Motor Functional Reorganization Is Triggered by Tumor Infiltration Into the Primary Motor Area and Repeated Surgery

More widespread functionality of posterior language area in patients with brain tumors

Damage to the posterior language area (PLA), or Wernicke's area causes cortical reorganization in the corresponding regions of the contralateral hemisphere. However, the details of reorganization within the ipsilateral hemisphere are not fully understood. In this context, direct electrical stimulation during awake surgery can provide valuable opportunities to investigate neuromodulation of the human brain in vivo, which is difficult through the non-invasive approaches. Thus, in this study, we aimed to investigate the characteristics of the cortical reorganization of the PLA within the ipsilateral hemisphere. Sixty-two patients with left hemispheric gliomas were divided into groups depending on whether the lesion extended to the PLA. All patients underwent direct cortical stimulation with a picture-naming task. We further performed functional connectivity analyses using resting-state functional magnetic resonance imaging (MRI) in a subset of patients and calculated betweenness centrality, an index of the network importance of brain areas. During direct cortical stimulation, the regions showing positive (impaired) responses in the non-PLA group were localized mainly in the posterior superior temporal gyrus (pSTG), whereas those in the PLA group were widely distributed from the pSTG to the posterior supramarginal gyrus (pSMG). Notably, the percentage of positive responses in the pSMG was significantly higher in the PLA group (47%) than in the non-PLA group (8%). In network analyses of functional connectivity, the pSMG was identified as a hub region with high betweenness centrality in both the groups. These findings suggest that the language area can spread beyond the PLA to the pSMG, a hub region, in patients with lesion progression to the pSTG. The change in the pattern of the language area may be a compensatory mechanism to maintain efficient brain networks.

Structural changes in eloquent cortex secondary to glioma in sensorimotor area

This study aims to investigate the structural reorganization in the sensorimotor area of the brain in patients with gliomas, distinguishing between those with impaired and unimpaired strength. Using voxel-based morphometry (VBM) and region of interest (ROI) analysis, gray matter volumes (GMV) were compared in the contralesional primary motor gyrus, primary sensory gyrus, premotor area, bilateral supplementary motor area, and medial Brodmann area 8 (BA8). The results revealed that in patients with right hemisphere gliomas, the right medial BA8 volume was significantly larger in the impaired group than in the unimpaired group, with both groups exceeding the volume in 16 healthy controls (HCs). In patients with left hemisphere gliomas, the right supplementary motor area (SMA) was more pronounced in the impaired group compared to the unimpaired group, and both groups were greater than HCs. Additionally, the volumes of the right medial BA8 in both the impaired group were greater than HCs. Contralateral expansions in the gray matter of hand- and trunk-related cortices of the premotor area, precentral gyrus, and postcentral gyrus were observed compared to HCs. Furthermore, a negative correlation was found between hand Medical Research Council (MRC) score and volumes of the contralateral SMA and bilateral medial BA8. Notably, our findings reveal consistent results across both analytical approaches in identifying significant structural reorganizations within the sensorimotor cortex. These consistent findings underscore the adaptive neuroplastic responses to glioma presence, highlighting potential areas of interest for further neurosurgical planning and rehabilitation strategies.

An update on tests used for intraoperative monitoring of cognition during awake craniotomy

PURPOSE

Mapping higher-order cognitive functions during awake brain surgery is important for cognitive preservation which is related to postoperative quality of life. A systematic review from 2018 about neuropsychological tests used during awake craniotomy made clear that until 2017 language was most often monitored and that the other cognitive domains were underexposed (Ruis, J Clin Exp Neuropsychol 40(10):1081-1104, 218). The field of awake craniotomy and cognitive monitoring is however developing rapidly. The aim of the current review is therefore, to investigate whether there is a change in the field towards incorporation of new tests and more complete mapping of (higher-order) cognitive functions.

METHODS

We replicated the systematic search of the study from 2018 in PubMed and Embase from February 2017 to November 2023, yielding 5130 potentially relevant articles. We used the artificial machine learning tool ASReview for screening and included 272 papers that gave a detailed description of the neuropsychological tests used during awake craniotomy.

