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Seidel K, Szelényi A, Bello L. Intraoperative mapping and monitoring during brain tumor surgeries. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:133-149. [PMID: 35772883 DOI: 10.1016/b978-0-12-819826-1.00013-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Many different methodologies and paradigms are available to guide surgery of supratentorial tumors with the aim to preserve quality of life of the patients and to increase the extent of tumor resection. Neurophysiologic monitoring techniques (such as different evoked potentials) may help to continuously assess functional integrity of the observed systems and warn about vascular injury. For neurophysiologic mapping methods, the focus is not only to preserve cortical sites, but also to prevent injury to subcortical pathways. Therefore, cortical mapping is not enough but should be combined with subcortical mapping to identify tracts. This may be done by alternating resection and stimulation, or by continuous mapping via an electrified surgical tool such as a stimulating suction tip. Increasingly refined techniques are evolving to improve mapping of complex motor networks as well as language and higher cortical functions. Finally, in deciding between an awake vs asleep intraoperative setting, various factors need to be considered, such as the surgical goal, patient expectation and cooperation, treating team expertise, and neurooncologic aspects including histopathology. Therefore, the choice of protocol depends on the clinical context and the experience of the interdisciplinary team treating the patients.
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Affiliation(s)
- Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Andrea Szelényi
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Lorenzo Bello
- Department of Oncology and Hemato-Oncology, Neurosurgical Oncology Unit, Università degli Studi di Milano, Milan, Italy
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2
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Rossi M, Sciortino T, Conti Nibali M, Gay L, Viganò L, Puglisi G, Leonetti A, Howells H, Fornia L, Cerri G, Riva M, Bello L. Clinical Pearls and Methods for Intraoperative Motor Mapping. Neurosurgery 2021; 88:457-467. [PMID: 33476393 PMCID: PMC7884143 DOI: 10.1093/neuros/nyaa359] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/26/2020] [Indexed: 12/13/2022] Open
Abstract
Resection of brain tumors involving motor areas and pathways requires the identification and preservation of various cortical and subcortical structures involved in motor control at the time of the procedure, in order to maintain the patient's full motor capacities. The use of brain mapping techniques has now been integrated into clinical practice for many years, as they help the surgeon to identify the neural structures involved in motor functions. A common definition of motor function, as well as knowledge of its neural organization, has been continuously evolving, underlining the need for implementing intraoperative strategies at the time of the procedure. Similarly, mapping strategies have been subjected to continuous changes, enhancing the likelihood of preservation of full motor capacities. As a general rule, the motor mapping strategy should be as flexible as possible and adapted strictly to the individual patient and clinical context of the tumor. In this work, we present an overview of current knowledge of motor organization, indications for motor mapping, available motor mapping, and monitoring strategies, as well as their advantages and limitations. The use of motor mapping improves resection and outcomes in patients harboring tumors involving motor areas and pathways, and should be considered the gold standard in the resection of this type of tumor.
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Affiliation(s)
- Marco Rossi
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Marco Conti Nibali
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Gay
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Luca Viganò
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Antonella Leonetti
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Luca Fornia
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Gabriella Cerri
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Marco Riva
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
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Lim SH, Kim KK, Jang MH, Kim KE, Park SK. Artifacts and Troubleshooting in Intraoperative Neurophysiological Monitoring. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2021. [DOI: 10.15324/kjcls.2021.53.1.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sung Hyuk Lim
- Department of Neurology, Institute of Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Kap Kyu Kim
- Department of Rehabilitation Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Min Hwan Jang
- Department of Neurology, Institute of Neuroscience Center, Samsung Medical Center, Seoul, Korea
| | - Ki Eob Kim
- Department of Neurology, Korea University Anam Hospital, Seoul, Korea
| | - Sang-Ku Park
- Department of Neurosurgery, Konkuk University Medical Center, Seoul, Korea
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Boëx C, Goga C, Bérard N, Haemmerli J, Zegarek G, Bartoli A, Momjian S, Schaller K. Introduction of a novel connection clip for the ultrasonic aspirator for subcortical continuous motor mapping. BRAIN AND SPINE 2021; 1:100002. [PMID: 36247400 PMCID: PMC9559965 DOI: 10.1016/j.bas.2021.100002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 10/31/2022]
Abstract
Introduction Research question Material and methods Results Discussion Conclusion A connection clip was introduced to stimulate directly the ultrasonic aspirator For integrated and continuous motor mapping simultaneously to the resection process Distance (y, mm) of the stimulation (x, mA) site to the tract found: y = 0.63x + 2.33 Confidence intervals of the regression, underline the role of motor evoked potentials Absence of seizures was observed here using biphasic pulse waveform
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Benyaich Z, Hajhouji F, Laghmari M, Ghannane H, Aniba K, Lmejjati M, Ait Benali S. Awake Craniotomy with Functional Mapping for Glioma Resection in a Limited-Resource-Setting: Preliminary Experience from a Lower-Middle Income Country. World Neurosurg 2020; 139:200-207. [PMID: 32311556 DOI: 10.1016/j.wneu.2020.04.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/04/2020] [Accepted: 04/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Awake craniotomy with brain mapping aims to maximize resection of gliomas located within eloquent regions while minimizing the risk of postoperative deficits. This technique is common practice in the developed world but has yet to be implemented in most low- and middle-income countries (LMICs). We assessed the feasibility, safety, and efficiency of functional-based glioma resection using minimal facilities in a limited-resource institution. METHODS This is a retrospective review of patients harboring gliomas within eloquent regions who underwent awake craniotomy and tumor resection guided by cortico-subcortical mapping at a tertiary hospital of an LMIC. Patient characteristics, surgical results, and functional outcomes were studied. RESULTS Twenty consecutive patients with a mean age of 37 years were enrolled in the study. Seizure, present in 70% of patients, was the major presenting symptom. Eighteen patients had diffuse low-grade gliomas and 2 patients had high-grade gliomas. Intraoperative events were dominated by seizures, occurring in 5 patients (25%). The average extent of tumor removal was 89.5% and the rate of total and subtotal removal was 85%. New postoperative deficits were observed in 5 patients (25%), and permanent deficits were found in 1 patient (5%). The main hurdles encountered were the difficulties in investigating patients and human resource availability. CONCLUSIONS Awake craniotomy with brain mapping for functional-based resection of gliomas can be safely achieved in a limited-resource institution with good functional and oncologic results.
