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Ramírez-Ferrer E, Aguilera-Pena MP, Duffau H. Functional and oncological outcomes after right hemisphere glioma resection in awake versus asleep patients: a systematic review and meta-analysis. Neurosurg Rev 2024; 47:160. [PMID: 38625548 DOI: 10.1007/s10143-024-02370-8] [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: 02/27/2024] [Revised: 03/04/2024] [Accepted: 03/24/2024] [Indexed: 04/17/2024]
Abstract
The right hemisphere has been underestimated by being considered as the non-dominant hemisphere. However, it is involved in many functions, including movement, language, cognition, and emotion. Therefore, because lesions on this side are usually not resected under awake mapping, there is a risk of unfavorable neurological outcomes. The goal of this study is to compare the functional and oncological outcomes of awake surgery (AwS) versus surgery under general anesthesia (GA) in supratentorial right-sided gliomas. A systematic review of the literature according to PRISMA guidelines was performed up to March 2023. Four databases were screened. Primary outcome to assess was return to work (RTW). Secondary outcomes included the rate of postoperative neurological deficit, postoperative Karnofsky Performance Status (KPS) score and the extent of resection (EOR). A total of 32 articles were included with 543 patients who underwent right hemisphere tumor resection under awake surgery and 294 under general anesthesia. There were no significant differences between groups regarding age, gender, handedness, perioperative KPS, tumor location or preoperative seizures. Preoperative and long-term postoperative neurological deficits were statistically lower after AwS (p = 0.03 and p < 0.01, respectively), even though no difference was found regarding early postoperative course (p = 0.32). A subsequent analysis regarding type of postoperative impairment was performed. Severe postoperative language deficits were not different (p = 0.74), but there were fewer long-term mild motor and high-order cognitive deficits (p < 0.05) in AwS group. A higher rate of RTW (p < 0.05) was documented after AwS. The EOR was similar in both groups. Glioma resection of the right hemisphere under awake mapping is a safer procedure with a better preservation of high-order cognitive functions and a higher rate of RTW than resection under general anesthesia, despite similar EOR.
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Affiliation(s)
- Esteban Ramírez-Ferrer
- School of Medicine, Universidad del Rosario, Bogotá, Colombia.
- Department of Neurosurgery, Hospital Universitario La Samaritana, Bogotá, Colombia.
- Department of Neurosurgery, Hospital Universitario Mayor de Méderi, Bogotá, Colombia.
- Center of Research and Training in Neurosurgery (CIEN), Bogotá, Colombia.
| | - Maria Paula Aguilera-Pena
- Center of Research and Training in Neurosurgery (CIEN), Bogotá, Colombia
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Hugues Duffau
- Department of Neurosurgery, Gui De Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- U1191 Laboratory, Team "Brain Plasticity, Stem Cells and Glial Tumors", Institute of Functional Genomics of Montpellier, National Institute for Health and Medical Research (INSERM), University of Montpellier, Montpellier, France
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2
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Shah K, Bhartia V, Biswas C, Sahu A, Shetty PM, Singh V, Velayutham P, Awate SP, Moiyadi AV. Tumor location and neurocognitive function-Unravelling the association and identifying relevant anatomical substrates in intra-axial brain tumors. Neurooncol Adv 2024; 6:vdae020. [PMID: 38464948 PMCID: PMC10924535 DOI: 10.1093/noajnl/vdae020] [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] [Indexed: 03/12/2024] Open
Abstract
Background Neurocognitive function is a key outcome indicator of therapy in brain tumors. Understanding the underlying anatomical substrates involved in domain function and the pathophysiological basis of dysfunction can help ameliorate the effects of therapy and tailor directed rehabilitative strategies. Methods Hundred adult diffuse gliomas were co-registered onto a common demographic-specific brain template to create tumor localization maps. Voxel-based lesion symptom (VLSM) technique was used to assign an association between individual voxels and neuropsychological dysfunction in various domains (attention and executive function (A & EF), language, memory, visuospatial/constructive abilities, and visuomotor speed). The probability maps thus generated were further co-registered to cortical and subcortical atlases. A permutation-based statistical testing method was used to evaluate the statistically and clinically significant anatomical parcels associated with domain dysfunction and to create heat maps. Results Neurocognition was affected in a high proportion of subjects (93%), with A & EF and memory being the most affected domains. Left-sided networks were implicated in patients with A & EF, memory, and language deficits with the perisylvian white matter tracts being the most common across domains. Visuospatial dysfunction was associated with lesions involving the right perisylvian cortical regions, whereas deficits in visuomotor speed were associated with lesions involving primary visual and motor output pathways. Conclusions Significant baseline neurocognitive deficits are prevalent in gliomas. These are multidomain and the perisylvian network especially on the left side seems to be very important, being implicated in dysfunction of many domains.
