to the lesion were generated using the same ROIs and then blindly assessed by a neurosurgeon for anatomic fidelity, perceived quality, and impact on surgical management. Tract volumes were compared for spatial overlap. RESULTS Two-slice simultaneous multislice diffusion reduced acquisition times from 141 to 45 seconds for routine diffusion and from 7.5 to 5.9 minutes for diffusion tractography using 3T MR imaging. The simultaneous multislice-accelerated diffusion sequence was rated equivalent for diagnostic utility despite reductions to perceived image quality. Simultaneous multislice-accelerated diffusion tractography was rated clinically equivalent. Dice similarity coefficients between routine and simultaneous multislice-generated corticospinal tract and arcuate fasciculus tract volumes were 0.78 (SD, 0.03) and 0.71 (SD, 0.05), respectively. CONCLUSIONS Two-slice simultaneous multislice diffusion appeared clinically equivalent for standard acquisitions and diffusion tractography. Simultaneous multislice makes it feasible to acquire higher angular and q-space-resolution diffusion acquisitions required for translating advanced diffusion models into clinical practice.
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Affiliation(s)
- M J Hoch
- From the Department of Radiology (M.J.H.), University of Pennsylvania, Philadelphia, Pennsylvania
| | - M Bruno
- Department of Radiology (M.B., Y.W.L., E.F., T.M.S.), New York University Langone School of Medicine, New York, New York
| | - D Pacione
- Department of Neurosurgery (D.P.), New York University Langone School of Medicine, New York, New York
| | - Y W Lui
- Department of Radiology (M.B., Y.W.L., E.F., T.M.S.), New York University Langone School of Medicine, New York, New York
| | - E Fieremans
- Department of Radiology (M.B., Y.W.L., E.F., T.M.S.), New York University Langone School of Medicine, New York, New York.,Center for Advanced Imaging Innovation and Research (E.F.), New York, New York
| | - T M Shepherd
- Department of Radiology (M.B., Y.W.L., E.F., T.M.S.), New York University Langone School of Medicine, New York, New York
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Hu R, Hoch MJ. Application of Diffusion Weighted Imaging and Diffusion Tensor Imaging in the Pretreatment and Post-treatment of Brain Tumor. Radiol Clin North Am 2021; 59:335-347. [PMID: 33926681 DOI: 10.1016/j.rcl.2021.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Diffusion MR imaging exploits the diffusion properties of water to generate contrast between normal tissue and pathology. Diffusion is an essential component of nearly all brain tumor MR imaging examinations. This review covers the important clinical applications of diffusion weighted imaging in the pretreatment diagnosis and grading of brain tumors and assessment of treatment response. Diffusion imaging improves the accuracy of identifying treatment-related effects that may mimic tumor improvement or worsening. Fiber tractography models of eloquent white matter pathways are generated using diffusion tensor imaging. A practical and concise tractography guide is provided for anyone new to preoperative surgical mapping.
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Affiliation(s)
- Ranliang Hu
- Department of Radiology & Imaging Sciences, Emory University, Emory University Hospital, 1364 Clifton Road, BG 20, Atlanta, GA 30322, USA
| | - Michael J Hoch
- Department of Radiology, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Suite 130, Philadelphia, PA 19104, USA.