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Affiliation(s)
- Zakariae Benyaich
- Department of Neurosurgery, Mohamed the VIth University Hospital Center of Marrakech, Faculty of Medicine and Pharmacy of Marrakech, Cadi Ayyad University, Marrakech, Morocco.
| | - Farouk Hajhouji
- Department of Neurosurgery, Mohamed the VIth University Hospital Center of Marrakech, Faculty of Medicine and Pharmacy of Marrakech, Cadi Ayyad University, Marrakech, Morocco
| | - Mehdi Laghmari
- Department of Neurosurgery, Mohamed the VIth University Hospital Center of Marrakech, Faculty of Medicine and Pharmacy of Marrakech, Cadi Ayyad University, Marrakech, Morocco
| | - Houssine Ghannane
- Department of Neurosurgery, Mohamed the VIth University Hospital Center of Marrakech, Faculty of Medicine and Pharmacy of Marrakech, Cadi Ayyad University, Marrakech, Morocco
| | - Khalid Aniba
- Department of Neurosurgery, Mohamed the VIth University Hospital Center of Marrakech, Faculty of Medicine and Pharmacy of Marrakech, Cadi Ayyad University, Marrakech, Morocco
| | - Mohamed Lmejjati
- Department of Neurosurgery, Mohamed the VIth University Hospital Center of Marrakech, Faculty of Medicine and Pharmacy of Marrakech, Cadi Ayyad University, Marrakech, Morocco
| | - Said Ait Benali
- Department of Neurosurgery, Mohamed the VIth University Hospital Center of Marrakech, Faculty of Medicine and Pharmacy of Marrakech, Cadi Ayyad University, Marrakech, Morocco
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Ries SK, Piai V, Perry D, Griffin S, Jordan K, Henry R, Knight RT, Berger MS. Roles of ventral versus dorsal pathways in language production: An awake language mapping study. BRAIN AND LANGUAGE 2019; 191:17-27. [PMID: 30769167 PMCID: PMC6402581 DOI: 10.1016/j.bandl.2019.01.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 01/09/2019] [Accepted: 01/09/2019] [Indexed: 06/09/2023]
Abstract
Human language is organized along two main processing streams connecting posterior temporal cortex and inferior frontal cortex in the left hemisphere, travelling dorsal and ventral to the Sylvian fissure. Some views propose a dorsal motor versus ventral semantic division. Others propose division by combinatorial mechanism, with the dorsal stream responsible for combining elements into a sequence and the ventral stream for forming semantic dependencies independent of sequential order. We acquired data from direct cortical stimulation in the left hemisphere in 17 neurosurgical patients and subcortical resection in a subset of 10 patients as part of awake language mapping. Two language tasks were employed: a sentence generation (SG) task tested the ability to form sequential and semantic dependencies, and a picture-word interference (PWI) task manipulated semantic interference. Results show increased error rates in the SG versus PWI task during subcortical testing in the dorsal stream territory, and high error rates in both tasks in the ventral stream territory. Connectivity maps derived from diffusion imaging and seeded in the tumor sites show that patients with more errors in the SG than in the PWI task had tumor locations associated with a dorsal stream connectivity pattern. Patients with the opposite pattern of results had tumor locations associated with a more ventral stream connectivity pattern. These findings provide initial evidence using fiber tract disruption with electrical stimulation that the dorsal pathways are critical for organizing words in a sequence necessary for sentence generation, and the ventral pathways are critical for processing semantic dependencies.
