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Weller J, de Dios E, Katzendobler S, Corell A, Dénes A, Schmutzer-Sondergeld M, Javanmardi N, Thon N, Tonn JC, Jakola AS. The T1/T2 Ratio is Associated With Resectability in Patients With Isocitrate Dehydrogenase-Mutant Astrocytomas Central Nervous System World Health Organization Grades 2 and 3. Neurosurgery 2024:00006123-990000000-01244. [PMID: 38920377 DOI: 10.1227/neu.0000000000003069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/09/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Isocitrate dehydrogenase (IDH)-mutant astrocytomas central nervous system World Health Organization grade 2 and 3 show heterogeneous appearance on MRI. In the premolecular era, the discrepancy between T1 hypointense and T2 hyperintense tumor volume in absolute values has been proposed as a marker for diffuse tumor growth. We set out to investigate if a ratio of T1 to T2 tumor volume (T1/T2 ratio) is associated with resectability and overall survival (OS) in patients with IDH-mutant astrocytomas. METHODS Patient data from 2 centers (Sahlgrenska University Hospital, Center A; LMU University Hospital, Center B) were collected retrospectively. Inclusion criteria were as follows: pre and postoperative MRI scans available for volumetric analysis (I), diagnosis of an IDH-mutant astrocytoma between 2003 and 2021 (II), and tumor resection at initial diagnosis (III). Tumor volumes were manually segmented. The T1/T2 ratio was calculated and correlated with extent of resection, residual T2 tumor volume, and OS. RESULTS The study comprised 134 patients with 65 patients included from Center A and 69 patients from Center B. The median OS was 134 months and did not differ between the cohorts (P = .29). Overall, the median T1/T2 ratio was 0.79 (range 0.15-1.0). Tumors displaying a T1/T2 ratio of 0.33 or lower showed significantly larger residual tumor volumes postoperatively (median 17.9 cm3 vs 4.6 cm3, P = .03). The median extent of resection in these patients was 65% vs 90% (P = .03). The ratio itself did not correlate with OS. In multivariable analyses, larger postoperative tumor volumes were associated with shorter survival times (hazard ratio 1.02, 95% CI 1.01-1.03, P < .01). CONCLUSION The T1/T2 ratio might be a good indicator for diffuse tumor growth on MRI and is associated with resectability in patients with IDH-mutant astrocytoma. This ratio might aid to identify patients in which an oncologically relevant tumor volume reduction cannot be safely achieved.
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Affiliation(s)
- Jonathan Weller
- Department of Neurosurgery, LMU University Hospital, LMU Munich, München, Germany
| | - Eddie de Dios
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sophie Katzendobler
- Department of Neurosurgery, LMU University Hospital, LMU Munich, München, Germany
| | - Alba Corell
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Anna Dénes
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | | | - Niloufar Javanmardi
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Niklas Thon
- Department of Neurosurgery, LMU University Hospital, LMU Munich, München, Germany
- German Consortium for Translational Cancer Research (DKTK), Partner site Munich, Heidelberg, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, LMU University Hospital, LMU Munich, München, Germany
- German Consortium for Translational Cancer Research (DKTK), Partner site Munich, Heidelberg, Germany
| | - Asgeir S Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
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Tomasino B, Weis L, Maieron M, Pauletto G, Verriello L, Budai R, Ius T, D'Agostini S, Fadiga L, Skrap M. Motor or non-motor speech interference? A multimodal fMRI and direct cortical stimulation mapping study. Neuropsychologia 2024; 198:108876. [PMID: 38555064 DOI: 10.1016/j.neuropsychologia.2024.108876] [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: 01/27/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/02/2024]
Abstract
We retrospectively analyzed data from 15 patients, with a normal pre-operative cognitive performance, undergoing awake surgery for left fronto-temporal low-grade glioma. We combined a pre-surgical measure (fMRI maps of motor- and language-related centers) with intra-surgical measures (MNI-registered cortical sites data obtained during intra-operative direct electrical stimulation, DES, while they performed the two most common language tasks: number counting and picture naming). Selective DES effects along the precentral gyrus/inferior frontal gyrus (and/or the connected speech articulation network) were obtained. DES of the precentral gyrus evoked the motor speech arrest, i.e., anarthria (with apparent mentalis muscle movements). We calculated the number of shared voxels between the lip-tongue and overt counting related- and silent naming-related fMRI maps and the Volumes of Interest (VOIs) obtained by merging together the MNI sites at which a given speech disturbance was observed, normalized on their mean the values (i.e., Z score). Both tongue- and lips-related movements fMRI maps maximally overlapped (Z = 1.05 and Z = 0.94 for lips and tongue vs. 0.16 and -1.003 for counting and naming) with the motor speech arrest seed. DES of the inferior frontal gyrus, pars opercularis and the rolandic operculum induced speech arrest proper (without apparent mentalis muscle movements). This area maximally overlapped with overt counting-related fMRI map (Z = -0.11 and Z = 0.09 for lips and tongue vs. 0.9 and 0.0006 for counting and naming). Interestingly, our fMRI maps indicated reduced Broca's area activity during silent speech compared to overt speech. Lastly, DES of the inferior frontal gyrus, pars opercularis and triangularis evoked variations of the output, i.e., dysarthria, a motor speech disorder occurring when patients cannot control the muscles used to produce articulated sounds (phonemes). Silent object naming-related fMRI map maximally overlapped (Z = -0.93 and Z = -1.04 for lips and tongue vs. -1.07 and 0.99 for counting and naming) with this seed. Speech disturbances evoked by DES may be thought of as selective interferences with specific recruitment of left inferior frontal gyrus and precentral cortex which are differentiable in terms of the specific interference induced.
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Affiliation(s)
| | - Luca Weis
- Istituto Italiano di Tecnologia, Genova, Italy
| | - Marta Maieron
- Fisica Medica, Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Italy
| | - Giada Pauletto
- Neurologia, Dipartimento "Testa, Collo e Neuroscienze", Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Italy
| | - Lorenzo Verriello
- Neurologia, Dipartimento "Testa, Collo e Neuroscienze", Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Italy
| | - Riccardo Budai
- Neurologia, Dipartimento "Testa, Collo e Neuroscienze", Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Italy
| | - Tamara Ius
- Neurochirurgia, Dipartimento "Testa, Collo e Neuroscienze", Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Italy
| | - Serena D'Agostini
- Neuroradiologia, Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Italy
| | - Luciano Fadiga
- Istituto Italiano di Tecnologia, Genova, Italy; Dipartimento di Neuroscienze e Riabilitazione, Università di Ferrara, Italy
| | - Miran Skrap
- Neurochirurgia, Dipartimento "Testa, Collo e Neuroscienze", Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Italy
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3
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Biswas C, Shetty PM, Sahu A, Velayutham P, Singh V, Shah K, Moiyadi AV. Factors affecting the extent of resection and neurological outcomes following transopercular resection of insular gliomas. Acta Neurochir (Wien) 2024; 166:244. [PMID: 38822919 PMCID: PMC11144144 DOI: 10.1007/s00701-024-06124-9] [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: 04/03/2024] [Accepted: 05/14/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Surgical resection of insular gliomas is a challenge. TO resection is considered more versatile and has lower risk of vascular damage. In this study, we aimed to understand the factors that affect resection rates, ischemic changes and neurological outcomes and studied the utility of IONM in patients who underwent TO resection for IGs. METHODS Retrospective analysis of 66 patients with IG who underwent TO resection was performed. RESULTS Radical resection was possible in 39% patients. Involvement of zone II and the absence of contrast enhancement predicted lower resection rate. Persistent deficit rate was 10.9%. Although dominant lobe tumors increased immediate deficit and fronto-orbital operculum involvement reduced prolonged deficit rate, no tumor related factor showed significant association with persistent deficits. 45% of patients developed a postoperative infarct, 53% of whom developed deficits. Most affected vascular territory was lenticulostriate (39%). MEP changes were observed in 9/57 patients. 67% of stable TcMEPs and 74.5% of stable strip MEPs did not develop any postoperative motor deficits. Long-term deficits were seen in 3 and 6% patients with stable TcMEP and strip MEPs respectively. In contrast, 25% and 50% of patients with reversible strip MEP and Tc MEP changes respectively had persistent motor deficits. DWI changes were clinically more relevant when accompanied by MEP changes intraoperatively, with persistent deficit rates three times greater when MEP changes occurred than when MEPs were stable. CONCLUSION Radical resection can be achieved in large, multizone IGs, with reasonable outcomes using TO approach and multimodal intraoperative strategy with IONM.
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Affiliation(s)
- Chandrima Biswas
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prakash M Shetty
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arpita Sahu
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Parthiban Velayutham
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vikas Singh
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kanchi Shah
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Aliasgar V Moiyadi
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India.
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
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Nichols NM, Ezzat B, Waters AC, Panov F, Yong RL, Germano IM. What is the cognitive footprint of insular glioma? Front Hum Neurosci 2024; 18:1382380. [PMID: 38859993 PMCID: PMC11163043 DOI: 10.3389/fnhum.2024.1382380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/29/2024] [Indexed: 06/12/2024] Open
Abstract
Cognitive impairment has a profound deleterious impact on long-term outcomes of glioma surgery. The human insula, a deep cortical structure covered by the operculum, plays a role in a wide range of cognitive functions including interceptive thoughts and salience processing. Both low-grade (LGG) and high-grade gliomas (HGG) involve the insula, representing up to 25% of LGG and 10% of HGG. Surgical series from the past 30 years support the role of primary cytoreductive surgery for insular glioma patients; however, reported cognitive outcomes are often limited to speech and language function. The breath of recent neuroscience literature demonstrates that the insula plays a broader role in cognition including interoceptive thoughts and salience processing. This article summarizes the vast functional role of the healthy human insula highlighting how this knowledge can be leveraged to improve the care of patients with insular gliomas.
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Affiliation(s)
- Noah M Nichols
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
| | - Bahie Ezzat
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
- School of Medicine, Mount Sinai School of Medicine, New York, NY, United States
| | - Allison C Waters
- Department of Neuroscience, Mount Sinai School of Medicine, New York, NY, United States
| | - Fedor Panov
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
| | - Raymund L Yong
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
| | - Isabelle M Germano
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
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Simon M, Hagemann A, Gajadin S, Signorelli F, Vincent AJ. Surgical treatment for insular gliomas. A systematic review and meta-analysis on behalf of the EANS neuro-oncology section. BRAIN & SPINE 2024; 4:102828. [PMID: 38859917 PMCID: PMC11163152 DOI: 10.1016/j.bas.2024.102828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
Introduction The appropriate surgical management of insular gliomas is controversial. Management strategies vary considerably between centers. Research question To provide robust resection, functional and epilepsy outcome figures, study growth patterns and tumor classification paradigms, analyze surgical approaches, mapping/monitoring strategies, surgery for insular glioblastoma, as well as molecular findings, and to identify open questions for future research. Material and methods On behalf of the EANS Neuro-oncology Section we performed a systematic review and meta-analysis (using a random-effects model) of the more current (2000-2023) literature in accordance with the PRISMA guidelines. Results The pooled postoperative motor and speech deficit rates were 6.8% and 3.6%. There was a 79.6% chance for postoperative epilepsy control. The postoperative KPI was 80-100 in 83.5% of cases. Functional monitoring/mapping paradigms (which may include awake craniotomies) seem mandatory. (Additional) awake surgery may result in slightly better functional but also worse resection outcomes. Transcortical approaches may carry a lesser rate of (motor) deficits than transsylvian surgeries. Discussion and conclusions This paper provides an inclusive overview and analysis of current surgical management of insular gliomas. Risks and complication rates in experienced centers do not necessarily compare unfavorably with the results of routine neuro-oncological procedures. Limitations of the current literature prominently include a lack of standardized outcome reporting. Questions and issues that warrant more attention include surgery for insular glioblastomas and how to classify the various growth patterns of insular gliomas.
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Affiliation(s)
- Matthias Simon
- Dept. of Neurosurgery, Bethel Clinic, University of Bielefeld Medical Center OWL, Bielefeld, Germany
| | | | - Sanjana Gajadin
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Francesco Signorelli
- Division of Neurosurgery, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University "Aldo Moro", Bari, Italy
| | - Arnaud J.P.E. Vincent
- Division of Neurosurgery, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University "Aldo Moro", Bari, Italy
| | - for the EANS Neuro-oncology Section
- Dept. of Neurosurgery, Bethel Clinic, University of Bielefeld Medical Center OWL, Bielefeld, Germany
- Society for Epilepsy Research, Bielefeld, Germany
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
- Division of Neurosurgery, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University "Aldo Moro", Bari, Italy
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d'Orio P, Squarza S, Revay M, Cardinale F, Castana L, Sartori I, Tassi L, Lo Russo G, Cossu M. Neurological morbidity of surgery for suprasylvian operculoinsular epilepsy. Epilepsia 2024; 65:402-413. [PMID: 38041557 DOI: 10.1111/epi.17844] [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: 07/24/2023] [Revised: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE The objective of this study was to identify risk factors associated with surgery-related neurological morbidity in patients with drug-resistant epilepsy undergoing suprasylvian operculoinsular resections. As secondary outcomes, we also analyzed the risk factors for ischemic lesion (IL) of corona radiata and seizure recurrence. METHODS A retrospective analysis was conducted on a cohort of patients who underwent suprasylvian operculoinsular resections for drug-resistant epilepsy. The association of several presurgical, surgical, and postsurgical factors with both primary (persistent neurological deficits) and secondary (structural abnormalities on postoperative magnetic resonance imaging [MRI] and seizure recurrence) postoperative outcomes was investigated with univariate and multivariate statistical analysis. RESULTS The study included a total of 65 patients; 46.2% of patients exhibited postoperative neurological deficits, but only 12.3% experienced persistent deficits. On postoperative MRI, IL in the corona radiata and corticospinal tract Wallerian degeneration (CSTWd) were seen in 68% and 29% of cases, respectively. Only CSTWd was significantly associated with persistent neurological deficits (relative risk [RR] = 2.6). Combined operculoinsular resection (RR = 3.62) and surgery performed on the left hemisphere (RR = .37) were independently associated with IL in the corona radiata. Variables independently associated with CSTWd were the presence of malacic components in the IL (RR = 1.96), right central operculum resection (RR = 1.79), and increasing age at surgery (RR = 1.03). Sixty-two patients had a postoperative follow-up > 12 months (median = 56, interquartile range = 30.75-73.5), and 62.9% were in Engel class I at last outpatient control. The risk of seizure recurrence was reduced by selective opercular resection (RR = .25) and increased by the histological diagnosis of aspecific gliosis (RR = 1.39). SIGNIFICANCE This study provides insights into the risk factors associated with surgery-related neurological morbidity, as well as further evidence on the postoperative occurrence of subcortical injury and seizure recurrence in epileptic patients undergoing suprasylvian operculoinsular resections. The findings highlighted in this study may be useful to better understand the processes supporting the increased surgical risk in the operculoinsular region.
