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Bhanja D, James JG, McNutt S, Kray K, Rizk E. Awake craniotomy in pediatric low-grade glioma: barriers and future directions. Childs Nerv Syst 2024:10.1007/s00381-024-06457-x. [PMID: 38985318 DOI: 10.1007/s00381-024-06457-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION The goal of surgical management in pediatric low-grade gliomas (pLGGs) is gross total resection (GTR), as it is considered curative with favorable long-term outcomes. Achieving GTR can be challenging in the setting of eloquent-region gliomas, in which resection may increase risk of neurological deficits. Awake craniotomy (AC) with intraoperative neurofunctional mapping (IONM) offers a promising approach to achieve maximal resection while preserving neurological function. However, its adoption in pediatric cases has been hindered, and barriers to its adoption have not previously been elucidated. FINDINGS This review includes two complementary investigations. First, a survey study was conducted querying pediatric neurosurgeons on their perceived barriers to the procedure in children with pLGG. Next, these critical barriers were analyzed in the context of existing literature. These barriers included the lack of standardized IONM techniques for children, inadequate surgical and anesthesia experience, concerns regarding increased complication risks, doubts about children's ability to tolerate the procedure, and perceived non-indications due to alternative monitoring tools. CONCLUSION Efforts to overcome these barriers include standardizing IONM protocols, refining anesthesia management, enhancing patient preparation strategies, and challenging entrenched beliefs about pediatric AC. Collaborative interdisciplinary efforts and further studies are needed to establish safety guidelines and broaden the application of AC, ultimately improving outcomes for children with pLGG.
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Affiliation(s)
- Debarati Bhanja
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | - Justin G James
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | - Sarah McNutt
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | - Kimberly Kray
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | - Elias Rizk
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA.
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Harikrishna A, Chatzidakis S, Ishak A, Faropoulos K, Fotakopoulos G, Georgakopoulou VE, Sklapani P, Trakas N, Yiallouris A, Iosif C, Agouridis AP, Hadjigeorgiou G. Awake craniotomy in patients with arteriovenous malformation: A systematic review and meta‑analysis. MEDICINE INTERNATIONAL 2024; 4:42. [PMID: 38912418 PMCID: PMC11190880 DOI: 10.3892/mi.2024.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/22/2024] [Indexed: 06/25/2024]
Abstract
The present systematic review aimed to identify all the available literature on awake craniotomy (AC) in patients with arteriovenous malformation (AVM) in order to evaluate its safety, risks, benefits and effectiveness. All available literature on AC in patients with AVM was collected and evaluated in an aim to provide a better understanding of its safety, associated risks and benefits. A systematic search for studies employing AC in patients with AVM was conducted using the PubMed, Scopus and ScienceDirect databases without restrictions on the year of publication, language, or study design, from inception up to May 30, 2021. A total of 11 studies published between 2004 and 2021 with 106 patients who underwent ACs were considered eligible. The rate of complete resection was 93% [95% confidence interval (CI), 82 to 100%; I2 0%]. The intraoperative complication rate was 21% (95% CI, 1 to 41%; I2 55%) and the post-operative complication rate was 33% (95% CI, 19 to 48%; I2 40%). During follow-up, the complication rate was 6% (95% CI, 1 to 10%; I2 30%). The post-operative complication rate was higher in the Spetzler-Martin grade (SMG) III-V group (31%; 95% CI, 21 to 42%; I2 46%) than in the SMG I-II group (12%; 95% CI, 2 to 22%; I2 0%). Similarly, the follow-up complication rate was higher in the SMG III-V group (9%; 95% CI, 2 to 16%; I2 34%) than in the SMG I-II group (0%; 95% CI, 0 to 4%; I2 0%). On the whole, the present study provides preliminary evidence to indicate that AC is a possible and useful option for the resection of AVM in selected patients. Well-designed future studies with long-term follow-up are required however, to investigate various aspects of safety and provide solid data for AC in patients with AVM.
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Affiliation(s)
- Arya Harikrishna
- School of Medicine, European University Cyprus, 2404 Nicosia, Cyprus
| | | | - Angela Ishak
- School of Medicine, European University Cyprus, 2404 Nicosia, Cyprus
| | | | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | | | - Christina Iosif
- School of Medicine, European University Cyprus, 2404 Nicosia, Cyprus
| | - Aris P. Agouridis
- School of Medicine, European University Cyprus, 2404 Nicosia, Cyprus
| | - George Hadjigeorgiou
- School of Medicine, European University Cyprus, 2404 Nicosia, Cyprus
- Department of Minimally Invasive Neurosurgery, Athens Medical Center, 14562 Athens, Greece
- Department of Neurosurgery, Apollonion Private Hospital, 2054 Nicosia, Cyprus
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Abu Mhanna HY, Omar AF, Radzi YM, Oglat AA, Akhdar HF, Ewaidat HA, Almahmoud A, Badarneh LA, Malkawi AA, Malkawi A. Systematic Review Between Resting-State fMRI and Task fMRI in Planning for Brain Tumour Surgery. J Multidiscip Healthc 2024; 17:2409-2424. [PMID: 38784380 PMCID: PMC11111578 DOI: 10.2147/jmdh.s470809] [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: 03/26/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
As an alternative to task-based functional magnetic resonance imaging (T-fMRI), resting-state functional magnetic resonance imaging (Rs-fMRI) is suggested for preoperative mapping of patients with brain tumours, with an emphasis on treatment guidance and neurodegeneration prediction. A systematic review was conducted of 18 recent studies involving 1035 patients with brain tumours and Rs-fMRI protocols. This was accomplished by searching the electronic databases PubMed, Scopus, and Web of Science. For clinical benefit, we compared Rs-fMRI to standard T-fMRI and intraoperative direct cortical stimulation (DCS). The results of Rs-fMRI and T-fMRI were compared and their correlation with intraoperative DCS results was examined through a systematic review. Our exhaustive investigation demonstrated that Rs-fMRI is a dependable and sensitive preoperative mapping technique that detects neural networks in the brain with precision and identifies crucial functional regions in agreement with intraoperative DCS. Rs-fMRI comes in handy, especially in situations where T-fMRI proves to be difficult because of patient-specific factors. Additionally, our exhaustive investigation demonstrated that Rs-fMRI is a valuable tool in the preoperative screening and evaluation of brain tumours. Furthermore, its capability to assess brain function, forecast surgical results, and enhance decision-making may render it applicable in the clinical management of brain tumours.
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Affiliation(s)
| | - Ahmad Fairuz Omar
- School of Physics, Universiti Sains Malaysia (USM), Penang, 11800, Malaysia
| | - Yasmin Md Radzi
- School of Physics, Universiti Sains Malaysia (USM), Penang, 11800, Malaysia
| | - Ammar A Oglat
- Faculty of Applied Medical Sciences, The Hashemite University, Zarqa, 13133, Jordan
| | - Hanan Fawaz Akhdar
- Physics Department, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, 13318, Saudi Arabia
| | - Haytham Al Ewaidat
- Department of Allied Medical Sciences-Radiologic Technology, Jordan University of Science and Technology (J.U.S.T), Irbid, 22110, Jordan
| | - Abdallah Almahmoud
- Department of Allied Medical Sciences-Radiologic Technology, Jordan University of Science and Technology (J.U.S.T), Irbid, 22110, Jordan
| | - Laith Al Badarneh
- School of Physics, Universiti Sains Malaysia (USM), Penang, 11800, Malaysia
| | | | - Ahmed Malkawi
- Business Department, Al-Zaytoonah University, Amman, 594, Jordan
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Hanihara M, Kawataki T, Kazama H, Ogiwara M, Yoshioka H, Kinouchi H. Maximal Resection of Gliomas Adjacent to the Corticospinal Tract Using 3-T Intraoperative Magnetic Resonance Imaging. World Neurosurg 2024; 185:e1207-e1215. [PMID: 38519017 DOI: 10.1016/j.wneu.2024.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Gliomas adjacent to the corticospinal tract (CST) should be carefully resected to preserve motor function while achieving maximal surgical resection. Modern high-field intraoperative magnetic resonance imaging (iMRI) enables precise visualization of the residual tumor and intraoperative tractography. We prospectively evaluated the extent of resection and distance between the tumor resection cavity and CST using 3-T iMRI combined with motor evoked potentials (MEP) in glioma surgery. METHODS Participants comprised patients who underwent surgery for solitary supratentorial glioma located within 10 mm of the CST. All cases underwent surgery using neuronavigation with overlaid CST under MEP monitoring. The correlation between distance from CST and transcortical MEP amplitude was calculated using Spearman rank correlation. RESULTS Among the 63 patients who underwent surgery, 27 patients were enrolled in the study. Gross total resections were achieved in 26 of the 27 cases. Volumetric analysis showed the extent of resection was 98.6%. Motor function was stable or improved in 24 patients (Stable/Improved group) and deteriorated in 3 patients (Deteriorated group). All patients in the Deteriorated group showed motor deficit before surgery. Mean intraoperative minimal distance was significantly longer in the Stable/Improved group (7.3 mm) than in the Deteriorated group (1.1 mm; P < 0.05). MEP amplitude correlated with minimal distance between the resection cavity and CST (R = 0.64). CONCLUSIONS Resection of gliomas adjacent to CST with a navigation system using 3-T iMRI could result in an ultimate EOR >98%. The combination of intraoperative tractography and MEP contributes to maximal removal of motor-eloquent gliomas.
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Affiliation(s)
- Mitsuto Hanihara
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi, Japan.
| | - Tomoyuki Kawataki
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Hirofumi Kazama
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Masakazu Ogiwara
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Hideyuki Yoshioka
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Hiroyuki Kinouchi
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Yamanashi, Japan
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Ricciuti RA, Mancini F, Guzzi G, Marruzzo D, Dario A, Puppa AD, Ricci A, Barbanera A, Talacchi A, Schwarz A, Germanò A, Raco A, Colamaria A, Santoro A, Boccaletti R, Conti C, Conti C, Cenci N, Cossandi C, Bernucci C, Lucantoni C, Costella GB, Garbossa D, Zotta DC, De Gonda F, Esposito F, Giordano F, D'Andrea G, Piatelli G, Zona G, Spena G, Tringali G, Barbagallo G, Giussani C, Gladi M, Landi A, Lavano A, Morabito L, Mastronardi L, Locatelli M, D'Agruma M, Lanotte MM, Montano N, Santonocito OS, Pompucci A, de Falco R, Randi F, Bruscella S, Sartori I, Signorelli F, Tosatto L, Trignani R, Esposito V, Innocenzi G, Paolini S, Vitiello V, Cavallo MA, Sala F. The "state of the art" of intraoperative neurophysiological monitoring: An Italian neurosurgical survey. BRAIN & SPINE 2024; 4:102796. [PMID: 38698806 PMCID: PMC11063224 DOI: 10.1016/j.bas.2024.102796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/25/2024] [Accepted: 03/30/2024] [Indexed: 05/05/2024]
Abstract
Introduction Intraoperative Neurophysiological Monitoring (IOM) is widely used in neurosurgery but specific guidelines are lacking. Therefore, we can assume differences in IOM application between Neurosurgical centers. Research question The section of Functional Neurosurgery of the Italian Society of Neurosurgery realized a survey aiming to obtain general data on the current practice of IOM in Italy. Materials and methods A 22-item questionnaire was designed focusing on: volume procedures, indications, awake surgery, experience, organization and equipe. The questionnaire has been sent to Italian Neurosurgery centers. Results A total of 54 centers completed the survey. The annual volume of surgeries range from 300 to 2000, and IOM is used in 10-20% of the procedures. In 46% of the cases is a neurologist or a neurophysiologist who performs IOM. For supra-tentorial pathology, almost all perform MEPs (94%) SSEPs (89%), direct cortical stimulation (85%). All centers perform IOM in spinal surgery and 95% in posterior fossa surgery. Among the 50% that perform peripheral nerve surgery, all use IOM. Awake surgery is performed by 70% of centers. The neurosurgeon is the only responsible for IOM in 35% of centers. In 83% of cases IOM implementation is adequate to the request. Discussion and conclusions The Italian Neurosurgical centers perform IOM with high level of specialization, but differences exist in organization, techniques, and expertise. Our survey provides a snapshot of the state of the art in Italy and it could be a starting point to implement a consensus on the practice of IOM.
