Awake surgery for skills preservation during a sensory area tumor resection in a clarinet player

Abstract BACKGROUND Maximal safe resection of brain tumors affecting language areas has been a matter of increasing interest worldwide in the last decades. Functional MRI, tractography, and awake cranial surgery are standard procedures in our department since 2006. The aim of this study was to describe our experience in a series of 58 patients who underwent awake cranial surgery with intraoperative language mapping. METHODS Retrospective study of 58 adult patients who underwent awake surgery for brain tumors between January 2006 and January 2021. Preoperative neuropsychological assessment served as inclusion criteria. Language was evaluated according to the BDAE (Boston diagnostic aphasia examination) and WAB (Western aphasia battery) and strength according to the MRC (Medical Research Council) motor scale in the preoperative, immediate postoperative, and 3-months follow up. Functional MRI and tractography depicting white-matter tracts, neuronavigation, cortical and subcortical stimulation were performed in all cases. Conscious sedation was the anesthetic technique (propofol, fentanyl, and NSAIDs). Minimum follow-up was 6 months. FINDINGS The average age was 35 years (16–74). The anatomopathological findings were: low-grade glioma in 75,8% (n = 44), high-grade glioma in 15,6% (n = 9) and others in 8,6% (n = 5). No complications were registered during postoperative course. At the immediate postoperative evaluation 65% of patients presented with speech disturbances but at the 3-months follow up speech recovery was observed in all cases. Only 1 patient remained with moderate aphasia. mRS score at 3- months follow up was ≤ 1 in 96% of patients. Two patients had a persistent moderate hemiparesis. CONCLUSION Tumor resection in awake patients showed to be a safe procedure, and well tolerated by the patients. Preoperative planning of anatomical and functional aspects and intraoperative neurophysiological assessment are the cornerstones for pursuing maximal safe resection.

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History of awake mapping and speech and language localization: from modules to networks

Neurosurgical FOCUS ◽

10.3171/2019.7.focus19347 ◽

2019 ◽

Vol 47 (3) ◽

pp. E4 ◽

Cited By ~ 1

Author(s):

Shervin Rahimpour ◽

Michael M. Haglund ◽

Allan H. Friedman ◽

Hugues Duffau

Keyword(s):

Large Scale ◽

Tumor Resection ◽

Historical Review ◽

Awake Surgery ◽

Speech And Language ◽

Cortical Organization ◽

History Of ◽

Mapping Techniques ◽

Large Scale Networks ◽

Subcortical Mapping

Lesion-symptom correlations shaped the early understanding of cortical localization. The classic Broca-Wernicke model of cortical speech and language organization underwent a paradigm shift in large part due to advances in brain mapping techniques. This initially started by demonstrating that the cortex was excitable. Later, advancements in neuroanesthesia led to awake surgery for epilepsy focus and tumor resection, providing neurosurgeons with a means of studying cortical and subcortical pathways to understand neural architecture and obtain maximal resection while avoiding so-called critical structures. The aim of this historical review is to highlight the essential role of direct electrical stimulation and cortical-subcortical mapping and the advancements it has made to our understanding of speech and language cortical organization. Specifically, using cortical and subcortical mapping, neurosurgeons shifted from a localist view in which the brain is composed of rigid functional modules to one of dynamic and integrative large-scale networks consisting of interconnected cortical subregions.

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Preserving executive functions in nondominant frontal lobe glioma surgery: an intraoperative tool

Journal of Neurosurgery ◽

10.3171/2018.4.jns18393 ◽

2019 ◽

Vol 131 (2) ◽

pp. 474-480 ◽

Cited By ~ 8

Author(s):

Guglielmo Puglisi ◽

Tommaso Sciortino ◽

Marco Rossi ◽

Antonella Leonetti ◽

Luca Fornia ◽

...

