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Kram L, Neu B, Schroeder A, Wiestler B, Meyer B, Krieg SM, Ille S. Toward a systematic grading for the selection of patients to undergo awake surgery: identifying suitable predictor variables. Front Hum Neurosci 2024; 18:1365215. [PMID: 38756845 PMCID: PMC11096515 DOI: 10.3389/fnhum.2024.1365215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
Background Awake craniotomy is the standard of care for treating language eloquent gliomas. However, depending on preoperative functionality, it is not feasible in each patient and selection criteria are highly heterogeneous. Thus, this study aimed to identify broadly applicable predictor variables allowing for a more systematic and objective patient selection. Methods We performed post-hoc analyses of preoperative language status, patient and tumor characteristics including language eloquence of 96 glioma patients treated in a single neurosurgical center between 05/2018 and 01/2021. Multinomial logistic regression and stepwise variable selection were applied to identify significant predictors of awake surgery feasibility. Results Stepwise backward selection confirmed that a higher number of paraphasias, lower age, and high language eloquence level were suitable indicators for an awake surgery in our cohort. Subsequent descriptive and ROC-analyses indicated a cut-off at ≤54 years and a language eloquence level of at least 6 for awake surgeries, which require further validation. A high language eloquence, lower age, preexisting semantic and phonological aphasic symptoms have shown to be suitable predictors. Conclusion The combination of these factors may act as a basis for a systematic and standardized grading of patients' suitability for an awake craniotomy which is easily integrable into the preoperative workflow across neurosurgical centers.
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Affiliation(s)
- Leonie Kram
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - Beate Neu
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Benedikt Wiestler
- Section of Diagnostic and Interventional Neuroradiology, Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
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Kram L, Schroeder A, Meyer B, Krieg SM, Ille S. Function-guided differences of arcuate fascicle and inferior fronto-occipital fascicle tractography as diagnostic indicators for surgical risk stratification. Brain Struct Funct 2024:10.1007/s00429-024-02787-3. [PMID: 38597941 DOI: 10.1007/s00429-024-02787-3] [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: 09/17/2023] [Accepted: 03/05/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Several patients with language-eloquent gliomas face language deterioration postoperatively. Persistent aphasia is frequently associated with damage to subcortical language pathways. Underlying mechanisms still need to be better understood, complicating preoperative risk assessment. This study compared qualitative and quantitative functionally relevant subcortical differences pre- and directly postoperatively in glioma patients with and without aphasia. METHODS Language-relevant cortical sites were defined using navigated transcranial magnetic stimulation (nTMS) language mapping in 74 patients between 07/2016 and 07/2019. Post-hoc nTMS-based diffusion tensor imaging tractography was used to compare a tract's pre- and postoperative visualization, volume and fractional anisotropy (FA), and the preoperative distance between tract and lesion and postoperative overlap with the resection cavity between the following groups: no aphasia (NoA), tumor- or previous resection induced aphasia persistent pre- and postoperatively (TIA_P), and surgery-induced transient or permanent aphasia (SIA_T or SIA_P). RESULTS Patients with NoA, TIA_P, SIA_T, and SIA_P showed distinct fasciculus arcuatus (AF) and inferior-fronto-occipital fasciculus (IFOF) properties. The AF was more frequently reconstructable, and the FA of IFOF was higher in NoA than TIA_P cases (all p ≤ 0.03). Simultaneously, SIA_T cases showed higher IFOF fractional anisotropy than TIA_P cases (p < 0.001) and the most considerable AF volume loss overall. While not statistically significant, the four SIA_P cases showed complete loss of ventral language streams postoperatively, the highest resection-cavity-AF-overlap, and the shortest AF to tumor distance. CONCLUSION Functionally relevant qualitative and quantitative differences in AF and IFOF provide a pre- and postoperative pathophysiological and clinically relevant diagnostic indicator that supports surgical risk stratification.
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Affiliation(s)
- Leonie Kram
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University, Heidelberg, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University, Heidelberg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany.
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University, Heidelberg, Germany.
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Kram L, Ohlerth AK, Ille S, Meyer B, Krieg SM. CompreTAP: Feasibility and reliability of a new language comprehension mapping task via preoperative navigated transcranial magnetic stimulation. Cortex 2024; 171:347-369. [PMID: 38086145 DOI: 10.1016/j.cortex.2023.09.023] [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: 11/01/2022] [Revised: 02/01/2023] [Accepted: 09/25/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Stimulation-based language mapping approaches that are used pre- and intraoperatively employ predominantly overt language tasks requiring sufficient language production abilities. Yet, these production-based setups are often not feasible in brain tumor patients with severe expressive aphasia. This pilot study evaluated the feasibility and reliability of a newly developed language comprehension task with preoperative navigated transcranial magnetic stimulation (nTMS). METHODS Fifteen healthy subjects and six brain tumor patients with severe expressive aphasia unable to perform classic overt naming tasks underwent preoperative nTMS language mapping based on an auditory single-word Comprehension TAsk for Perioperative mapping (CompreTAP). Comprehension was probed by button-press responses to auditory stimuli, hence not requiring overt language responses. Positive comprehension areas were identified when stimulation elicited an incorrect or delayed button press. Error categories, case-wise cortical error rate distribution and inter-rater reliability between two experienced specialists were examined. RESULTS Overall, the new setup showed to be feasible. Comprehension-disruptions induced by nTMS manifested in no responses, delayed or hesitant responses, searching behavior or selection of wrong target items across all patients and controls and could be performed even in patients with severe expressive aphasia. The analysis agreement between both specialists was substantial for classifying comprehension-positive and -negative sites. Extensive left-hemispheric individual cortical comprehension sites were identified for all patients. Apart from one case presenting with transient worsening of aphasic symptoms, pre-existing language deficits did not aggravate if results were used for subsequent surgical planning. CONCLUSION Employing this new comprehension-based nTMS setup allowed to identify language relevant cortical sites in all healthy subjects and severely aphasic patients who were thus far precluded from classic production-based mapping. This pilot study, moreover, provides first indications that the CompreTAP mapping results may support the preservation of residual language function if used for subsequent surgical planning.
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Affiliation(s)
- Leonie Kram
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Germany; Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Ann-Katrin Ohlerth
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Germany; Neurobiology of Language Department, Max Planck Institute for Psycholinguistics, Nijmegen, the Netherlands
| | - Sebastian Ille
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Germany; TUM Neuroimaging Center, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Germany; Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Germany; TUM Neuroimaging Center, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Germany; Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany.
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Kram L, Neu B, Schröder A, Meyer B, Krieg SM, Ille S. Improving specificity of stimulation-based language mapping in stuttering glioma patients: A mixed methods serial case study. Heliyon 2023; 9:e21984. [PMID: 38045205 PMCID: PMC10692765 DOI: 10.1016/j.heliyon.2023.e21984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/29/2023] [Accepted: 11/01/2023] [Indexed: 12/05/2023] Open
Abstract
Objective Stimulation-based language mapping relies on identifying stimulation-induced language disruptions, which preexisting speech disorders affecting the laryngeal and orofacial speech system can confound. This study ascertained the effects of preexisting stuttering on pre- and intraoperative language mapping to improve the reliability and specificity of established language mapping protocols in the context of speech fluency disorders. Method Differentiation-ability of a speech therapist and two experienced nrTMS examiners between stuttering symptoms and stimulation-induced language errors during preoperative mappings were retrospectively compared (05/2018-01/2021). Subsequently, the impact of stuttering on intraoperative mappings was evaluated in all prospective patients (01/2021-12/2022). Results In the first part, 4.85 % of 103 glioma patients stuttered. While both examiners had a significant agreement for misclassifying pauses in speech flow and prolongations (Κ ≥ 0.50, p ≤ 0.02, respectively), less experience resulted in more misclassified stuttering symptoms. In one awake surgery case within the second part, stuttering decreased the reliability of intraoperative language mapping.Comparison with Existing Method(s): By thoroughly differentiating speech fluency symptoms from stimulation-induced disruptions, the reliability and proportion of stuttering symptoms falsely attributed to stimulation-induced language network disruptions can be improved. This may increase the consistency and specificity of language mapping results in stuttering glioma patients. Conclusions Preexisting stuttering negatively impacted language mapping specificity. Thus, surgical planning and the functional outcome may benefit substantially from thoroughly differentiating speech fluency symptoms from stimulation-induced disruptions by trained specialists.
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Affiliation(s)
- Leonie Kram
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Beate Neu
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Axel Schröder
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht-Karls-University Heidelberg, Germany
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Boerner C, Schroeder A, Meyer B, Krieg SM, Ille S. Cortical Location of Language Function May Differ between Languages While White Matter Pathways Are Similar in Brain Lesion Patients. Brain Sci 2023; 13:1141. [PMID: 37626496 PMCID: PMC10452579 DOI: 10.3390/brainsci13081141] [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: 04/16/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023] Open
Abstract
The neural representation of language can be identified cortically using navigated repetitive transcranial magnetic stimulation and subcortically using the fiber tracking of diffusion tensor imaging. We investigated how cortical locations of language and language-eloquent white matter pathways differ in 40 brain lesion patients speaking various languages. Error rates related to stimulations at single sites in the frontal and parietal lobe differed significantly between Balto-Slavic and Indo-European languages. Error rates related to stimulations at single sites in the temporal lobe differed significantly between bilingual individuals. No differences were found in the white matter language pathway volumes between Balto-Slavic and Indo-European languages nor between bilingual patients. These original and exploratory data indicate that the underlying subcortical structure might be similar across languages, with initially observed differences in the cortical location of language depending on the semantic processing, but these could not be confirmed using detailed statistical analyses pointing at a similar cortical and subcortical network.
