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Schlosser-Perrin F, Rossel O, Duffau H, Bonnetblanc F, Mandonnet E. How far does electrical stimulation activate white matter tracts? A computational modeling study. Clin Neurophysiol 2023; 153:68-78. [PMID: 37459667 DOI: 10.1016/j.clinph.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/08/2023] [Accepted: 06/16/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE The aim of this study was to model how the different parameters of electrical stimulation (intensity, pulse shape, probe geometry) influence the extent of white matter activation. METHODS The electrical potentials generated by the stimulating electrodes were determined by solving Laplace equation. The temporal evolution of membrane potentials at each nodes of Ranvier of an axon was then computed by solving the coupled system of differential equations describing membrane dynamics and cable propagation. RESULTS Regions of unilateral propagation were observed for monophasic pulses delivered with a bipolar probe aligned along the tract. For biphasic pulses, the largest activation areas and depths were found with a high inter-electrode-distance (IED) bipolar probe, oriented orthogonally to the tract. The smallest activation areas and depths were found for bipolar stimulations with the probe aligned parallel to the tract and low IED. For isotropic white matter regions, the activation area and depth were three times larger than for anisotropic white matter tracts. CONCLUSIONS Bipolar probes with biphasic pulses offer the greatest versatility: an orthogonal orientation acts as two monopolars (increased sensitivity when searching for a tract), whereas a parallel orientation corresponds to a single monopolar (increased specificity). Activation is more superficial when stimulating highly anisotropic tracts. SIGNIFICANCE This knowledge is essential for interpreting the behavorial effects of stimulation and the recordings of axono-cortical evoked potentials.
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Affiliation(s)
| | | | - Hugues Duffau
- Département de Neurochirurgie, Centre Hospitalier Universitaire de Montpellier Gui de Chauliac, Montpellier, France; Team "Neuroplasticity, Stem Cells and Glial Tumors", Institute of Functional Genomics, INSERM U-1191, University of Montpellier, 34090 Montpellier, France; Université de Montpellier, Montpellier, France
| | | | - Emmanuel Mandonnet
- Frontlab, Paris Brain Institute, CNRS UMR 7225, INSERM U1127, Paris, France; Department of Neurosurgery, Lariboisière Hospital, Paris, France; Université de Paris Cité, Paris, France.
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Yamada S, Chaki T, Kimura Y, Mikuni N, Yamakage M. Effect of a Low Concentration of Sevoflurane Combined With Propofol on Transcranial Electrical Stimulation Motor Evoked Potential: A Case Series. Cureus 2023; 15:e41562. [PMID: 37559854 PMCID: PMC10407964 DOI: 10.7759/cureus.41562] [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] [Accepted: 07/08/2023] [Indexed: 08/11/2023] Open
Abstract
Transcranial electrical motor evoked potential (TCeMEP) is used to monitor the integrity of intraoperative motor function. Total intravenous anesthesia (TIVA) is the preferred method because its effect on MEP is relatively smaller than volatile anesthetics. However, maintaining the balanced anesthesia in long-time surgery using TIVA is challenging and may sometime cause problems including body movement during microsurgery. Such problems can be avoided by intraoperative anesthesia management using a mixture of propofol and a low concentration of sevoflurane. We recorded TCeMEP under a mixture of propofol and low concentration of sevoflurane anesthesia in three cases of neurosurgery. Anesthesia was induced with a 5.0 µg/mL target-controlled infusion of propofol and 0.6 mg/kg rocuronium. General anesthesia was maintained by propofol and 0.1-0.25 µg/kg/min remifentanil infusion. After the recording of control TCeMEP, sequential inhalation of 0.2 minimum alveolar concentration (MAC) and 0.5 MAC of sevoflurane was performed. The duration of each sevoflurane inhalation was 10 minutes, and the MACs were adjusted by the patient's age. In our cases, the combination of propofol and 0.2 MAC sevoflurane suppressed the amplitude of TCeMEP to 38.0±21.7% (379.8±212.0 µV), but the amplitude was high enough for evaluation of motor function monitoring. On the other hand, the combination of 0.5 MAC sevoflurane greatly decreased the amplitude of TCeMEP to 6.3±6.0% (71.9±66.9 µV) resulting in less than 150 µV, and it was difficult to record the change in TCeMEP amplitude over time. The combination of 0.2 MAC sevoflurane with TIVA might enable TCeMEP monitoring with TIVA.
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Affiliation(s)
- Shoto Yamada
- Division of Clinical Engineering, Sapporo Medical University Hospital, Sapporo, JPN
| | - Tomohiro Chaki
- Department of Anesthesiology, Sapporo Medical University, Sapporo, JPN
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, JPN
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, JPN
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University, Sapporo, JPN
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Yamada S, Enatsu R, Ishikawa S, Kimura Y, Komatsu K, Chaki T, Akiyama Y, Mikami T, Mikuni N. Transcranial electrical stimulation technique for induction of unilateral motor evoked potentials. Clin Neurophysiol 2023; 150:194-196. [PMID: 37080125 DOI: 10.1016/j.clinph.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/06/2023] [Accepted: 03/17/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE Transcranial electrical stimulation motor evoked potentials (TES-MEP) are widely used to monitor motor function; however, broad current spread and induced body movement are limitations of this technique. We herein report a localized stimulation technique for TES-MEP that induces unilateral MEP responses. METHODS The stimulation of C1(+)-C4(-) or C2(+)-C3(-) was performed to induce right- or left-sided muscle contraction, respectively, in 70 patients. Electromyography was recorded by placing electrodes on the bilateral abductor pollicis brevis (APB) and abductor hallucis (AH) muscles. Stimulation conditions were regulated in the range to induce unilateral muscle contractions contralateral to the anodal stimulation. The thresholds and amplitudes of TES-MEP were retrospectively analyzed. RESULTS The thresholds of APB were lower than those of AH in 47 patients, AH thresholds were lower than those of APB in 6 patients, and both APB and AH started to respond at the same intensity in 15 patients. This technical stimulation induced contralateral limb contractions with a suprathreshold stimulation of 129.4 ± 35.6 mA (mean ± standard deviation) in 68 patients (97%). Amplitudes in the suprathreshold stimulation of APB and AH responses were 727.5 ± 695.7 and 403.3 ± 325.7 μV, respectively. CONCLUSIONS The C1(+)-C4/C2(+)-C3(-) stimulation in TES-MEP enables a localized stimulation to induce unilateral MEP responses. SIGNIFICANCE Our stimulation technique enables the stable and safe monitoring of unilateral limbs, and contributes to the reliable monitoring of motor function in neurosurgery.
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Yamada S, Akiyama Y, Tachibana S, Hayamizu K, Kimura Y, Hashimoto S, Yamakage M, Mikuni N. The intraoperative motor-evoked potential when propofol was changed to remimazolam during general anesthesia: a case series. J Anesth 2023; 37:154-159. [PMID: 36319911 DOI: 10.1007/s00540-022-03112-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/22/2022] [Indexed: 11/07/2022]
Abstract
Remimazolam is a short-acting benzodiazepine that was approved for clinical use in 2020. We report three patients who underwent surgery for cerebral and spinal cord tumors, in whom transcranial electrical stimulation-motor-evoked potential (TES-MEP) was successfully monitored under general anesthesia with remimazolam. During total intravenous anesthesia with propofol at a target concentration of 2.7 - 3.5 µg/mL and 0.1 - 0.35 µg/kg/min of remifentanil, delayed awakening, bradycardia, and hypotension during propofol anesthesia were expected in all three cases. With patient safety as the top priority, we considered changing the anesthetic agent. Propofol was replaced with remimazolam at a loading dose of 12 mg/kg/h for a few seconds (case 3), followed by 1 mg/kg/h for maintenance (cases 1-3). TES-MEP was recorded during propofol and remimazolam administration in all three patients. Amplitudes of TES-MEP during anesthesia with propofol and remimazolam were 461.5 ± 150 µV and 590.5 ± 100.9 µV, 1542 ± 127 µV and 1698 ± 211 µV, and 581.5 ± 91.3 µV and 634 ± 82.7 µV sequentially from Case 1. Our findings suggest that intraoperative TES-MEP could be measured when anesthesia was managed with remimazolam at 1 mg/kg/h.
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Affiliation(s)
- Shoto Yamada
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan.
| | - Shunsuke Tachibana
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan
| | - Kengo Hayamizu
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan
| | - Shuichi Hashimoto
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan
| | - Michiaki Yamakage
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan
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Silverstein JW, Greisman JD, Dadario NB, Park J, D'Amico RS. A Cost-Effective, Adjustable, Dynamic Subcortical Stimulation Device - Technical Note. Neurodiagn J 2022; 62:193-205. [PMID: 36179326 DOI: 10.1080/21646821.2022.2121544] [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: 01/04/2023]
Abstract
Brain mapping and neuromonitoring remain the gold standard for identifying and preserving functional neuroanatomic regions during safe, maximal brain tumor resection. Subcortical stimulation (SCS) can identify white matter tracts and approximate their distance from the leading edge of an advancing resection cavity. Dynamic (continuous) devices permitting simultaneous suction and stimulation have recently emerged as time-efficient alternatives to traditional static (discontinuous) techniques. However, the high cost, fixed cap size, and fixed tube diameter of commercially available suction devices preclude universal adoption. Our objective is to modify available suction devices into monopolar probes for subcortical stimulation mapping. We describe our technique using a novel, cost-effective, dynamic SCS technique as part of our established neuromonitoring protocol. We electrified and insulated a conventional variable suction device using an alligator clip and red rubber catheter, respectively. We adjusted the catheter's length to expose metal on both sides, effectively converting the suction device into a monopolar stimulation probe capable of cortical and subcortical monopolar stimulation that does not differ from commercially available discontinuous or continuous devices. We fashioned a dynamic SCS suction probe using inexpensive materials compatible with all suction styles and sizes. Qualitative and quantitative analysis in future prospective case series is needed to assess efficacy and utility.
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Affiliation(s)
- Justin W Silverstein
- Department of NeurologyLenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York.,Department of Clinical Neurophysiology Neuro Protective Solutions, New York, New York
| | - Jacob D Greisman
- Department of Neurological Surgery Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Nicholas B Dadario
- Department of Neurological Surgery Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Jung Park
- Department of Neurological Surgery Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Randy S D'Amico
- Department of Neurological Surgery Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
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Axelson HW, Latini F, Jemstedt M, Ryttlefors M, Zetterling M. Continuous subcortical language mapping in awake glioma surgery. Front Oncol 2022; 12:947119. [PMID: 36033478 PMCID: PMC9416475 DOI: 10.3389/fonc.2022.947119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022] Open
Abstract
Repetitive monopolar short-train stimulation (STS) delivered from a suction probe enables continuous mapping and distance assessment of corticospinal tracts during asleep glioma resection. In this study, we explored this stimulation technique in awake glioma surgery. Fourteen patients with glioma involving language-related tracts were prospectively included. Continuous (3-Hz) cathodal monopolar STS (five pulses, 250 Hz) was delivered via the tip of a suction probe throughout tumor resection while testing language performance. At 70 subcortical locations, surgery was paused to deliver STS in a steady suction probe position. Monopolar STS influence on language performance at different subcortical locations was separated into three groups. Group 1 represented locations where STS did not produce language disturbance. Groups 2 and 3 represented subcortical locations where STS produced language interference at different threshold intensities (≥7.5 and ≤5 mA, respectively). For validation, bipolar Penfield stimulation (PS; 60 Hz for 3 s) was used as a “gold standard” comparison method to detect close proximity to language-related tracts and classified as positive or negative regarding language interference. There was no language interference from STS in 28 locations (Group 1), and PS was negative for all sites. In Group 2 (STS threshold ≥ 7.5 mA; median, 10 mA), there was language interference at 18 locations, and PS (median, 4 mA) was positive in only one location. In Group 3 (STS threshold ≤ 5 mA; median, 5 mA), there was language interference at 24 locations, and positive PS (median 4 mA) was significantly (p < 0.01) more common (15 out of 24 locations) compared with Groups 1 and 2. Despite the continuous stimulation throughout tumor resection, there were no seizures in any of the patients. In five patients, temporary current spread to the facial nerve was observed. We conclude that continuous subcortical STS is feasibly also in awake glioma surgery and that no language interference from STS or interference at ≥7.5 mA seems to indicate safe distance to language tracts as judged by PS comparisons. STS language interference at STS ≤ 5 mA was not consistently confirmed by PS, which needs to be addressed.