Keyword(s):

Executive Functions ◽

Frontal Lobe ◽

Brain Mapping ◽

Tumor Resection ◽

Awake Surgery ◽

Tumor Removal ◽

Motor Functions ◽

Inferior Margin ◽

Functional Integrity ◽

The Impact

OBJECTIVEThe goal of surgery for gliomas is maximal tumor removal while preserving the patient’s full functional integrity. At present during frontal tumor removal, this goal is mostly achieved, although the risk of impairing the executive functions (EFs), and thus the quality of life, remains significant. The authors investigated the accuracy of an intraoperative version of the Stroop task (iST), adapted for intraoperative mapping, to detect EF-related brain sites by evaluating the impact of the iST brain mapping on preserving functional integrity following a maximal tumor resection.METHODSForty-five patients with nondominant frontal gliomas underwent awake surgery; brain mapping was used to establish the functional boundaries for the resection. In 18 patients language, praxis, and motor functions, but not EFs (control group), were mapped intraoperatively at the cortical-subcortical level. In 27 patients, in addition to language, praxis, and motor functions, EFs were mapped with the iST at the cortical-subcortical level (Stroop group). In both groups the EF performance was evaluated preoperatively, at 7 days and 3 months after surgery.RESULTSThe iST was successfully administered in all patients. Consistent interferences, such as color-word inversion/latency, were obtained by stimulating precise white matter sites below the inferior and middle frontal gyri, anterior to the insula and over the putamen, and these were used to establish the posterior functional limit of the resection. Procedures implemented with iST dramatically reduced the EF deficits at 3 months. The EOR was similar in Stroop and control groups.CONCLUSIONSBrain mapping with the iST allows identification and preservation of the frontal lobe structures involved in inhibition of automatic responses, reducing the incidence of postoperative EF deficits and enhancing the further posterior and inferior margin of tumor resection.

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Intraoperative Motor Symptoms during Brain Tumor Resection in the Supplementary Motor Area (SMA) without Positive Mapping during Awake Surgery

Neurologia medico-chirurgica ◽

10.2176/nmc.oa.2014-0343 ◽

2015 ◽

Vol 55 (5) ◽

pp. 442-450 ◽

Cited By ~ 10

Author(s):

Riho NAKAJIMA ◽

Mitsutoshi NAKADA ◽

Katsuyoshi MIYASHITA ◽

Masashi KINOSHITA ◽

Hirokazu OKITA ◽

...

Keyword(s):

Brain Tumor ◽

Supplementary Motor Area ◽

Tumor Resection ◽

Motor Area ◽

Awake Surgery ◽

Motor Symptoms ◽

Positive Mapping ◽

Brain Tumor Resection

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Preoperative functional MRI use in neurooncology patients: a clinician survey

Neurosurgical FOCUS ◽

10.3171/2019.11.focus19779 ◽

2020 ◽

Vol 48 (2) ◽

pp. E11 ◽

Cited By ~ 2

Author(s):

Brittany M. Stopa ◽

Joeky T. Senders ◽

Marike L. D. Broekman ◽

Mark Vangel ◽

Alexandra J. Golby

Keyword(s):