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Affiliation(s)
- Corinna Boerner
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
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Al-Adli NN, Young JS, Sibih YE, Berger MS. Technical Aspects of Motor and Language Mapping in Glioma Patients. Cancers (Basel) 2023; 15:cancers15072173. [PMID: 37046834 PMCID: PMC10093517 DOI: 10.3390/cancers15072173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023] Open
Abstract
Gliomas are infiltrative primary brain tumors that often invade functional cortical and subcortical regions, and they mandate individualized brain mapping strategies to avoid postoperative neurological deficits. It is well known that maximal safe resection significantly improves survival, while postoperative deficits minimize the benefits associated with aggressive resections and diminish patients’ quality of life. Although non-invasive imaging tools serve as useful adjuncts, intraoperative stimulation mapping (ISM) is the gold standard for identifying functional cortical and subcortical regions and minimizing morbidity during these challenging resections. Current mapping methods rely on the use of low-frequency and high-frequency stimulation, delivered with monopolar or bipolar probes either directly to the cortical surface or to the subcortical white matter structures. Stimulation effects can be monitored through patient responses during awake mapping procedures and/or with motor-evoked and somatosensory-evoked potentials in patients who are asleep. Depending on the patient’s preoperative status and tumor location and size, neurosurgeons may choose to employ these mapping methods during awake or asleep craniotomies, both of which have their own benefits and challenges. Regardless of which method is used, the goal of intraoperative stimulation is to identify areas of non-functional tissue that can be safely removed to facilitate an approach trajectory to the equator, or center, of the tumor. Recent technological advances have improved ISM’s utility in identifying subcortical structures and minimized the seizure risk associated with cortical stimulation. In this review, we summarize the salient technical aspects of which neurosurgeons should be aware in order to implement intraoperative stimulation mapping effectively and safely during glioma surgery.
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Affiliation(s)
- Nadeem N. Al-Adli
- Department of Neurological Surgery, University of California, San Francisco, CA 94131, USA
- School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Jacob S. Young
- Department of Neurological Surgery, University of California, San Francisco, CA 94131, USA
| | - Youssef E. Sibih
- School of Medicine, University of California, San Francisco, CA 94131, USA
| | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, CA 94131, USA
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Ius T, Sabatino G, Panciani PP, Fontanella MM, Rudà R, Castellano A, Barbagallo GMV, Belotti F, Boccaletti R, Catapano G, Costantino G, Della Puppa A, Di Meco F, Gagliardi F, Garbossa D, Germanò AF, Iacoangeli M, Mortini P, Olivi A, Pessina F, Pignotti F, Pinna G, Raco A, Sala F, Signorelli F, Sarubbo S, Skrap M, Spena G, Somma T, Sturiale C, Angileri FF, Esposito V. Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review. J Neurooncol 2023; 162:267-293. [PMID: 36961622 PMCID: PMC10167129 DOI: 10.1007/s11060-023-04274-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/20/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. METHODS A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. RESULTS A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). CONCLUSIONS A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity.
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Affiliation(s)
- Tamara Ius
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Pier Paolo Panciani
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
| | - Marco Maria Fontanella
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University of Turin and City of Health and Science Hospital, 10094, Torino, Italy
- Neurology Unit, Hospital of Castelfranco Veneto, 31033, Castelfranco Veneto, Italy
| | - Antonella Castellano
- Department of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe Maria Vincenzo Barbagallo
- Department of Medical and Surgical Sciences and Advanced Technologies (G.F. Ingrassia), Neurological Surgery, Policlinico "G. Rodolico - San Marco" University Hospital, University of Catania, Catania, Italy
- Interdisciplinary Research Center On Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Francesco Belotti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe Catapano
- Division of Neurosurgery, Department of Neurological Sciences, Ospedale del Mare, Naples, Italy
| | | | - Alessandro Della Puppa
- Neurosurgical Clinical Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi Hospital, University of Florence, Florence, Italy
| | - Francesco Di Meco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Johns Hopkins Medical School, Baltimore, MD, USA
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Torino, Italy
| | | | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica Delle Marche, Azienda Ospedali Riuniti, Ancona, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | | | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Italy
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Italy
| | - Fabrizio Pignotti
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Giampietro Pinna
- Unit of Neurosurgery, Department of Neurosciences, Hospital Trust of Verona, 37134, Verona, Italy
| | - Antonino Raco
- Division of Neurosurgery, Department of NESMOS, AOU Sant'Andrea, Sapienza University, Rome, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicines and Movement Sciences, Institute of Neurosurgery, University of Verona, 37134, Verona, Italy
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Neurosurgery Unit, University "Aldo Moro", 70124, Bari, Italy
| | - Silvio Sarubbo
- Department of Neurosurgery, Santa Chiara Hospital, Azienda Provinciale Per I Servizi Sanitari (APSS), Trento, Italy
| | - Miran Skrap
- Division of Neurosurgery, Head-Neck and NeuroScience Department, University Hospital of Udine, Udine, Italy
| | | | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | | | | | - Vincenzo Esposito
- Department of Neurosurgery "Giampaolo Cantore"-IRCSS Neuromed, Pozzilli, Italy
- Department of Human, Neurosciences-"Sapienza" University of Rome, Rome, Italy
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Dmitriev AY, Dashyan VG. [Tractography in functional neuronavigation]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:12-18. [PMID: 37490660 DOI: 10.17116/jnevro202312307112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
The review addresses the combined use of tractography and neuronavigation. Fundamentals of diffusion tensor imaging are given, technical aspects of fiber tracking in general and in depicting separate subcortical tracts are described. Main advantages of the method and possible causes of errors are highlighted. Precision assessment of this technology is given by comparing with results of subcortical neurostimulation. Surgical tactics is described depending on distance between the tumor and subcortical pathways.
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Affiliation(s)
- A Yu Dmitriev
- Sklifosovsky Research Institute for Emergency, Moscow, Russia
- Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V G Dashyan
- Sklifosovsky Research Institute for Emergency, Moscow, Russia
- Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Raffa G, Marzano G, Curcio A, Espahbodinea S, Germanò A, Angileri FF. Personalized surgery of brain tumors in language areas: the role of preoperative brain mapping in patients not eligible for awake surgery. Neurosurg Focus 2022. [DOI: 10.3171/2022.9.focus22415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE
Awake surgery represents the gold standard for resection of brain tumors close to the language network. However, in some cases patients may be considered not eligible for awake craniotomy. In these cases, a personalized brain mapping of the language network may be achieved by navigated transcranial magnetic stimulation (nTMS), which can guide resection in patients under general anesthesia. Here the authors describe their tailored nTMS-based strategy and analyze its impact on the extent of tumor resection (EOR) and language outcome in a series of patients not eligible for awake surgery.
METHODS
The authors reviewed data from all patients harboring a brain tumor in or close to the language network who were considered not eligible for awake surgery and were operated on during asleep surgery between January 2017 and July 2022, under the intraoperative guidance of nTMS data. The authors analyzed the effectiveness of nTMS-based mapping data in relation to 1) the ability of the nTMS-based mapping to stratify patients according to surgical risks, 2) the occurrence of postoperative language deficits, and 3) the EOR.
RESULTS
A total of 176 patients underwent preoperative nTMS cortical language mapping and nTMS-based tractography of language fascicles. According to the nTMS-based mapping, tumors in 115 patients (65.3%) were identified as true-eloquent tumors because of a close spatial relationship with the language network. Conversely, tumors in 61 patients (34.7%) for which the nTMS mapping disclosed a location at a safer distance from the network were identified as false-eloquent tumors. At 3 months postsurgery, a permanent language deficit was present in 13 patients (7.3%). In particular, a permanent deficit was observed in 12 of 115 patients (10.4%) with true-eloquent tumors and in 1 of 61 patients (1.6%) with false-eloquent lesions. With nTMS-based mapping, neurosurgeons were able to distinguish true-eloquent from false-eloquent tumors in a significant number of cases based on the occurrence of deficits at discharge (p < 0.0008) and after 3 months from surgery (OR 6.99, p = 0.03). Gross-total resection was achieved in 80.1% of patients overall and in 69.5% of patients with true-eloquent lesions and 100% of patients with false-eloquent tumors.
CONCLUSIONS
nTMS-based mapping allows for reliable preoperative mapping of the language network that may be used to stratify patients according to surgical risks. nTMS-guided asleep surgery should be considered a good alternative for personalized preoperative brain mapping of the language network that may increase the possibility of safe and effective resection of brain tumors in the dominant hemisphere whenever awake mapping is not feasible.