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Affiliation(s)
- Hans W. Axelson
- Department of Medical Sciences, Section of Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
- *Correspondence: Hans W. Axelson,
| | - Francesco Latini
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Malin Jemstedt
- Department of Medical Sciences, Speech-Language Pathology, Uppsala University, Uppsala, Sweden
| | - Mats Ryttlefors
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Maria Zetterling
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Real-Time Neuropsychological Testing of sensorimotor cognition during awake surgery in pre-central and post-somatosensory areas. World Neurosurg 2022; 164:e599-e610. [DOI: 10.1016/j.wneu.2022.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/18/2022]
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8
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Ren X, Yang X, Huang W, Yang K, Liu L, Cui Y, Guo L, Qiao H, Lin S. The Minimal Subcortical Electronic Threshold Predicts the Motor Deficit and Survivals in Non-Awake Surgery for Gliomas Involving the Motor Pathway. Front Oncol 2022; 12:789705. [PMID: 35372030 PMCID: PMC8965070 DOI: 10.3389/fonc.2022.789705] [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: 10/05/2021] [Accepted: 02/17/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose Direct subcortical motor mapping is the golden criterion to detect and monitor the motor pathway during glioma surgery. Minimal subcortical monopolar threshold (MSCMT) means the minimal distance away from the motor pathway and is critical to decide to continue or interrupt glioma resection. However, the optimal cutoff value of MSCMT for glioma resection in non-awake patients has not been reported discreetly. In this study, we try to establish the safe cutoff value of MSCMT for glioma resection and analyzed its relationship with postoperative motor deficit and long-term survivals. Methods We designed this prospective study with high-frequency electronic stimulus method. The cutoff MSCMT of postoperative motor deficits was statistically calculated by receiver operating characteristic (ROC) curve, and its relationship with motor deficit and survivals was analyzed by logistic and Cox regression, respectively. Results The cutoff MSCMT to predict motor deficit after surgery was 3.9 mA on day 1, 3.7 mA on day 7, 5.2 mA at 3 months, and 5.2 mA at 6 months. MSCMT ≤3.9 mA and MSCMT ≤5.2 mA independently predicted postoperative motor deficits at four times after surgery (P < 0.05) but had no effect on the removal degree of tumor (P > 0.05). In high-grade gliomas, MSCMT ≤3.9 mA independently predicted shorter progression-free survival [odds ratio (OR) = 3.381 (1.416–8.076), P = 0.006] and overall survival [OR = 3.651 (1.336–9.977), P = 0.012]. Power model has the best fitness for paired monopolar and bipolar high-frequency thresholds. Conclusions This study showed strong cause–effect relation between MSCMT and postoperative motor deficit and prognoses. The cutoff MSCMT was dug out to avoid postoperative motor deficit. Further studies are needed to establish the results above.
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Affiliation(s)
- Xiaohui Ren
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Xiaocui Yang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Wei Huang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Kaiyuan Yang
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Li Liu
- Beijing Neurosurgical Institute, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Yong Cui
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Lanjun Guo
- Surgical Neuromonitoring Service, University of California, San Francisco, CA, United States
| | - Hui Qiao
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
| | - Song Lin
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China.,Institute for Brain Disorders and Beijing Key Laboratory of Brain Tumor, Beijing, China
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9
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Greisman JD, Dadario NB, Park J, Silverstein JW, D'Amico RS. Subcortical Stimulation in Brain Tumor Surgery: A closer look beneath the surface. World Neurosurg 2022; 161:55-63. [PMID: 35149248 DOI: 10.1016/j.wneu.2022.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Maximizing a patient's onco-functional balance is the central tenet of brain tumor surgery. As a result, numerous surgical adjuncts have been developed to facilitate identification of the tumor-brain interface and preservation of functional anatomy. Among these, intraoperative neurophysiologic monitoring (IONM) with direct cortical and subcortical stimulation remains the gold standard for real time, functional mapping of motor and language activity. However, stimulation techniques are not standardized and vary significantly across institutions. This is particularly true with subcortical stimulation for mapping of motor function. METHODS We review the state of subcortical IONM and mapping techniques. Historical and predicate literature were reviewed as well as new and emerging techniques. We discuss their evolution, clinical utility, and limitations to direct future research and application. RESULTS We evaluate and discuss the background and current clinical use of direct cortical and subcortical stimulation techniques and protocols and identify current trends and limitations. We focus specifically on methods of subcortical stimulation given the heterogeneity in the published literature. We also suggest directions to optimize the clinical utility of these tools. CONCLUSION Despite significant heterogeneity in published techniques, trends support the use of the Taniguchi method for subcortical stimulation. Novel dynamic stimulation techniques may improve accuracy. Prospective studies to define standardized guidelines are needed.
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Affiliation(s)
- Jacob D Greisman
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Nicholas B Dadario
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Jung Park
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
| | - Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA; Neuro Protective Solutions, New York, New York, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA.
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Gerritsen JKW, Broekman MLD, De Vleeschouwer S, Schucht P, Jungk C, Krieg SM, Nahed BV, Berger MS, Vincent AJPE. Global comparison of awake and asleep mapping procedures in glioma surgery: An international multicenter survey. Neurooncol Pract 2022; 9:123-132. [PMID: 35371523 PMCID: PMC8965050 DOI: 10.1093/nop/npac005] [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] [Indexed: 12/04/2022] Open
Abstract
Background Mapping techniques are frequently used to preserve neurological function during glioma surgery. There is, however, no consensus regarding the use of many variables of these techniques. Currently, there are almost no objective data available about potential heterogeneity between surgeons and centers. The goal of this survey is therefore to globally identify, evaluate and analyze the local mapping procedures in glioma surgery. Methods The survey was distributed to members of the neurosurgical societies of the Netherlands (Nederlandse Vereniging voor Neurochirurgie—NVVN), Europe (European Association of Neurosurgical Societies—EANS), and the United States (Congress of Neurological Surgeons—CNS) between December 2020 and January 2021 with questions about awake mapping, asleep mapping, assessment of neurological morbidity, and decision making. Results Survey responses were obtained from 212 neurosurgeons from 42 countries. Overall, significant differences were observed for equipment and its settings that are used for both awake and asleep mapping, intraoperative assessment of eloquent areas, the use of surgical adjuncts and monitoring, anesthesia management, assessment of neurological morbidity, and perioperative decision making. Academic practices performed awake and asleep mapping procedures more often and employed a clinical neurophysiologist with telemetric monitoring more frequently. European neurosurgeons differed from US neurosurgeons regarding the modality for cortical/subcortical mapping and awake/asleep mapping, the use of surgical adjuncts, and anesthesia management during awake mapping. Discussion This survey demonstrates the heterogeneity among surgeons and centers with respect to their procedures for awake mapping, asleep mapping, assessing neurological morbidity, and decision making in glioma patients. These data invite further evaluations for key variables that can be optimized and may therefore benefit from consensus.
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Affiliation(s)
| | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center The Hague, The Netherlands
| | | | - Philippe Schucht
- Department of Neurosurgery, University Hospital Bern, Switzerland
| | - Christine Jungk
- Department of Neurosurgery, University Hospital Heidelberg, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University Munich, Germany
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston MA, USA
| | - Mitchel S Berger
- Department of Neurosurgery, University of California, San Francisco CA, USA
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Seidel K, Szelényi A, Bello L. Intraoperative mapping and monitoring during brain tumor surgeries. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:133-149. [PMID: 35772883 DOI: 10.1016/b978-0-12-819826-1.00013-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Many different methodologies and paradigms are available to guide surgery of supratentorial tumors with the aim to preserve quality of life of the patients and to increase the extent of tumor resection. Neurophysiologic monitoring techniques (such as different evoked potentials) may help to continuously assess functional integrity of the observed systems and warn about vascular injury. For neurophysiologic mapping methods, the focus is not only to preserve cortical sites, but also to prevent injury to subcortical pathways. Therefore, cortical mapping is not enough but should be combined with subcortical mapping to identify tracts. This may be done by alternating resection and stimulation, or by continuous mapping via an electrified surgical tool such as a stimulating suction tip. Increasingly refined techniques are evolving to improve mapping of complex motor networks as well as language and higher cortical functions. Finally, in deciding between an awake vs asleep intraoperative setting, various factors need to be considered, such as the surgical goal, patient expectation and cooperation, treating team expertise, and neurooncologic aspects including histopathology. Therefore, the choice of protocol depends on the clinical context and the experience of the interdisciplinary team treating the patients.
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Affiliation(s)
- Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Andrea Szelényi
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Lorenzo Bello
- Department of Oncology and Hemato-Oncology, Neurosurgical Oncology Unit, Università degli Studi di Milano, Milan, Italy
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12
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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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13
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MacDonald DB, Simon MV, Nuwer MR. Neurophysiology during epilepsy surgery. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:103-121. [PMID: 35772880 DOI: 10.1016/b978-0-12-819826-1.00017-x] [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: 06/15/2023]
Abstract
Intraoperative neuromonitoring (IONM) complements modern presurgical investigations by providing information about the epileptic focus as well as real-time identification of critical functional tissue and assessment of ongoing neural integrity during resective epilepsy surgery. This chapter summarizes current IONM methods for mapping the epileptic focus and for mapping and monitoring functionally important structures with direct brain stimulation and evoked potentials. These techniques include electrocorticography, computerized high-frequency oscillation mapping, single-pulse electric stimulation, cortical and subcortical motor evoked potentials, somatosensory evoked potentials, visual evoked potentials, and cortico-cortical evoked potentials. They may help to maximize epileptic tissue resection while avoiding permanent postoperative neurologic deficits.
