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Muscas G, Bardazzi T, Pedone A, Campagnaro L, Bonaudo C, Fainardi E, Baldanzi F, Troiano S, Carrai R, Grippo A, Della Puppa A. Heads-Up Micronavigation Reliability of Preoperative Transcranial Magnetic Stimulation Maps for the Motor Function: Comparison With Direct Cortical Stimulation. Oper Neurosurg (Hagerstown) 2024; 26:173-179. [PMID: 37889002 DOI: 10.1227/ons.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/02/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES We aimed to assess the reliability of preoperative navigated transcranial magnetic stimulation (nTMS) maps for motor function as visualized intraoperatively with augmented reality heads-up display and to assess its accuracy via direct point-by-point comparison with the gold-standard direct cortical stimulation (DCS). METHODS From January 2022 to January 2023, candidates for surgical removal of lesions involving the motor pathways underwent preoperative nTMS assessment to obtain cortical maps of motor function. Intraoperatively and before tumor removal, nTMS maps were superimposed on the cortical surface, and DCS was performed on positive points with increasing current intensity until obtaining a positive response at 16 mA. The outcome of each stimulation was recorded to obtain discrimination metrics. RESULTS Twelve patients were enrolled (5 females [42%] vs 7 males [58%], mean age 62.9 ± 12.8 years), for a total of 304 investigated points. Agreement between nTMS and DCS was moderate (κ = 0.43, P < .005), with 0.66 (0.53-0.78) sensitivity, 0.87 (0.82-0.90) specificity, 0.50 (0.39-0.62) positive predictive values, 0.93 (0.89-0.95) negative predictive value, and 0.83 (0.79-0.87) accuracy. A loss of accuracy was observed with higher DCS current intensities. CONCLUSION We performed a point-by-point validation of preoperative nTMS maps for motor function using augmented reality visualization. The high negative predictive value and low positive predictive values highlight nTMS reliability to visualize safe cortical zones but not to identify critical functional areas, confirming previous findings of nTMS maps for the language function and suggesting the need for combined use of nTMS maps and DCS for optimal maximal safe resection.
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Affiliation(s)
- Giovanni Muscas
- Neurosurgical Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence , Italy
| | - Tommaso Bardazzi
- Neurosurgical Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence , Italy
| | - Agnese Pedone
- Neurosurgical Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence , Italy
| | - Luca Campagnaro
- Neurosurgical Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence , Italy
| | - Camilla Bonaudo
- Neurosurgical Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence , Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence , Italy
| | - Fabrizio Baldanzi
- Neurophysiopathology Unit, Careggi University Hospital, Florence , Italy
| | - Simone Troiano
- Neurophysiopathology Unit, Careggi University Hospital, Florence , Italy
| | - Riccardo Carrai
- Neurophysiopathology Unit, Careggi University Hospital, Florence , Italy
| | - Antonello Grippo
- Neurophysiopathology Unit, Careggi University Hospital, Florence , Italy
| | - Alessandro Della Puppa
- Neurosurgical Clinic, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Florence , Italy
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Eibl T, Schrey M, Liebert A, Ritter L, Lange R, Steiner HH, Schebesch KM. Influence of clinical and tumor-specific factors on the resting motor threshold in navigated transcranial magnetic stimulation. Neurophysiol Clin 2023; 53:102920. [PMID: 37944292 DOI: 10.1016/j.neucli.2023.102920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE Preoperative non-invasive mapping of motor function with navigated transcranial magnetic stimulation (nTMS) has become a widely used diagnostic procedure. Determination of the patient-individual resting motor threshold (rMT) is of great importance to achieve reliable results when conducting nTMS motor mapping. Factors which contribute to differences in rMT of brain tumor patients have not been fully investigated. METHODS We included adult patients with all types of de novo and recurrent intracranial lesions, suspicious for intra-axial brain tumors. The outcome measure was the rMT of the upper extremity, defined as the stimulation intensity eliciting motor evoked potentials with amplitudes greater than 50µV in 50 % of applied stimulations. RESULTS Eighty nTMS examinations in 75 patients (37.5 % female) aged 57.9 ± 14.9 years were evaluated. In non-parametric testing, rMT values were higher in patients with upper extremity paresis (p = 0.024) and lower in patients with high grade gliomas (HGG) (p = 0.001). rMT inversely correlated with patient age (rs=-0.28, p = 0.013) and edema volume (rs=-0.28, p = 0.012) In regression analysis, infiltration of the precentral gyrus (p<0.001) increased rMT values. Values of rMT were reduced in high grade gliomas (p<0.001), in patients taking Levetiracetam (p = 0.019) and if perilesional edema infiltrated motor eloquent brain (p<0.001). Subgroup analyses of glioma patients revealed similar results. Values of rMT did not differ between hand and forearm muscles. CONCLUSION Most factors confounding rMT in our study were specific to the lesion. These factors contributed to the variability in cortical excitability and must be considered in clinical work with nTMS to achieve reliable results with nTMS motor mapping.
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Affiliation(s)
- Thomas Eibl
- Department of Neurosurgery, Paracelsus Medical University Nuremberg, Germany.
| | - Michael Schrey
- Department of Neurosurgery, Paracelsus Medical University Nuremberg, Germany
| | - Adrian Liebert
- Department of Neurosurgery, Paracelsus Medical University Nuremberg, Germany
| | - Leonard Ritter
- Department of Neurosurgery, Paracelsus Medical University Nuremberg, Germany
| | - Rüdiger Lange
- Department of Neurology, Paracelsus Medical University Nuremberg, Germany
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3
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Assessing the feasibility of mapping the tibialis anterior muscle with navigated transcranial magnetic stimulation in neuro-oncologic patients. Sci Rep 2022; 12:18719. [PMID: 36333400 PMCID: PMC9636142 DOI: 10.1038/s41598-022-23444-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Mapping the lower extremity with navigated transcranial magnetic stimulation (nTMS) still remains challenging for the investigator. Clinical factors influencing leg mapping with nTMS have not been fully investigated yet. The aim of the study was to identify factors which influence the possibility of eliciting motor evoked potentials (MEPs) from the tibialis anterior muscle (TA). Patient records, imaging, nTMS examinations and tractography were retrospectively evaluated. 48 nTMS examinations were performed in 46 brain tumor patients. Reproducible MEPs were recorded in 20 patients (41.67%). Younger age (p = 0.044) and absence of perifocal edema (p = 0.035, Cramer's V = 0.34, OR = 0.22, 95% CI = 0.06-0.81) facilitated mapping the TA muscle. Leg motor deficit (p = 0.49, Cramer's V = 0.12, OR = 0.53, 95%CI = 0.12-2.36), tumor entity (p = 0.36, Cramer's V = 0.22), tumor location (p = 0.52, Cramer's V = 0.26) and stimulation intensity (p = 0.158) were no significant factors. The distance between the tumor and the pyramidal tract was higher (p = 0.005) in patients with successful mapping of the TA. The possibility to stimulate the leg motor area was associated with no postoperative aggravation of motor deficits in general (p = 0.005, Cramer's V = 0.45, OR = 0.63, 95%CI = 0.46-0.85) but could not serve as a specific predictor of postoperative lower extremity function. In conclusion, successful mapping of the TA muscle for neurosurgical planning is influenced by young patient age, absence of edema and greater distance to the CST, whereas tumor entity and stimulation intensity were non-significant.
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Rosenstock T, Pöser P, Wasilewski D, Bauknecht HC, Grittner U, Picht T, Misch M, Onken JS, Vajkoczy P. MRI-Based Risk Assessment for Incomplete Resection of Brain Metastases. Front Oncol 2022; 12:873175. [PMID: 35651793 PMCID: PMC9149256 DOI: 10.3389/fonc.2022.873175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Object Recent studies demonstrated that gross total resection of brain metastases cannot always be achieved. Subtotal resection (STR) can result in an early recurrence and might affect patient survival. We initiated a prospective observational study to establish a MRI-based risk assessment for incomplete resection of brain metastases. Methods All patients in whom ≥1 brain metastasis was resected were prospectively included in this study (DRKS ID: DRKS00021224; Nov 2020 - Nov 2021). An interdisciplinary board of neurosurgeons and neuroradiologists evaluated the pre- and postoperative MRI (≤48h after surgery) for residual tumor. Extensive neuroradiological analyses were performed to identify risk factors for an unintended STR which were integrated into a regression tree analysis to determine the patients' individual risk for a STR. Results We included 150 patients (74 female; mean age: 61 years), in whom 165 brain metastases were resected. A STR was detected in 32 cases (19.4%) (median residual tumor volume: 1.36ml, median EORrel: 93.6%), of which 6 (3.6%) were intended STR (median residual tumor volume: 3.27ml, median EORrel: 67.3%) - mainly due to motor-eloquent location - and 26 (15.8%) were unintended STR (uSTR) (median residual tumor volume: 0.64ml, median EORrel: 94.7%). The following risk factors for an uSTR could be identified: subcortical metastasis ≥5mm distant from cortex, diffuse contrast agent enhancement, proximity to the ventricles, contact to falx/tentorium and non-transcortical approaches. Regression tree analysis revealed that the individual risk for an uSTR was mainly associated to the distance from the cortex (distance ≥5mm vs. <5mm: OR 8.0; 95%CI: 2.7 - 24.4) and the contrast agent patterns (diffuse vs. non-diffuse in those with distance ≥5mm: OR: 4.2; 95%CI: 1.3 - 13.7). The preoperative tumor volume was not substantially associated with the extent of resection. Conclusions Subcortical metastases ≥5mm distant from cortex with diffuse contrast agent enhancement showed the highest incidence of uSTR. The proposed MRI-based assessment allows estimation of the individual risk for uSTR and can help indicating intraoperative imaging.