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Affiliation(s)
- Kanchi Shah
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Center, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vinayak Bhartia
- Computer Science and Engineering Department, Indian Institute of Technology (IIT) Bombay. Mumbai, Maharashtra, India
| | - Chandrima Biswas
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Center, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arpita Sahu
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Department of Radiodiagnosis, Tata Memorial Center, Mumbai, Maharashtra, India
| | - Prakash M Shetty
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Center, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vikas Singh
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Center, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Parthiban Velayutham
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Center, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Suyash P Awate
- Computer Science and Engineering Department, Indian Institute of Technology (IIT) Bombay. Mumbai, Maharashtra, India
| | - Aliasgar V Moiyadi
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Center, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Duque ACM, Cuesta TAC, Melo ADS, Maldonado IL. Right hemisphere and metaphor comprehension: A connectionist perspective. Neuropsychologia 2023; 187:108618. [PMID: 37321404 DOI: 10.1016/j.neuropsychologia.2023.108618] [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: 09/26/2022] [Revised: 04/11/2023] [Accepted: 06/10/2023] [Indexed: 06/17/2023]
Abstract
Metaphor comprehension is a cognitively complex task, with evidence pointing to the engagement of multiple cerebral areas. In addition, the involvement of the right hemisphere appears to vary with cognitive effort. Therefore, the interconnecting pathways of such distributed cortical centers should be taken into account when studying this topic. Despite this, the potential contribution of white matter fasciculi has received very little attention in the literature to date and is not mentioned in most metaphor comprehension studies. To highlight the probable implications of the right inferior fronto-occipital fasciculus, right superior longitudinal system, and callosal radiations, we bring together findings from different research fields. The aim is to describe important insights enabled by the cross-fertilization of functional neuroimaging, clinical findings, and structural connectivity.
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Affiliation(s)
- Anna Clara Mota Duque
- Programa de Pós-Graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador, Brazil; Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Taryn Ariadna Castro Cuesta
- Programa de Pós-Graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador, Brazil; Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Ailton de Souza Melo
- Programa de Pós-Graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador, Brazil; Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | - Igor Lima Maldonado
- Programa de Pós-Graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador, Brazil; Dep. Biomorfologia, Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador, Brazil; UMR 1253, iBrain, Université de Tours, Inserm, Tours, France.
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4
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Rech F, Duffau H. Beyond Avoiding Hemiplegia after Glioma Surgery: The Need to Map Complex Movement in Awake Patient to Preserve Conation. Cancers (Basel) 2023; 15:cancers15051528. [PMID: 36900318 PMCID: PMC10001205 DOI: 10.3390/cancers15051528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Improving the onco-functional balance has always been a challenge in glioma surgery, especially regarding motor function. Given the importance of conation (i.e., the willingness which leads to action) in patient's quality of life, we propose here to review the evolution of its intraoperative assessment through a reminder of the increasing knowledge of its neural foundations-based upon a meta-networking organization at three levels. Historical preservation of the primary motor cortex and pyramidal pathway (first level), which was mostly dedicated to avoid hemiplegia, has nonetheless shown its limits to prevent the occurrence of long-term deficits regarding complex movement. Then, preservation of the movement control network (second level) has permitted to prevent such more subtle (but possibly disabling) deficits thanks to intraoperative mapping with direct electrostimulations in awake conditions. Finally, integrating movement control in a multitasking evaluation during awake surgery (third level) enabled to preserve movement volition in its highest and finest level according to patients' specific demands (e.g., to play instrument or to perform sports). Understanding these three levels of conation and its underlying cortico-subcortical neural basis is therefore critical to propose an individualized surgical strategy centered on patient's choice: this implies an increasingly use of awake mapping and cognitive monitoring regardless of the involved hemisphere. Moreover, this also pleads for a finer and systematic assessment of conation before, during and after glioma surgery as well as for a stronger integration of fundamental neurosciences into clinical practice.