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Affiliation(s)
| | - Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Marc R Nuwer
- Departments of Neurology and Clinical Neurophysiology, David Geffen School of Medicine, University of California Los Angeles, and Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
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14
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Simon MV, Nuwer MR, Szelényi A. Electroencephalography, electrocorticography, and cortical stimulation techniques. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:11-38. [PMID: 35772881 DOI: 10.1016/b978-0-12-819826-1.00001-6] [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: 06/15/2023]
Abstract
Electroencephalography (EEG) and electrocorticography (ECoG) are two important neurophysiologic techniques used in the operating room for monitoring and mapping electrical brain activity. In this chapter, we detail their principle, recording methodology, and address specifics of their interpretation in the intraoperative setting (e.g., effect of anesthetics), as well as their clinical applications in epilepsy and non-epilepsy surgeries. In addition, we address differences between scalp, surface, and deep cortical recordings that will help towards a more reliable interpretation of the significance of electrophysiologic parameters such as amplitude and morphology as well as in differentiation between abnormal and normal patterns of electrical brain activity. Electrical stimulation is used for intraoperative mapping of different cortical functions such as language, parietal, and motor. Stimulation paradigms used in clinical practice vary with regard to stimulation frequencies and probes being used. Parameters, such as the number of phases per pulse, pulse/phase duration, pulse frequency, organization, and polarity, define their characteristics, including their safety, propensity to trigger seizures, efficiency and reliability of stimulation, and the mapping thresholds. Specifically, in this chapter, we will address differences between monopolar and bipolar stimulation; anodal and cathodal polarity; monophasic and biphasic pulses; constant voltage, and constant current paradigms.
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Affiliation(s)
- Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.
| | - Marc R Nuwer
- Departments of Neurology and Clinical Neurophysiology, David Geffen School of Medicine, University of California Los Angeles, and Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Andrea Szelényi
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
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15
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Aaronson DM, Martinez Del Campo E, Boerger TF, Conway B, Cornell S, Tate M, Mueller WM, Chang EF, Krucoff MO. Understanding Variable Motor Responses to Direct Electrical Stimulation of the Human Motor Cortex During Brain Surgery. Front Surg 2021; 8:730367. [PMID: 34660677 PMCID: PMC8517489 DOI: 10.3389/fsurg.2021.730367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
Direct electrical stimulation of the brain is the gold standard technique used to define functional-anatomical relationships during neurosurgical procedures. Areas that respond to stimulation are considered “critical nodes” of circuits that must remain intact for the subject to maintain the ability to perform certain functions, like moving and speaking. Despite its routine use, the neurophysiology underlying downstream motor responses to electrical stimulation of the brain, such as muscle contraction or movement arrest, is poorly understood. Furthermore, varying and sometimes counterintuitive responses can be seen depending on how and where the stimulation is applied, even within the human primary motor cortex. Therefore, here we review relevant neuroanatomy of the human motor system, provide a brief historical perspective on electrical brain stimulation, explore mechanistic variations in stimulation applications, examine neurophysiological properties of different parts of the motor system, and suggest areas of future research that can promote a better understanding of the interaction between electrical stimulation of the brain and its function.
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Affiliation(s)
- Daniel M Aaronson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Timothy F Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Brian Conway
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Sarah Cornell
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Matthew Tate
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Wade M Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Edward F Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, United States
| | - Max O Krucoff
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Biomedical Engineering, Marquette University, Milwaukee, WI, United States
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16
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Scerrati A, Mongardi L, Cavallo MA, Labanti S, Simioni V, Ricciardi L, De Bonis P. Awake surgery for skills preservation during a sensory area tumor resection in a clarinet player. Acta Neurol Belg 2021; 121:1235-1239. [PMID: 32372400 DOI: 10.1007/s13760-020-01368-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/24/2020] [Indexed: 01/01/2023]
Abstract
Tumors in primary sensory area are challenging to remove without causing a neurological deficit, especially in musicians who present complex neuronal networks. Indeed, in this kind of patients, somatosensory evoked potentials (SSEPs) are not plenty. We describe our experience for sensory and proprioception preservation in a professional clarinet player undergoing surgery for a right parietal glioblastoma. The patient underwent surgery for a right parietal glioblastoma. Intraoperative monitoring and awake surgery while playing instrument, were performed. During resection, intraoperative stimulation caused a transient impairment of left hand movements, without SSEPs alteration. The resection was stopped anytime there was a movement impairment. We obtained a gross total tumor resection. Patient did not present neurological deficits. Standard neurophysiological monitoring is fundamental but cannot be sufficient. More complex strategies of monitoring, such as awake surgery and playing an instrument could be of help for preserving complex sensory-motor functions.
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Affiliation(s)
| | | | | | | | | | - Luca Ricciardi
- UOC di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Dipartimento NESMOS, Sapienza, Rome, Italy
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17
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Yamada S, Enatsu R, Kimura Y, Komatsu K, Akiyama Y, Mikami T, Ochi S, Mikuni N. Effects of polarity of bipolar sensorimotor direct cortical stimulation on intraoperative motor evoked potentials. Clin Neurophysiol 2021; 132:2351-2356. [PMID: 34454261 DOI: 10.1016/j.clinph.2021.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 05/24/2021] [Accepted: 06/21/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The present study investigated the effects of the stimulus polarity and location of motor evoked potential (MEP) to establish a stimulation protocol. METHODS Nineteen patients who intraoperatively underwent MEP in bipolar direct cortical stimulation were enrolled in the present study. Somatosensory evoked potentials (SEP) of the contralateral median nerve stimulation were recorded to determine stimulation sites. MEP was performed under two settings in all patients: 1. Anodal bipolar stimulation: an anode on the precentral gyrus and a cathode on the postcentral gyrus, 2. Cathodal bipolar stimulation: a cathode on the precentral gyrus and an anode on the postcentral gyrus. MEP amplitudes and the coefficient of variation (CV) at a stimulation intensity of 25 mA and the thresholds of induced MEP were compared between the two settings. RESULTS An electrical stimulation at 25 mA induced a significantly higher amplitude in cathodal bipolar stimulation than in anodal bipolar stimulation. Cathodal bipolar stimulation also showed significantly lower thresholds than anodal stimulation. CV did not significantly differ between the two groups. CONCLUSIONS These results indicate that cathodal bipolar stimulation is superior to anodal bipolar stimulation for intraoperative MEP monitoring. SIGNIFICANCE MEP in cathodal bipolar cortical stimulation may be used in a safe and useful evaluation method of motor fiber damage that combines sensitivity and specificity.
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Affiliation(s)
- Shoto Yamada
- Division of Clinical Engineering, Sapporo Medical University Hospital, Sapporo, Japan
| | - Rei Enatsu
- Department of Neurosurgery, Sapporo Medical University Hospital, Sapporo, Japan.
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University Hospital, Sapporo, Japan
| | - Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University Hospital, Sapporo, Japan
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University Hospital, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University Hospital, Sapporo, Japan
| | - Satoko Ochi
- Department of Neurosurgery, Sapporo Medical University Hospital, Sapporo, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University Hospital, Sapporo, Japan
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18
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Targeting Primary Motor Cortex (M1) Functional Components in M1 Gliomas Enhances Safe Resection and Reveals M1 Plasticity Potentials. Cancers (Basel) 2021; 13:cancers13153808. [PMID: 34359709 PMCID: PMC8345096 DOI: 10.3390/cancers13153808] [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: 06/05/2021] [Revised: 07/13/2021] [Accepted: 07/21/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Primary-Motor-Cortex (M1) hosts two functional components, at its posterior and anterior borders, the first being faster and more excitable than the second. Our study reports a novel technique for the on-line identification of these functional components during M1 tumors resection. It reports for the first time the potential plastic reorganization of M1 and specifically how its functional organization is affected by a growing tumor and correlated to clinical, tumor-related factors and patient motor functional performance. It also shows for the first time that detecting the M1 functional architecture and targeting the two M1 functional components facilitates tumor resection, increasing the rate of complete tumor removal, while maintaining the patient’s functional motor capacity. Abstract Primary-Motor-Cortex (M1) hosts two functional components, at its posterior and anterior borders, being the first faster and more excitable. We developed a mapping-technique for M1 components identification and determined their functional cortical-subcortical architecture in M1 gliomas and the impact of their identification on tumor resection and motor performance. A novel advanced mapping technique was used in 102 tumors within M1 or CorticoSpinal-Tract to identify M1-two components. High-Frequency-stimulation (2–5 pulses) with an on-line qualitative and quantitative analysis of motor responses was used; the two components’ cortical/subcortical spatial distribution correlated to clinical, tumor-related factor and patients’ motor outcome; a cohort treated with standard-mapping was used for comparison. The two functional components were always identified on-line; in tumors not affecting M1, its functional segregation was preserved. In M1 tumors, two architectures, both preserving the two components, were disclosed: in 50%, a normal cortical/subcortical architecture emerged, while 50% revealed a distorted architecture with loss of anatomical reference and somatotopy, not associated with tumor histo-molecular features or volume, but with a previous treatment. Motor performance was maintained, suggesting functional compensation. By preserving the highest and resecting the lowest excitability component, the complete-resection increased with low morbidity. The real-time identification of two M1 functional components and the preservation of the highest excitability one increases safe resection, revealing M1 plasticity potentials.
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19
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Cabrera JP, Vera F, López E, Luna F. Letter to the Editor regarding "Use of intra-operative stimulation of brainstem lesion target sites for frameless stereotactic biopsies". Childs Nerv Syst 2021; 37:2133-2135. [PMID: 33909084 DOI: 10.1007/s00381-021-05180-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Juan P Cabrera
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, San Martín 1436, Concepción, Chile. .,Faculty of Medicine, University of Concepción, Concepción, Chile.
| | - Franco Vera
- Faculty of Medicine, University of Concepción, Concepción, Chile
| | - Eduardo López
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, San Martín 1436, Concepción, Chile
| | - Francisco Luna
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, San Martín 1436, Concepción, Chile.,Faculty of Medicine, University of Concepción, Concepción, Chile
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20
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You H, Qiao H. Intraoperative Neuromonitoring During Resection of Gliomas Involving Eloquent Areas. Front Neurol 2021; 12:658680. [PMID: 34248818 PMCID: PMC8260928 DOI: 10.3389/fneur.2021.658680] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/18/2021] [Indexed: 11/23/2022] Open
Abstract
In the case of resection of gliomas involving eloquent areas, equal consideration should be given to maintain maximal extent of resection (EOR) and neurological protection, for which the intraoperative neuromonitoring (IONM) proves an effective and admirable approach. IONM techniques applied in clinical practice currently consist of somatosensory evoked potential (SSEP), direct electrical stimulation (DES), motor evoked potential (MEP), electromyography (EMG), and electrocorticography (ECoG). The combined use of DES and ECoG has been adopted widely. With the development of technology, more effective IONM tactics and programs would be proposed. The ultimate goal would be strengthening the localization of eloquent areas and epilepsy foci, reducing the incidence of postoperative dysfunction and epilepsy improving the life quality of patients.
