Catheter guided cerebral glioma resection combined with awake craniotomy: its usefulness and surgical outcome

Transcortical transcatheter ultrasound-assisted technique for deep-seated brain tumors. Technical note

PURPOSE

Surgery of deep-seated brain tumors can be challenging. Several methods have been described to facilitate transcortical approaches, including ultrasound-assisted resection. Ultrasound-guided placement of a standard ventricular catheter is a widely reported technique and has been used to approach these lesions via the transcortical route. We describe how we usually perform this useful technique to assist and enhance the transcortical resection of some deep-seated brain tumors.

METHODS

Standard electromagnetic frameless navigation (S8 Neuronavigation System, Medtronic, Minneapolis, USA) was employed to focus the craniotomy and to plan the trajectory of the ventricular catheter. After dural opening, an ultrasound device (Arietta 850, Hitachi-Aloka Medical, Tokyo, Japan) was used for intraoperative ultrasound (IOUS) assessment. A ventricular catheter was placed from the cortex to the lateral wall of the tumor under direct real-time IOUS visualization to guide the further transcortical dissection.

RESULTS

Transcortical transcatheter ultrasound-assisted technique involved minimal time and infrastructure requirements. There were no major technical difficulties during its use, providing confidence and improving subcortical white matter dissection by guiding the route to the tumor.

CONCLUSIONS

Recent improvement of IOUS image-quality devices offers several attractive options for real-time navigation. The combination of conventional neuronavigation systems with real-time IOUS assessment during the intradural step provides a higher degree of control by improving the execution of the surgery. We hope this description may be a useful tool for some selected cases and contribute to the further enhancement and improvement of this widely used technique.

Preoperative assessment of eloquence in neurosurgery: a systematic review

BACKGROUND AND OBJECTIVES

Tumor location and eloquence are two crucial preoperative factors when deciding on the optimal treatment choice in glioma management. Consensus is currently lacking regarding the preoperative assessment and definition of eloquent areas. This systematic review aims to evaluate the existing definitions and assessment methods of eloquent areas that are used in current clinical practice.

METHODS

A computer-aided search of Embase, Medline (OvidSP), and Google Scholar was performed to identify relevant studies. This review includes articles describing preoperative definitions of eloquence in the study's Methods section. These definitions were compared and categorized by anatomical structure. Additionally, various techniques to preoperatively assess tumor eloquence were extracted, along with their benefits, drawbacks and ease of use.

RESULTS

This review covers 98 articles including 12,714 participants. Evaluation of these studies indicated considerable variability in defining eloquence. Categorization of these definitions yielded a list of 32 brain regions that were considered eloquent. The most commonly used methods to preoperatively determine tumor eloquence were anatomical classification systems and structural MRI, followed by DTI-FT, functional MRI and nTMS.

CONCLUSIONS

There were major differences in the definitions and assessment methods of eloquence, and none of them proved to be satisfactory to express eloquence as an objective, quantifiable, preoperative factor to use in glioma decision making. Therefore, we propose the development of a novel, objective, reliable, preoperative classification system to assess eloquence. This should in the future aid neurosurgeons in their preoperative decision making to facilitate personalized treatment paradigms and to improve surgical outcomes.

Impact of Intraoperative Magnetic Resonance Imaging (i-MRI) on Surgeon Decision Making and Clinical Outcomes in Cranial Tumor Surgery

Background  Although intraoperative magnetic resonance imaging (iMRI) has an established role in guiding intraoperative extent of resection (EOR) in cranial tumor surgery, the details of how iMRI data are used by the surgeon in the real-time decision-making process is lacking.

Materials and Methods  The authors retrospectively reviewed 40 consecutive patients who underwent cranial tumor resection with the guidance of iMRI. The tumor volumes were measured by volumetric software. Intraoperative and postoperative EOR were calculated and compared. Surgeon preoperative EOR intention, intraoperative EOR assessment, and how iMRI data impacted surgeon decisions were analyzed.

Results  The pathology consisted of 29 gliomas, 8 pituitary tumors, and 3 other tumors. Preoperative surgeon intention called for gross total resection (GTR) in 28 (70%) cases. After resection and before iMRI scanning, GTR was 20 (50.0%) cases based on the surgeon's perception. After iMRI scanning, the results helped identify 19 (47.5%) cases with unexpected results consisting of 5 (12.5%) with unexpected locations of residual tumors and 14 (35%) with unexpected EOR. Additional resection was performed in 24 (60%) cases after iMRI review, including 6 (15%) cases with expected iMRI results. Among 34 cases with postoperative MRI results, iMRI helped improve EOR in 12 (35.3%) cases.

Conclusion  In cranial tumor surgery, the surgeon's preoperative and intraoperative assessment is frequently imprecise. iMRI data serve several purposes, including identifying the presence of residual tumors, providing residual tumor locations, giving spatial relation data of the tumor with nearby eloquent structures, and updating the neuro-navigation system for the final stage of tumor resection.

A Magnetic T7 Peptide&AS1411 Aptamer-Modified Microemulsion for Triple Glioma-Targeted Delivery of Shikonin and Docetaxel

Glioma-targeted drug delivery is a hugely challenging task because of the multibarrier in the brain. In this study, we report a magnetic T7 peptide&AS1411 aptamer-modified microemulsion for triple glioma-targeted delivery of shikonin and docetaxel (Fe3O4@T7/AS1411/DTX&SKN-M). Such a system comprises two tumor-targeted ligands (T7 peptide and AS1411 aptamer), ultra-small superparamagnetic iron oxide nanoparticle (Fe3O4), and shikonin&docetaxel-coloaded microemulsion (SKN&DTX-M). Fe3O4@T7/AS1411/DTX&SKN-M is capable of stably circulating in the blood, accumulating around the brain under an external magnetic field, distributing inside the glioma via the affinity to nucleolin/transferrin receptor, and retarding the growth of orthotopic glioma. Fe3O4@T7/AS1411/DTX&SKN-M encapsulated Fe3O4 nanoparticles in the core to obtain the superparamagnetism, which did not influence the main surface properties. Introducing 6% (wt%) of DSPE-PEG2000-T7 and 180 nM of AS1411 collaboratively enhanced the murine glioma (G422) cellular uptake of Fe3O4@T7/AS1411/DTX&SKN-M and thereby achieved the strongest antiproliferation among all the groups. Notably, the drug distribution at the brain sites of orthotopic Luc-G422 glioma tumor-bearing nude mice treated with Fe3O4@T7/AS1411/DTX&SKN-M was overwhelming among all the treatments. Most importantly, Fe3O4@T7/AS1411/DTX&SKN-M not only significantly reduced the luminescence signal at the brain areas of orthotopic Luc-G422 glioma mice but also prolonged the overall survival period. The enhancement of anti-glioma efficacy was associated with down-regulating the population of CD133- and CD44-positive cells within the tumors. In summary, such a triple glioma-targeted delivery of shikonin and docetaxel using combinational magnetism and T7/AS1411 modification strategies provides a promising method for synergistic and precise glioma therapy.