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Affiliation(s)
- Piergiorgio d'Orio
- "Claudio Munari" Epilepsy Surgery Center, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Medicine and Surgery, Unit of Neuroscience, University of Parma, Parma, Italy
| | - Silvia Squarza
- Neuroradiology Department, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Martina Revay
- "Claudio Munari" Epilepsy Surgery Center, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Medicine and Surgery, Unit of Neuroscience, University of Parma, Parma, Italy
| | - Francesco Cardinale
- "Claudio Munari" Epilepsy Surgery Center, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Medicine and Surgery, Unit of Neuroscience, University of Parma, Parma, Italy
| | - Laura Castana
- "Claudio Munari" Epilepsy Surgery Center, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Ivana Sartori
- "Claudio Munari" Epilepsy Surgery Center, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laura Tassi
- "Claudio Munari" Epilepsy Surgery Center, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giorgio Lo Russo
- "Claudio Munari" Epilepsy Surgery Center, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Massimo Cossu
- "Claudio Munari" Epilepsy Surgery Center, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Ramakrishnan PK, Saeed F, Thomson S, Corns R, Mathew RK, Sivakumar G. Awake craniotomy for high-grade gliomas - a prospective cohort study in a UK tertiary-centre. Surgeon 2024; 22:e3-e12. [PMID: 38008681 DOI: 10.1016/j.surge.2023.11.002] [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: 10/07/2023] [Accepted: 11/02/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Studies from the UK reporting on awake craniotomy (AC) include a heterogenous group of patients which limit the evaluation of the true impact of AC in high-grade glioma (HGG) patients. This study aims to report solely the experience and outcomes of AC for HGG surgery from our centre. METHODS A prospective review of all patients who underwent AC for HGG from 2013 to 2019 were performed. Data on patient characteristics including but not limited to demographics, pre- and post-operative Karnofsky performance status (KPS), tumour location and volume, type of surgery, extent of resection (EOR), tumour histopathology, intra- and post-operative complications, morbidity, mortality, disease recurrence, progression-free survival (PFS) and overall survival (OS) from the time of surgery were collected. RESULTS Fifteen patients (6 males; 9 females; 17 surgeries) underwent AC for HGG (median age = 55 years). Two patients underwent repeat surgeries due to disease recurrence. Median pre- and post-operative KPS score was 90 (range:80-100) and 90 (range:60-100), respectively. The EOR ranges from 60 to 100 % with a minimum of 80 % achieved in 81.3 % cases. Post-operative complications include focal seizures (17.6 %), transient aphasia/dysphasia (17.6 %), permanent motor deficit (11.8 %), transient motor deficit (5.9 %) and transient sensory disturbance (5.9 %). There were no surgery-related mortality or post-operative infection. The median PFS and OS were 13 (95%CI 5-78) and 30 (95%CI 21-78) months, respectively. CONCLUSION This is the first study in the UK to solely report outcomes of AC for HGG surgery. Our data demonstrates that AC for HGG in eloquent region is safe, feasible and provides comparable outcomes to those reported in the literature.
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Affiliation(s)
- Piravin Kumar Ramakrishnan
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Fozia Saeed
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Simon Thomson
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Robert Corns
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Ryan K Mathew
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom; School of Medicine, University of Leeds, Woodhouse, Leeds LS2 9JT, United Kingdom.
| | - Gnanamurthy Sivakumar
- Department of Neurosurgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, United Kingdom.
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Papadopoulou A, Kumar NS. Prognostic Factors and Resectability Predictors in Insular Gliomas: A Systematic Review. J Neurol Surg A Cent Eur Neurosurg 2024; 85:74-87. [PMID: 37619597 PMCID: PMC10764153 DOI: 10.1055/s-0043-1769128] [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: 01/08/2023] [Accepted: 04/03/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Insular gliomas (INGs) remain a surgically intimidating glioma subgroup encased by eloquent cortical parcels and white matter language tracts, and traversed by multiple middle cerebral artery branches. The predictive power of prognostic factors affecting overall survival (OS), progression-free survival (PFS), and resectability of INGs remain disputed. This comprehensive systematic review analyses prognostic factors and resectability predictors of INGs substantiating pragmatic management options. MATERIALS AND METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) and the Cochrane Handbook of Systematic Reviews of Interventions guidelines. The PubMed, MEDLINE, and Embase databases were searched in April 2022. All clinical studies with ≥10 patients harboring INGs with any intervention and reporting predictors of OS, PFS, and tumor resectability in INGs were included. Molecular ING prognosticators were also included. Studies combining insular and other gliomas analysis, case studies, experimental and animal studies, conference abstracts, letters to the editor, and articles in other languages were excluded. RESULTS Of the 2,384 articles returned, 27 fulfilled the inclusion criteria totaling 1,985 patients. The review yielded 18 OS and 17 PFS prognosticators. These were classified as preoperative (radiologic; clinical), intraoperative, and postoperative (molecular; histopathologic; clinical) prognosticators. In addition, 21 resectability predictors were categorized as preoperative (radiologic; clinical), intraoperative (surgical approach and assistive technology), and postoperative (histopathologic; clinical). The quality assessment revealed 24/27 studies had low risk of bias. One study with moderate and two studies with high risk of bias were included. CONCLUSION Negative prognosticators reported in ≥2 studies included putaminal or paralimbic involvement and higher tumor grade, while seizures at presentation, isocitrate dehydrogenase (IDH) mutation, increased extent of resection, and higher Karnofsky Performance Status preoperatively and at 3 months postoperation were positive prognosticators. Resectability predictors reported in ≥2 studies included the positive predictors of zone I/zone IV tumor location and intraoperative imaging use and the negative predictor of encased lenticulostriate arteries. Paralimbic INGs are not a single entity with homogeneous prognosis. Integration of identified prognosticators in a prospective trial to devise a grading system for INGs can improve clinical decision-making.
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Affiliation(s)
- Ariadni Papadopoulou
- Division of Medicine, University College London Medical School, London, United Kingdom of Great Britain and Northern Ireland
| | - Niraj S. Kumar
- Division of Medicine, University College London Medical School, London, United Kingdom of Great Britain and Northern Ireland
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9
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A Review on the Surgical Management of Insular Gliomas. Neurol Sci 2023; 50:1-9. [PMID: 34711299 DOI: 10.1017/cjn.2021.248] [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: 11/07/2022]
Abstract
The surgical treatment of insular gliomas requires specialized knowledge. Over the last three decades, increased momentum in surgical resection of insular gliomas shifted the focus from one of expectant management to maximal safe resection to establish a diagnosis, characterize tumor genetics, treat preoperative symptoms (i.e., seizures), and delay malignant transformation through tumor cytoreduction. A comprehensive review of the literature was performed regarding insular glioma classification/genetics, insular anatomy, surgical approaches, and patient outcomes. Modern large, published series of insular resections have reported a median 80% resection, 80% improvement in preoperative seizures, and postsurgical permanent neurologic deficits of less than 10%. Major complication avoidance includes recognition and preservation of eloquent cortex for language and respecting the lateral lenticulostriate arteries.
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10
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Raffa G, Marzano G, Curcio A, Espahbodinea S, Germanò A, Angileri FF. Personalized surgery of brain tumors in language areas: the role of preoperative brain mapping in patients not eligible for awake surgery. Neurosurg Focus 2022. [DOI: 10.3171/2022.9.focus22415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE
Awake surgery represents the gold standard for resection of brain tumors close to the language network. However, in some cases patients may be considered not eligible for awake craniotomy. In these cases, a personalized brain mapping of the language network may be achieved by navigated transcranial magnetic stimulation (nTMS), which can guide resection in patients under general anesthesia. Here the authors describe their tailored nTMS-based strategy and analyze its impact on the extent of tumor resection (EOR) and language outcome in a series of patients not eligible for awake surgery.
METHODS
The authors reviewed data from all patients harboring a brain tumor in or close to the language network who were considered not eligible for awake surgery and were operated on during asleep surgery between January 2017 and July 2022, under the intraoperative guidance of nTMS data. The authors analyzed the effectiveness of nTMS-based mapping data in relation to 1) the ability of the nTMS-based mapping to stratify patients according to surgical risks, 2) the occurrence of postoperative language deficits, and 3) the EOR.
RESULTS
A total of 176 patients underwent preoperative nTMS cortical language mapping and nTMS-based tractography of language fascicles. According to the nTMS-based mapping, tumors in 115 patients (65.3%) were identified as true-eloquent tumors because of a close spatial relationship with the language network. Conversely, tumors in 61 patients (34.7%) for which the nTMS mapping disclosed a location at a safer distance from the network were identified as false-eloquent tumors. At 3 months postsurgery, a permanent language deficit was present in 13 patients (7.3%). In particular, a permanent deficit was observed in 12 of 115 patients (10.4%) with true-eloquent tumors and in 1 of 61 patients (1.6%) with false-eloquent lesions. With nTMS-based mapping, neurosurgeons were able to distinguish true-eloquent from false-eloquent tumors in a significant number of cases based on the occurrence of deficits at discharge (p < 0.0008) and after 3 months from surgery (OR 6.99, p = 0.03). Gross-total resection was achieved in 80.1% of patients overall and in 69.5% of patients with true-eloquent lesions and 100% of patients with false-eloquent tumors.
CONCLUSIONS
nTMS-based mapping allows for reliable preoperative mapping of the language network that may be used to stratify patients according to surgical risks. nTMS-guided asleep surgery should be considered a good alternative for personalized preoperative brain mapping of the language network that may increase the possibility of safe and effective resection of brain tumors in the dominant hemisphere whenever awake mapping is not feasible.
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Affiliation(s)
- Giovanni Raffa
- Division of Neurosurgery, BIOMORF Department, University of Messina; and
| | - Giuseppina Marzano
- Division of Neurosurgery, A.O.U. Policlinico “G. Martino,” Messina, Italy
| | - Antonello Curcio
- Division of Neurosurgery, BIOMORF Department, University of Messina; and
| | | | - Antonino Germanò
- Division of Neurosurgery, BIOMORF Department, University of Messina; and
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11
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Review of Intraoperative Adjuncts for Maximal Safe Resection of Gliomas and Its Impact on Outcomes. Cancers (Basel) 2022; 14:cancers14225705. [PMID: 36428797 PMCID: PMC9688206 DOI: 10.3390/cancers14225705] [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: 10/24/2022] [Revised: 11/12/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
Maximal safe resection is the mainstay of treatment in the neurosurgical management of gliomas, and preserving functional integrity is linked to favorable outcomes. How these modalities differ in their effectiveness on the extent of resection (EOR), survival, and complications remains unknown. A systematic literature search was performed with the following inclusion criteria: published between 2005 and 2022, involving brain glioma surgery, and including one or a combination of intraoperative modalities: intraoperative magnetic resonance imaging (iMRI), awake/general anesthesia craniotomy mapping (AC/GA), fluorescence-guided imaging, or combined modalities. Of 525 articles, 464 were excluded and 61 articles were included, involving 5221 glioma patients, 7(11.4%) articles used iMRI, 21(36.8%) used cortical mapping, 15(24.5%) used 5-aminolevulinic acid (5-ALA) or fluorescein sodium, and 18(29.5%) used combined modalities. The heterogeneity in reporting the amount of surgical resection prevented further analysis. Progression-free survival/overall survival (PFS/OS) were reported in 18/61(29.5%) articles, while complications and permanent disability were reported in 38/61(62.2%) articles. The reviewed studies demonstrate that intraoperative adjuncts such as iMRI, AC/GA mapping, fluorescence-guided imaging, and a combination of these modalities improve EOR. However, PFS/OS were underreported. Combining multiple intraoperative modalities seems to have the highest effect compared to each adjunct alone.
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12
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Tomasino B, Guarracino I, Pauletto G, Pez S, Ius T, Furlan D, Nilo A, Isola M, De Martino M, Mauro S, Verriello L, Lettieri C, Gigli GL, Valente M, Deana C, Skrap M. Performing real time neuropsychological testing during awake craniotomy: are dexmedetomidine or propofol the same? A preliminary report. J Neurooncol 2022; 160:707-716. [DOI: 10.1007/s11060-022-04191-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022]
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13
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Hou Z, Huang Z, Li Z, Deng Z, Li G, Xu Y, Wang M, Sun S, Zhang Y, Qiao H, Xie J. Incidence of ischemic complications and technical nuances of arteries preservation for insular gliomas resection. Front Surg 2022; 9:956872. [PMID: 36311934 PMCID: PMC9614341 DOI: 10.3389/fsurg.2022.956872] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Insular gliomas have complex anatomy and microvascular supply that make resection difficult. Furthermore, resection of insular glioma is associated with a significant risk of postoperative ischemic complications. Thus, this study aimed to assess the incidence of ischemic complications related to insular glioma resection, determine its risk factors, and describe a single surgeon's experience of artery-preserving tumor resection. Methods We enrolled 75 consecutive patients with insular gliomas who underwent transcortical tumor resection. Preoperative and postoperative demographic, clinical, radiological [including diffusion-weighted imaging (DWI)], intraoperative neurophysiological data, and functional outcomes were analyzed. Motor evoked potentials (MEPs) and radiological characteristics like the relationship between the proximal segment of the lateral lenticulostriate arteries (LLSAs) and the tumor, the flat inner edge sign (the inner edge of the insular glioma is well-defined) or obscure inner edge sign, the distance between the lesion and posterior limb of the internal capsule and the invasion of the superior limiting sulcus by the tumor were analyzed. Strategies such as "residual triangle," "basal ganglia outline reappearance," and "sculpting" technique were used to preserve the LLSAs and the main branches of M2 for maximal tumor resection according to the Berger-Sinai classification. Results Postoperative DWI showed acute ischemia in 44 patients (58.7%). Moreover, nine patients (12%) had developed new motor deficits, as determined by the treating neurosurgeons. The flat inner edge sign [odds ratio (OR), 0.144; 95% confidence interval (CI), 0.024-0.876) and MEPs (>50%) (OR, 18.182; 95% CI, 3.311-100.00) were significantly associated with postoperative core ischemia, which affected the posterior limb of the internal capsule or corona radiata. Conclusions Insular glioma resection was associated with a high incidence of ischemia, as detected by DWI, as well as new motor deficits that were determined by the treating neurosurgeons. Insular glioma patients with obscure inner edge signs and intraoperative MEPs decline >50% had a higher risk of developing core ischemia. With our strategies, maximal safe resection of insular gliomas may be achieved.