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Affiliation(s)
- Tizian Rosenstock
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin, Germany
| | - Paul Pöser
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - David Wasilewski
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Hans-Christian Bauknecht
- Institute of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Cluster of Excellence: "Matters of Activity. Image Space Material," Humboldt University, Berlin, Germany
| | - Martin Misch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Julia Sophie Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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5
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Roshchina KE, Bekyashev AK, Gasparyan TG, Aleshin VA, Osinov IK, Savateev AN, Khalafyan DA. Modern possibilities of neurosurgical treatment of brain metastases. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:119-125. [PMID: 36252202 DOI: 10.17116/neiro202286051119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Despite significant progress in neuroimaging and introduction of new combined treatments for solid tumors, brain metastases are still adverse factor for overall survival. Brain metastases are diagnosed in 8-10% of patients and associated with extremely poor prognosis. These lesions result focal and general cerebral symptoms. Literature review highlights the current principles of surgical treatment of metastatic brain lesions in patients with solid tumors.
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Affiliation(s)
- K E Roshchina
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
| | - A Kh Bekyashev
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
- Russian Medical Academy for Continuous Professional Education, Moscow, Russia
| | - T G Gasparyan
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
- Scientific Center of Neurology, Moscow, Russia
| | - V A Aleshin
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
| | - I K Osinov
- Burdenko Neurosurgical Center, Moscow, Russia
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6
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Ille S, Schroeder A, Hostettler IC, Wostrack M, Meyer B, Krieg SM. Impacting the Treatment of Highly Eloquent Supratentorial Cerebral Cavernous Malformations by Noninvasive Functional Mapping-An Observational Cohort Study. Oper Neurosurg (Hagerstown) 2021; 21:467-477. [PMID: 34624894 DOI: 10.1093/ons/opab318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/18/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) may cause cavernoma-related epilepsy (CRE) and intracranial hemorrhage (ICH). Functional mapping has shown its usefulness during the resection of eloquent lesions including the treatment of brain arteriovenous malformations. OBJECTIVE To evaluate the impact of noninvasive functional mapping on decision-making and resection of eloquently located CCM. METHODS Of 126 patients with intracranial cavernomas, we prospectively included 40 consecutive patients (31.7%) with highly eloquent CCM between 2012 and 2020. We performed functional mapping via navigated transcranial magnetic stimulation (nTMS) motor mapping in 30 cases and nTMS language mapping in 20 cases. Twenty patients suffered from CRE. CCM caused ICH in 18 cases. RESULTS We used functional mapping data including function-based tractography in all cases. Indication toward (31 cases) or against (9 cases) CCM resection was influenced by noninvasive functional mapping in 36 cases (90%). We resected CCMs in 24 cases, and 7 patients refused the recommendation for surgery. In 19 and 4 cases, we used additional intraoperative neuromonitoring and awake craniotomy, respectively. Patients suffered from transient postoperative motor or language deficits in 2 and 2 cases, respectively. No patient suffered from permanent deficits. After 1 yr of follow-up, anti-epileptic drugs could be discontinued in all patients who underwent surgery but 1 patient. CONCLUSION Surgery-related deficit rates are low even for highly eloquent CCM and seizure outcome is excellent. The present results show that noninvasive functional mapping and function-based tractography is a useful tool for the decision-making process and during microsurgical resection of eloquently located CCM.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Axel Schroeder
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Isabel C Hostettler
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
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7
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Abstract
As the epidemiological and clinical burden of brain metastases continues to grow, advances in neurosurgical care are imperative. From standard magnetic resonance imaging (MRI) sequences to functional neuroimaging, preoperative workups for metastatic disease allow high-resolution detection of lesions and at-risk structures, facilitating safe and effective surgical planning. Minimally invasive neurosurgical approaches, including keyhole craniotomies and tubular retractors, optimize the preservation of normal parenchyma without compromising extent of resection. Supramarginal surgery has pushed the boundaries of achieving complete removal of metastases without recurrence, especially in eloquent regions when paired with intraoperative neuromonitoring. Brachytherapy has highlighted the potential of locally delivering therapeutic agents to the resection cavity with high rates of local control. Neuronavigation has become a cornerstone of operative workflow, while intraoperative ultrasound (iUS) and intraoperative brain mapping generate real-time renderings of the brain unaffected by brain shift. Endoscopes, exoscopes, and fluorescent-guided surgery enable increasingly high-definition visualizations of metastatic lesions that were previously difficult to achieve. Pushed forward by these multidisciplinary innovations, neurosurgery has never been a safer, more effective treatment for patients with brain metastases.
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Affiliation(s)
- Patrick R Ng
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bryan D Choi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Manish K Aghi
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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8
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Sollmann N, Krieg SM, Säisänen L, Julkunen P. Mapping of Motor Function with Neuronavigated Transcranial Magnetic Stimulation: A Review on Clinical Application in Brain Tumors and Methods for Ensuring Feasible Accuracy. Brain Sci 2021; 11:brainsci11070897. [PMID: 34356131 PMCID: PMC8305823 DOI: 10.3390/brainsci11070897] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/29/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022] Open
Abstract
Navigated transcranial magnetic stimulation (nTMS) has developed into a reliable non-invasive clinical and scientific tool over the past decade. Specifically, it has undergone several validating clinical trials that demonstrated high agreement with intraoperative direct electrical stimulation (DES), which paved the way for increasing application for the purpose of motor mapping in patients harboring motor-eloquent intracranial neoplasms. Based on this clinical use case of the technique, in this article we review the evidence for the feasibility of motor mapping and derived models (risk stratification and prediction, nTMS-based fiber tracking, improvement of clinical outcome, and assessment of functional plasticity), and provide collected sets of evidence for the applicability of quantitative mapping with nTMS. In addition, we provide evidence-based demonstrations on factors that ensure methodological feasibility and accuracy of the motor mapping procedure. We demonstrate that selection of the stimulation intensity (SI) for nTMS and spatial density of stimuli are crucial factors for applying motor mapping accurately, while also demonstrating the effect on the motor maps. We conclude that while the application of nTMS motor mapping has been impressively spread over the past decade, there are still variations in the applied protocols and parameters, which could be optimized for the purpose of reliable quantitative mapping.
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Affiliation(s)
- Nico Sollmann
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany;
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, San Francisco, CA 94143, USA
- Correspondence:
| | - Sandro M. Krieg
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany;
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Laura Säisänen
- Department of Clinical Neurophysiology, Kuopio University Hospital, 70029 Kuopio, Finland; (L.S.); (P.J.)
- Department of Applied Physics, University of Eastern Finland, 70211 Kuopio, Finland
| | - Petro Julkunen
- Department of Clinical Neurophysiology, Kuopio University Hospital, 70029 Kuopio, Finland; (L.S.); (P.J.)
- Department of Applied Physics, University of Eastern Finland, 70211 Kuopio, Finland
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9
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Narayana S, Gibbs SK, Fulton SP, McGregor AL, Mudigoudar B, Weatherspoon SE, Boop FA, Wheless JW. Clinical Utility of Transcranial Magnetic Stimulation (TMS) in the Presurgical Evaluation of Motor, Speech, and Language Functions in Young Children With Refractory Epilepsy or Brain Tumor: Preliminary Evidence. Front Neurol 2021; 12:650830. [PMID: 34093397 PMCID: PMC8170483 DOI: 10.3389/fneur.2021.650830] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/25/2021] [Indexed: 11/25/2022] Open
Abstract
Accurate presurgical mapping of motor, speech, and language cortices, while crucial for neurosurgical planning and minimizing post-operative functional deficits, is challenging in young children with neurological disease. In such children, both invasive (cortical stimulation mapping) and non-invasive functional mapping imaging methods (MEG, fMRI) have limited success, often leading to delayed surgery or adverse post-surgical outcomes. We therefore examined the clinical utility of transcranial magnetic stimulation (TMS) in young children who require functional mapping. In a retrospective chart review of TMS studies performed on children with refractory epilepsy or a brain tumor, at our institution, we identified 47 mapping sessions in 36 children 3 years of age or younger, in whom upper and lower extremity motor mapping was attempted; and 13 children 5–6 years old in whom language mapping, using a naming paradigm, was attempted. The primary hand motor cortex was identified in at least one hemisphere in 33 of 36 patients, and in both hemispheres in 27 children. In 17 children, primary leg motor cortex was also successfully identified. The language cortices in temporal regions were successfully mapped in 11 of 13 patients, and in six of them language cortices in frontal regions were also mapped, with most children (n = 5) showing right hemisphere dominance for expressive language. Ten children had a seizure that was consistent with their clinical semiology during or immediately following TMS, none of which required intervention or impeded completion of mapping. Using TMS, both normal motor, speech, and language developmental patterns and apparent disease induced reorganization were demonstrated in this young cohort. The successful localization of motor, speech, and language cortices in young children improved the understanding of the risk-benefit ratio prior to surgery and facilitated surgical planning aimed at preserving motor, speech, and language functions. Post-operatively, motor function was preserved or improved in nine out of 11 children who underwent surgery, as was language function in all seven children who had surgery for lesions near eloquent cortices. We provide feasibility data that TMS is a safe, reliable, and effective tool to map eloquent cortices in young children.
