Improving surgical outcome for gliomas with intraoperative mapping

Resting State Functional Networks in Gliomas: Validation With Direct Electric Stimulation Using a New Tool for Planning Brain Resections

BACKGROUND AND OBJECTIVES

Precise mapping of functional networks in patients with brain tumor is essential for tailoring personalized treatment strategies. Resting-state functional MRI (rs-fMRI) offers an alternative to task-based fMRI, capable of capturing multiple networks within a single acquisition, without necessitating task engagement. This study demonstrates a strong concordance between preoperative rs-fMRI maps and the gold standard intraoperative direct electric stimulation (DES) mapping during awake surgery.

METHODS

We conducted an analysis involving 28 patients with glioma who underwent awake surgery with DES mapping. A total of 100 DES recordings were collected to map sensorimotor (SMN), language (LANG), visual (VIS), and speech articulation cognitive domains. Preoperative rs-fMRI maps were generated using an updated version of the ReStNeuMap software, specifically designed for rs-fMRI data preprocessing and automatic detection of 7 resting-state networks (SMN, LANG, VIS, speech articulation, default mode, frontoparietal, and visuospatial). To evaluate the agreement between these networks and those mapped with invasive cortical mapping, we computed patient-specific distances between them and intraoperative DES recordings.

RESULTS

Automatically detected preoperative functional networks exhibited excellent agreement with intraoperative DES recordings. When we spatially compared DES points with their corresponding networks, we found that SMN, VIS, and speech articulatory DES points fell within the corresponding network (median distance = 0 mm), whereas for LANG a median distance of 1.6 mm was reported.

CONCLUSION

Our findings show the remarkable consistency between key functional networks mapped noninvasively using presurgical rs-fMRI and invasive cortical mapping. This evidence highlights the utility of rs-fMRI for personalized presurgical planning, particularly in scenarios where awake surgery with DES is not feasible to protect eloquent areas during tumor resection. We have made the updated tool for automated functional network estimation publicly available, facilitating broader utilization of rs-fMRI mapping in various clinical contexts, including presurgical planning, functional reorganization over follow-up periods, and informing future treatments such as radiotherapy.

Hypnosis-Assisted Awake Craniotomy for Eloquent Brain Tumors: Advantages and Pitfalls

BACKGROUND

Awake craniotomy (AC) is recommended for the resection of tumors in eloquent areas. It is traditionally performed under monitored anesthesia care (MAC), which relies on hypnotics and opioids. Hypnosis-assisted AC (HAAC) is an emerging technique that aims to provide psychological support while reducing the need for pharmacological sedation and analgesia. We aimed to compare the characteristics and outcomes of patients who underwent AC under HAAC or MAC.

METHODS

We retrospectively analyzed the clinical, anesthetic, surgical, and neuropsychological data of patients who underwent awake surgical resection of eloquent brain tumors under HAAC or MAC. We used Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated-measures analyses of variance to identify statistically significant differences at the 0.05 level.

RESULTS

A total of 22 patients were analyzed, 14 in the HAAC group and 8 in the MAC group. Demographic, radiological, and surgical characteristics as well as postoperative outcomes were similar. Patients in the HAAC group received less remifentanil (p = 0.047) and propofol (p = 0.002), but more dexmedetomidine (p = 0.025). None of them received ketamine as a rescue analgesic. Although patients in the HAAC group experienced higher levels of perioperative pain (p < 0.05), they reported decreasing stress levels (p = 0.04) and greater levels of satisfaction (p = 0.02).

CONCLUSION

HAAC is a safe alternative to MAC as it reduces perioperative stress and increases overall satisfaction. Further research is necessary to assess whether hypnosis is clinically beneficial.

Structural networking of the developing brain: from maturation to neurosurgical implications

Modern neuroscience agrees that neurological processing emerges from the multimodal interaction among multiple cortical and subcortical neuronal hubs, connected at short and long distance by white matter, to form a largely integrated and dynamic network, called the brain "connectome." The final architecture of these circuits results from a complex, continuous, and highly protracted development process of several axonal pathways that constitute the anatomical substrate of neuronal interactions. Awareness of the network organization of the central nervous system is crucial not only to understand the basis of children's neurological development, but also it may be of special interest to improve the quality of neurosurgical treatments of many pediatric diseases. Although there are a flourishing number of neuroimaging studies of the connectome, a comprehensive vision linking this research to neurosurgical practice is still lacking in the current pediatric literature. The goal of this review is to contribute to bridging this gap. In the first part, we summarize the main current knowledge concerning brain network maturation and its involvement in different aspects of normal neurocognitive development as well as in the pathophysiology of specific diseases. The final section is devoted to identifying possible implications of this knowledge in the neurosurgical field, especially in epilepsy and tumor surgery, and to discuss promising perspectives for future investigations.