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Affiliation(s)
- Zonggang Hou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhenxing Huang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhenye Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhenghai Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gen Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yaokai Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingran Wang
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Shengjun Sun
- Neuroimaging Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Hui Qiao
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China,Correspondence: Jian Xie Hui Qiao
| | - Jian Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,Correspondence: Jian Xie Hui Qiao
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14
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Zhang JJY, Lee KS, Wang DD, Hervey-Jumper SL, Berger MS. Seizure outcome after resection of insular glioma: a systematic review, meta-analysis, and institutional experience. J Neurosurg 2022; 138:1242-1253. [PMID: 36242570 PMCID: PMC10404476 DOI: 10.3171/2022.8.jns221067] [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: 05/05/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gliomas arising from the insular cortex can be epileptogenic, with a significant proportion of patients having medically refractory epilepsy. The impact of surgery on seizure control for such tumors is not well established. In this study, the authors aimed to investigate seizure outcomes after resection of insular gliomas using a meta-analysis and institutional experience. METHODS Three databases (Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials) were systematically searched for published studies of seizure outcomes after insular glioma resection from database inception to March 27, 2021. In addition, data were retrospectively collected on all adults (age > 17 years) who had undergone insular glioma resection between June 1997 and June 2015 at the authors' institution. Primary outcome measures were seizure freedom rates at 1 year and the last follow-up. Secondary outcome measures consisted of persistent postoperative neurological deficit beyond 90 days, mortality, and tumor progression or recurrence. RESULTS Eight studies reporting on 453 patients who had undergone 460 operations were included in the meta-analysis. The pooled mean age of the patients was 42 years. The pooled percentages of patients with extents of resection (EORs) ≥ 90%, 70%-89%, and < 70% were 55%, 33%, and 11%, respectively. The pooled seizure freedom rate at 1 year was 73% for Engel class IA and 78% for Engel class I. The pooled seizure freedom rate at the last follow-up was 60% for Engel class IA and 79% for Engel class I. The pooled percentage of persistent neurological deficit beyond 90 days was 3%. At the authors' institution, 109 patients had undergone resection of insular glioma. A greater EOR was the only significant independent predictor of seizure freedom after surgery (HR 0.290, p = 0.017). The optimal threshold for seizure freedom corresponded to an EOR of 81%. Patients with an EOR > 81% had a significantly higher seizure freedom rate (OR 2.16, p = 0.048). CONCLUSIONS Maximal safe resection can be performed with minimal surgical morbidity to achieve favorable seizure freedom rates in both the short and long term. When gross-total resection is not possible, an EOR > 81% confers the greatest sensitivity and specificity for achieving seizure freedom. Systematic review registration no.: CRD42021249404 (https://www.crd.york.ac.uk/prospero/).
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Affiliation(s)
- John J Y Zhang
- 1Department of Neurological Surgery, University of California, San Francisco, California.,2Department of Neurosurgery, National Neuroscience Institute, Singapore; and
| | - Keng Siang Lee
- 1Department of Neurological Surgery, University of California, San Francisco, California.,3Bristol Medical School, University of Bristol, United Kingdom
| | - Doris D Wang
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Shawn L Hervey-Jumper
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Mitchel S Berger
- 1Department of Neurological Surgery, University of California, San Francisco, California
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15
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Duffau H. Awake Mapping With Transopercular Approach in Right Insular-Centered Low-Grade Gliomas Improves Neurological Outcomes and Return to Work. Neurosurgery 2022; 91:182-190. [PMID: 35445665 DOI: 10.1227/neu.0000000000001966] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 02/05/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Asleep vs awake surgery for right insula-centered low-grade glioma (LGG) is still debated. OBJECTIVE To compare neurological outcomes and return to work after resection for right insular/paralimbic LGG performed without vs with awake mapping. METHODS A personal surgical experience of right insula-centered LGG was analyzed, by comparing 2 consecutive periods. In the first period (group 1), patients underwent asleep surgery with motor mapping. In the second period (group 2), patients underwent intraoperative awake mapping of movement and cognitive functions. RESULTS This consecutive series included 143 LGGs: 41 in group 1 (1999-2009) and 102 in group 2 (2009-2020). There were no significant difference concerning preoperative clinicoradiological characteristics and histopathology results between both groups. Intraoperative motor mapping was positive in all cases in group 1. In group 2, beyond motor mapping, somatosensory, visuospatial, language, and/or cognitive functions were identified during cortical-subcortical stimulation. Postoperatively, 3 patients experienced a long-lasting deterioration with 2 hemiparesis due to deep stroke (1.3%) and 1 severe depressive syndrome, all of them in group 1 vs none in group 2 (P = .022). The rate of RTW was 81.5% in group 1 vs 95.5% in group 2 (P = .016). The tumor volume and extent of resection did not significantly differ across both groups. CONCLUSION This is the first study comparing asleep vs awake surgery for right insula-centered LGG. Despite similar extent of resection, functional outcomes were significantly better in awake patients by avoiding permanent neurological impairment and by increasing RTW. These results support the mapping of higher-order functions during awake procedure.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Low-grade gliomas," INSERM U1191, Institute of Functional Genomics, University of Montpellier, Montpellier, France
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16
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Matsumae M, Nishiyama J, Kuroda K. Intraoperative MR Imaging during Glioma Resection. Magn Reson Med Sci 2022; 21:148-167. [PMID: 34880193 PMCID: PMC9199972 DOI: 10.2463/mrms.rev.2021-0116] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/11/2021] [Indexed: 11/09/2022] Open
Abstract
One of the major issues in the surgical treatment of gliomas is the concern about maximizing the extent of resection while minimizing neurological impairment. Thus, surgical planning by carefully observing the relationship between the glioma infiltration area and eloquent area of the connecting fibers is crucial. Neurosurgeons usually detect an eloquent area by functional MRI and identify a connecting fiber by diffusion tensor imaging. However, during surgery, the accuracy of neuronavigation can be decreased due to brain shift, but the positional information may be updated by intraoperative MRI and the next steps can be planned accordingly. In addition, various intraoperative modalities may be used to guide surgery, including neurophysiological monitoring that provides real-time information (e.g., awake surgery, motor-evoked potentials, and sensory evoked potential); photodynamic diagnosis, which can identify high-grade glioma cells; and other imaging techniques that provide anatomical information during the surgery. In this review, we present the historical and current context of the intraoperative MRI and some related approaches for an audience active in the technical, clinical, and research areas of radiology, as well as mention important aspects regarding safety and types of devices.
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Affiliation(s)
- Mitsunori Matsumae
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Jun Nishiyama
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kagayaki Kuroda
- Department of Human and Information Sciences, School of Information Science and Technology, Tokai University, Hiratsuka, Kanagawa, Japan
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17
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Kim EH, Yoo J, Jung IH, Oh JW, Kim JS, Yoon JS, Moon JH, Kang SG, Chang JH, Roh TH. Endoscopic transorbital approach to the insular region: cadaveric feasibility study and clinical application (SevEN-005). J Neurosurg 2021; 135:1164-1172. [PMID: 33482646 DOI: 10.3171/2020.8.jns202255] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The insula is a complex anatomical structure. Accessing tumors in the insula remains a challenge due to its anatomical complexity and the high chance of morbidity. The goal of this study was to evaluate the feasibility of an endoscopic transorbital approach (ETOA) to the insular region based on a cadaveric study. METHODS One cadaveric head was used to study the anatomy of the insula and surrounding vessels. Then, anatomical dissection was performed in 4 human cadaveric heads using a dedicated endoscopic system with the aid of neuronavigation guidance. To assess the extent of resection, CT scanning was performed before and after dissection. The insular region was directly exposed by a classic transcranial approach to check the extent of resection from the side with a classic transcranial approach. RESULTS The entire procedure consisted of two phases: an extradural orbital phase and an intradural sylvian phase. After eyelid incision, the sphenoid bone and orbital roof were extensively drilled out with exposure of the frontal and temporal dural layers. After making a dural window, the anterior ramus of the sylvian fissure was opened and dissected. The M2 segment of the middle cerebral artery (MCA) was identified and traced posterolaterally. A small corticectomy was performed on the posterior orbital gyrus. Through the window between the lateral lenticulostriate arteries and M2, the cortex and medulla of the insula were resected in an anteroposterior direction without violation of the M2 segment of the MCA or its major branches. When confirmed by pterional craniotomy, the sylvian fissure and the MCA were found to be anatomically preserved. After validation of the feasibility and safety based on a cadaveric study, the ETOA was successfully performed in a patient with a high-grade glioma (WHO grade III) in the right insula. CONCLUSIONS The transorbital route can be considered a potential option to access tumors located in the insula. Using an ETOA, the MCA and its major branches were identified and preserved while removal was performed along the long axis of the insula. In particular, lesions in the anterior part of the insula are most benefited by this approach. Because this approach was implemented in only one patient, additional discussion and further verification is required.
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Affiliation(s)
- Eui Hyun Kim
- 1Department of Neurosurgery, Yonsei University College of Medicine, Seoul
- 2Brain Tumor Center, Severance Hospital, Seoul
| | - Jihwan Yoo
- 1Department of Neurosurgery, Yonsei University College of Medicine, Seoul
| | - In-Ho Jung
- 1Department of Neurosurgery, Yonsei University College of Medicine, Seoul
| | - Ji Woong Oh
- 1Department of Neurosurgery, Yonsei University College of Medicine, Seoul
| | - Ju-Seong Kim
- 3Department of Neurosurgery, Ewha Seoul Hospital, Ewha Womans University College of Medicine, Seoul
| | - Jin Sook Yoon
- 4Department of Ophthalmology, Yonsei University College of Medicine, Seoul; and
| | - Ju Hyung Moon
- 1Department of Neurosurgery, Yonsei University College of Medicine, Seoul
- 2Brain Tumor Center, Severance Hospital, Seoul
| | - Seok-Gu Kang
- 1Department of Neurosurgery, Yonsei University College of Medicine, Seoul
- 2Brain Tumor Center, Severance Hospital, Seoul
| | - Jong Hee Chang
- 1Department of Neurosurgery, Yonsei University College of Medicine, Seoul
- 2Brain Tumor Center, Severance Hospital, Seoul
| | - Tae Hoon Roh
- 5Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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18
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Pallud J, Roux A, Trancart B, Peeters S, Moiraghi A, Edjlali M, Oppenheim C, Varlet P, Chrétien F, Dhermain F, Zanello M, Dezamis E. Surgery of Insular Diffuse Gliomas-Part 2: Probabilistic Cortico-Subcortical Atlas of Critical Eloquent Brain Structures and Probabilistic Resection Map During Transcortical Awake Resection. Neurosurgery 2021; 89:579-590. [PMID: 34383936 DOI: 10.1093/neuros/nyab255] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/12/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Insular diffuse glioma surgery is challenging, and tools to help surgical planning could improve the benefit-to-risk ratio. OBJECTIVE To provide a probabilistic resection map and frequency atlases of critical eloquent regions of insular diffuse gliomas based on our surgical experience. METHODS We computed cortico-subcortical "eloquent" anatomic sites identified intraoperatively by direct electrical stimulations during transcortical awake resection of insular diffuse gliomas in adults. RESULTS From 61 insular diffuse gliomas (39 left, 22 right; all left hemispheric dominance for language), we provided a frequency atlas of eloquence of the opercula (left/right; pars orbitalis: 0%/5.0%; pars triangularis: l5.6%/4.5%; pars opercularis: 37.8%/27.3%; precentral gyrus: 97.3%/95.4%; postcentral and supramarginal gyri: 75.0%/57.1%; temporal pole and superior temporal gyrus: 13.3%/0%), which tailored the transcortical approach (frontal operculum to reach the antero-superior insula, temporal operculum to reach the inferior insula, parietal operculum to reach the posterior insula). We provided a frequency atlas of eloquence identifying the subcortical functional boundaries (36.1% pyramidal pathways, 50.8% inferior fronto-occipital fasciculus, 13.1% arcuate and superior longitudinal fasciculi complex, 3.3% somatosensory pathways, 8.2% caudate and lentiform nuclei). Vascular boundaries and increasing errors during testing limited the resection in 8.2% and 11.5% of cases, respectively. We provided a probabilistic 3-dimensional atlas of resectability. CONCLUSION Functional mapping under awake conditions has to be performed intraoperatively in each patient to guide surgical approach and resection of insular diffuse gliomas in right and left hemispheres. Frequency atlases of opercula eloquence and of subcortical eloquent anatomic boundaries, and probabilistic 3-dimensional atlas of resectability could guide neurosurgeons.
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Affiliation(s)
- Johan Pallud
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Alexandre Roux
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Bénédicte Trancart
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Sophie Peeters
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Alessandro Moiraghi
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Myriam Edjlali
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neuroradiology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Catherine Oppenheim
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neuroradiology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Pascale Varlet
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neuropathology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Fabrice Chrétien
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Department of Neuropathology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Frédéric Dhermain
- Department of Radiotherapy, Gustave Roussy University Hospital, Villejuif, France
| | - Marc Zanello
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
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19
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Pallud J, Zanello M, Moiraghi A, Peeters S, Trancart B, Edjlali M, Oppenheim C, Varlet P, Chrétien F, Dhermain F, Roux A, Dezamis E. Surgery of Insular Diffuse Gliomas-Part 1: Transcortical Awake Resection Is Safe and Independently Improves Overall Survival. Neurosurgery 2021; 89:565-578. [PMID: 34383938 DOI: 10.1093/neuros/nyab254] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 05/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Insular diffuse glioma resection is at risk of vascular injury and of postoperative new neurocognitive deficits. OBJECTIVE To assess safety and efficacy of surgical management of insular diffuse gliomas. METHODS Observational, retrospective, single-institution cohort analysis (2005-2019) of 149 adult patients surgically treated for an insular diffuse glioma: transcortical awake resection with intraoperative functional mapping (awake resection subgroup, n = 61), transcortical asleep resection without functional mapping (asleep resection subgroup, n = 50), and stereotactic biopsy (biopsy subgroup, n = 38). All cases were histopathologically assessed according to the 2016 World Health Organization classification and cIMPACT-NOW update 3. RESULTS Following awake resection, 3/61 patients had permanent motor deficit, seizure control rates improved (89% vs 69% preoperatively, P = .034), and neurocognitive performance improved from 5% to 24% in tested domains, despite adjuvant oncological treatments. Resection rates were higher in the awake resection subgroup (median 94%) than in the asleep resection subgroup (median 46%; P < .001). There was more gross total resection (25% vs 12%) and less partial resection (34% vs 80%) in the awake resection subgroup than in the asleep resection subgroup (P < .001). Karnofsky Performance Status score <70 (adjusted hazard ratio [aHR] 2.74, P = .031), awake resection (aHR 0.21, P = .031), isocitrate dehydrogenase (IDH)-mutant grade 2 astrocytoma (aHR 5.17, P = .003), IDH-mutant grade 3 astrocytoma (aHR 6.11, P < .001), IDH-mutant grade 4 astrocytoma (aHR 13.36, P = .008), and IDH-wild-type glioblastoma (aHR 21.84, P < .001) were independent predictors of overall survival. CONCLUSION Awake surgery preserving the brain connectivity is safe, allows larger resections for insular diffuse gliomas than asleep resection, and positively impacts overall survival.