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Briggs RG, Lin YH, Dadario NB, Kim SJ, Young IM, Bai MY, Dhanaraj V, Fonseka RD, Hormovas J, Tanglay O, Chakraborty AR, Milligan TM, Abraham CJ, Anderson CD, Palejwala AH, Conner AK, O'Donoghue DL, Sughrue ME. Anatomy and White Matter Connections of the Middle Frontal Gyrus. World Neurosurg 2021; 150:e520-e529. [PMID: 33744423 DOI: 10.1016/j.wneu.2021.03.045] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The middle frontal gyrus (MFG) is involved in attention, working memory, and language-related processing. A detailed understanding of the subcortical white matter tracts connected within the MFG can facilitate improved navigation of white matter lesions in and around this gyrus and explain the postoperative morbidity after surgery. We aimed to characterize the fiber tracts within the MFG according to their connection to neuroanatomic structures through the use of diffusion spectrum imaging-based fiber tractography and validate the findings by gross anatomic dissection for qualitative visual agreement. METHODS Tractography analysis was completed using diffusion imaging data from 10 healthy, adult subjects enrolled in the Human Connectome Project. We assessed the MFG as a whole component according to its fiber connectivity with other neural regions. Mapping was completed on all tracts within both hemispheres, with the resultant tract volumes used to calculate a lateralization index. A modified Klingler technique was used on 10 postmortem dissections to demonstrate the location and orientation of the major tracts. RESULTS Two major connections of the MFG were identified: the superior longitudinal fasciculus, which connects the MFG to parts of the inferior parietal lobule, posterior temporal lobe, and lateral occipital cortex; and the inferior fronto-occipital fasciculus, which connected the MFG to the lingual gyrus and cuneus. Intra- and intergyral short association, U-shaped fibers were also identified. CONCLUSIONS Subcortical white matter pathways integrated within the MFG include the superior longitudinal fasciculus and inferior fronto-occipital fasciculus. The MFG is implicated in a variety of tasks involving attention and memory, making it an important cortical region. The postoperative neurologic outcomes related to surgery in and around the MFG could be clarified in the context of the anatomy of the fiber bundles highlighted in the present study.
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Affiliation(s)
- Robert G Briggs
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Yueh-Hsin Lin
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Nicholas B Dadario
- Rutgers Robert Wood Johnson School of Medicine, Rutgers University, New Brunswick, New Jersey, USA
| | - Sihyong J Kim
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Isabella M Young
- Cingulum Research, Cingulum Health, Sydney, New South Wales, Australia
| | - Michael Y Bai
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Vukshitha Dhanaraj
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - R Dineth Fonseka
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Jorge Hormovas
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Onur Tanglay
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Arpan R Chakraborty
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Ty M Milligan
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Carol J Abraham
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Christopher D Anderson
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Ali H Palejwala
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Daniel L O'Donoghue
- Department of Cell Biology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia.
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Zoli M, Talozzi L, Martinoni M, Manners DN, Badaloni F, Testa C, Asioli S, Mitolo M, Bartiromo F, Rochat MJ, Fabbri VP, Sturiale C, Conti A, Lodi R, Mazzatenta D, Tonon C. From Neurosurgical Planning to Histopathological Brain Tumor Characterization: Potentialities of Arcuate Fasciculus Along-Tract Diffusion Tensor Imaging Tractography Measures. Front Neurol 2021; 12:633209. [PMID: 33716935 PMCID: PMC7952864 DOI: 10.3389/fneur.2021.633209] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/26/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Tractography has been widely adopted to improve brain gliomas' surgical planning and guide their resection. This study aimed to evaluate state-of-the-art of arcuate fasciculus (AF) tractography for surgical planning and explore the role of along-tract analyses in vivo for characterizing tumor histopathology. Methods: High angular resolution diffusion imaging (HARDI) images were acquired for nine patients with tumors located in or near language areas (age: 41 ± 14 years, mean ± standard deviation; five males) and 32 healthy volunteers (age: 39 ± 16 years; 16 males). Phonemic fluency task fMRI was acquired preoperatively for patients. AF tractography was performed using constrained spherical deconvolution diffusivity modeling and probabilistic fiber tracking. Along-tract analyses were performed, dividing the AF into 15 segments along the length of the tract defined using the Laplacian operator. For each AF segment, diffusion tensor imaging (DTI) measures were compared with those obtained in healthy controls (HCs). The hemispheric laterality index (LI) was calculated from language task fMRI activations in the frontal, parietal, and temporal lobe parcellations. Tumors were grouped into low/high grade (LG/HG). Results: Four tumors were LG gliomas (one dysembryoplastic neuroepithelial tumor and three glioma grade II) and five HG gliomas (two grade III and three grade IV). For LG tumors, gross total removal was achieved in all but one case, for HG in two patients. Tractography identified the AF trajectory in all cases. Four along-tract DTI measures potentially discriminated LG and HG tumor patients (false discovery rate < 0.1): the number of abnormal MD and RD segments, median AD, and MD measures. Both a higher number of abnormal AF segments and a higher AD and MD measures were associated with HG tumor patients. Moreover, correlations (unadjusted p < 0.05) were found between the parietal lobe LI and the DTI measures, which discriminated between LG and HG tumor patients. In particular, a more rightward parietal lobe activation (LI < 0) correlated with a higher number of abnormal MD segments (R = −0.732) and RD segments (R = −0.724). Conclusions: AF tractography allows to detect the course of the tract, favoring the safer-as-possible tumor resection. Our preliminary study shows that along-tract DTI metrics can provide useful information for differentiating LG and HG tumors during pre-surgical tumor characterization.
