Multimodal navigation in the functional microsurgical resection of intrinsic brain tumors located in eloquent motor areas: role of tractography

Is FLAIRectomy Directly Correlated with Prolonged Survival in Glioblastoma? A Prospective National Multicenter Study on Correlation Between Extent of Tumor Resection and Clinical Outcome

BACKGROUND AND OBJECTIVES

Several articles have demonstrated a positive correlation between glioblastoma supramarginal resection, based on MRI fluid-attenuated inversion-recovery (FLAIR) sequences (ie, FLAIRectomy), and prolonged survival. This study analyses the efficacy, safety, and reliability of FLAIRectomy in a multicentric cohort of patients, correlating the extent of FLAIR resection (EOFR) with clinical outcome and survival.

METHODS

One hundred fifty glioblastoma or grade IV astrocytoma patients (82 men), with a mean age of 58.2 years (range 36-82 years), from 3 neurosurgical centers were included. In all cases, supramarginal resection was deemed feasible preoperatively; multicentric neoplasms or tumors with enhancing nodule involving eloquent areas were excluded. Analysis of EOFR was based on comparison between preoperative and postoperative 3-dimensional FLAIR images. EOFR was compared with extent of tumor resection (EOTR) based on gadolinium-enhanced T1 sequences; theses data were also statistically correlated with survival parameters as well as with clinical and biomolecular data.

RESULTS

EOFR rate was 78.8% in the entire cohort, whereas EOTR based on T1 sequences was 98.3%. Mean progression free survival (PFS) and overall survival (OS) were 16.33 and 28.4 months, respectively. Adjusted Cox-regression models showed that a higher EOTR based on T1 sequences and EOFR were both associated with improved OS in individuals with either isocytrate dehydrogenase-1 wild-type or isocytrate dehydrogenase-1 mutated tumors. After adjustment, only the EOFR retained a statistically significant association with OS. Specifically, the risk of mortality decreased by 6.8% and 12.1% with each one-unit increase in EOFR, respectively. Further analysis based on artificial intelligence demonstrated that the cluster of patients with higher values of PFS and OS received greater rate of FLAIRectomy.

CONCLUSION

This multicenter study demonstrates that EOFR is a more reliable predictor of PFS and OS than extent of resection based on gadolinium-enhanced T1 sequences, if supramarginal resection is performed according to specific preoperative planning. 3-dimensional FLAIR navigation-guided resection may represent the optimal strategy to achieve a real FLAIRectomy.

Navigated Transcranial Magnetic Stimulation and Diffusion Tensor Imaging Tractography in Insular Glioma Surgery

BACKGROUND AND OBJECTIVES

The surgical resection of insular gliomas is associated with a high rate of postoperative morbidity as they grow close to descending motor fibers and lenticulostriate arteries. It is believed that intraoperative perforator infarctions are the determining factor for patients' postoperative outcome, while the majority of patients with intraoperative ischemic events do not develop postoperative motor deficits. This study aims to evaluate whether navigated transcranial magnetic stimulation (nTMS) and nTMS-based fiber tracking could be valuable for the preoperative assessment of patients with insular gliomas.

METHODS

Thirty-two patients with insular gliomas were presurgically examined by nTMS. The resting motor threshold and cortical representation areas of legs, hands, and face were identified on both hemispheres. Motor evoked potential positive stimulation points were then used as a region of interest for diffusion tensor imaging tractographies. Somatotopic fiber tracking was performed enabling analyses of the spatial relation between tumor and cortico-spinal tract (CST) as well as the extraction of fiber tract integrity, measured by fractional anisotropy and the apparent diffusion coefficient.

RESULTS

The performance of nTMS mappings of the motor cortex and reconstruction of descending motor fibers for legs, hands, and facial functioning was successful in all patients. Higher preoperative resting motor threshold ratios and a distance between tumor and CST of <3 mm were associated with a permanent deterioration in motor function (P = .029 and P = .007). Shorter distances between CST and tumorous tissue were correlated with lowered peritumoral fractional anisotropy values, suggesting alterations in fiber tract integrity. Lower interhemispheric peritumoral fractional anisotropy ratios showed an association with new postoperative motor deficits (P = .017).

CONCLUSION

nTMS-based diffusion tensor imaging tractography enables somatotopic tract visualization and provides a valuable tool for preoperative planning, intraoperative orientation, and individual risk stratification. Thus, it may be beneficial to increase safety in insular glioma resection surgery.

The Application of Intraoperative Ultrasound with Burr Hole Probe in Minimally Invasive Diagnosis and Treatment in Neurosurgery

OBJECTIVE

To summarize the preliminary application experience of intraoperative ultrasound with burr hole probe in minimally invasive neurosurgery and to explore its application value.

METHODS

Thirty-one patients who underwent intraoperative ultrasound guided puncture with burr hole probe in our center from August 2018 to May 2024 were collected, including 16 cases of ventriculoperitoneal shunt operation, 6 cases of assisted stereotactic needle biopsy, 3 cases of intracranial pressure probe implantation in lateral ventricle, 3 cases of brain abscess puncture for external drainage, and 3 cases of intracranial cyst puncture and peritoneal drainage. During the procedures, the burr hole probe was used to locate the intracranial targets and guide the puncture. The postoperative computed tomography (CT) scans or combined postoperative pathological results could verify the accuracy of puncture. In addition, the intervention effect and recovery status of patients were also recorded.

RESULTS

The intraoperative ultrasound with burr hole probe could clearly display all the purposed targets and accurately guide the puncture procedures in all cases. All patients achieved satisfactory diagnostic and therapeutic results without new neurological dysfunction and serious complications.

CONCLUSIONS

The intraoperative ultrasound with burr hole probe is an effective device for demonstrating intracranial structures. It not only enables minimally invasive and precise diagnosis or treatment of many neurosurgical diseases, but also is simple and safe to operate, which has important promotional value in the neurosurgery.

The difference of functional MR imaging in evaluating outcome of patients with diffuse and compact brain arteriovenous malformation

Microsurgical resection is an effective method to treat brain arteriovenous malformations (BAVMs). Functional magnetic resonance imaging (fMRI) can evaluate the spatial relationship of nidus and eloquent. Diffuse BAVMs are related to poor outcomes postoperatively. The role of fMRI in evaluating outcomes in patients with different nidus types remains unclear. BAVM patients received microsurgical resection were included from a prospective, multicenter cohort study. All patients underwent fMRI evaluation preoperatively and were regularly followed up postoperatively. Diffuse BAVM is radiologically identified as nidus containing normal brain tissue interspersing between malformed vessels. Lesion-to-eloquent distance (LED) was calculated based on the relationship between nidus and eloquent. The primary outcome was 180-day unfavorable neurological status postoperatively. The risk of primary outcome was investigated within different BAVM nidus types. The LED's performance to predict poor outcome was evaluated using area under curve (AUC). 346 BAVM patients were included in this study. 93 (26.9%) patients were found to have a 180-day unfavorable outcome. Multivariate logistic analysis demonstrated LED (odd ratio [OR], 0.44; 0.34-0.57; P < 0.001) and mRS at admission (OR, 2.59; 1.90-3.54; P < 0.001) as factors of unfavorable outcome. Subgroup analysis showed LED and mRS at admission as factors of unfavorable outcome for patients with compact BAVMs (all P < 0.05), but not for patients with diffuse BAVMs. Subsequent analysis showed that LED performed poorly to predict the unfavorable outcome for patients with diffuse BAVMs, compared with patients with compact BAVMs (AUC as 0.69 vs. 0.86, P < 0.05). A larger cutoff value of LED to unfavorable outcome was found in patients with diffuse BAVMs (15 mm) compared with patients with compact BAVMs (4.7 mm). Usage of LED to evaluate postoperative outcome of patients with diffuse BAVMs differs from its use in patients with compact BAVMs. Specific assessment strategy considering BAVM nidus types could help improve patients' outcome. MITASREAVM cohort (unique identifier: NCT02868008, https://clinicaltrials.gov/study/NCT02868008?term=NCT02868008&rank=1 ).