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Affiliation(s)
- S K Ries
- School of Speech, Language, and Hearing Sciences, San Diego State University, United States; Center for Clinical and Cognitive Neuroscience, San Diego State University, United States; Joint Doctoral Program in Language and Communicative Disorders, San Diego State University and University of California San Diego, United States.
| | - V Piai
- Radboud University, Donders Institute for Brain Cognition and Behaviour, Donders Centre for Cognition, Nijmegen, the Netherlands; Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Department of Medical Psychology, Nijmegen, the Netherlands
| | - D Perry
- University of California San Francisco, Department of Neurological Surgery, United States
| | - S Griffin
- University of California Berkeley, Department of Psychology and the Helen Wills Neuroscience Institute, United States
| | - K Jordan
- University of California San Francisco, Department of Neurology, United States; Joint Doctoral Program in Bioengineering, University of California San Francisco and Berkeley, United States
| | - R Henry
- University of California San Francisco, Department of Neurology, United States
| | - R T Knight
- University of California Berkeley, Department of Psychology and the Helen Wills Neuroscience Institute, United States
| | - M S Berger
- University of California San Francisco, Department of Neurological Surgery, United States
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White-matter pathways and semantic processing: intrasurgical and lesion-symptom mapping evidence. NEUROIMAGE-CLINICAL 2019; 22:101704. [PMID: 30743137 PMCID: PMC6370559 DOI: 10.1016/j.nicl.2019.101704] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 11/23/2022]
Abstract
In the present study, we aimed to test the association between the correct function of the left ventral white matter pathways and semantic processing (dual stream models for language processing, Hickok & Poeppel, 2004), using a new set of language tasks during intraoperative electrical stimulation at white matter level. Additionally, we evaluated brain regions needed for correct performance on the different semantic tasks using lesion-symptom analyses (voxel lesion-symptom mapping and track-wise lesion analysis) in a sample of 62 candidates for the awake brain surgery. We found that electrical stimulation in the vicinity of the inferior longitudinal and inferior fronto-occipital fasciculi disturbed performance on semantic processing tasks. Individuals presented with significantly more semantic paraphasias during brain tumor resection than during the electrical stimulation at the cortex level. Track-wise analyses confirmed the role of these left ventral pathways in semantic processing: a significant relationship was observed between the probability of inferior fronto-occipital fasciculus disconnection/damage and the semantic matching tasks, as well as the number of semantic paraphasias in naming. Importantly, the same analyses for the total score of the Boston Naming Test confirmed significant relationships between this test score and the integrity of the inferior fronto-occipital, inferior longitudinal and uncinate fasciculi. This was further supported by the results of VLSM analyses showing a significant relationship between BNT and the presence of lesion within left middle and inferior temporal gyri. The present findings provide new intraoperative evidence for the role of the white-matter ventral pathways in semantic processing, while at the same time emphasizing the need to include a broader assessment of semantic-conceptual aspects during the awake neurosurgical intervention. This approach will ensure better preservation of functional tissue in the tumoral vicinity and therefore substantially diminish post-surgical language impairments. Direct electrical stimulation on the ventral white matter disrupts semantic processing. Track-wise analyses confirm intraoperative findings. Semantic matching a good candidate for monitoring in brain tumor surgeries.
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Corrivetti F, de Schotten MT, Poisson I, Froelich S, Descoteaux M, Rheault F, Mandonnet E. Dissociating motor–speech from lexico-semantic systems in the left frontal lobe: insight from a series of 17 awake intraoperative mappings in glioma patients. Brain Struct Funct 2019; 224:1151-1165. [DOI: 10.1007/s00429-019-01827-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
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Barzilai O, Lidar Z, Constantini S, Salame K, Bitan-Talmor Y, Korn A. Continuous mapping of the corticospinal tracts in intramedullary spinal cord tumor surgery using an electrified ultrasonic aspirator. J Neurosurg Spine 2017; 27:161-168. [DOI: 10.3171/2016.12.spine16985] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intramedullary spinal cord tumors (IMSCTs) represent a rare entity, accounting for 4%–10% of all central nervous system tumors. Microsurgical resection of IMSCTs is currently considered the primary treatment modality. Intraoperative neurophysiological monitoring (IONM) has been shown to aid in maximizing tumor resection and minimizing neurological morbidity, consequently improving patient outcome. The gold standard for IONM to date is multimodality monitoring, consisting of both somatosensory evoked potentials, as well as muscle-based transcranial electric motor evoked potentials (tcMEPs). Monitoring of tcMEPs is optimal when combining transcranial electrically stimulated muscle tcMEPs with D-wave monitoring. Despite continuous monitoring of these modalities, when classic monitoring techniques are used, there can be an inherent delay in time between actual structural or vascular-based injury to the corticospinal tracts (CSTs) and its revelation. Often, tcMEP stimulation is precluded by the surgeon’s preference that the patient not twitch, especially at the most crucial times during resection. In addition, D-wave monitoring may require a few seconds of averaging until updating, and can be somewhat indiscriminate to laterality. Therefore, a method that will provide immediate information regarding the vulnerability of the CSTs is still needed.The authors performed a retrospective series review of resection of IMSCTs using the tip of an ultrasonic aspirator for continuous proximity mapping of the motor fibers within the spinal cord, along with classic muscle-based tcMEP and D-wave monitoring.The authors present their preliminary experience with 6 patients who underwent resection of an IMSCT using the tip of an ultrasonic aspirator for continuous proximity mapping of the motor fibers within the spinal cord, together with classic muscle-based tcMEP and D-wave monitoring. This fusion of technologies can potentially assist in optimizing resection while preserving neurological function in these challenging surgeries.