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Affiliation(s)
- Matteo Zoli
- Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Lia Talozzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Matteo Martinoni
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - David N Manners
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Filippo Badaloni
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Claudia Testa
- Department of Physics and Astronomy, University of Bologna, Bologna, Italy
| | - Sofia Asioli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Anatomic Pathology Unit, Azienda USL di Bologna, Bologna, Italy
| | - Micaela Mitolo
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Fiorina Bartiromo
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Magali Jane Rochat
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Viscardo Paolo Fabbri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Carmelo Sturiale
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Alfredo Conti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Raffaele Lodi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Diego Mazzatenta
- Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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Henderson F, Abdullah KG, Verma R, Brem S. Tractography and the connectome in neurosurgical treatment of gliomas: the premise, the progress, and the potential. Neurosurg Focus 2021; 48:E6. [PMID: 32006950 DOI: 10.3171/2019.11.focus19785] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/13/2019] [Indexed: 12/21/2022]
Abstract
The ability of diffusion tensor MRI to detect the preferential diffusion of water in cerebral white matter tracts enables neurosurgeons to noninvasively visualize the relationship of lesions to functional neural pathways. Although viewed as a research tool in its infancy, diffusion tractography has evolved into a neurosurgical tool with applications in glioma surgery that are enhanced by evolutions in crossing fiber visualization, edema correction, and automated tract identification. In this paper the current literature supporting the use of tractography in brain tumor surgery is summarized, highlighting important clinical studies on the application of diffusion tensor imaging (DTI) for preoperative planning of glioma resection, and risk assessment to analyze postoperative outcomes. The key methods of tractography in current practice and crucial white matter fiber bundles are summarized. After a review of the physical basis of DTI and post-DTI tractography, the authors discuss the methodologies with which to adapt DT image processing for surgical planning, as well as the potential of connectomic imaging to facilitate a network approach to oncofunctional optimization in glioma surgery.
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Affiliation(s)
- Fraser Henderson
- 1Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania.,3Department of Neurosurgery, The Medical University of South Carolina, Charleston, South Carolina; and
| | - Kalil G Abdullah
- 4Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ragini Verma
- 1Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania.,2DiCIPHR (Diffusion and Connectomics in Precision Healthcare Research) Lab, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven Brem
- 1Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania
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Schneider JR, Raval AB, Black K, Schulder M. Diffusion Tensor Imaging Color-Coded Maps: An Alternative to Tractography. Stereotact Funct Neurosurg 2021; 99:295-304. [PMID: 33461209 DOI: 10.1159/000512092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 10/04/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION White matter tracts can be observed using tractograms generated from diffusion tensor imaging (DTI). However, the dependence of these white matter tract images on subjective variables, including how seed points are placed and the preferred level of fractional anisotropy, introduces interobserver inconsistency and potential lack of reliability. We propose that color-coded maps (CCM) generated from DTI can be a preferred method for the visualization of important white matter tracts, circumventing bias in preoperative brain tumor resection planning. METHODS DTI was acquired retrospectively in 25 patients with brain tumors. Lesions included 15 tumors of glial origin, 9 metastatic tumors, 2 meningiomas, and 1 cavernous angioma. Tractograms of the pyramidal tract and/or optic radiations, based on tumor location, were created by marking seed regions of interest using known anatomical locations. We compared the degree of tract involvement and white matter alteration between CCMs and tractograms. Neurological outcomes were obtained from chart reviews. RESULTS The pyramidal tract was evaluated in 20/25 patients, the visual tracts were evaluated in 10/25, and both tracts were evaluated in 5/25. In 19/25 studies, the same patterns of white matter alternations were found between the CCMs and tractograms. In the 6 patients where patterns differed, 2 tractograms were not useful in determining pattern alteration; in the remaining 4/6, no practical difference was seen in comparing the studies. Two patients were lost to follow-up. Thirteen patients were neurologically improved or remained intact after intervention. In these, 10 of the 13 patients showed tumor-induced white matter tract displacement on CCM. Twelve patients had no improvement of their preoperative deficit. In 9 of these 12 patients, CCM showed white matter disruption. CONCLUSION CCMs provide a convenient, practical, and objective method of visualizing white matter tracts, obviating the need for potentially subjective and time-consuming tractography. CCMs are at least as reliable as tractograms in predicting neurological outcomes after neurosurgical intervention.