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Affiliation(s)
- Fabien Rech
- Department of Neurosurgery, CHRU de Nancy, Université de Lorraine, F-54000 Nancy, France
- Le Centre de Recherche en Automatique de Nancy, Le Centre National de la Recherche Scientifique, Université de Lorraine, F-54000 Nancy, France
| | - Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, F-34295 Montpellier, France
- Team ‘Plasticity of Central Nervous System, Stem Cells and Glial Tumours’, INSERM U1191, Institute of Genomics of Montpellier, University of Montpellier, F-34295 Montpellier, France
- Correspondence:
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5
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Yao S, Yang R, Du C, Jiang C, Wang Y, Peng C, Bai H. Maximal safe resection of diffuse lower grade gliomas primarily within central lobe using cortical/subcortical direct electrical stimulation under awake craniotomy. Front Oncol 2023; 13:1089139. [PMID: 36895476 PMCID: PMC9990258 DOI: 10.3389/fonc.2023.1089139] [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: 11/03/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
Background Diffuse lower-grade glioma (DLGG) in the central lobe is a challenge for safe resection procedures. To improve the extent of resection and reduce the risk of postoperative neurological deficits, we performed an awake craniotomy with cortical-subcortical direct electrical stimulation (DES) mapping for patients with DLGG located primarily within the central lobe. We investigated the outcomes of cortical-subcortical brain mapping using DES in an awake craniotomy for central lobe DLGG resection. Methods We performed a retrospective analysis of clinical data of a cohort of consecutively treated patients from February 2017 to August 2021 with diffuse lower-grade gliomas located primarily within the central lobe. All patients underwent awake craniotomy with DES for cortical and subcortical mapping of eloquent brain areas, neuronavigation, and/or ultrasound to identify tumor location. Tumors were removed according to functional boundaries. Maximum safe tumor resection was the surgical objective for all patients. Results Thirteen patients underwent 15 awake craniotomies with intraoperative mapping of eloquent cortices and subcortical fibers using DES. Maximum safe tumor resection was achieved according to functional boundaries in all patients. The pre-operative tumor volumes ranged from 4.3 cm3 to 137.3 cm3 (median 19.2 cm3). The mean extent of tumor resection was 94.6%, with eight cases (53.3%) achieving total resection, four (26.7%) subtotal and three (20.0%) partial. The mean tumor residue was 1.2 cm3. All patients experienced early postoperative neurological deficits or worsening conditions. Three patients (20.0%) experienced late postoperative neurological deficits at the 3-month follow-up, including one moderate and two mild neurological deficits. None of the patients experienced late onset severe neurological impairments post-operatively. Ten patients with 12 tumor resections (80.0%) had resumed activities of daily living at the 3-month follow-up. Among 14 patients with pre-operative epilepsy, 12 (85.7%) were seizure-free after treatment with antiepileptic drugs 7 days after surgery up to the last follow-up. Conclusions DLGG located primarily in the central lobe deemed inoperable can be safely resected using awake craniotomy with intraoperative DES without severe permanent neurological sequelae. Patients experienced an improved quality of life in terms of seizure control.