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Affiliation(s)
| | | | - Giusy Guzzi
- Neurosurgery, AOU Ospedaliero Mater Domini di Catanzaro, Italy
| | | | | | | | | | - Andrea Barbanera
- Department of Neurosurgery, AON SS. Antonio e Biagio e Cesare Arrigo H, Alessandria, Italy
| | - Andrea Talacchi
- Unit of Neurosurgery, AO San Giovanni Addolorata, Roma, Italy
| | | | - Antonino Germanò
- Unit of Neurosurgery, AOU Policlinico G. Martino di Messina, Italy
| | - Antonino Raco
- Neurosurgery Clinic, Azienda Ospedaliera Sant’Andrea, Roma, Italy
| | - Antonio Colamaria
- Unit of Neurosurgery, Azienda Ospedaliera Policlinico Riuniti Foggia, Foggia, Italy
| | - Antonio Santoro
- Neurosurgery Clinic, Azienda Ospedaliera Universitaria, La Sapienza Policlinico Umberto I° Roma, Roma, Italy
| | | | - Carlo Conti
- Unit of Neurosurgery, Azienda Ospedaliera S. Maria, Terni, Italy
| | - Carlo Conti
- Unit of Neurosurgery, ARNAS G.Brotzu, Cagliari, Italy
| | - Nunzia Cenci
- Neurosurgery, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Christian Cossandi
- Unit of Neurosurgery, AOU Maggiore Della Carità di Novara, Novara, Italy
| | | | | | | | - Diego Garbossa
- Neurosurgery Clinic, AOU Città Della Salute e Della Scienza di Torino, Italy
| | | | | | - Felice Esposito
- Neurosurgery Clinic, A.O.U. Policlinico Federico II - Università Degli Studi di Napoli, Italy
| | - Flavio Giordano
- Unit of Pediatric Neurosurgery, Meyer Children's Hospital IRCCS, Firenze, Italy
- University of Florence, Italy
| | | | | | - Gianluigi Zona
- Neurosurgery Clinic, IRCCS Policlinico San Martino, Genova, Italy
| | | | | | | | - Carlo Giussani
- Neurosurgery Clinic, IRCCS Fondazione Ospedale San Gerardo Dei Tintori di Monza, Università Bicocca, Milano, Italy
| | - Maurizio Gladi
- Neurosurgery Clinic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Italy
| | - Andrea Landi
- Neurosurgery Clinic, Azienda Ospedaliera Universitaria di Padova, Italy
| | - Angelo Lavano
- Neurosurgery, AOU Ospedaliero Mater Domini di Catanzaro, Italy
| | | | | | - Marco Locatelli
- Neurosurgery Clinic, Fondazione IRCCS Ospedale Maggiore Policlinico di Milano, Università Degli Studi di Milano, Italy
| | | | - Michele Maria Lanotte
- Unit of Functional Neurosurgery, AOU Città Della Salute e Della Scienza di Torino, Italy
| | - Nicola Montano
- Neurosurgery Clinic, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | | | | | - Raffaele de Falco
- Neurosurgery, Ospedale Santa Maria Delle Grazie di Pozzuoli, Napoli, Italy
| | - Franco Randi
- Neurosurgery, Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Sara Bruscella
- Neurosurgery, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - Ivana Sartori
- Unit of Epilepsy Neurosurgery, ASST GOM Niguarda, Milano, Italy
| | | | | | | | | | | | | | | | | | - Francesco Sala
- Neurosurgery Clinic, Azienda Ospedaliera Universitaria di Verona, Verona, Italy
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Ahmed Khan R, Rahman MM, Ziauddin M, Chowdhury M, Hasan M. Awake brain mapping by direct cortical stimulation; technical note to get higher resection rate and low morbidity in low-grade glioma patients. Ann Med Surg (Lond) 2024; 86:1861-1866. [PMID: 38576956 PMCID: PMC10990364 DOI: 10.1097/ms9.0000000000001837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 02/02/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction Direct cortical stimulation has been used for brain mapping and localization of eloquent areas in awake patients. This simplified technique is to provide the positive areas, which can be preserved if the tumor or lesions are involved eloquent areas. Objective The main objective of this study is to determine whether direct cortical stimulation in awake brain mapping for low-grade glioma patients increases the rate of resection or not. Method The authors present a retrospective study between 2020 to 2022 that includes 35 cases in a single center, to get higher resection rate, and their consequences in awake craniotomy in low-grade glioma patients. Here, two neurosurgeons were involved and the minimum follow-up was 12 months. Results The authors achieved 80% removal of tumors. To get higher resection rate we emphasized negative mapping with prior anatomical analysis to understand functional realignment. Stimulation-related complications will be thoroughly discussed with a potential future direction to minimize the issues. The authors used PROMIS score to measure patients physical and mental health status and kernofsky score to measure performance status before and after successful surgery. The authors found three cases of transient deficit in repetitive stimulation. Repeated stimulation to identify the eloquent areas with low voltage frequency is a good option. Numbness in the face related to stimulation may continue for 6 weeks. Conclusion Functional realignment in shifted brain and edema can be seen while doing cortical and subcortical stimulation. Most of the stimulation from low to high for language mapping may vary from patient to patient. For safe removal of low-grade glioma a steep learning curve is needed to find out the negative areas, though the authors emphasize positive mapping of areas to secure the maximum eloquence.
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Affiliation(s)
| | | | - Md. Ziauddin
- Neurosurgery Department, National Institute of Neuroscience and Hospital
| | | | - Mahbub Hasan
- Bangabandhu Sheikh Mujib Medical University Hospital, Dhaka, Bangladesh
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Bonosi L, Torrente A, Brighina F, Tito Petralia CC, Merlino P, Avallone C, Gulino V, Costanzo R, Brunasso L, Iacopino DG, Maugeri R. Corticocortical Evoked Potentials in Eloquent Brain Tumor Surgery. A Systematic Review. World Neurosurg 2024; 181:38-51. [PMID: 37832637 DOI: 10.1016/j.wneu.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023]
Abstract
Eloquent brain tumor surgery involves the delicate task of resecting tumors located in regions of the brain responsible for critical functions, such as language, motor control, and sensory perception. Preserving these functions is of paramount importance to maintain the patient's quality of life. Corticocortical evoked potentials (CCEPs) have emerged as a valuable intraoperative monitoring technique that aids in identifying and preserving eloquent cortical areas during surgery. This systematic review aimed to assess the utility of CCEPs in eloquent brain tumor surgery and determine their effectiveness in improving patient outcomes. A comprehensive literature search was conducted using electronic databases, including PubMed/Medline and Scopus. The search strategy identified 11 relevant articles for detailed analysis. The findings of the included studies consistently demonstrated the potential of CCEPs in guiding surgical decision making, minimizing the risk of postoperative neurological deficits, and mapping functional connectivity during surgery. However, further research and standardization are needed to fully establish the clinical benefits and refine the implementation of CCEPs in routine neurosurgical practice.
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Affiliation(s)
- Lapo Bonosi
- Department of Biomedicine Neurosciences and Advanced Diagnostics, Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in NeurologiSurgery, School of Medicine, University of Palermo, Palermo, Italy.
| | - Angelo Torrente
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Cateno Concetto Tito Petralia
- Department of Biomedicine Neurosciences and Advanced Diagnostics, Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in NeurologiSurgery, School of Medicine, University of Palermo, Palermo, Italy
| | - Pietro Merlino
- Department of Neuroscience, Psychology, Pharmacology and Child Health, Neurosurgery Clinic, Careggi University Hospital and University of Florence, Florence, Italy
| | - Chiara Avallone
- Department of Biomedicine Neurosciences and Advanced Diagnostics, Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in NeurologiSurgery, School of Medicine, University of Palermo, Palermo, Italy
| | - Vincenzo Gulino
- Department of Biomedicine Neurosciences and Advanced Diagnostics, Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in NeurologiSurgery, School of Medicine, University of Palermo, Palermo, Italy
| | - Roberta Costanzo
- Department of Biomedicine Neurosciences and Advanced Diagnostics, Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in NeurologiSurgery, School of Medicine, University of Palermo, Palermo, Italy
| | - Lara Brunasso
- Department of Biomedicine Neurosciences and Advanced Diagnostics, Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in NeurologiSurgery, School of Medicine, University of Palermo, Palermo, Italy
| | - Domenico Gerardo Iacopino
- Department of Biomedicine Neurosciences and Advanced Diagnostics, Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in NeurologiSurgery, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosario Maugeri
- Department of Biomedicine Neurosciences and Advanced Diagnostics, Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in NeurologiSurgery, School of Medicine, University of Palermo, Palermo, Italy
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Freund BE, Feyissa AM, Khan A, Middlebrooks EH, Grewal SS, Sabsevitz D, Sherman WJ, Quiñones-Hinojosa A, Tatum WO. Early Postoperative Seizures Following Awake Craniotomy and Functional Brain Mapping for Lesionectomy. World Neurosurg 2024; 181:e732-e742. [PMID: 37898274 DOI: 10.1016/j.wneu.2023.10.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE Awake craniotomy with electrocorticography (ECoG) and direct electrical stimulation (DES) facilitates lesionectomy while avoiding adverse effects. Early postoperative seizures (EPS), occurring within 7 days following surgery, can lead to morbidity. However, risk factors for EPS after awake craniotomy including clinical and ECoG data are not well defined. METHODS We retrospectively studied the incidence and risk factors of EPS following awake craniotomy for lesionectomy, and report short-term outcomes between January 1, 2020, and December 31, 2022. RESULTS We included 138 patients (56 female) who underwent 142 awake craniotomies, average age was 50.78 ± 15.97 years. Eighty-eight (63.7%) patients had a preoperative history of tumor-related epilepsy treated with antiseizure medication (ASM), 12 (13.6%) with drug-resistance. All others (36.3%) received ASM prophylaxis with levetiracetam perioperatively and continued for 14 days. An equal number of cases (71) each utilized a novel circle grid or strip electrodes for ECoG. There were 31 (21.8%) cases of intraoperative seizures, 16 with EPS (11.3%). Acute abnormality on early postoperative neuroimaging (P = 0.01), subarachnoid hemorrhage (P = 0.01), young age (P = 0.01), and persistent postoperative neurologic deficits (P = 0.013) were associated with EPS. Acute abnormality on neuroimaging remained significant in multivariate analysis. Outcomes during hospitalization and early outpatient follow up were worse with EPS. CONCLUSIONS We report novel findings using ECoG and clinical features to predict EPS, including acute perioperative brain injury, persistent postoperative deficits and young age. Given worse outcomes with EPS, clinical indicators for EPS should alert clinicians of potential need for early postoperative EEG monitoring and perioperative ASM adjustment.
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Affiliation(s)
- Brin E Freund
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA.
| | | | - Aafreen Khan
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Erik H Middlebrooks
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA; Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Sanjeet S Grewal
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - David Sabsevitz
- Department of Psychology and Psychiatry, Mayo Clinic, Jacksonville, Florida, USA
| | - Wendy J Sherman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
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9
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Rammeloo E, Schouten JW, Krikour K, Bos EM, Berger MS, Nahed BV, Vincent AJPE, Gerritsen JKW. Preoperative assessment of eloquence in neurosurgery: a systematic review. J Neurooncol 2023; 165:413-430. [PMID: 38095774 DOI: 10.1007/s11060-023-04509-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/12/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Tumor location and eloquence are two crucial preoperative factors when deciding on the optimal treatment choice in glioma management. Consensus is currently lacking regarding the preoperative assessment and definition of eloquent areas. This systematic review aims to evaluate the existing definitions and assessment methods of eloquent areas that are used in current clinical practice. METHODS A computer-aided search of Embase, Medline (OvidSP), and Google Scholar was performed to identify relevant studies. This review includes articles describing preoperative definitions of eloquence in the study's Methods section. These definitions were compared and categorized by anatomical structure. Additionally, various techniques to preoperatively assess tumor eloquence were extracted, along with their benefits, drawbacks and ease of use. RESULTS This review covers 98 articles including 12,714 participants. Evaluation of these studies indicated considerable variability in defining eloquence. Categorization of these definitions yielded a list of 32 brain regions that were considered eloquent. The most commonly used methods to preoperatively determine tumor eloquence were anatomical classification systems and structural MRI, followed by DTI-FT, functional MRI and nTMS. CONCLUSIONS There were major differences in the definitions and assessment methods of eloquence, and none of them proved to be satisfactory to express eloquence as an objective, quantifiable, preoperative factor to use in glioma decision making. Therefore, we propose the development of a novel, objective, reliable, preoperative classification system to assess eloquence. This should in the future aid neurosurgeons in their preoperative decision making to facilitate personalized treatment paradigms and to improve surgical outcomes.
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Affiliation(s)
- Emma Rammeloo
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Joost Willem Schouten
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Keghart Krikour
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Eelke Marijn Bos
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Mitchel Stuart Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Brian Vala Nahed
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Jasper Kees Wim Gerritsen
- Department of Neurosurgery, Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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Voets NL, Bartsch AJ, Plaha P. Functional MRI applications for intra-axial brain tumours: uses and nuances in surgical practise. Br J Neurosurg 2023; 37:1544-1559. [PMID: 36148501 DOI: 10.1080/02688697.2022.2123893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 09/07/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Functional MRI (fMRI) has well-established uses to inform risks and plan maximally safe approaches in neurosurgery. In the field of brain tumour surgery, however, fMRI is currently in a state of clinical equipoise due to debate around both its sensitivity and specificity. MATERIALS AND METHODS In this review, we summarise the role and our experience of fMRI in neurosurgery for gliomas and metastases. We discuss nuances in the conduct and interpretation of fMRI that, based on our practise, most directly impact fMRI's usefulness in the neurosurgical setting. RESULTS Illustrated examples in which fMRI in our hands directly influences the neurosurgical treatment of brain tumours include evaluating the probability and nature of functional risks, especially for language functions. These presurgical risk assessments, in turn, help to predict the resectability of tumours, select or deselect patients for awake surgery, indicate the need for neurophysiological monitoring and guide the optimal use of intra-operative stimulation mapping. A further emerging application of fMRI is in measuring functional adaptation of functional networks after (partial) surgery, of potential use in the timing of further surgery. CONCLUSIONS In appropriately selected patients with a clearly defined surgical question, fMRI offers a valuable complementary tool in the pre-surgical evaluation of brain tumours. However, there is a great need for standards in the administration and analysis of fMRI as much as in the techniques that it is commonly evaluated against. Surprisingly little data exists that evaluates the accuracy of fMRI not just against complementary methods, but in terms of its ultimate clinical aim of minimising post-surgical morbidity.