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Affiliation(s)
- Giovanni Raffa
- Division of Neurosurgery, BIOMORF Department, University of Messina; and
| | - Giuseppina Marzano
- Division of Neurosurgery, A.O.U. Policlinico “G. Martino,” Messina, Italy
| | - Antonello Curcio
- Division of Neurosurgery, BIOMORF Department, University of Messina; and
| | | | - Antonino Germanò
- Division of Neurosurgery, BIOMORF Department, University of Messina; and
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Natalizi F, Piras F, Vecchio D, Spalletta G, Piras F. Preoperative Navigated Transcranial Magnetic Stimulation: New Insight for Brain Tumor-Related Language Mapping. J Pers Med 2022; 12:1589. [PMID: 36294728 PMCID: PMC9604795 DOI: 10.3390/jpm12101589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 08/30/2023] Open
Abstract
Preoperative brain mapping methods are particularly important in modern neuro-oncology when a tumor affects eloquent language areas since damage to parts of the language circuits can cause significant impairments in daily life. This narrative review examines the literature regarding preoperative and intraoperative language mapping using repetitive navigated transcranial magnetic stimulation (rnTMS) with or without direct electrical stimulation (DES) in adult patients with tumors in eloquent language areas. The literature shows that rnTMS is accurate in detecting preexisting language disorders and positive intraoperative mapping regions. In terms of the region extent and clinical outcomes, rnTMS has been shown to be accurate in identifying positive sites to guide resection, reducing surgery duration and craniotomy size and thus improving clinical outcomes. Before incorporating rnTMS into the neurosurgical workflow, the refinement of protocols and a consensus within the neuro-oncology community are required.
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Affiliation(s)
- Federica Natalizi
- Laboratory of Neurophychiatry, IRCSS Santa Lucia Fundation, Via Ardeatina 306, 00134 Rome, Italy
- Department of Psychology, “Sapienza” University of Rome, Via dei Marsi 78, 00185 Rome, Italy
- PhD Program in Behavioral Neuroscience, Sapienza University of Rome, 00161 Rome, Italy
| | - Federica Piras
- Laboratory of Neurophychiatry, IRCSS Santa Lucia Fundation, Via Ardeatina 306, 00134 Rome, Italy
| | - Daniela Vecchio
- Laboratory of Neurophychiatry, IRCSS Santa Lucia Fundation, Via Ardeatina 306, 00134 Rome, Italy
| | - Gianfranco Spalletta
- Laboratory of Neurophychiatry, IRCSS Santa Lucia Fundation, Via Ardeatina 306, 00134 Rome, Italy
| | - Fabrizio Piras
- Laboratory of Neurophychiatry, IRCSS Santa Lucia Fundation, Via Ardeatina 306, 00134 Rome, Italy
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11
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Cognitive deficits in adult patients with high-grade glioma: A systematic review. Clin Neurol Neurosurg 2022; 219:107296. [DOI: 10.1016/j.clineuro.2022.107296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 04/04/2022] [Accepted: 05/13/2022] [Indexed: 11/15/2022]
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12
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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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13
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Gerritsen JKW, Broekman MLD, De Vleeschouwer S, Schucht P, Nahed BV, Berger MS, Vincent AJPE. Safe Surgery for Glioblastoma: Recent Advances and Modern Challenges. Neurooncol Pract 2022; 9:364-379. [PMID: 36127890 PMCID: PMC9476986 DOI: 10.1093/nop/npac019] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
One of the major challenges during glioblastoma surgery is balancing between maximizing extent of resection and preventing neurological deficits. Several surgical techniques and adjuncts have been developed to help identify eloquent areas both preoperatively (fMRI, nTMS, MEG, DTI) and intraoperatively (imaging (ultrasound, iMRI), electrostimulation (mapping), cerebral perfusion measurements (fUS)), and visualization (5-ALA, fluoresceine)). In this review, we give an update of the state-of-the-art management of both primary and recurrent glioblastomas. We will review the latest surgical advances, challenges, and approaches that define the onco-neurosurgical practice in a contemporary setting and give an overview of the current prospective scientific efforts.
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Affiliation(s)
| | | | | | - Philippe Schucht
- Department of Neurosurgery, University Hospital Bern, Switzerland
| | - Brian Vala Nahed
- Department of Neurosurgery, Massachusetts General Hospital/Harvard Medical School, Boston MA, USA
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14
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Muir M, Patel R, Traylor J, de Almeida Bastos DC, Prinsloo S, Liu HL, Noll K, Wefel J, Tummala S, Kumar V, Prabhu S. Validation of Non-invasive Language Mapping Modalities for Eloquent Tumor Resection: A Pilot Study. Front Neurosci 2022; 16:833073. [PMID: 35299624 PMCID: PMC8923233 DOI: 10.3389/fnins.2022.833073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Many studies have established a link between extent of resection and survival in patients with gliomas. Surgeons must optimize the oncofunctional balance by maximizing the extent of resection and minimizing postoperative neurological morbidity. Preoperative functional imaging modalities are important tools for optimizing the oncofunctional balance. Transcranial magnetic stimulation (TMS) and functional magnetic resonance imaging (fMRI) are non-invasive imaging modalities that can be used for preoperative functional language mapping. Scarce data exist evaluating the accuracy of these preoperative modalities for language mapping compared with gold standard intraoperative data in the same cohort. This study compares the accuracy of fMRI and TMS for language mapping compared with intraoperative direct cortical stimulation (DCS). We also identified significant predictors of preoperative functional imaging accuracy, as well as significant predictors of functional outcomes. Evidence from this study could inform clinical judgment as well as provide neuroscientific insight. We used geometric distances to determine copositivity between preoperative data and intraoperative data. Twenty-eight patients were included who underwent both preoperative fMRI and TMS procedures, as well as an awake craniotomy and intraoperative language mapping. We found that TMS shows significantly superior correlation to intraoperative DCS compared with fMRI. TMS also showed significantly higher sensitivity and negative predictive value than specificity and positive predictive value. Poor cognitive baseline was associated with decreased TMS accuracy as well as increased risk for worsened aphasia postoperatively. TMS has emerged as a promising preoperative language mapping tool. Future work should be done to identify the proper role of each imaging modality in a comprehensive, multimodal approach to optimize the oncofunctional balance.
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Affiliation(s)
- Matthew Muir
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rajan Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Jeffrey Traylor
- Department of Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | - Sarah Prinsloo
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ho-Ling Liu
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kyle Noll
- Department of Neuropsychology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jeffrey Wefel
- Department of Neuropsychology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sudhakar Tummala
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Vinodh Kumar
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sujit Prabhu
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- *Correspondence: Sujit Prabhu,
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15
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Giampiccolo D, Nunes S, Cattaneo L, Sala F. Functional Approaches to the Surgery of Brain Gliomas. Adv Tech Stand Neurosurg 2022; 45:35-96. [PMID: 35976447 DOI: 10.1007/978-3-030-99166-1_2] [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] [Indexed: 06/15/2023]
Abstract
In the surgery of gliomas, recent years have witnessed unprecedented theoretical and technical development, which extensively increased indication to surgery. On one hand, it has been solidly demonstrated the impact of gross total resection on life expectancy. On the other hand, the paradigm shift from classical cortical localization of brain function towards connectomics caused by the resurgence of awake surgery and the advent of tractography has permitted safer surgeries focused on subcortical white matter tracts preservation and allowed for surgical resections within regions, such as Broca's area or the primary motor cortex, which were previously deemed inoperable. Furthermore, new asleep electrophysiological techniques have been developed whenever awake surgery is not an option, such as operating in situations of poor compliance (including paediatric patients) or pre-existing neurological deficits. One such strategy is the use of intraoperative neurophysiological monitoring (IONM), enabling the identification and preservation of functionally defined, but anatomically ambiguous, cortico-subcortical structures through mapping and monitoring techniques. These advances tie in with novel challenges, specifically risk prediction and the impact of neuroplasticity, the indication for tumour resection beyond visible borders, or supratotal resection, and most of all, a reappraisal of the importance of the right hemisphere from early psychosurgery to mapping and preservation of social behaviour, executive control, and decision making.Here we review current advances and future perspectives in a functional approach to glioma surgery.
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Affiliation(s)
- Davide Giampiccolo
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, University of Verona, Verona, Italy
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College London, London, UK
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Institute of Neurosciences, Cleveland Clinic London, London, UK
| | - Sonia Nunes
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, University of Verona, Verona, Italy
| | - Luigi Cattaneo
- Center for Mind and Brain Sciences (CIMeC) and Center for Medical Sciences (CISMed), University of Trento, Trento, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, University of Verona, Verona, Italy.
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16
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Dmitriev AY, Dashyan VG. [Intraoperative brain shift in neuronavigation. Causes, clinical significance and solution of the problem]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:119-124. [PMID: 35412721 DOI: 10.17116/neiro202286021119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Intraoperative brain shift is the main cause of inaccurate navigation. This limits the use of both conventional and functional neuronavigation. Causes of brain shift are divided into surgical, pathophysiological and metabolic ones. Brain shift is usually unidirectional and directed towards gravitation. Brain dislocation depends on lesion size and its location. Shift is minimal in patients with tumors <20 ml and skull base neoplasms. Small craniotomy, retractor-free surgery and no ventriculostomy are valuable to reduce brain shift. Brain dislocation increases during surgery that's why marking of eloquent lesions at the beginning of surgery and primary resection near subcortical tracts minimize the risk of damage to conduction pathways. Augmented reality and manual shift of marked objects are the cornerstones of linear correction of brain shift in modern navigation systems. In case of nonlinear brain shift, sonography and intraoperative magnetic resonance imaging can clarify location of surgical target and cerebral structures.
