Is non-awake surgery for supratentorial adult low-grade glioma treatment still feasible?

OBJECTIVEThe authors conducted a study to determine whether cognitive functioning of patients with presumed low-grade glioma is associated with white matter (WM) tract changes.METHODSThe authors included 77 patients with presumed low-grade glioma who underwent awake surgery between 2005 and 2013. Diffusion tensor imaging with deterministic tractography was performed preoperatively to identify the arcuate, inferior frontooccipital, and uncinate fasciculi and to obtain the mean fractional anisotropy (FA) and mean diffusivity per tract. All patients were evaluated preoperatively using an extensive neuropsychological protocol that included assessments of the language, memory, and attention/executive function domains. Linear regression models were used to analyze each cognitive domain and each diffusion tensor imaging metric of the 3 WM tracts.RESULTSSignificant correlations (corrected for multiple testing) were found between FA of the arcuate fasciculus and results of the repetition test for the language domain (β = 0.59, p < 0.0001) and between FA of the inferior frontooccipital fasciculus and results of the imprinting test for the memory domain (β = −0.55, p = 0.002) and the attention test for the attention and executive function domain (β = −0.62, p = 0.006).CONCLUSIONSIn patients with glioma, language deficits in repetition of speech, imprinting, and attention deficits are associated with changes in the microarchitecture of the arcuate and inferior frontooccipital fasciculi.

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Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice

Neurosurgical FOCUS ◽

10.3171/2009.12.focus09237 ◽

2010 ◽

Vol 28 (2) ◽

pp. E7 ◽

Cited By ~ 186

Author(s):

Andrea Szelényi ◽

Lorenzo Bello ◽

Hugues Duffau ◽

Enrica Fava ◽

Guenther C. Feigl ◽

...

Keyword(s):

Electrical Stimulation ◽

Cognitive Function ◽

Low Grade Glioma ◽

Awake Craniotomy ◽

Awake Surgery ◽

Low Grade ◽

Glioma Surgery ◽

Neurological Sequelae ◽

Intraoperative Electrical Stimulation ◽

Methodological Aspects

There is increasing evidence that the extent of tumor removal in low-grade glioma surgery is related to patient survival time. Thus, the goal of resecting the largest amount of tumor possible without leading to permanent neurological sequelae is a challenge for the neurosurgeon. Electrical stimulation of the brain to detect cortical and axonal areas involved in motor, language, and cognitive function and located within the tumor or along its boundaries has become an essential tool in combination with awake craniotomy. Based on a literature review, discussions within the European Low-Grade Glioma Group, and illustrative clinical experience, the authors of this paper provide an overview for neurosurgeons, neurophysiologists, linguists, and anesthesiologists as well as those new to the field about the stimulation techniques currently being used for mapping sensorimotor, language, and cognitive function in awake surgery for low-grade glioma. The paper is intended to help the understanding of these techniques and facilitate a comparison of results between users.

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Awake Mapping Optimizes the Extent of Resection for Low-Grade Gliomas in Eloquent Areas

Neurosurgery ◽

10.1227/01.neu.0000369514.74284.78 ◽

2010 ◽

Vol 66 (6) ◽

pp. 1074-1084 ◽

Cited By ~ 149

Author(s):

Alessandro De Benedictis ◽

Sylvie Moritz-Gasser ◽

Hugues Duffau

Keyword(s):

