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Hageboutros K, Hewitt KC, Lee GP, Bansal A, Block C, Pedersen NP, Willie JT, Loring DW, Schoenberg MR, Smith KA, Giller CA, Gross RE, Drane DL. Comparison of minimally invasive to standard temporal lobectomy approaches to epilepsy surgery: Seizure relief and visual confrontation naming outcomes. Epilepsy Behav 2024; 155:109669. [PMID: 38663142 DOI: 10.1016/j.yebeh.2024.109669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/05/2024] [Accepted: 01/23/2024] [Indexed: 05/28/2024]
Abstract
The purpose of this study was to systematically examine three different surgical approaches in treating left medial temporal lobe epilepsy (mTLE) (viz., subtemporal selective amygdalohippocampectomy [subSAH], stereotactic laser amygdalohippocampotomy [SLAH], and anterior temporal lobectomy [ATL]), to determine which procedures are most favorable in terms of visual confrontation naming and seizure relief outcome. This was a retrospective study of 33 adults with intractable mTLE who underwent left temporal lobe surgery at three different epilepsy surgery centers who also underwent pre-, and at least 6-month post-surgical neuropsychological testing. Measures included the Boston Naming Test (BNT) and the Engel Epilepsy Surgery Outcome Scale. Fisher's exact tests revealed a statistically significant decline in naming in ATLs compared to SLAHs, but no other significant group differences. 82% of ATL and 36% of subSAH patients showed a significant naming decline whereas no SLAH patient (0%) had a significant naming decline. Significant postoperative naming improvement was seen in 36% of SLAH patients in contrast to 9% improvement in subSAH patients and 0% improvement in ATLs. Finally, there were no statistically significant differences between surgical approaches with regard to seizure freedom outcome, although there was a trend towards better seizure relief outcome among the ATL patients. Results support a possible benefit of SLAH in preserving visual confrontation naming after left TLE surgery. While result interpretation is limited by the small sample size, findings suggest outcome is likely to differ by surgical approach, and that further research on cognitive and seizure freedom outcomes is needed to inform patients and providers of potential risks and benefits with each.
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Affiliation(s)
- Karine Hageboutros
- Neuropsychology Department, Barrow Neurological Institute, Phoenix, AZ 85013, USA
| | - Kelsey C Hewitt
- Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Gregory P Lee
- Neuropsychology Department, Barrow Neurological Institute, Phoenix, AZ 85013, USA; Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Aastha Bansal
- Emory College of Arts and Sciences, Atlanta, GA 30322, USA
| | - Cady Block
- Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Nigel P Pedersen
- Department of Neurology, University of California Davis, Sacramento, CA 95816, USA
| | - Jon T Willie
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - David W Loring
- Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Mike R Schoenberg
- Department of Neurosurgery, University of South Florida, Tampa, FL 33606, USA
| | - Kris A Smith
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA
| | - Cole A Giller
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Robert E Gross
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Daniel L Drane
- Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA; Department of Neurology, University of Washington School of Medicine, Seattle, WA 98195, USA.
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2
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Sattari SA, Rincon-Torroella J, Sattari AR, Feghali J, Yang W, Kim JE, Xu R, Jackson CM, Mukherjee D, Lin SC, Gallia GL, Comair YG, Weingart J, Huang J, Bettegowda C. Awake Versus Asleep Craniotomy for Patients With Eloquent Glioma: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 94:38-52. [PMID: 37489887 DOI: 10.1227/neu.0000000000002612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/22/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Awake vs asleep craniotomy for patients with eloquent glioma is debatable. This systematic review and meta-analysis sought to compare awake vs asleep craniotomy for the resection of gliomas in the eloquent regions. METHODS MEDLINE and PubMed were searched from inception to December 13, 2022. Primary outcomes were the extent of resection (EOR), overall survival (month), progression-free survival (month), and rates of neurological deficit, Karnofsky performance score, and seizure freedom at the 3-month follow-up. Secondary outcomes were duration of operation (minute) and length of hospital stay (LOS) (day). RESULTS Fifteen studies yielded 2032 patients, from which 800 (39.4%) and 1232 (60.6%) underwent awake and asleep craniotomy, respectively. The meta-analysis concluded that the awake group had greater EOR (mean difference [MD] = MD = 8.52 [4.28, 12.76], P < .00001), overall survival (MD = 2.86 months [1.35, 4.37], P = .0002), progression-free survival (MD = 5.69 months [0.75, 10.64], P = .02), 3-month postoperative Karnofsky performance score (MD = 13.59 [11.08, 16.09], P < .00001), and 3-month postoperative seizure freedom (odds ratio = 8.72 [3.39, 22.39], P < .00001). Furthermore, the awake group had lower 3-month postoperative neurological deficit (odds ratio = 0.47 [0.28, 0.78], P = .004) and shorter LOS (MD = -2.99 days [-5.09, -0.88], P = .005). In addition, the duration of operation was similar between the groups (MD = 37.88 minutes [-34.09, 109.86], P = .30). CONCLUSION Awake craniotomy for gliomas in the eloquent regions benefits EOR, survival, postoperative neurofunctional outcomes, and LOS. When feasible, the authors recommend awake craniotomy for surgical resection of gliomas in the eloquent regions.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Ali Reza Sattari
- Department of Surgery, Saint Agnes Hospital, Baltimore , Maryland , USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jennifer E Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Shih-Chun Lin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Youssef G Comair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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3
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Voets NL, Bartsch AJ, Plaha P. Functional MRI applications for intra-axial brain tumours: uses and nuances in surgical practise. Br J Neurosurg 2023; 37:1544-1559. [PMID: 36148501 DOI: 10.1080/02688697.2022.2123893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 09/07/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Functional MRI (fMRI) has well-established uses to inform risks and plan maximally safe approaches in neurosurgery. In the field of brain tumour surgery, however, fMRI is currently in a state of clinical equipoise due to debate around both its sensitivity and specificity. MATERIALS AND METHODS In this review, we summarise the role and our experience of fMRI in neurosurgery for gliomas and metastases. We discuss nuances in the conduct and interpretation of fMRI that, based on our practise, most directly impact fMRI's usefulness in the neurosurgical setting. RESULTS Illustrated examples in which fMRI in our hands directly influences the neurosurgical treatment of brain tumours include evaluating the probability and nature of functional risks, especially for language functions. These presurgical risk assessments, in turn, help to predict the resectability of tumours, select or deselect patients for awake surgery, indicate the need for neurophysiological monitoring and guide the optimal use of intra-operative stimulation mapping. A further emerging application of fMRI is in measuring functional adaptation of functional networks after (partial) surgery, of potential use in the timing of further surgery. CONCLUSIONS In appropriately selected patients with a clearly defined surgical question, fMRI offers a valuable complementary tool in the pre-surgical evaluation of brain tumours. However, there is a great need for standards in the administration and analysis of fMRI as much as in the techniques that it is commonly evaluated against. Surprisingly little data exists that evaluates the accuracy of fMRI not just against complementary methods, but in terms of its ultimate clinical aim of minimising post-surgical morbidity.
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Affiliation(s)
- Natalie L Voets
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- GenesisCare Ltd, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Andreas J Bartsch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Puneet Plaha
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Neurosurgery, University of Oxford, Oxford, UK
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Mirkoska V, Antonsson M, Hartelius L, Nylén F. Detection of Subclinical Motor Speech Deficits after Presumed Low-Grade Glioma Surgery. Brain Sci 2023; 13:1631. [PMID: 38137079 PMCID: PMC10741922 DOI: 10.3390/brainsci13121631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/11/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Motor speech performance was compared before and after surgical resection of presumed low-grade gliomas. This pre- and post-surgery study was conducted on 15 patients (mean age = 41) with low-grade glioma classified based on anatomic features. Repetitions of /pa/, /ta/, /ka/, and /pataka/ recorded before and 3 months after surgery were analyzed regarding rate and regularity. A significant reduction (6 to 5.6 syllables/s) pre- vs. post-surgery was found in the rate for /ka/, which is comparable to the approximate average decline over 10-15 years of natural aging reported previously. For all other syllable types, rates were within normal age-adjusted ranges in both preoperative and postoperative sessions. The decline in /ka/ rate might reflect a subtle reduction in motor speech production, but the effects were not severe. All but one patient continued to perform within normal ranges post-surgery; one performed two standard deviations below age-appropriate norms pre- and post-surgery in all syllable tasks. The patient experienced motor speech difficulties, which may be related to the tumor's location in an area important for speech. Low-grade glioma may reduce maximum speech-motor performance in individual patients, but larger samples are needed to elucidate how often the effect occurs.
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Affiliation(s)
- Vesna Mirkoska
- Speech and Language Pathology Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, 40530 Gothenburg, Sweden; (M.A.); (L.H.)
| | - Malin Antonsson
- Speech and Language Pathology Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, 40530 Gothenburg, Sweden; (M.A.); (L.H.)
| | - Lena Hartelius
- Speech and Language Pathology Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, 40530 Gothenburg, Sweden; (M.A.); (L.H.)
| | - Fredrik Nylén
- Department of Clinical Sciences, Umeå University, 90736 Umeå, Sweden
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Pasquini L, Peck KK, Jenabi M, Holodny A. Functional MRI in Neuro-Oncology: State of the Art and Future Directions. Radiology 2023; 308:e222028. [PMID: 37668519 PMCID: PMC10546288 DOI: 10.1148/radiol.222028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 05/15/2023] [Accepted: 05/26/2023] [Indexed: 09/06/2023]
Abstract
Since its discovery in the early 1990s, functional MRI (fMRI) has been used to study human brain function. One well-established application of fMRI in the clinical setting is the neurosurgical planning of patients with brain tumors near eloquent cortical areas. Clinical fMRI aims to preoperatively identify eloquent cortices that serve essential functions in daily life, such as hand movement and language. The primary goal of neurosurgery is to maximize tumor resection while sparing eloquent cortices adjacent to the tumor. When a lesion presents in the vicinity of an eloquent cortex, surgeons may use fMRI to plan their best surgical approach by determining the proximity of the lesion to regions of activation, providing guidance for awake brain surgery and intraoperative brain mapping. The acquisition of fMRI requires patient preparation prior to imaging, determination of functional paradigms, monitoring of patient performance, and both processing and analysis of images. Interpretation of fMRI maps requires a strong understanding of functional neuroanatomy and familiarity with the technical limitations frequently present in brain tumor imaging, including neurovascular uncoupling, patient compliance, and data analysis. This review discusses clinical fMRI in neuro-oncology, relevant ongoing research topics, and prospective future developments in this exciting discipline.
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Affiliation(s)
- Luca Pasquini
- From the Neuroradiology Service, Department of Radiology (L.P.,
K.K.P., M.J., A.H.), Department of Medical Physics (K.K.P.), and Brain Tumor
Center (A.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York,
NY 10065; Neuroradiology Unit, NESMOS Department, Sant'Andrea Hospital,
La Sapienza University, Rome, Italy (L.P.); Department of Radiology, Weill
Medical College of Cornell University, New York, NY (A.H.); and Department of
Neuroscience, Weill Cornell Medicine Graduate School of Medical Sciences, New
York, NY (A.H.)
| | - Kyung K. Peck
- From the Neuroradiology Service, Department of Radiology (L.P.,
K.K.P., M.J., A.H.), Department of Medical Physics (K.K.P.), and Brain Tumor
Center (A.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York,
NY 10065; Neuroradiology Unit, NESMOS Department, Sant'Andrea Hospital,
La Sapienza University, Rome, Italy (L.P.); Department of Radiology, Weill
Medical College of Cornell University, New York, NY (A.H.); and Department of
Neuroscience, Weill Cornell Medicine Graduate School of Medical Sciences, New
York, NY (A.H.)
| | - Mehrnaz Jenabi
- From the Neuroradiology Service, Department of Radiology (L.P.,
K.K.P., M.J., A.H.), Department of Medical Physics (K.K.P.), and Brain Tumor
Center (A.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York,
NY 10065; Neuroradiology Unit, NESMOS Department, Sant'Andrea Hospital,
La Sapienza University, Rome, Italy (L.P.); Department of Radiology, Weill
Medical College of Cornell University, New York, NY (A.H.); and Department of
Neuroscience, Weill Cornell Medicine Graduate School of Medical Sciences, New
York, NY (A.H.)
| | - Andrei Holodny
- From the Neuroradiology Service, Department of Radiology (L.P.,
K.K.P., M.J., A.H.), Department of Medical Physics (K.K.P.), and Brain Tumor
Center (A.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York,
NY 10065; Neuroradiology Unit, NESMOS Department, Sant'Andrea Hospital,
La Sapienza University, Rome, Italy (L.P.); Department of Radiology, Weill
Medical College of Cornell University, New York, NY (A.H.); and Department of
Neuroscience, Weill Cornell Medicine Graduate School of Medical Sciences, New
York, NY (A.H.)
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Fauvet C, Villain M, Gatignol P. Repeated awake surgery and quality of life in patients with diffuse glioma: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:156. [PMID: 37382692 DOI: 10.1007/s10143-023-02073-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/12/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
Diffuse gliomas significantly affect patients' daily lives. Because of the high risk of recurrence and anaplasic transformation, repeated surgery can be proposed in awake condition to prolongs overall survival by limiting and reducing residual tumour volume. However, oncological interest alone is no longer sufficient due to the consequent increase in median survival, and quality of life is becoming an important issue in clinical decision-making. This systematic review focuses on the effects of repeated surgery in awake condition on the quality of life of adults with diffuse glioma through three parameters: return to work, presence of postoperative neurocognitive disorders, and occurrence of epileptic seizures. A systematic review of the last 20 years was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standards. Summarized data from selected studies were processed quantitatively, using a meta-analysis process, with the Review Manager 5.4 software. Five databases (PubMed, Web of Science, Science Direct, Dimensions, and Embase) were used. Fifteen articles were selected for qualitative analysis and 11 for meta-analysis. One hundred and fifty-one patients (85%) returned to an active socio-professional life after repeated surgery, and 78 (41%) presented neurocognitive disorders in the immediate postoperative period, only 3% (n = 4) of them suffering from permanent disorders. One hundred and forty-nine (78%) participants were free of epileptic seizure after repeated surgery. This systematic review of the literature highlights the benefit of repeated surgery on the quality of life of patients with adult diffuse glioma.