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Affiliation(s)
- Julia R Schneider
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Ami B Raval
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Karen Black
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Michael Schulder
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA,
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48
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Fountain DM, Bryant A, Barone DG, Waqar M, Hart MG, Bulbeck H, Kernohan A, Watts C, Jenkinson MD. Intraoperative imaging technology to maximise extent of resection for glioma: a network meta-analysis. Cochrane Database Syst Rev 2021; 1:CD013630. [PMID: 33428222 PMCID: PMC8094975 DOI: 10.1002/14651858.cd013630.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Multiple studies have identified the prognostic relevance of extent of resection in the management of glioma. Different intraoperative technologies have emerged in recent years with unknown comparative efficacy in optimising extent of resection. One previous Cochrane Review provided low- to very low-certainty evidence in single trial analyses and synthesis of results was not possible. The role of intraoperative technology in maximising extent of resection remains uncertain. Due to the multiple complementary technologies available, this research question is amenable to a network meta-analysis methodological approach. OBJECTIVES To establish the comparative effectiveness and risk profile of specific intraoperative imaging technologies using a network meta-analysis and to identify cost analyses and economic evaluations as part of a brief economic commentary. SEARCH METHODS We searched CENTRAL (2020, Issue 5), MEDLINE via Ovid to May week 2 2020, and Embase via Ovid to 2020 week 20. We performed backward searching of all identified studies. We handsearched two journals, Neuro-oncology and the Journal of Neuro-oncology from 1990 to 2019 including all conference abstracts. Finally, we contacted recognised experts in neuro-oncology to identify any additional eligible studies and acquire information on ongoing randomised controlled trials (RCTs). SELECTION CRITERIA RCTs evaluating people of all ages with presumed new or recurrent glial tumours (of any location or histology) from clinical examination and imaging (computed tomography (CT) or magnetic resonance imaging (MRI), or both). Additional imaging modalities (e.g. positron emission tomography, magnetic resonance spectroscopy) were not mandatory. Interventions included fluorescence-guided surgery, intraoperative ultrasound, neuronavigation (with or without additional image processing, e.g. tractography), and intraoperative MRI. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the search results for relevance, undertook critical appraisal according to known guidelines, and extracted data using a prespecified pro forma. MAIN RESULTS We identified four RCTs, using different intraoperative imaging technologies: intraoperative magnetic resonance imaging (iMRI) (2 trials, with 58 and 14 participants); fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) (1 trial, 322 participants); and neuronavigation (1 trial, 45 participants). We identified one ongoing trial assessing iMRI with a planned sample size of 304 participants for which results are expected to be published around winter 2020. We identified no published trials for intraoperative ultrasound. Network meta-analyses or traditional meta-analyses were not appropriate due to absence of homogeneous trials across imaging technologies. Of the included trials, there was notable heterogeneity in tumour location and imaging technologies utilised in control arms. There were significant concerns regarding risk of bias in all the included studies. One trial of iMRI found increased extent of resection (risk ratio (RR) for incomplete resection was 0.13, 95% confidence interval (CI) 0.02 to 0.96; 49 participants; very low-certainty evidence) and one trial of 5-ALA (RR for incomplete resection was 0.55, 95% CI 0.42 to 0.71; 270 participants; low-certainty evidence). The other trial assessing iMRI was stopped early after an unplanned interim analysis including 14 participants; therefore, the trial provided very low-quality evidence. The trial of neuronavigation provided insufficient data to evaluate the effects on extent of resection. Reporting of adverse events was incomplete and suggestive of significant reporting bias (very low-certainty evidence). Overall, the proportion of reported events was low in most trials and, therefore, issues with power to detect differences in outcomes that may or may not have been present. Survival outcomes were not adequately reported, although one trial reported no evidence of improvement in overall survival with 5-ALA (hazard ratio (HR) 0.82, 95% CI 0.62 to 