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Affiliation(s)
- Shalini Narayana
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States.,Le Bonheur Children's Hospital, The Neuroscience Institute, Memphis, TN, United States.,Department of Anatomy and Neurobiology, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Savannah K Gibbs
- Le Bonheur Children's Hospital, The Neuroscience Institute, Memphis, TN, United States
| | - Stephen P Fulton
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States.,Le Bonheur Children's Hospital, The Neuroscience Institute, Memphis, TN, United States
| | - Amy Lee McGregor
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States.,Le Bonheur Children's Hospital, The Neuroscience Institute, Memphis, TN, United States
| | - Basanagoud Mudigoudar
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States.,Le Bonheur Children's Hospital, The Neuroscience Institute, Memphis, TN, United States
| | - Sarah E Weatherspoon
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States.,Le Bonheur Children's Hospital, The Neuroscience Institute, Memphis, TN, United States
| | - Frederick A Boop
- Le Bonheur Children's Hospital, The Neuroscience Institute, Memphis, TN, United States.,Semmes Murphey Neurologic and Spine Institute, Memphis, TN, United States.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - James W Wheless
- Division of Pediatric Neurology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States.,Le Bonheur Children's Hospital, The Neuroscience Institute, Memphis, TN, United States
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10
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Dzierma Y, Schuermann M, Melchior P, Nuesken F, Oertel J, Rübe C, Hendrix P. Optimizing Adjuvant Stereotactic Radiotherapy of Motor-Eloquent Brain Metastases: Sparing the nTMS-Defined Motor Cortex and the Hippocampus. Front Oncol 2021; 11:628007. [PMID: 33718201 PMCID: PMC7953904 DOI: 10.3389/fonc.2021.628007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/06/2021] [Indexed: 12/25/2022] Open
Abstract
Brain metastases can effectively be treated with surgical resection and adjuvant stereotactic radiotherapy (SRT). Navigated transcranial magnetic stimulation (nTMS) has been used to non-invasively map the motor cortex prior to surgery of motor eloquent brain lesions. To date, few studies have reported the integration of such motor maps into radiotherapy planning. The hippocampus has been identified as an additional critical structure of radiation-induced deficits. The aim of this study is to assess the feasibility of selective dose reduction to both the nTMS-based motor cortex and the hippocampi in SRT of motor-eloquent brain metastases. Patients with motor-eloquent brain metastases undergoing surgical resection and adjuvant SRT between 07/2014 and 12/2018 were retrospectively analyzed. The radiotherapy treatment plans were retrieved from the treatment planning system (“original” plan). For each case, two intensity-modulated treatment plans were created: the “motor” plan aimed to reduce the dose to the motor cortex, the “motor & hipp” plan additionally reduce the dose to the hippocampus. The optimized plans were compared with the “original” plan regarding plan quality, planning target volume (PTV) coverage, and sparing of organs at risk (OAR). 69 plans were analyzed, all of which were clinically acceptable with no significant differences for PTV coverage. All OAR were protected according to standard protocols. Sparing of the nTMS motor map was feasible: mean dose 9.66 ± 5.97 Gy (original) to 6.32 ± 3.60 Gy (motor) and 6.49 ± 3.78 Gy (motor & hipp), p<0.001. In the “motor & hipp” plan, dose to the ipsilateral hippocampi could be significantly reduced (max 1.78 ± 1.44 Gy vs 2.49 ± 1.87 Gy in “original”, p = 0.003; mean 1.01 ± 0.92 Gy vs. 1.32 ± 1.07 Gy in “original”, p = 0.007). The study confirms the results from previous studies that inclusion of nTMS motor information into radiotherapy treatment planning is possible with a relatively straightforward workflow and can achieve reduced doses to the nTMS-defined motor area without compromising PTV coverage. Furthermore, we demonstrate the feasibility of selective dose reduction to the hippocampus at the same time. The clinical significance of these optimized plans yet remains to be determined. However, with no apparent disadvantages these optimized plans call for further and broader exploration.
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Affiliation(s)
- Yvonne Dzierma
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Michaela Schuermann
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Patrick Melchior
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Frank Nuesken
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Centre and Saarland University Faculty of Medicine, Homburg, Germany
| | - Christian Rübe
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Philipp Hendrix
- Department of Neurosurgery, Saarland University Medical Centre and Saarland University Faculty of Medicine, Homburg, Germany
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11
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Fekonja LS, Wang Z, Aydogan DB, Roine T, Engelhardt M, Dreyer FR, Vajkoczy P, Picht T. Detecting Corticospinal Tract Impairment in Tumor Patients With Fiber Density and Tensor-Based Metrics. Front Oncol 2021; 10:622358. [PMID: 33585250 PMCID: PMC7873606 DOI: 10.3389/fonc.2020.622358] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022] Open
Abstract
Tumors infiltrating the motor system lead to significant disability, often caused by corticospinal tract injury. The delineation of the healthy-pathological white matter (WM) interface area, for which diffusion magnetic resonance imaging (dMRI) has shown promising potential, may improve treatment outcome. However, up to 90% of white matter (WM) voxels include multiple fiber populations, which cannot be correctly described with traditional metrics such as fractional anisotropy (FA) or apparent diffusion coefficient (ADC). Here, we used a novel fixel-based along-tract analysis consisting of constrained spherical deconvolution (CSD)-based probabilistic tractography and fixel-based apparent fiber density (FD), capable of identifying fiber orientation specific microstructural metrics. We addressed this novel methodology's capability to detect corticospinal tract impairment. We measured and compared tractogram-related FD and traditional microstructural metrics bihemispherically in 65 patients with WHO grade III and IV gliomas infiltrating the motor system. The cortical tractogram seeds were based on motor maps derived by transcranial magnetic stimulation. We extracted 100 equally distributed cross-sections along each streamline of corticospinal tract (CST) for along-tract statistical analysis. Cross-sections were then analyzed to detect differences between healthy and pathological hemispheres. All metrics showed significant differences between healthy and pathologic hemispheres over the entire tract and between peritumoral segments. Peritumoral values were lower for FA and FD, but higher for ADC within the entire cohort. FD was more specific to tumor-induced changes in CST than ADC or FA, whereas ADC and FA showed higher sensitivity. The bihemispheric along-tract analysis provides an approach to detect subject-specific structural changes in healthy and pathological WM. In the current clinical dataset, the more complex FD metrics did not outperform FA and ADC in terms of describing corticospinal tract impairment.
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Affiliation(s)
- Lucius S. Fekonja
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Cluster of Excellence: “Matters of Activity. Image Space Material”, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ziqian Wang
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dogu B. Aydogan
- Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland
| | - Timo Roine
- Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland
| | - Melina Engelhardt
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Felix R. Dreyer
- Cluster of Excellence: “Matters of Activity. Image Space Material”, Humboldt-Universität zu Berlin, Berlin, Germany
- Brain Language Laboratory, Department of Philosophy and Humanities, Freie Universität Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Cluster of Excellence: “Matters of Activity. Image Space Material”, Humboldt-Universität zu Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
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12
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Ille S, Krieg SM. Functional Mapping for Glioma Surgery, Part 1: Preoperative Mapping Tools. Neurosurg Clin N Am 2020; 32:65-74. [PMID: 33223027 DOI: 10.1016/j.nec.2020.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although intraoperative mapping of brain areas was shown to promote greater extent of resection and reduce functional deficits, this was shown only recently for some noninvasive techniques. Yet, proper surgical planning, indication, and patient consultation require reliable noninvasive techniques. Because functional magnetic resonance imaging, tractography, and neurophysiologic methods like navigated transcranial magnetic stimulation and magnetoencephalography allow identifying eloquent areas prior to resective surgery and tailor the surgical approach, this article provides an overview on the individual strengths and limitations of each modality.