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Affiliation(s)
- Hao You
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Hui Qiao
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
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21
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Simon MV, Lee DK, Choi BD, Talati PA, Yang JC, Koch MJ, Jones PS, Curry WT. Neurophysiologic Mapping of Thalamocortical Tract in Asleep Craniotomies: Promising Results From an Early Experience. Oper Neurosurg (Hagerstown) 2021; 20:219-225. [PMID: 33269396 DOI: 10.1093/ons/opaa330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 08/02/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Subcortical mapping of the corticospinal tract has been extensively used during craniotomies under general anesthesia to achieve maximal resection while avoiding postoperative motor deficits. To our knowledge, similar methods to map the thalamocortical tract (TCT) have not yet been developed. OBJECTIVE To describe a neurophysiologic technique for TCT identification in 2 patients who underwent resection of frontoparietal lesions. METHODS The central sulcus (CS) was identified using the somatosensory evoked potentials (SSEP) phase reversal technique. Furthermore, monitoring of the cortical postcentral N20 and precentral P22 potentials was performed during resection. Subcortical electrical stimulation in the resection cavity was done using the multipulse train (case #1) and Penfield (case #2) techniques. RESULTS Subcortical stimulation within the postcentral gyrus (case #1) and in depth of the CS (case #2), resulted in a sudden drop in amplitudes in N20 (case #1) and P22 (case #2), respectively. In both patients, the potentials promptly recovered once the stimulation was stopped. These results led to redirection of the surgical plane with avoidance of damage of thalamocortical input to the primary somatosensory (case #1) and motor regions (case #2). At the end of the resection, there were no significant changes in the median SSEP. Both patients had no new long-term postoperative sensory or motor deficit. CONCLUSION This method allows identification of TCT in craniotomies under general anesthesia. Such input is essential not only for preservation of sensory function but also for feedback modulation of motor activity.
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Affiliation(s)
- Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel K Lee
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Bryan D Choi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pratik A Talati
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jimmy C Yang
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew J Koch
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pamela S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - William T Curry
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
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22
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Keeble H, Lavrador JP, Pereira N, Lente K, Brogna C, Gullan R, Bhangoo R, Vergani F, Ashkan K. Electromagnetic Navigation Systems and Intraoperative Neuromonitoring: Reliability and Feasibility Study. Oper Neurosurg (Hagerstown) 2021; 20:373-382. [PMID: 33432974 DOI: 10.1093/ons/opaa407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND A recent influx of intraoperative technology is being used in neurosurgery, but few reports investigate the accuracy and safety of these technologies when used simultaneously. OBJECTIVE To assess the ability to use an electromagnetic navigation system alongside multimodal intraoperative neurophysiological monitoring (IONM). METHODS Single-institution prospective cohort study of patients requiring craniotomy for brain tumor resection operated using an electromagnetic navigation system (AxiEM, Medtronic®). motor evoked potentials, somatosensory evoked potentials (SSEPs), electroencephalography, and electromyography were recorded and analyzed with AxiEM on (with/without filters) and off. The neurological outcomes of the patients were recorded. RESULTS A total of 15 patients were included (8 males/7 females, mean age 52.13 yr). Even though the raw acquisition is affected by the electromagnetic field (particularly SSEPs), no significant difference was detected in the morphology, amplitude, and latency of the different monitoring modalities (AxiEM off vs on) after the appropriate software filter application. Adjustments to the frequency of SSEP stimulation and number of averages, and reductions to the low-pass filters were applied. Notch filters were used appropriately and changes to the physical setup of the IONM and electromagnetic navigation system equipment reduced noise. Postoperatively, none of the patients developed new focal deficits; 7 patients showed improvement in their motor deficit (4 recovered fully). CONCLUSION The information provided by the IONM in intracranial neurosurgery patients whilst also using electromagnetic navigation systems is reliable for monitoring, mapping, and detecting intraoperative complications, provided that the appropriate software filters and tools are applied.
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Affiliation(s)
| | - José Pedro Lavrador
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | | | | | - Christian Brogna
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | - Richard Gullan
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | - Ranjeev Bhangoo
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | - Francesco Vergani
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
| | - Keyoumars Ashkan
- Neurosurgical Department, King's College Hospital Foundation Trust, London, United Kingdom
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23
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Rossi M, Puglisi G, Conti Nibali M, Viganò L, Sciortino T, Gay L, Leonetti A, Zito P, Riva M, Bello L. Asleep or awake motor mapping for resection of perirolandic glioma in the nondominant hemisphere? Development and validation of a multimodal score to tailor the surgical strategy. J Neurosurg 2021; 136:16-29. [PMID: 34144525 DOI: 10.3171/2020.11.jns202715] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Resection of glioma in the nondominant hemisphere involving the motor areas and pathways requires the use of brain-mapping techniques to spare essential sites subserving motor control. No clear indications are available for performing motor mapping under either awake or asleep conditions or for the best mapping paradigm (e.g., resting or active, high-frequency [HF] or low-frequency [LF] stimulation) that provides the best oncological and functional outcomes when tailored to the clinical context. This work aimed to identify clinical and imaging factors that influence surgical strategy (asleep motor mapping vs awake motor mapping) and that are associated with the best functional and oncological outcomes and to design a "motor mapping score" for guiding tumor resection in this area. METHODS The authors evaluated a retrospective series of patients with nondominant-hemisphere glioma-located or infiltrating within 2 cm anteriorly or posteriorly to the central sulcus and affecting the primary motor cortex, its fibers, and/or the praxis network-who underwent operations with asleep (HF monopolar probe) or awake (LF and HF probes) motor mapping. Clinical and imaging variables were used to design a motor mapping score. A prospective series of patients was used to validate this motor mapping score. RESULTS One hundred thirty-five patients were retrospectively analyzed: 69 underwent operations with asleep (HF stimulation) motor mapping, and 66 underwent awake (LF and HF stimulation and praxis task evaluation) motor mapping. Previous motor (strength) deficit, previous treatment (surgery/radiotherapy), tumor volume > 30 cm3, and tumor involvement of the praxis network (on MRI) were identified and used to design the mapping score. Motor deficit, previous treatment, and location within or close to the central sulcus favor use of asleep motor mapping; large tumor volume and involvement of the praxis network favor use of awake motor mapping. The motor mapping score was validated in a prospective series of 52 patients-35 underwent operations with awake motor mapping and 17 with asleep motor mapping on the basis of the score indications-who had a low rate of postoperative motor-praxis deficit (3%) and a high extent of resection (median 97%; complete resection in > 70% of patients). CONCLUSIONS Extensive resection of tumor involving the eloquent areas for motor control is feasible, and when an appropriate mapping strategy is applied, the incidence of postoperative motor-praxis deficit is low. Asleep (HF stimulation) motor mapping is preferable for lesions close to or involving the central sulcus and/or in patients with preoperative strength deficit and/or history of previous treatment. When a patient has no motor deficit or previous treatment and has a lesion (> 30 cm3) involving the praxis network, awake mapping is preferable.
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Affiliation(s)
- Marco Rossi
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Guglielmo Puglisi
- 2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and.,3Neurosurgical Oncology Unit, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano
| | - Marco Conti Nibali
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Luca Viganò
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Tommaso Sciortino
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Lorenzo Gay
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
| | - Antonella Leonetti
- 2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and.,3Neurosurgical Oncology Unit, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano
| | - Paola Zito
- 4Department of Anesthesia and Intensive Care, Humanitas Research Hospital, IRCCS, Rozzano, Italy
| | - Marco Riva
- 2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and.,3Neurosurgical Oncology Unit, Department of Medical Biotechnologies and Translational Medicine, Università degli Studi di Milano
| | - Lorenzo Bello
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology, and.,2Neurosurgical Oncology Unit, IRCCS Istituto Ortopedico Galeazzi, Milano; and
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24
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Asimakidou E, Abut PA, Raabe A, Seidel K. Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review. Cancers (Basel) 2021; 13:2803. [PMID: 34199853 PMCID: PMC8200078 DOI: 10.3390/cancers13112803] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 12/31/2022] Open
Abstract
During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined.
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Affiliation(s)
- Evridiki Asimakidou
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Pablo Alvarez Abut
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
- Department of Neurosurgery, Clínica 25 de Mayo, 7600 Mar del Plata, Argentina
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
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Rosenstock T, Tuncer MS, Münch MR, Vajkoczy P, Picht T, Faust K. Preoperative nTMS and Intraoperative Neurophysiology - A Comparative Analysis in Patients With Motor-Eloquent Glioma. Front Oncol 2021; 11:676626. [PMID: 34094981 PMCID: PMC8175894 DOI: 10.3389/fonc.2021.676626] [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: 03/05/2021] [Accepted: 04/23/2021] [Indexed: 01/26/2023] Open
Abstract
Background The resection of a motor-eloquent glioma should be guided by intraoperative neurophysiological monitoring (IOM) but its interpretation is often difficult and may (unnecessarily) lead to subtotal resection. Navigated transcranial magnetic stimulation (nTMS) combined with diffusion-tensor-imaging (DTI) is able to stratify patients with motor-eloquent lesion preoperatively into high- and low-risk cases with respect to a new motor deficit. Objective To analyze to what extent preoperative nTMS motor risk stratification can improve the interpretation of IOM phenomena. Methods In this monocentric observational study, nTMS motor mapping with DTI fiber tracking of the corticospinal tract was performed before IOM-guided surgery for motor-eloquent gliomas in a prospectively collected cohort from January 2017 to October 2020. Descriptive analyses were performed considering nTMS data (motor cortex infiltration, resting motor threshold (RMT), motor evoked potential (MEP) amplitude, latency) and IOM data (transcranial MEP monitoring, intensity of monopolar subcortical stimulation (SCS), somatosensory evoked potentials) to examine the association with the postoperative motor outcome (assessed at day of discharge and at 3 months). Results Thirty-seven (56.1%) of 66 patients (27 female) with a median age of 48 years had tumors located in the right hemisphere, with glioblastoma being the most common diagnosis with 39 cases (59.1%). Three patients (4.9%) had a new motor deficit that recovered partially within 3 months and 6 patients had a persistent deterioration (9.8%). The more risk factors of the nTMS risk stratification model (motor cortex infiltration, tumor-tract distance (TTD) ≤8mm, RMTratio <90%/>110%) were detected, the higher was the risk for developing a new postoperative motor deficit, whereas no patient with a TTD >8mm deteriorated. Irreversible MEP amplitude decrease >50% was associated with worse motor outcome in all patients, while a MEP amplitude decrease ≤50% or lower SCS intensities ≤4mA were particularly correlated with a postoperative worsened motor status in nTMS-stratified high-risk cases. No patient had postoperative deterioration of motor function (except one with partial recovery) when intraoperative MEPs remained stable or showed only reversible alterations. Conclusions The preoperative nTMS-based risk assessment can help to interpret ambiguous IOM phenomena (such as irreversible MEP amplitude decrease ≤50%) and adjustment of SCS stimulation intensity.
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Affiliation(s)
- Tizian Rosenstock
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Biomedical Innovation Academy, Berlin, Germany
| | - Mehmet Salih Tuncer
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Max Richard Münch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Cluster of Excellence: "Matters of Activity. Image Space Material", Humboldt University, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Rossi M, Sciortino T, Conti Nibali M, Gay L, Viganò L, Puglisi G, Leonetti A, Howells H, Fornia L, Cerri G, Riva M, Bello L. Clinical Pearls and Methods for Intraoperative Motor Mapping. Neurosurgery 2021; 88:457-467. [PMID: 33476393 PMCID: PMC7884143 DOI: 10.1093/neuros/nyaa359] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/26/2020] [Indexed: 12/13/2022] Open
Abstract
Resection of brain tumors involving motor areas and pathways requires the identification and preservation of various cortical and subcortical structures involved in motor control at the time of the procedure, in order to maintain the patient's full motor capacities. The use of brain mapping techniques has now been integrated into clinical practice for many years, as they help the surgeon to identify the neural structures involved in motor functions. A common definition of motor function, as well as knowledge of its neural organization, has been continuously evolving, underlining the need for implementing intraoperative strategies at the time of the procedure. Similarly, mapping strategies have been subjected to continuous changes, enhancing the likelihood of preservation of full motor capacities. As a general rule, the motor mapping strategy should be as flexible as possible and adapted strictly to the individual patient and clinical context of the tumor. In this work, we present an overview of current knowledge of motor organization, indications for motor mapping, available motor mapping, and monitoring strategies, as well as their advantages and limitations. The use of motor mapping improves resection and outcomes in patients harboring tumors involving motor areas and pathways, and should be considered the gold standard in the resection of this type of tumor.