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Affiliation(s)
- A Yu Dmitriev
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V G Dashyan
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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17
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Ille S, Schroeder A, Hostettler IC, Wostrack M, Meyer B, Krieg SM. Impacting the Treatment of Highly Eloquent Supratentorial Cerebral Cavernous Malformations by Noninvasive Functional Mapping-An Observational Cohort Study. Oper Neurosurg (Hagerstown) 2021; 21:467-477. [PMID: 34624894 DOI: 10.1093/ons/opab318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/18/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) may cause cavernoma-related epilepsy (CRE) and intracranial hemorrhage (ICH). Functional mapping has shown its usefulness during the resection of eloquent lesions including the treatment of brain arteriovenous malformations. OBJECTIVE To evaluate the impact of noninvasive functional mapping on decision-making and resection of eloquently located CCM. METHODS Of 126 patients with intracranial cavernomas, we prospectively included 40 consecutive patients (31.7%) with highly eloquent CCM between 2012 and 2020. We performed functional mapping via navigated transcranial magnetic stimulation (nTMS) motor mapping in 30 cases and nTMS language mapping in 20 cases. Twenty patients suffered from CRE. CCM caused ICH in 18 cases. RESULTS We used functional mapping data including function-based tractography in all cases. Indication toward (31 cases) or against (9 cases) CCM resection was influenced by noninvasive functional mapping in 36 cases (90%). We resected CCMs in 24 cases, and 7 patients refused the recommendation for surgery. In 19 and 4 cases, we used additional intraoperative neuromonitoring and awake craniotomy, respectively. Patients suffered from transient postoperative motor or language deficits in 2 and 2 cases, respectively. No patient suffered from permanent deficits. After 1 yr of follow-up, anti-epileptic drugs could be discontinued in all patients who underwent surgery but 1 patient. CONCLUSION Surgery-related deficit rates are low even for highly eloquent CCM and seizure outcome is excellent. The present results show that noninvasive functional mapping and function-based tractography is a useful tool for the decision-making process and during microsurgical resection of eloquently located CCM.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Isabel C Hostettler
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
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18
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Clinical and Imaging Study of Repetitive Transcranial Magnetic Stimulation in the Treatment of Morphine Dependence Through mGluR5/TDP43/NR2B Pathway. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:6733963. [PMID: 34721826 PMCID: PMC8550831 DOI: 10.1155/2021/6733963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022]
Abstract
Morphine is tolerable after long-term use. After long-term use, it will have a great impact on the human body, and the treatment effect is not good. In recent years, the continuous development of repetitive transcranial magnetic stimulation (rTMS) treatment technology has made a treatment. Drug-resistant morphine dependence has a breakthrough. In this article, to study the effect of repeated transcranial magnetic stimulation in the treatment of morphine dependence through mGluR5/TDP43/NR2B pathway, experiments were carried out on rats to compare the changes in the images of rats after different periods of morphine use and their effects on morphine withdrawal. During the period, the performance of rats provides a reference for repeated transcranial stimulation to treat morphine dependence. According to the experimental results, after stopping morphine, withdrawal from the rats, irritable acts, and patience diminished. This is a decrease of more than 50% in comparison with the one of the normal group. There was a different degree of variability in the treatment images of mGluR5/TDP43 and so on after rTMS treatment, and the changes were large. These reductions in detoxification responses in rodents suggest that rTMS serves an instrumental role in the prevention and treatment of phosphorylation related to morphine dependence.
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19
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Bihemispheric Navigated Transcranial Magnetic Stimulation Mapping for Action Naming Compared to Object Naming in Sentence Context. Brain Sci 2021; 11:brainsci11091190. [PMID: 34573211 PMCID: PMC8469437 DOI: 10.3390/brainsci11091190] [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: 08/14/2021] [Accepted: 09/03/2021] [Indexed: 11/17/2022] Open
Abstract
Preoperative language mapping with navigated transcranial magnetic stimulation (nTMS) is currently based on the disruption of performance during object naming. The resulting cortical language maps, however, lack accuracy when compared to intraoperative mapping. The question arises whether nTMS results can be improved, when another language task is considered, involving verb retrieval in sentence context. Twenty healthy German speakers were tested with object naming and a novel action naming task during nTMS language mapping. Error rates and categories in both hemispheres were compared. Action naming showed a significantly higher error rate than object naming in both hemispheres. Error category comparison revealed that this discrepancy stems from more lexico-semantic errors during action naming, indicating lexico-semantic retrieval of the verb being more affected than noun retrieval. In an area-wise comparison, higher error rates surfaced in multiple right-hemisphere areas, but only trends in the left ventral postcentral gyrus and middle superior temporal gyrus. Hesitation errors contributed significantly to the error count, but did not dull the mapping results. Inclusion of action naming coupled with a detailed error analysis may be favorable for nTMS mapping and ultimately improve accuracy in preoperative planning. Moreover, the results stress the recruitment of both left- and right-hemispheric areas during naming.
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20
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Silva LL, Tuncer MS, Vajkoczy P, Picht T, Rosenstock T. Distinct approaches to language pathway tractography: comparison of anatomy-based, repetitive navigated transcranial magnetic stimulation (rTMS)-based, and rTMS-enhanced diffusion tensor imaging-fiber tracking. J Neurosurg 2021; 136:589-600. [PMID: 34330091 DOI: 10.3171/2020.12.jns204028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Visualization of subcortical language pathways by means of diffusion tensor imaging-fiber tracking (DTI-FT) is evolving as an important tool for surgical planning and decision making in patients with language-suspect brain tumors. Repetitive navigated transcranial magnetic stimulation (rTMS) cortical language mapping noninvasively provides additional functional information. Efforts to incorporate rTMS data into DTI-FT are promising, but the lack of established protocols makes it hard to assess clinical utility. The authors performed DTI-FT of important language pathways by using five distinct approaches in an effort to evaluate the respective clinical usefulness of each approach. METHODS Thirty patients with left-hemispheric perisylvian lesions underwent preoperative rTMS language mapping and DTI. FT of the principal language tracts was conducted according to different strategies: Ia, anatomical landmark based; Ib, lesion-focused landmark based; IIa, rTMS based; IIb, rTMS based with postprocessing; and III, rTMS enhanced (based on a combination of structural and functional data). The authors analyzed the respective success of each method in revealing streamlines and conducted a multinational survey with expert clinicians to evaluate aspects of clinical utility. RESULTS The authors observed high usefulness and accuracy ratings for anatomy-based approaches (Ia and Ib). Postprocessing of rTMS-based tractograms (IIb) led to more balanced perceived information content but did not improve the usefulness for surgical planning and risk assessment. Landmark-based tractography (Ia and Ib) was most successful in delineating major language tracts (98% success), whereas rTMS-based tractography (IIa and IIb) frequently failed to reveal streamlines and provided less complete tractograms than the landmark-based approach (p < 0.001). The lesion-focused landmark-based (Ib) and the rTMS-enhanced (III) approaches were the most preferred methods. CONCLUSIONS The lesion-focused landmark-based approach (Ib) achieved the best ratings and enabled visualization of the principal language tracts in almost all cases. The rTMS-enhanced approach (III) was positively evaluated by the experts because it can reveal cortico-subcortical connections, but the functional relevance of these connections is still unclear. The use of regions of interest derived solely from cortical rTMS mapping (IIa and IIb) leads to cluttered images that are of limited use in clinical practice.
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Affiliation(s)
- Luca L Silva
- Departments of1Neurosurgery and.,2Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | | | | | - Thomas Picht
- Departments of1Neurosurgery and.,3Cluster of Excellence: "Matters of Activity. Image Space Material"-Humboldt University, Berlin; and
| | - Tizian Rosenstock
- Departments of1Neurosurgery and.,4Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin, Germany
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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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Di Cristofori A, Basso G, de Laurentis C, Mauri I, Sirtori MA, Ferrarese C, Isella V, Giussani C. Perspectives on (A)symmetry of Arcuate Fasciculus. A Short Review About Anatomy, Tractography and TMS for Arcuate Fasciculus Reconstruction in Planning Surgery for Gliomas in Language Areas. Front Neurol 2021; 12:639822. [PMID: 33643213 PMCID: PMC7902861 DOI: 10.3389/fneur.2021.639822] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/05/2021] [Indexed: 11/13/2022] Open
Abstract
Gliomas are brain tumors that are treated with surgical resection. Prognosis is influenced by the extent of resection and postoperative neurological status. As consequence, given the extreme interindividual and interhemispheric variability of subcortical white matter (WM) surgical planning requires to be patient's tailored. According to the “connectionist model,” there is a huge variability among both cortical areas and subcortical WM in all human beings, and it is known that brain is able to reorganize itself and to adapt to WM lesions. Brain magnetic resonance imaging diffusion tensor imaging (DTI) tractography allows visualization of WM bundles. Nowadays DTI tractography is widely available in the clinical setting for presurgical planning. Arcuate fasciculus (AF) is a long WM bundle that connects the Broca's and Wernicke's regions with a complex anatomical architecture and important role in language functions. Thus, its preservation is important for the postoperative outcome, and DTI tractography is usually performed for planning surgery within the language-dominant hemisphere. High variability among individuals and an asymmetrical pattern has been reported for this WM bundle. However, the functional relevance of AF in the contralateral non-dominant hemisphere in case of tumoral or surgical lesion of the language-dominant AF is unclear. This review focuses on AF anatomy with special attention to its asymmetry in both normal and pathological conditions and how it may be explored with preoperative tools for planning surgery on gliomas in language areas. Based on the findings available in literature, we finally speculate about the potential role of preoperative evaluation of the WM contralateral to the surgical site.