Brain Tumor ◽

Functional Mri ◽

Preoperative Planning ◽

Adult Population ◽

Tumor Resection ◽

Final Analysis ◽

High Grade Glioma ◽

Awake Surgery ◽

Planning Tool ◽

Intraoperative Mapping

OBJECTIVEFunctional MRI (fMRI) is increasingly being investigated for use in neurosurgical patient care. In the current study, the authors characterize the clinical use of fMRI by surveying neurosurgeons’ use of and attitudes toward fMRI as a surgical planning tool in neurooncology patients.METHODSA survey was developed to inquire about clinicians’ use of and experiences with preoperative fMRI in the neurooncology patient population, including example case images. The survey was distributed to all neurosurgical departments with a residency program in the US.RESULTSAfter excluding incomplete surveys and responders that do not use fMRI (n = 11), 50 complete responses were included in the final analysis. Responders were predominantly from academic programs (88%), with 20 years or more in practice (40%), with a main area of practice in neurooncology (48%) and treating an adult population (90%). All 50 responders currently use fMRI in neurooncology patients, mostly for low- (94%) and high-grade glioma (82%). The leading decision factors for ordering fMRI were location of mass in dominant hemisphere, location in a functional area, motor symptoms, and aphasia. Across 10 cases, language fMRI yielded the highest interrater reliability agreement (Fleiss’ kappa 0.437). The most common reasons for ordering fMRI were to identify language laterality, plan extent of resection, and discuss neurological risks with patients. Clinicians reported that fMRI results were not obtained when ordered a median 10% of the time and were suboptimal a median 27% of the time. Of responders, 70% reported that they had ever resected an fMRI-positive functional site, of whom 77% did so because the site was “cleared” by cortical stimulation. Responders reported disagreement between fMRI and awake surgery 30% of the time. Overall, 98% of responders reported that if results of fMRI and intraoperative mapping disagreed, they would rely on intraoperative mapping.CONCLUSIONSAlthough fMRI is increasingly being adopted as a practical preoperative planning tool for brain tumor resection, there remains a substantial degree of discrepancy with regard to its current use and presumed utility. There is a need for further research to evaluate the use of preoperative fMRI in neurooncology patients. As fMRI continues to gain prominence, it will be important for clinicians to collectively share best practices and develop guidelines for the use of fMRI in the preoperative planning phase of brain tumor patients.

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SURG-05. AN AWAKE SURGERY FOR A CHILD SUFFERING FROM EPILEPSY DUE TO DYSEMBRYPLASTIC NEUROEPITHELIAL TUMOR LOCATED IN THE LEFT PARIETAL LOBE

Neuro-Oncology ◽

10.1093/neuonc/noaa222.802 ◽

2020 ◽

Vol 22 (Supplement_3) ◽

pp. iii461-iii462

Author(s):

Juri Kiyokawa ◽

Shinji Yamamoto ◽

Yasuhiro Murota ◽

Mariko Ishikawa ◽

Hiroto Yamaoka ◽

...

Keyword(s):

Parietal Lobe ◽

Tumor Resection ◽

Epileptic Seizures ◽

Awake Surgery ◽

Tumor Biopsy ◽

Eloquent Areas ◽

Poor Tolerance ◽

Epileptic Spikes ◽

Two Stages ◽

Intracranial Electrodes

Abstract BACKGROUND An awake surgery is a useful measure to remove tumors located close to eloquent areas of the brain to reduce surgical complications and maximize the resection. However, it has some disadvantages compared to surgeries under general anesthesia. Generally speaking, applying it to a child under 15 years-old (y/o) is hesitating because of anxiety, poor tolerance, failure to cooperate in tasks and so forth. Here, we present a case of a 13y/o girl who underwent an awake surgery due to dysembryplastic neuroepithelial tumor (DNT) located in the left parietal lobe. CASE PRESENTATION: She consulted our hospital for epileptic seizures. MRI showed a multilocular mass lesion in the left parietal lobe. The tumor was located in or close to eloquent areas. The epilepsy was refractory even with multiple antiepileptic drugs (AEDs). A Wada examination revealed that her speech area is on the left hemisphere. The operations were performed in two stages. Prior to the operations, we had several thought-out simulations in the operating room and ICU with her, her parents, and our staff including nurses and lab technicians. The first operation was to perform tumor biopsy and place intracranial electrodes. The histological diagnosis was DNT. Video electroencephalogram showed that the epileptogenic lesion was around the tumor. The second operation resulted in total tumor resection and reduction of paroxysmal epileptic spikes without major complications. She is seizure free for more than three years with two AEDs. CONCLUSION Careful preparations may enable an awake surgery even for a child under 15y/o.

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Right parietal cortex and calculation processing: intraoperative functional mapping of multiplication and addition in patients affected by a brain tumor

Journal of Neurosurgery ◽

10.3171/2013.6.jns122445 ◽

2013 ◽

Vol 119 (5) ◽

pp. 1107-1111 ◽

Cited By ~ 25

Author(s):

Alessandro Della Puppa ◽

Serena De Pellegrin ◽

Elena d'Avella ◽

Giorgio Gioffrè ◽

Marina Munari ◽

...