RESULTS

Comparable to the previous study of 2018, the majority of studies (90.4%) reported tests for assessing language functions (Ruis, J Clin Exp Neuropsychol 40(10):1081-1104, 218). Nevertheless, an increasing number of studies now also describe tests for monitoring visuospatial functions, social cognition, and executive functions.

CONCLUSIONS

Language remains the most extensively tested cognitive domain. However, a broader range of tests are now implemented during awake craniotomy and there are (new developed) tests which received more attention. The rapid development in the field is reflected in the included studies in this review. Nevertheless, for some cognitive domains (e.g., executive functions and memory), there is still a need for developing tests that can be used during awake surgery.

Understanding the role of zingerone on biochemical and behavioral changes in rat brain inflicted with C6 glioma cells

Malignant glioma is the deadliest form of brain cancer. Zingerone (ZO), a polyphenolic compound found in ginger, offers pharmacological properties that make it a promising agent for containing the growth of glioma cells. The present study was conducted to understand the efficacy of ZO in containing the growth of C6 glioma cells. The study also assessed the prophylactic role of ZO on rat brain glioma induced by C6 cell lines by addressing its antioxidative action on biochemical, behavioral, and histoarchitectural indices. For dose optimization, the animals were pretreated with different doses of ZO for a period of 2 weeks before the inoculation of glioma cells (1 × 105 /10 µL phosphate-buffered saline) in the caudate region of rat brain and the treatment with ZO continued for 4 more weeks post implantation. In vitro studies were done to assess the radical scavenging activity of ZO and also to determine its effects on viability of C6 glioma cells at different concentrations. Glioma-bearing rats showed significant alterations in memory; exploratory and muscular activities which were appreciably improved upon simultaneous supplementation of ZO administered at a dose of 50 mg/kg body weight and were also visible even at a higher dose. Glioma-bearing rats revealed a significant increase in reactive oxygen species, protein carbonyl contents, and lipid peroxidation, but showed a significant decrease in reduced glutathione and antioxidative enzymes in the brain tissue. Interestingly, all the biochemical indices and altered brain histoarchitecture displaying cellular atypia and hyperplasia showed appreciable improvement when supplemented with ZO at a dose of 50 mg/kg body weight.

Large-scale brain networks and intra-axial tumor surgery: a narrative review of functional mapping techniques, critical needs, and scientific opportunities

In recent years, a paradigm shift in neuroscience has been occurring from "localizationism," or the idea that the brain is organized into separately functioning modules, toward "connectomics," or the idea that interconnected nodes form networks as the underlying substrates of behavior and thought. Accordingly, our understanding of mechanisms of neurological function, dysfunction, and recovery has evolved to include connections, disconnections, and reconnections. Brain tumors provide a unique opportunity to probe large-scale neural networks with focal and sometimes reversible lesions, allowing neuroscientists the unique opportunity to directly test newly formed hypotheses about underlying brain structural-functional relationships and network properties. Moreover, if a more complete model of neurological dysfunction is to be defined as a "disconnectome," potential avenues for recovery might be mapped through a "reconnectome." Such insight may open the door to novel therapeutic approaches where previous attempts have failed. In this review, we briefly delve into the most clinically relevant neural networks and brain mapping techniques, and we examine how they are being applied to modern neurosurgical brain tumor practices. We then explore how brain tumors might teach us more about mechanisms of global brain dysfunction and recovery through pre- and postoperative longitudinal connectomic and behavioral analyses.