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Affiliation(s)
| | - Marie Villain
- AP-HP, Service MPR, Pitié-Salpêtrière University Hospital, Paris, France.
- Speech Therapy Department, Sorbonne Université, Paris, France.
- Sorbonne Université, GRC No. 24, Handicap Moteur Et Cognitif & Réadaptation (HaMCRe) AP-HP, Sorbonne Université, 75013, Paris, France.
| | - Peggy Gatignol
- AP-HP, Service MPR, Pitié-Salpêtrière University Hospital, Paris, France
- Speech Therapy Department, Sorbonne Université, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale Et Clinique, Paris, France
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"Neural dynamics supporting longitudinal plasticity of action naming across languages: MEG evidence from bilingual brain tumor patients". Neuropsychologia 2023; 181:108494. [PMID: 36708918 DOI: 10.1016/j.neuropsychologia.2023.108494] [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: 08/24/2022] [Revised: 01/17/2023] [Accepted: 01/25/2023] [Indexed: 01/27/2023]
Abstract
Previous evidence suggests that distinct ventral and dorsal streams respectively underpin the semantic processing of object and action knowledge. Recently, we found that brain tumor patients with dorsal gliomas in frontoparietal hubs show a selective longitudinal compensation (post-vs. pre-surgery) during the retrieval of lexico-semantic information about actions (but not objects), indexed by power increases in beta rhythms (13-28 Hz). Here, we move one-step further and ask whether a similar organizational principle also stands across the different languages a bilingual speaks. To test this hypothesis, we combined a picture-naming task with MEG recordings and evaluated highly proficient Spanish-Basque bilinguals undergoing surgery for tumor resection in left frontoparietal regions. We assessed patients before and three months after surgery. At the behavioral level, we observed a similar performance across sessions irrespectively of the language at use, suggesting overall successful function preservation. At the oscillatory level, we found longitudinal selective power increases in beta for action naming in Spanish and Basque. Nevertheless, tumor resection triggered a differential reorganization of the L1 and the L2, with the latter one additionally recruiting the right hemisphere. Overall, our results provide evidence for (i) the specific involvement of frontoparietal regions in the semantic retrieval/representation of action knowledge across languages; (ii) a key role of beta oscillations as a signature of language compensation and (iii) the existence of divergent plasticity trajectories in L1 and L2 after surgery. By doing so, they provide new insights into the spectro-temporal dynamics supporting postoperative recovery in the bilingual brain.
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8
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Pasquini L, Peck KK, Tao A, Del Ferraro G, Correa DD, Jenabi M, Kobylarz E, Zhang Z, Brennan C, Tabar V, Makse H, Holodny AI. Longitudinal Evaluation of Brain Plasticity in Low-Grade Gliomas: fMRI and Graph-Theory Provide Insights on Language Reorganization. Cancers (Basel) 2023; 15:cancers15030836. [PMID: 36765795 PMCID: PMC9913404 DOI: 10.3390/cancers15030836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Language reorganization may represent an adaptive phenomenon to compensate tumor invasion of the dominant hemisphere. However, the functional changes over time underlying language plasticity remain unknown. We evaluated language function in patients with low-grade glioma (LGG), using task-based functional MRI (tb-fMRI), graph-theory and standardized language assessment. We hypothesized that functional networks obtained from tb-fMRI would show connectivity changes over time, with increased right-hemispheric participation. We recruited five right-handed patients (4M, mean age 47.6Y) with left-hemispheric LGG. Tb-fMRI and language assessment were conducted pre-operatively (pre-op), and post-operatively: post-op1 (4-8 months), post-op2 (10-14 months) and post-op3 (16-23 months). We computed the individual functional networks applying optimal percolation thresholding. Language dominance and hemispheric connectivity were quantified by laterality indices (LI) on fMRI maps and connectivity matrices. A fixed linear mixed model was used to assess the intra-patient correlation trend of LI values over time and their correlation with language performance. Individual networks showed increased inter-hemispheric and right-sided connectivity involving language areas homologues. Two patterns of language reorganization emerged: Three/five patients demonstrated a left-to-codominant shift from pre-op to post-op3 (type 1). Two/five patients started as atypical dominant at pre-op, and remained unchanged at post-op3 (type 2). LI obtained from tb-fMRI showed a significant left-to-right trend in all patients across timepoints. There were no significant changes in language performance over time. Type 1 language reorganization may be related to the treatment, while type 2 may be tumor-induced, since it was already present at pre-op. Increased inter-hemispheric and right-side connectivity may represent the initial step to develop functional plasticity.
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Affiliation(s)
- Luca Pasquini
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Neuroradiology Unit, NESMOS Department, Sant’Andrea Hospital, La Sapienza University, 00189 Rome, Italy
- Correspondence:
| | - Kyung K. Peck
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Alice Tao
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Gino Del Ferraro
- Center for Neural Science, New York University, New York, NY 10003, USA
| | - Denise D. Correa
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, NY 10021, USA
| | - Mehrnaz Jenabi
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Erik Kobylarz
- Department of Neurology, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Cameron Brennan
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Hernán Makse
- Levich Institute and Physics Department, City College of New York, New York, NY 10031, USA
| | - Andrei I. Holodny
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, NY 10021, USA
- Department of Radiology, Weill Medical College of Cornell University, New York, NY 10065, USA
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9
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Nieberlein L, Rampp S, Gussew A, Prell J, Hartwigsen G. Reorganization and Plasticity of the Language Network in Patients with Cerebral Gliomas. Neuroimage Clin 2023; 37:103326. [PMID: 36736198 PMCID: PMC9926312 DOI: 10.1016/j.nicl.2023.103326] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/15/2022] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
Language is organized in large-scale networks in the human brain that show a strong potential for flexible interactions and adaptation. Neuroplasticity is the central mechanism that allows such dynamic modulation to changing conditions across the life span and is particularly important for network reorganization after brain lesions. Most studies on language reorganization focused on language recovery after stroke. Yet, a strong degree of adaptive neuroplasticity can also be observed in patients with brain tumors in language-eloquent brain areas. This review discusses key mechanisms for neural reorganization in patients with brain tumors. Our main aim is to elucidate the underlying mechanisms for intra- and interhemispheric plasticity in the language network in these patients. The following reorganization patterns are discussed: 1) Persisting function within the tumor; 2) Reorganization in perilesional regions; 3) Reorganization in a distributed network of the affected hemisphere; 4) Reorganization to the contralesional hemisphere. In this context, we shed light on language-related reorganization patterns in frontal and temporo-parietal areas and discuss their functional relevance. We also address tumor-related changes in structural and functional connectivity between eloquent brain regions. Thereby, we aim to expand the general understanding of the plastic potential of the neural language network and facilitate clinical decision-making processes for effective, function-preserving tumor treatment.
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Affiliation(s)
- Laura Nieberlein
- Lise Meitner Research Group Cognition and Plasticity, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.
| | - Stefan Rampp
- Department of Neurosurgery, University Hospital Halle (Saale), Germany; Department of Neurosurgery, University Hospital Erlangen, Germany
| | - Alexander Gussew
- Department of Medical Physics, University Hospital Halle (Saale), Germany
| | - Julian Prell
- Department of Neurosurgery, University Hospital Halle (Saale), Germany
| | - Gesa Hartwigsen
- Lise Meitner Research Group Cognition and Plasticity, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Wilhelm Wundt Institute for Psychology, Leipzig University, Germany
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10
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Pasquini L, Jenabi M, Peck KK, Holodny AI. Language reorganization in patients with left-hemispheric gliomas is associated with increased cortical volume in language-related areas and in the default mode network. Cortex 2022; 157:245-255. [PMID: 36356409 PMCID: PMC10201933 DOI: 10.1016/j.cortex.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/02/2022] [Accepted: 09/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Language function may reorganize to overcome focal impairment; however, the relation between functional and structural changes in patients with brain tumors remains unclear. We investigated the cortical volume of atypical language dominant (AD) patients with left frontal-insular high-grade (HGG) and low-grade glioma (LGG). We hypothesized atypical language being associated with areas of increased cortical volume in the right hemisphere, including language areas homologues. METHODS Patient were recruited following the criteria: left frontal-insular glioma; functional MRI and 3DT1-weighted images; no artifacts. We calculated an hemispheric language laterality index (LI), defined as: AD if LI < .2; left-dominant (LD) if LI ≥ .2. We measured cortical volume in three voxel-based morphometry (VBM) analyses: total AD vs. LD patients; AD vs. LD in HGG; AD vs. LD in LGG. We repeated the analysis in AD vs. LD healthy controls (HC). A minimum threshold of t > 2 and corrected p < .025 (Bonferroni) was employed. RESULTS We recruited 119 patients (44LGG, 75HGG). Hemispheric LI demonstrated 64/119AD and 55/119LD patients. The first VBM analysis demonstrated significantly increased cortical volume in AD patients in the right inferior frontal gyrus (IFG), right superior temporal gyrus (STG), right insula, right fusiform gyrus (FG), right precentral gyrus, right temporal-parietal junction, right posterior cingulate cortex (PCC), right hippocampus, right- and left cerebellum. AD patients with HGG showed the same areas of significantly increased cortical volume. AD patients with LGG displayed significantly increased cortical volume in right IFG, right STG, right insula, right FG, right anterior cingulate cortex, right PCC, right dorsal-lateral prefrontal cortex. HC showed no significant results. CONCLUSION Right-sided (atypical) language activations in patients with left-hemispheric gliomas are associated with areas of increased cortical volume. Additionally, default mode network nodes showed greater cortical volume in AD patients regardless of the tumor grade, supporting the idea of these cortices participating in the development of language plasticity.
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Affiliation(s)
- Luca Pasquini
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Neuroradiology Unit, NESMOS Department, Sant'Andrea Hospital, La Sapienza University, Rome 00189, Italy.
| | - Mehrnaz Jenabi
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Kyung K Peck
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andrei I Holodny
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Radiology, Weill Medical College of Cornell University, New York, NY 10065, USA; Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY 10065, USA
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11
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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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12
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Postoperative speech impairment and cranial nerve deficits after secondary surgery of posterior fossa tumours in childhood: a prospective European multicentre study. Childs Nerv Syst 2022; 38:747-758. [PMID: 35157109 DOI: 10.1007/s00381-022-05464-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Brain tumours constitute 25% of childhood neoplasms, and half of them are in the posterior fossa. Surgery is a fundamental component of therapy, because gross total resection is associated with a higher progression-free survival. Patients with residual tumour, progression of residual tumour or disease recurrence commonly require secondary surgery. We prospectively investigated the risk of postoperative speech impairment (POSI) and cranial nerve dysfunction (CND) following primary and secondary resection for posterior cranial fossa tumours. METHODS In the Nordic-European study of the cerebellar mutism syndrome, we prospectively included children undergoing posterior fossa tumour resection or open biopsy in one of the 26 participating European centres. Neurological status was assessed preoperatively, and surgical details were noted post-operatively. Patients were followed up 2 weeks, 2 months and 1 year postoperatively. Here, we analyse the risk of postoperative speech impairment (POSI), defined as either mutism or reduced speech, and cranial nerve dysfunction (CND) following secondary, as compared to primary, surgery. RESULTS We analysed 426 children undergoing primary and 78 undergoing secondary surgery between 2014 and 2020. The incidence of POSI was significantly lower after secondary (12%) compared with primary (28%, p = 0.0084) surgery. In a multivariate analysis adjusting for tumour histology, the odds ratio for developing POSI after secondary surgery was 0.23, compared with primary surgery (95% confidence interval: 0.08-0.65, p = 0.006). The frequency of postoperative CND did not differ significantly after primary vs. secondary surgery (p = 0.21). CONCLUSION Children have a lower risk of POSI after secondary than after primary surgery for posterior fossa tumours but remain at significant risk of both POSI and CND. The present findings should be taken in account when weighing risks and benefits of secondary surgery for posterior fossa tumours.
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Coburger J, Onken J, Rueckriegel S, von der Brelie C, Nadji-Ohl M, Forster MT, Gerlach R, Unteroberdörster M, Roder C, Kniese K, Schommer S, Rothenbacher D, Nagel G, Wirtz CR, Ernestus RI, Nabavi A, Tatagiba M, Czabanka M, Ganslandt O, Rohde V, Löhr M, Vajkoczy P, Pala A. Eloquent Lower Grade Gliomas, a Highly Vulnerable Cohort: Assessment of Patients' Functional Outcome After Surgery Based on the LoG-Glio Registry. Front Oncol 2022; 12:845992. [PMID: 35311092 PMCID: PMC8927728 DOI: 10.3389/fonc.2022.845992] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 11/28/2022] Open
Abstract
Majority of lower grade glioma (LGG) are located eloquently rendering surgical resection challenging. Aim of our study was to assess rate of permanent deficits and its predisposing risk factors. We retrieved 83 patients harboring an eloquently located LGGs from the prospective LoG-Glio Database. Patients without surgery or incomplete postoperative data were excluded. Sign rank test, explorative correlations by Spearman ρ and multivariable regression for new postoperative deficits were calculated. Eloquent region involved predominantly motor (45%) and language (40%). At first follow up after 3 months permanent neuro-logical deficits (NDs) were noted in 39%. Mild deficits remained in 29% and severe deficits in 10%. Complete tumor removal (CTR) was successfully in 62% of intended cases. Postoperative and 3-month follow up National Institute of Health Stroke Score (NIHSS) showed significantly lower values than preoperatively (p<0.001). 38% cases showed a decreased NIHSS at 3-month, while occurrence was only 14% at 9-12-month follow up. 6/7 patients with mild aphasia recovered after 9-12 months, while motor deficits present at 3-month follow up were persistent in majority of patients. Eastern oncology group functional status (ECOG) significantly decreased by surgery (p < 0.001) in 31% of cases. Between 3-month and 9-12-months follow up no significant improvement was seen. In the multivariable model CTR (p=0.019, OR 31.9), and ECOG>0 (p=0.021, OR 8.5) were independent predictors for permanent postoperative deficit according to NIHSS at 3-month according to multivariable regression model. Patients harboring eloquently located LGG are highly vulnerable for permanent deficits. Almost one third of patients have a permanent reduction of their functional status based on ECOG. Risk of an extended resection has to be balanced with the respective oncological benefit. Especially, patients with impaired pre-operative status are at risk for new permanent deficits. There is a relevant improvement of neurological symptoms in the first year after surgery, especially for patients with slight aphasia.