1.07; 270 participants; low-certainty evidence). Data for quality of life were only available for one study and there was significant attrition bias (very low-certainty evidence). AUTHORS' CONCLUSIONS Intraoperative imaging technologies, specifically 5-ALA and iMRI, may be of benefit in maximising extent of resection in participants with high-grade glioma. However, this is based on low- to very low-certainty evidence. Therefore, the short- and long-term neurological effects are uncertain. Effects of image-guided surgery on overall survival, progression-free survival, and quality of life are unclear. Network and traditional meta-analyses were not possible due to the identified high risk of bias, heterogeneity, and small trials included in this review. A brief economic commentary found limited economic evidence for the equivocal use of iMRI compared with conventional surgery. In terms of costs, one non-systematic review of economic studies suggested that, compared with standard surgery, use of image-guided surgery has an uncertain effect on costs and that 5-ALA was more costly. Further research, including completion of ongoing trials of ultrasound-guided surgery, is needed.
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Affiliation(s)
- Daniel M Fountain
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Damiano Giuseppe Barone
- Department of Clinical Neurosciences, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Mueez Waqar
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Michael G Hart
- Academic Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrookes Hospital, Cambridge, UK
| | | | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Colin Watts
- Chair Birmingham Brain Cancer Program, University of Birmingham, Edgbaston, UK
| | - Michael D Jenkinson
- Department of Neurosurgery & Institute of Systems Molecular and Integrative Biology, The Walton Centre & University of Liverpool, Liverpool, UK
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Xiao X, Kong L, Pan C, Zhang P, Chen X, Sun T, Wang M, Qiao H, Wu Z, Zhang J, Zhang L. The role of diffusion tensor imaging and tractography in the surgical management of brainstem gliomas. Neurosurg Focus 2021; 50:E10. [PMID: 33386023 DOI: 10.3171/2020.10.focus20166] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 10/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) have the ability to noninvasively visualize changes in white matter tracts, as well as their relationships with lesions and other structures. DTI/DTT has been increasingly used to improve the safety and results of surgical treatment for lesions in eloquent areas, such as brainstem cavernous malformations. This study aimed to investigate the application value of DTI/DTT in brainstem glioma surgery and to validate the spatial accuracy of reconstructed corticospinal tracts (CSTs). METHODS A retrospective analysis was performed on 54 patients with brainstem gliomas who had undergone surgery from January 2016 to December 2018 at Beijing Tiantan Hospital. All patients underwent preoperative DTI and tumor resection with the assistance of DTT-merged neuronavigation and electrophysiological monitoring. Preoperative conventional MRI and DTI data were collected, and the muscle strength and modified Rankin Scale (mRS) score before and after surgery were measured. The surgical plan was created with the assistance of DTI/DTT findings. The accuracy of DTI/DTT was validated by performing direct subcortical stimulation (DsCS) intraoperatively. Multiple linear regression was used to investigate the relationship between quantitative parameters of DTI/DTT (such as the CST score and tumor-to-CST distance [TCD]) and postoperative muscle strength and mRS scores. RESULTS Among the 54 patients, 6 had normal bilateral CSTs, 12 patients had unilateral CST impairments, and 36 had bilateral CSTs involved. The most common changes in the CSTs were deformation (n = 29), followed by deviation (n = 28) and interruption (n = 27). The surgical approach was changed in 18 cases (33.3%) after accounting for the DTI/DTT results. Among 55 CSTs on which DsCS was performed, 46 (83.6%) were validated as spatially accurate by DsCS. The CST score and TCD were significantly correlated with postoperative muscle strength (r = -0.395, p < 0.001, and r = 0.275, p = 0.004, respectively) and postoperative mRS score (r = 0.430, p = 0.001, and r = -0.329, p = 0.015, respectively). The CST score was independently linearly associated with postoperative muscle strength (t = -2.461, p = 0.016) and the postoperative mRS score (t = 2.052, p = 0.046). CONCLUSIONS DTI/DTT is a valuable tool in the surgical management of brainstem gliomas. With good accuracy, it can help optimize surgical planning, guide tumor resection, and predict the postoperative muscle strength and postoperative quality of life of patients.