Maximal Resection of Gliomas Adjacent to the Corticospinal Tract Using 3-T Intraoperative Magnetic Resonance Imaging

BACKGROUND

Gliomas adjacent to the corticospinal tract (CST) should be carefully resected to preserve motor function while achieving maximal surgical resection. Modern high-field intraoperative magnetic resonance imaging (iMRI) enables precise visualization of the residual tumor and intraoperative tractography. We prospectively evaluated the extent of resection and distance between the tumor resection cavity and CST using 3-T iMRI combined with motor evoked potentials (MEP) in glioma surgery.

METHODS

Participants comprised patients who underwent surgery for solitary supratentorial glioma located within 10 mm of the CST. All cases underwent surgery using neuronavigation with overlaid CST under MEP monitoring. The correlation between distance from CST and transcortical MEP amplitude was calculated using Spearman rank correlation.

RESULTS

Among the 63 patients who underwent surgery, 27 patients were enrolled in the study. Gross total resections were achieved in 26 of the 27 cases. Volumetric analysis showed the extent of resection was 98.6%. Motor function was stable or improved in 24 patients (Stable/Improved group) and deteriorated in 3 patients (Deteriorated group). All patients in the Deteriorated group showed motor deficit before surgery. Mean intraoperative minimal distance was significantly longer in the Stable/Improved group (7.3 mm) than in the Deteriorated group (1.1 mm; P < 0.05). MEP amplitude correlated with minimal distance between the resection cavity and CST (R = 0.64).

CONCLUSIONS

Resection of gliomas adjacent to CST with a navigation system using 3-T iMRI could result in an ultimate EOR >98%. The combination of intraoperative tractography and MEP contributes to maximal removal of motor-eloquent gliomas.

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.

Karawun: a software package for assisting evaluation of advances in multimodal imaging for neurosurgical planning and intraoperative neuronavigation

PURPOSE

The neuroimaging research community-which includes a broad range of scientific, medical, statistical, and engineering disciplines-has developed many tools to advance our knowledge of brain structure, function, development, aging, and disease. Past research efforts have clearly shaped clinical practice. However, translation of new methodologies into clinical practice is challenging. Anything that can reduce these barriers has the potential to improve the rate at which research outcomes can contribute to clinical practice. In this article, we introduce Karawun, a file format conversion tool, that has become a key part of our work in translating advances in diffusion imaging acquisition and analysis into neurosurgical practice at our institution.

METHODS

Karawun links analysis workflows created using open-source neuroimaging software, to Brainlab (Brainlab AG, Munich, Germany), a commercially available surgical planning and navigation suite. Karawun achieves this using DICOM standards supporting representation of 3D structures, including tractography streamlines, and thus offers far more than traditional screenshot or color overlay approaches.

RESULTS

We show that neurosurgical planning data, created from multimodal imaging data using analysis methods implemented in open-source research software, can be imported into Brainlab. The datasets can be manipulated as if they were created by Brainlab, including 3D visualizations of white matter tracts and other objects.

CONCLUSION

Clinicians can explore and interact with the results of research neuroimaging pipelines using familiar tools within their standard clinical workflow, understand the impact of the new methods on their practice and provide feedback to methods developers. This capability has been important to the translation of advanced analysis techniques into practice at our institution.

Standard clinical approaches and emerging modalities for glioblastoma imaging

Glioblastoma (GBM) is the most common primary adult intracranial malignancy and carries a dismal prognosis despite an aggressive multimodal treatment regimen that consists of surgical resection, radiation, and adjuvant chemotherapy. Radiographic evaluation, largely informed by magnetic resonance imaging (MRI), is a critical component of initial diagnosis, surgical planning, and post-treatment monitoring. However, conventional MRI does not provide information regarding tumor microvasculature, necrosis, or neoangiogenesis. In addition, traditional MRI imaging can be further confounded by treatment-related effects such as pseudoprogression, radiation necrosis, and/or pseudoresponse(s) that preclude clinicians from making fully informed decisions when structuring a therapeutic approach. A myriad of novel imaging modalities have been developed to address these deficits. Herein, we provide a clinically oriented review of standard techniques for imaging GBM and highlight emerging technologies utilized in disease characterization and therapeutic development.

Subcortical Stimulation in Brain Tumor Surgery: A closer look beneath the surface

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.

Transcranial magnetic stimulation (TMS) seeded tractography provides superior prediction of eloquence compared to anatomic seeded tractography

Background

For patients with brain tumors, maximizing the extent of resection while minimizing postoperative neurological morbidity requires accurate preoperative identification of eloquent structures. Recent studies have provided evidence that anatomy may not always predict eloquence. In this study, we directly compare transcranial magnetic stimulation (TMS) data combined with tractography to traditional anatomic grading criteria for predicting permanent deficits in patients with motor eloquent gliomas.

Methods

We selected a cohort of 42 glioma patients with perirolandic tumors who underwent preoperative TMS mapping with subsequent resection and intraoperative mapping. We collected clinical outcome data from their chart with the primary outcome being new or worsened motor deficit present at 3 month follow up, termed “permanent deficit”. We overlayed the postoperative resection cavity onto the preoperative MRI containing preoperative imaging features.

Results

Almost half of the patients showed TMS positive points significantly displaced from the precentral gyrus, indicating tumor induced neuroplasticity. In multivariate regression, resection of TMS points was significantly predictive of permanent deficits while the resection of the precentral gyrus was not. TMS tractography showed significantly greater predictive value for permanent deficits compared to anatomic tractography, regardless of the fractional anisotropic (FA) threshold. For the best performing FA threshold of each modality, TMS tractography provided both higher positive and negative predictive value for identifying true nonresectable, eloquent cortical and subcortical structures.

Conclusion

TMS has emerged as a preoperative mapping modality capable of capturing tumor induced plastic reorganization, challenging traditional presurgical imaging modalities.

Adaptive Physics-Based Non-Rigid Registration for Immersive Image-Guided Neuronavigation Systems

Objective: In image-guided neurosurgery, co-registered preoperative anatomical, functional, and diffusion tensor imaging can be used to facilitate a safe resection of brain tumors in eloquent areas of the brain. However, the brain deforms during surgery, particularly in the presence of tumor resection. Non-Rigid Registration (NRR) of the preoperative image data can be used to create a registered image that captures the deformation in the intraoperative image while maintaining the quality of the preoperative image. Using clinical data, this paper reports the results of a comparison of the accuracy and performance among several non-rigid registration methods for handling brain deformation. A new adaptive method that automatically removes mesh elements in the area of the resected tumor, thereby handling deformation in the presence of resection is presented. To improve the user experience, we also present a new way of using mixed reality with ultrasound, MRI, and CT.

