Specificities of Awake Craniotomy and Brain Mapping in Children for Resection of Supratentorial Tumors in the Language Area

BACKGROUND

In the pediatric population, awake craniotomy began to be used for the resection of brain tumor located close to eloquent areas. Some specificities must be taken into account to adapt this method to children.

OBJECTIVE

The aim of this clinical study is to not only confirm the feasibility of awake craniotomy and language brain mapping in the pediatric population but also identify the specificities and necessary adaptations of the procedure.

METHODS

Six children aged 11 to 16 were operated on while awake under local anesthesia with language brain mapping for supratentorial brain lesions (tumor and cavernoma). The preoperative planning comprised functional magnetic resonance imaging (MRI) and neuropsychologic and psychologic assessment. The specific preoperative preparation is clearly explained including hypnosis conditioning and psychiatric evaluation. The success of the procedure was based on the ability to perform the language brain mapping and the tumor removal without putting the patient to sleep. We investigated the pediatric specificities, psychological experience, and neuropsychologic follow-up.

RESULTS

The children experienced little anxiety, probably in large part due to the use of hypnosis. We succeeded in doing the cortical-subcortical mapping and removing the tumor without putting the patient to sleep in all cases. The psychological experience was good, and the neuropsychologic follow-up showed a favorable evolution.

CONCLUSIONS

Preoperative preparation and hypnosis in children seemed important for performing awake craniotomy and contributing language brain mapping with the best possible psychological experience. The pediatrics specificities are discussed.

Neuropsychological differences between survivors of supratentorial and infratentorial brain tumours

BACKGROUND

The purpose of this study is to evaluate the relationship between brain tumour location and core areas of cognitive and behavioural functioning for paediatric brain tumour survivors. The extant literature both supports and refutes an association between paediatric brain tumour location and neurocognitive outcomes. We examined neuropsychological test data to identify any differences in neurocognitive and behavioural profile associated with supratentorial versus infratentorial tumour location.

METHODS

Following Institutional Review Board approval, the medical records and neuropsychological test data collected between 1997 and 2002 for 70 children treated for brain tumour at Children's Hospital Los Angeles were reviewed. Fifty-one per cent of the participants had tumours located in the supratentorial regions of the brain, whereas 49% had infratentorial tumours. Primary medical treatments involved tumour resection (90%), cranial radiation therapy (76%), chemotherapy (71%), and 59% all three medical procedures. The two tumour location groups did not differ significantly in the cumulative treatment dose of irradiation to the tumour bed or in the dose delivered to the whole brain. Neuropsychological test data included measures of verbal and non-verbal intellectual functioning, attention/working memory, processing speed, verbal and visual memory, fine motor skills, visual-motor integration, academic achievement, and social-emotional functioning. Differences between the two groups were evaluated using anova, t-tests and chi-squared statistical tests.

RESULTS

The supratentorial and infratentorial tumour location groups did not differ on measures of intellectual functioning. However, survivors of infratentorial tumours performed more poorly on selected measures of more specific cognitive functions and on parent-report of social-emotional functioning relative to survivors of supratentorial tumours, even when age at diagnosis was held as a covariate. Higher frequency of auditory deficits was noted in the infratentorial tumour group and was associated with lowered academic achievement scores.

CONCLUSIONS

The differences by location found in more specific neurocognitive and social-emotional variables, after controlling for age at diagnosis, may possibly reflect tumour location-specific effects. However, this interpretation remains tentative given the limitations in our study and inability to control for the range of medical and treatment-related factors that may have contributed towards the outcomes observed in our sample. At the same time, most of our findings appear consistent with reports from recent studies in this area.

[Apathy or depression? Do you have a nose for it? Four case reports of paramedian frontal tumors]

We report four cases of patients with clinically isolated apathy which was mistaken for depression even though they were suffering from voluminous brain tumors. These cases remind us that rigorous clinical analysis is essential: searching for signs of organic origin or psychiatric etiology is fundamental to avoid an incorrect diagnosis. In particular, these four patients displayed anosmia, an uncommon symptom for patients suffering from depression. In addition, brain imaging is important to correctly identify the most prudent medical and/or surgical management strategy. In this short discussion, we propose an algorithm for the clinical diagnosis of apathy.