Intraoperative functional remapping unveils evolving patterns of cortical plasticity

The efficiency with which the brain reorganizes following injury not only depends on the extent and the severity of the lesion, but also on its temporal features. It is established that diffuse low-grade gliomas (DLGG), brain tumours with a slow-growth rate, induce a compensatory modulation of the anatomo-functional architecture, making this kind of tumours an ideal lesion model to study the dynamics of neuroplasticity. Direct electrostimulation (DES) mapping is a well-tried procedure used during awake resection surgeries to identify and spare cortical epicentres which are critical for a range of functions. Because DLGG is a chronic disease, it inevitably relapses years after the initial surgery, and thus requires a second surgery to reduce tumour volume again. In this context, contrasting the cortical mappings obtained during two sequential neurosurgeries offers a unique opportunity to both identify and characterize the dynamic (i.e. re-evolving) patterns of cortical re-arrangements. Here, we capitalized on an unprecedented series of 101 DLGG patients who benefited from two DES-guided neurosurgeries usually spaced several years apart, resulting in a large DES dataset of 2082 cortical sites. All sites (either non-functional or associated with language, speech, motor, somatosensory and semantic processing) were recorded in Montreal Neurological Institute (MNI) space. Next, we used a multi-step approach to generate probabilistic neuroplasticity maps that reflected the dynamic rearrangements of cortical mappings from one surgery to another, both at the population and individual level. Voxel-wise neuroplasticity maps revealed regions with a relatively high potential of evolving reorganizations at the population level, including the supplementary motor area (SMA, Pmax = 0.63), the dorsolateral prefrontal cortex (dlPFC, Pmax = 0.61), the anterior ventral premotor cortex (vPMC, Pmax = 0.43) and the middle superior temporal gyrus (STG Pmax = 0.36). Parcel-wise neuroplasticity maps confirmed this potential for the dlPFC (Fisher's exact test, PFDR-corrected = 6.6 × 10-5), the anterior (PFDR-corrected = 0.0039) and the ventral precentral gyrus (PFDR-corrected = 0.0058). A series of clustering analyses revealed a topological migration of clusters, especially within the left dlPFC and STG (language sites); the left vPMC (speech arrest/dysarthria sites) and the right SMA (negative motor response sites). At the individual level, these dynamic changes were confirmed for the dlPFC (bilateral), the left vPMC and the anterior left STG (threshold free cluster enhancement, 5000 permutations, family-wise error-corrected). Taken as a whole, our results provide a critical insight into the dynamic potential of DLGG-induced continuing rearrangements of the cerebral cortex, with considerable implications for re-operations.

Variables associated with cortical motor mapping thresholds: A retrospective data review with a unique case of interlimb motor facilitation

Introduction

Intraoperative neuromonitoring (IONM) is crucial to preserve eloquent neurological functions during brain tumor resections. We observed a rare interlimb cortical motor facilitation phenomenon in a patient with recurrent high-grade glioma undergoing craniotomy for tumor resection; the patient's upper arm motor evoked potentials (MEPs) increased in amplitude significantly (up to 44.52 times larger, p < 0.001) following stimulation of the ipsilateral posterior tibial nerve at 2.79 Hz. With the facilitation effect, the cortical MEP stimulation threshold was reduced by 6 mA to maintain appropriate continuous motor monitoring. It likely has the benefit of reducing the occurrence of stimulation-induced seizures and other adverse events associated with excessive stimulation.

Methods

We conducted a retrospective data review including 120 patients who underwent brain tumor resection with IONM at our center from 2018 to 2022. A broad range of variables collected pre-and intraoperatively were reviewed. The review aimed to determine: (1) whether we overlooked this facilitation phenomenon in the past, (2) whether this unique finding is related to any specific demographic information, clinical presentation, stimulation parameter (s) or anesthesia management, and (3) whether it is necessary to develop new techniques (such as facilitation methods) to reduce cortical stimulation intensity during intraoperative functional mapping.

Results

There is no evidence suggesting that clinical presentation, stimulation configuration, or intraoperative anesthesia management of the patient with the facilitation effect were significantly different from our general patient cohort. Even though we did not identify the same facilitation effect in any of these patients, we were able to determine that stimulation thresholds for motor mapping are significantly associated with the location of stimulation (p = 0.003) and the burst suppression ratio (BSR) (p < 0.001). Stimulation-induced seizures, although infrequent (4.05%), could occur unexpectedly even when the BSR was 70%.