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Affiliation(s)
- Shujing Yao
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Ruixin Yang
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Chenggang Du
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Che Jiang
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Yang Wang
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Chongqi Peng
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Hongmin Bai
- Department of Neurosurgery, General Hospital of Southern Theater Command of PLA, Guangzhou, China
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Shah HA, Mehta NH, Saleem MI, D’Amico RS. Connecting the connectome: A bibliometric investigation of the 50 most cited articles. Clin Neurol Neurosurg 2022; 223:107481. [DOI: 10.1016/j.clineuro.2022.107481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 11/29/2022]
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7
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Duffau H, Ng S, Lemaitre AL, Moritz-Gasser S, Herbet G. Constant Multi-Tasking With Time Constraint to Preserve Across-Network Dynamics Throughout Awake Surgery for Low-Grade Glioma: A Necessary Step to Enable Patients Resuming an Active Life. Front Oncol 2022; 12:924762. [PMID: 35712489 PMCID: PMC9196728 DOI: 10.3389/fonc.2022.924762] [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: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 12/18/2022] Open
Abstract
Awake surgery for brain gliomas improves resection while minimizing morbidity. Although intraoperative mapping was originally used to preserve motor and language functions, the considerable increase of life expectancy, especially in low-grade glioma, resulted in the need to enhance patients’ long-term quality of life. If the main goal of awake surgery is to resume normal familial and socio-professional activities, preventing hemiparesis and aphasia is not sufficient: cognitive and emotional functions must be considered. To monitor higher-order functions, e.g., executive control, semantics or mentalizing, further tasks were implemented into the operating theater. Beyond this more accurate investigation of function-specific neural networks, a better exploration of the inter-system communication is required. Advances in brain connectomics led to a meta-network perspective of neural processing, which emphasizes the pivotal role of the dynamic interplay between functional circuits to allow complex and flexible, goal-directed behaviors. Constant multi-tasking with time constraint in awake patients may be proposed during intraoperative mapping, since it provides a mirror of the (dys)synchronization within and across neural networks and it improves the sensitivity of behavioral monitoring by increasing cognitive demand throughout the resection. Electrical mapping may hamper the patient to perform several tasks simultaneously whereas he/she is still capable to achieve each task in isolation. Unveiling the meta-network organization during awake mapping by using a more ecological multi-demand testing, more representative of the real-life conditions, constitutes a reliable way to tailor the surgical onco-functional balance based upon the expectations of each patient, enabling him/her to resume an active life with long-lasting projects.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", U1191 Laboratory, Institute of Functional Genomics, National Institute for Health and Medical Research (INSERM), University of Montpellier, Montpellier, France
| | - Sam Ng
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", U1191 Laboratory, Institute of Functional Genomics, National Institute for Health and Medical Research (INSERM), University of Montpellier, Montpellier, France
| | - Anne-Laure Lemaitre
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Glial Tumors", U1191 Laboratory, Institute of Functional Genomics, National Institute for Health and Medical Research (INSERM), University 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", U1191 Laboratory, Institute of Functional Genomics, National Institute for Health and Medical Research (INSERM), University of Montpellier, Montpellier, France.,Department of Speech-Language Pathology, University of Montpellier, 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", U1191 Laboratory, Institute of Functional Genomics, National Institute for Health and Medical Research (INSERM), University of Montpellier, Montpellier, France.,Department of Speech-Language Pathology, University of Montpellier, Montpellier, France
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8
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Le Lann F, Cristante J, De Schlichting E, Quehan R, Réhault E, Lotterie JA, Roux FE. Variability of Intraoperative Electrostimulation Parameters in Conscious Individuals: Language Fasciculi. World Neurosurg 2022; 164:e194-e202. [PMID: 35472645 DOI: 10.1016/j.wneu.2022.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The authors analyzed the current-intensity thresholds for electrostimulation of language fasciculi and the possible consequences of threshold variability on brain mapping. METHODS A prospective protocol of subcortical electrostimulation was used in 50 patients undergoing brain mapping, directly stimulating presumed language fasciculi identified by diffusion tensor imaging. RESULTS The stimulation-intensity thresholds for identification of language fasciculi varied among patients (mean minimum current intensity of 4.4 mA, range = 1.5-10 mA, standard deviation = 1.1 mA), and 23% of fascicular interferences were detected only above 5 mA. Repeated stimulation of the same site with the same intensity led to different types of interferences in 20% of patients, and a higher current intensity led to changes in the type of response in 27%. The mean minimum stimulation intensities did not differ significantly between different fasciculi, between the different types of interference obtained, or with age, sex, or type of tumor. Positive results on cortical mapping were significantly associated with positive results on subcortical mapping (P < 0.001). Subcortical intensity thresholds were slightly lower than cortical ones (mean = 4.43 vs. 5.25 mA, P = 0.034). In 23 of 50 subcortical mappings, fascicular stimulation produced no language interference. CONCLUSIONS Individual variability of minimum stimulation-intensity thresholds for identification of language fasciculi is frequent. Nevertheless, even when a high current intensity was used, many stimulations on language fasciculi remained negative for various hypothetic reasons. Finding the optimal current intensity for identifying language fasciculi is of paramount importance to refine the clinical results and scientific data derived from brain mapping.