Materials and methods: This study focuses on 30 glioma surgeries performed at two different hospitals, many of which involved the resection of significant tumor volumes. An Adaptive Physics-Based Non-Rigid Registration method (A-PBNRR) registers preoperative and intraoperative MRI for each patient. The results are compared with three other readily available registration methods: a rigid registration implemented in 3D Slicer v4.4.0; a B-Spline non-rigid registration implemented in 3D Slicer v4.4.0; and PBNRR implemented in ITKv4.7.0, upon which A-PBNRR was based. Three measures were employed to facilitate a comprehensive evaluation of the registration accuracy: (i) visual assessment, (ii) a Hausdorff Distance-based metric, and (iii) a landmark-based approach using anatomical points identified by a neurosurgeon.

Results: The A-PBNRR using multi-tissue mesh adaptation improved the accuracy of deformable registration by more than five times compared to rigid and traditional physics based non-rigid registration, and four times compared to B-Spline interpolation methods which are part of ITK and 3D Slicer. Performance analysis showed that A-PBNRR could be applied, on average, in <2 min, achieving desirable speed for use in a clinical setting.

Conclusions: The A-PBNRR method performed significantly better than other readily available registration methods at modeling deformation in the presence of resection. Both the registration accuracy and performance proved sufficient to be of clinical value in the operating room. A-PBNRR, coupled with the mixed reality system, presents a powerful and affordable solution compared to current neuronavigation systems.

Diffusion MRI tractography for neurosurgery: the basics, current state, technical reliability and challenges

Diffusion magnetic resonance imaging (dMRI) tractography is currently the only imaging technique that allows for non-invasive delineation and visualisation of white matter (WM) tractsin vivo,prompting rapid advances in related fields of brain MRI research in recent years. One of its major clinical applications is for pre-surgical planning and intraoperative image guidance in neurosurgery, where knowledge about the location of WM tracts nearby the surgical target can be helpful to guide surgical resection and optimise post-surgical outcomes. Surgical injuries to these WM tracts can lead to permanent neurological and functional deficits, making the accuracy of tractography reconstructions paramount. The quality of dMRI tractography is influenced by many modifiable factors, ranging from MRI data acquisition through to the post-processing of tractography output, with the potential of error propagation based on decisions made at each and subsequent processing steps. Research over the last 25 years has significantly improved the anatomical accuracy of tractography. An updated review about tractography methodology in the context of neurosurgery is now timely given the thriving research activities in dMRI, to ensure more appropriate applications in the clinical neurosurgical realm. This article aims to review the dMRI physics, and tractography methodologies, highlighting recent advances to provide the key concepts of tractography-informed neurosurgery, with a focus on the general considerations, the current state of practice, technical challenges, potential advances, and future demands to this field.

Anatomy and White Matter Connections of the Superior Parietal Lobule

BACKGROUND

The superior parietal lobule (SPL) is involved in somatosensory and visuospatial integration with additional roles in attention, written language, and working memory. A detailed understanding of the exact location and nature of associated white matter tracts could improve surgical decisions and subsequent postoperative morbidity related to surgery in and around this gyrus.

OBJECTIVE

To characterize the fiber tracts of the SPL based on relationships to other well-known neuroanatomic structures through diffusion spectrum imaging (DSI)-based fiber tracking validated by gross anatomical dissection as ground truth.

METHODS

Neuroimaging data of 10 healthy, adult control subjects was obtained from a publicly accessible database published in Human Connectome Project for subsequent tractographic analyses. White matter tracts were mapped between both cerebral hemispheres, and a lateralization index was calculated based on resultant tract volumes. Post-mortem dissections of 10 cadavers identified the location of major tracts and validated our tractography results based on qualitative visual agreement.

RESULTS

We identified 9 major connections of the SPL: U-fiber, superior longitudinal fasciculus, inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, middle longitudinal fasciculus, extreme capsule, vertical occipital fasciculus, cingulum, and corpus callosum. There was no significant fiber lateralization detected.

CONCLUSION

The SPL is an important region implicated in a variety of tasks involving visuomotor and visuospatial integration. Improved understanding of the fiber bundle anatomy elucidated in this study can provide invaluable information for surgical treatment decisions related to this region.

FLAIRectomy in Supramarginal Resection of Glioblastoma Correlates With Clinical Outcome and Survival Analysis: A Prospective, Single Institution, Case Series

BACKGROUND

Extent of tumor resection (EOTR) in glioblastoma surgery plays an important role in improving survival.

OBJECTIVE

To analyze the efficacy, safety and reliability of fluid-attenuated inversion-recovery (FLAIR) magnetic resonance (MR) images used to guide glioblastoma resection (FLAIRectomy) and to volumetrically measure postoperative EOTR, which was correlated with clinical outcome and survival.

METHODS

A total of 68 glioblastoma patients (29 males, mean age 65.8) were prospectively enrolled. Hyperintense areas on FLAIR images, surrounding gadolinium-enhancing tissue on T1-weighted MR images, were screened for signal changes suggesting tumor infiltration and evaluated for supramaximal resection. The surgical protocol included 5-aminolevulinic acid (5-ALA) fluorescence, neuromonitoring, and intraoperative imaging tools. 5-ALA fluorescence intensity was analyzed and matched with the different sites on navigated MR, both on postcontrast T1-weighted and FLAIR images. Volumetric evaluation of EOTR on T1-weighted and FLAIR sequences was compared.

RESULTS

FLAIR MR volumetric evaluation documented larger tumor volume than that assessed on contrast-enhancing T1 MR (72.6 vs 54.9 cc); residual tumor was seen in 43 patients; postcontrast T1 MR volumetric analysis showed complete resection in 64 cases. O6-methylguanine-DNA methyltransferase promoter was methylated in 8/68 (11.7%) cases; wild type Isocytrate Dehydrogenase-1 (IDH-1) was found in 66/68 patients. Progression free survival and overall survival (PFS and OS) were 17.43 and 25.11 mo, respectively. Multiple regression analysis showed a significant correlation between EOTR based on FLAIR, PFS (R2 = 0.46), and OS (R2 = 0.68).

CONCLUSION

EOTR based on FLAIR and 5-ALA fluorescence is feasible. Safety of resection relies on the use of neuromonitoring and intraoperative multimodal imaging tools. FLAIR-based EOTR appears to be a stronger survival predictor compared to gadolinium-enhancing, T1-based resection.

Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review

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.

Anatomy and White Matter Connections of the Middle Frontal Gyrus

BACKGROUND

The middle frontal gyrus (MFG) is involved in attention, working memory, and language-related processing. A detailed understanding of the subcortical white matter tracts connected within the MFG can facilitate improved navigation of white matter lesions in and around this gyrus and explain the postoperative morbidity after surgery. We aimed to characterize the fiber tracts within the MFG according to their connection to neuroanatomic structures through the use of diffusion spectrum imaging-based fiber tractography and validate the findings by gross anatomic dissection for qualitative visual agreement.

METHODS

Tractography analysis was completed using diffusion imaging data from 10 healthy, adult subjects enrolled in the Human Connectome Project. We assessed the MFG as a whole component according to its fiber connectivity with other neural regions. Mapping was completed on all tracts within both hemispheres, with the resultant tract volumes used to calculate a lateralization index. A modified Klingler technique was used on 10 postmortem dissections to demonstrate the location and orientation of the major tracts.