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Affiliation(s)
- Marco Rossi
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Marco Conti Nibali
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Gay
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Luca Viganò
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Antonella Leonetti
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Luca Fornia
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Gabriella Cerri
- Laboratory of Motor Control, Department of Biotechnology and Translational Medicine, Università degli Studi di Milano Milano, Italy
| | - Marco Riva
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgery , Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milano, Italy
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Use of intra-operative stimulation of brainstem lesion target sites for frameless stereotactic biopsies. Childs Nerv Syst 2021; 37:1515-1523. [PMID: 33683422 DOI: 10.1007/s00381-021-05101-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/24/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Frameless stereotactic navigation is used to direct the trajectory and biopsy site of target lesions. We report on a novel intra-operative stimulating (IOS) probe that is integrated into a commercially available stereotactic biopsy needle with the rationale that stimulation of the intended biopsy site should predict functional tissue thus preventing inadvertent biopsy of eloquent tissue. METHODS Patients undergoing brainstem biopsies for atypical lesions were offered the additional stimulation procedure. The IOS probe was used to deliver stimulation in an attempt to determine the proximity of eloquent tissue. Once the desired location of the biopsy needle was achieved, the IOS probe was inserted down the centre of the biopsy needle and the stimulus applied. If no action potential was recorded, biopsies from four quadrants of the lesion were taken. If however a compound action potential was recorded, a new target was selected. RESULTS Nine patients had the biopsy and stimulation procedure performed. The median age was 36 months. A minimum of 8 samples were obtained from each patient. Biopsy material was adequate to obtain a diagnosis in all 9 patients. In 2 cases use of the device influenced the insertion trajectory or biopsy site. No patients experienced any complications directly attributable to either the biopsy procedure or application of the stimulation. CONCLUSIONS Use of the IOS probe for intra-operative stimulation of the intended brainstem biopsy site was found to be safe and feasible. The addition of stimulation using the IOS probe can be done with minimal change in workflow.
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Bander ED, Shelkov E, Modik O, Kandula P, Karceski SC, Ramakrishna R. Use of the train-of-five bipolar technique to provide reliable, spatially accurate motor cortex identification in asleep patients. Neurosurg Focus 2021; 48:E4. [PMID: 32006941 DOI: 10.3171/2019.11.focus19776] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative cortical and subcortical mapping techniques have become integral for achieving a maximal safe resection of tumors that are in or near regions of eloquent brain. The recent literature has demonstrated successful motor/language mapping with lower rates of stimulation-induced seizures when using monopolar high-frequency stimulation compared to traditional low-frequency bipolar stimulation mapping. However, monopolar stimulation carries with it disadvantages that include more radiant spread of electrical stimulation and a theoretically higher potential for tissue damage. The authors report on the successful use of bipolar stimulation with a high-frequency train-of-five (TOF) pulse physiology for motor mapping. METHODS Between 2018 and 2019, 13 patients underwent motor mapping with phase-reversal and both low-frequency and high-frequency bipolar stimulation. A retrospective chart review was conducted to determine the success rate of motor mapping and to acquire intraoperative details. RESULTS Thirteen patients underwent both high- and low-frequency bipolar motor mapping to aid in tumor resection. Of the lesions treated, 69% were gliomas, and the remainder were metastases. The motor cortex was identified at a significantly greater rate when using high-frequency TOF bipolar stimulation (n = 13) compared to the low-frequency bipolar stimulation (n = 4) (100% vs 31%, respectively; p = 0.0005). Intraoperative seizures and afterdischarges occurred only in the group of patients who underwent low-frequency bipolar stimulation, and none occurred in the TOF group (31% vs 0%, respectively; p = 0.09). CONCLUSIONS Using a bipolar wand with high-frequency TOF stimulation, the authors achieved a significantly higher rate of successful motor mapping and a low rate of intraoperative seizure compared to traditional low-frequency bipolar stimulation. This preliminary study suggests that high-frequency TOF stimulation provides a reliable additional tool for motor cortex identification in asleep patients.
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Affiliation(s)
| | - Evgeny Shelkov
- 2Neurology, NewYork-Presbyterian/Weill Cornell Medicine, New York, New York
| | - Oleg Modik
- 2Neurology, NewYork-Presbyterian/Weill Cornell Medicine, New York, New York
| | - Padmaja Kandula
- 2Neurology, NewYork-Presbyterian/Weill Cornell Medicine, New York, New York
| | - Steven C Karceski
- 2Neurology, NewYork-Presbyterian/Weill Cornell Medicine, New York, New York
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Boëx C, Goga C, Bérard N, Haemmerli J, Zegarek G, Bartoli A, Momjian S, Schaller K. Introduction of a novel connection clip for the ultrasonic aspirator for subcortical continuous motor mapping. BRAIN AND SPINE 2021; 1:100002. [PMID: 36247400 PMCID: PMC9559965 DOI: 10.1016/j.bas.2021.100002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 10/31/2022]
Abstract
Introduction Research question Material and methods Results Discussion Conclusion A connection clip was introduced to stimulate directly the ultrasonic aspirator For integrated and continuous motor mapping simultaneously to the resection process Distance (y, mm) of the stimulation (x, mA) site to the tract found: y = 0.63x + 2.33 Confidence intervals of the regression, underline the role of motor evoked potentials Absence of seizures was observed here using biphasic pulse waveform
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Policicchio D, Ticca S, Dipellegrini G, Doda A, Muggianu G, Boccaletti R. Multimodal Surgical Management of Cerebral Lesions in Motor-Eloquent Areas Combining Intraoperative 3D Ultrasound with Neurophysiological Mapping. J Neurol Surg A Cent Eur Neurosurg 2020; 82:344-356. [PMID: 33352612 DOI: 10.1055/s-0040-1717111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Resection of tumors adjacent to motor pathways carries risks of both postoperative motor deficit and incomplete resection. Our aim was to assess usefulness and limitations of a multimodal strategy that combines intraoperative ultrasound (iUS) guided resection with intraoperative neurophysiology. METHODOLOGY This is a prospective study of 25 patients with brain lesions adjacent to motor areas who underwent intracranial surgery with assistance of the iUS guidance system and intraoperative neurophysiological monitoring and mapping. Pathologies treated included 19 gliomas, 3 metastases, 1 anaplastic meningioma, 1 arteriovenous malformation (AVM), and 1 ependymoma. The iUS-guided lesion removal accuracy and the extent of resection were estimated and compared with a 30-day postoperative brain MRI. The results were assessed considering the extent of resection related to 6-month motor function outcome. RESULTS iUS was accurate in checking the extent of resection in 17 patients, whereas in 8 cases the decline of the iUS images quality did not allow a valuable assessment. Positive mapping was obtained in 16 patients. Gross total resection was achieved in 16 patients. In five of nine cases with subtotal resection, surgery was stopped because a functional area was reached. In four patients, tumor removal was limited due to the difficulty of identifying neoplastic tissue. Motor function worsening was transient in six patients and permanent in two. CONCLUSIONS The integrated use of intraoperative neuromonitoring to identify motor areas and iUS to identify tumor-tissue interface could help increase the rate of radical resection respecting the eloquent areas.
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Affiliation(s)
- Domenico Policicchio
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Stefano Ticca
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Giosuè Dipellegrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Artan Doda
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Giampiero Muggianu
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Riccardo Boccaletti
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
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Morshed RA, Young JS, Lee AT, Berger MS, Hervey-Jumper SL. Clinical Pearls and Methods for Intraoperative Awake Language Mapping. Neurosurgery 2020; 89:143-153. [PMID: 33289505 DOI: 10.1093/neuros/nyaa440] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/12/2020] [Indexed: 12/12/2022] Open
Abstract
Intraoperative language mapping of tumor and peritumor tissue is a well-established technique for avoiding permanent neurological deficits and maximizing extent of resection. Although there are several components of language that may be tested intraoperatively (eg, naming, writing, reading, and repetition), there is a lack of consistency in how patients are tested intraoperatively as well as the techniques involved to ensure safety during an awake procedure. Here, we review appropriate patient selection, neuroanesthetic techniques, cortical and subcortical language mapping stimulation paradigms, and selection of intraoperative language tasks used during awake craniotomies. We also expand on existing language mapping reviews by considering how intensity and timing of electrical stimulation may impact interpretation of mapping results.
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Abstract
Intraoperative functional mapping of tumor and peri-tumor tissue is a well-established technique for avoiding permanent neurologic deficits and maximizing extent of resection. Motor, language, and other cognitive domains may be assessed with intraoperative tasks. This article describes techniques used for motor and language mapping including awake mapping considerations in addition to less traditional intraoperative testing paradigms for cognition. It also discusses complications associated with mapping and insights into complication avoidance.
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Kosyrkova AV, Goryainov SA, Ogurtsova AA, Okhlopkov VA, Kravchuk AD, Batalov AI, Afandiev RM, Bayev AA, Pogosbekyan EL, Pronin IN, Zakharova NE, Danilov GV, Strunina YV, Potapov AA. [Comparative analysis of mono- and bipolar pyramidal tract mapping in patients with supratentorial tumors adjacent to motor areas: comparison of data at 64 stimulation points]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:29-40. [PMID: 33095531 DOI: 10.17116/neiro20208405129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare monopolar and bipolar mapping in point-by-point fashion by using of threshold amperage, frequency of positive motor responses and the number of muscles involved in response. MATERIAL AND METHODS A prospective non-randomized study included 14 patients with supratentorial tumors who underwent surgery in 2018-2019. All neoplasms were localized within 2 cm from the motor cortex and pyramidal tract. Age of patients ranged from 25 to 74 years. There were 9 women and 5 men. Eight patients had malignant glioma (grade III - 4, grade IV - 4), 6 patients - meningioma. Motor functions were assessed in all patients before and after surgery (1, 7 days and 3 months later) by using of a 5-point scale. In addition to routine neurophysiological monitoring, comparative mono- and bipolar mapping of the pyramidal tract within the bed of excised tumor was carried out at the end of surgery. The points of motor responses were marked. Comparative analysis of mono- and bipolar stimulation at identical points included threshold amperage, frequency of positive motor responses and the number of muscles involved in response (leg, forearm, hand, facial muscles). Brain MRI was performed in early postoperative period for assessment of resection quality. RESULTS There were 64 points of motor responses in 14 patients. The number of these points ranged from 2 to 8 per a patient (mean 5 points). Motor responses were recorded in 57 points during monopolar and bipolar stimulation, in other 7 points - only during monopolar stimulation. Amperage of monopolar stimulation was 3-15 mA, bipolar stimulation - 2.5-25 mA. Threshold amperage (7.37 mA for monopolar stimulation and 8.88 mA for bipolar stimulation; p=0.12), frequency of positive motor responses and the number of muscles involved in response (p=0.1 and p=0.73) were similar. Seven (50%) patients had neurological deterioration in early postoperative period (4 patients with glial tumors and 3 patients with meningiomas). At the same time, only 2 patients (14.3%) had persistent neurological deficit (both patients with infiltrative meningioma). According to postoperative MRI in T1+C mode, resection volume was 100% in 1 patient with contrast-enhanced glioma and 94% in another one. According to FLAIR MRI data, resection volume exceeded 70% in 2 patients with non-enhancing glioma and less than 70% in 2 patients. Meningioma resection volume was estimated according to postoperative T1+C MRI data and made up over 90% in 4 patients. CONCLUSION Monopolar stimulation is a reliable method of pyramidal tract identification in supratentorial brain tumor surgery.