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Affiliation(s)
- Johan Pallud
- Department of Neurosurgery, GHU Paris-Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France
| | - Marc Zanello
- Department of Neurosurgery, GHU Paris-Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France
| | - Alessandro Moiraghi
- Department of Neurosurgery, GHU Paris-Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France
| | - Sophie Peeters
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Bénédicte Trancart
- Department of Neurosurgery, GHU Paris-Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France
| | - Myriam Edjlali
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Catherine Oppenheim
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Pascale Varlet
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neuropathology, GHU Paris-Sainte-Anne Hospital, Paris, France
| | - Fabrice Chrétien
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Department of Neuropathology, GHU Paris-Sainte-Anne Hospital, Paris, France
| | - Frédéric Dhermain
- Department of Radiotherapy, Gustave Roussy University Hospital, Villejuif, France
| | - Alexandre Roux
- Department of Neurosurgery, GHU Paris-Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, GHU Paris-Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
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20
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Pepper J, Cuthbert H, Scott T, Ughratdar I, Wykes V, Watts C, D'Urso P, Karabatsou K, Moor CC, Albanese E. Seizure Outcome After Surgery for Insular High-Grade Glioma. World Neurosurg 2021; 154:e718-e723. [PMID: 34343689 DOI: 10.1016/j.wneu.2021.07.114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The insular cortex is an eloquent island of mesocortex surrounded by vital structures making this region relatively challenging to neurosurgeons. Historically, lesions in this region were considered too high risk to approach given the strong chance of poor surgical outcome. Advances in recent decades have meant that surgeons can more safely access this eloquent region. Seizure outcome after excision of insular low-grade gliomas is well reported, but little is known about seizure outcomes after excision of insular high-grade gliomas. METHODS A retrospective analysis was performed of all patients presenting with new-onset seizures during 2015-2019 who underwent excision of an insular high-grade glioma at 3 regional neurosurgical centers in the United Kingdom. RESULTS We identified 38 patients with a mean (SD) age of 45.7 (15.3) years with median follow-up of 21 months. At long-term follow-up, of 38 patients, 23 were seizure-free (Engel class I), 2 had improved seizures (Engel class II), 6 had poor seizure control (Engel class III/IV), and 7 died. CONCLUSIONS Excision of insular high-grade gliomas is safe and results in excellent postoperative seizure control.
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Affiliation(s)
- Joshua Pepper
- Department of Neurosurgery, University Hospital of North Midlands, Stoke on Trent, United Kingdom.
| | - Hadleigh Cuthbert
- Department of Neurosurgery, University Hospital of North Midlands, Stoke on Trent, United Kingdom
| | - Teresa Scott
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Ismail Ughratdar
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Victoria Wykes
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Colin Watts
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Pietro D'Urso
- Department of Neurosurgery, Salford Royal Hospital, Salford, United Kingdom
| | | | - Carl-Christian Moor
- Department of Neurology, University Hospital of North Midlands, Stoke on Trent, United Kingdom
| | - Erminia Albanese
- Department of Neurosurgery, University Hospital of North Midlands, Stoke on Trent, United Kingdom
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21
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Dziedzic TA, Bala A, Marchel A. Anatomical aspects of the insula, opercula and peri-insular white matter for a transcortical approach to insular glioma resection. Neurosurg Rev 2021; 45:793-806. [PMID: 34292438 PMCID: PMC8827298 DOI: 10.1007/s10143-021-01602-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/16/2021] [Accepted: 06/29/2021] [Indexed: 11/01/2022]
Abstract
The insula is a lobe located deep in each hemisphere of the brain and is surrounded by eloquent cortical, white matter, and basal ganglia structures. The aim of this study was to provide an anatomical description of the insula and white matter tracts related to surgical treatment of gliomas through a transcortical approach. The study also discusses surgical implications in terms of intraoperative brain mapping. Five adult brains were prepared according to the Klingler technique. Cortical anatomy was evaluated with the naked eye, whereas white matter dissection was performed with the use of a microscope. The widest exposure of the insular surface was noted through the temporal operculum, mainly in zones III and IV according to the Berger-Sanai classification. By going through the pars triangularis in all cases, the anterior insular point and most of zone I were exposed. The narrowest and deepest operating field was observed by going through the parietal operculum. This method provided a suitable approach to zone II, where the corticospinal tract is not covered by the basal ganglia and is exposed just under the superior limiting sulcus. At the subcortical level, the identification of the inferior frontoocipital fasciculus at the level of the limen insulae is critical in terms of preserving the lenticulostriate arteries. Detailed knowledge of the anatomy of the insula and subcortical white matter that is exposed through each operculum is essential in preoperative planning as well as in the intraoperative decision-making process in terms of intraoperative brain mapping.
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Affiliation(s)
- Tomasz Andrzej Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland.
| | - Aleksandra Bala
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland.,Faculty of Psychology, University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland
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22
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Raffa G, Quattropani MC, Marzano G, Curcio A, Rizzo V, Sebestyén G, Tamás V, Büki A, Germanò A. Mapping and Preserving the Visuospatial Network by repetitive nTMS and DTI Tractography in Patients With Right Parietal Lobe Tumors. Front Oncol 2021; 11:677172. [PMID: 34249716 PMCID: PMC8268025 DOI: 10.3389/fonc.2021.677172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The goal of brain tumor surgery is the maximal resection of neoplastic tissue, while preserving the adjacent functional brain tissues. The identification of functional networks involved in complex brain functions, including visuospatial abilities (VSAs), is usually difficult. We report our preliminary experience using a preoperative planning based on the combination of navigated transcranial magnetic stimulation (nTMS) and DTI tractography to provide the preoperative 3D reconstruction of the visuospatial (VS) cortico-subcortical network in patients with right parietal lobe tumors. MATERIAL AND METHODS Patients affected by right parietal lobe tumors underwent mapping of both hemispheres using an nTMS-implemented version of the Hooper Visual Organization Test (HVOT) to identify cortical areas involved in the VS network. DTI tractography was used to compute the subcortical component of the network, consisting of the three branches of the superior longitudinal fasciculus (SLF). The 3D reconstruction of the VS network was used to plan and guide the safest surgical approach to resect the tumor and avoid damage to the network. We retrospectively analyzed the cortical distribution of nTMS-induced errors, and assessed the impact of the planning on surgery by analyzing the extent of tumor resection (EOR) and the occurrence of postoperative VSAs deficits in comparison with a matched historical control group of patients operated without using the nTMS-based preoperative reconstruction of the VS network. RESULTS Twenty patients were enrolled in the study (Group A). The error rate (ER) induced by nTMS was higher in the right vs. the left hemisphere (p=0.02). In the right hemisphere, the ER was higher in the anterior supramarginal gyrus (aSMG) (1.7%), angular gyrus (1.4%) superior parietal lobule (SPL) (1.3%), and dorsal lateral occipital gyrus (dLoG) (1.2%). The reconstruction of the cortico-subcortical VS network was successfully used to plan and guide tumor resection. A gross total resection (GTR) was achieved in 85% of cases. After surgery no new VSAs deficits were observed and a slightly significant improvement of the HVOT score (p=0.02) was documented. The historical control group (Group B) included 20 patients matched for main clinical characteristics with patients in Group A, operated without the support of the nTMS-based planning. A GTR was achieved in 90% of cases, but the postoperative HVOT score resulted to be worsened as compared to the preoperative period (p=0.03). The comparison between groups showed a significantly improved postoperative HVOT score in Group A vs. Group B (p=0.03). CONCLUSIONS The nTMS-implemented HVOT is a feasible approach to map cortical areas involved in VSAs. It can be combined with DTI tractography, thus providing a reconstruction of the VS network that could guide neurosurgeons to preserve the VS network during tumor resection, thus reducing the occurrence of postoperative VSAs deficits as compared to standard asleep surgery.
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Affiliation(s)
- Giovanni Raffa
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | | | - Giuseppina Marzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonello Curcio
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Vincenzo Rizzo
- Division of Neurology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gabriella Sebestyén
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Viktória Tamás
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - András Büki
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Antonino Germanò
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
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23
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Pitskhelauri D, Bykanov A, Konovalov A, Danilov G, Buklina S, Sanikidze A, Sufianov R. Transsylvian Insular Glioma Surgery: New Classification System, Clinical Outcome in a Consecutive Series of 79 Cases. Oper Neurosurg (Hagerstown) 2021; 20:541-548. [PMID: 33677610 DOI: 10.1093/ons/opab051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 12/11/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surgery of insular glial tumors remains a challenge because of high incidence of postoperative neurological deterioration and the complex anatomy of the insular region. OBJECTIVE To explore the prognostic role of our and Berger-Sanai classifications on the extent of resection (EOR) and clinical outcome. METHODS From 2012 to 2017, a transsylvian removal of insular glial tumors was performed in 79 patients. The EOR was assessed depending on magnetic resonance imaging scans performed in the first 48 h after surgery. RESULTS The EOR ≥90% was achieved in 30 (38%) cases and <90% in 49 (62.0%) cases. In the early postoperative period, the new neurological deficit was observed in 31 (39.2%) patients, and in 5 patients (6.3%), it persisted up to 3 mo.We proposed a classification of insular gliomas based on its volumetric and anatomical characteristics. A statistically significant differences were found between proposed classes in tumor volume before and after surgery (P < .001), EOR (P = .02), rate of epileptic seizures before the surgical treatment (P = .04), and the incidence of persistent postoperative complications (P = .03).In the logistic regression model, tumor location in zone II (Berger-Sanai classification) was the predictor significantly related to less likely EOR of ≥90% and the maximum rate of residual tumor detection (P = .02). CONCLUSION The proposed classification of the insular gliomas was an independent predictor of the EOR and persistent postoperative neurological deficit. According to Berger-Sanai classification, zone II was a predictor of less EOR through the transsylvian approach.
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Affiliation(s)
- David Pitskhelauri
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Andrey Bykanov
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexander Konovalov
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Gleb Danilov
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Svetlana Buklina
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexander Sanikidze
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Rinat Sufianov
- N. N. Burdenko National Medical Research Center of Neurosurgery, Ministry of Health of the Russian Federation, Moscow, Russia
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24
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Luna LP, Sherbaf FG, Sair HI, Mukherjee D, Oliveira IB, Köhler CA. Can Preoperative Mapping with Functional MRI Reduce Morbidity in Brain Tumor Resection? A Systematic Review and Meta-Analysis of 68 Observational Studies. Radiology 2021; 300:338-349. [PMID: 34060940 DOI: 10.1148/radiol.2021204723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Preoperative functional MRI (fMRI) is one of several techniques developed to localize critical brain structures and brain tumors. However, the usefulness of fMRI for preoperative surgical planning and its potential effect on neurologic outcomes remain unclear. Purpose To assess the overall postoperative morbidity among patients with brain tumors by using preoperative fMRI versus surgery without this tool or with use of standard (nonfunctional) neuronavigation. Materials and Methods A systematic review and meta-analysis of studies across major databases from 1946 to June 20, 2020, were conducted. Inclusion criteria were original studies that (a) included patients with brain tumors, (b) performed preoperative neuroimaging workup with fMRI, (c) investigated the usefulness of a preoperative or intraoperative functional neuroimaging technique and used that technique to resect cerebral tumors, and (d) reported postoperative clinical measures. Pooled estimates for adverse event rate (ER) effect size (log ER, log odds ratio, or Hedges g) with 95% CIs were computed by using a random-effects model. Results Sixty-eight studies met eligibility criteria (3280 participants; 58.9% men [1555 of 2641]; mean age, 46 years ± 8 [standard deviation]). Functional deterioration after surgical procedure was less likely to occur when fMRI mapping was performed before the operation (odds ratio, 0.25; 95% CI: 0.12, 0.53; P < .001]), and postsurgical Karnofsky performance status scores were higher in patients who underwent fMRI mapping (Hedges g, 0.66; 95% CI: 0.21, 1.11; P = .004]). Craniotomies for tumor resection performed with preoperative fMRI were associated with a pooled adverse ER of 11% (95% CI: 8.4, 13.1), compared with a 21.0% ER (95% CI: 12.2, 33.5) in patients who did not undergo fMRI mapping. Conclusion From the currently available data, the benefit of preoperative functional MRI planning for the resection of brain tumors appears to reduce postsurgical morbidity, especially when used with other advanced imaging techniques, such as diffusion-tensor imaging, intraoperative MRI, or cortical stimulation. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Licia P Luna
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Farzaneh Ghazi Sherbaf
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Haris I Sair
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Debraj Mukherjee
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Isabella Bezerra Oliveira
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Cristiano André Köhler
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
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25
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Ius T, Mazzucchi E, Tomasino B, Pauletto G, Sabatino G, Della Pepa GM, La Rocca G, Battistella C, Olivi A, Skrap M. Multimodal integrated approaches in low grade glioma surgery. Sci Rep 2021; 11:9964. [PMID: 33976246 PMCID: PMC8113473 DOI: 10.1038/s41598-021-87924-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/01/2021] [Indexed: 12/30/2022] Open
Abstract
Surgical management of Diffuse Low-Grade Gliomas (DLGGs) has radically changed in the last 20 years. Awake surgery (AS) in combination with Direct Electrical Stimulation (DES) and real-time neuropsychological testing (RTNT) permits continuous intraoperative feedback, thus allowing to increase the extent of resection (EOR). The aim of this study was to evaluate the impact of the technological advancements and integration of multidisciplinary techniques on EOR. Two hundred and eighty-eight patients affected by DLGG were enrolled. Cases were stratified according to the surgical protocol that changed over time: 1. DES; 2. DES plus functional MRI/DTI images fused on a NeuroNavigation system; 3. Protocol 2 plus RTNT. Patients belonging to Protocol 1 had a median EOR of 83% (28–100), while those belonging to Protocol 2 and 3 had a median EOR of 88% (34–100) and 98% (50–100) respectively (p = 0.0001). New transient deficits with Protocol 1, 2 and 3 were noted in 38.96%, 34.31% and 31,08% of cases, and permanent deficits in 6.49%, 3.65% and 2.7% respectively. The average follow-up period was 6.8 years. OS was influenced by molecular class (p = 0.028), EOR (p = 0.018) and preoperative tumor growing pattern (p = 0.004). Multimodal surgical approach can provide a safer and wider removal of DLGG with potential subsequent benefits on OS. Further studies are necessary to corroborate our findings.