RESULTS

Two major connections of the MFG were identified: the superior longitudinal fasciculus, which connects the MFG to parts of the inferior parietal lobule, posterior temporal lobe, and lateral occipital cortex; and the inferior fronto-occipital fasciculus, which connected the MFG to the lingual gyrus and cuneus. Intra- and intergyral short association, U-shaped fibers were also identified.

CONCLUSIONS

Subcortical white matter pathways integrated within the MFG include the superior longitudinal fasciculus and inferior fronto-occipital fasciculus. The MFG is implicated in a variety of tasks involving attention and memory, making it an important cortical region. The postoperative neurologic outcomes related to surgery in and around the MFG could be clarified in the context of the anatomy of the fiber bundles highlighted in the present study.

Tractography and the connectome in neurosurgical treatment of gliomas: the premise, the progress, and the potential

The ability of diffusion tensor MRI to detect the preferential diffusion of water in cerebral white matter tracts enables neurosurgeons to noninvasively visualize the relationship of lesions to functional neural pathways. Although viewed as a research tool in its infancy, diffusion tractography has evolved into a neurosurgical tool with applications in glioma surgery that are enhanced by evolutions in crossing fiber visualization, edema correction, and automated tract identification. In this paper the current literature supporting the use of tractography in brain tumor surgery is summarized, highlighting important clinical studies on the application of diffusion tensor imaging (DTI) for preoperative planning of glioma resection, and risk assessment to analyze postoperative outcomes. The key methods of tractography in current practice and crucial white matter fiber bundles are summarized. After a review of the physical basis of DTI and post-DTI tractography, the authors discuss the methodologies with which to adapt DT image processing for surgical planning, as well as the potential of connectomic imaging to facilitate a network approach to oncofunctional optimization in glioma surgery.

Diffusion Tensor Imaging Color-Coded Maps: An Alternative to Tractography

INTRODUCTION

White matter tracts can be observed using tractograms generated from diffusion tensor imaging (DTI). However, the dependence of these white matter tract images on subjective variables, including how seed points are placed and the preferred level of fractional anisotropy, introduces interobserver inconsistency and potential lack of reliability. We propose that color-coded maps (CCM) generated from DTI can be a preferred method for the visualization of important white matter tracts, circumventing bias in preoperative brain tumor resection planning.

METHODS

DTI was acquired retrospectively in 25 patients with brain tumors. Lesions included 15 tumors of glial origin, 9 metastatic tumors, 2 meningiomas, and 1 cavernous angioma. Tractograms of the pyramidal tract and/or optic radiations, based on tumor location, were created by marking seed regions of interest using known anatomical locations. We compared the degree of tract involvement and white matter alteration between CCMs and tractograms. Neurological outcomes were obtained from chart reviews.

RESULTS

The pyramidal tract was evaluated in 20/25 patients, the visual tracts were evaluated in 10/25, and both tracts were evaluated in 5/25. In 19/25 studies, the same patterns of white matter alternations were found between the CCMs and tractograms. In the 6 patients where patterns differed, 2 tractograms were not useful in determining pattern alteration; in the remaining 4/6, no practical difference was seen in comparing the studies. Two patients were lost to follow-up. Thirteen patients were neurologically improved or remained intact after intervention. In these, 10 of the 13 patients showed tumor-induced white matter tract displacement on CCM. Twelve patients had no improvement of their preoperative deficit. In 9 of these 12 patients, CCM showed white matter disruption.

CONCLUSION

CCMs provide a convenient, practical, and objective method of visualizing white matter tracts, obviating the need for potentially subjective and time-consuming tractography. CCMs are at least as reliable as tractograms in predicting neurological outcomes after neurosurgical intervention.

[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]

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.

Tractography in Neurosurgery: A Systematic Review of Current Applications

The ability to visualize the brain's fiber connections noninvasively in vivo is relatively young compared with other possibilities of functional magnetic resonance imaging. Although many studies showed tractography to be of promising value for neurosurgical care, the implications remain inconclusive. An overview of current applications is presented in this systematic review. A search was conducted for (("tractography" or "fiber tracking" or "fibre tracking") and "neurosurgery") that produced 751 results. We identified 260 relevant articles and added 20 more from other sources. Most publications concerned surgical planning for resection of tumors (n = 193) and vascular lesions (n = 15). Preoperative use of transcranial magnetic stimulation was discussed in 22 of these articles. Tractography in skull base surgery presents a special challenge (n = 29). Fewer publications evaluated traumatic brain injury (TBI) (n = 25) and spontaneous intracranial bleeding (n = 22). Twenty-three articles focused on tractography in pediatric neurosurgery. Most authors found tractography to be a valuable addition in neurosurgical care. The accuracy of the technique has increased over time. There are articles suggesting that tractography improves patient outcome after tumor resection. However, no reliable biomarkers have yet been described. The better rehabilitation potential after TBI and spontaneous intracranial bleeding compared with brain tumors offers an insight into the process of neurorehabilitation. Tractography and diffusion measurements in some studies showed a correlation with patient outcome that might help uncover the neuroanatomical principles of rehabilitation itself. Alternative corticofugal and cortico-cortical networks have been implicated in motor recovery after ischemic stroke, suggesting more complex mechanisms in neurorehabilitation that go beyond current models. Hence tractography may potentially be able to predict clinical deficits and rehabilitation potential, as well as finding possible explanations for neurologic disorders in retrospect. However, large variations of the results indicate a lack of data to establish robust diagnostical concepts at this point. Therefore, in vivo tractography should still be interpreted with caution and by experienced surgeons.

The role of diffusion tractography in refining glial tumor resection

Primary brain tumors are notoriously hard to resect surgically. Due to their infiltrative nature, finding the optimal resection boundary without damaging healthy tissue can be challenging. One potential tool to help make this decision is diffusion-weighted magnetic resonance imaging (dMRI) tractography. dMRI exploits the diffusion of water molecule along axons to generate a 3D modelization of the white matter bundles in the brain. This feature is particularly useful to visualize how a tumor affects its surrounding white matter and plan a surgical path. This paper reviews the different ways in which dMRI can be used to improve brain tumor resection, its benefits and also its limitations. We expose surgical tools that can be paired with dMRI to improve its impact on surgical outcome, such as loading the 3D tractography in the neuronavigation system and direct electrical stimulation to validate the position of the white matter bundles of interest. We also review articles validating dMRI findings using other anatomical investigation techniques, such as postmortem dissections, manganese-enhanced MRI, electrophysiological stimulations, and phantom studies with known ground truth. We will be discussing the areas of the brain where dMRI performs well and where the future challenges are. We will conclude this review with suggestions and take home messages for neurosurgeons, tractographers, and vendors for advancing the field and on how to benefit from tractography's use in clinical practice.

Outcomes of tumour related epilepsy in a specialised epilepsy surgery unit

INTRODUCTION

Seizures are an important cause of morbidity in patients with low grade gliomas with approximately 40% of cases drug resistant. The pathogenesis is quite complex and poorly understood. The treatment aims vary between almost purely epilepsy considerations and those that are primarily oncologic.

AIM

To determine whether patients who present with seizures and are found to have a low grade glioma have better outcomes when managed through a specialized epilepsy unit compared to the general neurosurgical service.