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Affiliation(s)
| | | | | | | | | | - A I Batalov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A A Bayev
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - G V Danilov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A A Potapov
- Burdenko Neurosurgical Center, Moscow, Russia
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Abstract
The resection of brain tumors located within or near the eloquent tissue has a higher risk of postoperative neurological deficits. The primary concerns include loss of sensory and motor functions in the contralateral face, upper and lower extremities, as well as speech deficits. Intraoperative neurophysiological monitoring (IONM) techniques are performed routinely for the identification and preservation of the functional integrity of the eloquent brain areas during neurosurgical procedures. The IONM modalities involve sensory, motor, and language mapping, which helps in the identification of the boundaries of these areas during surgical resection. Cortical motor Mapping (CmM) technique is considered as a gold-standard technique for mapping of the brain. We present the intraoperative CmM technique, including anesthesia recommendations, types of electrodes, as well as stimulation and recording parameters for successful monitoring.
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Affiliation(s)
- Faisal R Jahangiri
- Neurophysiology, Axis Neuromonitoring, Richardson, USA.,School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, USA.,Neurophysiology, Global Innervation, LLC, Dallas, USA
| | - Aksharkumar Dobariya
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, USA.,Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas, USA
| | - Aaron Kruse
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, USA
| | - Olga Kalyta
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, USA
| | - John D Moorman
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, USA
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Senft C, Behrens M, Lortz I, Wenger K, Filipski K, Seifert V, Forster MT. The ability to return to work: a patient-centered outcome parameter following glioma surgery. J Neurooncol 2020; 149:403-411. [PMID: 32960402 PMCID: PMC7609423 DOI: 10.1007/s11060-020-03609-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND With refinements in diagnosis and therapy of gliomas, the importance of survival time as the sole outcome parameter has decreased, and patient-centered outcome parameters have gained interest. Pursuing a profession is an indispensable component of human happiness. The aim of this study was to analyze the professional outcomes besides their neuro-oncological and functional evaluation after surgery for gliomas in eloquent areas. METHODS We assessed neuro-oncological and functional outcomes of patients with gliomas WHO grades II and III undergoing surgery between 2012 and 2018. All patients underwent routine follow-up and adjuvant treatment. Treatment and survival parameters were collected prospectively. Repercussions of the disease on the patients' professional status, socio-economic situation, and neurocognitive function were evaluated retrospectively with questionnaires. RESULTS We analyzed data of 58 patients with gliomas (WHO II: 9; III: 49). Median patient age was 35.8 years (range 21-63 years). Awake surgery techniques were applied in 32 patients (55.2%). Gross total and subtotal tumor resections were achieved in 33 (56.9%) and 17 (29.3%) patients, respectively, whereas in 8 patients (13.8%) resection had to remain partial. Most patients (n = 46; 79.3%) received adjuvant treatment. Median follow up was 43.8 months (range 11-82 months). After treatment 41 patients (70.7%) were able to resume a working life. Median time until returning to work was 8.0 months (range 0.2-22.0 months). To be younger than 40 at the time of the surgery was associated with a higher probability to return to work (p < .001). Multivariable regression analysis showed that patient age < 40 years as well as occupational group and self-reported fatigue were factors independently associated with the ability to return to work. CONCLUSION The ability to resume professional activities following brain tumor surgery is an important patient-oriented outcome parameter. We found that the majority of patients with gliomas were able to return to work following surgical and adjuvant treatment. Preservation of neurological function is of utmost relevance for individual patients´ quality of life.
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Affiliation(s)
- Christian Senft
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany. .,University Cancer Center Frankfurt - UCT, Frankfurt, Germany.
| | - Marion Behrens
- Department of Neurology, Goethe-University Hospital, Frankfurt, Germany
| | - Irina Lortz
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Katharina Wenger
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany
| | - Katharina Filipski
- Neurological Institute (Edinger-Institute), Goethe-University, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany.,German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Heidelberg, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany
| | - Marie-Thérèse Forster
- Department of Neurosurgery, Goethe-University Hospital, Schleusenweg 2-16, 60528, Frankfurt, Germany.,University Cancer Center Frankfurt - UCT, Frankfurt, Germany
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Gogos AJ, Young JS, Morshed RA, Avalos LN, Noss RS, Villanueva-Meyer JE, Hervey-Jumper SL, Berger MS. Triple motor mapping: transcranial, bipolar, and monopolar mapping for supratentorial glioma resection adjacent to motor pathways. J Neurosurg 2020; 134:1728-1737. [PMID: 32502996 DOI: 10.3171/2020.3.jns193434] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Maximal safe resection of gliomas near motor pathways is facilitated by intraoperative mapping. The authors and other groups have described the use of bipolar or monopolar direct stimulation to identify functional tissue, as well as transcranial or transcortical motor evoked potentials (MEPs) to monitor motor pathways. Here, the authors describe their initial experience using all 3 modalities to identify, monitor, and preserve cortical and subcortical motor systems during glioma surgery. METHODS Intraoperative mapping data were extracted from a prospective registry of glioma resections near motor pathways. Additional demographic, clinical, pathological, and imaging data were extracted from the electronic medical record. All patients with new or worsened postoperative motor deficits were followed for at least 6 months. RESULTS Between January 2018 and August 2019, 59 operations were performed in 58 patients. Overall, patients in 6 cases (10.2%) had new or worse immediate postoperative deficits. Patients with temporary deficits all had at least Medical Research Council grade 4/5 power. Only 2 patients (3.4%) had permanently worsened deficits after 6 months, both of which were associated with diffusion restriction consistent with ischemia within the corticospinal tract. One patient's deficit improved to 4/5 and the other to 4/5 proximally and 3/5 distally in the lower limb, allowing ambulation following rehabilitation. Subcortical motor pathways were identified in 51 cases (86.4%) with monopolar high-frequency stimulation, but only in 6 patients using bipolar stimulation. Transcranial or cortical MEPs were diminished in only 6 cases, 3 of which had new or worsened deficits, with 1 permanent deficit. Insula location (p = 0.001) and reduction in MEPs (p = 0.01) were the only univariate predictors of new or worsened postoperative deficits. Insula location was the only predictor of permanent deficits (p = 0.046). The median extent of resection was 98.0%. CONCLUSIONS Asleep triple motor mapping is safe and resulted in a low rate of deficits without compromising the extent of resection.
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Affiliation(s)
| | | | | | | | - Roger S Noss
- 3Neuromonitoring Service, University of California, San Francisco, California
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The role of tailored intraoperative neurophysiological monitoring in glioma surgery: a single institute experience. J Neurooncol 2020; 146:459-467. [PMID: 32020476 DOI: 10.1007/s11060-019-03347-0] [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] [Received: 09/30/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Glioma surgery near the functional area is still a dilemma. Intraoperative neurophysiologic monitoring (IONM) and functional mapping can play a role to maximize the extent of resection (EOR), while minimizing the risk of sequelae. We herein review the utility of tailored intraoperative mapping and monitoring in patients undergoing glioma surgery in our institute. METHODS Patients were divided into two groups on the basis of application tailored IONM (group A, 2013-2017, n = 53) or not (group B, 2008-2012, n = 49) between January 2008 and December 2017. The setup, tailored IONM protocols, surgery, and clinical results of all patients with eloquent glioma were analyzed with the EOR, functionality scores, overall survival (OS) and progression-free survival (PFS) retrospectively. RESULTS The 102 patients were considered eligible for analysis. High grade and low grade gliomas accounted for 73 (72%) and 29 (28%) cases, respectively. There was a positive association between the application of neuromonitor and post-operative functional preservation, but no significant statistical differences over the EOR, OS and PFS between the two groups. CONCLUSIONS In our experience, tailored intraoperative functional mapping provides an effective neurological function preservation. Routine implementation of neurophysiological monitoring with adequate pre-operative planning and intraoperative teamwork in eloquent glioma can get more satisfied functional preservation. Due to the maturation and experience of our IONM team may also be the variation factor, prospective studies with a more prominent sample and proper multivariate analysis will be expected to determine the real benefit.
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Tsetsou S, Butler W, Borges L, Eskandar EN, Fehnel KP, See RB, Simon MV. Dynamic mapping of the corticospinal tract in open cordotomy and myelomeningocele surgery. J Clin Neurosci 2020; 74:225-231. [PMID: 31973921 DOI: 10.1016/j.jocn.2020.01.054] [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: 10/28/2019] [Accepted: 01/11/2020] [Indexed: 11/25/2022]
Abstract
OBJECT Spinal cord surgeries carry a high risk for significant neurological impairments. The initial techniques for spinal cord mapping emerged as an aid to identify the dorsal columns and helped select a safe myelotomy site in intramedullary tumor resection. Advancements in motor mapping of the cord have also been made recently, but exclusively with tumor surgery. We hereby present our experiences with dynamic mapping of the corticospinal tract (CST) in other types of spinal cord procedures that carry an increased risk of postoperative motor deficit, and thus could directly benefit from this technique. CASE REPORTS Two patients with intractable unilateral lower extremity pain due to metastatic disease of the sacrum and a thoraco-lumbar chordoma, respectively underwent thoracic cordotomy to interrupt the nociceptive pathways. A third patient with progressive leg weakness underwent cord untethering and surgical repair of a large thoracic myelomeningocele. In all three cases, multimodality intraoperative neurophysiologic testing included somatosensory and motor evoked potentials monitoring as well as dynamic mapping of the CST. CONCLUSION CST mapping allowed safe advancement of the cordotomy probe and exploration of the meningocele sac with untethering of the anterior-lateral aspect of the cord respectively, resulting in postoperative preservation or improvement of motor strength from the pre-operative baseline. Stimulus thresholds varied likely with the distance between the stimulating probe and the CST as well as with the baseline motor strength in the mapped myotomes.