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Affiliation(s)
- Ori Barzilai
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Zvi Lidar
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Shlomi Constantini
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
- 2Department of Pediatric Neurosurgery, “Dana” Children’s Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Khalil Salame
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Yifat Bitan-Talmor
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Akiva Korn
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
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Pallud J, Rigaux-Viode O, Corns R, Muto J, Lopez Lopez C, Mellerio C, Sauvageon X, Dezamis E. Direct electrical bipolar electrostimulation for functional cortical and subcortical cerebral mapping in awake craniotomy. Practical considerations. Neurochirurgie 2017; 63:164-174. [DOI: 10.1016/j.neuchi.2016.08.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/22/2016] [Accepted: 08/27/2016] [Indexed: 10/20/2022]
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Wager M, Rigoard P, Bouyer C, Baudiffier V, Stal V, Bataille B, Gil R, Du Boisgueheneuc F. Operating environment for awake brain surgery – Choice of tests. Neurochirurgie 2017; 63:150-157. [DOI: 10.1016/j.neuchi.2016.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/25/2016] [Accepted: 10/17/2016] [Indexed: 10/19/2022]
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Roth J, Korn A, Bitan-Talmor Y, Kaufman R, Ekstein M, Constantini S. Subcortical Mapping Using an Electrified Cavitron UltraSonic Aspirator in Pediatric Supratentorial Surgery. World Neurosurg 2017; 101:357-364. [PMID: 28213194 DOI: 10.1016/j.wneu.2017.02.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 02/06/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intraoperative electrophysiology is increasingly used for various lesion resections, both in adult and pediatric brain surgery. Subcortical mapping is often used in adult surgery when lesions lie in proximity to the corticospinal tract (CST). We describe a novel technique of continuous subcortical mapping using an electrified Cavitron UltraSonic Aspirator (CUSA) in children with supratentorial lesions. METHODS We evaluated the method of subcortical mapping using a CUSA as a stimulation probe. Included in this study were children (<18 years of age) with supratentorial lesions in proximity to the CST in which the CUSA stimulator was applied. Data were collected retrospectively. RESULTS Eleven children were included. Lesions were located in the thalamus (3), basal-ganglia (2), lateral ventricle (1), and convexity (5). Lesions included low-grade gliomas (6), arteriovenous malformation (1), cavernoma (1), cortical dysplasia (1), ependymoma grade II (1), and high-grade glioma (1). Seven patients had positive mapping responses to CUSA-based stimulation at various stimulation intensities. These responses led to a more limited resection in 5 cases. There were no complications related to the mapping technique. CONCLUSION Continuous CUSA-based subcortical stimulation is a feasible mapping technique for assessing proximity to the CST during resection of supratentorial lesions in children. Future studies should be performed to better correlate the current threshold for eliciting a motor response with the distance from the CST, as well as the effect of age on this technique.
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Affiliation(s)
- Jonathan Roth
- Departments of Pediatric Neurosurgery and Anesthesiology, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel.
| | - Akiva Korn
- Intraoperative Neurophysiological Monitoring Service, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yifat Bitan-Talmor
- Intraoperative Neurophysiological Monitoring Service, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Rivka Kaufman
- Intraoperative Neurophysiological Monitoring Service, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Margaret Ekstein
- Department of Critical Care, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Shlomi Constantini
- Departments of Pediatric Neurosurgery and Anesthesiology, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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Sierpowska J, Gabarrós A, Fernandez-Coello A, Camins À, Castañer S, Juncadella M, Morís J, Rodríguez-Fornells A. Words are not enough: nonword repetition as an indicator of arcuate fasciculus integrity during brain tumor resection. J Neurosurg 2017; 126:435-445. [DOI: 10.3171/2016.2.jns151592] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Subcortical electrical stimulation during brain surgery may allow localization of functionally crucial white matter fibers and thus tailoring of the tumor resection according to its functional limits. The arcuate fasciculus (AF) is a white matter bundle connecting frontal, temporal, and parietal cortical areas that is often disrupted by left brain lesions. It plays a critical role in several cognitive functions related to phonological processing, but current intraoperative monitoring methods do not yet allow mapping of this tract with sufficient precision. In the present study the authors aimed to test a new paradigm for the intraoperative monitoring of the AF.
METHODS
In this report, the authors studied 12 patients undergoing awake brain surgery for tumor resection with a related risk of AF damage. To preserve AF integrity and the cognitive processes sustained by this tract in the intraoperative context, the authors used real word repetition (WR) and nonword repetition (NWR) tasks as complements to standard picture naming.
RESULTS
Compared with the errors identified by WR or picture naming, the NWR task allowed the detection of subtle errors possibly related to AF alterations. Moreover, only 3 patients demonstrated phonological paraphasias in standard picture naming, and in 2 of these patients the paraphasias co-occurred with the total loss of WR and NWR ability. Before surgery, lesion volume predicted a patient's NWR performance.
CONCLUSIONS
The authors suggest that monitoring NWR intraoperatively may complement the standard naming tasks and could permit better preservation of the important language production functions subserved by the AF.