METHODS

A review of the prospectively collected database was performed over a 10 year period to identify 48 adult patients who present with a seizure and were subsequently found to have a low grade glioma. These patients were analysed with respect to management through the specialized epilepsy service or the general neurosurgical service. The primary outcome was Engel classification between the two groups. Secondary outcomes included recurrence, postoperative deficits, delay to surgery, histology, grade and extent of resection.

OUTCOMES

The patients managed through the epilepsy service had significantly higher rate of favourable Engel outcomes (I and II) compared to the general neurosurgery service (OR: 13.2, 95% CI: 1.239-140.679; P = 0.033). The epilepsy surgery group patients had a significantly higher delay to surgery (P < 0.001). The patients in the epilepsy service had a significantly higher resection ratio compared to the general neurosurgery service (73% vs 127%, P = 0.014). Rates of recurrence were not different between the two groups.

CONCLUSION

Patients with tumour related epilepsy who undergo an intensive presurgical evaluation may obtain better seizure related outcomes.

3D microsurgical anatomy of the cortico-spinal tract and lemniscal pathway based on fiber microdissection and demonstration with tractography

OBJECTIVE

To demonstrate tridimensionally the anatomy of the cortico-spinal tract and the medial lemniscus, based on fiber microdissection and diffusion tensor tractography (DTT).

MATERIAL AND METHODS

Ten brain hemispheres and brain-stem human specimens were dissected and studied under the operating microscope with microsurgical instruments by applying the fiber microdissection technique. Brain magnetic resonance imaging was obtained from 15 healthy subjects using diffusion-weighted images, in order to reproduce the cortico-spinal tract and the lemniscal pathway on DTT images.

RESULTS

The main bundles of the cortico-spinal tract and medial lemniscus were demonstrated and delineated throughout most of their trajectories, noticing their gross anatomical relation to one another and with other white matter tracts and gray matter nuclei the surround them, specially in the brain-stem; together with their corresponding representation on DTT images.

CONCLUSIONS

Using the fiber microdissection technique we were able to distinguish the disposition, architecture and general topography of the cortico-spinal tract and medial lemniscus. This knowledge has provided a unique and profound anatomical perspective, supporting the correct representation and interpretation of DTT images. This information should be incorporated in the clinical scenario in order to assist surgeons in the detailed and critic analysis of lesions located inside the brain-stem, and therefore, improve the surgical indications and planning, including the preoperative selection of optimal surgical strategies and possible corridors to enter the brainstem, to achieve safer and more precise microsurgical technique.

Evaluation of Diffusion Tensor Imaging-Based Tractography of the Corticospinal Tract: A Correlative Study With Intraoperative Magnetic Resonance Imaging and Direct Electrical Subcortical Stimulation

Background

The accuracy of intraoperative diffusion tensor imaging (DTI)–based tractography of the corticospinal tract (CST) is crucial for its use in neurosurgical planning and its implementation in image-guided surgery. To the best of our knowledge, this is the largest prospective correlative study of the intraoperative DTI tractography of the CST and intraoperative direct electrical subcortical stimulation (DESS) of the CST, with application of intraoperative magnetic resonance imaging (iMR).

Objective

To evaluate intraoperatively acquired DTI-based tractography of the CST in correlation with DESS.

Methods

Twenty patients with gliomas (grades II-IV) adjacent to the CST were included in this prospective study. Bilateral DTI tractography of the CST was performed pre- and intraoperatively with application of 1.5-T iMRI and the results correlated and compared with the prevailing gold standard of DESS. Sensitivity, specificity, positive predictive value, and negative predictive value were considered to quantify the correlation of DTI tractography with DESS. The intensity of DESS was correlated with the distance from the CST. Moreover, the tissue quality of stimulation points at the wall of the resection cavity was evaluated with 5-aminolevulinic acid. The clinical and volumetric outcomes at postoperative and follow-up periods were also analyzed.

Results

The mean ± SD age of the patients was 54.9 ± 12 years. A total of 40 CSTs were reconstructed and 36 stimulations were included at 20 pathological CSTs, resulting in 18 true-positive, 5 false-positive, and 13 true-negative responses. The sensitivity, specificity, positive predictive value, and negative predictive value of DTI tractography to localize the CST were 100%, 72%, 78%, and 100%, respectively. DTI-based tractography correlated well at 86% of DESSs, and a linear correlation was detected between the intensity of DESS and the distance. All of the patients improved clinically, and the mean extent of resection was 97.2%. 5-Aminolevulinic acid was valuable in visualizing tumor infiltration in the false-positive cases, suggesting an infiltration of the CST at stimulation points.

Conclusion

CST visualization in the iMRI setting appears to have a high sensitivity in accurately localizing the area of the CST adjacent to the resection cavity in glioma surgery. More prospective studies with a large sample size are needed to further support the results.

The Impact of Intracranial Tumor Proximity to White Matter Tracts on Morbidity and Mortality: A Retrospective Diffusion Tensor Imaging Study

Background

Using diffusion tensor imaging (DTI) in neurosurgical planning allows identification of white matter tracts and has been associated with a reduction in postoperative functional deficits.

Objective

This study explores the relationship between the lesion-to-tract distance (LTD) and postoperative morbidity and mortality in patients with brain tumors in order to evaluate the role of DTI in predicting postoperative outcomes.

Methods

Adult patients with brain tumors (n = 60) underwent preoperative DTI. Three major white matter pathways (superior longitudinal fasciculi [SLF], cingulum, and corticospinal tract) were identified using DTI images, and the shortest LTD was measured for each tract. Postoperative morbidity and mortality information was collected from electronic medical records.

Results

The ipsilesional corticospinal tract LTD and left SLF LTD were significantly associated with the occurrence rate of total postoperative motor (P = .018) and language (P < .001) deficits, respectively. The left SLF LTD was also significantly associated with the occurrence rate of new postoperative language deficits (P = .003), and the LTD threshold that best predicted this occurrence was 1 cm (P < .001). Kaplan–Meier log-rank survival analyses in patients having high-grade tumors demonstrated a significantly higher mortality for patients with a left SLF LTD <1 cm (P = .01).

Conclusion

Measuring tumor proximity to major white matter tracts using DTI can inform clinicians of the likelihood of postoperative functional deficits. A distance of 1 cm or less from eloquent white matter structures most significantly predicts the occurrence of new deficits with current surgical and imaging techniques.

Blood-Brain Barrier Disruption, Sodium Fluorescein, And Fluorescence-Guided Surgery Of Gliomas

PURPOSE

Sodium fluorescein (SF) is an ideal dye for intraoperative guided-resection of high-grade gliomas (HGGs). However, it is not well understood whether the SF-guided technique is suitable for different grades of gliomas, and the correlation between fluorescence and pathology is also not yet clear.

MATERIALS AND METHODS

In this study, we investigated 28 patients, including 23 patients with HGG and 5 patients with low-grade glioma (LGG). All patients were treated using the SF-guided technique on a Pentero 900 microscope (Carl Zeiss, Oberkochen, Germany). Claudin-5 immunohistochemical (IHC) staining for the tumours and peritumour tissues was analyzed.

RESULTS

Intraoperative yellow fluorescence was noted in all the HGGs but not in the LGGs. Claudin-5 expression in the blood brain barrier endothelial cells was downregulated and disconnected in the HGGs (p < 0.05), but had no difference or slightly decreased in the LGGs (p > 0.05).