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Affiliation(s)
- Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Piazzale Santa Maria della Misericordia, 15, 33100, Udine, Italy.
| | - Edoardo Mazzucchi
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Barbara Tomasino
- IRCCS "E. Medea," Polo Regionale del FVG, San Vito al Tagliamento, Pordenone, Italy
| | - Giada Pauletto
- Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | | | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | | | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
| | - Miran Skrap
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Piazzale Santa Maria della Misericordia, 15, 33100, Udine, Italy
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26
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Zarino B, Sirtori MA, Meschini T, Bertani GA, Caroli M, Bana C, Borellini L, Locatelli M, Carrabba G. Insular lobe surgery and cognitive impairment in gliomas operated with intraoperative neurophysiological monitoring. Acta Neurochir (Wien) 2021; 163:1279-1289. [PMID: 33236177 DOI: 10.1007/s00701-020-04643-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND For a long time, surgery of insular gliomas was considered at high risk for postoperative cognitive deficits, but recent studies highlighted the feasibility of the surgical approach. The aims of our study were to investigate the presence of language impairment before and after surgery and the relationship between language impairment and tumor volume preoperatively and extent of resection (EOR) 3 months after surgery. METHODS Thirty-five patients with insular gliomas underwent an extensive language assessment before and few days after surgery, and after 3 months. Intraoperative neurophysiological monitoring (IOM) and brain mapping with direct electrical stimulation (DES) were used in all the cases; 8 patients underwent awake craniotomy. Statistical analysis was performed on the language tests administered. RESULTS Patients with pure left insular lesion showed language impairment before and after surgery. Overall, patients with a left lesion showed a drop of performance after surgery followed by a partial recovery. Moreover, when the tumor involved the insula and adjacent networks, we observed a more severe deficit. No correlations were found between tumor volume, EOR, and language impairment. CONCLUSIONS Left insular lobe is an important hub in language networks; its involvement determines pre- and postsurgical deficits, together with the involvement of white matter connections. Tumor volume and EOR are not risk factors per se directly related to language functioning. Surgery of insular gliomas is possible with a pre- and intraoperative extensive study of the patient with IOM and awake surgery, and encouraged by the trend of cognitive recovery highlighted.
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Affiliation(s)
- Barbara Zarino
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy.
| | - Martina Andrea Sirtori
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Tommaso Meschini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulio Andrea Bertani
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
| | - Manuela Caroli
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
| | - Cristina Bana
- Neuropathophysilogy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Linda Borellini
- Neuropathophysilogy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Locatelli
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgio Carrabba
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Padiglione Monteggia, 20122, Milan, Italy
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27
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Microsurgical resection of fronto-temporo-insular gliomas in the non-dominant hemisphere, under general anesthesia using adjunct intraoperative MRI and no cortical and subcortical mapping: a series of 20 consecutive patients. Sci Rep 2021; 11:6994. [PMID: 33772073 PMCID: PMC7997967 DOI: 10.1038/s41598-021-86165-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 02/23/2021] [Indexed: 12/18/2022] Open
Abstract
Fronto-temporo-insular (FTI) gliomas continue to represent a surgical challenge despite numerous technical advances. Some authors advocate for surgery in awake condition even for non-dominant hemisphere FTI, due to risk of sociocognitive impairment. Here, we report outcomes in a series of patients operated using intraoperative magnetic resonance imaging (IoMRI) guided surgery under general anesthesia, using no cortical or subcortical mapping. We evaluated the extent of resection, functional and neuropsychological outcomes after IoMRI guided surgery under general anesthesia of FTI gliomas located in the non-dominant hemisphere. Twenty patients underwent FTI glioma resection using IoMRI in asleep condition. Seventeen tumors were de novo, three were recurrences. Tumor WHO grades were II:12, III:4, IV:4. Patients were evaluated before and after microsurgical resection, clinically, neuropsychologically (i.e., social cognition) and by volumetric MR measures (T1G+ for enhancing tumors, FLAIR for non-enhancing). Fourteen (70%) patients benefited from a second IoMRI. The median age was 33.5 years (range 24–56). Seizure was the inaugural symptom in 71% of patients. The median preoperative volume was 64.5 cm3 (min 9.9, max 211). Fourteen (70%) patients underwent two IoMRI. The final median EOR was 92% (range 69–100). The median postoperative residual tumor volume (RTV) was 4.3 cm3 (range 0–38.2). A vast majority of residual tumors were located in the posterior part of the insula. Early postoperative clinical events (during hospital stay) were three transient left hemiparesis (which lasted less than 48 h) and one prolonged left brachio-facial hemiparesis. Sixty percent of patients were free of any symptom at discharge. The median Karnofsky Performance Score was of 90 both at discharge and at 3 months. No significant neuropsychological impairment was reported, excepting empathy distinction in less than 40% of patients. After surgery, 45% of patients could go back to work. In our experience and using IoMRI as an adjunct, microsurgical resection of non-dominant FTI gliomas under general anesthesia is safe. Final median EOR was 92%, with a vast majority of residual tumors located in the posterior insular part. Patients experienced minor neurological and neuropsychological morbidity. Moreover, neuropsychological evaluation reported a high preservation of sociocognitive abilities. Solely empathy seemed to be impaired in some patients.
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Rossi M, Gay L, Conti Nibali M, Sciortino T, Ambrogi F, Leonetti A, Puglisi G, Howells H, Zito P, Villa F, Ciroi G, Riva M, Bello L. Challenging Giant Insular Gliomas With Brain Mapping: Evaluation of Neurosurgical, Neurological, Neuropsychological, and Quality of Life Results in a Large Mono-Institutional Series. Front Oncol 2021; 11:629166. [PMID: 33828981 PMCID: PMC8019925 DOI: 10.3389/fonc.2021.629166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/01/2021] [Indexed: 01/23/2023] Open
Abstract
Objective Giant insular tumors are commonly not amenable to complete resection and are associated with a high postoperative morbidity rate. Transcortical approach and brain mapping techniques allow to identify peri-insular functional networks and, with neurophysiological monitoring, to reduce vascular-associated insults. Cognitive functions to be mapped are still under debate, and the analysis of the functional risk of surgery is currently limited to neurological examination. This work aimed to investigate the neurosurgical outcome (extent of resection, EOR) and functional impact of giant insular gliomas resection, focusing on neuropsychological and Quality of Life (QoL) outcomes. Methods In our retrospective analysis, we included all patients admitted in a five-year period with a radiological diagnosis of giant insular glioma. A transcortical approach was adopted in all cases. Resections were pursued up to functional boundaries defined intraoperatively by brain mapping techniques. We examined clinical, radiological, and intra-operative factors possibly affecting EOR and postoperative neurological, neuropsychological, and Quality of Life (QoL) outcomes. Results We finally enrolled 95 patients in the analysis. Mean EOR was 92.3%. A Gross Total Resection (GTR) was obtained in 70 cases (73.7%). Five patients reported permanent morbidity (aphasia in 3, 3.2%, and superior quadrantanopia in 2, 2.1%). Suboptimal EOR associated with poor seizures control postoperatively. Extensive intraoperative mapping (inclusive of cognitive, visual, and haptic functions) decreased long-term neurological, neuropsychological, and QoL morbidity and increased EOR. Tumor infiltration of deep perforators (vessels arising either medial to lenticulostriate arteries through the anterior perforated substance or from the anterior choroidal artery) associated with a higher chance of postoperative ischemia in consonant areas, with the persistence of new-onset motor deficits 1-month post-op, and with minor EOR. Ischemic insults in eloquent sites represented the leading factor for long-term neurological and neuropsychological morbidity. Conclusion In giant insular gliomas, the use of a transcortical approach with extensive brain mapping under awake anesthesia ensures broad insular exposure and extension of the surgical resection preserving patients’ functional integrity. The relation between tumor mass and deep perforators predicts perioperative ischemic insults, the most relevant risk factor for long-term and permanent postoperative morbidity.
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Affiliation(s)
- Marco Rossi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Lorenzo Gay
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Marco Conti Nibali
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Federico Ambrogi
- Laboratory of Medical Statistics, Biometry, and Epidemiology "G.A. Maccararo," Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Antonella Leonetti
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Laboratorio Interdisciplinare di Tecnologie Avanzate (LITA), Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Laboratorio Interdisciplinare di Tecnologie Avanzate (LITA), Milano, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Laboratorio Interdisciplinare di Tecnologie Avanzate (LITA), Milano, Italy
| | - Paola Zito
- Department of Anesthesia and Intensive Care, Humanitas Research Hospital, IRCCS, Milano, Italy
| | - Federico Villa
- Department of Anesthesia and Intensive Care, Humanitas Research Hospital, IRCCS, Milano, Italy
| | - Gjulio Ciroi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Marco Riva
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
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Lombardi G, Barresi V, Castellano A, Tabouret E, Pasqualetti F, Salvalaggio A, Cerretti G, Caccese M, Padovan M, Zagonel V, Ius T. Clinical Management of Diffuse Low-Grade Gliomas. Cancers (Basel) 2020; 12:E3008. [PMID: 33081358 PMCID: PMC7603014 DOI: 10.3390/cancers12103008] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/06/2020] [Accepted: 10/14/2020] [Indexed: 12/21/2022] Open
Abstract
Diffuse low-grade gliomas (LGG) represent a heterogeneous group of primary brain tumors arising from supporting glial cells and usually affecting young adults. Advances in the knowledge of molecular profile of these tumors, including mutations in the isocitrate dehydrogenase genes, or 1p/19q codeletion, and in neuroradiological techniques have contributed to the diagnosis, prognostic stratification, and follow-up of these tumors. Optimal post-operative management of LGG is still controversial, though radiation therapy and chemotherapy remain the optimal treatments after surgical resection in selected patients. In this review, we report the most important and recent research on clinical and molecular features, new neuroradiological techniques, the different therapeutic modalities, and new opportunities for personalized targeted therapy and supportive care.
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Affiliation(s)
- Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of oncology-IRCCS, 35128 Padova, Italy; (G.C.); (M.C.); (M.P.); (V.Z.)
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, 37129 Verona, Italy;
| | - Antonella Castellano
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Emeline Tabouret
- Team 8 GlioMe, CNRS, INP, Inst Neurophysiopathol, Aix-Marseille University, 13005 Marseille, France;
| | | | - Alessandro Salvalaggio
- Department of Neuroscience, University of Padova, 35128 Padova, Italy;
- Padova Neuroscience Center (PNC), University of Padova, 35128 Padova, Italy
| | - Giulia Cerretti
- Department of Oncology, Oncology 1, Veneto Institute of oncology-IRCCS, 35128 Padova, Italy; (G.C.); (M.C.); (M.P.); (V.Z.)
| | - Mario Caccese
- Department of Oncology, Oncology 1, Veneto Institute of oncology-IRCCS, 35128 Padova, Italy; (G.C.); (M.C.); (M.P.); (V.Z.)
| | - Marta Padovan
- Department of Oncology, Oncology 1, Veneto Institute of oncology-IRCCS, 35128 Padova, Italy; (G.C.); (M.C.); (M.P.); (V.Z.)
| | - Vittorina Zagonel
- Department of Oncology, Oncology 1, Veneto Institute of oncology-IRCCS, 35128 Padova, Italy; (G.C.); (M.C.); (M.P.); (V.Z.)
| | - Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy;
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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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Somma T, Baiano C, Santi L, Sabatino G, Della Pepa GM, La Rocca G, Cappabianca P, Olivi A, Skrap M, Ius T. Diffuse low grade glioma and pregnancy: Practical considerations and clinical tips. Clin Neurol Neurosurg 2020; 198:106110. [PMID: 32818754 DOI: 10.1016/j.clineuro.2020.106110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/10/2020] [Accepted: 07/24/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The interaction between pregnancy and diffuse low-grade glioma (DLGG) is poorly investigated. The goal of this study was to provide further insights into the relationship between pregnancy and DLGG. METHODS A total of 12 patients were selected from a shared database of DLGGs, according to the following inclusion criteria: DLGG diagnosis in post-partum, DLGG recurrence after pregnancy in patients previously operated for DLGG. The extent of surgical resection (EOR) at first surgery were evaluated. All cases were assessed based on the 2016 WHO classification. The tumor growing patter, expresses by preoperative ΔT2T1 MRI index was evaluated. RESULTS In four cases newly diagnosed DLGG were detected patients in post-partum. Seven women, previously operated for DLGG, experienced pregnancy during the natural history of glioma, and were affected by tumor recurrence after pregnancy. One singular had an incidental LGG not surgically treated, who presented an important tumor growth after pregnancy. Radiological and surgical data were discussed according to literature. CONCLUSIONS Pregnancy does not seem to have an impact on the survival of women with DLGG. The potential role of pregnancy as risk factor in tumor recurrence is described, however, not proven. In this regard, the association between pregnancy and Tumor recurrence is extremely doubtful, and currently attributable to the simple coincidence. Further multicenter molecular investigations are required to better understand the mechanisms by which the pregnancy, in patients with a pervious surgery for DLGG, may influence tumor regrowth in comparison with the natural history of the disease.
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Affiliation(s)
- Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Cinzia Baiano
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Laura Santi
- Neurosurgical Unit of Sondrio ASST - Valtellina e alto Lario, Sondrio, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Catholic University, Rome, Italy; Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | | | - Giuseppe La Rocca
- Institute of Neurosurgery, Catholic University, Rome, Italy; Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
| | | | - Miran Skrap
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Tamara Ius
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, Udine, Italy.