Feasibility of intraoperative neuromonitoring and cortical/subcortical mapping in patients with cerebral lesions of highly functional localizations-pathway to case adapted monitoring and mapping procedures

BACKGROUND

Intraoperative neuromonitoring (IONM) and mapping procedures via direct cortical stimulation (DCS) are required for resection of eloquently located cerebral lesions. In our neurooncological department, mapping and monitoring are used either combined or separately for surgery of functional lesions. The study aims to provide a practical insight into strengths and pitfalls of intraoperative neuromonitoring and mapping in supratentorial functionally located infiltrating lesions.

METHODS

IONM and mapping techniques performed in eloquent located brain tumors were analyzed with a focus on neurological outcome and resection results obtained via MRI. Additionally, the surgeons' view on obligatory techniques was explored retrospectively immediately after surgery. To evaluate the impact of the described items, we correlated intraoperative techniques in various issues.

RESULTS

Majority of the 437 procedures were performed as awake surgery (53%). Monopolar stimulation was used in 348 procedures and correlated with a postoperative temporary neurological deficit. Bipolar stimulation was performed in 127 procedures, particularly on tumors in the left hemisphere for language mapping. Overall permanent deficit was seen in 2% of the patients; neither different mapping or monitoring modes nor stimulation intensity, localization, or histopathological findings correlated significantly with permanent deficits. Evaluation of post-OP MRI revealed total resection (TR) in 209 out of 417 cases. Marginal residual volume in cases where total resection was assumed but MRI failed to proof TR was found (0.4 ml). Surgeons' post-OP evaluation of obligatory techniques matched in 73% with the techniques actually used.

CONCLUSION

We report 437 surgical procedures on highly functional located brain lesions. Resection without permanent deficit was adequately achievable in 98% of the procedures. Chosen mapping or monitoring techniques mostly depended on localization and vascular conflicts but also in some procedures on availability of resources, which was emphasized by the post-OP surgeons' evaluation. With the present study, we aimed to pave the way to á la carte choice of monitoring and or mapping techniques, reflecting the possibilities of even supratotal resection in eloquent brain tumor lesions and the herewith increased need for monitoring and limiting resources.

Resection of Eloquent Located Brain Tumors by Mapping Only-A Feasibility Study

BACKGROUND

Patients with eloquently located cerebral lesions require surgery that usually employs mapping and monitoring techniques for the preservation of motor and language function. However, in many cases, mapping only might be sufficient, reducing the need for technical and personnel logistics. Here, we report our experiences using a device that can be operated by the surgeon independently, providing mapping techniques but omitting monitoring techniques.

METHODS

For monopolar and bipolar cortical/subcortical stimulation, pre-set programs were available and intraoperatively used-two enabling EMG real-time tracking of eight muscles for monopolar (cortical/subcortical) mapping, and two programs for 60 Hz stimulation, one with EMG and one without. Motor mapping was performed under continuous observation of the screened EMG signal and acoustic feedback by the surgeon. For the 60 Hz stimulation, a standard bipolar stimulation probe was connected through a second port. The preoperative application of the subdermal EMG needles, as well as the intraoperative handling of the device, were performed by the surgeons independently. Postoperatively, an evaluation of the autonomous handling and feasibility of the device for the chosen test parameters was conducted.

RESULTS

From 04/19-09/21, 136 procedures in patients with eloquently located cerebral lesions were performed by using the "mapping-only" device. Mapping was performed in 82% of the monopolar cases and in 42% of the bipolar cases. Regarding the setup and sufficiency for the cortical/subcortical mapping, the device was evaluated as independently usable for motor and language mapping in 129 procedures (95%). Gross total resection was achieved, or functional limit throughout resection was reached, in 79% of the patients. 13 patients postoperatively suffered from a new neurological deficit. At the 3-6-month follow-up, three patients showed persistent deficit (2%). All of them had language disturbances. The setup time for the device was less than 7 min.

CONCLUSIONS

The device was evaluated as sufficient in over 90% of cases concerning monopolar and bipolar mapping, and the setup and handling was sufficient in all patients. With the present data we show that in well-selected cases, a very simple system providing mapping only is sufficient to achieve gross total resection with the preservation of functionality.