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Affiliation(s)
- Florian Le Lann
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; Université de Toulouse, UPS, Toulouse, France.
| | | | - Emmanuel De Schlichting
- Université Grenoble Alpes, Faculté de Médecine, Grenoble, France; Neurochirurgie, Centre Hospitalo-Universitaire de Grenoble, Toulouse, France
| | - Romain Quehan
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; Université de Toulouse, UPS, Toulouse, France
| | - Emilie Réhault
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
| | - Jean-Albert Lotterie
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; Université de Toulouse, UPS, Toulouse, France
| | - Franck-Emmanuel Roux
- Pole Neurosciences (Neurochirurgie), Centre Hospitalo-Universitaire de Toulouse, Toulouse, France; Université de Toulouse, UPS, Toulouse, France; Centre de Recherche Cerveau et Cognition (CNRS; CerCo), Toulouse, France
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9
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Current Status of Neuromodulation-Induced Cortical Prehabilitation and Considerations for Treatment Pathways in Lower-Grade Glioma Surgery. LIFE (BASEL, SWITZERLAND) 2022; 12:life12040466. [PMID: 35454957 PMCID: PMC9024440 DOI: 10.3390/life12040466] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/19/2022] [Accepted: 03/19/2022] [Indexed: 12/15/2022]
Abstract
The infiltrative character of supratentorial lower grade glioma makes it possible for eloquent neural pathways to remain within tumoural tissue, which renders complete surgical resection challenging. Neuromodulation-Induced Cortical Prehabilitation (NICP) is intended to reduce the likelihood of premeditated neurologic sequelae that otherwise would have resulted in extensive rehabilitation or permanent injury following surgery. This review aims to conceptualise current approaches involving Repetitive Transcranial Magnetic Stimulation (rTMS-NICP) and extraoperative Direct Cortical Stimulation (eDCS-NICP) for the purposes of inducing cortical reorganisation prior to surgery, with considerations derived from psychiatric, rehabilitative and electrophysiologic findings related to previous reports of prehabilitation. Despite the promise of reduced risk and incidence of neurologic injury in glioma surgery, the current data indicates a broad but compelling possibility of effective cortical prehabilitation relating to perisylvian cortex, though it remains an under-explored investigational tool. Preliminary findings may prove sufficient for the continued investigation of prehabilitation in small-volume lower-grade tumour or epilepsy patients. However, considering the very low number of peer-reviewed case reports, optimal stimulation parameters and duration of therapy necessary to catalyse functional reorganisation remain equivocal. The non-invasive nature and low risk profile of rTMS-NICP may permit larger sample sizes and control groups until such time that eDCS-NICP protocols can be further elucidated.
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10
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Aaronson DM, Martinez Del Campo E, Boerger TF, Conway B, Cornell S, Tate M, Mueller WM, Chang EF, Krucoff MO. Understanding Variable Motor Responses to Direct Electrical Stimulation of the Human Motor Cortex During Brain Surgery. Front Surg 2021; 8:730367. [PMID: 34660677 PMCID: PMC8517489 DOI: 10.3389/fsurg.2021.730367] [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: 06/24/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
Direct electrical stimulation of the brain is the gold standard technique used to define functional-anatomical relationships during neurosurgical procedures. Areas that respond to stimulation are considered “critical nodes” of circuits that must remain intact for the subject to maintain the ability to perform certain functions, like moving and speaking. Despite its routine use, the neurophysiology underlying downstream motor responses to electrical stimulation of the brain, such as muscle contraction or movement arrest, is poorly understood. Furthermore, varying and sometimes counterintuitive responses can be seen depending on how and where the stimulation is applied, even within the human primary motor cortex. Therefore, here we review relevant neuroanatomy of the human motor system, provide a brief historical perspective on electrical brain stimulation, explore mechanistic variations in stimulation applications, examine neurophysiological properties of different parts of the motor system, and suggest areas of future research that can promote a better understanding of the interaction between electrical stimulation of the brain and its function.