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Affiliation(s)
- Sebastian Ille
- Department of Neurosurgery, Technical University of Munich, Germany, School of Medicine, Klinikum rechts der Isar, Ismaninger Strasse 22, Munich 81675, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University of Munich, Germany, School of Medicine, Klinikum rechts der Isar, Ismaninger Strasse 22, Munich 81675, Germany.
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13
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Short-Interval Intracortical Facilitation Improves Efficacy in nTMS Motor Mapping of Lower Extremity Muscle Representations in Patients with Supra-Tentorial Brain Tumors. Cancers (Basel) 2020; 12:cancers12113233. [PMID: 33147827 PMCID: PMC7692031 DOI: 10.3390/cancers12113233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023] Open
Abstract
Navigated transcranial magnetic stimulation (nTMS) is increasingly used for mapping of motor function prior to surgery in patients harboring motor-eloquent brain lesions. To date, single-pulse nTMS (sp-nTMS) has been predominantly used for this purpose, but novel paired-pulse nTMS (pp-nTMS) with biphasic pulse application has been made available recently. The purpose of this study was to systematically evaluate pp-nTMS with biphasic pulses in comparison to conventionally used sp-nTMS for preoperative motor mapping of lower extremity (lE) muscle representations. Thirty-nine patients (mean age: 56.3 ± 13.5 years, 69.2% males) harboring motor-eloquent brain lesions of different entity underwent motor mapping of lE muscle representations in lesion-affected hemispheres and nTMS-based tractography of the corticospinal tract (CST) using data from sp-nTMS and pp-nTMS with biphasic pulses, respectively. Compared to sp-nTMS, pp-nTMS enabled motor mapping with lower stimulation intensities (61.8 ± 13.8% versus 50.7 ± 11.6% of maximum stimulator output, p < 0.0001), and it provided reliable motor maps even in the most demanding cases where sp-nTMS failed (pp-nTMS was able to provide a motor map in five patients in whom sp-nTMS did not provide any motor-positive points, and pp-nTMS was the only modality to provide a motor map in one patient who also did not show motor-positive points during intraoperative stimulation). Fiber volumes of the tracked CST were slightly higher when motor maps of pp-nTMS were used, and CST tracking using pp-nTMS data was also possible in the five patients in whom sp-nTMS failed. In conclusion, application of pp-nTMS with biphasic pulses enables preoperative motor mapping of lE muscle representations even in the most challenging patients in whom the motor system is at high risk due to lesion location or resection.
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14
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Zuo F, Hu K, Kong J, Zhang Y, Wan J. Surgical Management of Brain Metastases in the Perirolandic Region. Front Oncol 2020; 10:572644. [PMID: 33194673 PMCID: PMC7649351 DOI: 10.3389/fonc.2020.572644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/06/2020] [Indexed: 01/22/2023] Open
Abstract
Brain metastases (BM) are the most frequent intracranial tumors, which may result in significant morbidity and mortality when the lesions involve the perirolandic region. Surgical intervention for BM in the perirolandic region is still under discussion even though prompt relief of mass effect and avoidance of necrosis together with brain edema may not be achieved by radiotherapy. More recently, several researchers attempt to evaluate the benefit of surgery for BM within this pivotal sensorimotor area. Nevertheless, data are sparse and optimal treatment paradigm is not yet widely described. Since the advance in intraoperative neuroimaging and neurophysiology, resection of BM in the perirolandic region has been proven to be safe and efficacious, sparing this eloquent area while retaining reasonably low morbidity rates. Although management of BM becomes much more tailored and multimodal, surgery remains the cornerstone and principles of resection as well as indications for surgery should be well defined. This is the first review concerning the characteristics of BM involving the perirolandic region and the current impact of surgical therapy for the lesions. Future perspectives of advanced neurosurgical techniques are also presented.
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Affiliation(s)
- Fuxing Zuo
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianxin Kong
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinghai Wan
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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15
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Sollmann N, Zhang H, Kelm A, Schröder A, Meyer B, Pitkänen M, Julkunen P, Krieg SM. Paired-pulse navigated TMS is more effective than single-pulse navigated TMS for mapping upper extremity muscles in brain tumor patients. Clin Neurophysiol 2020; 131:2887-2898. [PMID: 33166740 DOI: 10.1016/j.clinph.2020.09.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/10/2020] [Accepted: 09/09/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Single-pulse navigated transcranial magnetic stimulation (sp-nTMS) is used for presurgical motor mapping in patients with motor-eloquent lesions. However, recently introduced paired-pulse nTMS (pp-nTMS) with biphasic pulses could improve motor mapping. METHODS Thirty-four patients (mean age: 56.0 ± 12.7 years, 53.0% high-grade glioma) with motor-eloquent lesions underwent motor mapping of upper extremity representations and nTMS-based tractography of the corticospinal tract (CST) by both sp-nTMS and pp-nTMS with biphasic pulses for the tumor-affected hemisphere before resection. RESULTS In three patients (8.8%), conventional sp-nTMS did not provide motor-positive points, in contrast to pp-nTMS that was capable of generating motor maps in all patients. Good concordance between pp-nTMS and sp-nTMS in the spatial location of motor hotspots and center of gravity (CoG) as well as for CST tracking was observed, with pp-nTMS leading to similar motor map volumes (585.0 ± 667.8 vs. 586.8 ± 204.2 mm3, p = 0.9889) with considerably lower resting motor thresholds (35.0 ± 8.8 vs. 32.8 ± 7.6% of stimulator output, p = 0.0004). CONCLUSIONS Pp-nTMS with biphasic pulses may provide motor maps even in highly demanding cases with tumor-affected motor structures or edema, using lower stimulation intensity compared to sp-nTMS. SIGNIFICANCE Pp-nTMS with biphasic pulses could replace standardly used sp-nTMS for motor mapping and may be safer due to lower stimulation intensity.
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Affiliation(s)
- Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany; TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Haosu Zhang
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany
| | - Anna Kelm
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany.
| | - Axel Schröder
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany.
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany.
| | - Minna Pitkänen
- Department of Clinical Neurophysiology, Kuopio University Hospital, POB 100, 70029 KYS, Kuopio, Finland; A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland; Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland
| | - Petro Julkunen
- Department of Clinical Neurophysiology, Kuopio University Hospital, POB 100, 70029 KYS, Kuopio, Finland; Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.
| | - Sandro M Krieg
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany.
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16
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Bartek J, Cooray G, Islam M, Jensdottir M. Stereotactic Brain Biopsy in Eloquent Areas Assisted by Navigated Transcranial Magnetic Stimulation: a Technical Case Report. Oper Neurosurg (Hagerstown) 2020; 17:E124-E129. [PMID: 30371829 DOI: 10.1093/ons/opy321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 09/19/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Stereotactic brain biopsy (SB) is an important part of the neurosurgical armamentarium, with the possibility of achieving histopathological diagnosis in otherwise inaccessible lesions of the brain. Nevertheless, the procedure is not without the risk of morbidity, which is especially true for lesions in eloquent parts of the brain, where even a minor adverse event can result in significant deficits. Navigated transcranial magnetic stimulation (nTMS) is widely used to chart lesions in eloquent areas, successfully guiding maximal safe resection, while its potential role in aiding with the planning of a stereotactic biopsy is so far unexplored. CLINICAL PRESENTATION Magnetic resonance imaging of a 67-yr-old woman presenting with dysphasia revealed a noncontrast enhancing left-sided lesion in the frontal and parietal pars opercularis. Due to the location of the lesion, nTMS was used to chart both primary motor and language cortex, utilizing this information to plan a safe SB trajectory and sampling area according to the initial work-up recommendations from the multidisciplinary neuro-oncology board. The SB was uneventful, with histology revealing a ganglioglioma, WHO I. The patient was discharged the following day, having declined to proceed with tumor resection (awake surgery) due to the non-negligible risk of morbidity. Upon 1- and 3-mo follow-up, she showed no signs of any procedure-related deficits. CONCLUSION nTMS can be implemented to aid with the planning of a stereotactic biopsy procedure in eloquent areas of the brain, and should be considered part of the neurosurgical armamentarium.
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Affiliation(s)
- Jiri Bartek
- Department of Clinical Neuroscience and Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gerald Cooray
- Department of Clinical Neuroscience and Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mominul Islam
- Department of Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Margret Jensdottir
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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17
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Abstract
Brain metastases are the most common intracranial tumor and a leading cause of morbidity and mortality for patients with systemic cancer. En bloc surgical resection of brain metastases improves survival, local recurrence rates, and functional independence in patients with up to three metastases and controlled extracranial disease. Modern techniques and technologies provide the neurosurgeon with minimally invasive approaches, such as keyhole craniotomies and tubular retractors. Preoperative planning for tumors located in eloquent regions includes mapping with functional MRI and diffusion tensor imaging, and intraoperative mapping and monitoring with electrophysiologic techniques under general or awake anesthesia to preserve normal neurologic function.