Tolerability of Repeat Awake Craniotomy: A Propensity-Score-Matched Analysis on 607 Consecutive Cases

BACKGROUND

Awake craniotomy is used for addressing lesions adjacent to eloquent brain regions to minimize damage to neurological functions, and to expedite postoperative recovery. Redo (i.e., repeat) awake surgery is not common, but always an option, especially for recurrent tumors. This study investigated the tolerability of redo awake surgery in terms of surgical characteristics and postoperative clinical course.

METHODS

Single-institution cohort study of 607 awake craniotomies by 1 surgeon at Toronto Western Hospital, 2006-2018.

RESULTS

Out of 607 surgeries, 501 surgeries were first-time, and 106 surgeries were redo. Between the 2 groups, surgery time was longer in redo cases than first-time cases and the rate of reoperation was higher in the former. Matched propensity cohort analysis included 104 cases each, based on adjustments for age, sex, tumor location, malignancy, and preoperative performance status. This revealed differences again in surgery time (128.0 vs. 111.9 minutes, P = 0.0004) and the reoperation rate (7.4 vs. 1.0%, P = 0.03). The causes of reoperation were infection (3 wound infection and 3 brain abscess) and wound dehiscence (n = 1). There was no significant difference in the length of hospital stay, the rates of postoperative hemorrhage, new postoperative neurological deficits, home discharge, or readmission.

CONCLUSIONS

Although redo surgery might increase the surgery time and the risk of reoperation due to postoperative infection, it was found to be well tolerated in other aspects overall. With extra care to infection and wound healing, redo awake surgery is a viable option to patients with the same surgical indication as for first-time surgery.

Perioperative Factors Affecting Readmission After Awake Craniotomy: Analysis of 609 Consecutive Cases

BACKGROUND

Awake craniotomy is being used widely for tumors near eloquent areas of the brain and also to facilitate early discharge from the hospital. Although most of the complications occur early in the postoperative period, there is a certain risk of delayed postoperative adverse events after discharge. This study investigated the incidence and the risk factors for postdischarge readmission after awake surgeries.

METHODS

This was a single-institution cohort study of 609 awake craniotomies by one surgeon at Toronto Western Hospital, 2006-2018.

RESULTS

Of 609 cases, 562 cases were available for analyses on postoperative readmission. In total, 6.0% (34 cases) were readmitted for medical reasons within 30 days after surgery, including neurologic decline (n = 9, 1.6%), infection at the surgical site (n = 8, 1.4%), followed by seizure (n = 5, 0.9%). Preoperative history of seizure (generalized or complex) was associated with readmission (P = 0.02). Eight of these plus 6 other cases experienced reoperation, and all the cases were due to infection but one (intraventricular hemorrhage). Investigations on correlations between perioperative factors and the reoperation found that redo surgery and findings of hemorrhage on postoperative imaging were significantly associated with reoperation (P = 0.0032, 0.0104 on multivariate analyses, respectively).

CONCLUSIONS

Although age, malignancy, or preoperative performance status were not related to readmission or reoperation, redo surgery cases and cases with postoperative hematoma were found to be at an increased risk for reoperation. Special attention and care need to be paid to these cases for potential complications after discharge, especially in situations in which patients tend to be discharged early after awake surgeries.

Language recovery through a two-stage awake surgery in an aphasic patient with a voluminous left fronto-temporo-insular glioma: case report

Awake surgery is difficult in glioma patients with preoperative aphasia. A 29-year-old right-handed bilingual (Spanish/English) patient experienced intractable seizures with severe language disorders due to a voluminous left fronto-temporo-insular tumor. We performed awake procedure with initial laborious language mapping, but with real-time improvement throughout the debulking, allowing preservation of the connectivity. A substantial residue was left. Postoperative cognitive rehabilitation resulted in a dramatic functional improvement, in both languages, permitting a complementary awake surgery, this time with a perfect collaboration of the patient. This multistep strategy enabled 92% of resection while enhancing quality of life with language recovery and epilepsy control.

Presence of a translator in the operating theater for awake mapping in foreign patients with low-grade glioma: a surgical experience based on 18 different native languages

OBJECTIVE

Intraoperative brain mapping with neurocognitive monitoring during awake surgery is currently the standard pattern of care for patients with diffuse low-grade glioma (DLGG), allowing a maximization of the extent of resection (EOR) while preserving quality of life. This study evaluated the feasibility of DLGG resections performed with intraoperative cognitive monitoring via the assistance of a translator for patients speaking foreign languages, and compared the surgical functional and oncological outcomes according to the possibility of direct communication with the surgical team.