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Affiliation(s)
- Natalie L Voets
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- GenesisCare Ltd, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Andreas J Bartsch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Puneet Plaha
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Neurosurgery, University of Oxford, Oxford, UK
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11
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Mofatteh M, Mashayekhi MS, Arfaie S, Wei H, Kazerouni A, Skandalakis GP, Pour-Rashidi A, Baiad A, Elkaim L, Lam J, Palmisciano P, Su X, Liao X, Das S, Ashkan K, Cohen-Gadol AA. Awake craniotomy during pregnancy: A systematic review of the published literature. Neurosurg Rev 2023; 46:290. [PMID: 37910275 PMCID: PMC10620271 DOI: 10.1007/s10143-023-02187-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/07/2023] [Accepted: 10/14/2023] [Indexed: 11/03/2023]
Abstract
Neurosurgical pathologies in pregnancy pose significant complications for the patient and fetus, and physiological stressors during anesthesia and surgery may lead to maternal and fetal complications. Awake craniotomy (AC) can preserve neurological functions while reducing exposure to anesthetic medications. We reviewed the literature investigating AC during pregnancy. PubMed, Scopus, and Web of Science databases were searched from the inception to February 7th, 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Studies in English investigating AC in pregnant patients were included in the final analysis. Nine studies composed of nine pregnant patients and ten fetuses (one twin-gestating patient) were included. Glioma was the most common pathology reported in six (66.7%) patients. The frontal lobe was the most involved region (4 cases, 44.4%), followed by the frontoparietal region (2 cases, 22.2%). The awake-awake-awake approach was the most common protocol in seven (77.8%) studies. The shortest operation time was two hours, whereas the longest one was eight hours and 29 min. The mean gestational age at diagnosis was 13.6 ± 6.5 (2-22) and 19.6 ± 6.9 (9-30) weeks at craniotomy. Seven (77.8%) studies employed intraoperative fetal heart rate monitoring. None of the AC procedures was converted to general anesthesia. Ten healthy babies were delivered from patients who underwent AC. In experienced hands, AC for resection of cranial lesions of eloquent areas in pregnant patients is safe and feasible and does not alter the pregnancy outcome.
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Affiliation(s)
- Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK.
- Neuro International Collaboration (NIC), London, UK.
| | - Mohammad Sadegh Mashayekhi
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Neuro International Collaboration (NIC), Ottawa, ON, Canada
| | - Saman Arfaie
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
- Department of Molecular and Cell Biology, University of California Berkeley, Berkeley, CA, USA
- Neuro International Collaboration (NIC), Montreal, QC, Canada
| | - Hongquan Wei
- Department of 120 Emergency Command Center, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - Arshia Kazerouni
- Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Georgios P Skandalakis
- First Department of Neurosurgery, Evangelismos General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ahmad Pour-Rashidi
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Abed Baiad
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Lior Elkaim
- Montreal Neurological Institute and Hospital, Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Jack Lam
- Department of 120 Emergency Command Center, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | | | - Xiumei Su
- Obstetrical Department, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xuxing Liao
- Department of Neurosurgery, Foshan Sanshui District People's Hospital, Foshan, China
- Department of Surgery of Cerebrovascular Diseases, Foshan First People's Hospital, Foshan, China
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Keyoumars Ashkan
- Neuro International Collaboration (NIC), London, UK
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- King's Health Partners Academic Health Sciences Centre, London, UK
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Aaron A Cohen-Gadol
- The Neurosurgical Atlas, Carmel, IN, USA
- Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
- Neuro International Collaboration, Indianapolis, IN, USA
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12
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Mofatteh M, Mashayekhi MS, Arfaie S, Adeleye AO, Jolayemi EO, Ghomsi NC, Shlobin NA, Morsy AA, Esene IN, Laeke T, Awad AK, Labuschagne JJ, Ruan R, Abebe YN, Jabang JN, Okunlola AI, Barrie U, Lekuya HM, Idi Marcel E, Kabulo KDM, Bankole NDA, Edem IJ, Ikwuegbuenyi CA, Nguembu S, Zolo Y, Bernstein M. Awake Craniotomy in Africa: A Scoping Review of Literature and Proposed Solutions to Tackle Challenges. Neurosurgery 2023; 93:274-291. [PMID: 36961213 PMCID: PMC10319364 DOI: 10.1227/neu.0000000000002453] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/10/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC. OBJECTIVE To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa. METHODS We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included. RESULTS Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources. CONCLUSION Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers.
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Affiliation(s)
- Mohammad Mofatteh
- School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | - Saman Arfaie
- School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Amos Olufemi Adeleye
- Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Nathalie C. Ghomsi
- Neurosurgery Department, Felix Houphouet Boigny Unversity Abidjan, Cote d’Ivoire
| | - Nathan A. Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ahmed A. Morsy
- Department of Neurosurgery, Zagazig University, Zagazig, Egypt
| | - Ignatius N. Esene
- Neurosurgery Division, Faculty of Health Sciences, University of Bamenda, Bambili, Cameroon
| | - Tsegazeab Laeke
- Neurosurgery Division, Department of Surgery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmed K. Awad
- Faculty of Medicine, Ain-shams University, Cairo, Egypt
| | - Jason J. Labuschagne
- Department of Neurosurgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard Ruan
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Yared Nigusie Abebe
- Department of Neurosurgery, Haramaya University Hiwot Fana Comprehensive Specialized Hospital, Harar, Ethiopia
| | | | - Abiodun Idowu Okunlola
- Department of Surgery, Federal Teaching Hospital Ido Ekiti and Afe Babalola University, Ado Ekiti, Nigeria
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hervé Monka Lekuya
- Department of Neurosurgery, Makerere University/Mulago Hospital, Kampala, Uganda
| | - Ehanga Idi Marcel
- Department of Neurosurgery, College of Surgeons of East, Central and Southern Africa/Mulago Hospital, Kampala, Uganda
| | - Kantenga Dieu Merci Kabulo
- Department of Neurosurgery, Jason Sendwe General Provincial Hospital, Lubumbashi, Democratic Republic of the Congo
| | - Nourou Dine Adeniran Bankole
- Department of Neurosurgery, Hôpital Des Spécialités, WFNS Rabat Training Center For Young, African Neurosurgeons, Faculty of Medicine, Mohammed V University, Rabat, Morocco
| | - Idara J. Edem
- Department of Surgery, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
| | | | - Stephane Nguembu
- Department of Neurosurgery, Higher Institute of Health Sciences, Université des Montagnes, Bangangté, Cameroon
| | - Yvan Zolo
- Global Surgery Division, University of Cape Town, Cape Town, South Africa
| | - Mark Bernstein
- Division of Neurosurgery, Department of Surgery, University of Toronto, University Health Network, Toronto, Ontario, Canada
- Temmy Latner Center for Palliative Care, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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13
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Shah Z, Bakhshi SK, Khalil M, Shafiq F, Enam SA, Shamim MS. Intraoperative Seizures During Awake Craniotomy for Brain Tumor Resection. Cureus 2023; 15:e43454. [PMID: 37711958 PMCID: PMC10498660 DOI: 10.7759/cureus.43454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2023] [Indexed: 09/16/2023] Open
Abstract
Background Intra-operative seizures (IOS) can occur during awake craniotomies (AC) for brain tumors. They can potentially result in an increased risk of morbidity; however, literature is scarce on IOS, its risk factors, and predictors. This study aims to ascertain the frequency of IOS in patients undergoing AC and determine possible IOS predictors. Methods In this retrospective study, we reviewed the records of all patients who underwent AC for tumor resection at a single university hospital between January 2016 and December 2020. IOS was defined as any seizure, including partial or generalized, experienced by any patient at any time from the beginning of the procedure till the end of surgery. Results Two hundred patients underwent AC during the study period. Seven (3.5%) patients experienced IOS. Compared to the non-seizure group, no significant correlation existed with any demographic variable. No significant difference was seen between the initial complaints presented by the two groups. In addition, the post-operative course of the seizure group did not significantly differ from the non-seizure group. Due to the low frequency of IOS in our cohort, an extensive analysis to determine predictors could not be performed. Conclusion In this study, we observed a low frequency of IOS (3.5%) during AC. The possible predictors and risk factors must be further investigated in large cohorts; to help limit the consequences of this possible intraoperative complication.
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Affiliation(s)
- Zara Shah
- Research, Aga Khan University Hospital, Karachi, PAK
| | | | | | - Faraz Shafiq
- Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
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14
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Shakir M, Khowaja AH, Altaf A, Tameezuddin A, Bukhari SS, Enam SA. Risk factors and predictors of intraoperative seizures during awake craniotomy: A systematic review and meta-analysis. Surg Neurol Int 2023; 14:195. [PMID: 37404511 PMCID: PMC10316139 DOI: 10.25259/sni_135_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: 02/08/2023] [Accepted: 05/04/2023] [Indexed: 07/06/2023] Open
Abstract
Background Awake craniotomy (AC) aims to minimize postoperative neurological complications while allowing maximum safe resection. Intraoperative seizures (IOSs) have been a reported complication during AC; however, literature delving into the predictors of IOS remains limited. Therefore, we planned a systematic review and meta-analysis of existing literature to explore predictors of IOS during AC. Methods From the inception until June 1, 2022, systematic searches of PubMed, Scopus, the Cochrane Library, CINAHL, and Cochrane's Central Register of Controlled Trials were conducted to look for published studies reporting IOS predictors during AC. Results We found 83 different studies in total; included were six studies with a total of 1815 patients, and 8.4% of them experienced IOSs. The mean age of included patients was 45.3 years, and 38% of the sample was female. Glioma was the most common diagnosis among the patients. A pooled random effect odds ratio (OR) of frontal lobe lesions was 2.42 (95% confidence intervals [CI]: 1.10-5.33, P = 0.03). Those with a pre-existing history of seizures had an OR of 1.80 (95% CI: 1.13-2.87, P = 0.01), and patients on antiepileptic drugs (AEDs) had a pooled OR of 2.47 (95% CI: 1.59-3.85, P < 0.001). Conclusion Patients with lesions of the frontal lobe, a prior history of seizures, and patients on AEDs are at higher risk of IOSs. These factors should be taken into consideration during the patient's preparation for an AC to avoid an intractable seizure and consequently a failed AC.
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Affiliation(s)
- Muhammad Shakir
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Aly Hamza Khowaja
- Medical student, Aga Khan University Medical College, Aga Khan University, Karachi, Pakistan
| | - Ahmed Altaf
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Syed Sarmad Bukhari
- Department of Neurosurgery, Northwest School of Medicine, Peshawar, Pakistan
| | - Syed Ather Enam
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
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15
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Fu KH, Wang YC, Lim SN, Cheng MY, Wu T, Chang CW, Chang BL, Lee CY, Lee CH, Tseng WEJ, Chiang HI, Liao TW, Tu PH. Long-term Outcome of Seizure Control and Neurologic Performance After Limited Hippocampal Radiofrequency Thermocoagulation for Mesial Temporal Lobe Epilepsy. World Neurosurg 2023; 173:e18-e26. [PMID: 36693618 DOI: 10.1016/j.wneu.2023.01.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Limited hippocampal radiofrequency thermocoagulation (RFTC) for patients with mesial temporal lobe epilepsy was associated with good short-term seizure control and few complications. We aimed to demonstrate the neuropsychologic outcomes and assess the prognostic factors of long-term seizure control in these patients. METHODS We included all patients with mesial temporal lobe epilepsy who underwent limited hippocampal RFTC from January 2016 to December 2020. Clinical data of age, sex, seizure control before and after operation were all corrected. Pre- and postoperative neuropsychologic function including full-scale intelligence quotient (FSIQ), memory quotient, and the Mini-Mental State Examination was used. RESULTS Thirty-one patients (17 female and 14 male) with a mean epilepsy duration of 22.3 years and seizure frequency of 5.7 times per month were included. The intraoperative seizure rate was 19.3%, and a higher preoperative seizure frequency (P = 0.001) and longer duration of epilepsy (P = 0.042) were associated with the occurrence of intraoperative seizures. The postoperative FSIQ scores were significantly better than preoperative scores (mean 92.1 vs. 89.7, P = 0.014). Nine patients (29%) who underwent limited hippocampal RFTC were seizure-free at 1 year of follow-up. Responders represented 58% (n = 18) of patients at 1 year. The mean follow-up period was 34.7 ± 13.3 months. Five patients remained seizure free and 13 patients are still responders at the last follow-up visits. Long-term seizure frequency was 2.32 ± 2.86 times per month. CONCLUSIONS Limited hippocampal RFTC is a safe stereotactic minimal invasive procedure with good neuropsychologic outcome and acceptable efficacy of seizure reduction in appropriately selected patients.