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Affiliation(s)
- Joshua L Wang
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Doan Hall N1004, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - J Bradley Elder
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Doan Hall N1004, 410 West 10th Avenue, Columbus, OH 43210, USA
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18
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Application of Navigated Transcranial Magnetic Stimulation to Map the Supplementary Motor Area in Healthy Subjects. J Clin Neurophysiol 2020; 37:140-149. [DOI: 10.1097/wnp.0000000000000530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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19
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Caffo M, Cardali SM, Raffa G, Caruso G, Barresi V, Ricciardo G, Gorgoglione N, Granata F, Germanò A. The Value of Preoperative Planning Based on Navigated Transcranical Magnetic Stimulation for Surgical Treatment of Brain Metastases Located in the Perisylvian Area. World Neurosurg 2020; 134:e442-e452. [DOI: 10.1016/j.wneu.2019.10.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 02/07/2023]
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20
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Kandeel H, Mirza A, Lavrador JP, Patel S, Gullan R, Bhangoo R, Vergani F, Ashkan K. Safety and tolerability of navigated transcranial magnetic stimulation in a tumor patient with no bone flap. Clin Neurophysiol 2019; 131:592-593. [PMID: 31843503 DOI: 10.1016/j.clinph.2019.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 10/20/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Hussein Kandeel
- Neurosurgical Department, King's College Hospital Foundation Trust, London, UK.
| | - Asfand Mirza
- Neurosurgical Department, King's College Hospital Foundation Trust, London, UK
| | - José Pedro Lavrador
- Neurosurgical Department, King's College Hospital Foundation Trust, London, UK
| | - Sabina Patel
- Neurosurgical Department, King's College Hospital Foundation Trust, London, UK
| | - Richard Gullan
- Neurosurgical Department, King's College Hospital Foundation Trust, London, UK
| | - Ranjeev Bhangoo
- Neurosurgical Department, King's College Hospital Foundation Trust, London, UK
| | - Francesco Vergani
- Neurosurgical Department, King's College Hospital Foundation Trust, London, UK
| | - Keyoumars Ashkan
- Neurosurgical Department, King's College Hospital Foundation Trust, London, UK
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21
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Scharl S, Kirstein A, Kessel KA, Diehl C, Oechsner M, Straube C, Meyer B, Zimmer C, Combs SE. Stereotactic irradiation of the resection cavity after surgical resection of brain metastases - when is the right timing? Acta Oncol 2019; 58:1714-1719. [PMID: 31368403 DOI: 10.1080/0284186x.2019.1643917] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose: This study aimed to evaluate whether an early beginning of the adjuvant stereotactic radiotherapy after macroscopic complete resection of 1-3 brain metastases is essential or whether longer intervals between surgery and radiotherapy are feasible.Material and methods: Sixty-six patients with 69 resection cavities treated with HFSRT after macroscopic complete resection of 1-3 brain metastases between 2009 and 2016 in our institution were included in this study. Overall survival, local recurrence and locoregional recurrence were evaluated depending on the time interval from surgery to the start of radiation therapy.Results: Patients that started radiotherapy within 21 days from surgery had a significantly decreased OS compared to patients treated after a longer interval from surgery (p < .01). There was no significant difference between patients treated ≥ 34 and 22-33 days from surgery (p = .210). In the univariate analysis, local control was superior for patients starting treatment 22-33 days from surgery compared to a later start (p = .049). This effect did not prevail in a multivariate model. There was no significant difference between patients treated within 21 days and patients treated more than 33 days after surgery (p = .203). Locoregional control was not influenced by RT timing (p = .508).Conclusion: A short delay in the start of radiotherapy does not seem to negatively impact the outcome in patients with resected brain metastases. We even observed an unexpected reduction in OS in patients treated within 21 days from surgery. Further studies are needed to define the optimal timing of postoperative radiotherapy to the resection cavity.
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Affiliation(s)
- Sophia Scharl
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Anna Kirstein
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Oberschleißheim, Germany
| | - Kerstin A. Kessel
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Oberschleißheim, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site, Munich, Germany
| | - Christian Diehl
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technische Universität München (TUM), Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Technische Universität München (TUM), Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Oberschleißheim, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site, Munich, Germany
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22
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Raffa G, Quattropani MC, Germanò A. When imaging meets neurophysiology: the value of navigated transcranial magnetic stimulation for preoperative neurophysiological mapping prior to brain tumor surgery. Neurosurg Focus 2019; 47:E10. [DOI: 10.3171/2019.9.focus19640] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/04/2019] [Indexed: 11/06/2022]
Abstract
Maximal safe resection is the modern goal for surgery of intrinsic brain tumors located in or close to brain eloquent areas. Nowadays different neuroimaging techniques provide important anatomical and functional information regarding the brain functional organization that can be used to plan a customized surgical strategy to preserve functional networks, and to increase the extent of tumor resection. Among these techniques, navigated transcranial magnetic stimulation (nTMS) has recently gained great favor among the neurosurgical community for preoperative mapping and planning prior to brain tumor surgery. It represents an advanced neuroimaging technique based on the neurophysiological mapping of the functional cortical brain organization. Moreover, it can be combined with other neuroimaging techniques such as diffusion tensor imaging tractography, thus providing a reliable reconstruction of brain eloquent networks. Consequently, nTMS mapping may provide reliable noninvasive brain functional mapping, anticipating information that otherwise may be available to neurosurgeons only in the operating theater by using direct electrical stimulation. The authors describe the reliability and usefulness of the preoperative nTMS-based approach in neurosurgical practice, and briefly discuss their experience using nTMS as well as currently available evidence in the literature supporting its clinical use. In particular, special attention is reserved for the discussion of the role of nTMS as a novel tool for the preoperative neurophysiological mapping of motor and language networks prior to surgery of intrinsic brain tumors located in or close to eloquent networks, as well as for future and promising applications of nTMS in neurosurgical practice.
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Affiliation(s)
- Giovanni Raffa
- 1Division of Neurosurgery, BIOMORF Department, University of Messina, Italy; and
| | | | - Antonino Germanò
- 1Division of Neurosurgery, BIOMORF Department, University of Messina, Italy; and
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23
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Diehl CD, Shiban E, Straube C, Gempt J, Wilkens JJ, Oechsner M, Kessel C, Zimmer C, Wiestler B, Meyer B, Combs SE. Neoadjuvant stereotactic radiosurgery for intracerebral metastases of solid tumors (NepoMUC): a phase I dose escalation trial. Cancer Commun (Lond) 2019; 39:73. [PMID: 31706337 PMCID: PMC6842524 DOI: 10.1186/s40880-019-0416-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022] Open
Abstract
Background More than 25% of patients with solid cancers develop intracerebral metastases. Aside of surgery, radiation therapy (RT) is a mainstay in the treatment of intracerebral metastases. Postoperative fractionated stereotactic RT (FSRT) to the resection cavity of intracerebral metastases is a treatment of choice to reduce the risk of local recurrence. However, FSRT has to be delayed until a sufficient wound healing is attained; hence systemic therapy might be postponed. Neoadjuvant stereotactic radiosurgery (SRS) might offer advantages over adjuvant FSRT in terms of better target delineation and an earlier start of systemic chemotherapy. Here, we conducted a study to find the maximum tolerated dose (MTD) of neoadjuvant SRS for intracerebral metastases. Methods This is a single-center, phase I dose escalation study on neoadjuvant SRS for intracerebral metastases that will be conducted at the Klinikum rechts der Isar Hospital, Technical University of Munich. The rule-based traditional 3 + 3 design for this trial with 3 dose levels and 4 different cohorts depending on lesion size will be applied. The primary endpoint is the MTD for which no dose-limiting toxicities (DLT) occur. The adverse events of each participant will be evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 continuously during the study until the first follow-up visit (4–6 weeks after surgery). Secondary endpoints include local control rate, survival, immunological tumor characteristics, quality of life (QoL), CTCAE grade of late clinical, neurological, and neurocognitive toxicities. In addition to the intracerebral metastasis which is treated with neoadjuvant SRS and resection up to four additional intracerebral metastases can be treated with definitive SRS. Depending on the occurrence of DLT up to 72 patients will be enrolled. The recruitment phase will last for 24 months. Discussion Neoadjuvant SRS for intracerebral metastases offers potential advantages over postoperative SRS to the resection cavity, such as better target volume definition with subsequent higher efficiency of eliminating tumor cells, and lower damage to surrounding healthy tissue, and much-needed systemic chemotherapy could be initiated more rapidly. Trial registration The local ethical review committee of Technical University of Munich (199/18S) approved this study on September 05, 2018. This trial was registered on German Clinical Trials Register (DRKS00016613; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00016613) on January 29, 2019.
