Resting-State Functional Magnetic Resonance Imaging for Surgical Neuro-Oncology Planning: Towards a Standardization in Clinical Settings

Staged intervention to enable the resection of a large left temporoinsular cystic glioblastoma with language preservation: illustrative case

BACKGROUND

Resection of glioblastoma (GBM) in eloquent regions depends on functional mapping to limit perioperative neurological morbidity. When neurological deficits preclude reliable mapping, neurosurgeons should explore potential mitigation strategies. The authors present the case of a patient with a large left cystic temporoinsular GBM and aphasia, for whom the authors used intraoperative language mapping and a staged approach to enable safe tumor resection.

OBSERVATIONS

A 49-year-old female presented with progressive mixed aphasia for 1 month and new-onset right facial droop. Magnetic resonance imaging (MRI) revealed a large, heterogeneously enhancing, left temporoinsular tumor with a significant cystic component. Her aphasia was profound, and resection without reliable language mapping was deemed unsafe. An initial stereotactic tumoral cyst aspiration was performed, which reduced local mass effect and improved her language function. Cyst decompression thereby enabled both task-based functional MRI and intraoperative awake speech mapping, resulting in a safe resection of her GBM.

LESSONS

Safe resection of eloquently localized GBM is compromised when neurological deficits prohibit intraoperative functional mapping. This case demonstrates a mitigation strategy specific to cystic lesions in which an initial-stage stereotactic cyst aspiration is aimed at generating sufficient interval neurological improvement, such that intraoperative functional mapping can be performed during a second-stage resection. https://thejns.org/doi/10.3171/CASE24362.

7 T and beyond: toward a synergy between fMRI-based presurgical mapping at ultrahigh magnetic fields, AI, and robotic neurosurgery

Presurgical evaluation with functional magnetic resonance imaging (fMRI) can reduce postsurgical morbidity. Here, we discuss presurgical fMRI mapping at ultra-high magnetic fields (UHF), i.e., ≥ 7 T, in the light of the current growing interest in artificial intelligence (AI) and robot-assisted neurosurgery. The potential of submillimetre fMRI mapping can help better appreciate uncertainty on resection margins, though geometric distortions at UHF might lessen the accuracy of fMRI maps. A useful trade-off for UHF fMRI is to collect data with 1-mm isotropic resolution to ensure high sensitivity and subsequently a low risk of false negatives. Scanning at UHF might yield a revival interest in slow event-related fMRI, thereby offering a richer depiction of the dynamics of fMRI responses. The potential applications of AI concern denoising and artefact removal, generation of super-resolution fMRI maps, and accurate fusion or coregistration between anatomical and fMRI maps. The latter can benefit from the use of T1-weighted echo-planar imaging for better visualization of brain activations. Such AI-augmented fMRI maps would provide high-quality input data to robotic surgery systems, thereby improving the accuracy and reliability of robot-assisted neurosurgery. Ultimately, the advancement in fMRI at UHF would promote clinically useful synergies between fMRI, AI, and robotic neurosurgery.Relevance statement This review highlights the potential synergies between fMRI at UHF, AI, and robotic neurosurgery in improving the accuracy and reliability of fMRI-based presurgical mapping.Key points• Presurgical fMRI mapping at UHF improves spatial resolution and sensitivity.• Slow event-related designs offer a richer depiction of fMRI responses dynamics.• AI can support denoising, artefact removal, and generation of super-resolution fMRI maps.• AI-augmented fMRI maps can provide high-quality input data to robotic surgery systems.

Systematic Review Between Resting-State fMRI and Task fMRI in Planning for Brain Tumour Surgery

As an alternative to task-based functional magnetic resonance imaging (T-fMRI), resting-state functional magnetic resonance imaging (Rs-fMRI) is suggested for preoperative mapping of patients with brain tumours, with an emphasis on treatment guidance and neurodegeneration prediction. A systematic review was conducted of 18 recent studies involving 1035 patients with brain tumours and Rs-fMRI protocols. This was accomplished by searching the electronic databases PubMed, Scopus, and Web of Science. For clinical benefit, we compared Rs-fMRI to standard T-fMRI and intraoperative direct cortical stimulation (DCS). The results of Rs-fMRI and T-fMRI were compared and their correlation with intraoperative DCS results was examined through a systematic review. Our exhaustive investigation demonstrated that Rs-fMRI is a dependable and sensitive preoperative mapping technique that detects neural networks in the brain with precision and identifies crucial functional regions in agreement with intraoperative DCS. Rs-fMRI comes in handy, especially in situations where T-fMRI proves to be difficult because of patient-specific factors. Additionally, our exhaustive investigation demonstrated that Rs-fMRI is a valuable tool in the preoperative screening and evaluation of brain tumours. Furthermore, its capability to assess brain function, forecast surgical results, and enhance decision-making may render it applicable in the clinical management of brain tumours.

The Brain Connectome for Clinical Neuroscience

In this chapter, we introduce the topic of the brain connectome, consisting of the complete set of both the structural and functional connections of the brain. Connectomic information and the large-scale network architecture of the brain provide an improved understanding of the organization and functional relevance of human cortical and subcortical anatomy. We discuss various analytical methods to both identify and interpret structural and functional connectivity data. In turn, we discuss how these data provide significant clinical promise for neurosurgery, neurology, and psychiatry in that more informed decisions can be made based on connectomic information. These data can provide safer and more informed network-based neurosurgery for brain tumor patients and even offer the possibility to modulate the brain connectome.