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Affiliation(s)
- Joanna Sierpowska
- 1Cognition and Brain Plasticity Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat
- 2Department of Basic Psychology, Campus Bellvitge, University of Barcelona, L'Hospitalet de Llobregat
| | - Andreu Gabarrós
- 3Hospital Universitari de Bellvitge, Neurosurgery Section, Campus Bellvitge, University of Barcelona, IDIBELL, L'Hospitalet de Llobregat
| | - Alejandro Fernandez-Coello
- 3Hospital Universitari de Bellvitge, Neurosurgery Section, Campus Bellvitge, University of Barcelona, IDIBELL, L'Hospitalet de Llobregat
- 4CIBER de Bioingeniería, Biomateriales y Nanomedicina
| | - Àngels Camins
- 5Institut de Diagnòstic per la Imatge, Centre Bellvitge, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat
| | - Sara Castañer
- 5Institut de Diagnòstic per la Imatge, Centre Bellvitge, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat
| | - Montserrat Juncadella
- 6Hospital Universitari de Bellvitge, Neurology Section, Campus Bellvitge, University of Barcelona, IDIBELL, L'Hospitalet de Llobregat; and
| | - Joaquín Morís
- 1Cognition and Brain Plasticity Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat
- 2Department of Basic Psychology, Campus Bellvitge, University of Barcelona, L'Hospitalet de Llobregat
| | - Antoni Rodríguez-Fornells
- 1Cognition and Brain Plasticity Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat
- 2Department of Basic Psychology, Campus Bellvitge, University of Barcelona, L'Hospitalet de Llobregat
- 7Catalan Institution for Research and Advanced Studies, ICREA, Barcelona, Spain
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Michaud K, Duffau H. Surgery of insular and paralimbic diffuse low-grade gliomas: technical considerations. J Neurooncol 2016; 130:289-298. [DOI: 10.1007/s11060-016-2120-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/02/2016] [Indexed: 01/16/2023]
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Boetto J, Bertram L, Moulinié G, Herbet G, Moritz-Gasser S, Duffau H. Low Rate of Intraoperative Seizures During Awake Craniotomy in a Prospective Cohort with 374 Supratentorial Brain Lesions: Electrocorticography Is Not Mandatory. World Neurosurg 2015; 84:1838-44. [PMID: 26283485 DOI: 10.1016/j.wneu.2015.07.075] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Awake craniotomy (AC) in brain lesions has allowed an improvement of both oncologic and functional results. However, intraoperative seizures (IOSs) were reported as a cause of failure of AC. Here, we analyze the incidence, risk factors, and consequences of IOSs in a prospective cohort of 374 ACs without electrocorticography (ECoG). METHODS We performed a prospective study including all patients who underwent AC for an intra-axial supratentorial cerebral lesion from 2009-2014 in our department. Occurrence of IOS was analyzed with respect to medical and epilepsy history, tumor characteristics, operative technique, and postoperative outcomes. RESULTS The study comprised 374 patients with a major incidence of low-grade glioma (86%). Most of the patients (83%) had epilepsy history before surgery (20% had intractable seizures). Preoperative mean Karnofsky performance scale (KPS) score was 91. IOSs occurred in 13 patients (3.4%). All IOSs were partial seizures, which quickly resolved by irrigation with cold Ringer lactate. No procedure failed because of IOS, and the rate of aborted AC whatever the cause was nil. Mean stimulation current intensity for cortical and subcortical mapping was 2.25 ± 0.6 mA. Presurgical refractory epilepsy was not associated with a higher incidence of IOS. Three months after surgery, no patients had severe or disabling permanent worsening, even within the IOS group (mean KPS score of 93.7). CONCLUSIONS AC for intra-axial brain lesion can be safely and reproducibly achieved without ECoG, with a low rate of IOS and excellent functional results, even in patients with preoperative intractable epilepsy.
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Affiliation(s)
- Julien Boetto
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Luc Bertram
- Department of Anesthesiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Gérard Moulinié
- Department of Anesthesiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Guillaume Herbet
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France; Institute for Neuroscience of Montpellier, Saint Eloi Hospital, Montpellier University Medical Center, Montpellier, France
| | - Sylvie Moritz-Gasser
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France; Institute for Neuroscience of Montpellier, Saint Eloi Hospital, Montpellier University Medical Center, Montpellier, France
| | - Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France; Institute for Neuroscience of Montpellier, Saint Eloi Hospital, Montpellier University Medical Center, Montpellier, France.
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16
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Sierpowska J, Gabarrós A, Fernandez-Coello A, Camins À, Castañer S, Juncadella M, de Diego-Balaguer R, Rodríguez-Fornells A. Morphological derivation overflow as a result of disruption of the left frontal aslant white matter tract. BRAIN AND LANGUAGE 2015; 142:54-64. [PMID: 25658634 DOI: 10.1016/j.bandl.2015.01.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 12/22/2014] [Accepted: 01/02/2015] [Indexed: 06/04/2023]
Abstract
The frontal aslant tract (FAT) is a recently described major connection between the preSMA and Broca's area, whose functional role remains undefined. In this study we examined a patient presenting a morphological overregularization strategy in a verb generation task during awake surgery. This specific language deficit coincided with brain tumor resection at the level of the left FAT. During the task execution the patient formed the non-existent verbs by applying a morphological derivation rule to the given nouns, instead of retrieving the appropriate verbs. DTI results confirmed left FAT damage. Neuropsychological follow-up showed that this morphological derivation impairment partially persisted after surgery, whereas the results on a wide spectrum of other language-related tasks remained satisfactory. Additionally, we compared the pre- and the post-operational fMRI activation maps for the same verb generation task. We discuss the potential role of the left FAT in the morphological derivation process and in lexical retrieval.