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Affiliation(s)
- Kuan-Hao Fu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Siew-Na Lim
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Mei-Yun Cheng
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Tony Wu
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chun-Wei Chang
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Bao-Luen Chang
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Ching-Yi Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chih-Hong Lee
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Wei-En Johnny Tseng
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan; PhD Program in Biomedical Engineering, Chang Gung University, Taoyuan City, Taiwan
| | - Hsing-I Chiang
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Ting-Wei Liao
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Po-Hsun Tu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan City, Taiwan; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
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16
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Deana C, Pez S, Ius T, Furlan D, Nilo A, Isola M, De Martino M, Mauro S, Verriello L, Lettieri C, Tomasino B, Valente M, Skrap M, Vetrugno L, Pauletto G. Effect of Dexmedetomidine versus Propofol on Intraoperative Seizure Onset During Awake Craniotomy: A Retrospective Study. World Neurosurg 2023; 172:e428-e437. [PMID: 36682527 DOI: 10.1016/j.wneu.2023.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The effect of dexmedetomidine (DEX) compared with propofol on intraoperative seizures (IOSs) detected using electrocorticography during awake craniotomy for resection of brain tumors is unknown. This investigation aimed to compare IOS rate in patients receiving DEX versus propofol as sedative agent. METHODS In this retrospective single-center study, awake craniotomies performed from January 2014 to December 2019 were analyzed. All IOSs detected by electrocorticography along with vital signs were recorded. RESULTS Of 168 adults enrolled in the study, 58 were administered DEX and 110 were administered propofol. IOSs occurred more frequently in the DEX group (22%) versus the propofol group (11%) (P = 0.046). A higher incidence of bradycardia was also observed in the DEX group (P < 0.001). Higher incidence of hypertension and a higher mean heart rate were recorded in the propofol group (P = 0.006 and P < 0.001, respectively). No serious adverse events requiring active drug administration were noted in either group. At univariate regression analysis, DEX demonstrated a tendency to favor IOS onset but without statistical significance (odds ratio = 2.36, P = 0.051). Patients in both groups had a similar epilepsy outcome at the 1-year postoperative follow-up. CONCLUSIONS IOSs detected with electrocorticography during awake craniotomy occurred more frequently in patients receiving DEX than propofol. However, patients receiving DEX were not shown to be at a statistically significant greater risk for IOS onset. DEX is a valid alternative to propofol during awake craniotomy in patients affected by tumor-related epilepsy.
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy.
| | - Sara Pez
- Department of Medicine, University of Udine, Udine, Italy
| | - Tamara Ius
- Department of Neurological Sciences, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy; Department of Neuroscience, Mental Health and Sense Organs, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Davide Furlan
- Department of Medicine, University of Udine, Udine, Italy
| | - Annacarmen Nilo
- Department of Neurological Sciences, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy
| | - Miriam Isola
- Division of Medical Statistic, Department of Medicine, University of Udine, Udine, Italy
| | - Maria De Martino
- Division of Medical Statistic, Department of Medicine, University of Udine, Udine, Italy
| | - Stefano Mauro
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy
| | - Lorenzo Verriello
- Department of Neurological Sciences, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy
| | - Christian Lettieri
- Department of Neurological Sciences, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy
| | - Barbara Tomasino
- Department of Neurological Sciences, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy; Scientific Institute, IRCCS Eugenio Medea, San Vito al Tagliamento, Italy
| | - Mariarosaria Valente
- Department of Medicine, University of Udine, Udine, Italy; Department of Neurological Sciences, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy
| | - Miran Skrap
- Department of Neurological Sciences, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy; Department of Medical, Oral and Biotechnological Sciences, D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Giada Pauletto
- Department of Neurological Sciences, Health Integrated Agency of Friuli Centrale, Academic Hospital of Udine, Udine, Italy
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Mofatteh M, Mashayekhi MS, Arfaie S, Chen Y, Hendi K, Kwan ATH, Honarvar F, Solgi A, Liao X, Ashkan K. Stress, Anxiety, and Depression Associated With Awake Craniotomy: A Systematic Review. Neurosurgery 2023; 92:225-240. [PMID: 36580643 DOI: 10.1227/neu.0000000000002224] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/09/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Awake craniotomy (AC) enables real-time monitoring of cortical and subcortical functions when lesions are in eloquent brain areas. AC patients are exposed to various preoperative, intraoperative, and postoperative stressors, which might affect their mental health. OBJECTIVE To conduct a systematic review to better understand stress, anxiety, and depression in AC patients. METHODS PubMed, Scopus, and Web of Science databases were searched from January 1, 2000, to April 20, 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. RESULTS Four hundred forty-seven records were identified that fit our inclusion and exclusion criteria for screening. Overall, 24 articles consisting of 1450 patients from 13 countries were included. Sixteen studies (66.7%) were prospective, whereas 8 articles (33.3%) were retrospective. Studies evaluated stress, anxiety, and depression during different phases of AC. Twenty-two studies (91.7%) were conducted on adults, and 2 studies were on pediatrics (8.3 %). Glioma was the most common AC treatment with 615 patients (42.4%). Awake-awake-awake and asleep-awake-asleep were the most common protocols, each used in 4 studies, respectively (16.7%). Anxiety was the most common psychological outcome evaluated in 19 studies (79.2%). The visual analog scale and self-developed questionnaire by the authors (each n = 5, 20.8%) were the most frequently tools used. Twenty-three studies (95.8%) concluded that AC does not increase stress, anxiety, and/or depression in AC patients. One study (4.2%) identified younger age associated with panic attack. CONCLUSION In experienced hands, AC does not cause an increase in stress, anxiety, and depression; however, the psychiatric impact of AC should not be underestimated.
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Affiliation(s)
- Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, UK
| | | | - Saman Arfaie
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.,Department of Molecular and Cell Biology, University of California Berkeley, California, USA
| | - Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Kasra Hendi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Faraz Honarvar
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Arad Solgi
- School of Kinesiology & Health Science, York University, Toronto, Ontario, Canada
| | - Xuxing Liao
- Department of Neurosurgery, Foshan Sanshui District People's Hospital, Foshan, China.,Department of Surgery of Cerebrovascular Diseases, Foshan First People's Hospital, Foshan, China
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK.,Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.,King's Health Partners Academic Health Sciences Centre, London, UK.,School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
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18
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Lettieri C, Ius T, Verriello L, Budai R, Isola M, Valente M, Skrap M, Gigli GL, Pauletto G. Risk Factors for Intraoperative Seizures in Glioma Surgery: Electrocorticography Matters. J Clin Neurophysiol 2023; 40:27-36. [PMID: 34038932 DOI: 10.1097/wnp.0000000000000854] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Few and contradictory data are available regarding intraoperative seizures during surgery for low-grade gliomas. Aim of this study was to evaluate possible risk factors for the occurrence of IOS. METHODS The authors performed a retrospective analysis of 155 patients affected by low-grade gliomas and tumor-related epilepsy, who underwent surgery in our Department, between 2007 and 2018. A statistical analysis was performed by means of univariate and multivariate regression to evaluate any possible correlation between seizure occurrence and several demographic, clinical, neurophysiological, and histopathological features. RESULTS Intraoperative seizure occurred in 39 patients (25.16%) with a total of 62 seizure events recorded. Focal seizures were the prevalent seizure type: among them, 39 seizures did not show motor signs, being those with only electrographic and/or with cognitive features the most represented subtypes. Twenty-six seizures occurring during surgery were not spontaneous: direct cortical stimulation with Penfield paradigm was the most prevalent evoking factor. The univariate analysis showed that the following prognostic factors were statistically associated with the occurrence of intraoperative seizure: the awake technique ( P = 0.01) and the interictal epileptiform discharges detected on the baseline electrocorticography (ECoG) ( P < 0.001). After controlling for confounding factors with multivariate analysis, the awake surgery and the epileptic ECoG pattern kept statistical significance. CONCLUSIONS The awake surgery procedure and the epileptic ECoG pattern are risk factors for intraoperative seizure. ECoG is mandatory to detect electrographic seizures or seizures without motor signs.
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Affiliation(s)
- Christian Lettieri
- Neurology and Clinical Neurophysiology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Tamara Ius
- Neurosurgery Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Lorenzo Verriello
- Neurology and Clinical Neurophysiology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Riccardo Budai
- Neurology and Clinical Neurophysiology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Miriam Isola
- Department of Medicine (DAME), University of Udine, Italy
| | - Mariarosaria Valente
- Department of Medicine (DAME), University of Udine, Italy
- Clinical Neurology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy; and
| | - Miran Skrap
- Neurosurgery Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
| | - Gian Luigi Gigli
- Clinical Neurology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy; and
- Department of Mathematics, Informatics and Physics (DMIF), University of Udine, Italy
| | - Giada Pauletto
- Neurology and Clinical Neurophysiology Unit, "S. Maria della Misericordia" University-Hospital, Udine, Italy
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Risk factors and prognostic implications of surgery-related strokes following resection of high-grade glioma. Sci Rep 2022; 12:22594. [PMID: 36585482 PMCID: PMC9803666 DOI: 10.1038/s41598-022-27127-5] [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: 07/09/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023] Open
Abstract
Surgery-related strokes are an important cause of morbidity following resection of high-grade glioma (HGG). We explored the incidence, risk factors and clinical consequences of intra-operative ischemic strokes in surgeries for resection of HGG. We retrospectively followed a cohort of 239 patients who underwent surgical resection of HGG between 2013 and 2017. Tumor types included both isocitrate dehydrogenase (IDH) wildtype glioblastoma and IDH-mutant WHO grade 4 astrocytoma. We analyzed pre- and post-operative demographic, clinical, radiological, anesthesiology and intraoperative neurophysiology data, including overall survival and functional outcomes. Acute ischemic strokes were seen on postoperative diffusion-weighted imaging (DWI) in 30 patients (12.5%), 13 of whom (43%) developed new neurological deficits. Infarcts were more common in insular (23%, p = 0.019) and temporal surgeries (57%, p = 0.01). Immediately after surgery, 35% of patients without infarcts and 57% of those with infarcts experienced motor deficits (p = 0.022). Six months later, rates of motor deficits decreased to 25% in the non-infarcts group and 37% in the infarcts group (p = 0.023 and 0.105, respectively) with a significantly lower Karnofsky-Performance Score (KPS, p = 0.001). Intra-operative language decline in awake procedures was a significant indicator of the occurrence of intra-operative stroke (p = 0.029). In conclusion, intraoperative ischemic events are more common in insular and temporal surgeries for resection of HGG and their intra-operative detection is limited. These strokes can impair motor and speech functions as well as patients' performance status.
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20
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Wide Dissection Trans-Sulcal Approach for Resection of Deep Intra-Axial Lesions in Eloquent Brain Areas. Curr Oncol 2022; 29:7396-7410. [PMID: 36290858 PMCID: PMC9600937 DOI: 10.3390/curroncol29100581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction: Resection of intra-axial tumors (IaT) in eloquent brain regions risks major postoperative neurological deficits. Awake craniotomy is often used to navigate these areas; however, some patients are ineligible for awake procedures. The trans-sulcal approach (TScal) was introduced to reduce parenchymal trauma during tumor resection. We report our experiences utilizing TScal for resection of deep IaT located in eloquent areas. Materials and Methods: This is a single-center retrospective analysis of patients who underwent IaT resection in eloquent areas via TScal from January 2013 to April 2021. Seventeen cases were reviewed, and relevant data was collected. Fluorescence-guided surgery with 5-aminolevulinic acid (ALA) and intraoperative ultrasound was performed in some cases. Results: Seventeen patients (10 males, 7 females) averaging 61.2 years-old (range, 21-76) were included in this study. Average length of stay was 4.8 days, and only 2 patients (11.8%) required hospital readmission within 30 days. Gross total resection (GTR) was achieved in 15 patients (88.2%), while subtotal resection occurred in 2 patients (11.8%). Eleven patients (64.7%) reported full resolution of symptoms, 4 patients (23.5%) reported deficit improvement, and 2 patients (11.8%) experienced no change from their preoperative deficits. No patient developed new permanent deficits postoperatively. Discussion: GTR, preoperative deficit reduction, and complications were comparable to awake craniotomy and other TScal studies. Ancillary intraoperative techniques, such as brain mapping, 5-ALA and intraoperative ultrasound, are afforded by TScal to improve resection rates and overall outcomes. Conclusions: TScal can be an option for patients with deep lesions in eloquent areas who are not candidates for awake surgeries.
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21
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Carrabba G, Fiore G, Di Cristofori A, Bana C, Borellini L, Zarino B, Conte G, Triulzi F, Rocca A, Giussani C, Caroli M, Locatelli M, Bertani G. Diffusion tensor imaging, intra-operative neurophysiological monitoring and small craniotomy: Results in a consecutive series of 103 gliomas. Front Oncol 2022; 12:897147. [PMID: 36176387 PMCID: PMC9513471 DOI: 10.3389/fonc.2022.897147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
Diffusion tensor imaging (DTI) allows visualization of the main white matter tracts while intraoperative neurophysiological monitoring (IONM) represents the gold standard for surgical resection of gliomas. In recent years, the use of small craniotomies has gained popularity thanks to neuronavigation and to the low morbidity rates associated with shorter surgical procedures. The aim of this study was to review a series of patients operated for glioma using DTI, IONM, and tumor-targeted craniotomies. The retrospective analysis included patients with supratentorial glioma who met the following inclusion criteria: preoperative DTI, intraoperative IONM, tumor-targeted craniotomy, pre- and postoperative MRI, and complete clinical charts. The DTI was performed on a 3T scanner. The IONM included electroencephalography (EEG), transcranial (TC) and/or cortical motor-evoked potentials (MEP), electrocorticography (ECoG), and direct electrical stimulation (DES). Outcomes included postoperative neurological deficits, volumetric extent of resection (EOR), and overall survival (OS). One hundred and three patients (61 men, 42 women; mean age 54 ± 14 years) were included and presented the following WHO histologies: 65 grade IV, 19 grade III, and 19 grade II gliomas. After 3 months, only three patients had new neurological deficits. The median postoperative volume was 0cc (IQR 3). The median OS for grade IV gliomas was 15 months, while for low-grade gliomas it was not reached. In our experience, a small craniotomy and a tumor resection supported by IONM and DTI permitted to achieve satisfactory results in terms of neurological outcomes, EOR, and OS for glioma patients.