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Suarez-Meade P, Marenco-Hillembrand L, Prevatt C, Murguia-Fuentes R, Mohamed A, Alsaeed T, Lehrer EJ, Brigham T, Ruiz-Garcia H, Sabsevitz D, Middlebrooks EH, Bechtle PS, Quinones-Hinojosa A, Chaichana KL. Awake vs. asleep motor mapping for glioma resection: a systematic review and meta-analysis. Acta Neurochir (Wien) 2020; 162:1709-1720. [PMID: 32388682 DOI: 10.1007/s00701-020-04357-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/16/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Intraoperative stimulation (IS) mapping has become the preferred standard treatment for eloquent tumors as it permits a more accurate identification of functional areas, allowing surgeons to achieve higher extents of resection (EOR) and decrease postoperative morbidity. For lesions adjacent to the perirolandic area and descending motor tracts, mapping can be done with both awake craniotomy (AC) and under general anesthesia (GA). OBJECTIVE We aimed to determine which anesthetic protocol-AC vs. GA-provides better patient outcomes by comparing EOR and postoperative morbidity for surgeries using IS mapping in gliomas located near or in motor areas of the brain. METHODS A systematic literature search was carried out to identify relevant studies from 1983 to 2019. Seven databases were screened. A total of 2351 glioma patients from 17 studies were analyzed. RESULTS A random-effects meta-analysis revealed a trend towards a higher mean EOR in AC [90.1% (95% C.I. 85.8-93.8)] than with GA [81.7% (95% C.I. 72.4-89.7)] (p = 0.06). Neurological deficits were divided by timing and severity for analysis. There was no significant difference in early neurological deficits [20.9% (95% C.I. 4.1-45.0) vs. 25.4% (95% C.I. 13.6-39.2)] (p = 0.74), late neurological deficits [17.1% (95% C.I. 0.0-50.0) vs. 3.8% (95% C.I. 1.1-7.6)] (p = 0.06), or in non-severe [28.4% (95% C.I. 0.0-88.5) vs. 20.1% (95% C.I. 7.1-32.2)] (p = 0.72), and severe morbidity [2.6% (95% C.I. 0.0-15.5) vs. 4.5% (95% C.I. 1.1-9.6)] (p = 0.89) between patients who underwent AC versus GA, respectively. CONCLUSION Mapping during resection of gliomas located in or near the perirolandic area and descending motor tracts can be safely carried out with both AC and GA.
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Affiliation(s)
- Paola Suarez-Meade
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Lina Marenco-Hillembrand
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Calder Prevatt
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Ricardo Murguia-Fuentes
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Alea Mohamed
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Thannon Alsaeed
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tara Brigham
- Mayo Clinic Libraries, Mayo Clinic, Jacksonville, FL, USA
| | - Henry Ruiz-Garcia
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - David Sabsevitz
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Perry S Bechtle
- Anesthesiology Department, Mayo Clinic, Jacksonville, FL, USA
| | | | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Przybylowski CJ, Baranoski JF, So VM, Wilson J, Sanai N. Surgical morbidity of transsylvian versus transcortical approaches to insular gliomas. J Neurosurg 2020; 132:1731-1738. [PMID: 30952129 DOI: 10.3171/2018.12.jns183075] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/18/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The choice of transsylvian versus transcortical corridors for resection of insular gliomas remains controversial. Functional pathway compromise from transcortical transgression and vascular injury during transsylvian dissection are the primary concerns. In this study, data from a single-center experience with both approaches were compared to determine whether one approach was associated with a higher rate of morbidity than the other. METHODS The authors identified 100 consecutive patients who underwent resection of pure insular gliomas at the Barrow Neurological Institute. Volumetric analysis was performed using FLAIR and contrast-enhanced T1-weighted MRI for low- and high-grade gliomas, respectively, for extent of resection (EOR) and diffusion-weighted sequences were used to detect for postoperative ischemia. Step-wise logistic regression analysis was performed to identify predictors of neurological morbidity. RESULTS Data from 100 patients with low-grade or high-grade insular gliomas were analyzed. Fifty-two patients (52%) underwent a transsylvian approach, and 48 patients (48%) underwent a transcortical approach. The mean (± SD) EOR was 91.6% ± 12.4% in the transsylvian group and 88.6% ± 14.2% in the transcortical group (p = 0.26). Clinical outcome metrics for the 2 groups were similar. Overall, 13 patients (25%) in the transsylvian group and 10 patients (21%) in the transcortical group had evidence of ischemia on postoperative MR images. For both approaches, high-grade histology was associated with permanent morbidity (p = 0.01). For patients with gliomas located within the superior-posterior quadrant of the insula, development of postoperative ischemia was associated with only the transsylvian approach (46% vs 0%, p = 0.02). CONCLUSIONS Areas of restricted diffusion are common on postoperative MRI following resection of insular gliomas, but only a minority of these patients develop permanent neurological deficits. Insular glioma patients with high-grade histology may be at particular risk for developing symptomatic postoperative ischemia. Both the transcortical and transsylvian corridors are associated with reasonable morbidity profiles, although gliomas situated within the superior-posterior quadrant of the insula are more safely accessed with a transcortical approach.
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Affiliation(s)
| | | | - Veronica M So
- 2University of Arizona College of Medicine-Phoenix; and
| | - Jeffrey Wilson
- 3Department of Biostatistics, Arizona State University, Phoenix, Arizona
| | - Nader Sanai
- 1Department of Neurosurgery, Barrow Neurological Institute
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Rudà R, Angileri FF, Ius T, Silvani A, Sarubbo S, Solari A, Castellano A, Falini A, Pollo B, Del Basso De Caro M, Papagno C, Minniti G, De Paula U, Navarria P, Nicolato A, Salmaggi A, Pace A, Fabi A, Caffo M, Lombardi G, Carapella CM, Spena G, Iacoangeli M, Fontanella M, Germanò AF, Olivi A, Bello L, Esposito V, Skrap M, Soffietti R. Italian consensus and recommendations on diagnosis and treatment of low-grade gliomas. An intersociety (SINch/AINO/SIN) document. J Neurosurg Sci 2020; 64:313-334. [PMID: 32347684 DOI: 10.23736/s0390-5616.20.04982-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In 2018, the SINch (Italian Society of Neurosurgery) Neuro-Oncology Section, AINO (Italian Association of Neuro-Oncology) and SIN (Italian Association of Neurology) Neuro-Oncology Section formed a collaborative Task Force to look at the diagnosis and treatment of low-grade gliomas (LGGs). The Task Force included neurologists, neurosurgeons, neuro-oncologists, pathologists, radiologists, radiation oncologists, medical oncologists, a neuropsychologist and a methodologist. For operational purposes, the Task Force was divided into five Working Groups: diagnosis, surgical treatment, adjuvant treatments, supportive therapies, and follow-up. The resulting guidance document is based on the available evidence and provides recommendations on diagnosis and treatment of LGG patients, considering all aspects of patient care along their disease trajectory.
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Affiliation(s)
- Roberta Rudà
- Department of Neuro-Oncology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Filippo F Angileri
- Section of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy -
| | - Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Antonio Silvani
- Department of Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvio Sarubbo
- Department of Neurosurgery, Structural and Functional Connectivity Lab Project, "S. Chiara" Hospital, Trento, Italy
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Antonella Castellano
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Falini
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Bianca Pollo
- Section of Oncologic Neuropathology, Division of Neurology V - Neuropathology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Costanza Papagno
- Center of Neurocognitive Rehabilitation (CeRiN), Interdepartmental Center of Mind/Brain, University of Trento, Trento, Italy.,Department of Psychology, University of Milan-Bicocca, Milan, Italy
| | - Giuseppe Minniti
- Radiation Oncology Unit, Department of Medicine, Surgery and Neurosciences, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Ugo De Paula
- Unit of Radiotherapy, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Pierina Navarria
- Department of Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Antonio Nicolato
- Unit of Stereotaxic Neurosurgery, Department of Neurosciences, Hospital Trust of Verona, Verona, Italy
| | - Andrea Salmaggi
- Neurology Unit, Department of Neurosciences, A. Manzoni Hospital, Lecco, Italy
| | - Andrea Pace
- IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alessandra Fabi
- Division of Medical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maria Caffo
- Section of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Giuseppe Lombardi
- Unit of Oncology 1, Department of Oncology, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | | | - Giannantonio Spena
- Neurosurgery Unit, Department of Neurosciences, A. Manzoni Hospital, Lecco, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Marche Polytechnic University, Umberto I General University Hospital, Ancona, Italy
| | - Marco Fontanella
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonino F Germanò
- Section of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Alessandro Olivi
- Neurosurgery Unit, Department of Neurosciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico "A. Gemelli", Rome, Italy
| | - Lorenzo Bello
- Unit of Oncologic Neurosurgery, Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Vincenzo Esposito
- Sapienza University, Rome, Italy.,Giampaolo Cantore Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Miran Skrap
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, Città della Salute e della Scienza, University of Turin, Turin, Italy
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Cognitive Functions in Repeated Glioma Surgery. Cancers (Basel) 2020; 12:cancers12051077. [PMID: 32357421 PMCID: PMC7281009 DOI: 10.3390/cancers12051077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 12/12/2022] Open
Abstract
Low-grade gliomas (LGG) are slow-growing brain tumors infiltrating the central nervous system which tend to recur, often with malignant degeneration after primary treatment. Re-operations are not always recommended due to an assumed higher risk of neurological and cognitive deficits. However, this assumption is relatively ungrounded due to a lack of extensive neuropsychological testing. We retrospectively examined a series of 40 patients with recurrent glioma in eloquent areas of the left hemisphere, who all completed comprehensive pre- (T3) and post-surgical (T4) neuropsychological assessments after a second surgery (4-month follow up). The lesions were most frequent in the left insular cortex and the inferior frontal gyrus. Among this series, in 17 patients the cognitive outcomes were compared before the first surgery (T1), 4 months after the first surgery (T2), and at T3 and T4. There was no significant difference either in the number of patients scoring within the normal range between T3 and T4, or in their level of performance. Further addressing the T1-T4 evolution, there was no significant difference in the number of patients scoring within the normal range. As to their level of performance, the only significant change was in phonological fluency. This longitudinal follow-up study showed that repeated glioma surgery is possible without major damage to cognitive functions in the short-term period (4 months) after surgery.
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Guarracino I, Ius T, Pauletto G, Maieron M, Skrap M, Tomasino B. Junior-Real Time neuropsychological testing (j-RTNT) for a young patient undergoing awake craniotomy. Brain Cogn 2020; 140:105535. [DOI: 10.1016/j.bandc.2020.105535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
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Ius T, Pauletto G, Tomasino B, Maieron M, Budai R, Isola M, Cesselli D, Lettieri C, Skrap M. Predictors of Postoperative Seizure Outcome in Low Grade Glioma: From Volumetric Analysis to Molecular Stratification. Cancers (Basel) 2020; 12:cancers12020397. [PMID: 32046310 PMCID: PMC7072647 DOI: 10.3390/cancers12020397] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/21/2020] [Accepted: 02/06/2020] [Indexed: 12/16/2022] Open
Abstract
The importance of the extent of resection (EOR) has been widely demonstrated as the main predictor for survival, nevertheless its effect on tumor related epilepsy is less investigated. A total of 155 patients were enrolled after a first-line surgery for supratentorial Diffuse Low Grade Gliomas (DLGGs). Postoperative seizure outcome was analyzed stratifying the results by tumor volumetric data and molecular markers according to 2016 WHO classification. Receiver operating characteristic (ROC) curves were computed to asses EOR, residual tumor volume, and ΔT2T1 MRI index (expressing the tumor growing pattern) corresponding to optimal seizure outcome. A total of 70.97% of patients were seizure-free 18 months after surgery. Better seizure outcome was observed in IDH1/2 mutated and 1p/19q codeleted subgroup. At multivariate analysis, age (p = 0.014), EOR (p = 0.030), ΔT2T1 MRI index (p = 0.016) resulted as independent predictors of postoperative seizure control. Optimal parameters to improve postoperative seizure outcome were EOR ≥ 85%, ΔT2T1 MRI index ≤ 18 cm3, residual tumor volume ≤ 15 cm3. This study confirms the role of EOR and tumor growing pattern on postoperative seizure outcome independently from the molecular class. Higher ΔT2T1 MRI index, representing the infiltrative component of the tumor, is associated with worse seizure outcome and strengthens the evidence of common pathogenic mechanisms underlying tumor growth and postoperative seizure outcome.
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Affiliation(s)
- Tamara Ius
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy
- Correspondence: or ; Tel.: +39-347-0178730/+39-0432-554493
| | - Giada Pauletto
- Neurology Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (G.P.); (R.B.); (C.L.)
| | - Barbara Tomasino
- Scientific Institute, IRCCS E. Medea, San Vito al Tagliamento, 33078 Pordenone, Italy
| | - Marta Maieron
- Medical Physics, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy;
| | - Riccardo Budai
- Neurology Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (G.P.); (R.B.); (C.L.)
| | - Miriam Isola
- Department of Medicine, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy;
| | - Daniela Cesselli
- Institute of Pathology, Santa Maria della Misericordia University Hospital, 33100 Udine Post, Italy;
| | - Christian Lettieri
- Neurology Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (G.P.); (R.B.); (C.L.)
| | - Miran Skrap
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy
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Multimodal Assessment Shows a Mostly Preserved Cognitive Status in Incidentally Discovered Low Grade Gliomas: A Single Institution Study. Cancers (Basel) 2020; 12:cancers12010156. [PMID: 31936400 PMCID: PMC7016855 DOI: 10.3390/cancers12010156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/11/2019] [Accepted: 12/31/2019] [Indexed: 11/22/2022] Open
Abstract
Incidentally discovered low-grade gliomas (iLGGs) are poorly reported in the literature. Still less is known about iLGG patients’ neuropsychological profile: It is unclear whether iLGG patients are cognitively proficient, thus further confirming the concept of asymptomatic. From our monoinstitutional cohort of 332 patients operated for LGG from 2000 to 2017 we selected those who underwent a neuropsychological testing (n = 217, from 2008 to 2017), and identified 24 young (mean age 38.5 ± 1.06) patients with iLGGs (16 of 24, left hemisphere iLGGs, 8 of 24 right hemisphere iLGGs). The maximum lesions overlap occurred in the left inferior frontal gyrus and in the right anterior cingulate/superior medial frontal gyrus. Patients were cognitively preserved except mild to borderline difficulties in a few of them. The analysis of the equivalent scores (a score laying below or equal to the external nonparametric tolerance limit of adjusted scores corresponding to 0, 1, 2 and 3 are intermediate) highlighted the presence of additional borderline performances. Molecular class correlated with a normal function at visual–spatial intelligence (p = 0.05) and at spatial short-term memory (p = 0.029). Results indicate that at this time of tumor growth, patients’ cognitive abilities are still functional, but are slowly approaching the borderline level.