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Affiliation(s)
- Joanna Sierpowska
- Cognition and Brain Plasticity Group [Bellvitge Biomedical Research Institute - IDIBELL], 08097 L'Hospitalet de Llobregat, Barcelona, Spain; Dept. of Basic Psychology, Campus Bellvitge, University of Barcelona, 08097 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Andreu Gabarrós
- Hospital Universitari de Bellvitge (HUB), Neurosurgery Section, Campus Bellvitge, University of Barcelona - IDIBELL, 08097 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alejandro Fernandez-Coello
- Hospital Universitari de Bellvitge (HUB), Neurosurgery Section, Campus Bellvitge, University of Barcelona - IDIBELL, 08097 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Àngels Camins
- Institut de Diagnòstic per la Imatge, Centre Bellvitge, Hospital Universitari de Bellvitge, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sara Castañer
- Institut de Diagnòstic per la Imatge, Centre Bellvitge, Hospital Universitari de Bellvitge, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Montserrat Juncadella
- Hospital Universitari de Bellvitge (HUB), Neurology Section, Campus Bellvitge, University of Barcelona - IDIBELL, 08097 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ruth de Diego-Balaguer
- Cognition and Brain Plasticity Group [Bellvitge Biomedical Research Institute - IDIBELL], 08097 L'Hospitalet de Llobregat, Barcelona, Spain; Dept. of Basic Psychology, Campus Bellvitge, University of Barcelona, 08097 L'Hospitalet de Llobregat, Barcelona, Spain; Catalan Institution for Research and Advanced Studies, ICREA, 08010 Barcelona, Spain
| | - Antoni Rodríguez-Fornells
- Cognition and Brain Plasticity Group [Bellvitge Biomedical Research Institute - IDIBELL], 08097 L'Hospitalet de Llobregat, Barcelona, Spain; Dept. of Basic Psychology, Campus Bellvitge, University of Barcelona, 08097 L'Hospitalet de Llobregat, Barcelona, Spain; Catalan Institution for Research and Advanced Studies, ICREA, 08010 Barcelona, Spain.
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17
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Dziedzic T, Bernstein M. Awake craniotomy for brain tumor: indications, technique and benefits. Expert Rev Neurother 2014; 14:1405-15. [PMID: 25413123 DOI: 10.1586/14737175.2014.979793] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Increasing interest in the quality of life of patients after treatment of brain tumors has led to the exploration of methods that can improve intraoperative assessment of neurological status to avoid neurological deficits. The only method that can provide assessment of all eloquent areas of cerebral cortex and white matter is brain mapping during awake craniotomy. This method helps ensure that the quality of life and the neuro-oncological result of treatment are not compromised. Apart from the medical aspects of awake surgery, its economic issues are also favorable. Here, we review the main aspects of awake brain tumor surgery. Neurosurgical, neuropsychological, neurophysiological and anesthetic issues are briefly discussed.
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Affiliation(s)
- Tomasz Dziedzic
- Medical University of Warsaw, Neurosurgery, Banacha 1a, Warsaw, 02-097, Poland
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18
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Bello L, Riva M, Fava E, Ferpozzi V, Castellano A, Raneri F, Pessina F, Bizzi A, Falini A, Cerri G. Tailoring neurophysiological strategies with clinical context enhances resection and safety and expands indications in gliomas involving motor pathways. Neuro Oncol 2014; 16:1110-28. [PMID: 24500420 DOI: 10.1093/neuonc/not327] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Resection of motor pathway gliomas requires the intraoperative recognition of essential cortical-subcortical motor structures. The degree of involvement of motor structures is variable, and increases as result of treatments patients are submitted to. Intraoperative neurophysiology offers various stimulation modalities, which efficiency is based on the ability to recognize essential sites with the highest possible resolution in most clinical conditions. Two stimulation paradigms evolved for intraoperative guidance of motor tumors removal: the 60 Hz-technique [low frequency (LF)] and the pulse-technique [high frequency-(HF)], delivered by bipolar or monopolar probe respectively. Most surgical teams rely on to either of the 2 techniques. The key point is the integration of the choice of the stimulation modality with the clinical context. METHODS In 591 tumors involving the corticospinal tract, the use of HF and LF was tailored to the clinical context defined by patient clinical history and tumor features (by imaging). The effect was evaluated on the feasibility of mapping, the impact on immediate and permanent morbidity, the extent of resection, and the number of patients treated. RESULTS By integrating the choice of the probe and the stimulation protocol with patient clinical history and tumor characteristics, the best probe-frequency match was identified for the different sets of clinical conditions. This integrative approach allows increasing the extent of resection and patient functional integrity, and greatly expands the number of patients who could benefit from surgery. CONCLUSIONS The integration of stimulation modalities with clinical context enhances the extent and safety of resection and expands the population of patients who could benefit from surgical treatment.
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Affiliation(s)
- Lorenzo Bello
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
| | - Marco Riva
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
| | - Enrica Fava
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
| | - Valentina Ferpozzi
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
| | - Antonella Castellano
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
| | - Fabio Raneri
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
| | - Federico Pessina
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
| | - Alberto Bizzi
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
| | - Andrea Falini
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
| | - Gabriella Cerri
- Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.)