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Affiliation(s)
- Giorgio Carrabba
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
- *Correspondence: Giorgio Carrabba,
| | - Giorgio Fiore
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Andrea Di Cristofori
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
| | - Cristina Bana
- Neurophysiopathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
| | - Linda Borellini
- Neurophysiopathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
| | - Barbara Zarino
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giorgio Conte
- Neuroradiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Fabio Triulzi
- Neuroradiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Alessandra Rocca
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Carlo Giussani
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Manuela Caroli
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Marco Locatelli
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
- Department of Medical-Surgical Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Giulio Bertani
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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22
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Surgical Treatment of Glioblastoma: State-of-the-Art and Future Trends. J Clin Med 2022; 11:jcm11185354. [PMID: 36143001 PMCID: PMC9505564 DOI: 10.3390/jcm11185354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022] Open
Abstract
Glioblastoma (GBM) is a highly aggressive disease and is associated with poor prognosis despite treatment advances in recent years. Surgical resection of tumor remains the main therapeutic option when approaching these patients, especially when combined with adjuvant radiochemotherapy. In the present study, we conducted a comprehensive literature review on the state-of-the-art and future trends of the surgical treatment of GBM, emphasizing topics that have been the object of recent study.
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23
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Neurological outcomes following awake and asleep craniotomies with motor mapping for eloquent tumor resection. Clin Neurol Neurosurg 2022; 213:107128. [DOI: 10.1016/j.clineuro.2022.107128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 12/13/2022]
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24
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Parsons MW, Peters KB, Floyd SR, Brown P, Wefel JS. Preservation of neurocognitive function in the treatment of brain metastases. Neurooncol Adv 2021; 3:v96-v107. [PMID: 34859237 PMCID: PMC8633744 DOI: 10.1093/noajnl/vdab122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Neurocognitive function (NCF) deficits are common in patients with brain metastases, occurring in up to 90% of cases. NCF deficits may be caused by tumor-related factors and/or treatment for the metastasis, including surgery, radiation therapy, chemotherapy, and immunotherapy. In recent years, strategies to prevent negative impact of treatments and ameliorate cognitive deficits for patients with brain tumors have gained momentum. In this review, we report on research that has established the efficacy of preventative and rehabilitative therapies for NCF deficits in patients with brain metastases. Surgical strategies include the use of laser interstitial thermal therapy and intraoperative mapping. Radiotherapy approaches include focal treatments such as stereotactic radiosurgery and tailored approaches such as hippocampal avoidant whole-brain radiotherapy (WBRT). Pharmacologic options include use of the neuroprotectant memantine to reduce cognitive decline induced by WBRT and incorporation of medications traditionally used for attention and memory problems. Integration of neuropsychology into the care of patients with brain metastases helps characterize cognitive patterns, educate patients and families regarding their management, and guide rehabilitative therapies. These and other strategies will become even more important for long-term survivors of brain metastases as treatment options improve.
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Affiliation(s)
- Michael W Parsons
- Pappas Center for Neuro-Oncology, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine B Peters
- Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Scott R Floyd
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Paul Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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25
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Hosainey SAM, Lykkedrang BL, Meling TR. Long-term risk of shunt failure after brain tumor surgery. Neurosurg Rev 2021; 45:1589-1600. [PMID: 34713351 PMCID: PMC8976775 DOI: 10.1007/s10143-021-01648-5] [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] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/31/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
Long-term risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus (HC) after craniotomy for brain tumors are largely unknown. The aim of this study was to establish the overall VP shunt survival rates during a decade after shunt insertion and to determine risks of shunt failure after brain tumor surgery in the long-term period. In this population-based cohort from a well-defined geographical region, all adult patients (> 18 years) from 2004 to 2013 who underwent craniotomies for intracranial tumors leading to VP shunt dependency were included. Our brain tumor database was cross-linked to procedure codes for shunt surgery (codes AAF) to extract brain tumor patients who became VP shunt dependent after craniotomy. The VP shunt survival time, i.e. the shunt longevity, was calculated from the day of shunt insertion after brain tumor surgery until the day of its failure. A total of 4174 patients underwent craniotomies, of whom 85 became VP shunt dependent (2%) afterwards. Twenty-eight patients (33%) had one or more shunt failures during their long-term follow-up, yielding 1-, 5-, and 10-year shunt success rates of 77%, 71%, and 67%, respectively. Patient age, sex, tumor location, primary/repeat craniotomy, placement of external ventricular drainage (EVD), ventricular entry, post-craniotomy hemorrhage, post-shunting meningitis/infection, and multiple shunt revisions were not statistically significant risk factors for shunt failure. Median shunt longevity was 457.5 days and 21.5 days for those with and without pre-craniotomy HC, respectively (p < 0.01). This study can serve as benchmark for future studies.
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Affiliation(s)
| | | | - Torstein R. Meling
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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26
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Peruzzi P, Valdes PQ, Aghi MK, Berger M, Chiocca EA, Golby AJ. The Evolving Role of Neurosurgical Intervention for Central Nervous System Tumors. Hematol Oncol Clin North Am 2021; 36:63-75. [PMID: 34565649 DOI: 10.1016/j.hoc.2021.08.003] [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: 11/04/2022]
Abstract
Since its inception, greater than a century ago, neurosurgery has represented the fundamental trait-d'union between clinical management, scientific investigation, and therapeutic advancements in the field of brain tumors. During the years, oncological neurosurgery has evolved as a self-standing subspecialty, due to technical progress, equipment improvement, evolution of therapeutic paradigms, and the progressively crucial role that it plays in the execution of complex therapeutic strategies and modern clinical trials.
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Affiliation(s)
- Pierpaolo Peruzzi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Hale Building for Transformative Medicine, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Pablo Q Valdes
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Hale Building for Transformative Medicine, 60 Fenwood Road, Boston, MA 02115, USA
| | - Manish K Aghi
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94117, USA
| | - Mitchel Berger
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94117, USA
| | - Ennio Antonio Chiocca
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Hale Building for Transformative Medicine, 60 Fenwood Road, Boston, MA 02115, USA
| | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Hale Building for Transformative Medicine, 60 Fenwood Road, Boston, MA 02115, USA; Department of Radiology, Brigham and Women's Hospital/Harvard Medical School, Hale Building for Transformative Medicine, 60 Fenwood Road, Boston, MA 02115, USA
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27
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Saito T, Muragaki Y, Tamura M, Maruyama T, Nitta M, Tsuzuki S, Ohashi M, Fukui A, Kawamata T. Awake craniotomy with transcortical motor evoked potential monitoring for resection of gliomas within or close to motor-related areas: validation of utility for predicting motor function. J Neurosurg 2021; 136:1052-1061. [PMID: 34560661 DOI: 10.3171/2021.3.jns21374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors previously showed that combined evaluation of changes in intraoperative voluntary movement (IVM) during awake craniotomy and transcortical motor evoked potentials (MEPs) was useful for predicting postoperative motor function in 30 patients with precentral gyrus glioma. However, the validity of the previous report is limited to precentral gyrus gliomas. Therefore, the current study aimed to validate whether the combined findings of IVM during awake craniotomy and transcortical MEPs were useful for predicting postoperative motor function of patients with a glioma within or close to motor-related areas and not limited to the precentral gyrus. METHODS The authors included 95 patients with gliomas within or close to motor-related areas who were treated between April 2000 and May 2020. All tumors were resected with IVM monitoring during awake craniotomy and transcortical MEP monitoring. Postoperative motor function was classified into four categories: "no change" or "declined," the latter of which was further categorization as "mild," "moderate," or "severe." The authors defined moderate and severe deficits as those that impact daily life. RESULTS Motor function 6 months after surgery was classified as no change in 71 patients, mild in 18, moderate in 5, and severe in 1. Motor function at 6 months after surgery significantly correlated with IVM (p < 0.0001), transcortical MEPs (decline ≤ or > 50%) (p < 0.0001), age, preoperative motor dysfunction, extent of resection, and ischemic change on postoperative MRI. Thirty-two patients with no change in IVM showed no change in motor function at 6 months after surgery. Five of 34 patients (15%) with a decline in IVM and a decline in MEPs ≤ 50% had motor dysfunction with mild deficits 6 months after surgery. Furthermore, 19 of 23 patients (83%) with a decline in IVM and decline in MEPs > 50% had a decline in motor function, including 13 patients with mild, 5 with moderate, and 1 with severe deficits. Six patients with moderate or severe deficits had the lowest MEP values, at < 100 µV. CONCLUSIONS This study validated the utility of combined application of IVM during awake craniotomy and transcortical MEP monitoring to predict motor function at 6 months after surgery in patients with a glioma within or close to motor-related areas, not limited to the precentral gyrus. The authors also validated the usefulness of the cutoff value, 100 µV, in MEP monitoring.
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Affiliation(s)
- Taiichi Saito
- 1Department of Neurosurgery.,2Faculty of Advanced Techno-Surgery; and
| | | | | | - Takashi Maruyama
- 1Department of Neurosurgery.,2Faculty of Advanced Techno-Surgery; and
| | | | | | - Mana Ohashi
- 3Central Clinical Laboratory, Tokyo Women's Medical University, Tokyo, Japan
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Galloway G. Use of CCEPs of the arcuate fasciculus under general anesthesia for language evaluation. Clin Neurophysiol 2021; 132:1957-1958. [PMID: 34099408 DOI: 10.1016/j.clinph.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Gloria Galloway
- Neurology Department of Neurology, 395 W 12th Avenue 7th Floor, Columbus, OH 43210, USA.
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29
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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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Aabedi AA, Kakaizada S, Young JS, Ahn E, Weissman DH, Berger MS, Brang D, Hervey-Jumper SL. Balancing task sensitivity with reliability for multimodal language assessments. J Neurosurg 2021; 135:1817-1824. [PMID: 34049284 PMCID: PMC10404475 DOI: 10.3171/2020.10.jns202947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative tasks for awake language mapping are typically selected based on the language tracts that will likely be encountered during tumor resection. However, diminished attention and arousal secondary to perioperative sedatives may reduce a task's usefulness for identifying eloquent cortex. For instance, accuracy in performing select language tasks may be high preoperatively but decline in the operating room. In the present study, the authors sought to identify language tasks that can be performed with high accuracy in both situational contexts so the neurosurgical team can be confident that speech errors committed during awake language mapping result from direct cortical stimulation to eloquent cortex, rather than from poor performance in general. METHODS We administered five language tasks to 44 patients: picture naming (PN), text reading (TR), auditory object naming (AN), repetition of 4-syllable words (4SYL), and production of syntactically intact sentences (SYNTAX). Performance was assessed using the 4-point scale of the quick aphasia battery 24 hours preoperatively and intraoperatively. We next determined whether or not accuracy on each task was higher preoperatively than intraoperatively. We also determined whether 1) intraoperative accuracy on a given task predicted intraoperative performance on the other tasks and 2) low preoperative accuracy on a task predicted a decrease in accuracy intraoperatively. RESULTS Relative to preoperative accuracy, intraoperative accuracy declined on PN (3.90 vs 3.82, p = 0.0001), 4SYL (3.96 vs 3.91, p = 0.0006), and SYNTAX (3.85 vs 3.67, p = 0.0001) but not on TR (3.96 vs 3.94, p = 0.13) or AN (3.70 vs 3.58, p = 0.058). Intraoperative accuracy on PN and AN independently predicted intraoperative accuracy on the remaining language tasks (p < 0.001 and p < 0.01, respectively). Finally, low preoperative accuracy on SYNTAX predicted a decrease in accuracy on this task intraoperatively (R2 = 0.36, p = 0.00002). CONCLUSIONS While TR lacks sensitivity in identifying language deficits at baseline, accuracy on TR is stable across testing settings. Baseline accuracy on the other four of our five language tasks was not predictive of intraoperative performance, signifying the need to repeat language tests prior to stimulation mapping to confirm reliability.
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Affiliation(s)
- Alexander A. Aabedi
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Sofia Kakaizada
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jacob S. Young
- Department of Neurological Surgery, University of California, San Francisco, California
| | - EunSeon Ahn
- Department of Psychology, University of Michigan, Ann Arbor, Michigan
| | | | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, California
| | - David Brang
- Department of Psychology, University of Michigan, Ann Arbor, Michigan
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De Witt Hamer PC, Klein M, Hervey-Jumper SL, Wefel JS, Berger MS. Functional Outcomes and Health-Related Quality of Life Following Glioma Surgery. Neurosurgery 2021; 88:720-732. [PMID: 33517431 PMCID: PMC7955971 DOI: 10.1093/neuros/nyaa365] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/25/2020] [Indexed: 12/19/2022] Open
Abstract
Functional outcome following glioma surgery is defined as how the patient functions or feels. Functional outcome is a coprimary end point of surgery in patients with diffuse glioma, together with oncological outcome. In this review, we structure the functional outcome measurements following glioma surgery as reported in the last 5 yr. We review various perspectives on functional outcome of glioma surgery with available measures, and offer suggestions for their use. From the recent neurosurgical literature, 160 publications were retrieved fulfilling the selection criteria. In these publications, neurological outcomes were reported most often, followed by activities of daily living, seizure outcomes, neurocognitive outcomes, and health-related quality of life or well-being. In more than a quarter of these publications functional outcome was not reported. A minimum essential consensus set of functional outcome measurements would benefit comparison across neurosurgical reports. The consensus set should be based on a combination of clinician- and patient-reported outcomes, assessed at a predefined time before and after surgery. The selected measurements should have psychometric properties supporting the intended use including validity-related evidence, reliability, and sensitivity to detect meaningful change with minimal burden to ensure compliance. We circulate a short survey as a start towards reporting guidelines. Many questions remain to better understand, report, and improve functional outcome following glioma surgery.