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Affiliation(s)
- Christian D Diehl
- Department of Radiation Oncology, Klinikum rechts der Isar Hospital, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany. .,Department of Radiation Sciences, Institute of Innovative Radiotherapy, 85764, Neuherberg, Germany.
| | - Ehab Shiban
- Department of Neurosurgery, Klinikum rechts der Isar Hospital, Technical University of Munich, 81675, Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Klinikum rechts der Isar Hospital, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.,Department of Radiation Sciences, Institute of Innovative Radiotherapy, 85764, Neuherberg, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar Hospital, Technical University of Munich, 81675, Munich, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, Klinikum rechts der Isar Hospital, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar Hospital, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Carmen Kessel
- Department of Radiation Oncology, Klinikum rechts der Isar Hospital, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar Hospital, Technical University of Munich, 81675, Munich, Germany
| | - Benedict Wiestler
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar Hospital, Technical University of Munich, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar Hospital, Technical University of Munich, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar Hospital, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.,Department of Radiation Sciences, Institute of Innovative Radiotherapy, 85764, Neuherberg, Germany
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Measurement of Active Motor Threshold Using a Dynamometer During Navigated Transcranial Magnetic Stimulation in a Patient with Postoperative Brain Tumor: Technical Note. World Neurosurg 2019; 133:42-48. [PMID: 31550542 DOI: 10.1016/j.wneu.2019.09.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/14/2019] [Accepted: 09/14/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Navigated transcranial magnetic stimulation (nTMS) is being used for different purposes in patients with brain tumors. However, the procedure requires a positive electrophysiological response. For patients with negative response in rest conditions, active motor threshold (AMT) may be used. However, sometimes it is difficult to obtain AMT measures owing to inability of the patient to sustain steady muscle contraction. Herein, we describe a simple method by using a hand dynamometer to obtain AMT measures during nTMS session. CASE DESCRIPTION A woman aged 68 years underwent total removal of a right frontal lobe oligodendroglioma World Health Organization grade II 15 years ago. Cranial magnetic resonance imaging during follow-up revealed local recurrence. In the postoperative period, she developed left upper limb paresis. A postoperative nTMS session was performed for motor electrophysiological evaluation. However, using the standard technique for AMT measurement, the patient was unable to perform sustained muscle contraction as required. A hand dynamometer was used. It allowed sustained muscle contraction for AMT measurement. A counter force for the index finger flexion, the hand support to stabilize hand joints, and a numerical screen serving for both the examiner and the patient as a feedback parameter may explain the success obtained with this simple device. CONCLUSIONS Although more studies are necessary to validate the method, the hand dynamometer should be considered for patients unable to sustain muscle contraction during AMT measurement.
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Kreidenhuber R, De Tiège X, Rampp S. Presurgical Functional Cortical Mapping Using Electromagnetic Source Imaging. Front Neurol 2019; 10:628. [PMID: 31249552 PMCID: PMC6584755 DOI: 10.3389/fneur.2019.00628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/28/2019] [Indexed: 02/03/2023] Open
Abstract
Preoperative localization of functionally eloquent cortex (functional cortical mapping) is common clinical practice in order to avoid or reduce postoperative morbidity. This review aims at providing a general overview of magnetoencephalography (MEG) and high-density electroencephalography (hdEEG) based methods and their clinical role as compared to common alternatives for functional cortical mapping of (1) verbal language function, (2) sensorimotor cortex, (3) memory, (4) visual, and (5) auditory cortex. We highlight strengths, weaknesses and limitations of these functional cortical mapping modalities based on findings in the recent literature. We also compare their performance relative to other non-invasive functional cortical mapping methods, such as functional Magnetic Resonance Imaging (fMRI), Transcranial Magnetic Stimulation (TMS), and to invasive methods like the intracarotid Amobarbital Test (WADA-Test) or intracranial investigations.
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Affiliation(s)
- Rudolf Kreidenhuber
- Department of Neurology, Christian-Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Xavier De Tiège
- Laboratoire de Cartographie Fonctionelle du Cerveau, ULB Neuroscience Institute, Université Libre de Bruxelles, Brussels, Belgium.,Department of Functional Neuroimaging, Service of Nuclear Medicine, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Stefan Rampp
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany.,Department of Neurosurgery, University Hospital Halle, Halle, Germany
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Fang X, Liu M, Lu C, Zhao Y, Liu X. Current status and potential application of navigated transcranial magnetic stimulation in neurosurgery: a literature review. Chin Neurosurg J 2019; 5:12. [PMID: 32922912 PMCID: PMC7398385 DOI: 10.1186/s41016-019-0159-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/25/2019] [Indexed: 12/13/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) is a noninvasive neurophysiologic technique that can stimulate the human brain. Positioning of the coil was often performed based merely on external landmarks on the head, meaning that the anatomical target in the cortex remains inaccurate. Navigated transcranial magnetic stimulation (nTMS) combines a frameless stereotactic navigational system and TMS coil and can provide a highly accurate delivery of TMS pulses with the guidance of imaging. Therefore, many novel utilities for TMS could be explored due to the ability of precise localization. Many studies have been published, which indicate nTMS enables presurgical functional mapping. This review aimed to provide a comprehensive literature review on nTMS, especially the principles and clinical applications of nTMS. All articles in PubMed with keywords of "motor mapping," "presurgical mapping," "navigated transcranial magnetic stimulation," and "language mapping" published from 2000 to 2018 were included in the study. Frequently cited publications before 2000 were also included. The most valuable published original and review articles related to our objective were selected. Motor mapping of nTMS is validated to be a trustful tool to recognize functional areas belonging to both normal and lesioned primary motor cortex. It can offer reliable mapping of speech and motor regions at cortex prior to operation and has comparable accuracy as direct electrical cortical stimulation. nTMS is a powerful tool for mapping of motor and linguistic function prior to operation, has high application value in neurosurgery and the treatment of neurological and psychiatric diseases, and has gained increasing acceptance in neurosurgical centers across the world.
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Affiliation(s)
- Xiaojing Fang
- Department of Neurology, Peking University International Hospital, 1 Life Science St, Changping District, Beijing, 102206 China
| | - Meige Liu
- Department of Neurology, Peking University People's Hospital, Beijing, 100044 China
| | - Changyu Lu
- Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 China
| | - Yuanli Zhao
- Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China.,Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 China
| | - Xianzeng Liu
- Department of Neurology, Peking University International Hospital, 1 Life Science St, Changping District, Beijing, 102206 China
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Raffa G, Scibilia A, Conti A, Ricciardo G, Rizzo V, Morelli A, Angileri FF, Cardali SM, Germanò A. The role of navigated transcranial magnetic stimulation for surgery of motor-eloquent brain tumors: a systematic review and meta-analysis. Clin Neurol Neurosurg 2019; 180:7-17. [DOI: 10.1016/j.clineuro.2019.03.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 01/08/2023]
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In Reply to the Letter to the Editor Regarding “First United Kingdom Experience of Navigated Transcranial Magnetic Stimulation in Preoperative Mapping of Brain Tumors”. World Neurosurg 2019; 125:551-552. [DOI: 10.1016/j.wneu.2019.01.288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 11/20/2022]
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Raffa G, Scibilia A, Conti A, Cardali SM, Rizzo V, Terranova C, Quattropani MC, Marzano G, Ricciardo G, Vinci SL, Germanò A. Multimodal Surgical Treatment of High-Grade Gliomas in the Motor Area: The Impact of the Combination of Navigated Transcranial Magnetic Stimulation and Fluorescein-Guided Resection. World Neurosurg 2019; 128:e378-e390. [PMID: 31029822 DOI: 10.1016/j.wneu.2019.04.158] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fluorescein-guided surgery of high-grade gliomas (HGGs) increases the extent of tumor resection but its efficacy has been questioned, especially for tumors located close to functional networks. In these cases, navigated transcranial magnetic stimulation (nTMS) may be used to plan and guide a safe resection. The aim of this study was to assess the impact of these techniques combined with intraoperative neurophysiologic mapping (IONM) to achieve the maximal safe resection of tumors located in the motor area. METHODS We collected data of patients operated using a multimodal combination of sodium fluorescein-guided resection, nTMS motor planning, and IONM for HGGs in the motor area. The nTMS planning accuracy, extent of resection, and postoperative motor and functional status were compared with a matched control group of patients with HGG operated on only by IONM-guided resection. RESULTS Forty-one patients treated by multimodal approach (group A) and 41 controls (group B) were included. The nTMS-based planning reliably identified the tumor/motor pathway spatial relationship (accuracy, 92.68%). We obtained in group A versus controls a higher gross total resection rate (73.17% vs. 51.22%; P = 0.04), and a reduction of cases with new permanent motor deficits (9.75% vs. 29.27%; P = 0.04) or Karnofsky Performance Status worsening (12.19% vs. 31.71%; P = 0.03). CONCLUSIONS This study supports the role of the combination of sodium fluorescein-guided resection and nTMS-based planning for surgery of HGGs close to the motor pathway. This multimodal approach in combination with IONM may lead to customized preoperative planning, increased extent of resection, and improved functional outcome, compared with standard IONM-guided surgery.