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Affiliation(s)
| | - Gianpaolo Basso
- Neurosurgery Unit, San Gerardo Hospital, ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neuroradiology Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Camilla de Laurentis
- Neurosurgery Unit, San Gerardo Hospital, ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Ilaria Mauri
- Neurology Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | | | - Carlo Ferrarese
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurology Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Valeria Isella
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurology Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Carlo Giussani
- Neurosurgery Unit, San Gerardo Hospital, ASST Monza, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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23
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Ille S, Schroeder A, Albers L, Kelm A, Droese D, Meyer B, Krieg SM. Non-Invasive Mapping for Effective Preoperative Guidance to Approach Highly Language-Eloquent Gliomas-A Large Scale Comparative Cohort Study Using a New Classification for Language Eloquence. Cancers (Basel) 2021; 13:cancers13020207. [PMID: 33430112 PMCID: PMC7827798 DOI: 10.3390/cancers13020207] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/20/2020] [Accepted: 01/06/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: A considerable number of gliomas require resection via direct electrical stimulation (DES) during awake craniotomy. Likewise, the feasibility of resecting language-eloquent gliomas purely based on navigated repetitive transcranial magnetic stimulation (nrTMS) has been shown. This study analyzes the outcomes after preoperative nrTMS-based and intraoperative DES-based glioma resection in a large cohort. Due to the necessity of making location comparable, a classification for language eloquence for gliomas is introduced. Methods: Between March 2015 and May 2019, we prospectively enrolled 100 consecutive cases that were resected based on preoperative nrTMS language mapping (nrTMS group), and 47 cases via intraoperative DES mapping during awake craniotomy (awake group) following a standardized clinical workflow. Outcome measures were determined preoperatively, 5 days after surgery, and 3 months after surgery. To make functional eloquence comparable, we developed a classification based on prior publications and clinical experience. Groups and classification scores were correlated with clinical outcomes. Results: The functional outcome did not differ between groups. Gross total resection was achieved in more cases in the nrTMS group (87%, vs. 72% in the awake group, p = 0.04). Nonetheless, the awake group showed significantly higher scores for eloquence than the nrTMS group (median 7 points; interquartile range 6-8 vs. 5 points; 3-6.75; p < 0.0001). Conclusion: Resecting language-eloquent gliomas purely based on nrTMS data is feasible in a high percentage of cases if the described clinical workflow is followed. Moreover, the proposed classification for language eloquence makes language-eloquent tumors comparable, as shown by its correlation with functional and radiological outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Sandro M. Krieg
- Correspondence: ; Tel.: +49-89-4140-2151; Fax: +49-89-4140-4889
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24
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Ille S, Krieg SM. Functional Mapping for Glioma Surgery, Part 1: Preoperative Mapping Tools. Neurosurg Clin N Am 2020; 32:65-74. [PMID: 33223027 DOI: 10.1016/j.nec.2020.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although intraoperative mapping of brain areas was shown to promote greater extent of resection and reduce functional deficits, this was shown only recently for some noninvasive techniques. Yet, proper surgical planning, indication, and patient consultation require reliable noninvasive techniques. Because functional magnetic resonance imaging, tractography, and neurophysiologic methods like navigated transcranial magnetic stimulation and magnetoencephalography allow identifying eloquent areas prior to resective surgery and tailor the surgical approach, this article provides an overview on the individual strengths and limitations of each modality.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Technical University of Munich, Germany, School of Medicine, Klinikum rechts der Isar, Ismaninger Strasse 22, Munich 81675, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University of Munich, Germany, School of Medicine, Klinikum rechts der Isar, Ismaninger Strasse 22, Munich 81675, Germany.
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25
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Jeltema HR, Ohlerth AK, de Wit A, Wagemakers M, Rofes A, Bastiaanse R, Drost G. Comparing navigated transcranial magnetic stimulation mapping and "gold standard" direct cortical stimulation mapping in neurosurgery: a systematic review. Neurosurg Rev 2020; 44:1903-1920. [PMID: 33009990 PMCID: PMC8338816 DOI: 10.1007/s10143-020-01397-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 09/05/2020] [Accepted: 09/17/2020] [Indexed: 12/14/2022]
Abstract
The objective of this systematic review is to create an overview of the literature on the comparison of navigated transcranial magnetic stimulation (nTMS) as a mapping tool to the current gold standard, which is (intraoperative) direct cortical stimulation (DCS) mapping. A search in the databases of PubMed, EMBASE, and Web of Science was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations were used. Thirty-five publications were included in the review, describing a total of 552 patients. All studies concerned either mapping of motor or language function. No comparative data for nTMS and DCS for other neurological functions were found. For motor mapping, the distances between the cortical representation of the different muscle groups identified by nTMS and DCS varied between 2 and 16 mm. Regarding mapping of language function, solely an object naming task was performed in the comparative studies on nTMS and DCS. Sensitivity and specificity ranged from 10 to 100% and 13.3–98%, respectively, when nTMS language mapping was compared with DCS mapping. The positive predictive value (PPV) and negative predictive value (NPV) ranged from 17 to 75% and 57–100% respectively. The available evidence for nTMS as a mapping modality for motor and language function is discussed.
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Affiliation(s)
- Hanne-Rinck Jeltema
- Department of Neurosurgery, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands.
| | - Ann-Katrin Ohlerth
- Center for Language and Cognition Groningen, University of Groningen, Oude Kijk in 't Jatstraat 26, 9712 EK, Groningen, the Netherlands
| | - Aranka de Wit
- Faculty of Medical Sciences, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, the Netherlands
| | - Michiel Wagemakers
- Department of Neurosurgery, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Adrià Rofes
- Center for Language and Cognition Groningen, University of Groningen, Oude Kijk in 't Jatstraat 26, 9712 EK, Groningen, the Netherlands
| | - Roelien Bastiaanse
- Center for Language and Cognition Groningen, University of Groningen, Oude Kijk in 't Jatstraat 26, 9712 EK, Groningen, the Netherlands.,Center for Language and Brain, National Research University, Higher School of Economics, Moscow, Russian Federation
| | - Gea Drost
- Department of Neurosurgery, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
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26
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Verburg N, de Witt Hamer PC. State-of-the-art imaging for glioma surgery. Neurosurg Rev 2020; 44:1331-1343. [PMID: 32607869 PMCID: PMC8121714 DOI: 10.1007/s10143-020-01337-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/25/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022]
Abstract
Diffuse gliomas are infiltrative primary brain tumors with a poor prognosis despite multimodal treatment. Maximum safe resection is recommended whenever feasible. The extent of resection (EOR) is positively correlated with survival. Identification of glioma tissue during surgery is difficult due to its diffuse nature. Therefore, glioma resection is imaging-guided, making the choice for imaging technique an important aspect of glioma surgery. The current standard for resection guidance in non-enhancing gliomas is T2 weighted or T2w-fluid attenuation inversion recovery magnetic resonance imaging (MRI), and in enhancing gliomas T1-weighted MRI with a gadolinium-based contrast agent. Other MRI sequences, like magnetic resonance spectroscopy, imaging modalities, such as positron emission tomography, as well as intraoperative imaging techniques, including the use of fluorescence, are also available for the guidance of glioma resection. The neurosurgeon’s goal is to find the balance between maximizing the EOR and preserving brain functions since surgery-induced neurological deficits result in lower quality of life and shortened survival. This requires localization of important brain functions and white matter tracts to aid the pre-operative planning and surgical decision-making. Visualization of brain functions and white matter tracts is possible with functional MRI, diffusion tensor imaging, magnetoencephalography, and navigated transcranial magnetic stimulation. In this review, we discuss the current available imaging techniques for the guidance of glioma resection and the localization of brain functions and white matter tracts.
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Affiliation(s)
- Niels Verburg
- Department of Neurosurgery and Cancer Center Amsterdam, Amsterdam UMC location VU University Medical Center, Amsterdam, The Netherlands. .,Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Brain Tumor Imaging Laboratory, University of Cambridge, Addenbrooke's Hospital, Hill Rd, Cambridge, CB2 0QQ, UK.
| | - Philip C de Witt Hamer
- Department of Neurosurgery and Cancer Center Amsterdam, Amsterdam UMC location VU University Medical Center, Amsterdam, The Netherlands
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27
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Bährend I, Muench MR, Schneider H, Moshourab R, Dreyer FR, Vajkoczy P, Picht T, Faust K. Incidence and linguistic quality of speech errors: a comparison of preoperative transcranial magnetic stimulation and intraoperative direct cortex stimulation. J Neurosurg 2020; 134:1409-1418. [PMID: 32470943 DOI: 10.3171/2020.3.jns193085] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Given the interindividual variance of functional language anatomy, risk prediction based merely on anatomical data is insufficient in language area-related brain tumor surgery, suggesting the need for direct cortical and subcortical mapping during awake surgery. Reliable, noninvasive preoperative methods of language localization hold the potential for reducing the necessity for awake procedures and may improve patient counseling and surgical planning. Repetitive navigated transcranial magnetic stimulation (rnTMS) is an evolving tool for localizing language-eloquent areas. The aim of this study was to investigate the reliability of rnTMS in locating cortical language sites. METHODS Twenty-five patients with brain tumors in speech-related areas were prospectively evaluated with preoperative rnTMS (5 Hz, train of five, average 105% resting motor threshold) and navigated direct cortical stimulation (DCS; bipolar, 50 Hz, 6-8 mA, 200-μsec pulse width) during awake surgeries employing a picture-naming task. Positive and negative stimulation spots within the craniotomy were documented in the same MRI data set. TMS and DCS language-positive areas were compared with regard to their spatial overlap, their allocation in a cortical parcellation system, and their linguistic qualities. RESULTS There were over twofold more positive language spots within the exposed area on rnTMS than on DCS. The comparison of positive rnTMS and DCS (ground truth) overlaps revealed low sensitivity (35%) and low positive predictive value (16%) but high specificity (90%) and high negative predictive value (96%). Within the overlaps, there was no correlation in error quality. On DCS, 73% of language-positive spots were located in the pars opercularis and pars triangularis of the frontal operculum and 24% within the supramarginal gyrus and dorsal portion of the superior temporal gyrus, while on rnTMS language positivity was distributed more evenly over a large number of gyri. CONCLUSIONS The current protocol for rnTMS for language mapping identified language-negative sites with good dependability but was unable to reliably detect language-positive spots. Further refinements of the technique will be needed to establish rnTMS language mapping as a useful clinical tool.