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19
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Wladis EJ, Kenning TJ. Cavitron ultrasonic surgical aspirator-assisted resection of combined orbital and intracranial tumors. Orbit 2014; 33:234-5. [PMID: 24409969 DOI: 10.3109/01676830.2013.873811] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Edward J Wladis
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Lions Eye Institute, Albany Medical College , Slingerlands, New York , USA and
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20
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Wager M, Du Boisgueheneuc F, Pluchon C, Bouyer C, Stal V, Bataille B, Guillevin CM, Gil R. Intraoperative monitoring of an aspect of executive functions: administration of the Stroop test in 9 adult patients during awake surgery for resection of frontal glioma. Neurosurgery 2013; 72:ons169-80; discussion ons180-1. [PMID: 23149965 DOI: 10.1227/neu.0b013e31827bf1d6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Awake brain surgery allows extensive intraoperative monitoring of not only motor and sensory functions and language but also executive functions. OBJECTIVE To administer the Stroop test intraoperatively to avoid dramatic side effects such as akinetic mutism and to monitor executive functions in an attempt to optimize the benefit/risk balance of surgery. METHODS A series of 9 adult patients with frontal glioma were operated on for gross tumor resection under local anesthesia. All procedures involved the anterior cingulate cortex (ACC). RESULTS Three types of response to the Stroop test were observed: 3 patients had a Stroop effect only for stimulation of the contralateral ACC; 3 patients had a Stroop effect for stimulation of the ipsilateral ACC; and 3 patients had no Stroop effect. Preoperative and postoperative neuropsychological and surgical results are presented and discussed. Stimulation sites eliciting a Stroop effect are compared with published image-based data, and insight provided by these surgical data regarding ACC function and plasticity is discussed. No operative complication related to intraoperative administration of the Stroop test was observed. CONCLUSION Administration of the Stroop test during resection of gliomas involving the ACC in adult patients is an option for intraoperative monitoring of executive functions during awake surgery. Globally, these results suggest functional compensation, mediated by plasticity mechanisms, by contralateral homologous regions of the ACC in adult patients with frontal glioma.
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Affiliation(s)
- Michel Wager
- Department of Neurosurgery, Imaging Laboratory, University Hospital Poitiers, 2 Rue de La Miletrie, Poitiers Cedex, France.
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21
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Zieliński P, Furtak J. Influence of intraoperative neurophysiologic monitoring on the development of surgical dissection techniques. Expert Rev Med Devices 2012; 9:571-5. [PMID: 23249153 DOI: 10.1586/erd.12.52] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intraoperative neurophysiologic monitoring (IONM) is essential in the preservation of function of nervous system. IONM is thus becoming the gold-standard method in nerve-sparing surgical procedures. Apart from spine and brain surgery, IONM is essential in significantly reducing morbidity in colorectal surgery, prostate and thyroid surgery, as well as in hip replacement, to name a few. IONM measures weak electric nerve potentials and, therefore, it is easily disturbed by other electromagnetic sources. Surgical dissection techniques and devices interfering with IONM make this technique useless because this is dissection that mainly endangers nerve structures. Therefore, there is a need to take into consideration the influence of various dissection techniques on IONM, and to develop or modify inert techniques that are currently not widely used.
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Affiliation(s)
- Piotr Zieliński
- Department of Sports Medicine, Gdansk University of Physical Education and Sport, Gorskiego 1 Str, 80-336 Gdansk, Poland.
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22
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Abstract
Preservation and even improvement of the quality of life is currently a priority in surgery for gliomas, in addition to the optimization of the extent of resection with significant increase of the overall survival. In this setting, the goal of the present review is to revisit technical aspects of glioma surgery in the lights of new concepts both in the fields of neurooncology and cognitive neurosciences, which recently emerged from translational researches - with special emphasis on diffuse low grade gliomas.Firstly, the vascularisation (arteries and veins) has to be more systematically spared, by performing subpial dissection and by limiting the use of coagulation within the brain. Secondly, individual cortical as well as subcortical mapping must be more regularly considered, with the aim of better understanding and preserving the white matter pathways underlying the functional connectivity - even in presumed "non-eloquent areas", to perform "supra-complete" resection.Therefore, brain surgeons should change their state of mind, in order to operate the nervous system involved by a chronic tumoral disease (and no more by operating a tumor mass within the brain). In other words, the neurosurgeon should see first the brain, and not the glioma, to adapt his surgical procedure to the three-dimensional anatomo-functional organization of each patient. It implies that brain surgeon must change his technique within the central nervous system, which has to be different from the surgical technique outside the brain. This perspective seems to represent the best way to build a modern and personalized "functional surgical neurooncology".