CONCLUSIONS

The SF-guided technique is suitable for HGG surgery but not for LGG surgery. Downregulation of claudin-5 expression may contribute to the presence of yellow fluorescence in the glioma in SF-guided surgery.

[Surgical treatment of eloquent brain area tumors using neurophysiological mapping of the speech and motor areas and conduction tracts]

AIM

To evaluate the efficacy of intraoperative neurophysiological mapping in removing eloquent brain area tumors (EBATs).

MATERIAL AND METHODS

Sixty five EBAT patients underwent surgical treatment using intraoperative neurophysiological mapping at the Pirogov National Medical and Surgical Center in the period from 2014 to 2015. On primary neurological examination, 46 (71%) patients were detected with motor deficits of varying severity. Speech disorders were diagnosed in 17 (26%) patients. Sixteen patients with concomitant or isolated lesions of the speech centers underwent awake surgery using the asleep-awake-asleep protocol. Standard neurophysiological monitoring included transcranial stimulation as well as motor and, if necessary, speech mapping. The motor and speech areas were mapped with allowance for the preoperative planning data (obtained with a navigation station) synchronized with functional MRI. In this case, a broader representation of the motor and speech centers was revealed in 12 (19%) patients. During speech mapping, no speech disorders were detected in 7 patients; in 9 patients, stimulation of the cerebral cortex in the intended surgical area induced motor (3 patients), sensory (4), and amnesic (2) aphasia. In the total group, we identified 11 patients in whom the tumor was located near the internal capsule. Upon mapping of the conduction tracts in the internal capsule area, the stimulus strength during tumor resection was gradually decreased from 10 mA to 5 mA. Tumor resection was stopped when responses retained at a stimulus strength of 5 mA, which, when compared to the navigation data, corresponded to a distance of about 5 mm to the internal capsule. Completeness of tumor resection was evaluated (contrast-enhanced MRI) in all patients on the first postoperative day.

RESULTS

According to the control MRI data, the tumor was resected totally in 60% of patients, subtotally in 24% of patients, and partially in 16% of patients. In the early postoperative period, the development or aggravation of a motor neurological deficit was detected in 18 patients: worsening of paresis was observed in 11 patients, and worsening of speech disorders occurred in 7 patients. After 4 months, motor and speech disorders regressed in 10 patients. Therefore, a persistent neurological deficit developed after surgery in 8 (12%) patients (motor deficit in 5 cases; speech deficit in 3 cases).

CONCLUSION

Resection of eloquent brain area tumors using intraoperative neurophysiological monitoring enables complete resection of the tumor at a low risk of persistent neurological deficits, which ultimately improves the patient's life prognosis.

Functional Magnetic Resonance Imaging (fMRI), Pre-intraoperative Tractography in Neurosurgery: The Experience of Sant' Andrea Rome University Hospital

BACKGROUND

The goal of neurosurgery for cerebral intraparenchymal neoplasms of the eloquent areas is maximal resection with the preservation of normal functions, and minimizing operative risk and postoperative morbidity. Currently, modern technological advances in neuroradiological tools, neuronavigation, and intraoperative magnetic resonance imaging (MRI) have produced great improvements in postoperative morbidity after the surgery of cerebral eloquent areas. The integration of preoperative functional MRI (fMRI), intraoperative MRI (volumetric and diffusion tensor imaging [DTI]), and neuronavigation, defined as "functional neuronavigation" has improved the intraoperative detection of the eloquent areas.

METHODS

We reviewed 142 patients operated between 2004 and 2010 for intraparenchymal neoplasms involving or close to one or more major white matter tracts (corticospinal tract [CST], arcuate fasciculus [AF], optic radiation). All the patients underwent neurosurgery in a BrainSUITE equipped with a 1.5 T MR scanner and were preoperatively studied with fMRI and DTI for tractography for surgical planning. The patients underwent MRI and DTI during surgery after dural opening, after the gross total resection close to the white matter tracts, and at the end of the procedure. We evaluated the impact of fMRI on surgical planning and on the selection of the entry point on the cortical surface. We also evaluated the impact of preoperative and intraoperative DTI, in order to modify the surgical approach, to define the borders of resection, and to correlate this modality with subcortical neurophysiological monitoring. We evaluated the impact of the preoperative fMRI by intraoperative neurophysiological monitoring, performing "neuronavigational" brain mapping, following its data to localize the previously elicited areas after brain shift correction by intraoperative MRI.

RESULTS

The mean age of the 142 patients (89 M/53 F) was 59.1 years and the lesion involved the CST in 66 patients (57 %), the language pathways in 24 (21 %), and the optic radiations in 25 (22 %). The integration of tractographic data into the volumetric dataset for neuronavigation was technically possible in all cases. In all patients intraoperative DTI demonstrated a shift of the bundle position caused by the surgical procedure; its dislocation was both outward and inward in the range of +6 mm and -2 mm.

CONCLUSION

We found a high concordance between fMRI/DTI and intraoperative brain mapping; their combination improves the sensitivity of each technique, reducing pitfalls and so defining "functional neuronavigation", increasing the definition of eloquent areas and also reducing the time of surgery.

[3D anatomy of cerebellar peduncles based on fibre microdissection and a demonstration with tractography]

OBJECTIVE

To perform an anatomical and radiological study, using fibre microdissection and diffusion tensor tractography (DTT), to demonstrate the three-dimensionality of the superior, middle and inferior cerebellar peduncles.

MATERIAL AND METHODS

A total of 15 brain-stem, 15 cerebellar hemispheres, and 5 brain hemispheres were dissected in the laboratory under the operating microscope with microsurgical instruments between July 2014 and July 2015. Brain magnetic resonance imaging was obtained from 15 healthy subjects between July and December of 2015, using diffusion-weighted images, in order to reproduce the cerebellar peduncles on DTT.

RESULTS

The main bundles of the cerebellar peduncles were demonstrated and delineated along most of their trajectory in the cerebellum and brain-stem, noticing their overall anatomical relationship to one another and with other white matter tracts and the grey matter nuclei the surround them, with their corresponding representations on DTT.

CONCLUSIONS

The arrangement, architecture, and general topography of the cerebellar peduncles were able to be distinguished using the fibre microdissection technique. This knowledge has given a unique and profound anatomical perspective, supporting the correct representation and interpretation of DTT images. This information should be incorporated in the clinical scenario in order to assist surgeons in the detailed and critical analysis of lesions that may be located near these main bundles in the cerebellum and/or brain-stem, and therefore, improve the surgical planning and achieve a safer and more precise microsurgical technique.

Survival in glioblastoma: a review on the impact of treatment modalities

Glioblastoma (GBM) is the most common and lethal tumor of the central nervous system. The natural history of treated GBM remains very poor with 5-year survival rates of 5 %. Survival has not significantly improved over the last decades. Currently, the best that can be offered is a modest 14-month overall median survival in patients undergoing maximum safe resection plus adjuvant chemoradiotherapy. Prognostic factors involved in survival include age, performance status, grade, specific markers (MGMT methylation, mutation of IDH1, IDH2 or TERT, 1p19q codeletion, overexpression of EGFR, etc.) and, likely, the extent of resection. Certain adjuncts to surgery, especially cortical mapping and 5-ALA fluorescence, favor higher rates of gross total resection with apparent positive impact on survival. Recurrent tumors can be offered re-intervention, participation in clinical trials, anti-angiogenic agent or local electric field therapy, without an evident impact on survival. Molecular-targeted therapies, immunotherapy and gene therapy are promising tools currently under research.