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Affiliation(s)
| | | | | | | | - Felix R Dreyer
- 3Brain Language Laboratory, Freie Universität Berlin, Germany
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28
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Aydinlar EI, Dikmen PY, Kocak M, Sahillioğlu E, Pamir MN. Intraoperative motor speech mapping under general anesthesia using long-latency response from laryngeal muscles. Clin Neurol Neurosurg 2020; 190:105672. [DOI: 10.1016/j.clineuro.2020.105672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 11/06/2019] [Accepted: 01/05/2020] [Indexed: 11/30/2022]
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29
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Raffa G, Quattropani MC, Germanò A. When imaging meets neurophysiology: the value of navigated transcranial magnetic stimulation for preoperative neurophysiological mapping prior to brain tumor surgery. Neurosurg Focus 2019; 47:E10. [DOI: 10.3171/2019.9.focus19640] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/04/2019] [Indexed: 11/06/2022]
Abstract
Maximal safe resection is the modern goal for surgery of intrinsic brain tumors located in or close to brain eloquent areas. Nowadays different neuroimaging techniques provide important anatomical and functional information regarding the brain functional organization that can be used to plan a customized surgical strategy to preserve functional networks, and to increase the extent of tumor resection. Among these techniques, navigated transcranial magnetic stimulation (nTMS) has recently gained great favor among the neurosurgical community for preoperative mapping and planning prior to brain tumor surgery. It represents an advanced neuroimaging technique based on the neurophysiological mapping of the functional cortical brain organization. Moreover, it can be combined with other neuroimaging techniques such as diffusion tensor imaging tractography, thus providing a reliable reconstruction of brain eloquent networks. Consequently, nTMS mapping may provide reliable noninvasive brain functional mapping, anticipating information that otherwise may be available to neurosurgeons only in the operating theater by using direct electrical stimulation. The authors describe the reliability and usefulness of the preoperative nTMS-based approach in neurosurgical practice, and briefly discuss their experience using nTMS as well as currently available evidence in the literature supporting its clinical use. In particular, special attention is reserved for the discussion of the role of nTMS as a novel tool for the preoperative neurophysiological mapping of motor and language networks prior to surgery of intrinsic brain tumors located in or close to eloquent networks, as well as for future and promising applications of nTMS in neurosurgical practice.
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Affiliation(s)
- Giovanni Raffa
- 1Division of Neurosurgery, BIOMORF Department, University of Messina, Italy; and
| | | | - Antonino Germanò
- 1Division of Neurosurgery, BIOMORF Department, University of Messina, Italy; and
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30
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Sollmann N, Kelm A, Ille S, Schröder A, Zimmer C, Ringel F, Meyer B, Krieg SM. Setup presentation and clinical outcome analysis of treating highly language-eloquent gliomas via preoperative navigated transcranial magnetic stimulation and tractography. Neurosurg Focus 2019; 44:E2. [PMID: 29852769 DOI: 10.3171/2018.3.focus1838] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Awake surgery combined with intraoperative direct electrical stimulation (DES) and intraoperative neuromonitoring (IONM) is considered the gold standard for the resection of highly language-eloquent brain tumors. Different modalities, such as functional magnetic resonance imaging (fMRI) or magnetoencephalography (MEG), are commonly added as adjuncts for preoperative language mapping but have been shown to have relevant limitations. Thus, this study presents a novel multimodal setup consisting of preoperative navigated transcranial magnetic stimulation (nTMS) and nTMS-based diffusion tensor imaging fiber tracking (DTI FT) as an adjunct to awake surgery. METHODS Sixty consecutive patients (63.3% men, mean age 47.6 ± 13.3 years) suffering from highly language-eloquent left-hemispheric low- or high-grade glioma underwent preoperative nTMS language mapping and nTMS-based DTI FT, followed by awake surgery for tumor resection. Both nTMS language mapping and DTI FT data were available for resection planning and intraoperative guidance. Clinical outcome parameters, including craniotomy size, extent of resection (EOR), language deficits at different time points, Karnofsky Performance Scale (KPS) score, duration of surgery, and inpatient stay, were assessed. RESULTS According to postoperative evaluation, 28.3% of patients showed tumor residuals, whereas new surgery-related permanent language deficits occurred in 8.3% of patients. KPS scores remained unchanged (median preoperative score 90, median follow-up score 90). CONCLUSIONS This is the first study to present a clinical outcome analysis of this very modern approach, which is increasingly applied in neurooncological centers worldwide. Although human language function is a highly complex and dynamic cortico-subcortical network, the presented approach offers excellent functional and oncological outcomes in patients undergoing surgery of lesions affecting this network.
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Affiliation(s)
- Nico Sollmann
- 1Department of Diagnostic and Interventional Neuroradiology.,3TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Anna Kelm
- 2Department of Neurosurgery, and.,3TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Sebastian Ille
- 2Department of Neurosurgery, and.,3TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Germany
| | | | - Claus Zimmer
- 1Department of Diagnostic and Interventional Neuroradiology.,3TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Germany
| | | | | | - Sandro M Krieg
- 2Department of Neurosurgery, and.,3TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Germany
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31
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Combs SE, Kessel KA, Hesse J, Straube C, Zimmer C, Schmidt-Graf F, Schlegel J, Gempt J, Meyer B. Moving Second Courses of Radiotherapy Forward: Early Re-Irradiation After Surgical Resection for Recurrent Gliomas Improves Efficacy With Excellent Tolerability. Neurosurgery 2019; 83:1241-1248. [PMID: 29462372 DOI: 10.1093/neuros/nyx629] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/27/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Generally, re-irradiation (Re-RT) is offered to patients with glioma recurrences with macroscopic lesions. Results are discussed controversially, and some centers postulate limited benefit of Re-RT. Re-RT is generally offered to tumors up to 4 cm in diameter. Re-resection is also discussed controversially; however, recent studies have shown significant benefit. OBJECTIVE To combine proactive re-resection and early Re-RT in patients with recurrent glioma. METHODS We included 108 patients treated between 2002 and 2016 for recurrent glioma. All patients underwent surgical resection for recurrence; Re-RT was applied with a median dose of 37.5 Gy (range 25 Gy-57Gy/equivalent dose in 2Gy fractions [EQD2]) with high-precision techniques. All patients were followed prospectively in an interdisciplinary follow-up program. RESULTS Median follow-up after Re-RT was 7 mo. Median survival after surgery and Re-RT was 12 mo (range 1-102 mo). Complete resection had a significant impact on the outcome (P = .03). The strongest predictors of outcome were MGMT-promotor methylation and Karnofsky Performance Score and time interval between primary and second RT. CONCLUSION Proactive resection of tumor recurrences combined with early Re-RT conveys into promising outcome in recurrent glioma. Complete resection and early Re-RT lead to improved survival. Thus, moving Re-RT to an earlier timepoint during the treatment of recurrent glioma, eg after complete macroscopic removal of the tumor, may be crucial for treatment optimization. Using advanced RT techniques, side effects are low. Currently, this concept is evaluated in the GLIOCAVE/NOA 17 trial.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany.,Institute of Innovative Radiotherapy ( i RT), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (dktk), Partner Site Munich, Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany.,Institute of Innovative Radiotherapy ( i RT), Helmholtz Zentrum München, Neuherberg, Germany
| | - Josefine Hesse
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Technical University of Munich (TUM), Munich, Germany
| | | | - Jürgen Schlegel
- Department of Neuropathology, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Technical University of Munich (TUM), Ismaninger Straße 22, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich (TUM), Ismaninger Straße 22, Munich, Germany
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32
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Kreidenhuber R, De Tiège X, Rampp S. Presurgical Functional Cortical Mapping Using Electromagnetic Source Imaging. Front Neurol 2019; 10:628. [PMID: 31249552 PMCID: PMC6584755 DOI: 10.3389/fneur.2019.00628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/28/2019] [Indexed: 02/03/2023] Open
Abstract
Preoperative localization of functionally eloquent cortex (functional cortical mapping) is common clinical practice in order to avoid or reduce postoperative morbidity. This review aims at providing a general overview of magnetoencephalography (MEG) and high-density electroencephalography (hdEEG) based methods and their clinical role as compared to common alternatives for functional cortical mapping of (1) verbal language function, (2) sensorimotor cortex, (3) memory, (4) visual, and (5) auditory cortex. We highlight strengths, weaknesses and limitations of these functional cortical mapping modalities based on findings in the recent literature. We also compare their performance relative to other non-invasive functional cortical mapping methods, such as functional Magnetic Resonance Imaging (fMRI), Transcranial Magnetic Stimulation (TMS), and to invasive methods like the intracarotid Amobarbital Test (WADA-Test) or intracranial investigations.