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Affiliation(s)
- H Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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23
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Szelényi A, Bello L, Duffau H, Fava E, Feigl GC, Galanda M, Neuloh G, Signorelli F, Sala F. Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice. Neurosurg Focus 2010; 28:E7. [PMID: 20121442 DOI: 10.3171/2009.12.focus09237] [Citation(s) in RCA: 242] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There is increasing evidence that the extent of tumor removal in low-grade glioma surgery is related to patient survival time. Thus, the goal of resecting the largest amount of tumor possible without leading to permanent neurological sequelae is a challenge for the neurosurgeon. Electrical stimulation of the brain to detect cortical and axonal areas involved in motor, language, and cognitive function and located within the tumor or along its boundaries has become an essential tool in combination with awake craniotomy. Based on a literature review, discussions within the European Low-Grade Glioma Group, and illustrative clinical experience, the authors of this paper provide an overview for neurosurgeons, neurophysiologists, linguists, and anesthesiologists as well as those new to the field about the stimulation techniques currently being used for mapping sensorimotor, language, and cognitive function in awake surgery for low-grade glioma. The paper is intended to help the understanding of these techniques and facilitate a comparison of results between users.
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Affiliation(s)
- Andrea Szelényi
- Department of Neurosurgery, Johann Wolfgang Goethe University, D-60528 Frankfurt am Main, Germany.
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24
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Bello L, Fava E, Casaceli G, Bertani G, Carrabba G, Papagno C, Falini A, Gaini SM. Intraoperative mapping for tumor resection. Neuroimaging Clin N Am 2010; 19:597-614. [PMID: 19959007 DOI: 10.1016/j.nic.2009.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This article describes the rationale, indications, and modality for intraoperative brain mapping for safe and effective surgical removal of tumors located within functional brain areas.
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Affiliation(s)
- Lorenzo Bello
- Department of Neurological Sciences, Università degli Studi di Milano, 20122. Milano, Italy.
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25
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Bello L, Fava E, Carrabba G, Papagno C, Gaini SM. Present day's standards in microsurgery of low-grade gliomas. Adv Tech Stand Neurosurg 2010; 35:113-57. [PMID: 20102113 DOI: 10.1007/978-3-211-99481-8_5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Low-grade gliomas are slow growing intrinsic lesions that induces a progressive functional reshaping of the brain. Surgical removal of these lesions requires the combined efforts of a multidiscipinary team of neurosurgeon, neuroradiologist, neuropsychologist, neurophysiologist, and neurooncologists that all together contribute in the definition of the location, extension, and extent of functional involvement that a specific lesion has induced in a particular patient. Each tumor has induced particular and specific changes of the functional network, that varies among patients. This requires that each treatment plan should be tailored to the tumor and to the patient. When this is reached, surgery should be accomplished according to functional and anatomical boundaries, and has to aim to the maximal resection with the maximal patient functional preservation. This can be reached at the time of the initial surgery, depending on the functional organization of the brain, or may require additional surgeries, eventually intermingled with adjuvant treatments. The use of so called brain mapping techniques extend surgical indications, improve extent of resection with greater oncological impact, minimization of morbidity and increase in quality of life. To achieve the goal of a satisfactory tumor resection associated with the full preservation of the patients abilities, a series of neuropsychological, neurophysiological, neuroradiological and intraoperative investigations have to be performed. In this chapter, we will describe the rationale, the indications and the modality for performing a safe and rewarding surgical removal of low-grade gliomas by using these techniques, as well as the functional and oncological results.
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Affiliation(s)
- L Bello
- Neurosurgery, Department of Neurological Sciences, Università degli Studi di Milano, Milano, Italy
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26
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Bertani G, Fava E, Casaceli G, Carrabba G, Casarotti A, Papagno C, Castellano A, Falini A, Gaini SM, Bello L. Intraoperative mapping and monitoring of brain functions for the resection of low-grade gliomas: technical considerations. Neurosurg Focus 2009; 27:E4. [PMID: 19795953 DOI: 10.3171/2009.8.focus09137] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Low-grade gliomas ([LGGs] WHO Grade II) are slow-growing intrinsic cerebral lesions that diffusely infiltrate the brain parenchyma along white matter tracts and almost invariably show a progression toward malignancy. The treatment of these tumors forces the neurosurgeon to face uncommon difficulties and is still a subject of debate. At the authors' institution, resection is the first option in the treatment of LGGs. It requires the combined efforts of a multidisciplinary team of neurosurgeons, neuroradiologists, neuropsychologists, and neurophysiologists, who together contribute to the definition of the location, extension, and extent of functional involvement that a specific lesion has caused in a particular patient. In fact, each tumor induces specific modifications of the brain functional network, with high interindividual variability. This requires that each treatment plan is tailored to the characteristics of the tumor and of the patient. Consequently, surgery is performed according to functional and anatomical boundaries to achieve the maximal resection with maximal functional preservation. The identification of eloquent cerebral areas, which are involved in motor, language, memory, and visuospatial functions and have to be preserved during surgery, is performed through the intraoperative use of brain mapping techniques. The use of these techniques extends surgical indications and improves the extent of resection, while minimizing the postoperative morbidity and safeguarding the patient's quality of life. In this paper the authors present their paradigm for the surgical treatment of LGGs, focusing on the intraoperative neurophysiological monitoring protocol as well as on the brain mapping technique. They briefly discuss the results that have been obtained at their institution since 2005 as well as the main critical points they have encountered when using this approach.
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Affiliation(s)
- Giulio Bertani
- Division of Neurosurgery, Department of Neurological Sciences, Università degli Studi di Milano, 20122 Milan, Italy
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