Feasibility of the Combined Application of Navigated Probabilistic Fiber Tracking and Navigated Ultrasonography in Brain Tumor Surgery

BACKGROUND

Surgical resection of intra-axial tumors is a challenging procedure because of indistinct tumor margins, infiltration, and displacement of white matter tracts surrounding the lesion. Hence, gross total tumor resection without causing new neurologic deficits is demanding, especially in tumor sites adjoining eloquent structures. Feasibility of the combination of navigated probabilistic fiber tracking to identify eloquent fiber pathways and navigated ultrasonography to control brain shift was tested.

METHODS

Eleven patients with lesions adjacent to eloquent white matter structures (pyramidal tract, optic radiation and arcuate fascicle) were preoperatively subjected to magnetic resonance imaging including diffusion-weighted imaging on a 3-T magnetic resonance system (Trio [Siemens, Erlangen, Germany]). Probabilistic fiber tracking was performed using the tools of the FMRIB Software Library (FSL). Results of probabilistic fiber tracking and high-resolution anatomic images were integrated into the neuronavigation system Stealth Station (Medtronic, Minneapolis, Minnesota, USA) together with the navigated ultrasonography (SonoNav [Medtronic]).

RESULTS

FSL-based probabilistic fiber tracking depicted the pyramidal tract, the optic radiation, and arcuate fascicle anatomically plausibly. Integration of the probabilistic fiber tracking into neuronavigation was technically feasible and allowed visualization of the reconstructed fiber pathways. Navigated ultrasonography controlled brain shift.

CONCLUSIONS

Integration of probabilistic fiber tracking and navigated ultrasonography into intraoperative neuronavigation facilitated anatomic orientation during glioma resection. FSL-based probabilistic fiber tracking integrated sophisticated fiber tracking algorithms, including modeling of crossing fibers. Combination with navigated ultrasonography provided a three-dimensional estimation of intraoperative brain shift and, therefore, improved the reliability of neuronavigation.

Diffusion tensor imaging tractography and intraoperative neurophysiological monitoring in surgery of intracranial tumors located near the pyramidal tract

BACKGROUND

Practical application of methods for intravital examination of the brain pathways, such as preoperative diffusion tensor imaging (DTI) tractography and intraoperative neurophysiological monitoring, facilitates safer resection of intracranial tumors located near the pyramidal tracts (PTs).

PURPOSE

The study purpose was to investigate the relationships between intracerebral tumors of different histological nature and the pyramidal tract based on preoperative DTI tractography and various methods of intraoperative neurophysiological monitoring for intraoperative identification of the pyramidal tract, depending on different variants of the topographo-anatomic relationships between the pyramidal fascicle and the tumor.

MATERIAL AND METHODS

The study included 29 patients with supratentorial tumors of a different histological structure. Of these, 2 patients had grade I tumors, 8 patients had grade II tumors, 4 patients had grade III tumors, 11 patients grade IV tumors, and 4 patients had brain metastases. The patients underwent preoperative DTI tractography with PT reconstruction and evaluation of the topographo-anatomic relationships between the pyramidal tract and the tumor (tract: intact, infiltrated, displaced). Neurophysiological monitoring (direct electrical stimulation in 24 patients and transcranial motor evoked potentials in 26 patients) was used during surgery. The strength of stimulating current for direct stimulation was varied from 10 to 30 mA. Postoperatively, the motor function was evaluated by using a 5-score scale, and the data were compared to the preoperative data.

RESULTS

According to preoperative DTI tractography in patients with grade I-II gliomas, the corticospinal tracts were infiltrated in 2 cases, displaced in 3 cases, and intact in 5 cases. In patients with grade III-IV gliomas and metastases, the tracts were infiltrated in 8 cases, displaced in 4 cases, and intact in 7 cases. Motor responses evoked by direct electrical stimulation were obtained in 5 out of 6 patients with the pyramidal tract displaced by the tumor and in 7 out of 8 patients with the tract infiltrated by the tumor. In the case of the intact tract, the PT to tumor distance and the stimulus strength play an important role: responses were obtained in 4 out of 10 patients. In the case of transcranial motor evoked potentials (TCMEPs), no dynamics of the potential amplitude was detected in 17 out of 26 patients during surgery; a reduced TCMEP amplitude was detected in 9 patients.

CONCLUSION

1. Patients with an infiltrated or displaced pyramidal tract had significantly more often hemiparesis before surgery and aggravation of hemiparesis after the surgery compared to patients with an intact tract. 2. In the case of direct electrical stimulation of the PT, motor responses (according to preoperative DTI tractography) were significantly more often observed for the pyramidal tract infiltrated and displaced by the tumor. 3. A reduction in the motor neurologic deficit in the postoperative period was significantly more often observed for application of a larger current strength during direct electrical stimulation. 4. Persistence of the TCMEP amplitude during surgery is a reliable predictor for no aggravation of the motor neurological deficit after surgery. Postoperative aggravation of hemiparesis was significantly more often observed when TC MEPs decreased during surgery.

Is the omega sign a reliable landmark for the neurosurgical team? An anatomical study about the central sulcus region

ABSTRACTThe central sulcus region is an eloquent area situated between the frontal and parietal lobes. During neurosurgical procedures, it is sometimes difficult to understand the cortical anatomy of this region.Objective Find alternative ways to anatomically navigate in this region during neurosurgical procedures.Method We analyzed eighty two human hemispheres using a surgical microscope and completed a review of the literature about central sulcus region.Results In 68/82 hemispheres, the central sulcus did not reach the posterior ramus of the lateral sulcus. A knob on the second curve of the precentral gyrus was reliably identified in only 64/82 hemispheres.Conclusion The morphometric data presented in this article can be useful as supplementary method to identify the central sulcus region landmarks.

Current trends in the surgical management and treatment of adult glioblastoma

This manuscript discusses the current surgical management of glioblastoma. This paper highlights the common pathophysiology attributes of glioblastoma, surgical options for diagnosis/treatment, current thoughts of extent of resection (EOR) of tumor, and post-operative (neo)adjuvant treatment. Glioblastoma is not a disease that can be cured with surgery alone, however safely performed maximal surgical resection is shown to significantly increase progression free and overall survival while maximizing quality of life. Upon invariable tumor recurrence, re-resection also is shown to impact survival in a select group of patients. As adjuvant therapy continues to improve survival, the role of surgical resection in the treatment of glioblastoma looks to be further defined.

Advances in the Surgical Management of Low-Grade Glioma

Over the past 2 decades, extent of resection has emerged as a significant prognostic factor in patients with low-grade gliomas (LGGs). Greater extent of resection has been shown to improve overall survival, progression-free survival, and time to malignant transformation. The operative goal in most LGG cases is to maximize extent of resection, while avoiding postoperative neurologic deficits. Several advanced surgical techniques have been developed in an attempt to better achieve maximal safe resection. Intraoperative magnetic resonance imaging, fluorescence-guided surgery, intraoperative functional pathway mapping, and neuronavigation are some of the most commonly used techniques with multiple studies to support their efficacy in glioma surgery. By using these techniques either alone or in combination, patients harboring LGGs have a better prognosis with less surgical morbidity following tumor resection.