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Affiliation(s)
- Rudolf Kreidenhuber
- Department of Neurology, Christian-Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Xavier De Tiège
- Laboratoire de Cartographie Fonctionelle du Cerveau, ULB Neuroscience Institute, Université Libre de Bruxelles, Brussels, Belgium.,Department of Functional Neuroimaging, Service of Nuclear Medicine, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Stefan Rampp
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany.,Department of Neurosurgery, University Hospital Halle, Halle, Germany
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33
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Raffa G, Scibilia A, Conti A, Ricciardo G, Rizzo V, Morelli A, Angileri FF, Cardali SM, Germanò A. The role of navigated transcranial magnetic stimulation for surgery of motor-eloquent brain tumors: a systematic review and meta-analysis. Clin Neurol Neurosurg 2019; 180:7-17. [DOI: 10.1016/j.clineuro.2019.03.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 01/08/2023]
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34
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Raffa G, Scibilia A, Conti A, Cardali SM, Rizzo V, Terranova C, Quattropani MC, Marzano G, Ricciardo G, Vinci SL, Germanò A. Multimodal Surgical Treatment of High-Grade Gliomas in the Motor Area: The Impact of the Combination of Navigated Transcranial Magnetic Stimulation and Fluorescein-Guided Resection. World Neurosurg 2019; 128:e378-e390. [PMID: 31029822 DOI: 10.1016/j.wneu.2019.04.158] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fluorescein-guided surgery of high-grade gliomas (HGGs) increases the extent of tumor resection but its efficacy has been questioned, especially for tumors located close to functional networks. In these cases, navigated transcranial magnetic stimulation (nTMS) may be used to plan and guide a safe resection. The aim of this study was to assess the impact of these techniques combined with intraoperative neurophysiologic mapping (IONM) to achieve the maximal safe resection of tumors located in the motor area. METHODS We collected data of patients operated using a multimodal combination of sodium fluorescein-guided resection, nTMS motor planning, and IONM for HGGs in the motor area. The nTMS planning accuracy, extent of resection, and postoperative motor and functional status were compared with a matched control group of patients with HGG operated on only by IONM-guided resection. RESULTS Forty-one patients treated by multimodal approach (group A) and 41 controls (group B) were included. The nTMS-based planning reliably identified the tumor/motor pathway spatial relationship (accuracy, 92.68%). We obtained in group A versus controls a higher gross total resection rate (73.17% vs. 51.22%; P = 0.04), and a reduction of cases with new permanent motor deficits (9.75% vs. 29.27%; P = 0.04) or Karnofsky Performance Status worsening (12.19% vs. 31.71%; P = 0.03). CONCLUSIONS This study supports the role of the combination of sodium fluorescein-guided resection and nTMS-based planning for surgery of HGGs close to the motor pathway. This multimodal approach in combination with IONM may lead to customized preoperative planning, increased extent of resection, and improved functional outcome, compared with standard IONM-guided surgery.
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Affiliation(s)
- Giovanni Raffa
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy.
| | - Antonino Scibilia
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy; Division of Neurosurgery, University of Strasbourg, Strasbourg, France
| | - Alfredo Conti
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | | | - Vincenzo Rizzo
- Division of Neurology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Carmen Terranova
- Division of Neurology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Giuseppina Marzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Ricciardo
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Sergio Lucio Vinci
- Division of Neuroradiology, BIOMORF Department, University of Messina, Messina, Italy
| | - Antonino Germanò
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
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Jung J, Lavrador JP, Patel S, Giamouriadis A, Lam J, Bhangoo R, Ashkan K, Vergani F. First United Kingdom Experience of Navigated Transcranial Magnetic Stimulation in Preoperative Mapping of Brain Tumors. World Neurosurg 2019; 122:e1578-e1587. [DOI: 10.1016/j.wneu.2018.11.114] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
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Ille S, Engel L, Kelm A, Meyer B, Krieg SM. Language-Eloquent White Matter Pathway Tractography and the Course of Language Function in Glioma Patients. Front Oncol 2018; 8:572. [PMID: 30574455 PMCID: PMC6291459 DOI: 10.3389/fonc.2018.00572] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/15/2018] [Indexed: 11/13/2022] Open
Abstract
Object: As various recent studies show, damage to white matter pathways leads to permanent functional deficits in a high percentage of patients. Particularly the subcortical language network is complex, and its visualization has a tremendous relevance for neurosurgeons. This pilot study aims to correlate language-eloquent white matter pathways with the course of language function after the resection of left-sided perisylvian gliomas. Methods: We included 10 patients who underwent resection of highly language-eloquent high- (9 pts) and low-grade gliomas (1 pts). We performed navigated repetitive transcranial magnetic stimulation (nrTMS)-based tractography via diffusion tensor imaging fiber trackings (DTI FT) preoperatively (PRE-1), postoperatively (POST-1), and at long-term follow up or tumor recurrence (PRE-2). We separately tracked the inferior fronto-occipital fascicle (IFOF), the frontal aslant tract (FAT), and the superior longitudinal (SLF), and arcuate fascicle (AF), and correlated the amount of visualized fibers to the patients' language function at each date. Results: The changes of nrTMS-based DTI FTs of single white matter pathways correlated with the according status of language function for any of the pathways in 80% of patients and in 19 of 30 (63%) single pathway comparisons between PRE-1 and POST-1. Between POST-1 and PRE-2 the nrTMS-based DTI FTs correlated with the status of language function for any of the pathways in all patients and in 24 of 30 (80%) single pathway comparisons. Single FT results correlated with the according status of language function at POST-1 in 60, 70, and 60% of cases, and with the according status of language function at PRE-2 in 60, 90, and 90% of cases for the tracking of the IFOF, FAT, and SLF/AF, respectively. Conclusion: By the present results we were able to show that nrTMS-based DTI FT of the IFOF, FAT, and SLF/AF mainly correlates with the according status of language function preoperatively, postoperatively, and at long-term follow up after the resection of left-sided perisylvian gliomas.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany.,TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
| | - Lara Engel
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany.,TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
| | - Anna Kelm
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany.,TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany.,TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technische Universität München, Münich, Germany
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Freyschlag CF, Krieg SM, Kerschbaumer J, Pinggera D, Forster MT, Cordier D, Rossi M, Miceli G, Roux A, Reyes A, Sarubbo S, Smits A, Sierpowska J, Robe PA, Rutten GJ, Santarius T, Matys T, Zanello M, Almairac F, Mondot L, Jakola AS, Zetterling M, Rofes A, von Campe G, Guillevin R, Bagatto D, Lubrano V, Rapp M, Goodden J, De Witt Hamer PC, Pallud J, Bello L, Thomé C, Duffau H, Mandonnet E. Imaging practice in low-grade gliomas among European specialized centers and proposal for a minimum core of imaging. J Neurooncol 2018; 139:699-711. [PMID: 29992433 PMCID: PMC6132968 DOI: 10.1007/s11060-018-2916-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/29/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Imaging studies in diffuse low-grade gliomas (DLGG) vary across centers. In order to establish a minimal core of imaging necessary for further investigations and clinical trials in the field of DLGG, we aimed to establish the status quo within specialized European centers. METHODS An online survey composed of 46 items was sent out to members of the European Low-Grade Glioma Network, the European Association of Neurosurgical Societies, the German Society of Neurosurgery and the Austrian Society of Neurosurgery. RESULTS A total of 128 fully completed surveys were received and analyzed. Most centers (n = 96, 75%) were academic and half of the centers (n = 64, 50%) adhered to a dedicated treatment program for DLGG. There were national differences regarding the sequences enclosed in MRI imaging and use of PET, however most included T1 (without and with contrast, 100%), T2 (100%) and TIRM or FLAIR (20, 98%). DWI is performed by 80% of centers and 61% of centers regularly performed PWI. CONCLUSION A minimal core of imaging composed of T1 (w/wo contrast), T2, TIRM/FLAIR, PWI and DWI could be identified. All morphologic images should be obtained in a slice thickness of ≤ 3 mm. No common standard could be obtained regarding advanced MRI protocols and PET. IMPORTANCE OF THE STUDY We believe that our study makes a significant contribution to the literature because we were able to determine similarities in numerous aspects of LGG imaging. Using the proposed "minimal core of imaging" in clinical routine will facilitate future cooperative studies.