Extent Of Resection ◽

Low Grade Glioma ◽

Awake Surgery ◽

Low Grade ◽

Functional Sites ◽

Social Lives ◽

Eloquent Areas ◽

Functional Regions ◽

First Time

Abstract BACKGROUND Awake craniotomy with intraoperative electrical mapping is a reliable method to minimize the risk of permanent deficit during surgery for low-grade glioma located within eloquent areas classically considered inoperable. However, it could be argued that preservation of functional sites might lead to a lesser degree of tumor removal. To the best of our knowledge, the extent of resection has never been directly compared between traditional and awake procedures. OBJECTIVE We report for the first time a series of patients who underwent 2 consecutive surgeries without and with awake mapping. METHODS Nine patients underwent surgery for a low-grade glioma in functional sites under general anesthesia in other institutions. The resection was subtotal in 3 cases and partial in 6 cases. There was a postoperative worsening in 3 cases. We performed a second surgery in the awake condition with intraoperative electrostimulation. The resection was performed according to functional boundaries at both the cortical and subcortical levels. RESULTS Postoperative magnetic resonance imaging showed that the resection was complete in 5 cases and subtotal in 4 cases (no partial removal) and that it was improved in all cases compared with the first surgery (P = .04). There was no permanent neurological worsening. Three patients improved compared with the presurgical status. All patients returned to normal professional and social lives. CONCLUSION Our results demonstrate that awake surgery, known to preserve the quality of life in patients with low-grade glioma, is also able to significantly improve the extent of resection for lesions located in functional regions.

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Analysis of Legal, Cultural, and Socioeconomic Parameters in Low-Grade Glioma Management: Variability Across Countries and Implications for Awake Surgery

World Neurosurgery ◽

10.1016/j.wneu.2018.08.155 ◽

2018 ◽

Vol 120 ◽

pp. 47-53 ◽

Cited By ~ 2

Author(s):

Clarissa Vanacôr ◽

Hugues Duffau

Keyword(s):

Low Grade Glioma ◽

Awake Surgery ◽

Low Grade

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Reply to: Letter to the Editor Regarding Anesthesia Management for Low-Grade Glioma Awake Surgery: A European Low-Grade Glioma Network Survey

Acta Neurochirurgica ◽

10.1007/s00701-020-04371-0 ◽

2020 ◽

Vol 162 (7) ◽

pp. 1723-1724

Author(s):

Catarina Madadaki ◽

◽

Sylvie Aubrun ◽

Lorenzo Bello ◽

Hugues Duffau ◽

...

Keyword(s):

Low Grade Glioma ◽

Awake Surgery ◽

Low Grade ◽

Anesthesia Management ◽

Letter To The Editor

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Awake Surgery for Left Posterior Insular Low-Grade Glioma Through the Parietorolandic Operculum: The Need to Preserve the Functional Connectivity. A Case Series

Frontiers in Surgery ◽

10.3389/fsurg.2021.824003 ◽

2022 ◽

Vol 8 ◽

Author(s):

Hugues Duffau

Keyword(s):

White Matter ◽

Functional Connectivity ◽

Case Series ◽

Low Grade Glioma ◽

Awake Surgery ◽

Cortical Mapping ◽

Lateral Part ◽

Low Grade ◽

Left Posterior ◽

Transcortical Approach

Objective: Surgical approach to low-grade glioma (LGG) involving the posterior insula is challenging, especially in the left hemisphere, with a high risk of sensorimotor, language, or visual deterioration. In this study, a case series of 5 right-handed patients harboring a left posterior insular LGG is reported, by detailing a transcorticosubcortical approach.Method: The five surgeries were achieved in awake patients using cortical and axonal electrostimulation mapping. The glioma was removed through the left rolandic and/or parietal opercula, with preservation of the subcortical connectivity.Results: The cortical mapping was positive in the five patients, enabling the selection of an optimal transcortical approach, via the anterolateral supramarginal gyrus in four patients and/or via the lateral retrocentral gyrus in three cases (plus through the left superior temporal gyrus in one case). Moreover, the white matter tracts were identified in all cases, i.e., the lateral part of the superior longitudinal fasciculus (five cases), the arcuate fasciculus (four cases), the thalamocortical somatosensory pathways (four cases), the motor pathway (one case), the semantic pathway (three cases), and the optic tract (one case). Complete resection of the LGG was achieved in two patients and near-total resection in three patients. There were no postoperative permanent sensorimotor, language, or visual deficits.Conclusion: A transcortical approach through the parietorolandic operculum in awake patients represents safe and effective access to the left posterior insular LGG. Detection and preservation of the functional connectivity using direct electrostimulation of the white matter bundles are needed in this cross-road brain region to prevent otherwise predictable postsurgical impairments.