METHODS

Foreign patients who underwent awake surgery with intraoperative electrical mapping with the assistance of a translator for the resection of a DLGG in the authors' institution between January 2010 and December 2020 were included. Patients whose native language included one of the three languages spoken by the surgical team (i.e., French, English, or Spanish) were excluded. The patients were classified into two groups. Group 1 was composed of patients able to communicate in at least one of these three languages in addition to their own native language. Group 2 was composed of patients who spoke none of these languages, and therefore were unable to communicate directly with the operating staff. The primary outcome was the patients' ability to return to work 3 months after surgery.

RESULTS

Eighty-four patients were included, of whom 63 were classified in group 1 and 21 in group 2. Eighteen different native languages were tested in the operating theater. Awake mapping was successful, with elicitation of transitory disturbances in all patients. There was no significant difference in the 3-month return-to-work status between the two groups (95% in group 1 [n = 58/61] vs 88% in group 2 [n = 15/17]; p = 0.298). Similarly, no significant difference between the two groups was found regarding the intraoperative tasks performed, the mean duration of the surgery, and the rate of permanent postoperative deficit. A significantly greater EOR was observed in group 1 patients in comparison to group 2 patients (90.4% ± 10.6% vs 87.7% ± 6.1%; p = 0.029).

CONCLUSIONS

Real-time translation by an interpreter during awake resection of glioma is feasible and safe in foreign patients. Nonetheless, when no direct verbal communication is possible between the surgical team and the patient, the EOR is less.

Intraoperative Neuromonitoring During Resection of Gliomas Involving Eloquent Areas

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.

Altered corticospinal microstructure and motor cortex excitability in gliomas: an advanced tractography and transcranial magnetic stimulation study

OBJECTIVE

This prospective case-control study was conducted to examine whether spherical deconvolution (SD) can unveil microstructural abnormalities in the corticospinal tract (CST) caused by IDH-mutant gliomas. To determine the significance of abnormal microstructure, the authors investigated the correlation between diffusion parameters and neurophysiological data collected with navigated transcranial magnetic stimulation (nTMS).

METHODS

Twenty participants (10 patients and 10 healthy controls) were recruited. Diffusion-weighted images were acquired on a 3-T MRI scanner using a cardiac-gated single-shot spin echo echo-planar imaging multiband sequence (TE 80 msec, TR 4000 msec) along 90 diffusion directions with a b-value of 2500 sec/mm2 (FOV 256 × 256 mm). Diffusion tensor imaging tractography and SD tractography were performed with deterministic tracking. The anterior portion of the ipsilateral superior peduncle and the precentral gyrus were used as regions of interest to delineate the CST. Diffusion indices were extracted and analyzed for significant differences between hemispheres in patients and between patient and control groups. A navigated brain stimulation system was used to deliver TMS pulses at hotspots at which motor evoked potentials (MEPs) for the abductor pollicis brevis, first digital interosseous, and abductor digiti minimi muscles are best elicited in patients and healthy controls. Functional measurements such as resting motor threshold (rMT), amplitude of MEPs, and latency of MEPs were noted. Significant differences between hemispheres in patients and between patients and controls were statistically analyzed. The Spearman rank correlation was used to investigate correlations between diffusion indices and functional measurements.

RESULTS

The hindrance modulated orientational anisotropy (HMOA), measured with SD tractography, is lower in the hemisphere ipsilateral to glioma (p = 0.028). The rMT in the hemisphere ipsilateral to a glioma is significantly greater than that in the contralateral hemisphere (p = 0.038). All measurements contralateral to the glioma, except for the mean amplitude of MEPs (p = 0.001), are similar to those of healthy controls. Mean diffusivity and axial diffusivity from SD tractography are positively correlated with rMT in the hemisphere ipsilateral to glioma (p = 0.02 and 0.006, respectively). The interhemispheric difference in HMOA and rMT is correlated in glioma patients (p = 0.007).

CONCLUSIONS

SD tractography can demonstrate microstructural abnormality within the CST of patients with IDH1-mutant gliomas that correlates to the functional abnormality measured with nTMS.

Planning Brain Tumor Resection Using a Probabilistic Atlas of Cortical and Subcortical Structures Critical for Functional Processing: A Proof of Concept

BACKGROUND

Functional preoperative planning for resection of intrinsic brain tumors in eloquent areas is still a challenge. Predicting subcortical functional framework is especially difficult. Direct electrical stimulation (DES) is the recommended technique for resection of these lesions. A reliable probabilistic atlas of the critical cortical epicenters and subcortical framework based on DES data was recently published.