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Affiliation(s)
- Jan Coburger
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité - University of Berlin, Berlin, Germany
| | | | | | - Minou Nadji-Ohl
- Department of Neurosurgery, Katharinenhospital Stuttgart, Stuttgart, Germany
| | | | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Hospital Erfurt, Erfurt, Germany
| | | | - Constantin Roder
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Katja Kniese
- Department of Neurosurgery, KRH Klinikum Region Hannover, Hannover, Germany
| | - Stefan Schommer
- Department of Neurosurgery, Katharinenhospital Stuttgart, Stuttgart, Germany
| | | | - Gabriele Nagel
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | | | | | - Arya Nabavi
- Department of Neurosurgery, KRH Klinikum Region Hannover, Hannover, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, University of Frankfurt, Frankfurt am Main, Germany
| | - Oliver Ganslandt
- Department of Neurosurgery, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Veit Rohde
- Department of Neurosurgery, University of Göttingen, Göttingen, Germany
| | - Mario Löhr
- Department of Neurosurgery, University of Würzburg, Würzburg, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - University of Berlin, Berlin, Germany
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Günzburg, Germany
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Muir M, Patel R, Traylor J, de Almeida Bastos DC, Prinsloo S, Liu HL, Noll K, Wefel J, Tummala S, Kumar V, Prabhu S. Validation of Non-invasive Language Mapping Modalities for Eloquent Tumor Resection: A Pilot Study. Front Neurosci 2022; 16:833073. [PMID: 35299624 PMCID: PMC8923233 DOI: 10.3389/fnins.2022.833073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Many studies have established a link between extent of resection and survival in patients with gliomas. Surgeons must optimize the oncofunctional balance by maximizing the extent of resection and minimizing postoperative neurological morbidity. Preoperative functional imaging modalities are important tools for optimizing the oncofunctional balance. Transcranial magnetic stimulation (TMS) and functional magnetic resonance imaging (fMRI) are non-invasive imaging modalities that can be used for preoperative functional language mapping. Scarce data exist evaluating the accuracy of these preoperative modalities for language mapping compared with gold standard intraoperative data in the same cohort. This study compares the accuracy of fMRI and TMS for language mapping compared with intraoperative direct cortical stimulation (DCS). We also identified significant predictors of preoperative functional imaging accuracy, as well as significant predictors of functional outcomes. Evidence from this study could inform clinical judgment as well as provide neuroscientific insight. We used geometric distances to determine copositivity between preoperative data and intraoperative data. Twenty-eight patients were included who underwent both preoperative fMRI and TMS procedures, as well as an awake craniotomy and intraoperative language mapping. We found that TMS shows significantly superior correlation to intraoperative DCS compared with fMRI. TMS also showed significantly higher sensitivity and negative predictive value than specificity and positive predictive value. Poor cognitive baseline was associated with decreased TMS accuracy as well as increased risk for worsened aphasia postoperatively. TMS has emerged as a promising preoperative language mapping tool. Future work should be done to identify the proper role of each imaging modality in a comprehensive, multimodal approach to optimize the oncofunctional balance.
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Affiliation(s)
- Matthew Muir
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rajan Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Jeffrey Traylor
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | - Sarah Prinsloo
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ho-Ling Liu
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kyle Noll
- Department of Neuropsychology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jeffrey Wefel
- Department of Neuropsychology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sudhakar Tummala
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Vinodh Kumar
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sujit Prabhu
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- *Correspondence: Sujit Prabhu,
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Pasquini L, Di Napoli A, Rossi-Espagnet MC, Visconti E, Napolitano A, Romano A, Bozzao A, Peck KK, Holodny AI. Understanding Language Reorganization With Neuroimaging: How Language Adapts to Different Focal Lesions and Insights Into Clinical Applications. Front Hum Neurosci 2022; 16:747215. [PMID: 35250510 PMCID: PMC8895248 DOI: 10.3389/fnhum.2022.747215] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/18/2022] [Indexed: 12/13/2022] Open
Abstract
When the language-dominant hemisphere is damaged by a focal lesion, the brain may reorganize the language network through functional and structural changes known as adaptive plasticity. Adaptive plasticity is documented for triggers including ischemic, tumoral, and epileptic focal lesions, with effects in clinical practice. Many questions remain regarding language plasticity. Different lesions may induce different patterns of reorganization depending on pathologic features, location in the brain, and timing of onset. Neuroimaging provides insights into language plasticity due to its non-invasiveness, ability to image the whole brain, and large-scale implementation. This review provides an overview of language plasticity on MRI with insights for patient care. First, we describe the structural and functional language network as depicted by neuroimaging. Second, we explore language reorganization triggered by stroke, brain tumors, and epileptic lesions and analyze applications in clinical diagnosis and treatment planning. By comparing different focal lesions, we investigate determinants of language plasticity including lesion location and timing of onset, longitudinal evolution of reorganization, and the relationship between structural and functional changes.
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Affiliation(s)
- Luca Pasquini
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Neuroradiology Unit, NESMOS Department, Sant’Andrea Hospital, La Sapienza University, Rome, Italy
| | - Alberto Di Napoli
- Neuroradiology Unit, NESMOS Department, Sant’Andrea Hospital, La Sapienza University, Rome, Italy
- Radiology Department, Castelli Hospital, Rome, Italy
- IRCCS Fondazione Santa Lucia, Rome, Italy
| | | | - Emiliano Visconti
- Neuroradiology Unit, Cesena Surgery and Trauma Department, M. Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Antonio Napolitano
- Medical Physics Department, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Andrea Romano
- Neuroradiology Unit, NESMOS Department, Sant’Andrea Hospital, La Sapienza University, Rome, Italy
| | - Alessandro Bozzao
- Neuroradiology Unit, NESMOS Department, Sant’Andrea Hospital, La Sapienza University, Rome, Italy
| | - Kyung K. Peck
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Andrei I. Holodny
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Radiology, Weill Medical College of Cornell University, New York, NY, United States
- Department of Neuroscience, Weill-Cornell Graduate School of the Medical Sciences, New York, NY, United States
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Duffau H. The death of localizationism: The concepts of functional connectome and neuroplasticity deciphered by awake mapping, and their implications for best care of brain-damaged patients. Rev Neurol (Paris) 2021; 177:1093-1103. [PMID: 34563375 DOI: 10.1016/j.neurol.2021.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/20/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022]
Abstract
Although clinical neurology was mainly erected on the dogma of localizationism, numerous reports have described functional recovery after lesions involving presumed non-compensable areas in an inflexible view of brain processing. Here, the purpose is to review new insights into the functional connectome and the mechanisms underpinning neural plasticity, gained from intraoperative direct electrostimulation mapping and real-time behavioral monitoring in awake patients, combined with perioperative neuropsychological and neuroimaging data. Such longitudinal anatomo-functional correlations resulted in the reappraisal of classical models of cognition, especially by highlighting the dynamic interplay within and between neural circuits, leading to the concept of meta-network (network of networks), as well as by emphasizing that subcortical connectivity is the main limitation of neuroplastic potential. Beyond their contribution to basic neurosciences, these findings might also be helpful for an optimization of care for brain-damaged patients, such as in resective oncological or epilepsy neurosurgery in structures traditionally deemed inoperable (e.g., in Broca's area) as well as for elaborating new programs of functional rehabilitation, eventually combined with transcranial brain stimulation, aiming to change the connectivity patterns in order to enhance cognitive competences following cerebral injury.
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Affiliation(s)
- H Duffau
- Department of Neurosurgery, Gui-de-Chauliac Hospital, Montpellier University Medical Center, 80, avenue Augustin-Fliche, 34295 Montpellier, France; National Institute for Health and Medical Research (INSERM), U1191 Laboratory, Team "Brain Plasticity, Stem Cells and Low-Grade Gliomas", Institute of Functional Genomics, University of Montpellier, 34091 Montpellier, France.
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Morales H. Current and Future Challenges of Functional MRI and Diffusion Tractography in the Surgical Setting: From Eloquent Brain Mapping to Neural Plasticity. Semin Ultrasound CT MR 2021; 42:474-489. [PMID: 34537116 DOI: 10.1053/j.sult.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Decades ago, Spetzler (1986) and Sawaya (1998) provided a rough brain segmentation of the eloquent areas of the brain, aimed to help surgical decisions in cases of vascular malformations and tumors, respectively. Currently in clinical use, their criteria are in need of revision. Defining functions (eg, sensorimotor, language and visual) that should be preserved during surgery seems a straightforward task. In practice, locating the specific areas that could cause a permanent vs transient deficit is not an easy task. This is particularly true for the associative cortex and cognitive domains such as language. The old model, with Broca's and Wernicke's areas at the forefront, has been superseded by a dual-stream model of parallel language processing; named ventral and dorsal pathways. This complicated network of cortical hubs and subcortical white matter pathways needing preservation during surgery is a work in progress. Preserving not only cortical regions but most importantly preserving the connections, or white matter fiber bundles, of core regions in the brain is the new paradigm. For instance, the arcuate fascicululs and inferior fronto-occipital fasciculus are key components of the dorsal and ventral language pathways, respectively; and their damage result in permanent language deficits. Interestedly, the damage of the temporal portions of these bundles -where there is a crossroad with other multiple bundles-, appears to be more important (permanent) than the damage of the frontal portions - where plasticity and contralateral activation could help. Although intraoperative direct cortical and subcortical stimulation have contributed largely, advanced MR techniques such as functional MRI (fMRI) and diffusion tractography (DT), are at the epi-center of our current understanding. Nevertheless, these techniques posse important challenges: such as neurovascular uncoupling or venous bias on fMRI; and appropriate anatomical validation or accurate representation of crossing fibers on DT. These limitations should be well understood and taken into account in clinical practice. Unifying multidisciplinary research and clinical efforts is desirable, so these techniques could contribute more efficiently not only to locate eloquent areas but to improve outcomes and our understanding of neural plasticity. Finally, although there are constant anatomical and functional regions at the individual level, there is a known variability at the inter-individual level. This concept should strengthen the importance of a personalized approach when evaluating these regions on fMRI and DT. It should strengthen the importance of personalized treatments as well, aimed to meet tailored needs and expectations.
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Affiliation(s)
- Humberto Morales
- Section of Neuroradiology, University of Cincinnati Medical Center, Cincinnati, OH.
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Hamdan N, Duffau H. Extending the multistage surgical strategy for recurrent initially low-grade gliomas: functional and oncological outcomes in 31 consecutive patients who underwent a third resection under awake mapping. J Neurosurg 2021; 136:1035-1044. [PMID: 34507287 DOI: 10.3171/2021.3.jns21264] [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: 01/31/2021] [Accepted: 03/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Maximal safe resection is the first treatment in diffuse low-grade glioma (DLGG). Due to frequent tumor recurrence, a second surgery has already been reported, with favorable results. This study assesses the feasibility and functional and oncological outcomes of a third surgery in recurrent DLGG. METHODS Patients with DLGG who underwent a third functional-based resection using awake mapping were consecutively selected. They were classified into group 1 in cases of slow tumor regrowth or group 2 if a radiological enhancement occurred during follow-up. All data regarding clinicoradiological features, histomolecular results, oncological treatment, and survival were collected. RESULTS Thirty-one patients were included, with a median age of 32 years. There were 20 astrocytomas and 11 oligodendrogliomas in these patients. Twenty-one patients had medical oncological treatment before the third surgery, consisting of chemotherapy in 19 cases and radiotherapy in 8 cases. No neurological deficit persisted after the third resection except mild missing words in 1 patient, with 84.6% of the patients returning to work. The median follow-up duration was 13.1 ± 3.4 years since diagnosis, and 3.1 ± 2.9 years since the third surgery. The survival rates at 7 and 10 years were 100% and 89.7%, respectively, with an estimated median overall survival of 17.8 years since diagnosis. A comparison between the groups showed that the Karnofsky Performance Scale score dropped below 80 earlier in group 2 (14.3 vs 17.1 years, p = 0.01). Median residual tumor volume at the third surgery was smaller (2.8 vs 14.4 cm3, p = 0.003) with a greater extent of resection (89% vs 70%, p = 0.003) in group 1. CONCLUSIONS This is the first consecutive series showing evidence that, in select patients with progressive DLGG, a third functional-based surgery can be achieved using awake mapping with low neurological risk and a high rate of total resection, especially when reoperation is performed before malignant transformation.