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Low-grade glioma

Oxford Textbook of Neurological Surgery ◽

10.1093/med/9780198746706.003.0006 ◽

2019 ◽

pp. 75-88 ◽

Cited By ~ 1

Author(s):

Thomas Santarius ◽

Lorenzo Bello ◽

Hugues Duffau

Keyword(s):

Overall Survival ◽

Oncological Outcome ◽

Low Grade Glioma ◽

Awake Surgery ◽

Low Grade ◽

Electrical Brain Stimulation ◽

Functional Balance ◽

Anaplastic Transformation ◽

Functional Boundary

Diffuse low-grade glioma affect young people in their twenties to forties. The management of this disease is tailored to the needs of each individual patient, taking into account their immediate, medium-, and long-term social and professional roles, personal aspirations, and interests, aiming to achieve optimum onco-functional balance. This starts with measurement of velocity of growth, for which a minimum of two scans with an interval of 2–3 months are obtained. The aim of surgery is resection to predefined functional boundary as this achieves most accurate histological diagnosis, best oncological outcome (prolonged time to anaplastic transformation and overall survival) and preserves function. Awake surgery with electrical brain stimulation mapping allows maximizing the degree of resection and minimize the risk of neurological deficit. Value of repeated surgeries as well as radiotherapy, chemotherapy, and molecular markers, such as IDH1 in the management of diffuse low-grade gliomas, is discussed.

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Return to Work Following Surgery for Incidental Diffuse Low-Grade Glioma: A Prospective Series With 74 Patients

Neurosurgery ◽

10.1093/neuros/nyz513 ◽

2019 ◽

Vol 87 (4) ◽

pp. 720-729 ◽

Cited By ~ 5

Author(s):

Sam Ng ◽

Guillaume Herbet ◽

Sylvie Moritz-Gasser ◽

Hugues Duffau

Keyword(s):

Return To Work ◽

Extent Of Resection ◽

Low Grade Glioma ◽

High Rate ◽

Awake Surgery ◽

Prophylactic Surgery ◽

Low Grade ◽

Oncological Treatment ◽

Asymptomatic Patients

Abstract BACKGROUND Therapeutic strategy concerning incidental low-grade glioma (ILGG) is still debated. Early “prophylactic” surgery has been proposed in asymptomatic patients with favorable neurological and oncological outcomes. OBJECTIVE To assess postoperative ability to resume employment following awake surgery in asymptomatic ILGG patients. To assess extent of resection (EOR), timeline for adjuvant oncological treatment, and survival. METHODS A total of 74 patients with ILGG who underwent awake surgery with intraoperative mapping were prospectively included, with a minimum follow-up of 12 mo. All clinicoradiological data were collected, and statistical correlations with return to work (RTW) were performed. RESULTS A total of 66 patients (97.1%) among 68 patients with preoperative professional activities resumed their employment including 62 (91.2%) within 12 mo. Mean time before RTW was 6.8 mo (median: 6 mo, range: 1-36). Two patients experienced seizure-related legal issues impacting their RTW. Clinicoradiological features did not correlate with RTW apart from postoperative seizures (P = .02). Mean EOR was 95.7%. A total of 43 patients (58.1%) underwent supratotal/total resections. All patients recovered from transient deficits at 3 mo. No patients received consecutive adjuvant treatment. A total of 24 patients (32.4%) were reoperated, 24 patients received chemotherapy, and 7 patients (9.5%) received radiotherapy, on average 73.1 mo after surgery. Mean follow-up was 67 mo (range 12-240). Four patients (5.4%) died during the follow-up. CONCLUSION We observed a high rate of RTW (97.1%, including 91.2% within 12 mo) after awake surgery in ILGG patients. Delayed resumption of work was due to employer not clearing them for RTW, personal choice, and, in rare occasions, related to seizures.

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