Discussion

We postulated that functional reorganization and neuronal hyperexcitability induced by glioma progression and repeated surgeries were probable underlying mechanisms of the interlimb facilitation phenomenon. Our retrospective review also provided a practical guide to cortical motor mapping in brain tumor patients under general anesthesia. We also underscored the need for developing new techniques to reduce the stimulation intensity and, hence, seizure occurrence.

Recovery of Visual Field After Awake Stimulation Mapping of the Optic Pathway in Glioma Patients

Brain mapping during awake craniotomy for gliomas can help preserve neurological functions, including maintenance of central and peripheral vision. However, the consecutive changes in the visual field remain unknown. We retrospectively assessed 14 patients who underwent awake craniotomy for gliomas infiltrating into the optic radiation. Cortico-subcortical direct electrical stimulation (DES) was intraoperatively applied until transient visual symptoms were elicited and recorded. The visual fields were examined consecutively in the preoperative period and postoperative subacute and chronic periods. To evaluate the anatomo-functional validity of the recordings, all DES-elicited points were overlaid onto a three-dimensional template that included the optic radiation, using voxel-based morphometry (VBM) mapping. All patients experienced visual symptoms that were classified as phosphenes, blurred vision, or hallucinations during DES, and surgical resection was limited to within the functional boundaries. In VBM, almost all the subcortical positive mapping points overlapped with the surface of the optic radiation, and the distribution of sites that induced visual phenomena in the upper or lower visual fields could be differentiated in the anatomical space. We observed no postoperative visual deficit in four patients (29%), time-dependent improvements in five out of eight patients that presented transient quadrantanopia or partial visual defect (36% out of 57%), and permanent hemianopsia (14%) in two patients with occipital lesions. Intraoperative DES that identifies and preserves optic radiation in awake craniotomy for gliomas is a reliable and effective technique to reduce risk of permanent deficits, but has a low success rate in patients with occipital involvement.

Neural Regulation of Cancer: Cancer-Induced Remodeling of the Central Nervous System

In recent years, there have been significant advances in understanding the neuronal influence on the biology of solid tumors such as prostate, pancreatic, gastric, and brain cancers. An increasing amount of experimental evidence across multiple tumor types strongly suggests the existence of bidirectional crosstalk between cancer cells and the neural microenvironment. However, unlike cancers affecting many solid organs, brain tumors, namely gliomas, can synaptically integrate into neural circuits and thus can exert a greater potential to induce dynamic remodeling of functional circuits resulting in long-lasting behavioral changes. The first part of the review describes dynamic changes in language, sensory, and motor networks following glioma development and presents evidence focused on how different patterns of glioma-induced cortical reorganization may predict the degree and time course of functional recovery in brain tumor patients. The second part focuses on the network and cellular-level mechanisms underlying glioma-induced cerebral reorganization. Finally, oncological and clinical factors influencing glioma-induced network remodeling in glioma patients are reviewed.

Posterior-prefrontal and medial orbitofrontal regions play crucial roles in happiness and sadness recognition

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Brain areas underlying trade-off relations between emotions were identified.

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Damage to the PPF area reduces accuracy of happiness recognition.

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Damage to the PPF increases accuracy of sadness recognition.

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A similar tendency was observed in orbitofrontal regions for sadness recognition.

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Only a deficit in sadness, but not happiness, persisted in the chronic phase.