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Affiliation(s)
- Noor Hamdan
- 1Department of Neurosurgery, Jean Minjoz Hospital, Besançon University Medical Center, Besançon.,2University of Bourgogne-Franche-Comté, Besançon
| | - Hugues Duffau
- 3Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier.,4Team "Plasticity of Central Nervous System, Stem Cells and Low-Grade Gliomas," INSERM U1191, Institute of Functional Genomics, Montpellier; and.,5University of Montpellier, France
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Intraoperative brain mapping during awake surgery in symptomatic supratentorial cavernomas. ACTA ACUST UNITED AC 2021; 32:217-223. [PMID: 34493402 DOI: 10.1016/j.neucie.2020.07.001] [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: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Complete resection of symptomatic supratentorial cavernoma (SCA) and removal of the surrounding gliotic area is recommended to minimize the risk of persistent seizures or (re)bleeding. Surgery of SCA located in an eloquent area, can carry out severe postoperative neurological morbidity. We report a study aimed to assess feasibility, extent of resection and outcome after surgical removal of CA by cortico-subcortical intraoperative brain stimulation (ioBS) in the awake patient. METHODS Six patients diagnosed of symptomatic SCA located on an eloquent area and operated on while awake under local anaesthesia ioBS, were included. Preoperative planning included neuropsychologic assessment of language-related functions, sociocognitive functions and executive functions. Intraoperatively, we recorded the results achieved in the planned neuropsychological tasks when stimulation was applied (cortical and subcortical). Postoperative control 3D MRI was scheduled at 1 month after surgery to calculate extent of resection. Neuropsychological assessment at 6 months after surgery was performed in all cases. RESULTS Six patients (5 females, 1 male) aged 24-48 years were included in our study. Locations of the lesions were right insular (n=1), left insular (n=1), left temporo-insular (n=1), left temporal (n=2) and left frontal (n=1). In all patients, positive findings were obtained during ioBS. In 5 patients, complete surgical resection was achieved. Two patients had postoperative transient neurological deficits, one case of hemiparesis, one case of dysnomia, both cleared over a 6-month period. Clinical follow-up revealed that all patients experienced complete recovery from preoperative symptoms within a year and five patients with seizures showed marked improvement and eventually quit antiepileptic drugs. Neuropsychological assessment at 6 months provided normal results compared to preoperative baseline in all domains. CONCLUSIONS Our study suggests that ioBS in the awake surgery of symptomatic SCA located in eloquent areas, allows to increase the rate of complete resection, minimizing postoperative neurological and neuropsychological deficit, and improving postoperative seizures control.
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Sprugnoli G, Rossi S, Rotenberg A, Pascual-Leone A, El-Fakhri G, Golby AJ, Santarnecchi E. Personalised, image-guided, noninvasive brain stimulation in gliomas: Rationale, challenges and opportunities. EBioMedicine 2021; 70:103514. [PMID: 34391090 PMCID: PMC8365310 DOI: 10.1016/j.ebiom.2021.103514] [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: 04/20/2021] [Revised: 07/12/2021] [Accepted: 07/19/2021] [Indexed: 11/22/2022] Open
Abstract
Malignant brain tumours are among the most aggressive human cancers, and despite intensive efforts made over the last decades, patients’ survival has scarcely improved. Recently, high-grade gliomas (HGG) have been found to be electrically integrated with healthy brain tissue, a communication that facilitates tumour mitosis and invasion. This link to neuronal activity has provided new insights into HGG pathophysiology and opened prospects for therapeutic interventions based on electrical modulation of neural and synaptic activity in the proximity of tumour cells, which could potentially slow tumour growth. Noninvasive brain stimulation (NiBS), a group of techniques used in research and clinical settings to safely modulate brain activity and plasticity via electromagnetic or electrical stimulation, represents an appealing class of interventions to characterise and target the electrical properties of tumour-neuron interactions. Beyond neuronal activity, NiBS may also modulate function of a range of substrates and dynamics that locally interacts with HGG (e.g., vascular architecture, perfusion and blood-brain barrier permeability). Here we discuss emerging applications of NiBS in patients with brain tumours, covering potential mechanisms of action at both cellular, regional, network and whole-brain levels, also offering a conceptual roadmap for future research to prolong survival or promote wellbeing via personalised NiBS interventions.
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Affiliation(s)
- Giulia Sprugnoli
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Radiology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy; Image Guided Neurosurgery laboratory, Department of Neurosurgery and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Brain investigation and Neuromodulation Laboratory (Si-BIN Lab), Department of Medicine, Surgery and Neuroscience, Neurology and Clinical Neurophysiology Unit, University of Siena, Siena, Italy
| | - Simone Rossi
- Brain investigation and Neuromodulation Laboratory (Si-BIN Lab), Department of Medicine, Surgery and Neuroscience, Neurology and Clinical Neurophysiology Unit, University of Siena, Siena, Italy
| | - Alexander Rotenberg
- Department of Neurology and Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research and Center for Memory Health, Hebrew Senior Life, Boston, MA, USA; Guttmann Brain Health Institute, Institut Guttmann, Universitat Autonoma, Barcelona, Spain
| | - Georges El-Fakhri
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra J Golby
- Image Guided Neurosurgery laboratory, Department of Neurosurgery and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Emiliano Santarnecchi
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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21
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Yu T, Yu S, Zuo Z, Lin N, Wang J, Zhao Y, Lin S. Dexmedetomidine inhibits unstable motor network in patients with primary motor area gliomas. Aging (Albany NY) 2021; 13:15139-15150. [PMID: 34032606 PMCID: PMC8221338 DOI: 10.18632/aging.203077] [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: 01/07/2021] [Accepted: 03/13/2021] [Indexed: 12/04/2022]
Abstract
Background: Sedative agents such as dexmedetomidine have been found to transiently exacerbate or unmask limb motor dysfunction in patients with eloquent area brain gliomas. The present study aims to investigate whether dexmedetomidine can inhibit motor plasticity in patients with glioma via fMRI. Methods: 21 patients with brain glioma were prospectively recruited between September 2017 and December 2018. Patients were classified into pre-M1 (primary motor cortex) group (n=9), post-M1 group (n=6), and non-eloquent group (control group) (n=6) according to the tumor position related to M1. The hand movement task-fMRI and resting state fMRI (rs-fMRI) were performed before and after sedation using dexmedetomidine. The lateralization index (LI) of activation voxels and magnitude and the functional connectivity (FC) of motor network were compared before and after sedation and among different groups. Results: Permanent postoperative motor deficit of the upper limb was found in 5 of 6 patients in the pre-M1 group, and none in other groups (P < .01). Task-fMRI showed the LI of activation volume and activation magnitude at M1 significantly increased only in the pre-M1 group after sedation (P < .05). Rs-fMRI showed 60.0% (27 of 45) FCs of motor network decreased in pre-M1 group after sedation (p[FDR] < .05); whereas there was no FC reduction in post-M1 and control groups (p[FDR] > .05). Conclusions: In patients with eloquent area gliomas, dexmedetomidine can inhibit the unstable compensative motor plasticity on both task- and rs-fMRI. fMRI may be a promising method for elucidating the effect of sedative agents on motor plasticity.
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Affiliation(s)
- Tao Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
| | - Songlin Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing 100070, China.,CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Zhentao Zuo
- State Key Laboratory of Brain and Cognitive Science, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China.,University of Chinese Academy of Sciences, Beijing 100049, China.,CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Nan Lin
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Jing Wang
- Department of Neurosurgery, Peking University International Hospital, Peking University Health Science Center, Beijing 102206, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing 100070, China.,Department of Neurosurgery, Peking University International Hospital, Peking University Health Science Center, Beijing 102206, China
| | - Song Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing 100070, China.,Department of Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
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22
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Voets NL, Parker Jones O, Isaac C, Mars RB, Plaha P. Tracking longitudinal language network reorganisation using functional MRI connectivity fingerprints. NEUROIMAGE-CLINICAL 2021; 30:102689. [PMID: 34215157 PMCID: PMC8122112 DOI: 10.1016/j.nicl.2021.102689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 12/03/2022]
Abstract
FMRI connectivity fingerprints represent patient-unique language networks. Fingerprints can be statistically tested to detect reorganisation in individuals. Connectivity fingerprints track surgery-related adaptations in individual patients. Network-level changes appear related to presence of language symptoms.
Large individual differences in how brain networks respond to treatment hinder efforts to personalise treatment in neurological conditions. We used a brain network fingerprinting approach to longitudinally track re-organisation of complementary phonological and semantic language networks in 19 patients before and after brain-tumour surgery. Patient task fingerprints were individually compared to normal networks established in 17 healthy controls. Additionally, pre- and post-operative patient fingerprints were directly compared to assess longitudinal network adaptations. We found that task networks remained stable over time in healthy controls, whereas treatment induced reorganisation in 47.4% of patient fluency networks and 15.8% of semantic networks. How networks adapted after surgery was highly unique; a subset of patients (10%) showed ‘normalisation’ while others (21%) developed newly atypical networks after treatment. The strongest predictor of adaptation of the fluency network was the presence of clinically reported language symptoms. Our findings indicate a tight coupling between processes disrupting performance and neural network adaptation, the patterns of which appear to be both task- and individually-unique. We propose that connectivity fingerprinting offers potential as a clinical marker to track adaptation of specific functional networks across treatment interventions over time.
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Affiliation(s)
- Natalie L Voets
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK; Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Oiwi Parker Jones
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Claire Isaac
- Russell Cairns Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rogier B Mars
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK; Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, the Netherlands
| | - Puneet Plaha
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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23
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Brain connectomics applied to oncological neuroscience: from a traditional surgical strategy focusing on glioma topography to a meta-network approach. Acta Neurochir (Wien) 2021; 163:905-917. [PMID: 33564906 DOI: 10.1007/s00701-021-04752-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/01/2021] [Indexed: 02/07/2023]
Abstract
The classical way for surgical selection and planning in cerebral glioma mainly focused on tumor topography. The emerging science of connectomics, which aims of mapping brain connectivity, resulted in a paradigmatic shift from a modular account of cerebral organization to a meta-network perspective. Adaptive behavior is actually mediated by constant changes in interactions within and across large-scale delocalized neural systems underlying conation, cognition, and emotion. Here, to optimize the onco-functional balance of glioma surgery, the purpose is to switch toward a connectome-based resection taking account of both relationships between the tumor and critical distributed circuits (especially subcortical pathways) as well as the perpetual instability of the meta-network. Such dynamic in the neural spatiotemporal integration permits functional reallocation leading to neurological recovery after massive resection in structures traditionally thought as "inoperable." This better understanding of connectome increases benefit/risk ratio of surgery (i) by selecting resection in areas deemed "eloquent" according to a localizationist dogma; (ii), conversely, by refining intraoperative awake cognitive mapping and monitoring in so-called non-eloquent areas; (iii) by improving preoperative information, enabling an optimal selection of intrasurgical tasks tailored to the patient's wishes; (iv) by developing an "oncological disconnection surgery"; (v) by defining a personalized multistep surgical strategy adapted to individual brain reshaping potential; and (vi) ultimately by preserving environmentally and socially appropriate behavior, including return to work, while increasing the extent of (possibly repeated) resection(s). Such a holistic vision of neural processing can enhance reliability of connectomal surgery in oncological neuroscience and may also be applied to restorative neurosurgery.
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24
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Ghinda DC, Lambert B, Lu J, Jiang N, Tsai E, Sachs A, Wu JS, Northoff G. Scale-Free Analysis of Intraoperative ECoG During Awake Craniotomy for Glioma. Front Oncol 2021; 10:625474. [PMID: 33708619 PMCID: PMC7942167 DOI: 10.3389/fonc.2020.625474] [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: 11/03/2020] [Accepted: 12/31/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Electrocorticography (ECoG) has been utilized in many epilepsy cases however, the use of this technique for evaluating electrophysiological changes within tumoral zones is spare. Nonetheless, epileptic activities seem to arise from the neocortex surrounding the gliomas suggesting a link between epileptogenesis and glioma cell infiltration in the peritumoral area. The purpose of this study was to implement novel scale-free measures to assess how cortical physiology is altered by the presence of an invasive brain tumor. METHODS Twelve patients undergoing an awake craniotomy for resection of a supratentorial glioma were included. ECoG data over the main tumor and the exposed surroundings was acquired intra-operatively just prior to tumor resection. Six of the patients presented with seizures and had data acquired both in the awake and anesthetic state. The corresponding anatomical location of each electrode in relation to the macroscopically-detectable tumor was recorded using the neuronavigation system based on structural anatomical images obtained pre-operatively. The electrodes were classified into tumoral, healthy or peritumoral based on the macroscopically detectable tumoral tissue from the pre-operative structural MRI. RESULTS The electrodes overlying the tumoral tissue revealed higher power law exponent (PLE) values across tumoral area compared to the surrounding tissues. The difference between the awake and anesthetic states was significant in the tumoral and healthy tissue (p < 0.05) but not in the peritumoral tissue. The absence of a significant PLE reduction in the peritumoral tissue from the anesthetic to the awake state could be considered as an index of the presence or absence of infiltration of tumor cells into the peritumoral tissue. CONCLUSIONS The current study portrays for the first time distinct power law exponent features in the tumoral tissue, which could provide a potential novel electrophysiological marker in the future. The distinct features seen in the peritumoral tissue of gliomas seem to indicate the area where both the onset of epileptiform activity and the tumor infiltration take place.
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Affiliation(s)
- Diana Cristina Ghinda
- Department of Neurosurgery, The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Mind, Brain Imaging and Neuroethics, Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada
| | - Ben Lambert
- Faculty of Engineering, Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Junfeng Lu
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ning Jiang
- Faculty of Engineering, Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Eve Tsai
- Department of Neurosurgery, The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Adam Sachs
- Department of Neurosurgery, The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jin-Song Wu
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Georg Northoff
- Mind, Brain Imaging and Neuroethics, Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada
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25
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Zhang N, Yuan B, Yan J, Cheng J, Lu J, Wu J. Multivariate machine learning-based language mapping in glioma patients based on lesion topography. Brain Imaging Behav 2021; 15:2552-2562. [PMID: 33619646 DOI: 10.1007/s11682-021-00457-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 12/11/2020] [Accepted: 01/21/2021] [Indexed: 12/21/2022]
Abstract
Diffusive and progressive tumor infiltration within language-related areas of the brain induces functional reorganization. However, the macrostructural basis of subsequent language deficits is less clear. To address this issue, lesion topography data from 137 preoperative patients with left cerebral language-network gliomas (81 low-grade gliomas and 56 high-grade gliomas), were adopted for multivariate machine-learning-based lesion-language mapping analysis. We found that tumor location in the left posterior middle temporal gyrus-a bottleneck where both dorsal and ventral language pathways travel-predicted deficits of spontaneous speech (cluster size = 1356 mm3, false discovery rate corrected P < 0.05) and naming scores (cluster size = 1491 mm3, false discovery rate corrected P < 0.05) in the high-grade glioma group. In contrast, no significant lesion-language mapping results were observed in the low-grade glioma group, suggesting a large functional reorganization. These findings suggest that in patients with gliomas, the macrostructural plasticity mechanisms that modulate brain-behavior relationships depend on glioma grade.