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Affiliation(s)
- Daniel M Aaronson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Timothy F Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Brian Conway
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Sarah Cornell
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Matthew Tate
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Wade M Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Edward F Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, United States
| | - Max O Krucoff
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Biomedical Engineering, Marquette University, Milwaukee, WI, United States
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11
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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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12
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Duffau H. Neural Connectivity: How to Reinforce the Bidirectional Synapse Between Basic Neuroscience and Routine Neurosurgical Practice? Front Neurol 2021; 12:705135. [PMID: 34354668 PMCID: PMC8336871 DOI: 10.3389/fneur.2021.705135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022] 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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13
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Ng S, Herbet G, Lemaitre AL, Moritz-Gasser S, Duffau H. Disrupting self-evaluative processing with electrostimulation mapping during awake brain surgery. Sci Rep 2021; 11:9386. [PMID: 33931714 PMCID: PMC8087680 DOI: 10.1038/s41598-021-88916-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/19/2021] [Indexed: 02/08/2023] Open
Abstract
Brain awake surgery with cognitive monitoring for tumor removal has become a standard of treatment for functional purpose. Yet, little attention has been given to patients' interpretation and awareness of their own responses to selected cognitive tasks during direct electrostimulation (DES). We aim to report disruptions of self-evaluative processing evoked by DES during awake surgery. We further investigate cortico-subcortical structures involved in self-assessment process and report the use of an intraoperative self-assessment tool, the self-confidence index (SCI). Seventy-two patients who had undergone awake brain tumor resections were selected. Inclusion criteria were the occurrence of a DES-induced disruption of an ongoing task followed by patient's failure to remember or criticize these impairments, or a dissociation between patient's responses to an ongoing task and patient's SCI. Disruptions of self-evaluation were frequently associated with semantic disorders and critical sites were mostly found along the left/right ventral semantic streams. Disconnectome analyses generated from a tractography-based atlas confirmed the high probability of the inferior fronto-occipital fasciculus to be transitory 'disconnected'. These findings suggest that white matters pathways belonging to the ventral semantic stream may be critically involved in human self-evaluative processing. Finally, the authors discuss the implementation of the SCI task during multimodal intraoperative monitoring.
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Affiliation(s)
- Sam Ng
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80 Av Augustin Fliche, 34295, Montpellier, France. .,Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM U1191, Montpellier, France.
| | - Guillaume Herbet
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80 Av Augustin Fliche, 34295, Montpellier, France.,Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM U1191, Montpellier, France.,Department of Speech-Language Pathology, University of Montpellier, Montpellier, France
| | - Anne-Laure Lemaitre
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80 Av Augustin Fliche, 34295, Montpellier, France.,Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM U1191, Montpellier, France
| | - Sylvie Moritz-Gasser
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80 Av Augustin Fliche, 34295, Montpellier, France.,Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM U1191, Montpellier, France.,Department of Speech-Language Pathology, University of Montpellier, Montpellier, France
| | - Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, 80 Av Augustin Fliche, 34295, Montpellier, France.,Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM U1191, Montpellier, France.,Department of Speech-Language Pathology, University of Montpellier, Montpellier, France
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14
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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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15