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Affiliation(s)
- Christian F Freyschlag
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Johannes Kerschbaumer
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | | | - Dominik Cordier
- Department of Neurosurgery, Universitätsspital Basel, Basel, Switzerland
| | - Marco Rossi
- Neurosurgical Oncology Unit, Humanitas Research Hospital, IRCCS, Milan, Italy
| | - Gabriele Miceli
- Center for Mind/Brain Sciences, University of Trento, Rovereto, Italy
| | - Alexandre Roux
- Department of Neurosurgery, Sainte-Anne Hospital, Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Inserm U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Andrés Reyes
- European Master's in Clinical Linguistics (EMCL), University of Groningen, Groningen, The Netherlands
- EMCL University of Potsdam, Potsdam, Germany
- Neuroscience Institute, and Laboratory of Experimental Psychology, Faculty of Psychology, El Bosque University, Bogotá, Colombia
| | - Silvio Sarubbo
- Division of Neurosurgery, Structural and Functional Connectivity Lab Project, "S. Chiara" Hospital, APSS, Trento, Italy
| | - Anja Smits
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Joanna Sierpowska
- Cognition and Brain Plasticity Unit, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
- Department of Cognition, Development and Education Psychology, Barcelona, Spain
| | - Pierre A Robe
- Department of Neurology and Neurosurgery, Rudolf Magnus Brain Institute, University Medical Center of Utrecht, Utrecht, The Netherlands
| | - Geert-Jan Rutten
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Thomas Santarius
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Tomasz Matys
- Department of Radiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Marc Zanello
- Department of Neurosurgery, Sainte-Anne Hospital, Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Inserm U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Fabien Almairac
- Neurosurgery Department, Hôpital Pasteur 2, University Hospital of Nice, Nice, France
| | - Lydiane Mondot
- Radiology Department, Hôpital Pasteur 2, University Hospital of Nice, Nice, France
| | - Asgeir S Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Maria Zetterling
- Department of Neurosurgery, Institution of Neuroscience, Uppsala University Hospital, Uppsala, Sweden
| | - Adrià Rofes
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
- Department of Cognitive Science, Johns Hopkins University, Baltimore, USA
| | - Gord von Campe
- Department of Neurosurgery, Medical University Graz, Graz, Austria
| | - Remy Guillevin
- DACTIM, UMR CNRS 7348, Université de Poitiers et CHU de Poitiers, Poitiers, France
| | - Daniele Bagatto
- Neuroradiology Department, University Hospital Santa Maria della Misericordia, Udine, Italy
| | - Vincent Lubrano
- Department of Neurosurgery, CHU Toulouse, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Marion Rapp
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - John Goodden
- Department of Neurosurgery, The General Infirmary at Leeds, Leeds, West Yorkshire, UK
| | | | - Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Inserm U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Lorenzo Bello
- Neurosurgical Oncology Unit, Humanitas Research Hospital, IRCCS, Milan, Italy
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier Medical University Center, Montpellier, France
- Institute of Neuroscience of Montpellier, INSERM U1051, University of Montpellier, Montpellier, France
| | - Emmanuel Mandonnet
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France
- University Paris 7, Paris, France
- IMNC, UMR 8165, Orsay, France
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Abstract
Focal epilepsy originating from the insular cortex is rare. One reason is the small amount of cortical tissue compared with other lobes of the brain. However, the incidence of insular epilepsy might be underestimated because of diagnostic difficulties. The semiology and the surface EEG are often not meaningful or even misleading, and elaborated imaging might be necessary. The close connections of the insular cortex with other potentially epileptogenic areas, such as the temporal lobe or frontal/central cortex, is increasingly recognized as possible reason for failure of epilepsy surgery for temporal or extratemporal seizures. Therefore, some centers consider invasive EEG recording of the insular cortex not only in case of insular epilepsy but also in other focal epilepsies with nonconclusive results from the presurgical work-up. The surgical approach to and resection of insular cortex is challenging because of its deep location and proximity to highly eloquent brain structures. Over the last decades, technical adjuncts like navigation tools, electrophysiological monitoring and intraoperative imaging have improved the outcome after surgery. Nevertheless, there is still a considerable rate of postoperative transient or permanent deficits, in some cases as unavoidable and calculated deficits. In most of the recent series, seizure outcome was favorable and comparable with extratemporal epilepsy surgery or even better. Up to now, the data volume concerning long-term follow-up is limited. This review focusses on the surgical challenges of resections to treat insular epilepsy, on prognostic factors concerning seizure outcome, on postoperative deficits and complications. Moreover, less invasive surgical techniques to treat epilepsy in this highly eloquent area are summarized.
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Functional brain mapping: overview of techniques and their application to neurosurgery. Neurosurg Rev 2018; 42:639-647. [DOI: 10.1007/s10143-018-1007-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/25/2018] [Accepted: 07/06/2018] [Indexed: 10/28/2022]
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Surgery of language-eloquent tumors in patients not eligible for awake surgery: the impact of a protocol based on navigated transcranial magnetic stimulation on presurgical planning and language outcome, with evidence of tumor-induced intra-hemispheric plasticity. Clin Neurol Neurosurg 2018; 168:127-139. [PMID: 29549813 DOI: 10.1016/j.clineuro.2018.03.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 02/28/2018] [Accepted: 03/06/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Awake surgery and intraoperative monitoring represent the gold standard for surgery of brain tumors located in the perisylvian region of the dominant hemisphere due to their ability to map and preserve the language network during surgery. Nevertheless, in some cases awake surgery is not feasible. This could increase the risk of postoperative language deficit. Navigated transcranial magnetic stimulation (nTMS) and nTMS-based DTI fiber tracking (DTI-FT) provide a preoperative mapping and reconstruction of the cortico-subcortical language network. This can be used to plan and guide the surgical strategy to preserve the language function. The objective if this study is to describe the impact of a non-invasive preoperative protocol for mapping the language network through the nTMS and nTMS-based DTI-FT in patients not eligible for awake surgery and thereby operated under general anesthesia for suspected language-eloquent brain tumors. PATIENTS AND METHODS We reviewed clinical data of patients not eligible for awake surgery and operated under general anaesthesia between 2015 and 2016. All patients underwent nTMS language cortical mapping and nTMS-based DTI-FT of subcortical language fascicles. The nTMS findings were used to plan and guide the maximal safe resection of the tumor. The impact on postoperative language outcome and the accuracy of the nTMS-based mapping in predicting language deficits were evaluated. RESULTS Twenty patients were enrolled in the study. The nTMS-based reconstruction of the language network was successful in all patients. Interestingly, we observed a significant association between tumor localization and the cortical distribution of the nTMS errors (p = 0.004), thereby suggesting an intra-hemispheric plasticity of language cortical areas, probably induced by the tumor itself. The nTMS mapping disclosed the true-eloquence of lesions in 12 (60%) of all suspected cases. In the remaining 8 cases (40%) the suspected eloquence of the lesion was disproved. The nTMS-based findings guided the planning and surgery through the visual feedback of navigation. This resulted in a slight reduction of the postoperative language performance at discharge that was completely recovered after one month from surgery. The accuracy of the nTMS-based protocol in predicting postoperative permanent deficits was significantly high, especially for false-eloquent lesions (p = 0.04; sensitivity 100%, specificity 57.14%, negative predictive value 100%, positive predicitive value 50%). CONCLUSIONS The nTMS-based preoperative mapping allows for a reliable visualization of the language network, being also able to identify an intra-hemispheric tumor-induced cortical plasticity. It allows for a customized surgical strategy that could preserve post-operative language function. This approach should be considered as a support for neurosurgeons whenever approaching patients affected by suspected language-eloquent tumors but not eligible for awake surgery.
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Relationship Between Perisylvian Essential Language Sites and Arcuate Fasciculus in the Left Hemisphere of Healthy Adults. Neurosci Bull 2017; 33:616-626. [PMID: 28501904 DOI: 10.1007/s12264-017-0137-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 04/11/2017] [Indexed: 10/19/2022] Open
Abstract
Essential language sites and the arcuate fasciculus (AF) have been extensively researched. However, the relationship between them remains insufficiently studied, especially in healthy people. Navigated transcranial magnetic stimulation (nTMS) is increasingly used in language mapping. While enjoying the advantage of non-invasiveness, it is also capable of inducing a virtual lesion in the brain. Thus, it offers the possibility of using the virtual-lesion method to study the healthy brain. This study combined nTMS and diffusion tensor imaging (DTI) tractography to investigate the relationship between essential language sites and the AF in 30 healthy right-handed volunteers. A total of 143 essential language sites were identified using nTMS, and a total of 175 AF terminations were identified using DTI tractography. Sixty-six sites had a direct correlation with the AF, accounting for 46% of the total essential language sites. Forty-seven AF terminations harbored essential language sites, accounting for 27% of the total AF terminations. Upon data rendering to the cortical parcellation system, a region-related heterogeneity of the correlation rate was found. This study provides the first data on the relationship between essential language sites and the AF in healthy adults.
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Preoperative rTMS Language Mapping in Speech-Eloquent Brain Lesions Resected Under General Anesthesia: A Pair-Matched Cohort Study. World Neurosurg 2017; 100:425-433. [PMID: 28109861 DOI: 10.1016/j.wneu.2017.01.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The value of preoperative repetitive transcranial magnetic stimulation (rTMS) language mapping for function preservation in surgery of speech-eloquent lesions under general anesthesia remains to be determined. METHODS We prospectively enrolled 20 consecutive right-handed patients with a malignant, left-sided perisylvian language-eloquent brain tumor. All patients were subjected to surgical resection under general anesthesia guided by preoperative rTMS language mapping (rTMS group, 2014-2016). A matched-pair analysis with 20 patients who also underwent surgical resection under general anesthesia in the pre-rTMS era (pre-rTMS group, 2009-2013) was performed. Language performance status was ranked from grade 0 to grade 3 (none, mild, medium, severe). RESULTS Rates of gross total resection, tumor residual, and complications were equal in both groups. Duration of surgery (P = 0.039) and inpatient stay (P = 0.001) were significantly shorter in the rTMS group. Preoperatively, 14 patients in the rTMS and 13 patients in the pre-rTMS group had language deficits (P = 0.380). One week after surgery, 8/14 patients (57.1%) in the rTMS group but only 1/13 patients (7.7%) in the pre-rTMS group experienced improvement of language performance status (P = 0.013). At 6 weeks follow-up, language performance status was significantly better in the rTMS group (P = 0.048). However, at 3 months follow-up, the rTMS and pre-rTMS groups showed an equal language performance status. CONCLUSIONS Implementation of preoperative rTMS language mapping seems to provide a favorable early language outcome in patients undergoing surgical resection of language-eloquent lesions under general anesthesia.
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