Intelligence and adaptive function in children diagnosed with brain tumour during infancy

BACKGROUND

Late effects of treatment in children diagnosed and treated for brain tumours in infancy is a major concern. Assessment of infants presenting with brain tumours is difficult and there is little information available regarding the development of infants prior to treatment and hence the impact of the tumour itself on developmental outcomes.

AIM

To describe the development of children diagnosed with brain tumours in infancy and to document their cognitive and adaptive function at school entry.

METHOD

Infants were psychologically evaluated at the time of diagnosis of a brain tumour and during their fifth or sixth year in preparation for school entry.

RESULTS

Children diagnosed with brain tumours in infancy display developmental delays in a number of areas of adaptive function. By the time these children are school age they display further compromise in cognitive and academic skills and adaptive behaviour. Higher levels of deficit at follow-up were associated with tumour location in the supratentorium, younger age at diagnosis and longer time since diagnosis. The effect of radiotherapy could not be determined because of differing degrees of developmental compromise in the treatment groups at baseline.

CONCLUSION

Brain tumours in infancy confer a risk of poor developmental progress at the time of diagnosis. These children display additional compromise of development by the time they reach school age. Research protocols evaluating the impact of treatment in infants diagnosed with brain tumours need to take account of the developmental status of the child at diagnosis.

Importance of baseline mini-mental state examination as a prognostic factor for patients with low-grade glioma

PURPOSE

The outcome and cognitive performance data collected in a prospective, intergroup clinical trial were analyzed to assess the prognostic importance of the baseline (before radiotherapy) Mini-Mental State Examination (MMSE) score in patients with low-grade glioma.

METHODS AND MATERIALS

The patients studied were 203 adults with a supratentorial low-grade glioma randomly assigned to low-dose (50.4 Gy in 28 fractions) or high-dose (64.8 Gy in 36 fractions) localized radiotherapy. Folstein MMSE scores and neurologic function scores at baseline in combination with multiple other baseline variables were analyzed. The median follow-up was 7.4 years for the 101 patients still alive.

RESULTS

Patients (n = 36) with an abnormal baseline MMSE score (< or =26) had a worse 5-year progression-free survival rate (27% vs. 60%; p <0.001) and overall survival rate (31% vs. 76%; p <0.001) compared with those with a normal score. On multivariate analysis, the baseline MMSE score was a statistically significant predictor of survival. Other factors associated with overall survival were age, tumor size, and tumor histologic type.

CONCLUSION

The presence of an abnormal baseline MMSE score was a strong predictor of poorer progression-free and overall survival for patients with a low-grade glioma. The baseline MMSE should be considered in future prognostic scoring systems.

Adult patients with supratentorial pilocytic astrocytomas: a prospective multicenter clinical trial

PURPOSE

Supratentorial pilocytic astrocytomas in adults are uncommon. A prospective clinical trial was conducted to obtain clinical and outcome data in these patients.

METHODS AND MATERIALS

Between 1986 and 1994, 20 eligible adults with supratentorial pilocytic astrocytomas were enrolled in a prospective intergroup trial of radiotherapy (RT) after biopsy (3 patients) or observation after gross (11 patients) or subtotal (6 patients) resection.

RESULTS

At the time of analysis (median follow-up, 10 years), 1 patient (5%) had died and 19 patients (95%) were alive. The 5-year progression-free and overall survival rates were 95%. The cause of death in the patient who died (2.1 years after enrollment) was unknown; a radiographic examination obtained shortly before the patient's demise revealed no signs of progression. Progression in 1 patient approximately 1 month after enrollment required injection of (32)P into an enlarging cyst. The patient required RT approximately 18 months later because of further progression. This patient was alive without evidence of progression 9 years after RT. No toxic effects had been recorded at the latest follow-up examinations.

CONCLUSION

With follow-up comparable or superior to that in many retrospective studies, the results of this prospective trial confirm that adults with pilocytic astrocytomas have a favorable prognosis with regard to survival and neurologic function. The vast majority of patients remained stable after gross or subtotal resection and no adjuvant therapy. RT need not be offered to adults with supratentorial pilocytic astrocytoma after gross or subtotal resection; instead, close observation is recommended. Because only 3 patients received RT after biopsy, it is difficult to comment on the effect of RT on their outcome as a group.