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Duffau H. Updated perspectives on awake neurosurgery with cognitive and emotional assessment for patients with low-grade gliomas. Expert Rev Neurother 2021; 21:463-473. [PMID: 33724148 DOI: 10.1080/14737175.2021.1901583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Thanks to early extensive surgical resection combined with medical oncological therapies, life expectancy dramatically increased in low-grade glioma (LGG), with an overall survival currently over 15 years. Therefore, patients should be able to maintain valuable family and socio-professional activities.Areas covered: For many decades, cognitive and emotional aspects were neglected by surgical and medical neurooncologists. The goal of surgery was to avoid hemiplegia and/or aphasia, with no considerations regarding behavior. However, because LGG patients live longer, they must be cognitively and affectively able to make long-term projects. Preservation of higher-order functions should be considered systematically in LGG surgery by means of awake cognitive/emotional mapping and monitoring.Expert opinion: The aim is to incorporate recent advances in neurosciences, which proposed revisited models of cerebral processing relying on a meta-network perspective, into the pre-, intra- and postoperative procedure. In this connectomal approach, brain functions result from complex interactions within and between neural networks. This improved understanding of a constant instability of the neural system allows a better cognitive/emotional assessment before and after each treatment over years, in order to preserve personality and adaptive behavior for each LGG patient, based on his/her own definition of quality of life. It is time to create oncological neurosciences.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery Gui De Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,National Institute for Health and Medical Research (INSERM), U1191 Laboratory Team "Brain Plasticity, Stem Cells and Low-Grade Gliomas", Institute of Functional Genomic, University of Montpellier, Montpellier, France
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16
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Baeg E, Doudlah R, Swader R, Lee H, Han M, Kim SG, Rosenberg A, Kim B. MRI Compatible, Customizable, and 3D-Printable Microdrive for Neuroscience Research. eNeuro 2021; 8:ENEURO.0495-20.2021. [PMID: 33593730 PMCID: PMC7986532 DOI: 10.1523/eneuro.0495-20.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/26/2021] [Accepted: 01/30/2021] [Indexed: 02/02/2023] Open
Abstract
The effective connectivity of brain networks can be assessed using functional magnetic resonance imaging (fMRI) to quantify the effects of local electrical microstimulation (EM) on distributed neuronal activity. The delivery of EM to specific brain regions, particularly with layer specificity, requires MRI compatible equipment that provides fine control of a stimulating electrode's position within the brain while minimizing imaging artifacts. To this end, we developed a microdrive made entirely of MRI compatible materials. The microdrive uses an integrated penetration grid to guide electrodes and relies on a microdrilling technique to eliminate the need for large craniotomies, further reducing implant maintenance and image distortions. The penetration grid additionally serves as a built-in MRI marker, providing a visible fiducial reference for estimating probe trajectories. Following the initial implant procedure, these features allow for multiple electrodes to be inserted, removed, and repositioned with minimal effort, using a screw-type actuator. To validate the design of the microdrive, we conducted an EM-coupled fMRI study with a male macaque monkey. The results verified that the microdrive can be used to deliver EM during MRI procedures with minimal imaging artifacts, even within a 7 Tesla (7T) environment. Future applications of the microdrive include neuronal recordings and targeted drug delivery. We provide computer aided design (CAD) templates and a parts list for modifying and fabricating the microdrive for specific research needs. These designs provide a convenient, cost-effective approach to fabricating MRI compatible microdrives for neuroscience research.
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Affiliation(s)
- Eunha Baeg
- Center for Neuroscience Imaging Research, Institute for Basic Science, Suwon, Republic of Korea 16060
- Department of Biomedical Engineering, Sungkyunkwan University, Suwon, Republic of Korea 16419
| | - Raymond Doudlah
- Department of Neuroscience, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705
| | | | - Hyowon Lee
- System Design Engineering, University of Waterloo, Waterloo, Ontario, Canada N2L 3G1
| | - Minjun Han
- Department of Biomedical Engineering, Sungkyunkwan University, Suwon, Republic of Korea 16419
| | - Seong-Gi Kim
- Center for Neuroscience Imaging Research, Institute for Basic Science, Suwon, Republic of Korea 16060
- Department of Biomedical Engineering, Sungkyunkwan University, Suwon, Republic of Korea 16419
| | - Ari Rosenberg
- Department of Neuroscience, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705
| | - Byounghoon Kim
- Department of Neuroscience, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705
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17