OBJECTIVE

To propose a pipeline for the automated alignment of the corticosubcortical maps of this atlas with T1-weighted MRI.

METHODS

To test the alignment, we selected 10 patients who underwent resection of brain lesions by using DES. We aligned different cortical and subcortical functional maps to preoperative volumetric T1 MRIs (with/without gadolinium). For each patient we quantified the quality of the alignment, and we calculated the match between the location of the functional sites found at DES and the functional maps of the atlas.

RESULTS

We found an accurate brain extraction and alignment of the functional maps with both the T1 MRIs of each patient. The matching analysis between functional maps and functional responses collected during surgeries was 88% at cortical and, importantly, 100% at subcortical level, providing a further proof of the correct alignment.

CONCLUSION

We demonstrated quantitatively and qualitatively the reliability of this tool that may be used for presurgical planning, providing further functional information at the cortical level and a unique probabilistic prevision of distribution of the critical subcortical structures. Finally, this tool offers the chance for multimodal planning through integrating this functional information with other neuroradiological and neurophysiological techniques.

Optimizing the onco-functional balance in supratentorial brain tumour surgery: A single institution's initial experience with intraoperative cortico-subcortical mapping and monitoring in Singapore

Intraoperative cortical mapping provides functional information that permits the safe and maximal resection of supratentorial lesions infiltrating the so-called eloquent cortex or subcortical white matter tracts. Primary and secondary brain tumours located in eloquent cortex can render surgical treatment ineffective if it results in new or worsening neurology. A cohort of forty-six consecutive patients with supratentorial tumours of variable pathology involving eloquent cortical regions and aided with intraoperative neurophysiology were included for retrospective analysis at a single-centre tertiary institution. Intraoperative neurophysiological data has been related to immediate post-operative neurologic status as well as 3-month follow-up in patients that underwent awake or asleep surgical resection. Patients that experienced new or worsening neurologic symptoms post-operatively demonstrated a high incidence of recovery at 3-months. Those without new neurologic symptoms post-operatively demonstrated little to no worsening at 3-months. Our study explored the extent to which cortical mapping permitted safe surgical resection whilst preserving neurologic function. To the authors' knowledge this is the first documented case series in Singapore that has incorporated a systematic and individually tailored multimodal workflow to cortico-subcortical mapping and monitoring for the safe resection of infiltrative lesions of the supratentorial region.

The landscape of postsurgical recurrence patterns in diffuse low-grade gliomas

Early and maximal safe surgical resection optionally followed by adjuvant treatment is currently recommended in diffuse low-grade glioma (DLGG). Although this management delays malignant transformation (MT), recurrence will most often occur. Because this relapse usually arises locally, reoperation can be considered, with possible further chemotherapy/radiotherapy. However, due to a prolonged overall survival, a large spectrum of unusual recurrence patterns begins to emerge during long-term follow-up, beyond the classical slow and local tumor re-growth. We review various atypical patterns of DLGG relapse, we discuss their pathophysiological mechanisms and how to adapt the treatment(s). Those patterns include very diffuse, ipsi- or bilateral gliomatosis-like progression, multicentric recurrence with emergence of remote low-grade or high-grade glioma, leptomeningeal dissemination, acute (early or delayed) local MT or bulky relapse into the operating cavity. This landscape of recurrence patterns may allow physicians to elaborate new tailored therapeutic strategies and scientists to develop original hypotheses for basic research.

The Dilemma of Cure and Damage in Oligodendroglioma: Ways to Tip the Balance Away from the Damage

Current treatments for oligodendrogliomas are powerful but have a negative impact on the rest of the body. The bone marrow is damaged by the chemotherapeutics, but other parts of the body are also affected. In this paper, the current treatment method and its collateral damage is described. Therefore, therapies are needed that are more effective against the tumor while having less negative effects on the patient’s quality of life. Some potential therapies include optimal removal of the tumor by fluorescent-guided surgery (FGS), intraoperative desorption electrospray ionization-mass spectrometry (DESI-MS), better monitoring of the effects of therapy by pseudo-coloring shades of gray of MRI pictures, and using recent data from RNA sequencing of single cells and immunotherapy. These are all open new ways of treating this tumor. The RNA sequencing of single tumor cells unravels specific tumor antigens present in the differentiation status of the cancer cell. Stem cell antigens were expressed in dividing cells, while hypoxia inducible factor-α (HIF-1α) is expressed in all tumor cells. Cancer stem cell antigens can be loaded on dendritic cells to induce cytotoxic T-cells directed to cancer stem cells. These recent discoveries suggest a better quality of life with the same overall survival.