Acute effects on neuropsychological function and quality of life by high-dose multiple daily fractionated radiotherapy for malignant astrocytomas: assessing the tolerability of a new radiotherapy regimen

Cognitive and other quality of life measures were assessed in 29 patients with supratentorial malignant astrocytomas before and after high-dose (8000 cGy) multiple daily fractionated radiotherapy. Assessments were done immediately before and after radiotherapy. Patients completed a neuropsychological evaluation and the Functional Living Index: Cancer (FLIC). Spouses completed the Family Environment Scale and the Profile of Mood States. Cognitive abilities generally improved over the course of radiotherapy. Occasionally, deterioration of potential clinical importance was observed on functions associated with the tumour site. Quality of life as assessed by the FLIC was stable in most cases and improved in five, but deteriorated in three patients. Families showed slightly less Conflict and slightly more Cohesion than the norm; this was especially so when patients had greater cognitive deficit. Emotional state of spouses was variable, with increased fatigue or reduced activity most commonly reported, followed by depression and anxiety. Mostly this improved with time or remained stable, but two spouses reported worsening emotional state. Results are generally encouraging for tolerance of this radiotherapy protocol, although they demonstrate that limited adverse effects may occur in some cases.

Early mental changes in patients with astrocytomas with special reference to anxiety and epilepsy

This study of 47 patients with low- and high-grade gliomas retrospectively focuses on the patients' history with regard to affective and cognitive disturbances as well as to the presence of epileptic manifestations. Early emotional changes with a sudden onset were common in both patient groups, especially panic-like anxiety. It is suggested that patients with a high-grade glioma may present with affective disturbances with a sudden onset, while such disturbances in patients with low-grade gliomas could be of epileptiform origin. It is also suggested that the biochemical bases of anxiety and epilepsy in glioma patients could be analyzed to understand underlying biopsychological mechanisms of malignant brain tumors.

[Supratentorial gliomas: neuropsychological study of long-term survivors]

A battery of psychologic tests was administered to 32 patients, aged from 26 to 61 years, who had survived 2 years or more after treatment with surgery and radiotherapy for supratentorial gliomas (18 low grade and 14 high grade) without evidence of recurrent tumor on MRI. Two groups were identified. A first group of 17 patients had neuropsychologic scores similar to estimated premorbid level (group I). A second group of 15 patients had abnormal neuropsychologic scores, lower that their estimated premorbid level (group II). In comparison with "normal" patients, those with abnormal neuropsychologic scores were older at the time of treatment, had a lower post-operative Karnofski Performance Status, a longer delay between surgery and the date of the tests and more often had left sided lesions. Comparison of Karnofski Performance Status between the post-operative time point and the date of neuropsychological evaluation did not show a significant change over time in groups I and II except in 3 patients who experienced progressive deterioration. Vigorous treatment of gliomas with surgery, radiotherapy and sometimes chemotherapy does not induce a substantial cognitive dysfunction in about half of the long term survivors (53%). Cognitive dysfunction is identified in the other half that could be related to post-operative sequelae (due to the tumor itself or to surgery) and/or to radiotherapy- and chemotherapy-induced delayed toxicity.

Cognitive impairment and quality of life in long-term survivors of malignant brain tumors

Thirtysix long-term survivors following the treatment of a malignant supratentorial brain tumor were examined for cognitive functions and global level of autonomy. Eighteen patients were symptom-free (SF) and 18 had clinical and neuroradiological recurrence (RE). The control group included 30 healthy subjects. All subjects underwent a neuropsychological battery for general and specific cognitive functions. The level of autonomy was assessed by means of the Karnofsky Performance Scale (KPS) for oncological patients. SF patients showed less impairment than RE patients both at the tests, as well as on the KPS. The cognitive deficits were subclinical in most SF patients, the tests for attention, memory and word fluency being the most sensitive in detecting subtle dysfunctions. The association between tumor location and specific cognitive deficits was inconstant in both patient groups. The results suggest that even subtle cognitive deficits can prevent SF long-term survivors from returning to premorbid autonomy and occupations, and that neuropsychological tests may be used as complementary routine indicators of their quality of life. Furthermore, our data show that, in selected patients, combined treatments and therapeutic insistence do not necessarily have the same deleterious effects.