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Affiliation(s)
- Nan Zhang
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Anhui, Hefei, China.,Glioma Surgery Division, Neurologic Surgery Department, Huashan Hospital, Fudan University, Shanghai, China
| | - Binke Yuan
- Institute for Brain Research and Rehabilitation, South China Normal University, Guangzhou, China.,Key Laboratory of Brain, Cognition and Education Sciences (South China Normal University), Ministry of Education, Guangzhou, China.,Center for Language and Brain, Shenzhen Institute of Neuroscience, Shenzhen, China
| | - Jing Yan
- Department of MRI , The First Affiliated Hospital of Zhengzhou University , Zhengzhou, China
| | - Jingliang Cheng
- Department of MRI , The First Affiliated Hospital of Zhengzhou University , Zhengzhou, China
| | - Junfeng Lu
- Glioma Surgery Division, Neurologic Surgery Department, Huashan Hospital, Fudan University, Shanghai, China.
| | - Jinsong Wu
- Glioma Surgery Division, Neurologic Surgery Department, Huashan Hospital, Fudan University, Shanghai, China.,Institute of Brain-Intelligence Technology , Zhangjiang Lab, Shanghai, China
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26
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Negative motor responses to direct electrical stimulation: Behavioral assessment hides different effects on muscles. Cortex 2021; 137:194-204. [PMID: 33640851 DOI: 10.1016/j.cortex.2021.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/11/2020] [Accepted: 01/19/2021] [Indexed: 11/22/2022]
Abstract
A negative motor response (NMR) is defined as the inability to continue voluntary movements without losing consciousness when direct electrical stimulation (DES) is applied during awake neurosurgery. While visual inspection is most commonly used to define an NMR, the actual effect of stimulation on muscle activity has been neglected by recent neurosurgical literature. We show that behavioral assessment of NMRs hides different site-dependent effects on muscles as revealed by electromyography (EMG), describing ten cases of brain tumor patients undergoing awake neurosurgery while performing a hand-object manipulation task. DES-induced NMRs were assessed behaviorally and related to the underlying electromyographic recording. Quantitative analysis of motor unit recruitment and regularity between phasic muscle contractions was computed. We show that similar NMRs classified based on behavioral criteria can be associated with suppression, increased recruitment or mixed effects on ongoing hand muscles. In some cases, suppression of hand muscle activity is associated with involuntary recruitment of muscles not involved in the task. Interestingly, stimulation of behaviorally defined "negative areas" across the frontal and parietal lobes elicits different electromyographic patterns, depending on the stimulation site. This study provides novel preliminary background as to the heterogeneous profile of muscle activity during NMRs. In fact, EMG monitoring paired with behavioral assessment can distinguish between NMRs that, despite similarity on behavioral inspection, are different in their related EMG, possibly underlying different neural substrates. The identification of different circuits hidden in similar NMRs may become relevant when planning the extension of resection.
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27
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Amoruso L, Geng S, Molinaro N, Timofeeva P, Gisbert-Muñoz S, Gil-Robles S, Pomposo I, Quiñones I, Carreiras M. Oscillatory and structural signatures of language plasticity in brain tumor patients: A longitudinal study. Hum Brain Mapp 2020; 42:1777-1793. [PMID: 33368838 PMCID: PMC7978121 DOI: 10.1002/hbm.25328] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 12/29/2022] Open
Abstract
Recent evidence suggests that damage to the language network triggers its functional reorganization. Yet, the spectro‐temporal fingerprints of this plastic rearrangement and its relation to anatomical changes is less well understood. Here, we combined magnetoencephalographic recordings with a proxy measure of white matter to investigate oscillatory activity supporting language plasticity and its relation to structural reshaping. First, cortical dynamics were acquired in a group of healthy controls during object and action naming. Results showed segregated beta (13–28 Hz) power decreases in left ventral and dorsal pathways, in a time‐window associated to lexico‐semantic processing (~250–500 ms). Six patients with left tumors invading either ventral or dorsal regions performed the same naming task before and 3 months after surgery for tumor resection. When longitudinally comparing patients' responses we found beta compensation mimicking the category‐based segregation showed by controls, with ventral and dorsal damage leading to selective compensation for object and action naming, respectively. At the structural level, all patients showed preoperative changes in white matter tracts possibly linked to plasticity triggered by tumor growth. Furthermore, in some patients, structural changes were also evident after surgery and showed associations with longitudinal changes in beta power lateralization toward the contralesional hemisphere. Overall, our findings support the existence of anatomo‐functional dependencies in language reorganization and highlight the potential role of oscillatory markers in tracking longitudinal plasticity in brain tumor patients. By doing so, they provide valuable information for mapping preoperative and postoperative neural reshaping and plan surgical strategies to preserve language function and patient's quality of life.
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Affiliation(s)
- Lucia Amoruso
- Basque Center on Cognition, Brain and Language (BCBL), San Sebastian, Spain.,IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
| | - Shuang Geng
- Basque Center on Cognition, Brain and Language (BCBL), San Sebastian, Spain.,University of the Basque Country, UPV/EHU, Bilbao, Spain
| | - Nicola Molinaro
- Basque Center on Cognition, Brain and Language (BCBL), San Sebastian, Spain.,IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
| | - Polina Timofeeva
- Basque Center on Cognition, Brain and Language (BCBL), San Sebastian, Spain.,University of the Basque Country, UPV/EHU, Bilbao, Spain
| | - Sandra Gisbert-Muñoz
- Basque Center on Cognition, Brain and Language (BCBL), San Sebastian, Spain.,University of the Basque Country, UPV/EHU, Bilbao, Spain
| | - Santiago Gil-Robles
- Department of Neurosurgery, Hospital Quiron, Madrid, Spain.,BioCruces Research Institute, Bilbao, Spain
| | | | - Ileana Quiñones
- Basque Center on Cognition, Brain and Language (BCBL), San Sebastian, Spain
| | - Manuel Carreiras
- Basque Center on Cognition, Brain and Language (BCBL), San Sebastian, Spain.,IKERBASQUE, Basque Foundation for Science, Bilbao, Spain.,University of the Basque Country, UPV/EHU, Bilbao, Spain
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28
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Isolan GR, Campero A, Ajler PM, Farina EM, Frigeri TM, Dini LI. El lóbulo de la ínsula: Parte 2 - anatomía microquirúrgica y correlación clínico-quirúrgica. Surg Neurol Int 2020. [DOI: 10.25259/sni_679_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El conocimiento profundo de la anatomía microquirúrgica del lóbulo de la ínsula es crucial para operar pacientes con tumores en esta región. El objetivo de la segunda parte de este estudio es correlacionar la anatomía microquirúrgica con casos ilustrativos retirados de nuestra casuística de 35 pacientes en los cuales fueron realizados 44 cirugías de tumores en relación con el lóbulo de la ínsula.
Métodos:
A lo largo de marzo de 2007 y agosto de 2014, 44 microcirugías fueron realizadas en 35 pacientes portadores de tumores insulares y los hallazgos de las cirugías y mapeo cerebral se correlacionaron con la anatomía microquirúrgica.
Resultados:
De una serie de 44 pacientes con tumores de la ínsula, la mayoría de los casos eran gliomas de bajo grado de malignidad (29 casos). El inicio de los síntomas en 34 pacientes fue epilepsia, siendo esta refractaria al tratamiento medicamentoso en 12 casos. El grado de resección fue subtotal o total en la mayoría de los casos de la serie. La mejoría en la calidad de vida (epilepsia, etc.) estuvo presente en más de la mitad de los pacientes. El dé cit neurológico permanente estuvo presente en tres pacientes.
Conclusión:
En los tumores insulares, es tan importante el conocimiento profundo de la anatomía, como el saber utilizar e interpretar en tiempo real las observaciones de la monitorización neuro siológica intraoperatoria.
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Affiliation(s)
- Gustavo Rassier Isolan
- Department of Surgery, The Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul, Brazil,
| | - Alvaro Campero
- Department of Neurosurgery, Hospital Padila, Country Las Yungas, Yerba Buena, Tucumán,
| | - Pablo Marcelo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Perón, Buenos Aires, Argentina,
| | - Edgar Manuel Farina
- Serviço de Neurocirurgia, Hospital Ministro Costa Cavalcanti Sanatório Le Blanc, Rua Joao Rouver, Foz do Iguaçu, Parana,
| | - Thomas More Frigeri
- Department of Neurosurgery, Pontifical Catholic University of Rio Grande do Sul, Luciana de Abreu, Porto Alegre,
| | - Leandro Infantini Dini
- Department of Neurosurgery, Center for Advanced Neurology and Neurosurgery, São Leopoldo, Rio Grande do Sul, Brazil
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29
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Lang S, Gan LS, McLennan C, Kirton A, Monchi O, Kelly JJP. Preoperative Transcranial Direct Current Stimulation in Glioma Patients: A Proof of Concept Pilot Study. Front Neurol 2020; 11:593950. [PMID: 33329346 PMCID: PMC7710969 DOI: 10.3389/fneur.2020.593950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/22/2020] [Indexed: 01/24/2023] Open
Abstract
Background: Transcranial direct current stimulation (tDCS) has been used extensively in patient populations to facilitate motor network plasticity. However, it has not been studied in patients with brain tumors. We aimed to determine the feasibility of a preoperative motor training and tDCS intervention in patients with glioma. In an exploratory manner, we assessed changes in motor network connectivity following this intervention and related these changes to predicted electrical field strength from the stimulated motor cortex. Methods: Patients with left-sided glioma (n=8) were recruited in an open label proof of concept pilot trial and participated in four consecutive days of motor training combined with tDCS. The motor training consisted of a 60-min period where the subject learned to play the piano with their right hand. Concurrently, they received 40 min of 2 mA anodal tDCS of the left motor cortex. Patients underwent task and resting state fMRI before and after this intervention. Changes in both the connectivity of primary motor cortex (M1) and general connectivity across the brain were assessed. Patient specific finite element models were created and the predicted electrical field (EF) resulting from stimulation was computed. The magnitude of the EF was extracted from left M1 and correlated to the observed changes in functional connectivity. Results: There were no adverse events and all subjects successfully completed the study protocol. Left M1 increased both local and global connectivity. Voxel-wide measures, not constrained by a specific region, revealed increased global connectivity of the frontal pole and decreased global connectivity of the supplementary motor area. The magnitude of EF applied to the left M1 correlated with changes in global connectivity of the right M1. Conclusion: In this proof of concept pilot study, we demonstrate for the first time that tDCS appears to be feasible in glioma patients. In our exploratory analysis, we show preoperative motor training combined with tDCS may alter sensorimotor network connectivity. Patient specific modeling of EF in the presence of tumor may contribute to understanding the dose-response relationship of this intervention. Overall, this suggests the possibility of modulating neural networks in glioma patients.
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Affiliation(s)
- Stefan Lang
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Non-invasive Neurostimulation Network, University of Calgary, Calgary, AB, Canada
| | - Liu Shi Gan
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Non-invasive Neurostimulation Network, University of Calgary, Calgary, AB, Canada
| | - Cael McLennan
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Adam Kirton
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Non-invasive Neurostimulation Network, University of Calgary, Calgary, AB, Canada
| | - Oury Monchi
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Non-invasive Neurostimulation Network, University of Calgary, Calgary, AB, Canada
| | - John J P Kelly
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada
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Duffau H. Can Non-invasive Brain Stimulation Be Considered to Facilitate Reoperation for Low-Grade Glioma Relapse by Eliciting Neuroplasticity? Front Neurol 2020; 11:582489. [PMID: 33304307 PMCID: PMC7693634 DOI: 10.3389/fneur.2020.582489] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 10/19/2020] [Indexed: 01/12/2023] Open
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 Glial Tumors, ” National Institute for Health and Medical Research (INSERM), U1191 Laboratory, Institute of Functional Genomics, University of Montpellier, Montpellier, France
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Intraoperative brain mapping of language, cognitive functions, and social cognition in awake surgery of low-grade gliomas located in the right non-dominant hemisphere. Clin Neurol Neurosurg 2020; 200:106363. [PMID: 33203593 DOI: 10.1016/j.clineuro.2020.106363] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 10/24/2020] [Accepted: 11/07/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of our study was to evaluate the usefulness of cortical-subcortical intraoperative brain mapping (ioBM) in resective awake surgery of low-grade gliomas (LGG) of the right non-dominant hemisphere (RndH). It was estimated how ioBM may affect both the extent of resection and postoperative outcome of language, spatial cognition, social cognition, and executive functions including attention and working memory. PATIENTS AND METHODS Fifteen patients that underwent ioBM in resective awake surgery of LGG located on the RndH, were included. A cohort of 15 patients with the same tumour location operated under general anaesthesia without brain mapping was used as control. Specific intraoperative tasks for each location were carried out and results registered. Neuropsychological assessment was performed preoperatively and at 6 months after surgery. RESULTS In the group of patients operated by using ioBM in awake surgery, an 86.66 % mean of resection was obtained compared to 60.33 % in the control group. Speech arrest and incorrect naming responses were elicited in higher proportion in frontal and insular locations. Parietal stimulation associated higher number of incorrect responses in social cognition task. Parietal and temporal stimulation were more frequently associated with incorrect performance of spatial cognition task. Parietal stimulation associated with higher frequency incorrect execution of attention and working memory tasks. After comparing clinical and neuropsychological results in both cohorts, worst outcome at 6 months was observed in the group of patients operated under general anaesthesia without brain mapping, especially in parietal and insular locations. CONCLUSIONS Intraoperative identification of language, cognitive functions, and social cognition of RndH by means of ioBM, can be of paramount importance in improving the extent of resection of low-grade gliomas and positively affects clinical and neuropsychological outcome at six months.