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Affiliation(s)
- Philip C De Witt Hamer
- Correspondence: Philip C. De Witt Hamer, MD, PhD, Amsterdam UMC, Vrije Universiteit, Department of Neurosurgery, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands.
| | - Martin Klein
- Amsterdam UMC, Vrije Universiteit, Department of Medical Psychology, Neuroscience Campus, Amsterdam, Netherlands
| | - Shawn L Hervey-Jumper
- University of California San Francisco, Department of Neurological Surgery, San Francisco, California
| | - Jeffrey S Wefel
- University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology and Department of Radiation Oncology, Houston, Texas
| | - Mitchel S Berger
- University of California San Francisco, Department of Neurological Surgery, San Francisco, California
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Minkin K, Gabrovski K, Karazapryanov P, Milenova Y, Sirakov S, Karakostov V, Romanski K, Dimova P. Awake Epilepsy Surgery in Patients with Focal Cortical Dysplasia. World Neurosurg 2021; 151:e257-e264. [PMID: 33872840 DOI: 10.1016/j.wneu.2021.04.021] [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: 02/02/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Awake craniotomy (AC) and direct electric stimulation emerged together with epilepsy surgery >80 years ago. The goal of our study was to evaluate the benefits of awake surgery in patients with drug-resistant epilepsy caused by focal cortical dysplasia (FCD) affecting eloquent areas. METHODS Our material included 95 patients with drug-resistant epilepsy and FCD, who were operated on between January 2009 and December 2018. These 95 patients were assigned into 3 groups: AC; general anesthesia (GA) with intraoperative neuromonitoring; and GA without intraoperative neuromonitoring. We investigated the following variables: age at surgery, lesion side, eloquent cortex involvement, brain mapping success rate, epilepsy surgery success rate, intraoperative complications, postoperative complications, and intraoperative changes of the preoperative resection plan according to results of the brain mapping by direct electric stimulation. RESULTS We found statistically significant differences between the AC and GA groups in the mean age at operation, lesion side, eloquent localization, and postoperative transient neurologic deficit. Seizure outcome in the AC was satisfactory (71% complete seizure control) and comparable to the seizure outcome in the GA groups. Our preoperative plan was changed because of functional constraints in 6 patients (43%) operated on during AC. CONCLUSIONS AC during epilepsy surgery for FCD in eloquent areas may change the preoperative plan. The good rate of postoperative seizure control and the absence of permanent postoperative neurologic deficit in our series is the main proof that AC is a useful tool in patients with FCD involving the eloquent cortex.
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Affiliation(s)
- Krasimir Minkin
- Department of Neurosurgery, University Hospital "St. Ivan Rilski", Sofia, Bulgaria.
| | - Kaloyan Gabrovski
- Department of Neurosurgery, University Hospital "St. Ivan Rilski", Sofia, Bulgaria
| | - Petar Karazapryanov
- Department of Neurosurgery, University Hospital "St. Ivan Rilski", Sofia, Bulgaria
| | - Yoana Milenova
- Department of Neurology, University Hospital "St. Ivan Rilski", Sofia, Bulgaria
| | - Stanimir Sirakov
- Department of Interventional Radiology, University Hospital "St. Ivan Rilski", Sofia, Bulgaria
| | - Vasil Karakostov
- Department of Neurosurgery, University Hospital "St. Ivan Rilski", Sofia, Bulgaria
| | - Kiril Romanski
- Department of Neurosurgery, Military Medical Academy, Sofia, Bulgaria
| | - Petia Dimova
- Department of Neurosurgery, University Hospital "St. Ivan Rilski", Sofia, Bulgaria
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Papatzalas C, Fountas K, Kapsalaki E, Papathanasiou I. The Use of Standardized Intraoperative Language Tests in Awake Craniotomies: A Scoping Review. Neuropsychol Rev 2021; 32:20-50. [PMID: 33786797 DOI: 10.1007/s11065-021-09492-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/22/2021] [Indexed: 12/12/2022]
Abstract
Assessment of speech and language functions is an essential part of awake craniotomies. Although standardized and validated tests have several advantages compared to homemade (or mixed) batteries, in the literature it is unclear how such tests are used or whether they are used at all. In this study, we performed a scoping review in order to locate standardized and validated intraoperative language tests. Our inquiry included two databases (PubMED and MEDLINE), gray literature, and snowball referencing. We discovered 87 studies reporting use of mixed batteries, which consist of homemade tasks and tests borrowed from other settings. The tests we found to meet the validation and standardization criteria we set were ultimately three (n = 3) and each one has its own advantages and disadvantages. We argue that tests with high sensitivity and specificity not only can lead to better outcomes postoperatively, but they can also help us to gain a better understanding of the neuroanatomy of language.
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Affiliation(s)
- Christos Papatzalas
- Department of Medicine, University of Thessaly, Larisa, Greece.
- Department of Neurosurgery, University Hospital of Larisa, Larisa, Greece.
| | - Kostas Fountas
- Department of Medicine, University of Thessaly, Larisa, Greece
- Department of Neurosurgery, University Hospital of Larisa, Larisa, Greece
| | - Eftychia Kapsalaki
- Department of Medicine, University of Thessaly, Larisa, Greece
- Department of Radiology, University Hospital of Larisa, Larisa, Greece
| | - Ilias Papathanasiou
- Department of Speech & Language Therapy, University of Patras, Patras, Greece
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Morsy AA, Ismail AM, Nasr YM, Waly SH, Abdelhameed EA. Predictors of stimulation-induced seizures during perirolandic glioma resection using intraoperative mapping techniques. Surg Neurol Int 2021; 12:117. [PMID: 33880222 PMCID: PMC8053429 DOI: 10.25259/sni_873_2020] [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: 12/04/2020] [Accepted: 02/20/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Intraoperative mapping techniques maximize safety and efficacy during perirolandic glioma resection but may induce seizures and limit the procedure. We aim to report the incidence and predictors of stimulation-induced seizures during mapping either patient is awake or under general anesthesia (GA). METHODS Retrospective analysis of 64 patients (40 awake and 24 GA) with perirolandic glioma underwent resection using intraoperative mapping techniques between 2014 and 2019. Preoperative data, operative details, postoperative neurological status, and extent of resection (EOR) were analyzed. Predictors of intraoperative seizures were assessed. RESULTS The mean cortical and subcortical stimulation intensities needed to evoke motor responses were significantly lower in awake cases than in GA patients (4.9 ± 0.42 vs. 8.9 ± 1.2 mA) and (8.3 ± 0.62 vs. 12.1 ± 1.1 mA), respectively (P = 0.01). Incidence of intraoperative seizures was lower but statistically non-significant in awake cases (10% vs. 12.5%) (P = 0.76). Preoperative multiple antiepileptic drugs (AEDs) (P = 0.03) and low-grade glioma (P = 0.04) were statistically significant predictors for intraoperative seizures. Mean EOR in awake cases was 92.03% and 90.05% in GA cases (P = 0.23). Postoperative deficits were permanent after 3 months only in 5% of awake patients versus 8.3% of GA group (P = 0.59). CONCLUSION Awake craniotomy with intraoperative mapping can be done safely for perirolandic gliomas with lower but statistically nonsignificant incidence of intraoperative seizures and this could be attributed to statistically significant lower stimulation intensities required for mapping. Preoperative multiple AEDs and low-grade glioma are significant predictors for intraoperative seizures.
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Affiliation(s)
- Ahmed A Morsy
- Department of Neurosurgery, Zagazig University, Zagazig, Alsharkia, Egypt
| | - Ayman M Ismail
- Department of Neurosurgery, Zagazig University, Zagazig, Alsharkia, Egypt
| | - Yasser M Nasr
- Department of Anesthesia and Surgical Intensive Care, Zagazig University, Zagazig, Alsharkia, Egypt
| | - Salwa H Waly
- Department of Anesthesia and Surgical Intensive Care, Zagazig University, Zagazig, Alsharkia, Egypt
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Manan HA, Franz EA, Yahya N. The utilisation of resting-state fMRI as a pre-operative mapping tool in patients with brain tumours in comparison to task-based fMRI and intraoperative mapping: A systematic review. Eur J Cancer Care (Engl) 2021; 30:e13428. [PMID: 33592671 DOI: 10.1111/ecc.13428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Resting-state functional Magnetic Resonance Imaging (rs-fMRI) is suggested to be a viable option for pre-operative mapping for patients with brain tumours. However, it remains an open issue whether the tool is useful in the clinical setting compared to task-based fMRI (T-fMRI) and intraoperative mapping. Thus, a systematic review was conducted to investigate the usefulness of this technique. METHODS A systematic literature search of rs-fMRI methods applied as a pre-operative mapping tool was conducted using the PubMed/MEDLINE and Cochrane Library electronic databases following PRISMA guidelines. RESULTS Results demonstrated that 50% (six out of twelve) of the studies comparing rs-fMRI and T-fMRI showed good concordance for both language and sensorimotor networks. In comparison to intraoperative mapping, 86% (six out of seven) studies found a good agreement to rs-fMRI. Finally, 87% (twenty out of twenty-three) studies agreed that rs-fMRI is a suitable and useful pre-operative mapping tool. CONCLUSIONS rs-fMRI is a promising technique for pre-operative mapping in assessing the functional brain areas. However, the agreement between rs-fMRI with other techniques, including T-fMRI and intraoperative maps, is not yet optimal. Studies to ascertain and improve the sophistication in pre-processing of rs-fMRI imaging data are needed.
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Affiliation(s)
- Hanani Abdul Manan
- Makmal Pemprosesan Imej Kefungsian (Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Elizabeth A Franz
- Department of Psychology and fMRIotago, University of Otago, Dunedin, New Zealand
| | - Noorazrul Yahya
- Diagnostic Imaging & Radiotherapy Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Curot J, Roux FE, Sol JC, Valton L, Pariente J, Barbeau EJ. Awake Craniotomy and Memory Induction Through Electrical Stimulation: Why Are Penfield's Findings Not Replicated in the Modern Era? Neurosurgery 2021; 87:E130-E137. [PMID: 31914177 DOI: 10.1093/neuros/nyz553] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 11/13/2019] [Indexed: 01/21/2023] Open
Abstract
From the 1930s through the early 1960s, Wilder Penfield12 collected a large number of memories induced by electrical brain stimulation (EBS) during awake craniotomy. As a result, he was a major contributor to several neuroscientific and neuropsychological concepts of long-term memory. His 1963 paper, which recorded all the cases of memories he induced in his operating room, remains a substantial point of reference in neuroscience in 2019, although some of his interpretations are now debatable. However, it is highly surprising that, since Penfield's12 reports, there has been no other surgical publication on memories induced during awake surgery. In this review, we explore this phenomenon and analyze some of the reasons that might explain it. We hypothesize that the main reasons for lack of subsequent reports are related to changes in operative procedures (ie, use of anesthetics, time constraints, and insufficient debriefings) and changes in EBS parameters, rather than to the sites that are stimulated, the pathology treated, or the tasks used. If reminiscences are still induced, they should be reported in detail to add valuable contributions to the understanding of long-term memory networks, especially memories that are difficult to reproduce in the laboratory, such as autobiographical memories.
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Affiliation(s)
- Jonathan Curot
- Department of Neurophysiological Explorations, Hôpital Pierre Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Centre de Recherche Cerveau et Cognition CerCo, CNRS, UMR5549, Toulouse, France.,Centre de Recherche Cerveau et Cognition, Université de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Franck-Emmanuel Roux
- Centre de Recherche Cerveau et Cognition CerCo, CNRS, UMR5549, Toulouse, France.,Centre de Recherche Cerveau et Cognition, Université de Toulouse, Université Paul Sabatier, Toulouse, France.,Department of Neurosurgery, Hôpital Pierre Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Jean-Christophe Sol
- Department of Neurosurgery, Hôpital Pierre Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,INSERM, U1214, TONIC, Toulouse Mind and Brain Institute, Toulouse, France
| | - Luc Valton
- Department of Neurophysiological Explorations, Hôpital Pierre Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,INSERM, U1214, TONIC, Toulouse Mind and Brain Institute, Toulouse, France.,Centre de Recherche Cerveau et Cognition, Université de Toulouse, Université Paul Sabatier, Toulouse, France
| | - Jéremie Pariente
- Department of Cognitive Neurology, Hôpital Pierre Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,INSERM, U1214, TONIC, Toulouse Mind and Brain Institute, Toulouse, France
| | - Emmanuel J Barbeau
- Centre de Recherche Cerveau et Cognition CerCo, CNRS, UMR5549, Toulouse, France.,Centre de Recherche Cerveau et Cognition, Université de Toulouse, Université Paul Sabatier, Toulouse, France
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Clavreul A, Aubin G, Delion M, Lemée JM, Ter Minassian A, Menei P. What effects does awake craniotomy have on functional and survival outcomes for glioblastoma patients? J Neurooncol 2021; 151:113-121. [PMID: 33394262 DOI: 10.1007/s11060-020-03666-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/18/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Neurosurgeons adopt several different surgical approaches to deal with glioblastomas (GB) located in or near eloquent areas. Some attempt maximal safe resection by awake craniotomy (AC), but doubts persist concerning the real benefits of this type of surgery in this situation. We performed a retrospective study to evaluate the extent of resection (EOR), functional and survival outcomes after AC of patients with GB in critical locations. METHODS Forty-six patients with primary GB treated with the Stupp regimen between 2004 and 2019, for whom brain mapping was feasible, were included. We assessed EOR, postoperative language and/or motor deficits three months after AC, progression-free survival (PFS) and overall survival (OS). RESULTS Complete resection was achieved in 61% of the 46 GB patients. The median PFS was 6.8 months (CI 6.1; 9.7) and the median OS was 17.6 months (CI 14.8; 34.1). Three months after AC, more than half the patients asymptomatic before surgery remained asymptomatic, and one third of patients with symptoms before surgery experienced improvements in language, but not motor functions. The risk of postoperative deficits was higher in patients with preoperative deficits or incomplete resection. Furthermore, the presence of postoperative deficits was an independent predictive factor for shorter PFS. CONCLUSION AC is an option for the resection of GB in critical locations. The observed survival outcomes are typical for GB patients in the Stupp era. However, the success of AC in terms of the recovery or preservation of language and/or motor functions cannot be guaranteed, given the aggressiveness of the tumor.