Applications of blood-oxygen-level-dependent functional magnetic resonance imaging and diffusion tensor imaging in epilepsy

The lifetime prevalence of epilepsy ranges from 2.7 to 12.4 per 1000 in Western countries. Around 30% of patients with epilepsy remain refractory to antiepileptic drugs and continue to have seizures. Noninvasive imaging techniques such as functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) have helped to better understand mechanisms of seizure generation and propagation, and to localize epileptic, eloquent, and cognitive networks. In this review, the clinical applications of fMRI and DTI are discussed, for mapping cognitive and epileptic networks and organization of white matter tracts in individuals with epilepsy.

Neurosurgical oncology: advances in operative technologies and adjuncts

Modern glioma surgery has evolved around the central tenet of safely maximizing resection. Recent surgical adjuncts have focused on increasing the maximum extent of resection while minimizing risk to functional brain. Technologies such as cortical and subcortical stimulation mapping, intraoperative magnetic resonance imaging, functional neuronavigation, navigable intraoperative ultrasound, neuroendoscopy, and fluorescence-guided resection have been developed to augment the identification of tumor while preserving brain anatomy and function. However, whether these technologies offer additional long-term benefits to glioma patients remains to be determined. Here we review advances over the past decade in operative technologies that have offered the most promising benefits for glioblastoma patients.

Comparison of parameter threshold combinations for diffusion tensor tractography in chronic stroke patients and healthy subjects

BACKGROUND

Although quantitative evaluation of diffusion tensor imaging (DTI) data seemed to be extremely important for clinical research its application is under debate. Besides fractional anisotropy (FA) the quantitative comparison between hemispheres of the number of fibers reconstructed by means of diffusion tensor tractography (DTT) is commonly used. However, the tractography-related parameters FA, minimum tract length (LENGTH) and the angle between two contiguous tracking steps (ANGLE) are inconsistently applied. Using 18 combinations we tested for the influence of parameter thresholds on the amount of reconstructed fibers for the posterior pyramidal tract in both hemispheres in order to obtain meaningful thresholds for DTT.

RESULTS

In 14 chronic stroke patients with unilateral lesions of the pyramidal tract around the height of the internal capsule and considerable motor deficits a 3-way repeated-measures ANOVA showed a significant interaction between the effects of FA and ANGLE level on reconstructed fiber lateralization, F (2.9, 37.67) = 3.01, p = 0.044, and a significant main effect FA, F (1.4, 18.1) = 11.58, p = 0.001. Post-hoc pairwise comparisons showed that this interaction was completely driven by FA. In 22 right-handed healthy subjects no significant interactions or main effects could be found.

CONCLUSION

The parameter threshold combinations with highest FA showed highest effect. ANGLE and LENGTH insofar influenced the lateralization effect when selected as liberal as possible, short LENGTH and large ANGLE thresholds. The DTT approach should be used with great care since results are highly dependent on the thresholds applied.

Low-threshold monopolar motor mapping for resection of lesions in motor eloquent areas in children and adolescents

OBJECT

Resection of lesions close to the primary motor cortex (M1) and the corticospinal tract (CST) is generally regarded as high-risk surgery due to reported rates of postoperative severe deficits of up to 50%. The authors' objective was to determine the feasibility and safety of low-threshold motor mapping and its efficacy for increasing the extent of lesion resection in the proximity of M1 and the CST in children and adolescents.

METHODS

The authors analyzed 8 consecutive pediatric patients in whom they performed 9 resections for lesions within or close (≤ 10 mm) to M1 and/or the CST. Monopolar high-frequency motor mapping with train-of-five stimuli (pulse duration 500 μsec, interstimulus interval 4.0 msec, frequency 250 Hz) was used. The motor threshold was defined as the minimal stimulation intensity that elicited motor evoked potentials (MEPs) from target muscles (amplitude > 30 μV). Resection was performed toward M1 and the CST at sites negative to 1- to 3-mA high-frequency train-of-five stimulation.

RESULTS

The M1 was identified through high-frequency train-of-five via application of varying low intensities. The lowest motor thresholds after final resection ranged from 1 to 9 mA in 8 cases and up to 18 mA in 1 case, indicating proximity to motor neurons. Intraoperative electroencephalography documented an absence of seizures during all surgeries. Two transient neurological deficits were observed, but there were no permanent deficits. Postoperative imaging revealed complete resection in 8 patients and a very small remnant (< 0.175 cm3) in 1 patient.

CONCLUSIONS

High-frequency train-of-five with a minimal threshold of 1-3 mA is a feasible and safe procedure for resections in the proximity of the CST. Thus, low-threshold motor mapping might help to expand the area for safe resection in pediatric patients with lesions located within the precentral gyrus and close to the CST, and may be regarded as a functional navigational tool. The additional use of continuous MEP monitoring serves as a safety feedback for the functional integrity of the CST, especially because the true excitability threshold in children is unknown.

Use of diffusion tensor imaging in glioma resection

Diffusion tensor imaging (DTI) is increasingly used in the resection of both high- and low-grade gliomas. Whereas conventional MRI techniques provide only anatomical information, DTI offers data on CNS connectivity by enabling visualization of important white matter tracts in the brain. Importantly, DTI allows neurosurgeons to better guide their surgical approach and resection. Here, the authors review basic scientific principles of DTI, include a primer on the technology and image acquisition, and outline the modality's evolution as a frequently used tool for glioma resection. Current literature supporting its use is summarized, highlighting important clinical studies on the application of DTI in preoperative planning for glioma resection, preoperative diagnosis, and postoperative outcomes. The authors conclude with a review of future directions for this technology.

Stereotactic iodine-125 brachytherapy for the treatment of WHO grades II and III gliomas located in the central sulcus region

BACKGROUND

Resection of gliomas located in eloquent brain areas remains a neurosurgical challenge. The reported incidence of transient or permanent neurological deficits after microsurgery in eloquent brain ranges 20%-100%, or 0%-47% among contemporary neurosurgical series. The aim of this study was to assess the feasibility of stereotactic brachytherapy (SBT) as a local treatment alternative to microsurgical resection for patients with gliomas in highly eloquent areas, located in the central sulcus region (CSR).

METHOD

Between 1997 and 2010, 60 patients with World Health Organization (WHO) grades II and III gliomas located in the CSR were treated with SBT (iodine-125 seeds; cumulative therapeutic dose, 50-65 Gy). Following SBT, WHO grade III glioma patients additionally received percutaneous radiotherapy (median boost dose, 25.2 Gy). We evaluated procedure-related complications, clinical outcome, and progression-free survival.

RESULTS

Procedure-related mortality was zero. Within 30 days of SBT, 3 patients (5%) had transient neurological deficits, and 8 patients (13%) had temporarily increased seizure activity. One patient (1.6%) deteriorated permanently. Space-occupying cysts (6 patients) and radiation necrosis (1 patient) developed after a median of 38 months and required surgical intervention. Seizure activity, rated 12 months following SBT, decreased in 82% of patients (Engel classes I-III). Median progression-free survivals were 62.2 ± 19.7 months (grade II gliomas) and 26.1 ± 17.9 months (grade III gliomas).

CONCLUSIONS

Compared with microsurgical resection, SBT harbors a low risk of procedural complications, is minimally invasive, and seems to be an effective local treatment option for patients with inoperable, eloquent WHO grade II and III gliomas in the CSR. However, the value of SBT for treating gliomas still needs to be determined in prospective, randomized studies.