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Isolan GR, Campero A, Ajler P, Farina EM, Frigeri TM, Dini LI. Parte I: Anatomía microquirúrgica tridimensional de la ínsula. Surg Neurol Int 2020. [DOI: 10.25259/sni_557_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El lóbulo de la ínsula, o ínsula, se encuentra oculto en la super cie lateral del cerebro. La ínsula está localizada profundamente en el surco lateral o cisura silviana, recubierta por los opérculos frontal, parietal y temporal. Estudiar la compleja anatomía del lóbulo de la ínsula, una de las regiones de mayor complejidad quirúrgica del cerebro humano, y su correlación anatómica con casos quirúrgicos.
Métodos:
En la primera parte de este estudio presentamos los resultados de nuestras disecciones microquirúrgicas en fotografías 2 D y 3D; en la segunda parte de nuestro trabajo, la correlación anatómica con una serie de 44 cirugías en pacientes con tumores de la ínsula, principalmente gliomas, operados entre 2007 y 2014.
Resultados:
Extenso conjunto de bras subcorticales, incluyendo el fascículo uncinado, fronto-occipital inferior y el fascículo arcuato, conectan la ínsula a las regiones vecinas. Varias estructuras anatómicas responsables por dé cits neurológicos severos están íntimamente relacionadas con la cirugía de la ínsula, tales como lesiones de la arteria cerebral Media, cápsula interna, áreas del lenguaje en el hemisferio dominante y arterias lenticuloestriadas.
Conclusión:
El entrenamiento en laboratorio de neuroanatomía, estudio de material impreso en 3D, el conocimiento sobre neuro siología intra-operatoria y el uso de armamento neuroquirúrgico moderno son factores que in uencian en los resultados quirúrgicos.
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Affiliation(s)
- Gustavo Rassier Isolan
- Department of Surgery, Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul, Brazil,
| | - Alvaro Campero
- Department of Neurosurgery, Hospital Padilla, Country Las Yungas, Yerba Buena, Tucumuán, Argentina,
| | - Pablo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Peron, Buenos Aires, Argentina,
| | - Edgar Manuel Farina
- Department of Serviço de Neurocirurgia, Hospital Ministro Costa Cavalcanti Sanatório Le Blanc, Foz do Iguacu, Paraná, Brazil,
| | - Thomas More Frigeri
- Department of Neurosurgery, Pontificical Catholic University of Rio Grande do Sul, Porto Alegre,
| | - Leandro Infantini Dini
- Department of Neurosurgery, Center for Advanced Neurology and Neurosurgery, São Leopoldo, Rio Grande do Sul, Brazil
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Prat-Acín R, Galeano-Senabre I, López-Ruiz P, García-Sánchez D, Ayuso-Sacido A, Espert-Tortajada R. Intraoperative brain mapping during awake surgery in symptomatic supratentorial cavernomas. Neurocirugia (Astur) 2020; 32:S1130-1473(20)30105-6. [PMID: 33060022 DOI: 10.1016/j.neucir.2020.07.004] [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: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Complete resection of symptomatic supratentorial cavernoma (SCA) and removal of the surrounding gliotic area is recommended to minimize the risk of persistent seizures or (re)bleeding. Surgery of SCA located in an eloquent area, can carry out severe postoperative neurological morbidity. We report a study aimed to assess feasibility, extent of resection and outcome after surgical removal of CA by cortico-subcortical intraoperative brain stimulation (ioBS) in the awake patient. METHODS Six patients diagnosed of symptomatic SCA located on an eloquent area and operated on while awake under local anaesthesia ioBS, were included. Preoperative planning included neuropsychologic assessment of language-related functions, sociocognitive functions and executive functions. Intraoperatively, we recorded the results achieved in the planned neuropsychological tasks when stimulation was applied (cortical and subcortical). Postoperative control 3D MRI was scheduled at 1 month after surgery to calculate extent of resection. Neuropsychological assessment at 6 months after surgery was performed in all cases. RESULTS Six patients (5 females, 1 male) aged 24-48 years were included in our study. Locations of the lesions were right insular (n=1), left insular (n=1), left temporo-insular (n=1), left temporal (n=2) and left frontal (n=1). In all patients, positive findings were obtained during ioBS. In 5 patients, complete surgical resection was achieved. Two patients had postoperative transient neurological deficits, one case of hemiparesis, one case of dysnomia, both cleared over a 6-month period. Clinical follow-up revealed that all patients experienced complete recovery from preoperative symptoms within a year and five patients with seizures showed marked improvement and eventually quit antiepileptic drugs. Neuropsychological assessment at 6 months provided normal results compared to preoperative baseline in all domains. CONCLUSIONS Our study suggests that ioBS in the awake surgery of symptomatic SCA located in eloquent areas, allows to increase the rate of complete resection, minimizing postoperative neurological and neuropsychological deficit, and improving postoperative seizures control.
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Affiliation(s)
- Ricardo Prat-Acín
- Servicio de Neurocirugía. Hospital Universitario I Politècnic La Fe, Valencia, Spain; Unidad Mixta Nanomedicina y Sensores: Fundación Hospital La Fe, Universidad Politécnica de Valencia, Spain.
| | - Inma Galeano-Senabre
- Servicio de Neurocirugía. Hospital Universitario I Politècnic La Fe, Valencia, Spain; Unidad Mixta Nanomedicina y Sensores: Fundación Hospital La Fe, Universidad Politécnica de Valencia, Spain
| | | | - Daniel García-Sánchez
- Servicio de Neurocirugía. Hospital Universitario I Politècnic La Fe, Valencia, Spain
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de la Peña MJ, Gil-Robles S, de Vega VM, Aracil C, Acevedo A, Rodríguez MR. A Practical Approach to Imaging of the Supplementary Motor Area and Its Subcortical Connections. Curr Neurol Neurosci Rep 2020; 20:50. [PMID: 32930895 DOI: 10.1007/s11910-020-01070-2] [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] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW First, an anatomical and functional review of these cortical areas and subcortical connections with T-fMRI and tractography techniques; second, to demonstrate the value of this approach in neurosurgical planning in a series of patients with tumors close to the SMA. RECENT FINDINGS Implications in language and cognitive networks with a clear hemispheric lateralization of these SMA/pre-SMA. The recommendation of the use of the advanced neuroimaging studies for surgical planning and preservation of these areas. The SMA/pre-SMA and their subcortical connections are functional areas to be taken into consideration in neurosurgical planning. These areas would be involved in the control/inhibition of movement, in verbal expression and fluency and in tasks of cognitive control capacity. Its preservation is key to the patient's postsurgical cognitive and functional evolution.
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Affiliation(s)
- Mar Jiménez de la Peña
- Department of Radiology, Hospital Universitario QuironSalud Madrid, C/ Diego de Velázquez 1, Pozuelo de Alarcón, 28223, Madrid, Spain.
| | - Santiago Gil-Robles
- Department of Neurosurgery, Hospital Universitario QuironSalud Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Vicente Martínez de Vega
- Department of Radiology, Hospital Universitario QuironSalud Madrid, C/ Diego de Velázquez 1, Pozuelo de Alarcón, 28223, Madrid, Spain
| | - Cristina Aracil
- Department of Neurosurgery, Hospital Universitario QuironSalud Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Agustín Acevedo
- Department of Pathology, Hospital Universitario QuironSalud Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Manuel Recio Rodríguez
- Department of Radiology, Hospital Universitario QuironSalud Madrid, C/ Diego de Velázquez 1, Pozuelo de Alarcón, 28223, Madrid, Spain
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Cargnelutti E, Ius T, Skrap M, Tomasino B. What do we know about pre- and postoperative plasticity in patients with glioma? A review of neuroimaging and intraoperative mapping studies. NEUROIMAGE-CLINICAL 2020; 28:102435. [PMID: 32980599 PMCID: PMC7522801 DOI: 10.1016/j.nicl.2020.102435] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 02/06/2023]
Abstract
Brain reorganization can take place before and after surgery of low- and high-grade gliomas. Plasticity is observed for low-grade but also for high-grade gliomas. The contralesional hemisphere can be vital for successful compensation. There is evidence of plasticity for both the language system and the sensorimotor system. Partial compensation can also occur at the white-matter level. Subcortical connectivity is crucial for brain reorganization.
Brain plasticity potential is a central theme in neuro-oncology and is currently receiving increased attention. Advances in treatment have prolonged life expectancy in neuro-oncological patients and the long-term preservation of their quality of life is, therefore, a new challenge. To this end, a better understanding of brain plasticity mechanisms is vital as it can help prevent permanent deficits following neurosurgery. Indeed, reorganization processes can be fundamental to prevent or recover neurological and cognitive deficits by reallocating brain functions outside the lesioned areas. According to more recent studies in the literature, brain reorganization taking place following neurosurgery is associated with good neurofunctioning at follow-up. Interestingly, in the last few years, the number of reports on plasticity has notably increased. Aim of the current review was to provide a comprehensive overview of pre- and postoperative neuroplasticity patterns. Within this framework, we aimed to shed light on some tricky issues, including i) involvement of the contralateral healthy hemisphere, ii) role and potential changes of white matter and connectivity patterns, and iii) reorganization in low- versus high-grade gliomas. We finally discussed the practical implications of these aspects and role of additional potentially relevant factors to be explored. Final purpose was to provide a guideline helpful in promoting increase in the extent of tumor resection while preserving the patients’ neurological and cognitive functioning.
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Affiliation(s)
- Elisa Cargnelutti
- Scientific Institute, IRCCS E. Medea, Dipartimento/Unità Operativa Pasian di Prato, Udine, Italy
| | - Tamara Ius
- SOC Neurochirurgia, Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Italy
| | - Miran Skrap
- SOC Neurochirurgia, Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Italy
| | - Barbara Tomasino
- Scientific Institute, IRCCS E. Medea, Dipartimento/Unità Operativa Pasian di Prato, Udine, Italy.
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Duffau H. Functional Mapping before and after Low-Grade Glioma Surgery: A New Way to Decipher Various Spatiotemporal Patterns of Individual Neuroplastic Potential in Brain Tumor Patients. Cancers (Basel) 2020; 12:E2611. [PMID: 32933174 PMCID: PMC7565450 DOI: 10.3390/cancers12092611] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/07/2020] [Accepted: 09/11/2020] [Indexed: 12/21/2022] Open
Abstract
Intraoperative direct electrostimulation mapping (DEM) is currently the gold-standard for glioma surgery, since functional-based resection allows an optimization of the onco-functional balance (increased resection with preserved quality of life). Besides intrasurgical awake mapping of conation, cognition, and behavior, preoperative mapping by means of functional neuroimaging (FNI) and transcranial magnetic stimulation (TMS) has increasingly been utilized for surgical selection and planning. However, because these techniques suffer from several limitations, particularly for direct functional mapping of subcortical white matter pathways, DEM remains crucial to map neural connectivity. On the other hand, non-invasive FNI and TMS can be repeated before and after surgical resection(s), enabling longitudinal investigation of brain reorganization, especially in slow-growing tumors like low-grade gliomas. Indeed, these neoplasms generate neuroplastic phenomena in patients with usually no or only slight neurological deficits at diagnosis, despite gliomas involving the so-called "eloquent" structures. Here, data gained from perioperative FNI/TMS mapping methods are reviewed, in order to decipher mechanisms underpinning functional cerebral reshaping induced by the tumor and its possible relapse, (re)operation(s), and postoperative rehabilitation. Heterogeneous spatiotemporal patterns of rearrangement across patients and in a single patient over time have been evidenced, with structural changes as well as modifications of intra-hemispheric (in the ipsi-lesional and/or contra-lesional hemisphere) and inter-hemispheric functional connectivity. Such various fingerprints of neural reconfiguration were correlated to different levels of cognitive compensation. Serial multimodal studies exploring neuroplasticity might lead to new management strategies based upon multistage therapeutic approaches adapted to the individual profile of functional reallocation.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Montpellier University Medical Center, 34295 Montpellier, France; ; Tel.: +33-4-67-33-66-12; Fax: +33-4-67-33-69-12
- Institute of Functional Genomics, INSERM U-1191, University of Montpellier, 34298 Montpellier, France
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37
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Bulubas L, Sardesh N, Traut T, Findlay A, Mizuiri D, Honma SM, Krieg SM, Berger MS, Nagarajan SS, Tarapore PE. Motor Cortical Network Plasticity in Patients With Recurrent Brain Tumors. Front Hum Neurosci 2020; 14:118. [PMID: 32317952 PMCID: PMC7146050 DOI: 10.3389/fnhum.2020.00118] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/16/2020] [Indexed: 12/15/2022] Open
Abstract
Objective: The adult brain’s potential for plastic reorganization is an important mechanism for the preservation and restoration of function in patients with primary glial neoplasm. Patients with recurrent brain tumors requiring multiple interventions over time present an opportunity to examine brain reorganization. Magnetoencephalography (MEG) is a noninvasive imaging modality that can be used for motor cortical network mapping which, when performed at regular intervals, offers insight into this process of reorganization. Utilizing MEG-based motor mapping, we sought to characterize the reorganization of motor cortical networks over time in a cohort of 78 patients with recurrent glioma. Methods: MEG-based motor cortical maps were obtained by measuring event-related desynchronization (ERD) in ß-band frequency during unilateral index finger flexion. Each patient presented at our Department at least on two occasions for tumor resection due to tumor recurrence, and MEG-based motor mapping was performed as part of preoperative assessment before each surgical resection. Whole-brain activation patterns from first to second MEG scan (obtained before first and second surgery) were compared. Additionally, we calculated distances of activation peaks, which represent the location of the primary motor cortex (MC), to determine the magnitude of movement in motor eloquent areas between the first and second MEG scan. We also explored which demographic, anatomic, and pathological factors influence these shifts. Results: The whole-brain activation motor maps showed a subtle movement of the primary MC from first to second timepoint, as was confirmed by the determination of motor activation peaks. The shift of ipsilesional MC was directly correlated with a frontal-parietal tumor location (p < 0.001), presence of motor deficits (p = 0.021), and with a longer period between MEG scans (p = 0.048). Also, a disengagement of wide areas in the contralesional (ipsilateral to finger movement) hemisphere at the second time point was observed. Conclusions: MEG imaging is a sensitive method for depicting the plasticity of the motor cortical network. Although the location of the primary MC undergoes only subtle changes, appreciable shifts can occur in the setting of a stronger and longer impairment of the tumor on the MC. The ipsilateral hemisphere may serve as a reservoir for functional recovery.