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Cesselli D, Ius T, Isola M, Del Ben F, Da Col G, Bulfoni M, Turetta M, Pegolo E, Marzinotto S, Scott CA, Mariuzzi L, Di Loreto C, Beltrami AP, Skrap M. Application of an Artificial Intelligence Algorithm to Prognostically Stratify Grade II Gliomas. Cancers (Basel) 2019; 12:cancers12010050. [PMID: 31877896 PMCID: PMC7016715 DOI: 10.3390/cancers12010050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022] Open
Abstract
(1) Background: Recently, it has been shown that the extent of resection (EOR) and molecular classification of low-grade gliomas (LGGs) are endowed with prognostic significance. However, a prognostic stratification of patients able to give specific weight to the single parameters able to predict prognosis is still missing. Here, we adopt classic statistics and an artificial intelligence algorithm to define a multiparametric prognostic stratification of grade II glioma patients. (2) Methods: 241 adults who underwent surgery for a supratentorial LGG were included. Clinical, neuroradiological, surgical, histopathological and molecular data were assessed for their ability to predict overall survival (OS), progression-free survival (PFS), and malignant progression-free survival (MPFS). Finally, a decision-tree algorithm was employed to stratify patients. (3) Results: Classic statistics confirmed EOR, pre-operative- and post-operative tumor volumes, Ki67, and the molecular classification as independent predictors of OS, PFS, and MPFS. The decision tree approach provided an algorithm capable of identifying prognostic factors and defining both the cut-off levels and the hierarchy to be used in order to delineate specific prognostic classes with high positive predictive value. Key results were the superior role of EOR on that of molecular class, the importance of second surgery, and the role of different prognostic factors within the three molecular classes. (4) Conclusions: This study proposes a stratification of LGG patients based on the different combinations of clinical, molecular, and imaging data, adopting a supervised non-parametric learning method. If validated in independent case studies, the clinical utility of this innovative stratification approach might be proved.
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Affiliation(s)
- Daniela Cesselli
- Department of Medicine, University of Udine, 33100 Udine, Italy; (M.I.); (F.D.B.); (C.A.S.); (L.M.); (C.D.L.)
- Department of Pathology, University Hospital of Udine, 33100 Udine, Italy; (M.B.); (E.P.); (S.M.)
- Correspondence: (D.C.); (A.P.B.)
| | - Tamara Ius
- Department of Neurosurgery, University Hospital of Udine, 33100 Udine, Italy; (T.I.); (M.S.)
| | - Miriam Isola
- Department of Medicine, University of Udine, 33100 Udine, Italy; (M.I.); (F.D.B.); (C.A.S.); (L.M.); (C.D.L.)
| | - Fabio Del Ben
- Department of Medicine, University of Udine, 33100 Udine, Italy; (M.I.); (F.D.B.); (C.A.S.); (L.M.); (C.D.L.)
- Immunopathology and Cancer Biomarkers, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano (PN), Italy;
| | - Giacomo Da Col
- SISSA (Scuola Internazionale Superiore di Studi Avanzati), 34136 Trieste, Italy;
| | - Michela Bulfoni
- Department of Pathology, University Hospital of Udine, 33100 Udine, Italy; (M.B.); (E.P.); (S.M.)
| | - Matteo Turetta
- Immunopathology and Cancer Biomarkers, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano (PN), Italy;
| | - Enrico Pegolo
- Department of Pathology, University Hospital of Udine, 33100 Udine, Italy; (M.B.); (E.P.); (S.M.)
| | - Stefania Marzinotto
- Department of Pathology, University Hospital of Udine, 33100 Udine, Italy; (M.B.); (E.P.); (S.M.)
| | - Cathryn Anne Scott
- Department of Medicine, University of Udine, 33100 Udine, Italy; (M.I.); (F.D.B.); (C.A.S.); (L.M.); (C.D.L.)
- Department of Pathology, University Hospital of Udine, 33100 Udine, Italy; (M.B.); (E.P.); (S.M.)
| | - Laura Mariuzzi
- Department of Medicine, University of Udine, 33100 Udine, Italy; (M.I.); (F.D.B.); (C.A.S.); (L.M.); (C.D.L.)
- Department of Pathology, University Hospital of Udine, 33100 Udine, Italy; (M.B.); (E.P.); (S.M.)
| | - Carla Di Loreto
- Department of Medicine, University of Udine, 33100 Udine, Italy; (M.I.); (F.D.B.); (C.A.S.); (L.M.); (C.D.L.)
- Department of Pathology, University Hospital of Udine, 33100 Udine, Italy; (M.B.); (E.P.); (S.M.)
| | - Antonio Paolo Beltrami
- Department of Medicine, University of Udine, 33100 Udine, Italy; (M.I.); (F.D.B.); (C.A.S.); (L.M.); (C.D.L.)
- Correspondence: (D.C.); (A.P.B.)
| | - Miran Skrap
- Department of Neurosurgery, University Hospital of Udine, 33100 Udine, Italy; (T.I.); (M.S.)
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Skrap M, Vescovi MC, Pauletto G, Maieron M, Tomasino B, Bagatto D, Tuniz F. Supratentorial Cavernous Malformations Involving the Corticospinal Tract and Sensory Motor Cortex: Treatment Strategies, Surgical Considerations, and Outcomes. Oper Neurosurg (Hagerstown) 2019; 15:483-497. [PMID: 29462365 DOI: 10.1093/ons/opx281] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/05/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cavernous malformations (CMs) are congenital malformations and may be located anywhere in the brain. We present a series of CMs located close to or inside of the motor-sensory cortex or corticospinal tract (CST) with clinical onset due to hemorrhage or mass effect. In such cases, surgery becomes an acceptable option. OBJECTIVE To evaluate the role of diffusion tensor imaging (DTI), functional-magnetic-resonance imaging (fMRI), intraoperative neurophysiological monitoring, neuronavigation, and brain-mapping and the clinical results of surgical treatment of CMs in this critical location. METHODS The study included 54 patients harboring 22 cortical and 32 deep locations. This series was distinct because in group I, where the DTI was not obtained, and in the group II, where this evaluation was performed. RESULTS The postoperative permanent morbidity rate was 4% in the historical group for the deeper CMs, and there was no morbidity in the second group. DTI and fMRI permitted us to estimate the distance between the CMs and both the cortical activation cluster and the pyramidal tract. These data, in addition to intraoperative mapping and monitoring, made it necessary for us to perform a partial resection in 2 cases in the second series. CONCLUSION CMs are congenital lesions and CST fibers can run directly on their surface. Integration of fMRI and DTI data with intraoperative functional monitoring and direct cortical and subcortical mapping are mandatory to accomplish an optimal resection, tailoring the best surgical approach to the acceptable morbidity. A subtotal resection could be considered an option for deep locations.
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Affiliation(s)
- Miran Skrap
- Department of Neurosurgery, Azienda Ospedaliero Universitaria S. Maria della Misericordia, Udine, Italy
| | - Maria Caterina Vescovi
- Department of Neurosurgery, Azienda Ospedaliero Universitaria S. Maria della Misericordia, Udine, Italy
| | - Giada Pauletto
- Department of Neurology, Azienda Ospedaliero Univer-sitaria S. Maria della Misericordia, Udine, Italy
| | - Marta Maieron
- Department of Physics, Azienda Ospedaliero Universitaria S. Maria della Misericordia, Udine, Italy
| | | | - Daniele Bagatto
- Department of Neuroradiology, Azienda Ospedaliero Universitaria S. Maria della Misericordia, Udine, Italy
| | - Francesco Tuniz
- Department of Neurosurgery, Azienda Ospedaliero Universitaria S. Maria della Misericordia, Udine, Italy
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Wang DD, Deng H, Hervey-Jumper SL, Molinaro AA, Chang EF, Berger MS. Seizure Outcome After Surgical Resection of Insular Glioma. Neurosurgery 2019; 83:709-718. [PMID: 29126238 DOI: 10.1093/neuros/nyx486] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 08/31/2017] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND A majority of patients with insular tumors present with seizures. Although a number of studies have shown that greater extent of resection improves overall patient survival, few studies have documented postoperative seizure control after insular tumor resection. OBJECTIVE To (1) characterize seizure control rates in patients undergoing insular tumor resection, (2) identify predictors of seizure control, and (3) evaluate the association between seizure recurrence and tumor progression. METHODS The study population included adults who had undergone resection of insular gliomas between 1997 and 2015 at our institution. Preoperative seizure characteristics, tumor characteristics, surgical factors, and postoperative seizure outcomes were reviewed. RESULTS One-hundred nine patients with sufficient clinical data were included in the study. At 1 yr after surgery, 74 patients (68%) were seizure free. At final follow-up, 42 patients (39%) were seizure free. Median time to seizure recurrence was 46 mo (95% confidence interval 31-65 mo). Multivariate Cox regression analysis revealed that greater extent of resection (hazard ratio = 0.2899 [0.1129, 0.7973], P = .0127) was a significant predictor of seizure freedom. Of patients who had seizure recurrence and tumor progression, seizure usually recurred within 3 mo prior to tumor progression. Repeat resection offered additional seizure control, as 8 of the 22 patients with recurrent seizures became seizure free after reoperation. CONCLUSION Maximizing the extent of resection in insular gliomas portends greater seizure freedom after surgery. Seizure recurrence is associated with tumor progression, and repeat operation can provide additional seizure control.
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Affiliation(s)
- Doris D Wang
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Hansen Deng
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Annette A Molinaro
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, California
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Morshed RA, Young JS, Han SJ, Hervey-Jumper SL, Berger MS. Perioperative outcomes following reoperation for recurrent insular gliomas. J Neurosurg 2019; 131:467-473. [PMID: 30239317 DOI: 10.3171/2018.4.jns18375] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Greater extent of resection (EOR) improves overall survival and progression-free survival for patients with low- and high-grade glioma. While resection for newly diagnosed insular gliomas can be performed with minimal morbidity, perioperative morbidity is not clearly defined for patients undergoing a repeat resection for recurrent insular gliomas. In this study the authors report on tumor characteristics, tumor EOR, and functional outcomes in patients undergoing reoperation for recurrent insular glioma. METHODS Adult patients with insular gliomas (WHO grades II-IV) who underwent index resection followed by reoperation were identified through the University of California San Francisco Brain Tumor Center. Treatment history and functional outcomes were collected retrospectively from the electronic medical record. Pre- and postoperative tumor volumes were quantified using software with region-of-interest analysis based on FLAIR and T1-weighted postgadolinium sequences from pre- and postoperative MRI. RESULTS Forty-four patients (63.6% male, 36.4% female) undergoing 49 reoperations for recurrent insular tumors were identified with a median follow-up of 741 days. Left- and right-sided tumors comprised 52.3% and 47.7% of the cohort, respectively. WHO grade II, III, and IV gliomas comprised 46.9%, 28.6%, and 24.5% of the cohort, respectively. Ninety-five percent (95.9%) of cases involved language and/or motor mapping. Median EOR of the insular component of grade II, III, and IV tumors were 82.1%, 75.0%, and 94.6%, respectively. EOR during reoperation was not impacted by Berger-Sanai insular zone or tumor side. At the time of reoperation, 44.9% of tumors demonstrated malignant transformation to a higher WHO grade. Ninety-day postoperative assessment confirmed that 91.5% of patients had no new postoperative deficit attributable to surgery. Of those with new deficits, 3 (6.4%) had a visual field cut and 1 (2.1%) had hemiparesis (strength grade 1-2/5). The presence of a new postoperative deficit did not vary with EOR. CONCLUSIONS Recurrent insular gliomas, regardless of insular zone and pathology, may be reoperated on with an overall acceptable degree of resection and safety despite their anatomical and functional complexities. The use of intraoperative mapping utilizing asleep or awake methods may reduce morbidity to acceptable rates despite prior surgery.
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Affiliation(s)
- Ramin A Morshed
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Jacob S Young
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Seunggu J Han
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Shawn L Hervey-Jumper
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Mitchel S Berger
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
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Ius T, Cesselli D, Isola M, Pauletto G, Tomasino B, D’Auria S, Bagatto D, Pegolo E, Beltrami AP, Loreto CD, Skrap M. Incidental Low-Grade Gliomas: Single-Institution Management Based on Clinical, Surgical, and Molecular Data. Neurosurgery 2019; 86:391-399. [DOI: 10.1093/neuros/nyz114] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 03/12/2019] [Indexed: 01/08/2023] Open
Abstract
Abstract
BACKGROUND
Incidentally discovered diffuse low-grade gliomas (iLGG) are poorly documented in the literature. They are diagnosed by chance during radiological examinations.
OBJECTIVE
To review a cohort of patients with iLGG surgically treated in our institution, analyzing clinical, molecular, and surgical aspects.
METHODS
Clinical, radiological, and treatment data of iLGG were retrieved and compared with those of symptomatic diffuse LGGs (sLGG). Histological and molecular review was carried out as well. The extent of resection was evaluated on preoperative and postoperative T2-weighted magnetic resonance imaging.
RESULTS
Thirty-four iLGG cases were identified within a monoinstitutional cohort of 332 patients operated for low-grade gliomas from 2000 to 2017. Clinically, patients with iLGG had higher preoperative karnofsky performance scale (KPS) (P = .003), smaller tumor volume (P = .0001), lower frequency of eloquent areas involvement (P = .0001), and higher rate of complete resection (P = .0001) compared to those with sLGG. No differences in the molecular profile and O6-methylguanine-DNA-methyltransferase promoter methylation were detected between iLGG and sLGG. Importantly, patients with iLGG had longer overall survival than those with sLGG (P = .0001), even when a complete surgical resection was achieved (P = .001).
CONCLUSION
Although the therapeutic strategy of iLGG is still a matter of debate, our data support the safety and the effectiveness of early surgical resection. The favorable prognosis of iLGG may be due to the higher practicability of extensive resection, noneloquent tumor location, and smaller tumor volume.