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Affiliation(s)
- Anne Clavreul
- Université d'Angers, CHU d'Angers, CRCINA, Angers, France
- Département de Neurochirurgie, CHU Angers, Angers, France
| | - Ghislaine Aubin
- Département de Neurologie, CHU Angers, Angers, France
- Les Capucins, Centre de Rééducation et Réadaptation Fonctionnelle Adulte et Pédiatrique, Angers, France
| | | | - Jean-Michel Lemée
- Université d'Angers, CHU d'Angers, CRCINA, Angers, France
- Département de Neurochirurgie, CHU Angers, Angers, France
| | | | - Philippe Menei
- Université d'Angers, CHU d'Angers, CRCINA, Angers, France.
- Département de Neurochirurgie, CHU Angers, Angers, France.
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Policicchio D, Ticca S, Dipellegrini G, Doda A, Muggianu G, Boccaletti R. Multimodal Surgical Management of Cerebral Lesions in Motor-Eloquent Areas Combining Intraoperative 3D Ultrasound with Neurophysiological Mapping. J Neurol Surg A Cent Eur Neurosurg 2020; 82:344-356. [PMID: 33352612 DOI: 10.1055/s-0040-1717111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Resection of tumors adjacent to motor pathways carries risks of both postoperative motor deficit and incomplete resection. Our aim was to assess usefulness and limitations of a multimodal strategy that combines intraoperative ultrasound (iUS) guided resection with intraoperative neurophysiology. METHODOLOGY This is a prospective study of 25 patients with brain lesions adjacent to motor areas who underwent intracranial surgery with assistance of the iUS guidance system and intraoperative neurophysiological monitoring and mapping. Pathologies treated included 19 gliomas, 3 metastases, 1 anaplastic meningioma, 1 arteriovenous malformation (AVM), and 1 ependymoma. The iUS-guided lesion removal accuracy and the extent of resection were estimated and compared with a 30-day postoperative brain MRI. The results were assessed considering the extent of resection related to 6-month motor function outcome. RESULTS iUS was accurate in checking the extent of resection in 17 patients, whereas in 8 cases the decline of the iUS images quality did not allow a valuable assessment. Positive mapping was obtained in 16 patients. Gross total resection was achieved in 16 patients. In five of nine cases with subtotal resection, surgery was stopped because a functional area was reached. In four patients, tumor removal was limited due to the difficulty of identifying neoplastic tissue. Motor function worsening was transient in six patients and permanent in two. CONCLUSIONS The integrated use of intraoperative neuromonitoring to identify motor areas and iUS to identify tumor-tissue interface could help increase the rate of radical resection respecting the eloquent areas.
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Affiliation(s)
- Domenico Policicchio
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Stefano Ticca
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Giosuè Dipellegrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Artan Doda
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Giampiero Muggianu
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Riccardo Boccaletti
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
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Young JS, Morshed RA, Gogos AJ, Amara D, Villanueva-Meyer JE, Berger MS, Hervey-Jumper SL. The Glioma-Network Interface: A Review of the Relationship Between Glioma Molecular Subtype and Intratumoral Function. Neurosurgery 2020; 87:1078-1084. [PMID: 34791466 DOI: 10.1093/neuros/nyaa362] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/05/2020] [Indexed: 11/13/2022] Open
Abstract
Gliomas are a major cause of morbidity. Direct cortical stimulation mapping offers the ability to identify functional areas within the broader neural network both cortically and subcortically. Since the World Health Organization (WHO) 2016 classification categorized gliomas into molecular subgroups with varied molecular signatures and clinical behavior, it is possible that gliomas may demonstrate rates of functional network integration. We therefore retrospectively reviewed a data registry of 181 patients with dominant hemisphere frontal, parietal, insular, or temporal gliomas. Our goal was to test the hypothesis that WHO glioma histopathology and molecular subtype influences functional language or motor sites identified within the tumor. Intratumoral function as determined by direct cortical and subcortical stimulation mapping was identified at the highest rate in isocitrate dehydrogenase mutant astrocytomas and oligodendrogliomas. Finally, we reviewed the emerging literature exploring the interface between functional neural networks and gliomas. These data shed light on glioma molecular and histological characteristics most commonly associated within intratumoral function.
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Affiliation(s)
- Jacob S Young
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Andrew J Gogos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Dominic Amara
- School of Medicine, University of California, San Francisco, San Francisco, California
| | - Javier E Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Mamani R, Jacobo JA, Mejia S, Nuñez-Velasco S, Aragon-Arreola J, Moreno S. Analysis of Intraoperative Seizures During Bipolar Brain Mapping in Eloquent Areas: Intraoperative Seizures in brain mapping. Clin Neurol Neurosurg 2020; 199:106304. [PMID: 33096426 DOI: 10.1016/j.clineuro.2020.106304] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/20/2020] [Accepted: 10/11/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Awake Craniotomy (AC) is a very well described technique that is performed to make an adequate tumor resection preserving the functionality of the patient. Intraoperative Seizures (IS) are reported as a failure of such procedure. We analyze the incidence and risk factor during AC. METHODS We made a review of the database of the National Institute of Neurology and Neurosurgery between January 2017 and May 2019 for intrinsic tumors located in eloquent areas of the brain. An analysis of ISconcerning the clinical history, clinical presentation, imaging techniques, histological findings and surgical technique was made. The factors associated with Mapping Failure (MF) were also evaluated. RESULTS 45 patients were included of whom 7 patients (15.6%) developed IS after cortical-subcortical stimulation, 5 presented partial motor seizures (11.1%) and 2 experimented generalized secondary seizures (4.5%). Of the patients that had a MF, one patient (14%) was due to generalized tonic-clonic seizures which couldn't be managed by cold saline irrigation and administration of anti-seizures drugs and was then converted to a general anesthetic technique. We observed that the patients that had a bigger tumoral volume (112.2 cm3 85.3, P = 0,07) had a bigger positive relation in presenting IS, having a peak sensibility and specificity above 70 cc (ROC). CONCLUSIONS In our analysis IS are more common in patients with high presurgical tumor volume. Even though the majority of the patients that presented IS didn't develop MF, it is important to acknowledge that the multidisciplinary group in the operating room must be prepared to detect these complications, treat them promptly and avoid MF.
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Affiliation(s)
- Rocio Mamani
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico; Department of Radiosurgery, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico.
| | - Javier A Jacobo
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Sonia Mejia
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Santiago Nuñez-Velasco
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Jorge Aragon-Arreola
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Sergio Moreno
- Department of Surgical Neuro-Oncology, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico; Department of Radiosurgery, National Institute of Neurology and Neurosurgery, South Insurgentes Avenue 3877, Tlalpan, 14269 Mexico City, Mexico
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Pascual JSG, Omar AT, Gaddi MJS, Iglesias RJO, Ignacio KHD, Jose GRB, Berger MS, Legaspi GD. Awake Craniotomy in Low-Resource Settings: Findings from a Retrospective Cohort in the Philippines. World Neurosurg 2020; 145:500-507.e1. [PMID: 33091650 DOI: 10.1016/j.wneu.2020.10.070] [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: 09/16/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Awake craniotomy is a technique used to maximize resection of lesions in eloquent areas of the brain and preserve function. Although its use in high-income centers is well documented for tumors and vascular lesions, reports of its use in low-middle-income countries are limited. There are no published series from the Philippines. METHODS We performed a retrospective review of all patients who underwent awake craniotomy at a tertiary referral center in Manila, Philippines from 2010 to 2019. Data on demographics, clinical features, diagnoses, intraoperative and postoperative complications, and outcomes were collected. Regression analyses were performed to correlate use of intraoperative adjuncts with outcome measures (extent of resection, complication rate, neurologic status after surgery and on last follow-up, and in-hospital mortality). RESULTS A total of 65 patients were included in the cohort, who had a male predilection (60%) and a mean age at diagnosis of 40.4 years. The most common indication was tumor excision (90%), followed by excision of arteriovenous malformations (5%) and cavernomas (3%). Of the tumors, the most common histopathologic diagnosis was low-grade glioma (48%). The intraoperative complication rate was 13.8%, with the most common complication being patient intolerance. Gross total excision rate for tumors was 78.3%. Univariate analysis showed that use of a cortical stimulator was associated with improved neurologic status on last follow-up (P = 0.0471). CONCLUSIONS Our experience shows that awake craniotomy is feasible in low-middle-income country settings and is safe and effective for excision of tumors, arteriovenous malformations, and cavernomas.
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Affiliation(s)
- Juan Silvestre G Pascual
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Abdelsimar T Omar
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Mairre James S Gaddi
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Rafa Jireh O Iglesias
- Division of Neuroanesthesia, Department of Anesthesiology, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Katrina Hannah D Ignacio
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Geraldine Raphaela B Jose
- Division of Neuroanesthesia, Department of Anesthesiology, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Mitchel S Berger
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Gerardo D Legaspi
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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Zhang JJY, Lee KS, Voisin MR, Hervey-Jumper SL, Berger MS, Zadeh G. Awake craniotomy for resection of supratentorial glioblastoma: a systematic review and meta-analysis. Neurooncol Adv 2020; 2:vdaa111. [PMID: 33063012 PMCID: PMC7542985 DOI: 10.1093/noajnl/vdaa111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background The goal of glioblastoma (GBM) surgery is to maximize the extent of resection (EOR) while minimizing postoperative neurological complications. Awake craniotomy (AC) has been demonstrated to achieve this goal for low-grade gliomas in or near eloquent areas. However, the efficacy of AC for GBM resection has not been established. Therefore, we aimed to investigate the outcomes of AC for surgical resection of GBM using a systematic review and meta-analysis of published studies. Methods Systematic searches of Ovid MEDLINE, Embase, Cochrane Controlled Register of Controlled Trials, and PubMed were performed from database inception to September 14, 2019 for published studies reporting outcomes of AC for GBM resection. Outcome measures analyzed included EOR and the event rate of postoperative neurological deficits. Results A total of 1928 unique studies were identified. Fourteen studies reporting 278 patients were included in our meta-analysis. Mean age of patients was 46.9 years (95% confidence interval [CI]: 43.9–49.9). Early and late postoperative neurological deficits occurred in 34.5% (95% CI: 21.9–48.2) and 1.9% (95% CI: 0.0–9.2) of patients, respectively. Pooled percentage of gross total resection (GTR) was 74.7% (95% CI: 66.7–82.1), while the pooled percentage reduction in tumor volume was 95.3% (95% CI: 92.2–98.4). Conclusions Limited current evidence suggests that the use of AC for resection of supratentorial GBM is associated with a low rate of persistent neurological deficits while achieving an acceptable rate of GTR. Our findings demonstrate the potential viability of AC in GBM resection and highlight the need for further research on this topic.
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Affiliation(s)
- John J Y Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Mathew R Voisin
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Gelareh Zadeh
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Optimizing the onco-functional balance in supratentorial brain tumour surgery: A single institution's initial experience with intraoperative cortico-subcortical mapping and monitoring in Singapore. J Clin Neurosci 2020; 79:224-230. [PMID: 33070901 DOI: 10.1016/j.jocn.2020.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 06/04/2020] [Accepted: 07/11/2020] [Indexed: 11/23/2022]
Abstract
Intraoperative cortical mapping provides functional information that permits the safe and maximal resection of supratentorial lesions infiltrating the so-called eloquent cortex or subcortical white matter tracts. Primary and secondary brain tumours located in eloquent cortex can render surgical treatment ineffective if it results in new or worsening neurology. A cohort of forty-six consecutive patients with supratentorial tumours of variable pathology involving eloquent cortical regions and aided with intraoperative neurophysiology were included for retrospective analysis at a single-centre tertiary institution. Intraoperative neurophysiological data has been related to immediate post-operative neurologic status as well as 3-month follow-up in patients that underwent awake or asleep surgical resection. Patients that experienced new or worsening neurologic symptoms post-operatively demonstrated a high incidence of recovery at 3-months. Those without new neurologic symptoms post-operatively demonstrated little to no worsening at 3-months. Our study explored the extent to which cortical mapping permitted safe surgical resection whilst preserving neurologic function. To the authors' knowledge this is the first documented case series in Singapore that has incorporated a systematic and individually tailored multimodal workflow to cortico-subcortical mapping and monitoring for the safe resection of infiltrative lesions of the supratentorial region.