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Affiliation(s)
- Giovanni Raffa
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy.
| | - Antonino Scibilia
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy; Division of Neurosurgery, University of Strasbourg, Strasbourg, France
| | - Alfredo Conti
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | | | - Vincenzo Rizzo
- Division of Neurology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Carmen Terranova
- Division of Neurology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Giuseppina Marzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Ricciardo
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Sergio Lucio Vinci
- Division of Neuroradiology, BIOMORF Department, University of Messina, Messina, Italy
| | - Antonino Germanò
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
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30
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Lavrador JP, Kandeel H, Patel S, Jung J, Acharya S, Giamouriadis A, Ashkan K, Bhangoo R, Vergani F. Navigated Transcranial Magnetic Stimulation in Patient with Cranioplasty in Situ: Safe and Accurate Procedure. World Neurosurg 2018; 122:176-179. [PMID: 30296623 DOI: 10.1016/j.wneu.2018.09.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Navigated transcranial magnetic stimulation (nTMS) is a nonsurgical mapping technique used in mapping of motor and language eloquent areas within and/or surrounding brain tumors. Previous reports support this as a safe technique with minor side effects associated with minor headaches and discomfort around the stimulation area. Currently there are no published reports concerning the accuracy and safety of this procedure in patients with a titanium cranioplasty in situ. CASE PRESENTATION A 59-year-old lady was diagnosed with a recurrent glioma in the context of increasing seizure frequency, left-sided numbness, and weakness. She was diagnosed with a World Health Organization grade 2 oligodendroglioma 10 years before her presentation, which was initially treated with radiotherapy and then surgical resection of this lesion 5 years later. The procedure was complicated with a wound infection, treated with a craniectomy and wound washout, followed by a titanium cranioplasty. Before proceeding with surgery for recurrence, nTMS was performed for motor mapping. No complications were identified. She underwent a craniotomy for tumor resection with aminolevulinic acid HCl (Gliolan), and the tumor was completely removed. Intraoperatively, the direct cortical stimulation correlated with the preoperative nTMS. The pathologic diagnosis on recurrence was an anaplastic oligodendroglioma grade III, and the patient is currently undergoing adjuvant chemotherapy. CONCLUSION This report confirms that nTMS is a safe and accurate procedure in patients who have a titanium cranioplasty in situ.
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Affiliation(s)
| | - Hussein Kandeel
- Department of Neurosurgery, King's College Hospital, London, United Kingdom.
| | - Sabina Patel
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - Josephine Jung
- Neurosciences Clinical Trials Unit, King's College Hospital, London, United Kingdom
| | - Shami Acharya
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | | | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - Ranjeev Bhangoo
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - Francesco Vergani
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
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31
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Folyovich A, Varga V, Várallyay G, Kozák L, Bakos M, Scheidl E, Béres-Molnár KA, Kajdácsi Z, Bereczki D. A case report of isolated distal upper extremity weakness due to cerebral metastasis involving the hand knob area. BMC Cancer 2018; 18:947. [PMID: 30285670 PMCID: PMC6171188 DOI: 10.1186/s12885-018-4857-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 09/26/2018] [Indexed: 12/05/2022] Open
Abstract
Background Unilateral weakness of an upper extremity is most frequently caused by traumatic nerve injury or compression neuropathy. In rare cases, lesion of the central nervous system may result in syndromes suggesting peripheral nerve damage by the initial examination. Pseudoperipheral hand palsy is the best known of these, most frequently caused by a small lesion in the contralateral motor cortex of the brain. The ‘hand knob’ area refers to a circumscribed region in the precentral gyrus of the posterior frontal lobe, the lesion of which leads to isolated weakness of the upper extremity mimicking peripheral nerve damage. The etiology of this rare syndrome is almost exclusively related to an embolic infarction. Case presentation We present the case of a 70-year-old male patient with isolated left sided upper extremity weakness and clumsiness without sensory disturbance suggesting a lesion of the radial nerve. Nerve conduction studies had normal results excluding peripheral nerve damage. Neuroimaging (cranial CT and MRI) detected 3 space occupying lesions, one of them in the right precentral gyrus. An irregularly shaped tumor was found by CT in the left lung with multiple associated lymph node conglomerates. The metastasis from this mucinous tubular adenocarcinoma with solid anaplastic parts to the ‘hand knob’ area was responsible for the first clinical sign related to the pulmonary malignancy. Conclusions Pseudoperipheral palsy of the upper extremity is not necessarily the consequence of an embolic stroke. If nerve conduction studies have normal results, neuroimaging – preferably MRI – should be performed, as lesion in the hand-knob area of the precentral gyrus can also be caused by a malignancy.
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Affiliation(s)
- András Folyovich
- Department of Neurology and Stroke Center, Szent János Hospital, Budapest, Hungary
| | - Viktória Varga
- Department of Neurology and Stroke Center, Szent János Hospital, Budapest, Hungary.,Department of Neurology, Uzsoki Hospital, Budapest, Hungary
| | | | - Lajos Kozák
- MR Research Centre, Semmelweis University, Budapest, Hungary
| | - Mária Bakos
- Department of Diagnostic Radiology, Szent János Hospital, Budapest, Hungary
| | - Erika Scheidl
- Department of Neurology and Stroke Center, Szent János Hospital, Budapest, Hungary.,Department of Neurology, Semmelweis University, Balassa u. 6., H- 1083, Budapest, Hungary
| | | | - Zita Kajdácsi
- Korányi National Institute for Tuberculosis and Pulmonology, Budapest, Hungary
| | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Balassa u. 6., H- 1083, Budapest, Hungary.
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32
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Schwendner MJ, Sollmann N, Diehl CD, Oechsner M, Meyer B, Krieg SM, Combs SE. The Role of Navigated Transcranial Magnetic Stimulation Motor Mapping in Adjuvant Radiotherapy Planning in Patients With Supratentorial Brain Metastases. Front Oncol 2018; 8:424. [PMID: 30333959 PMCID: PMC6176094 DOI: 10.3389/fonc.2018.00424] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/11/2018] [Indexed: 12/05/2022] Open
Abstract
Purpose: In radiotherapy (RT) of brain tumors, the primary motor cortex is not regularly considered in target volume delineation, although decline in motor function is possible due to radiation. Non-invasive identification of motor-eloquent brain areas is currently mostly restricted to functional magnetic resonance imaging (fMRI), which has shown to lack precision for this purpose. Navigated transcranial magnetic stimulation (nTMS) is a novel tool to identify motor-eloquent brain areas. This study aims to integrate nTMS motor maps in RT planning and evaluates the influence on dosage modulations in patients harboring brain metastases. Materials and Methods: Preoperative nTMS motor maps of 30 patients diagnosed with motor-eloquent brain metastases were fused with conventional planning imaging and transferred to the RT planning software. RT plans of eleven patients were optimized by contouring nTMS motor maps as organs at risk (OARs). Dose modulation analyses were performed using dose-volume histogram (DVH) parameters. Results: By constraining the dose applied to the nTMS motor maps outside the planning target volume (PTV) to 15 Gy, the mean dose (Dmean) to the nTMS motor maps was significantly reduced by 18.1% from 23.0 Gy (16.9–30.4 Gy) to 18.9 Gy (13.5–28.8 Gy, p < 0.05). The Dmean of the PTV increased by 0.6 ± 0.3 Gy (1.7%). Conclusion: Implementing nTMS motor maps in standard RT planning is feasible in patients suffering from intracranial metastases. A significant reduction of the dose applied to the nTMS motor maps can be achieved without impairing treatment doses to the PTV. Thus, nTMS might provide a valuable tool for safer application of RT in patients harboring motor-eloquent brain metastases.
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Affiliation(s)
- Maximilian J Schwendner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Nico Sollmann
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Christian D Diehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Department of Radiation Sciences, Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Munich, Germany
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Thon N, Kreth FW, Tonn JC. The role of surgery for brain metastases from solid tumors. HANDBOOK OF CLINICAL NEUROLOGY 2018; 149:113-121. [PMID: 29307348 DOI: 10.1016/b978-0-12-811161-1.00008-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Surgery, stereotactic radiosurgery, radiotherapy, and chemotherapy including novel targeted therapy strategies and any combination thereof as well as supportive care are the key elements for treatment of brain metastases. Goals of microsurgery are to obtain tissue samples for histologic diagnosis (particularly in case of uncertainty about the unknown primary tumor but also in the context of future targeted therapies), to relieve burden from space-occupying effects, to improve local tumor control, and to prolong overall survival. Complete surgical resection improves local tumor control and may even affect overall survival. Stereotactic radiosurgery is an equal effective alternative for metastases up to 3 cm in diameter, especially in highly eloquent or deep seated location. Gross total resection (as defined by immediate postoperative MRI) does not necessarily have to be combined with whole brain radiotherapy (WBRT), at least for patients with good performance status and controlled systemic disease. Particularly in cases of incomplete resections, focal irradiation or radiosurgery of the resection cavity or tumor remnant rather than WBRT may be attempted.