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Affiliation(s)
- Spyridoula Tsetsou
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - William Butler
- Deparmernt of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Lawrence Borges
- Deparmernt of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Emad N Eskandar
- Deparmernt of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Albert Einstein College of Medicine, New York, NY, United States
| | - Katie P Fehnel
- Deparmernt of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Reiner B See
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
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Rossi M, Conti Nibali M, Viganò L, Puglisi G, Howells H, Gay L, Sciortino T, Leonetti A, Riva M, Fornia L, Cerri G, Bello L. Resection of tumors within the primary motor cortex using high-frequency stimulation: oncological and functional efficiency of this versatile approach based on clinical conditions. J Neurosurg 2019; 133:642-654. [PMID: 31398706 DOI: 10.3171/2019.5.jns19453] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain mapping techniques allow one to effectively approach tumors involving the primary motor cortex (M1). Tumor resectability and maintenance of patient integrity depend on the ability to successfully identify motor tracts during resection by choosing the most appropriate neurophysiological paradigm for motor mapping. Mapping with a high-frequency (HF) stimulation technique has emerged as the most efficient tool to identify motor tracts because of its versatility in different clinical settings. At present, few data are available on the use of HF for removal of tumors predominantly involving M1. METHODS The authors retrospectively analyzed a series of 102 patients with brain tumors within M1, by reviewing the use of HF as a guide. The neurophysiological protocols adopted during resections were described and correlated with patients' clinical and tumor imaging features. Feasibility of mapping, extent of resection, and motor function assessment were used to evaluate the oncological and functional outcome to be correlated with the selected neurophysiological parameters used for guiding resection. The study aimed to define the most efficient protocol to guide resection for each clinical condition. RESULTS The data confirmed HF as an efficient tool for guiding resection of M1 tumors, affording 85.3% complete resection and only 2% permanent morbidity. HF was highly versatile, adapting the stimulation paradigm and the probe to the clinical context. Three approaches were used. The first was a "standard approach" (HF "train of 5," using a monopolar probe) applied in 51 patients with no motor deficit and seizure control, harboring a well-defined tumor, showing contrast enhancement in most cases, and reaching the M1 surface. Complete resection was achieved in 72.5%, and 2% had permanent morbidity. The second approach was an "increased train approach," that is, an increase in the number of pulses (7-9) and of pulse duration, using a monopolar probe. This second approach was applied in 8 patients with a long clinical history, previous treatment (surgery, radiation therapy, chemotherapy), motor deficit at admission, poor seizure control, and mostly high-grade gliomas or metastases. Complete resection was achieved in 87.5% using this approach, along with 0% permanent morbidity. The final approach was a "reduced train approach," which was the combined use of train of 2 or train of 1 pulses associated with the standard approach, using a monopolar or bipolar probe. This approach was used in 43 patients with a long clinical history and poorly controlled seizures, harboring tumors with irregular borders without contrast enhancement (low or lower grade), possibly not reaching the cortical surface. Complete resection was attained in 88.4%, and permanent morbidity was found in 2.3%. CONCLUSIONS Resection of M1 tumors is feasible and safe. By adapting the stimulation paradigm and probe appropriately to the clinical context, the best resection and functional results can be achieved.
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Affiliation(s)
- Marco Rossi
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology
| | - Marco Conti Nibali
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology
| | - Luca Viganò
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology
| | - Guglielmo Puglisi
- 2Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine; and
| | - Henrietta Howells
- 2Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine; and
| | - Lorenzo Gay
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology
| | - Tommaso Sciortino
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology
| | - Antonella Leonetti
- 2Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine; and
| | - Marco Riva
- 3Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano and Humanitas Research Hospital, IRCCS, Milano, Italy
| | - Luca Fornia
- 2Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine; and
| | - Gabriella Cerri
- 2Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine; and
| | - Lorenzo Bello
- 1Neurosurgical Oncology Unit, Department of Oncology and Hemato-Oncology
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Sala F. Penfield's stimulation for direct cortical motor mapping: An outdated technique? Clin Neurophysiol 2018; 129:2635-2637. [PMID: 30424944 DOI: 10.1016/j.clinph.2018.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 09/28/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Francesco Sala
- Institute of Neurosurgery, University Hospital, Verona, Italy.
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Gomez-Tames J, Kutsuna T, Tamura M, Muragaki Y, Hirata A. Intraoperative direct subcortical stimulation: comparison of monopolar and bipolar stimulation. Phys Med Biol 2018; 63:225013. [PMID: 30418938 DOI: 10.1088/1361-6560/aaea06] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intraoperative subcortical electrical stimulation is used to identify and preserve white matter tracts so that tumor resection can be performed while avoiding postsurgical deficits. The effects of the stimulating electrodes in identifying the white matter tracts have not been characterized; thus, different hospitals use different electrode configurations. Computational modeling can be used to conduct a systematic assessment of the effects of the stimulating electrode parameters. However, no realistic computational model of subcortical electrical stimulation has been implemented and verified. In this study, we investigated the interaction between the corticospinal tract (CST) and subcortical stimulation and compared different electrode configurations during monopolar and bipolar stimulation. For that, we computed the induced electric field in a realistic human head model coupled with a CST axon model. The implemented model was verified with available experimental data that were acquired during subcortical stimulation, and a systematic sensitivity analysis of parameters related to the stimulation was conducted. The results showed that the optimal stimulation varies according to the surgery conditions. If the CST was close to the resection border, bipolar stimulation could produce more selective activation. Monopolar stimulation was more robust and more effective for the CST far from the stimulation point.
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Affiliation(s)
- Jose Gomez-Tames
- Department of Electrical and Mechanical Engineering, Nagoya Institute of Technology, Nagoya, Aichi 466-8555, Japan. Author to whom any correspondence should be addressed
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Majchrzak K, Bobek-Billewicz B, Hebda A, Adamczyk P, Majchrzak H, Ładziński P. Surgical treatment of adult patients with thalamic tumors with the aid of tractography, fMRI, transcranial electrical stimulation and direct electrical stimulation of the subcortical white matter. Neurol Neurochir Pol 2018; 52:720-730. [DOI: 10.1016/j.pjnns.2018.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 07/07/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
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Sarnthein J, Wennberg R. Doing it the other way round - Mapping motor function by intrinsic activity. Clin Neurophysiol 2018; 129:2024-2025. [PMID: 30001935 DOI: 10.1016/j.clinph.2018.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 06/23/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Johannes Sarnthein
- Klinik für Neurochirurgie, UniversitätsSpital Zürich, Universität Zürich, Zurich, Switzerland.
| | - Richard Wennberg
- Krembil Neuroscience Centre, University Health Network, University of Toronto, Toronto, Canada
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Kim K, Cho C, Bang MS, Shin HI, Phi JH, Kim SK. Intraoperative Neurophysiological Monitoring : A Review of Techniques Used for Brain Tumor Surgery in Children. J Korean Neurosurg Soc 2018; 61:363-375. [PMID: 29742889 PMCID: PMC5957318 DOI: 10.3340/jkns.2018.0078] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 04/16/2018] [Indexed: 11/27/2022] Open
Abstract
Intraoperative monitoring (IOM) utilizes electrophysiological techniques as a surrogate test and evaluation of nervous function while a patient is under general anesthesia. They are increasingly used for procedures, both surgical and endovascular, to avoid injury during an operation, examine neurological tissue to guide the surgery, or to test electrophysiological function to allow for more complete resection or corrections. The application of IOM during pediatric brain tumor resections encompasses a unique set of technical issues. First, obtaining stable and reliable responses in children of different ages requires detailed understanding of normal ageadjusted brain-spine development. Neurophysiology, anatomy, and anthropometry of children are different from those of adults. Second, monitoring of the brain may include risk to eloquent functions and cranial nerve functions that are difficult with the usual neurophysiological techniques. Third, interpretation of signal change requires unique sets of normative values specific for children of that age. Fourth, tumor resection involves multiple considerations including defining tumor type, size, location, pathophysiology that might require maximal removal of lesion or minimal intervention. IOM techniques can be divided into monitoring and mapping. Mapping involves identification of specific neural structures to avoid or minimize injury. Monitoring is continuous acquisition of neural signals to determine the integrity of the full longitudinal path of the neural system of interest. Motor evoked potentials and somatosensory evoked potentials are representative methodologies for monitoring. Free-running electromyography is also used to monitor irritation or damage to the motor nerves in the lower motor neuron level : cranial nerves, roots, and peripheral nerves. For the surgery of infratentorial tumors, in addition to free-running electromyography of the bulbar muscles, brainstem auditory evoked potentials or corticobulbar motor evoked potentials could be combined to prevent injury of the cranial nerves or nucleus. IOM for cerebral tumors can adopt direct cortical stimulation or direct subcortical stimulation to map the corticospinal pathways in the vicinity of lesion. IOM is a diagnostic as well as interventional tool for neurosurgery. To prove clinical evidence of it is not simple. Randomized controlled prospective studies may not be possible due to ethical reasons. However, prospective longitudinal studies confirming prognostic value of IOM are available. Furthermore, oncological outcome has also been shown to be superior in some brain tumors, with IOM. New methodologies of IOM are being developed and clinically applied. This review establishes a composite view of techniques used today, noting differences between adult and pediatric monitoring.
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Affiliation(s)
- Keewon Kim
- Department of Rehabilitation Medicine, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Charles Cho
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Moon-Suk Bang
- Department of Rehabilitation Medicine, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Hoon Phi
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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Plans G, Fernández-Conejero I, Rifà-Ros X, Fernández-Coello A, Rosselló A, Gabarrós A. Evaluation of the High-Frequency Monopolar Stimulation Technique for Mapping and Monitoring the Corticospinal Tract in Patients With Supratentorial Gliomas. A Proposal for Intraoperative Management Based on Neurophysiological Data Analysis in a Series of 92 Patients. Neurosurgery 2018; 81:585-594. [PMID: 28327942 DOI: 10.1093/neuros/nyw087] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 11/25/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Intraoperative identification and preservation of the corticospinal tract is often necessary for glioma resection. OBJECTIVE To make a proposal for intraoperative management with the high-frequency monopolar stimulation technique for monitoring the corticospinal tract. METHODS Ninety-two patients operated on with the assistance of the high-frequency monopolar stimulation. Clinical and neurophysiological data have been related with the motor status at 3 months to establish prognostic factors of motor deterioration. RESULTS Twenty-one patients (22.8%) presented intraoperative alterations in motor-evoked potentials (MEPs). Twelve (13%) presented an increment in the MEP threshold ≥5 mA (no deficit at 3 months). Two (2.2%) presented an MEP amplitude reduction >50% (100% deficit at 3 months). Seven (7.6%) had an intraoperative MEP loss (80% deficit at 3 months). Subcortical stimulation was positive in 75 patients (81.5%). Eighty-five patients were available for the analysis at 3 months. Fourteen presented new deficits (16.5%). Among them, 5 presented a deficit in nonmonitored muscles (5.9%) and 1 presented a new deficit not detected intraoperatively. The combination of patients with preoperative motor deficits, MEP deterioration, or loss and intensity of subcortical stimulation ≤3 mA showed the highest sensitivity and specificity in the prediction of new deficits. CONCLUSIONS Persistent MEP loss or deterioration is associated with a high probability of new deficits. It seems recommendable to stop the subcortical resection before obtaining a subcortical MEP threshold at 3 mA especially in patients with preoperative motor deficits. A careful selection of muscles for the registration of MEPs is mandatory to avoid deficits in nonmonitored muscles.