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Shiraki A, Goto W, Fukagawa H, Arakawa Y, Kikuchi T, Mineharu Y, Yamao Y, Yasuda T, Hattori E, Fukui A, Matsui Y, Yonezawa A, Furukawa K, Mizota T. Effects of low-dose remifentanil infusion on analgesic or antiemetic requirement during brain function mapping: A retrospective cohort study. Acta Anaesthesiol Scand 2020; 64:735-741. [PMID: 31997302 DOI: 10.1111/aas.13554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/03/2020] [Accepted: 01/16/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pain and discomfort during the awake phase in awake craniotomy should be relieved to facilitate brain mapping. Although some anaesthesiologists use low-dose (0.01-0.05 µg/kg/min) remifentanil infusion to provide analgesia during this phase, its efficacy and side effects have never been evaluated. Therefore, this study primarily aimed to investigate the effects of low-dose remifentanil infusion on the need for antiemetic treatment during brain mapping and secondarily aimed to determine its effects on the need for additional analgesic treatment. METHODS This retrospective study included 218 patients who underwent awake craniotomy at our centre from 2008 to 2018. The relationship between low-dose remifentanil infusion during the awake phase and the requirement for analgesic or antiemetic treatment was examined. A multivariable competing risk regression analysis was performed to adjust for patient and operative variables. RESULTS Sixty-six patients (30.3%) received low-dose (median rate: 0.01 µg/kg/min) remifentanil infusion during the awake phase. Forty-nine patients (22.5%) received an antiemetic and 99 (45.4%) received additional analgesic treatment. The difference in additional analgesic treatment was not significant between patients who received low-dose remifentanil infusion and those who did not (adjusted hazard ratio: 1.13; 95% confidence interval: 0.75-1.70; P = .570); however, the use of antiemetics significantly increased in patients who received remifentanil (adjusted hazard ratio: 1.78; 95% confidence interval: 1.01-3.15; P = .047). CONCLUSION Low-dose remifentanil infusion during the awake phase in awake craniotomy significantly increased the need for antiemetics but did not decrease the need for additional analgesic treatment.
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Affiliation(s)
- Atsuko Shiraki
- Department of Anesthesia Kyoto University Hospital Kyoto Japan
| | - Wataru Goto
- Department of Anesthesia Kyoto University Hospital Kyoto Japan
| | | | - Yoshiki Arakawa
- Department of Neurosurgery Kyoto University Hospital Kyoto Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery Kyoto University Hospital Kyoto Japan
| | - Yohei Mineharu
- Department of Neurosurgery Kyoto University Hospital Kyoto Japan
| | - Yukihiro Yamao
- Department of Neurosurgery Kyoto University Hospital Kyoto Japan
| | - Takayuki Yasuda
- Department of Neurosurgery Kyoto University Hospital Kyoto Japan
| | - Etsuko Hattori
- Department of Neurosurgery Kyoto University Hospital Kyoto Japan
| | - Ayaka Fukui
- Department of Clinical Pharmacology and Therapeutics Kyoto University Hospital Kyoto Japan
| | - Yoshihiro Matsui
- Department of Clinical Pharmacology and Therapeutics Kyoto University Hospital Kyoto Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics Kyoto University Hospital Kyoto Japan
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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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Zelitzki R, Korn A, Arial E, Ben-Harosh C, Ram Z, Grossman R. Comparison of Motor Outcome in Patients Undergoing Awake vs General Anesthesia Surgery for Brain Tumors Located Within or Adjacent to the Motor Pathways. Neurosurgery 2020; 85:E470-E476. [PMID: 30783667 DOI: 10.1093/neuros/nyz007] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/07/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Surgical removal of intra-axial brain tumors aims at maximal tumor resection while preserving function. The potential benefit of awake craniotomy over craniotomy under general anesthesia (GA) for motor preservation is yet unknown. OBJECTIVE To compare the clinical outcomes of patients who underwent surgery for perirolandic tumors while either awake or under GA. METHODS Between 2004 and 2015, 1126 patients underwent surgical resection of newly diagnosed intra-axial tumors in a single institution. Data from 85 patients (44 awake, 41 GA) with full dataset who underwent resections for perirolandic tumors were retrospectively analyzed. RESULTS Identification of the motor cortex required significantly higher stimulation thresholds in anesthetized patients (9.1 ± 4 vs 6.2 ± 2.7 mA for awake patients, P = .0008). There was no group difference in the subcortical threshold for motor response used to assess the proximity of the lesion to the corticospinal (pyramidal) tract. High-grade gliomas were the most commonly treated pathology. The extent of resection and residual tumor volume were not different between groups. Postoperative motor deficits were more common in the anesthetized patients at 1 wk (P = .046), but no difference between the groups was detected at 3 mo. Patients in the GA group had a longer mean length of hospitalization (10.3 vs 6.7 d for the awake group, P = .003). CONCLUSION Awake craniotomy results in a better early postoperative motor outcome and shorter hospitalization compared with patients who underwent the same surgery under GA. The finding of higher cortical thresholds for the identification of the motor cortex in anesthetized patients may suggest an inhibitory effect of anesthetic agents on motor function.
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Affiliation(s)
- Roni Zelitzki
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Akiva Korn
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eti Arial
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Carmit Ben-Harosh
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Berger A, Tzarfati G, Costa M, Serafimova M, Korn A, Vendrov I, Alfasi T, Krill D, Aviram D, Ben Moshe S, Kashanian A, Ram Z, Grossman R. Incidence and impact of stroke following surgery for low-grade gliomas. J Neurosurg 2019; 134:153-161. [PMID: 31881532 DOI: 10.3171/2019.10.jns192301] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ischemic complications are a common cause of neurological deficits following low-grade glioma (LGG) surgeries. In this study, the authors evaluated the incidence, risk factors, and long-term implications of intraoperative ischemic events. METHODS The authors retrospectively evaluated patients who had undergone resection of an LGG between 2013 and 2017. Analysis included pre- and postoperative demographic, clinical, radiological, and anesthetic data, as well as intraoperative neurophysiology data, overall survival, and functional and neurocognitive outcomes. RESULTS Among the 82 patients included in the study, postoperative diffusion-weighted imaging showed evidence of acute ischemic strokes in 19 patients (23%), 13 of whom (68%) developed new neurological deficits. Infarcts were more common in recurrent and insular surgeries (p < 0.05). Survival was similar between the patients with and without infarcts. Immediately after surgery, 27% of the patients without infarcts and 58% of those with infarcts experienced motor deficits (p = 0.024), decreasing to 16% (p = 0.082) and 37% (p = 0.024), respectively, at 1 year. Neurocognitive functions before and 3 months after surgery were generally stable for the two groups, with the exception of a decline in verbal rhyming ability among patients with infarcts. Confusion during awake craniotomy was a strong predictor of the occurrence of an ischemic stroke. Mean arterial pressure at the beginning of surgery was significantly lower in the infarct group. CONCLUSIONS Recurrent surgeries and insular tumor locations are risk factors for intraoperative strokes. Although they do not affect survival, these strokes negatively affect patient activity and performance status, mainly during the first 3 postoperative months, with gradual functional improvement over 1 year. Several intraoperative parameters may suggest the impending development of an infarct.
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Rigolo L, Essayed WI, Tie Y, Norton I, Mukundan S, Golby A. Intraoperative Use of Functional MRI for Surgical Decision Making after Limited or Infeasible Electrocortical Stimulation Mapping. J Neuroimaging 2019; 30:184-191. [PMID: 31867823 DOI: 10.1111/jon.12683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/09/2019] [Accepted: 11/11/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Functional magnetic resonance imaging (fMRI) is becoming widely recognized as a key component of preoperative neurosurgical planning, although intraoperative electrocortical stimulation (ECS) is considered the gold standard surgical brain mapping method. However, acquiring and interpreting ECS results can sometimes be challenging. This retrospective study assesses whether intraoperative availability of fMRI impacted surgical decision-making when ECS was problematic or unobtainable. METHODS Records were reviewed for 191 patients who underwent presurgical fMRI with fMRI loaded into the neuronavigation system. Four patients were excluded as a bur-hole biopsy was performed. Imaging was acquired at 3 Tesla and analyzed using the general linear model with significantly activated pixels determined via individually determined thresholds. fMRI maps were displayed intraoperatively via commercial neuronavigation systems. RESULTS Seventy-one cases were planned ECS; however, 18 (25.35%) of these procedures were either not attempted or aborted/limited due to: seizure (10), patient difficulty cooperating with the ECS mapping (4), scarring/limited dural opening (3), or dural bleeding (1). In all aborted/limited ECS cases, the surgeon continued surgery using fMRI to guide surgical decision-making. There was no significant difference in the incidence of postoperative deficits between cases with completed ECS and those with limited/aborted ECS. CONCLUSIONS Preoperative fMRI allowed for continuation of surgery in over one-fourth of patients in which planned ECS was incomplete or impossible, without a significantly different incidence of postoperative deficits compared to the patients with completed ECS. This demonstrates additional value of fMRI beyond presurgical planning, as fMRI data served as a backup method to ECS.
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Affiliation(s)
- Laura Rigolo
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yanmei Tie
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Isaiah Norton
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Srinivasan Mukundan
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alexandra Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Stimulation-related intraoperative seizures during awake surgery: a review of available evidences. Neurosurg Rev 2019; 43:87-93. [PMID: 31797239 DOI: 10.1007/s10143-019-01214-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/08/2019] [Accepted: 11/13/2019] [Indexed: 01/01/2023]
Abstract
Awake surgery is a well-defined procedure with a very low morbidity. In particular, stimulation-related intraoperative seizure (IOS) is a commonly discussed and serious complication associated with awake surgery. Here, we reviewed the literature on awake surgery and IOS and sought to obtain evidences on the predictive factors of IOS and on the effect of IOS on postoperative outcomes. We conducted a comprehensive search of the Embase, MEDLINE, and Cochrane Central Register of Controlled Trials databases to identify potentially relevant articles from 2000 to 2019. We used combinations of the following search terms: "intraoperative seizure awake craniotomy," "awake surgery seizures," and pertinent associations; the search was restricted to publications in English and only to papers published in the last 20 years. The search returned 141 articles, including 39 papers that reported the IOS rate during awake craniotomy. The reported IOS rates ranged between 0 and 24% (mean, 7.7%). Only few studies have assessed the relationships between awake surgery and IOS, and hence, drawing clear conclusions is difficult. Nevertheless, IOS does not cause permanent and severe postoperative deficits, but can affect the patient's status perioperatively and the hospitalization duration. Anterior tumor location is an important perioperative factor associated with high IOS risk, whereas having seizures at tumor diagnosis does not seem to influence. However, the role of antiepileptic drug administration and prophylaxis remains unclear. In conclusion, given the difficulty in identifying predictors of IOS, we believe that prompt action at onset and awareness of appropriate management methods are vital.
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Krivosheya D, Rao G, Tummala S, Kumar V, Suki D, Bastos DCA, Prabhu SS. Impact of Multi-modality Monitoring Using Direct Electrical Stimulation to Determine Corticospinal Tract Shift and Integrity in Tumors using the Intraoperative MRI. J Neurol Surg A Cent Eur Neurosurg 2019; 82:375-380. [PMID: 31659724 DOI: 10.1055/s-0039-1698383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Preserving the integrity of the corticospinal tract (CST) while maximizing the extent of tumor resection is one of the key principles of brain tumor surgery to prevent new neurologic deficits. Our goal was to determine the impact of the use of perioperative diffusion tensor imaging (DTI) fiber-tracking protocols for location of the CSTs, in conjunction with intraoperative direct electrical stimulation (DES) on patient neurologic outcomes. The role of combining DES and CST shift in intraoperative magnetic resonance imaging (iMRI) to enhance extent of resection (EOR) has not been studied previously. METHODS A total of 53 patients underwent resection of tumors adjacent to the motor gyrus and the underlying CST between June 5, 2009, and April 16, 2013. All cases were performed in the iMRI (BrainSuite 1.5 T). Preoperative DTI mapping and intraoperative cortical and subcortical DES including postoperative DTI mapping were performed in all patients. There were 32 men and 21 women with 40 high-grade gliomas (76%), 4 low-grade gliomas (8%), and 9 (17%) metastases. Thirty-four patients (64%) were newly diagnosed, and 19 (36%) had a previous resection. There were 31 (59%) right-sided and 22 (42%) left-sided tumors. Eighteen patients (34%) had a re-resection after the first intraoperative scan. Most patients had motor-only mapping, and one patient had both speech and motor mapping. Relative to the resection margin, the CST after the first iMRI was designated as having an outward shift (OS), inward shift (IS), or no shift (NS). RESULTS A gross total resection (GTR) was achieved in 41 patients (77%), subtotal resection in 4 (7.5%), and a partial resection in 8 (15%). Eighteen patients had a re-resection, and the mean EOR increased from 84% to 95% (p = 0.002). Of the 18 patients, 7 had an IS, 8 an OS, and in 3 NS was noted. More patients in the OS group had a GTR compared with the IS or NS groups (p = 0.004). Patients were divided into four groups based on the proximity of the tumor to the CST as measured from the preoperative scan. Group 1 (32%) included patients whose tumors were 0 to 5 mm from the CST based on preoperative scans; group 2 (28%), 6 to 10 mm; group 3 (13%), 11 to 15 mm; and group 4 (26%), 16 to 20 mm, respectively. Patients in group 4 had fewer neurologic complications compared with other groups at 1 and 3 months postoperatively (p = 0.001 and p = 0.007, respectively) despite achieving a similar degree of resection (p = 0.61). Furthermore, the current of intraoperative DES was correlated to the distance of the tumor to the CST, and the regression equation showed a close linear relationship between the two parameters. CONCLUSIONS Combining information about intraoperative CST and DES in the iMRI can enhance resection in brain tumors (77% had a GTR). The relative relationship between the positions of the CST to the resection cavity can be a dynamic process that could further influence the surgeon's decision about the stimulation parameters and EOR. Also, the patients with an OS of the CST relative to the resection cavity had a GTR comparable with the other groups.
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Affiliation(s)
- Daria Krivosheya
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Ganesh Rao
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Sudhakar Tummala
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Vinodh Kumar
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Dima Suki
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Dheigo C A Bastos
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Sujit S Prabhu
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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