The core brain regions responsible for basic human emotions are not yet fully understood. We investigated the key areas responsible for emotion recognition of facial expressions of happiness and sadness using data obtained from patients who underwent local brain resection. A total of 44 patients with right cerebral hemispheric brain tumors and 33 healthy volunteers were enrolled and subjected to a facial expression recognition test. Voxel-based lesion-symptom mapping was performed to investigate the relationship between the accuracy of emotion recognition and the resected regions. Consequently, trade-off relationships were discovered: the posterior-prefrontal region was related to a low score of happiness recognition and a high score of sadness recognition (disorder-of-happiness group), whereas the medial orbitofrontal region was related to a low score of sadness recognition and a high score of happiness recognition (disorder-of-sadness group). The emotion recognition score in both the happiness and sadness disorder groups was significantly lower than that in the control group (p = 0.0009 and p = 0.021, respectively). Interestingly, the deficit in happiness recognition was temporary, whereas the deficit in sadness recognition persisted during the chronic phase. Using graph theoretical analysis, we identified structural connectivity between the posterior-prefrontal and medial orbitofrontal regions. When either of these regions was damaged, the tract volume connecting them was significantly reduced (p = 0.013). These results indicate that the posterior-prefrontal and medial orbitofrontal regions may be crucial for maintaining a balance between happiness and sadness recognition in humans. Investigating the clinical impact of certain area resections using lesion studies combined with connectivity analysis is a useful neuroimaging method for understanding neural networks.

Two different subcortical language networks supporting distinct Japanese orthographies: morphograms and phonograms

Language systems worldwide are based on either morphograms or phonograms, but Japanese is unique in that uses a complicated combination of kanji (morphogram) and kana (phonogram) characters. The white matter networks associated with reading have been investigated previously but remain incompletely understood. In this study, we performed intraoperative language mapping under local anesthesia and postoperative language assessments of 53 consecutive patients who underwent awake craniotomy for surgical resection of cerebral glioma within the dominant temporal or parietal lobe. Six cases showing intraoperative dyslexia elicited by direct electrical stimulation (DES) were examined, and all cases showed transient symptoms of kanji or kana dyslexia during DES. We investigated the intraoperative positive mapping points localized near four white matter bundles: the arcuate fascicle, posterior superior longitudinal fascicle, inferior fronto-occipital longitudinal fascicle, and inferior longitudinal fascicle (ILF). The intraoperative DES distributions for kanji dyslexia were especially associated with the anterior-inferior side of the ILF. On the other hand, the DES points associated with kana dyslexia were localized on the posterior-superior side of the complex composed of these four tracts. These results suggest the presence of specific non-interfering networks that subserve the processes of reading morphograms and phonograms.

Updated perspectives on awake neurosurgery with cognitive and emotional assessment for patients with low-grade gliomas

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.

Preserving Right Pre-motor and Posterior Prefrontal Cortices Contribute to Maintaining Overall Basic Emotion

Basic emotions such as happiness, sadness, and anger are universal, regardless of the human species, and are governed by specific brain regions. A recent report revealed that mentalizing, which is the ability to estimate other individuals’ emotional states via facial expressions, can be preserved with the help of awake surgery. However, it is still questionable whether we can maintain the ability to understand others’ emotions by preserving the positive mapping sites of intraoperative assessment. Here, we demonstrated the cortical regions related to basic emotions via awake surgery for patients with frontal glioma and investigated the usefulness of functional mapping in preserving basic emotion. Of the 56 consecutive patients with right cerebral hemispheric glioma who underwent awake surgery at our hospital, intraoperative assessment of basic emotion could be successfully performed in 22 patients with frontal glioma and were included in our study. During surgery, positive responses were found in 18 points in 12 patients (54.5%). Of these, 15 points from 11 patients were found at the cortical level, mainly the premotor and posterior part of the prefrontal cortices. Then, we focused on cortical 15 positive mappings with 40 stimulations and investigated the types of emotions that showed errors by every stimulation. There was no specific rule for the region-emotional type, which was beyond our expectations. In the postoperative acute phase, the test score of basic emotion declined in nine patients, and of these, it decreased under the cut-off value (Z-score ≤ −1.65) in three patients. Although the total score declined significantly just after surgery (p = 0.022), it recovered within 3 months postoperatively. Our study revealed that through direct electrical stimulation (DES), the premotor and posterior parts of the prefrontal cortices are related to various kinds of basic emotion, but not a single one. When the region with a positive mapping site is preserved during operation, basic emotion function might be maintained although it declines transiently after surgery.