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Affiliation(s)
| | - Lu Kong
- Departments of1Neurosurgery and
| | | | | | | | - Tao Sun
- Departments of1Neurosurgery and
| | - Mingran Wang
- 2Beijing Neurosurgical Institute, Capital Medical University; and.,3Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University
| | - Hui Qiao
- 2Beijing Neurosurgical Institute, Capital Medical University; and.,3Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University
| | - Zhen Wu
- Departments of1Neurosurgery and
| | | | - Liwei Zhang
- Departments of1Neurosurgery and.,4China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
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50
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Li FY, Liu HY, Zhang J, Sun ZH, Zhang JS, Sun GC, Yu XG, Chen XL, Xu BN. Identification of risk factors for poor language outcome in surgical resection of glioma involving the arcuate fasciculus: an observational study. Neural Regen Res 2021; 16:333-337. [PMID: 32859793 PMCID: PMC7896210 DOI: 10.4103/1673-5374.290901] [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] [Indexed: 01/12/2023] Open
Abstract
The arcuate fasciculus is a critical component of the neural substrate of human language function. Surgical resection of glioma adjacent to the arcuate fasciculus likely damages this region. In this study, we evaluated the outcome of surgical resection of glioma adjacent to the arcuate fasciculus under the guidance of magnetic resonance imaging and diffusion tensor imaging, and we aimed to identify the risk factors for postoperative linguistic deficit. In total, 54 patients with primary glioma adjacent to the arcuate fasciculus were included in this observational study. These patients comprised 38 men and 16 women (aged 43 ± 11 years). All patients underwent surgical resenction of glioma under the guidance of magnetic resonance imaging and diffusion tensor imaging. Intraoperative images were updated when necessary for further resection. The gross total resection rate of the 54 patients increased from 38.9% to 70.4% by intraoperative magnetic resonance imaging. Preoperative language function and glioma-to-arcuate fasciculus distance were associated with poor language outcome. Multivariable logistic regression analyses showed that glioma-to-arcuate fasciculus distance was the major independent risk factor for poor outcome. The cutoff point of glioma-to-arcuate fasciculus distance for poor outcome was 3.2 mm. These findings suggest that intraoperative magnetic resonance imaging combined with diffusion tensor imaging of the arcuate fasciculus can help optimize tumor resection and result in the least damage to the arcuate fasciculus. Notably, glioma-to-arcuate fasciculus distance is a key independent risk factor for poor postoperative language outcome. This study was approved by the Ethics Committee of the Chinese PLA General Hospital, China (approval No. S2014-096-01) on October 11, 2014.
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Affiliation(s)
- Fang-Ye Li
- Department of Neurosurgery, First Medical Center of Chinese PLA General Hospital, Beijing; Department of Neurosurgery, Hainan Hospital of Chinese PLA General Hospital, Sanya, Hainan Province, China
| | - Hong-Yu Liu
- Department of Neurosurgery, Hainan Hospital of Chinese PLA General Hospital, Sanya, Hainan Province, China
| | - Jun Zhang
- Department of Neurosurgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zheng-Hui Sun
- Department of Neurosurgery, First Medical Center of Chinese PLA General Hospital, Beijing; Department of Neurosurgery, Hainan Hospital of Chinese PLA General Hospital, Sanya, Hainan Province, China
| | - Jia-Shu Zhang
- Department of Neurosurgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Guo-Chen Sun
- Department of Neurosurgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xin-Guang Yu
- Department of Neurosurgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao-Lei Chen
- Department of Neurosurgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Bai-Nan Xu
- Department of Neurosurgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
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