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Affiliation(s)
- Gerard Plans
- Department of Neurosurgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Isabel Fernández-Conejero
- Department of Neurophysiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Rifà-Ros
- Cognition and Brain Plasticity Group, Bellvitge Biomedical Research Institute-IDIBELL, and Department of Basic Psychology, Campus Bellvitge, Universitat de Barcelona, L'Hos-pitalet de Llobregat, Barcelona, Spain
| | - Alejandro Fernández-Coello
- Department of Neurosurgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Aleix Rosselló
- Department of Neurosurgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Andreu Gabarrós
- Department of Neurosurgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Münnich T, Klein J, Hattingen E, Noack A, Herrmann E, Seifert V, Senft C, Forster MT. Tractography Verified by Intraoperative Magnetic Resonance Imaging and Subcortical Stimulation During Tumor Resection Near the Corticospinal Tract. Oper Neurosurg (Hagerstown) 2018; 16:197-210. [DOI: 10.1093/ons/opy062] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 03/08/2018] [Indexed: 02/07/2023] Open
Abstract
Abstract
BACKGROUND
Tractography is a popular tool for visualizing the corticospinal tract (CST). However, results may be influenced by numerous variables, eg, the selection of seeding regions of interests (ROIs) or the chosen tracking algorithm.
OBJECTIVE
To compare different variable sets by correlating tractography results with intraoperative subcortical stimulation of the CST, correcting intraoperative brain shift by the use of intraoperative MRI.
METHODS
Seeding ROIs were created by means of motor cortex segmentation, functional MRI (fMRI), and navigated transcranial magnetic stimulation (nTMS). Based on these ROIs, tractography was run for each patient using a deterministic and a probabilistic algorithm. Tractographies were processed on pre- and postoperatively acquired data.
RESULTS
Using a linear mixed effects statistical model, best correlation between subcortical stimulation intensity and the distance between tractography and stimulation sites was achieved by using the segmented motor cortex as seeding ROI and applying the probabilistic algorithm on preoperatively acquired imaging sequences. Tractographies based on fMRI or nTMS results differed very little, but with enlargement of positive nTMS sites the stimulation-distance correlation of nTMS-based tractography improved.
CONCLUSION
Our results underline that the use of tractography demands for careful interpretation of its virtual results by considering all influencing variables.
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Affiliation(s)
- Timo Münnich
- Department of Neurosurgery, Goet-he University Hospital, Frankfurt am Main, Germany
| | - Jan Klein
- Fraunhofer MEVIS, Institute for Medical Image Computing, Bremen, Germany
| | - Elke Hattingen
- Department of Neuroradiology, Goethe University Hospital, Frankfurt am Main, Germa-ny
| | - Anika Noack
- Department of Neurosurgery, Goet-he University Hospital, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institute for Biostatistics and Math-ematical Modelling, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goet-he University Hospital, Frankfurt am Main, Germany
| | - Christian Senft
- Department of Neurosurgery, Goet-he University Hospital, Frankfurt am Main, Germany
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Opciones de monitorización neurofisiológica en la resección de tumoraciones cerebrales. Documento de consenso entre el Grupo de Trabajo de Neurooncología de la Sociedad Española de Neurocirugía (SENEC) y la Sociedad Española de Neurofisiología Clínica (SENFC). Neurocirugia (Astur) 2018; 29:25-38. [DOI: 10.1016/j.neucir.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/17/2017] [Accepted: 07/25/2017] [Indexed: 11/23/2022]
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Raffa G, Conti A, Scibilia A, Cardali SM, Esposito F, Angileri FF, La Torre D, Sindorio C, Abbritti RV, Germanò A, Tomasello F. The Impact of Diffusion Tensor Imaging Fiber Tracking of the Corticospinal Tract Based on Navigated Transcranial Magnetic Stimulation on Surgery of Motor-Eloquent Brain Lesions. Neurosurgery 2017; 83:768-782. [DOI: 10.1093/neuros/nyx554] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/05/2017] [Indexed: 01/22/2023] Open
Abstract
Abstract
BACKGROUND
Navigated transcranial magnetic stimulation (nTMS) enables preoperative mapping of the motor cortex (M1). The combination of nTMS with diffusion tensor imaging fiber tracking (DTI-FT) of the corticospinal tract (CST) has been described; however, its impact on surgery of motor-eloquent lesions has not been addressed.
OBJECTIVE
To analyze the impact of nTMS-based mapping on surgery of motor-eloquent lesions.
METHODS
In this retrospective case-control study, we reviewed the data of patients operated for suspected motor-eloquent lesions between 2012 and 2015. The patients underwent nTMS mapping of M1 and, from 2014, nTMS-based DTI-FT of the CST. The impact on the preoperative risk/benefit analysis, surgical strategy, craniotomy size, extent of resection (EOR), and outcome were compared with a control group.
RESULTS
We included 35 patients who underwent nTMS mapping of M1 (group A), 35 patients who also underwent nTMS-based DTI-FT of the CST (group B), and a control group composed of 35 patients treated without nTMS (group C). The patients in groups A and B received smaller craniotomies (P = .01; P = .001), had less postoperative seizures (P = .02), and a better postoperative motor performance (P = .04) and Karnofsky Performance Status (P = .009) than the controls. Group B exhibited an improved risk/benefit analysis (P = .006), an increased EOR of nTMS-negative lesions in absence of preoperative motor deficits (P = .01), and less motor and Karnofsky Performance Status worsening in case of preoperative motor deficits (P = .02, P = .03) than group A.
CONCLUSION
nTMS-based mapping enables a tailored surgical approach for motor-eloquent lesions. It may improve the risk/benefit analysis, EOR and outcome, particularly when nTMS-based DTI-FT is performed.
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Affiliation(s)
- Giovanni Raffa
- Department of Neurosurgery, University of Messina, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alfredo Conti
- Department of Neurosurgery, University of Messina, Messina, Italy
| | | | | | - Felice Esposito
- Department of Neurosurgery, University of Messina, Messina, Italy
| | | | | | - Carmela Sindorio
- Department of Neurosurgery, University of Messina, Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Antonino Germanò
- Department of Neurosurgery, University of Messina, Messina, Italy
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Abalkhail TM, MacDonald DB, AlThubaiti I, AlOtaibi FA, Stigsby B, Mokeem AA, AlHamoud IA, Hassounah MI, Baz SM, AlSemari A, AlDhalaan HM, Khan S. Intraoperative direct cortical stimulation motor evoked potentials: Stimulus parameter recommendations based on rheobase and chronaxie. Clin Neurophysiol 2017; 128:2300-2308. [PMID: 29035822 DOI: 10.1016/j.clinph.2017.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/04/2017] [Accepted: 09/19/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine optimal interstimulus interval (ISI) and pulse duration (D) for direct cortical stimulation (DCS) motor evoked potentials (MEPs) based on rheobase and chronaxie derived with two techniques. METHODS In 20 patients under propofol/remifentanil anesthesia, 5-pulse DCS thenar MEP rheobase and chronaxie with 2, 3, 4 and 5ms ISI were measured by linear regression of five charge thresholds at 0.05, 0.1, 0.2, 0.5 and 1msD, and estimated from two charge thresholds at 0.1 and 1msD using simple arithmetic. Optimal parameters were defined by minimum threshold energy: the ISI with lowest rheobase2×chronaxie, and D at its chronaxie. Near-optimal was defined as threshold energy <25% above minimum. RESULTS The optimal ISI was 3 or 4 (n=7 each), 2 (n=4), or 5ms (n=2), but only 4ms was always either optimal or near-optimal. The optimal D was ∼0.2 (n=12), ∼0.1 (n=7) or ∼0.3ms (n=1). Two-point estimates closely approximated five-point measurements. CONCLUSIONS Optimal ISI/D varies, with 4ms/0.2ms being most consistently optimal or near-optimal. Two-point estimation is sufficiently accurate. SIGNIFICANCE The results endorse 4ms ISI and 0.2msD for general use. Two-point estimation could enable quick individual optimization.
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Affiliation(s)
- Tariq M Abalkhail
- Section of Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital & Research Center (KFSH), Saudi Arabia
| | - David B MacDonald
- Section of Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital & Research Center (KFSH), Saudi Arabia.
| | - Ibrahim AlThubaiti
- Section of Neurosurgery, Department of Neurosciences, KFSH, Saudi Arabia
| | - Faisal A AlOtaibi
- Section of Neurosurgery, Department of Neurosciences, KFSH, Saudi Arabia
| | - Bent Stigsby
- Section of Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital & Research Center (KFSH), Saudi Arabia
| | - Amal A Mokeem
- Section of Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital & Research Center (KFSH), Saudi Arabia
| | - Iftetah A AlHamoud
- Section of Neurophysiology, Department of Neurosciences, King Faisal Specialist Hospital & Research Center (KFSH), Saudi Arabia
| | - Maher I Hassounah
- Section of Neurosurgery, Department of Neurosciences, KFSH, Saudi Arabia
| | - Salah M Baz
- Section of Neurology, Department of Neurosciences, KFSH, Saudi Arabia
| | | | - Hesham M AlDhalaan
- Section of Pediatric Neurology, Department of Neurosciences, KFSH, Saudi Arabia
| | - Sameena Khan
- Section of Pediatric Neurology, Department of Neurosciences, KFSH, Saudi Arabia
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Barzilai O, Lidar Z, Constantini S, Salame K, Bitan-Talmor Y, Korn A. Continuous mapping of the corticospinal tracts in intramedullary spinal cord tumor surgery using an electrified ultrasonic aspirator. J Neurosurg Spine 2017; 27:161-168. [DOI: 10.3171/2016.12.spine16985] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intramedullary spinal cord tumors (IMSCTs) represent a rare entity, accounting for 4%–10% of all central nervous system tumors. Microsurgical resection of IMSCTs is currently considered the primary treatment modality. Intraoperative neurophysiological monitoring (IONM) has been shown to aid in maximizing tumor resection and minimizing neurological morbidity, consequently improving patient outcome. The gold standard for IONM to date is multimodality monitoring, consisting of both somatosensory evoked potentials, as well as muscle-based transcranial electric motor evoked potentials (tcMEPs). Monitoring of tcMEPs is optimal when combining transcranial electrically stimulated muscle tcMEPs with D-wave monitoring. Despite continuous monitoring of these modalities, when classic monitoring techniques are used, there can be an inherent delay in time between actual structural or vascular-based injury to the corticospinal tracts (CSTs) and its revelation. Often, tcMEP stimulation is precluded by the surgeon’s preference that the patient not twitch, especially at the most crucial times during resection. In addition, D-wave monitoring may require a few seconds of averaging until updating, and can be somewhat indiscriminate to laterality. Therefore, a method that will provide immediate information regarding the vulnerability of the CSTs is still needed.The authors performed a retrospective series review of resection of IMSCTs using the tip of an ultrasonic aspirator for continuous proximity mapping of the motor fibers within the spinal cord, along with classic muscle-based tcMEP and D-wave monitoring.The authors present their preliminary experience with 6 patients who underwent resection of an IMSCT using the tip of an ultrasonic aspirator for continuous proximity mapping of the motor fibers within the spinal cord, together with classic muscle-based tcMEP and D-wave monitoring. This fusion of technologies can potentially assist in optimizing resection while preserving neurological function in these challenging surgeries.
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Affiliation(s)
- Ori Barzilai
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Zvi Lidar
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Shlomi Constantini
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
- 2Department of Pediatric Neurosurgery, “Dana” Children’s Hospital, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Khalil Salame
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Yifat Bitan-Talmor
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
| | - Akiva Korn
- 1Department of Neurosurgery, Tel Aviv, “Sourasky” Medical Center, Tel Aviv University; and
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