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Senova S, Lefaucheur JP, Brugières P, Ayache SS, Tazi S, Bapst B, Abhay K, Langeron O, Edakawa K, Palfi S, Bardel B. Case Report: Multimodal Functional and Structural Evaluation Combining Pre-operative nTMS Mapping and Neuroimaging With Intraoperative CT-Scan and Brain Shift Correction for Brain Tumor Surgical Resection. Front Hum Neurosci 2021; 15:646268. [PMID: 33716700 PMCID: PMC7947337 DOI: 10.3389/fnhum.2021.646268] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/08/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Maximum safe resection of infiltrative brain tumors in eloquent area is the primary objective in surgical neuro-oncology. This goal can be achieved with direct electrical stimulation (DES) to perform a functional mapping of the brain in patients awake intraoperatively. When awake surgery is not possible, we propose a pipeline procedure that combines advanced techniques aiming at performing a dissection that respects the anatomo-functional connectivity of the peritumoral region. This procedure can benefit from intraoperative monitoring with computerized tomography scan (iCT-scan) and brain shift correction. Associated with this intraoperative monitoring, the additional value of preoperative investigation combining brain mapping by navigated transcranial magnetic stimulation (nTMS) with various neuroimaging modalities (tractography and resting state functional MRI) has not yet been reported. Case Report: A 42-year-old left-handed man had increased intracranial pressure (IICP), left hand muscle deficit, and dysarthria, related to an infiltrative tumor of the right frontal lobe with large mass effect and circumscribed contrast enhancement in motor and premotor cortical areas. Spectroscopy profile and intratumoral calcifications on CT-scan suggested an WHO grade III glioma, later confirmed by histology. The aforementioned surgical procedure was considered, since standard awake surgery was not appropriate for this patient. In preoperative time, nTMS mapping of motor function (deltoid, first interosseous, and tibialis anterior muscles) was performed, combined with magnetic resonance imaging (MRI)-based tractography reconstruction of 6 neural tracts (arcuate, corticospinal, inferior fronto-occipital, uncinate and superior and inferior longitudinal fasciculi) and resting-state functional MRI connectivity (rs-fMRI) of sensorimotor and language networks. In intraoperative time, DES mapping was performed with motor evoked response recording and tumor resection was optimized using non-rigid image transformation of the preoperative data (nTMS, tractography, and rs-fMRI) to iCT data. Image guidance was updated with correction for brain shift and tissue deformation using biomechanical modeling taking into account brain elastic properties. This correction was done at crucial surgical steps, i.e., when tumor bulged through the craniotomy after dura mater opening and when approaching the presumed eloquent brain regions. This procedure allowed a total resection of the tumor region with contrast enhancement as well as a complete regression of IICP and dysarthria. Hand paresis remained stable with no additional deficit. Postoperative nTMS mapping confirmed the good functional outcome. Conclusion: This case report and technical note highlights the value of preoperative functional evaluation by nTMS updated intraoperatively with correction of brain deformation by iCT. This multimodal approach may become the optimized technique of reference for patients with brain tumors in eloquent areas that are unsuitable for awake brain surgery.
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Affiliation(s)
- Suhan Senova
- Department of Neurosurgery, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Translational Psychiatry (Equipe 15), IMRB - INSERM U955, Univ Paris-Est Creteil, Creteil, France
| | - Jean-Pascal Lefaucheur
- Department of Clinical Neurophysiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Excitabilite Nerveuse et Therapeutique, EA 4391, Univ Paris-Est Creteil, Creteil, France
| | - Pierre Brugières
- Department of Neuroradiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France
| | - Samar S Ayache
- Department of Clinical Neurophysiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Excitabilite Nerveuse et Therapeutique, EA 4391, Univ Paris-Est Creteil, Creteil, France
| | - Sanaa Tazi
- Department of Neurosurgery, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Translational Psychiatry (Equipe 15), IMRB - INSERM U955, Univ Paris-Est Creteil, Creteil, France
| | - Blanche Bapst
- Department of Neuroradiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France
| | - Kou Abhay
- Department of Anesthesiology and Critical Care, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France
| | - Olivier Langeron
- Department of Anesthesiology and Critical Care, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Experimental Neuropathology Unit, Institut Pasteur, Paris, France
| | - Kohtaroh Edakawa
- Department of Neurosurgery, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Translational Psychiatry (Equipe 15), IMRB - INSERM U955, Univ Paris-Est Creteil, Creteil, France.,Department of Neurosurgery, Graduate School of Medicine Osaka University, Suita, Japan
| | - Stéphane Palfi
- Department of Neurosurgery, DMU CARe, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Translational Psychiatry (Equipe 15), IMRB - INSERM U955, Univ Paris-Est Creteil, Creteil, France
| | - Benjamin Bardel
- Department of Clinical Neurophysiology, DMU FIxIT, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Creteil, France.,Excitabilite Nerveuse et Therapeutique, EA 4391, Univ Paris-Est Creteil, Creteil, France
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