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Affiliation(s)
- Niklas Thon
- Department of Neurosurgery, University of Munich LMU, Munich, Germany
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Pintea B, Baumert B, Kinfe TM, Gousias K, Parpaley Y, Boström JP. Early motor function after local treatment of brain metastases in the motor cortex region with stereotactic radiotherapy/radiosurgery or microsurgical resection: a retrospective study of two consecutive cohorts. Radiat Oncol 2017; 12:177. [PMID: 29132382 PMCID: PMC5683312 DOI: 10.1186/s13014-017-0917-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/31/2017] [Indexed: 11/25/2022] Open
Abstract
Background We compared the functional outcome and influential factors of two standard treatment modalities for central cerebral metastases: electrophysiological-controlled microsurgical resection (MSR) and stereotactic radiotherapy/stereotactic radiosurgery (SRT/SRS). Methods We performed a database search for central metastasis treatments during the period from January 2008 to September 2012 in two clinical registers: 1) register for intraoperative neuromonitoring (Department of Neurosurgery), and 2) prospective database for SRT/SRS (Department of Radiotherapy). Neurological status before and after treatment, Karnofsky performance index (KPI), histology, tumor localization and volume, and oncological status were standardized and pooled together for analysis. Muscle strength was graded on a scale of 0–5. Results We identified 27 MSR and 41 SRT/SRS cases from 68 treatments. The MSR-treated patients had significant less muscle strength in the upper and lower extremities before and after the treatment as compared to the patients receiving SRT/SRS. Muscle strength of the extremities did not change for patients receiving SRT/SRS, while MSR patients had significant improvement in lower extremity muscle strength (p = 0.05) and a non-significant improvement in the upper extremities. MSR showed significant improvement in hemiparesis as compared to radiotherapy, but this was accompanied with a significant deterioration of extremity muscle strength after surgery, as compared to SRT/SRS (improvement p = 0.04, deterioration p = 0.10). Conclusion Electrophysiologically guided microsurgery of central metastases had a significantly better functional outcome regarding hemiparesis. However, there was also a trend for less secondary neurological deterioration after SRT/SRS. Trial registration ISRCTN81776764. Retrospectively Registered 27 July 2017.
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Affiliation(s)
- Bogdan Pintea
- Department of Neurosurgery, University Hospital of Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany. .,Department of Neurosurgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
| | - Brigitta Baumert
- Department of Radiosurgery and Stereotactic Radiotherapy, MediClin Robert Janker Clinic and MediClin MVZ Bonn, Villenstrasse 8, 53129, Bonn, Germany
| | - Thomas Mehari Kinfe
- Department of Neurosurgery, University Hospital of Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Konstantinos Gousias
- Department of Neurosurgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Yaroslav Parpaley
- Department of Neurosurgery, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, In der Schornau 23-25, 44892, Bochum, Germany
| | - Jan Patrick Boström
- Department of Neurosurgery, University Hospital of Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany.,Department of Radiosurgery and Stereotactic Radiotherapy, MediClin Robert Janker Clinic and MediClin MVZ Bonn, Villenstrasse 8, 53129, Bonn, Germany
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35
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Krieg SM, Lioumis P, Mäkelä JP, Wilenius J, Karhu J, Hannula H, Savolainen P, Lucas CW, Seidel K, Laakso A, Islam M, Vaalto S, Lehtinen H, Vitikainen AM, Tarapore PE, Picht T. Protocol for motor and language mapping by navigated TMS in patients and healthy volunteers; workshop report. Acta Neurochir (Wien) 2017; 159:1187-1195. [PMID: 28456870 DOI: 10.1007/s00701-017-3187-z] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/06/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Navigated transcranial magnetic stimulation (nTMS) is increasingly used for preoperative mapping of motor function, and clinical evidence for its benefit for brain tumor patients is accumulating. In respect to language mapping with repetitive nTMS, literature reports have yielded variable results, and it is currently not routinely performed for presurgical language localization. The aim of this project is to define a common protocol for nTMS motor and language mapping to standardize its neurosurgical application and increase its clinical value. METHODS The nTMS workshop group, consisting of highly experienced nTMS users with experience of more than 1500 preoperative nTMS examinations, met in Helsinki in January 2016 for thorough discussions of current evidence and personal experiences with the goal to recommend a standardized protocol for neurosurgical applications. RESULTS nTMS motor mapping is a reliable and clinically validated tool to identify functional areas belonging to both normal and lesioned primary motor cortex. In contrast, this is less clear for language-eloquent cortical areas identified by nTMS. The user group agreed on a core protocol, which enables comparison of results between centers and has an excellent safety profile. Recommendations for nTMS motor and language mapping protocols and their optimal clinical integration are presented here. CONCLUSION At present, the expert panel recommends nTMS motor mapping in routine neurosurgical practice, as it has a sufficient level of evidence supporting its reliability. The panel recommends that nTMS language mapping be used in the framework of clinical studies to continue refinement of its protocol and increase reliability.
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Affiliation(s)
- Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität Ismaninger Str. 22, 81675, Munich, Germany.
| | - Pantelis Lioumis
- BioMag Laboratory, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029, Helsinki, Finland
| | - Jyrki P Mäkelä
- BioMag Laboratory, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029, Helsinki, Finland
| | - Juha Wilenius
- Department of Clinical Neurophysiology, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029, Helsinki, Finland
| | - Jari Karhu
- Nexstim Plc, Elimäenkatu 9 B, 00510, Helsinki, Finland
| | - Henri Hannula
- Nexstim Plc, Elimäenkatu 9 B, 00510, Helsinki, Finland
- Department of Biomedical Engineering and Computational Science, Aalto University, Espoo, Finland
| | | | - Carolin Weiss Lucas
- Center of Neurosurgery, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Kathleen Seidel
- Department of Neurosurgery Inselspital, Bern University Hospital University of Berne, 3010, Berne, Switzerland
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Hospital and Clinical Neurosciences, Neurosurgery, University of Helsinki, P.O. Box 266, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Mominul Islam
- Department of Clinical Neurophysiology (R2:01), Karolinska University Hospital, 17176, Solna, Stockholm, Sweden
| | - Selja Vaalto
- Department of Clinical Neurophysiology, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029, Helsinki, Finland
| | - Henri Lehtinen
- Epilepsy Unit, Department of Pediatric Neurology, Helsinki University Central Hospital, Lastenlinnantie 2 PL 280, HUS, 00029, Helsinki, Finland
| | - Anne-Mari Vitikainen
- BioMag Laboratory, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, HUS, 00029, Helsinki, Finland
| | - Phiroz E Tarapore
- Department of Neurological Surgery, University of California, 505 Parnassus Ave, Moffitt, San Francisco, CA, 94143, USA
| | - Thomas Picht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Augustenburger Platz 1, 13353, Berlin, Germany
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36
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Sollmann N, Meyer B, Krieg SM. Implementing Functional Preoperative Mapping in the Clinical Routine of a Neurosurgical Department: Technical Note. World Neurosurg 2017; 103:94-105. [PMID: 28377253 DOI: 10.1016/j.wneu.2017.03.114] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Navigated transcranial magnetic stimulation (nTMS) is increasingly being used for mapping of various brain functions and in nTMS-based tractography in neurosurgical departments worldwide. When a department begins using nTMS data in the clinical workflow, smooth integration into the hospital's existing infrastructure is mandatory. Standardized approaches for this beyond the mapping or tractography procedures themselves have not yet been described. METHODS To create an effective workflow for neurosurgical nTMS mapping, we present the findings of our 7 years of experience and progressive integration into the clinical routine. RESULTS After indication for mapping is made, the workflow starts with patient admission and includes all preoperative steps until tumor resection. Importantly, only standard software and devices were used, enabling new centers to easily integrate data derived from nTMS mapping and nTMS-based tractography into their hospital's infrastructure. Registration of the patient, appointment planning, and documentation of results of the nTMS procedures within the hospital information system (HIS) can be achieved by a novel tailored software mask. As another important part of the workflow, nTMS data are imported into the picture archiving and communication system (PACS) via PACS integrator software. In addition, for surgical planning including nTMS-based tractography, nTMS data can be effectively included in surgical neuronavigation software. CONCLUSIONS Optimized integration of nTMS data can be achieved using a standardized workflow. The seamless integration and availability of nTMS data are crucial to the acceptance of these data in the clinical routine. This optimized workflow can serve as a guide for centers beginning to use nTMS data in patient care.
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Affiliation(s)
- Nico Sollmann
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; TUM Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; TUM Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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