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Affiliation(s)
- Lucia Bulubas
- Biomagnetic Imaging Lab, Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurosurgery and TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität (TU), Munich, Germany.,Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians Universität (LMU), Munich, Germany.,International Max Planck Research School for Translational Psychiatry (IMPRS-TP), Munich, Germany
| | - Nina Sardesh
- Biomagnetic Imaging Lab, Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Tavish Traut
- Biomagnetic Imaging Lab, Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Anne Findlay
- Biomagnetic Imaging Lab, Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Danielle Mizuiri
- Biomagnetic Imaging Lab, Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Susanne M Honma
- Biomagnetic Imaging Lab, Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Sandro M Krieg
- Department of Neurosurgery and TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität (TU), Munich, Germany
| | - Mitchel S Berger
- Biomagnetic Imaging Lab, Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Srikantan S Nagarajan
- Biomagnetic Imaging Lab, Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Phiroz E Tarapore
- Biomagnetic Imaging Lab, Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, CA, United States.,Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
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Lizarazu M, Gil-Robles S, Pomposo I, Nara S, Amoruso L, Quiñones I, Carreiras M. Spatiotemporal dynamics of postoperative functional plasticity in patients with brain tumors in language areas. BRAIN AND LANGUAGE 2020; 202:104741. [PMID: 31931399 DOI: 10.1016/j.bandl.2019.104741] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 12/17/2019] [Accepted: 12/27/2019] [Indexed: 06/10/2023]
Abstract
Postoperative functional neuroimaging provides a unique opportunity to investigate the neural mechanisms that facilitate language network reorganization. Previous studies in patients with low grade gliomas (LGGs) in language areas suggest that postoperative recovery is likely due to functional neuroplasticity in peritumoral and contra-tumoral healthy regions, but have attributed varying degrees of importance to specific regions. In this study, we used Magnetoencephalography (MEG) to investigate functional connectivity changes in peritumoral and contra-tumoral regions after brain tumor resection. MEG recordings of cortical activity during resting-state were obtained from 12 patients with LGGs in left-hemisphere language brain areas. MEG data were recorded before (Pre session), and 3 (Post_1 session) and 6 (Post_2 session) months after awake craniotomy. For each MEG session, we measured the functional connectivity of the peritumoral and contra-tumoral regions to the rest of the brain across the 1-100 Hz frequency band. We found that functional connectivity in the Post_1 and Post_2 sessions was higher than in the Pre session only in peritumoral regions and within the alpha frequency band. Functional connectivity in peritumoral regions did not differ between the Post_1 and Post_2 sessions. Alpha connectivity enhancement in peritumoral regions was observed in all patients regardless of the LGG location. Together, these results suggest that postoperative language functional reorganization occurs in peritumoral regions regardless of the location of the tumor and mostly develops within 3 months after surgery.
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Affiliation(s)
- Mikel Lizarazu
- BCBL, Basque Center on Cognition, Brain and Language, Donostia/San Sebastián, Spain; Laboratoire de Sciences Cognitives et Psycholinguistique (ENS, EHESS, CNRS), Ecole Normale Supérieure, PSL Research University, Paris, France.
| | - Santiago Gil-Robles
- Department of Neurosurgery, Hospital Quirón, Madrid, Spain; BioCruces Research Institute, Bilbao, Spain
| | | | - Sanjeev Nara
- BCBL, Basque Center on Cognition, Brain and Language, Donostia/San Sebastián, Spain
| | - Lucía Amoruso
- BCBL, Basque Center on Cognition, Brain and Language, Donostia/San Sebastián, Spain
| | - Ileana Quiñones
- BCBL, Basque Center on Cognition, Brain and Language, Donostia/San Sebastián, Spain
| | - Manuel Carreiras
- BCBL, Basque Center on Cognition, Brain and Language, Donostia/San Sebastián, Spain; Ikerbasque, Basque Foundation for Science, Bilbao, Spain; University of the Basque Country, UPV/EHU, Bilbao, Spain
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Yang X, Lin Y. Surgical resection of glioma involving eloquent brain areas: Tumor boundary, functional boundary, and plasticity consideration. GLIOMA 2020. [DOI: 10.4103/glioma.glioma_16_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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40
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Role of Functional Imaging Techniques to Assess Motor and Language Cortical Plasticity in Glioma Patients: A Systematic Review. Neural Plast 2019; 2019:4056436. [PMID: 31814822 PMCID: PMC6878806 DOI: 10.1155/2019/4056436] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/05/2019] [Indexed: 01/19/2023] Open
Abstract
Cerebral plasticity is the ability of the central nervous system to reorganize itself in response to different injuries. The reshaping of functional areas is a crucial mechanism to compensate for damaged function. It is acknowledged that functional remodeling of cortical areas may occur also in glioma patients. Principal limits of previous investigations on cortical plasticity of motor and language functions included scarce reports of longitudinal evaluations and limited sample sizes. This systematic review is aimed at elucidating cortical brain plasticity for motor and language functions, in adult glioma patients, by means of preoperative and intraoperative mapping techniques. We systematically reviewed the literature for prospective studies, assessing cortical plasticity of motor and language functions in low-grade and high-grade gliomas. Eight longitudinal studies investigated cortical plasticity, evaluated by motor and language task-based functional MRI (fMRI), motor navigated transcranial magnetic stimulation (n-TMS), and intraoperative mapping with cortical direct electrocortical stimulation (DES) of language and motor function. Motor function reorganization appeared relatively limited and mostly characterized by intrahemispheric functional changes, including secondary motor cortices. On the other hand, a high level of functional reshaping was found for language function in DES studies. Occurrence of cortical functional reorganization of language function was described focusing on the intrahemispheric recruitment of perilesional areas. However, the association between these functional patterns and recovery of motor and language deficits still remains partially clear. A number of relevant methodological issues possibly affecting the finding generalization emerged, such as the complexity of plasticity outcome measures and the lack of large longitudinal studies. Future studies are required to further confirm these evidences on cortical plasticity in larger samples, combining both functional imaging and intraoperative mapping techniques in longitudinally evaluations.
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Yuan B, Zhang N, Yan J, Cheng J, Lu J, Wu J. Resting-state functional connectivity predicts individual language impairment of patients with left hemispheric gliomas involving language network. NEUROIMAGE-CLINICAL 2019; 24:102023. [PMID: 31693978 PMCID: PMC6838935 DOI: 10.1016/j.nicl.2019.102023] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/05/2019] [Accepted: 09/27/2019] [Indexed: 01/26/2023]
Abstract
Language deficits following brain tumors should consider the dynamic interactions between different tumor growth kinetics and functional network reorganization. We measured the resting-state functional connectivity of 126 patients with left cerebral gliomas involving language network areas, including 77 patients with low-grade gliomas (LGG) and 49 patients with high-grade gliomas (HGG). Functional network mapping for language was performed by construction of a multivariate machine learning-based prediction model of individual aphasia quotient (AQ), a summary score that indicates overall severity of language impairment. We found that the AQ scores for HGG patients were significantly lower than those of LGG patients. The prediction accuracy of HGG patients (R2 = 0.27, permutation P = 0.007) was much higher than that of LGG patients (R2 = 0.09, permutation P = 0.032). The rsFC regions predictive of LGG's AQ involved the bilateral frontal, temporal, and parietal lobes, subcortical regions, and bilateral cerebro-cerebellar connections, mainly in regions belonging to the canonical language network. The functional network of language processing for HGG patients showed strong dependence on connections of the left cerebro-cerebellar connections, limbic system, and the temporal, occipital, and prefrontal lobes. Together, our findings suggested that individual language processing of glioma patients links large-scale, bilateral, cortico-subcortical, and cerebro-cerebellar functional networks with different network reorganizational mechanisms underlying the different levels of language impairments in LGG and HGG patients.
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Affiliation(s)
- Binke Yuan
- Center for Language and Brain, Shenzhen Institute of Neuroscience, Shenzhen, China
| | - Nan Zhang
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China; Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing Yan
- Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingliang Cheng
- Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junfeng Lu
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jinsong Wu
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Image Computing and Computer Assisted Intervention, Shanghai, China.
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Characterising neural plasticity at the single patient level using connectivity fingerprints. NEUROIMAGE-CLINICAL 2019; 24:101952. [PMID: 31357148 PMCID: PMC6664196 DOI: 10.1016/j.nicl.2019.101952] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/11/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
Abstract
The occurrence of wide-scale neuroplasticity in the injured human brain raises hopes for biomarkers to guide personalised treatment. At the individual level, functional reorganisation has proven challenging to quantify using current techniques that are optimised for population-based analyses. In this cross-sectional study, we acquired functional MRI scans in 44 patients (22 men, 22 women, mean age: 39.4 ± 14 years) with a language-dominant hemisphere brain tumour prior to surgery and 23 healthy volunteers (11 men, 12 women, mean age: 36.3 ± 10.9 years) during performance of a verbal fluency task. We applied a recently developed approach to characterise the normal range of functional connectivity patterns during task performance in healthy controls. Next, we statistically quantified differences from the normal in individual patients and evaluated factors driving these differences. We show that the functional connectivity of brain regions involved in language fluency identifies “fingerprints” of brain plasticity in individual patients, not detected using standard task-evoked analyses. In contrast to healthy controls, patients with a tumour in their language dominant hemisphere showed highly variable fingerprints that uniquely distinguished individuals. Atypical fingerprints were influenced by tumour grade and tumour location relative to the typical fluency-activated network. Our findings show how alterations in brain networks can be visualised and statistically quantified from connectivity fingerprints in individual brains. We propose that connectivity fingerprints offer a statistical metric of individually-specific network organisation through which behaviourally-relevant adaptations could be formally quantified and monitored across individuals, treatments and time. Personalised treatment awaits individualised measures of brain adaptation. Connectivity patterns from FMRI offer unique “fingerprints” of brain networks. Individual brain tumours disrupt the language fluency network in unique ways. By fingerprint matching, networks can be tested and visualised in single patients.
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Paľa A, Coburger J, Scherer M, Ahmeti H, Roder C, Gessler F, Jungk C, Scheuerle A, Senft C, Tatagiba M, Synowitz M, Wirtz CR, Schmitz B, Unterberg AW. To treat or not to treat? A retrospective multicenter assessment of survival in patients with IDH-mutant low-grade glioma based on adjuvant treatment. J Neurosurg 2019; 133:273-280. [PMID: 31323633 DOI: 10.3171/2019.4.jns183395] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The level of evidence for adjuvant treatment of diffuse WHO grade II glioma (low-grade glioma, LGG) is low. In so-called "high-risk" patients most centers currently apply an early aggressive adjuvant treatment after surgery. The aim of this assessment was to compare progression-free survival (PFS) and overall survival (OS) in patients receiving radiation therapy (RT) alone, chemotherapy (CT) alone, or a combined/consecutive RT+CT, with patients receiving no primary adjuvant treatment after surgery. METHODS Based on a retrospective multicenter cohort of 288 patients (≥ 18 years old) with diffuse WHO grade II gliomas, a subgroup analysis of patients with a confirmed isocitrate dehydrogenase (IDH) mutation was performed. The influence of primary adjuvant treatment after surgery on PFS and OS was assessed using Kaplan-Meier estimates and multivariate Cox regression models, including age (≥ 40 years), complete tumor resection (CTR), recurrent surgery, and astrocytoma versus oligodendroglioma. RESULTS One hundred forty-four patients matched the inclusion criteria. Forty patients (27.8%) received adjuvant treatment. The median follow-up duration was 6 years (95% confidence interval 4.8-6.3 years). The median overall PFS was 3.9 years and OS 16.1 years. PFS and OS were significantly longer without adjuvant treatment (p = 0.003). A significant difference in favor of no adjuvant therapy was observed even in high-risk patients (age ≥ 40 years or residual tumor, 3.9 vs 3.1 years, p = 0.025). In the multivariate model (controlled for age, CTR, oligodendroglial diagnosis, and recurrent surgery), patients who received no adjuvant therapy showed a significantly positive influence on PFS (p = 0.030) and OS (p = 0.009) compared to any other adjuvant treatment regimen. This effect was most pronounced if RT+CT was applied (p = 0.004, hazard ratio [HR] 2.7 for PFS, and p = 0.001, HR 20.2 for OS). CTR was independently associated with longer PFS (p = 0.019). Age ≥ 40 years, histopathological diagnosis, and recurrence did not achieve statistical significance. CONCLUSIONS In this series of IDH-mutated LGGs, adjuvant treatment with RT, CT with temozolomide (TMZ), or the combination of both showed no significant advantage in terms of PFS and OS. Even in high-risk patients, the authors observed a similar significantly negative impact of adjuvant treatment on PFS and OS. These results underscore the importance of a CTR in LGG. Whether patients ≥ 40 years old should receive adjuvant treatment despite a CTR should be a matter of debate. A potential tumor dedifferentiation by administration of early TMZ, RT, or RT+CT in IDH-mutated LGG should be considered. However, these data are limited by the retrospective study design and the potentially heterogeneous indication for adjuvant treatment.