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Affiliation(s)
- Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | | | - Miriam Isola
- Department of Medicine, University of Udine, Udine, Italy
| | - Giada Pauletto
- Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Barbara Tomasino
- IRCCS E. Medea, Polo Regionale del FVG, San Vito al Tagliamento, Pordenone, Italy
| | - Stanislao D’Auria
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Daniele Bagatto
- Department of Neuroradiology University of Udine, Udine, Italy
| | - Enrico Pegolo
- Department of Medicine, University of Udine, Udine, Italy
| | | | - Carla di Loreto
- Department of Medicine, University of Udine, Udine, Italy
- Institute of Pathology, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Miran Skrap
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
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Dasenbrock HH, See AP, Smalley RJ, Bi WL, Dolati P, Frerichs KU, Golby AJ, Chiocca EA, Aziz-Sultan MA. Frameless Stereotactic Navigation during Insular Glioma Resection using Fusion of Three-Dimensional Rotational Angiography and Magnetic Resonance Imaging. World Neurosurg 2019; 126:322-330. [PMID: 30898738 DOI: 10.1016/j.wneu.2019.03.096] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Perioperative cerebral infarction is a potential complication of glioma resection, of which insular tumors are at higher risk because of the proximity of middle cerebral artery branches, including the lateral lenticulostriates and long insular arteries. In this study, 3 patients received three-dimensional rotational angiography, which was fused with magnetic resonance imaging (MRI) for frameless stereotactic navigation during dominant-hemisphere insular glioma resection. METHODS All patients obtained a preoperative catheter angiogram with a three-dimensional rotational acquisition of the ipsilateral internal carotid artery. The pixel-based axial three-dimensional angiography data, thin-cut structural MRI, tractography from diffusion tensor imaging, and expressive language activation from functional MRI were uploaded into the iPlan software (Brainlab, Heimstetten, Germany) and fused. The target tumor, regional blood vessels, adjacent functional areas, and their associated fiber tracts were segmented and overlaid on the appropriate MRI sequence. This image fusion was used preoperatively to visualize the relationship of the mass with the adjacent vasculature and intraoperatively for frameless stereotactic navigation to optimize preservation of arterial structures. RESULTS Three patients aged 27-60 years with excellent baseline functional status presented with seizures and were found to have a large dominant-hemisphere T2 hyperintense nonenhancing insular mass. Surgical resection was performed using multimodality neuronavigation. None sustained a postoperative arterial infarction or a perioperative neurologic deficit. CONCLUSIONS Neuronavigation using a fusion of three-dimensional rotational angiography with MRI is a technique that can be used for preoperative planning and during resection of insular gliomas to optimize preservation of adjacent arteries.
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Affiliation(s)
- Hormuzdiyar H Dasenbrock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Alfred P See
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Smalley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parviz Dolati
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kai U Frerichs
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - E Antonio Chiocca
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - M Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Hervey-Jumper SL, Berger MS. Insular glioma surgery: an evolution of thought and practice. J Neurosurg 2019; 130:9-16. [PMID: 30611160 DOI: 10.3171/2018.10.jns181519] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVEThe goal of this article is to review the history of surgery for low- and high-grade gliomas located within the insula with particular focus on microsurgical technique, anatomical considerations, survival, and postoperative morbidity.METHODSThe authors reviewed the literature for published reports focused on insular region anatomy, neurophysiology, surgical approaches, and outcomes for adults with World Health Organization grade II-IV gliomas.RESULTSWhile originally considered to pose too great a risk, insular glioma surgery can be performed safely due to the collective efforts of many individuals. Similar to resection of gliomas located within other cortical regions, maximal resection of gliomas within the insula offers patients greater survival time and superior seizure control for both newly diagnosed and recurrent tumors in this region. The identification and the preservation of M2 perforating and lateral lenticulostriate arteries are critical steps to preventing internal capsule stroke and hemiparesis. The transcortical approach and intraoperative mapping are useful tools to maximize safety.CONCLUSIONSThe insula's proximity to middle cerebral and lenticulostriate arteries, primary motor areas, and perisylvian language areas makes accessing and resecting gliomas in this region challenging. Maximal safe resection of insular gliomas not only is possible but also is associated with excellent outcomes and should be considered for all patients with low- and high-grade gliomas in this area.
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Bouthillier A, Nguyen DK. Epilepsy Surgeries Requiring an Operculoinsular Cortectomy: Operative Technique and Results. Neurosurgery 2018; 81:602-612. [PMID: 28419327 DOI: 10.1093/neuros/nyx080] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 02/04/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Epilepsy surgeries requiring an operculoinsulectomy pose significant difficulties because the perisylvian area is highly vascular, deep, and functional. OBJECTIVE To report the operative technique and results of epilepsy surgeries requiring an operculoinsular cortectomy at our institution. METHODS The data of all consecutive patients who had undergone an epilepsy surgery requiring an operculoinsular cortectomy with a minimum follow-up of 1 yr were reviewed. Tumor and vascular malformation cases were excluded. Surgical techniques are described based on findings during surgery. RESULTS Twenty-five patients underwent an epilepsy surgery requiring an operculoinsular cortectomy: mean age at surgery was 35 y (9-51), mean duration of epilepsy was 19 y (5-36), 14 were female, and mean duration of follow-up was 4.7 y (1-16). Magnetic resonance imaging of the operculoinsular area was normal or revealed questionable nonspecific findings in 72% of cases. Investigation with intracranial EEG electrodes was done in 17 patients. Surgery was performed on the dominant side for language in 7 patients. An opercular resection was performed in all but 2 patients who only had an insulectomy. Engel class I seizure control was achieved in 80% of patients. Postoperative neurological deficits (paresis, dysphasia, alteration of taste, smell, hearing, pain, and thermal perceptions) were frequent (75%) but always transient except for 1 patient with persistent mild alteration of thermal and pain perception. CONCLUSION Surgical treatment of operculoinsular epilepsy is effective in achieving seizure control and is associated with an acceptable long-term complication rate.
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Affiliation(s)
- Alain Bouthillier
- Division of Neurosurgery, Hôpital Notre-Dame (CHUM), Université de Montréal, Quebec, Canada
| | - Dang Khoa Nguyen
- Division of Neurology, Hôpital Notre-Dame (CHUM), Université de Montréal, Quebec, Canada
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Raffa G, Conti A, Scibilia A, Cardali SM, Esposito F, Angileri FF, La Torre D, Sindorio C, Abbritti RV, Germanò A, Tomasello F. The Impact of Diffusion Tensor Imaging Fiber Tracking of the Corticospinal Tract Based on Navigated Transcranial Magnetic Stimulation on Surgery of Motor-Eloquent Brain Lesions. Neurosurgery 2017; 83:768-782. [DOI: 10.1093/neuros/nyx554] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/05/2017] [Indexed: 01/22/2023] Open
Abstract
Abstract
BACKGROUND
Navigated transcranial magnetic stimulation (nTMS) enables preoperative mapping of the motor cortex (M1). The combination of nTMS with diffusion tensor imaging fiber tracking (DTI-FT) of the corticospinal tract (CST) has been described; however, its impact on surgery of motor-eloquent lesions has not been addressed.
OBJECTIVE
To analyze the impact of nTMS-based mapping on surgery of motor-eloquent lesions.
METHODS
In this retrospective case-control study, we reviewed the data of patients operated for suspected motor-eloquent lesions between 2012 and 2015. The patients underwent nTMS mapping of M1 and, from 2014, nTMS-based DTI-FT of the CST. The impact on the preoperative risk/benefit analysis, surgical strategy, craniotomy size, extent of resection (EOR), and outcome were compared with a control group.
RESULTS
We included 35 patients who underwent nTMS mapping of M1 (group A), 35 patients who also underwent nTMS-based DTI-FT of the CST (group B), and a control group composed of 35 patients treated without nTMS (group C). The patients in groups A and B received smaller craniotomies (P = .01; P = .001), had less postoperative seizures (P = .02), and a better postoperative motor performance (P = .04) and Karnofsky Performance Status (P = .009) than the controls. Group B exhibited an improved risk/benefit analysis (P = .006), an increased EOR of nTMS-negative lesions in absence of preoperative motor deficits (P = .01), and less motor and Karnofsky Performance Status worsening in case of preoperative motor deficits (P = .02, P = .03) than group A.
CONCLUSION
nTMS-based mapping enables a tailored surgical approach for motor-eloquent lesions. It may improve the risk/benefit analysis, EOR and outcome, particularly when nTMS-based DTI-FT is performed.
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Affiliation(s)
- Giovanni Raffa
- Department of Neurosurgery, University of Messina, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alfredo Conti
- Department of Neurosurgery, University of Messina, Messina, Italy
| | | | | | - Felice Esposito
- Department of Neurosurgery, University of Messina, Messina, Italy
| | | | | | - Carmela Sindorio
- Department of Neurosurgery, University of Messina, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Antonino Germanò
- Department of Neurosurgery, University of Messina, Messina, Italy
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48
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Emotional concerns and coping strategies in Low Grade Glioma patients and reliability of their caregivers in reporting these concerns: Findings from a cross-sectional study. Eur J Oncol Nurs 2017; 30:113-119. [PMID: 29031307 DOI: 10.1016/j.ejon.2017.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 08/27/2017] [Accepted: 08/28/2017] [Indexed: 11/23/2022]
Abstract
PURPOSE To explore the emotional concerns and coping strategies of patients with Low Grade Glioma (LGG) and whether or not their caregivers are reliable in reporting these concerns as surrogate informants. METHODS An explorative cross-sectional study. Patients who had undergone a neurosurgical procedure at least one year before this study for LGG and who were capable of participating in a face-to-face interview were included. Each patient nominated a reference caregiver. Both the patient and the caregiver were interviewed independently, using the Beck Depression Inventory Scale, the State - Trait Anxiety Inventory, and the Jalowiec Coping Scale. MAIN RESULTS Forty-six patients and 46 caregivers were included. The average scores of the Beck scale were homogeneous between patients and caregivers (7.76 [CI 95% 5.76-9.75] vs. 6.23 [CI 95% 4.57-7.90]; p = 0.102). Patients reported significantly greater state and trait anxiety (44.26 [CI 95% 40.21-48.31] and 37.95 [CI 95% 34.97-40.94]), respectively compared to their caregivers (40.28 [CI 95% 36.64-43.91] and 35.17 [CI 95% 32.16-38.18]). The coping strategies enacted were homogeneous between patients and caregivers (82.78 [CI 95% 77.21-88.35] vs (80.93 [CI 95% 76.32-85.55]; p = 0.102) while the kind of strategies adopted were significantly diverse. CONCLUSIONS Patients suffer from depression and greater state anxiety as compared to trait anxiety; moreover, they enact less than half of the available coping strategies. Caregivers may be involved as surrogate informants when necessary for health-care professionals to detect depression while more caution is advised for what concerns anxiety and the coping strategies enacted by patients.
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49
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Ikegaya N, Takahashi A, Kaido T, Kaneko Y, Iwasaki M, Kawahara N, Otsuki T. Surgical strategy to avoid ischemic complications of the pyramidal tract in resective epilepsy surgery of the insula: technical case report. J Neurosurg 2017; 128:1173-1177. [PMID: 28598277 DOI: 10.3171/2017.1.jns161278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical treatment of the insula is notorious for its high probability of motor complications, particularly when resecting the superoposterior part. Ischemic damage to the pyramidal tract in the corona radiata has been regarded as the cause of these complications, resulting from occlusion of the perforating arteries to the pyramidal tract through the insular cortex. The authors describe a strategy in which a small piece of gray matter is spared at the bottom of the periinsular sulcus, where the perforating arteries pass en route to the pyramidal tract, in order to avoid these complications. This method was successfully applied in 3 patients harboring focal cortical dysplasia in the posterior insula and frontoparietal operculum surrounding the periinsular sulcus. None of the patients developed permanent postoperative motor deficits, and seizure control was achieved in all 3 cases. The method described in this paper can be adopted for functional preservation of the pyramidal tract in the corona radiata when resecting epileptogenic pathologies involving insular and opercular regions.
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Affiliation(s)
- Naoki Ikegaya
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira.,2Department of Neurosurgery, Yokohama City University, Yokohama; and
| | - Akio Takahashi
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Takanobu Kaido
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Yuu Kaneko
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Masaki Iwasaki
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Nobutaka Kawahara
- 2Department of Neurosurgery, Yokohama City University, Yokohama; and
| | - Taisuke Otsuki
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira.,3Epilepsy Hospital Bethel Japan, Iwanuma, Japan
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50
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Xu J, Elazab A, Liang J, Jia F, Zheng H, Wang W, Wang L, Hu Q. Cortical and Subcortical Structural Plasticity Associated with the Glioma Volumes in Patients with Cerebral Gliomas Revealed by Surface-Based Morphometry. Front Neurol 2017. [PMID: 28649229 PMCID: PMC5465275 DOI: 10.3389/fneur.2017.00266] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Postlesional plasticity has been identified in patients with cerebral gliomas by inducing a large functional reshaping of brain networks. Although numerous non-invasive functional neuroimaging methods have extensively investigated the mechanisms of this functional redistribution in patients with cerebral gliomas, little effort has been made to investigate the structural plasticity of cortical and subcortical structures associated with the glioma volume. In this study, we aimed to investigate whether the contralateral cortical and subcortical structures are able to actively reorganize by themselves in these patients. The compensation mechanism following contralateral cortical and subcortical structural plasticity is considered. We adopted the surface-based morphometry to investigate the difference of cortical and subcortical gray matter (GM) volumes in a cohort of 14 healthy controls and 13 patients with left-hemisphere cerebral gliomas [including 1 patients with World Health Organization (WHO I), 8 WHO II, and 4 WHO III]. The glioma volume ranges from 5.1633 to 208.165 cm2. Compared to healthy controls, we found significantly increased GM volume of the right cuneus and the left thalamus, as well as a trend toward enlargement in the right globus pallidus in patients with cerebral gliomas. Moreover, the GM volumes of these regions were positively correlated with the glioma volumes of the patients. These results provide evidence of cortical and subcortical enlargement, suggesting the usefulness of surface-based morphometry to investigate the structural plasticity. Moreover, the structural plasticity might be acted as the compensation mechanism to better fulfill its functions in patients with cerebral gliomas as the gliomas get larger.
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Affiliation(s)
- Jinping Xu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Ahmed Elazab
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,Misr Higher Institute for Commerce and Computers, Mansoura, Egypt
| | - Jinhua Liang
- Neurosurgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Fucang Jia
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Huimin Zheng
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Weimin Wang
- Neurosurgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Limin Wang
- Psychological Department, Guangzhou First People's Hospital, Guangzhou, China
| | - Qingmao Hu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
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