Statistical Approaches to Identify Pairwise and High-Order Brain Functional Connectivity Signatures on a Single-Subject Basis

Keeping up with the shift towards personalized neuroscience essentially requires the derivation of meaningful insights from individual brain signal recordings by analyzing the descriptive indexes of physio-pathological states through statistical methods that prioritize subject-specific differences under varying experimental conditions. Within this framework, the current study presents a methodology for assessing the value of the single-subject fingerprints of brain functional connectivity, assessed both by standard pairwise and novel high-order measures. Functional connectivity networks, which investigate the inter-relationships between pairs of brain regions, have long been a valuable tool for modeling the brain as a complex system. However, their usefulness is limited by their inability to detect high-order dependencies beyond pairwise correlations. In this study, by leveraging multivariate information theory, we confirm recent evidence suggesting that the brain contains a plethora of high-order, synergistic subsystems that would go unnoticed using a pairwise graph structure. The significance and variations across different conditions of functional pairwise and high-order interactions (HOIs) between groups of brain signals are statistically verified on an individual level through the utilization of surrogate and bootstrap data analyses. The approach is illustrated on the single-subject recordings of resting-state functional magnetic resonance imaging (rest-fMRI) signals acquired using a pediatric patient with hepatic encephalopathy associated with a portosystemic shunt and undergoing liver vascular shunt correction. Our results show that (i) the proposed single-subject analysis may have remarkable clinical relevance for subject-specific investigations and treatment planning, and (ii) the possibility of investigating brain connectivity and its post-treatment functional developments at a high-order level may be essential to fully capture the complexity and modalities of the recovery.

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.

Statistical Approaches to Characterize Functional Connectivity in Brain and Physiologic Networks on a Single-Subject Basis

The trend toward personalized medicine necessitates drawing conclusions from descriptive indexes of physiopathological states estimated from individual recordings of biomedical signals, using statistical analyses that focus on subject-specific differences between experimental conditions. In this context, the present work introduces an approach to assess functional connectivity in brain and physiologic networks by pairwise information-theoretic measures of coupling between signals, whose significance and variations between conditions are statistically validated on a single-subject basis through the use of surrogate and bootstrap data analyses. The approach is illustrated on single-subject recordings of (i) resting-state functional magnetic resonance imaging (rest-fMRI) signals acquired in a pediatric patient with hepatic encephalography associated to a portosystemic shunt and undergoing liver vascular shunt correction, and of (ii) cardiovascular and cerebrovascular time series acquired at rest and during head-up tilt in a subject suffering from orthostatic intolerance.

Maximal Safe Resection in Glioblastoma Surgery: A Systematic Review of Advanced Intraoperative Image-Guided Techniques

Glioblastoma multiforme (GBM) represents the most common and aggressive central nervous system tumor associated with a poor prognosis. The aim of this study was to depict the role of intraoperative imaging techniques in GBM surgery and how they can ensure the maximal extent of resection (EOR) while preserving the functional outcome. The authors conducted a systematic review following PRISMA guidelines on the PubMed/Medline and Scopus databases. A total of 1747 articles were identified for screening. Studies focusing on GBM-affected patients, and evaluations of EOR and functional outcomes with the aid of advanced image-guided techniques were included. The resulting studies were assessed for methodological quality using the Risk of Bias in Systematic Review tool. Open Science Framework registration DOI 10.17605/OSF.IO/3FDP9. Eighteen studies were eligible for this systematic review. Among the selected studies, eight analyzed Sodium Fluorescein, three analyzed 5-aminolevulinic acid, two evaluated IoMRI imaging, two evaluated IoUS, and three evaluated multiple intraoperative imaging techniques. A total of 1312 patients were assessed. Gross Total Resection was achieved in the 78.6% of the cases. Follow-up time ranged from 1 to 52 months. All studies assessed the functional outcome based on the Karnofsky Performance Status scale, while one used the Neurologic Assessment in Neuro-Oncology score. In 77.7% of the cases, the functional outcome improved or was stable over the pre-operative assessment. Combining multiple intraoperative imaging techniques could provide better results in GBM surgery than a single technique. However, despite good surgical outcomes, patients often present a neurocognitive decline leading to a marked deterioration of the quality of life. Advanced intraoperative image-guided techniques can allow a better understanding of the anatomo-functional relationships between the tumor and the surrounding brain, thus maximizing the EOR while preserving functional outcomes.

The Ipsilateral Interhemispheric Transprecuneal Approach to the Atrium: Technical Considerations and Clinical Outcome on a Series of 7 Patients

Surgical removal of tumors of the atrium is challenging due to their deep location, vascularization, and to their complex three-dimensional relationships with the highly functional white matter fibers of the region. To assess the feasibility and the effectiveness of the ipsilateral interhemispheric transprecuneus approach (IITA) for tumors involving the atrium and the posterior third of the temporal horn, a retrospective chart review of all patients who had undergone a surgical treatment for intraventricular tumors between January 2008 and January 2017 was performed, and the step-by-step approach is described. Ten patients affected by lesions of the atrium of the lateral ventricle underwent surgical treatment, seven of which were approached through the IITA. The mean age was 42.8 years (range 6–63 years). The symptoms presented included severe, drug-resistant headache (90%), lateral homonymous hemianopsia (50%), seizures (30%), and speech disturbances (30%). Histological examinations revealed seven patients with meningioma (70%), one with a metastasis (10%), one with a choroid plexus papilloma (10%) and one with a cavernoma (10%). In all cases, a gross total removal was obtained. All patients had a significant improvement in their headache. Two patients experienced a worsening of the pre-operative visual disturbances, while two patients had a significant improvement. No patients without pre-operative visual disturbances described a post-operative worsening of visual symptoms. The IITA represents a feasible approach for tumors of the atrium. The three-quarter prone position facilitates the enlargement of the interhemispheric fissure by increasing the working angle and facilitating the exposure of the lateral wall of the atrium.