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Affiliation(s)
| | | | | | - Hajrullah Ahmeti
- 3Department of Neurosurgery, University of Schleswig-Holstein, Kiel
| | | | - Florian Gessler
- 5Department of Neurosurgery, University of Frankfurt, Germany
| | | | | | - Christian Senft
- 5Department of Neurosurgery, University of Frankfurt, Germany
| | | | - Michael Synowitz
- 3Department of Neurosurgery, University of Schleswig-Holstein, Kiel
| | | | - Bernd Schmitz
- 7Department of Radiology, Section of Neuroradiology, University of Ulm, Günzburg
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Ille S, Engel L, Albers L, Schroeder A, Kelm A, Meyer B, Krieg SM. Functional Reorganization of Cortical Language Function in Glioma Patients-A Preliminary Study. Front Oncol 2019; 9:446. [PMID: 31231608 PMCID: PMC6558431 DOI: 10.3389/fonc.2019.00446] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/10/2019] [Indexed: 11/24/2022] Open
Abstract
Background: Functional reorganization (FR) was shown in glioma patients by direct electrical stimulation (DES) during awake craniotomy. This option for repeated mapping is available in cases of tumor recurrence and after decision for a second surgery. Navigated repetitive transcranial magnetic stimulation (nrTMS) has shown a high correlation with results of DES during awake craniotomy for language-negative sites (LNS) and allows for a non-invasive evaluation of language function. This preliminary study aims to examine FR in glioma patients by nrTMS. Methods: A cohort of eighteen patients with left-sided perisylvian gliomas underwent preoperative nrTMS language mapping twice. The mean time between mappings was 17 ± 12 months. The cortex was separated into anterior and posterior language-eloquent regions. We defined a tumor area and an area without tumor (WOT). Error rates (ER = number of errors per number of stimulations) and hemispheric dominance ratios (HDR) were calculated as the quotient of the left- and right-sided ER. Results: In cases in which most language function was located near the tumor during the first mapping, we found significantly more LNS in the tumor area during the second mapping as compared to cases in which function was not located near the tumor (p = 0.049). Patients with seizures showed fewer LNS during the second mapping. We found more changes of cortical language function in patients with a follow-up time of more than 13 months and lower WHO-graded tumors. Conclusion: Present results confirm that nrTMS can show FR of LNS in glioma patients. Its extent, clinical impact and correlation with DES requires further evaluation but could have a considerable impact in neuro-oncology.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
| | - Lara Engel
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
| | - Lucia Albers
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
| | - Anna Kelm
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Technische Universität München, Munich, Germany
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Freyschlag CF, Krieg SM, Kerschbaumer J, Pinggera D, Forster MT, Cordier D, Rossi M, Miceli G, Roux A, Reyes A, Sarubbo S, Smits A, Sierpowska J, Robe PA, Rutten GJ, Santarius T, Matys T, Zanello M, Almairac F, Mondot L, Jakola AS, Zetterling M, Rofes A, von Campe G, Guillevin R, Bagatto D, Lubrano V, Rapp M, Goodden J, De Witt Hamer PC, Pallud J, Bello L, Thomé C, Duffau H, Mandonnet E. Imaging practice in low-grade gliomas among European specialized centers and proposal for a minimum core of imaging. J Neurooncol 2018; 139:699-711. [PMID: 29992433 PMCID: PMC6132968 DOI: 10.1007/s11060-018-2916-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/29/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Imaging studies in diffuse low-grade gliomas (DLGG) vary across centers. In order to establish a minimal core of imaging necessary for further investigations and clinical trials in the field of DLGG, we aimed to establish the status quo within specialized European centers. METHODS An online survey composed of 46 items was sent out to members of the European Low-Grade Glioma Network, the European Association of Neurosurgical Societies, the German Society of Neurosurgery and the Austrian Society of Neurosurgery. RESULTS A total of 128 fully completed surveys were received and analyzed. Most centers (n = 96, 75%) were academic and half of the centers (n = 64, 50%) adhered to a dedicated treatment program for DLGG. There were national differences regarding the sequences enclosed in MRI imaging and use of PET, however most included T1 (without and with contrast, 100%), T2 (100%) and TIRM or FLAIR (20, 98%). DWI is performed by 80% of centers and 61% of centers regularly performed PWI. CONCLUSION A minimal core of imaging composed of T1 (w/wo contrast), T2, TIRM/FLAIR, PWI and DWI could be identified. All morphologic images should be obtained in a slice thickness of ≤ 3 mm. No common standard could be obtained regarding advanced MRI protocols and PET. IMPORTANCE OF THE STUDY We believe that our study makes a significant contribution to the literature because we were able to determine similarities in numerous aspects of LGG imaging. Using the proposed "minimal core of imaging" in clinical routine will facilitate future cooperative studies.
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Affiliation(s)
- Christian F Freyschlag
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Johannes Kerschbaumer
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | | | - Dominik Cordier
- Department of Neurosurgery, Universitätsspital Basel, Basel, Switzerland
| | - Marco Rossi
- Neurosurgical Oncology Unit, Humanitas Research Hospital, IRCCS, Milan, Italy
| | - Gabriele Miceli
- Center for Mind/Brain Sciences, University of Trento, Rovereto, Italy
| | - Alexandre Roux
- Department of Neurosurgery, Sainte-Anne Hospital, Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Inserm U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Andrés Reyes
- European Master's in Clinical Linguistics (EMCL), University of Groningen, Groningen, The Netherlands
- EMCL University of Potsdam, Potsdam, Germany
- Neuroscience Institute, and Laboratory of Experimental Psychology, Faculty of Psychology, El Bosque University, Bogotá, Colombia
| | - Silvio Sarubbo
- Division of Neurosurgery, Structural and Functional Connectivity Lab Project, "S. Chiara" Hospital, APSS, Trento, Italy
| | - Anja Smits
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Joanna Sierpowska
- Cognition and Brain Plasticity Unit, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
- Department of Cognition, Development and Education Psychology, Barcelona, Spain
| | - Pierre A Robe
- Department of Neurology and Neurosurgery, Rudolf Magnus Brain Institute, University Medical Center of Utrecht, Utrecht, The Netherlands
| | - Geert-Jan Rutten
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Thomas Santarius
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Tomasz Matys
- Department of Radiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Marc Zanello
- Department of Neurosurgery, Sainte-Anne Hospital, Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Inserm U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Fabien Almairac
- Neurosurgery Department, Hôpital Pasteur 2, University Hospital of Nice, Nice, France
| | - Lydiane Mondot
- Radiology Department, Hôpital Pasteur 2, University Hospital of Nice, Nice, France
| | - Asgeir S Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Maria Zetterling
- Department of Neurosurgery, Institution of Neuroscience, Uppsala University Hospital, Uppsala, Sweden
| | - Adrià Rofes
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
- Department of Cognitive Science, Johns Hopkins University, Baltimore, USA
| | - Gord von Campe
- Department of Neurosurgery, Medical University Graz, Graz, Austria
| | - Remy Guillevin
- DACTIM, UMR CNRS 7348, Université de Poitiers et CHU de Poitiers, Poitiers, France
| | - Daniele Bagatto
- Neuroradiology Department, University Hospital Santa Maria della Misericordia, Udine, Italy
| | - Vincent Lubrano
- Department of Neurosurgery, CHU Toulouse, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Marion Rapp
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - John Goodden
- Department of Neurosurgery, The General Infirmary at Leeds, Leeds, West Yorkshire, UK
| | | | - Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Inserm U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Lorenzo Bello
- Neurosurgical Oncology Unit, Humanitas Research Hospital, IRCCS, Milan, Italy
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier Medical University Center, Montpellier, France
- Institute of Neuroscience of Montpellier, INSERM U1051, University of Montpellier, Montpellier, France
| | - Emmanuel Mandonnet
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France
- University Paris 7, Paris, France
- IMNC, UMR 8165, Orsay, France
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Southwell DG, Birk HS, Han SJ, Li J, Sall JW, Berger MS. Resection of gliomas deemed inoperable by neurosurgeons based on preoperative imaging studies. J Neurosurg 2018; 129:567-575. [DOI: 10.3171/2017.5.jns17166] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVEMaximal safe resection is a primary objective in the management of gliomas. Despite this objective, surgeons and referring physicians may, on the basis of radiological studies alone, assume a glioma to be unresectable. Because imaging studies, including functional MRI, may not localize brain functions (such as language) with high fidelity, this simplistic approach may exclude some patients from what could be a safe resection. Intraoperative direct electrical stimulation (DES) allows for the accurate localization of functional areas, thereby enabling maximal resection of tumors, including those that may appear inoperable based solely on radiological studies. In this paper the authors describe the extent of resection (EOR) and functional outcomes following resections of tumors deemed inoperable by referring physicians and neurosurgeons.METHODSThe authors retrospectively examined the cases of 58 adult patients who underwent glioma resection within 6 months of undergoing a brain biopsy of the same lesion at an outside hospital. All patients exhibited unifocal supratentorial disease and preoperative Karnofsky Performance Scale scores ≥ 70. The EOR and 6-month functional outcomes for this population were characterized.RESULTSIntraoperative DES mapping was performed on 96.6% (56 of 58) of patients. Nearly half of the patients (46.6%, 27 of 58) underwent an awake surgical procedure with DES. Overall, the mean EOR was 87.6% ± 13.6% (range 39.0%–100%). Gross-total resection (resection of more than 99% of the preoperative tumor volume) was achieved in 29.3% (17 of 58) of patients. Subtotal resection (95%–99% resection) and partial resection (PR; < 95% resection) were achieved in 12.1% (7 of 58) and 58.6% (34 of 58) of patients, respectively. Of the cases that involved PR, the mean EOR was 79.4% ± 12.2%. Six months after surgery, no patient was found to have a new postoperative neurological deficit. The majority of patients (89.7%, 52 of 58) were free of neurological deficits both pre- and postoperatively. The remainder of patients exhibited either residual but stable deficits (5.2%, 3 of 58) or complete correction of preoperative deficits (5.2%, 3 of 58).CONCLUSIONSThe use of DES enabled maximal safe resections of gliomas deemed inoperable by referring neurosurgeons. With rare exceptions, tumor resectability cannot be determined solely by radiological studies.
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Affiliation(s)
| | - Harjus S. Birk
- 2School of Medicine, University of California, San Francisco, California
| | | | - Jing Li
- Departments of 1Neurological Surgery and
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Picart T, Herbet G, Moritz-Gasser S, Duffau H. Iterative Surgical Resections of Diffuse Glioma With Awake Mapping: How to Deal With Cortical Plasticity and Connectomal Constraints? Neurosurgery 2018; 85:105-116. [DOI: 10.1093/neuros/nyy218] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 04/28/2018] [Indexed: 01/17/2023] Open
Affiliation(s)
- Thiébaud Picart
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Guillaume Herbet
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Team “Plasticity of Central Nervous System, Stem Cells and Glial Tumors,” INSERM U1051, Institute for Neurosciences of Montpellier, Montpellier, France
| | - Sylvie Moritz-Gasser
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Team “Plasticity of Central Nervous System, Stem Cells and Glial Tumors,” INSERM U1051, Institute for Neurosciences of Montpellier, Montpellier, France
| | - Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Team “Plasticity of Central Nervous System, Stem Cells and Glial Tumors,” INSERM U1051, Institute for Neurosciences of Montpellier, Montpellier, France
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Duffau H. The error of Broca: From the traditional localizationist concept to a connectomal anatomy of human brain. J Chem Neuroanat 2018; 89:73-81. [DOI: 10.1016/j.jchemneu.2017.04.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 03/06/2017] [Accepted: 04/12/2017] [Indexed: 11/16/2022]
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Visualization of subcortical language pathways by diffusion tensor imaging fiber tracking based on rTMS language mapping. Brain Imaging Behav 2018; 11:899-914. [PMID: 27323766 DOI: 10.1007/s11682-016-9563-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diffusion tensor imaging fiber tracking (DTI FT) is used to visualize subcortical fiber tracts. Yet, there is no standard at hand to visualize language-involved subcortical fibers reliably. Thus, this study investigates the feasibility of using language-related cortical areas identified via repetitive navigated transcranial magnetic stimulation (rTMS) to seed DTI FT of subcortical language tracts. From 2011 to 2014, 37 patients with left-hemispheric perisylvian lesions were examined. Language-positive rTMS stimulation spots were integrated in the deterministic tractography software (BrainLAB, iPlanNet 3.0) as objects and used as seed regions for DTI FT. Tractography was then performed in each patient with 77 different combinations of fiber lengths (40 - 100 mm) and fractional anisotropy (FA; 0.01 - 0.5). The rTMS-based DTI FT identified all commonly known subcortical language tracts, such as the corticonuclear tract, arcuate fascicle, uncinate fascicle, superior longitudinal fascicle, inferior longitudinal fascicle, arcuate fibers, commissural fibers, corticothalamic fibers, and the fronto-occipital fascicle. In 32 patients (86.5 %), each above-named tract could be visualized, while at least 6 out of these 9 tracts were identified in each patient. A fiber length of 100 mm and an FA of 0.1 or 0.15 provided optimal visualization by revealing 125 and 61 individually tracked fibers per visualized language tract and 90 % and 73 % of all language-related tracts, respectively. This study proves the feasibility of rTMS-based DTI FT for subcortical language tracts, provides suitable settings, and shows its easy and standardizable application for the visualization of every language tract in 86.5 % of patients.
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50
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Negwer C, Beurskens E, Sollmann N, Maurer S, Ille S, Giglhuber K, Kirschke JS, Ringel F, Meyer B, Krieg SM. Loss of Subcortical Language Pathways Correlates with Surgery-Related Aphasia in Patients with Brain Tumor: An Investigation via Repetitive Navigated Transcranial Magnetic Stimulation–Based Diffusion Tensor Imaging Fiber Tracking. World Neurosurg 2018; 111:e806-e818. [DOI: 10.1016/j.wneu.2017.12.163] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 12/23/2017] [Accepted: 12/27/2017] [Indexed: 11/26/2022]
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