Keyword(s):

Brain Tumor ◽

Parietal Cortex ◽

Parietal Lobe ◽

Tumor Resection ◽

Functional Mapping ◽

Awake Surgery ◽

Intraparietal Sulcus ◽

Functional Sites ◽

Parietal Area ◽

The Right

Object The role of parietal areas in number processing is well known. The significance of intraoperative functional mapping of these areas has been only partially explored, however, and only a few discordant data are available in the surgical literature with regard to the right parietal lobe. The purpose of this study was to evaluate the clinical impact of simple calculation in cortical electrostimulation of right-handed patients affected by a right parietal brain tumor. Methods Calculation mapping in awake surgery was performed in 3 right-handed patients affected by high-grade gliomas located in the right parietal lobe. Preoperatively, none of the patients presented with calculation deficits. In all 3 cases, after sensorimotor and language mapping, cortical and intraparietal sulcus areas involved in single-digit multiplication and addition calculations were mapped using bipolar electrostimulation. Results In all patients, different sites of the right parietal cortex, mainly in the inferior lobule, were detected as being specifically related to calculation (multiplication or addition). In 2 patients the intraparietal sulcus was functionally specific for multiplication. No functional sites for language were detected. All sites functional for calculation were spared during tumor resection, which was complete in all cases without postoperative neurological deficits. Conclusions These findings provide intraoperative data in support of an anatomofunctional organization for multiplication and addition within the right parietal area. Furthermore, the study shows the potential clinical relevance of intraoperative mapping of calculation in patients undergoing surgery in the right parietal area. Further and larger studies are needed to confirm these data and assess whether mapped areas are effectively essential for function.

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Impact of Anticipated Awake Surgery on Psychooncological Distress in Brain Tumor Patients

Frontiers in Oncology ◽

10.3389/fonc.2021.795247 ◽

2022 ◽

Vol 11 ◽

Author(s):

Franziska Staub-Bartelt ◽

Oliver Radtke ◽

Daniel Hänggi ◽

Michael Sabel ◽

Marion Rapp

Keyword(s):

Brain Tumor ◽

Significant Influence ◽

Tumor Resection ◽

Statistical Analyses ◽

Distress Thermometer ◽

Awake Surgery ◽

Anxiety And Depression ◽

Cerebral Lesions ◽

Tumor Patients ◽

Significant Difference

BackgroundBrain tumor patients present high rates of distress, anxiety, and depression, in particular perioperatively. For resection of eloquent located cerebral lesions, awake surgery is the gold standard surgical method for the preservation of speech and motor function, which might be accompanied by increased psychological distress. The aim of the present study was to analyze if patients who are undergoing awake craniotomy suffer from increased prevalence or higher scores in distress, anxiety, or depression.MethodsPatients, who were electively admitted for brain tumor surgery at our neurooncological department, were perioperatively screened regarding distress, anxiety, and quality of life using three established self-assessment instruments (Hospital Anxiety and Depression Scale, distress thermometer, and European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30-BN20). Screening results were correlated regarding operation technique (awake vs. general anesthesia). Retrospective statistical analyses for nominal variables were conducted using chi-square test. Metric variables were analyzed using the Kruskal–Wallis test, the Mann–Whitney U-test, and independent-samples t-tests.ResultsData from 54 patients (26 male and 28 female) aged 29 to 82 years were available for statistical analyses. A total of 37 patients received primary resection and 17 recurrent tumor resection. Awake surgery was performed in 35 patients. There was no significant difference in awake versus non-awake surgery patients regarding prevalence (of distress (p = 0.465), anxiety (p = 0.223), or depression (p = 0.882). Furthermore, awake surgery had no significant influence on distress thermometer score (p = 0.668), anxiety score (p = 0.682), or depression score (p = 0.630) as well as future uncertainty (p = 0.436) or global health status (p = 0.943). Additionally, analyses revealed that primary or recurrent surgery also did not have any significant influence on the prevalence or scoring of the evaluated items.ConclusionAnalyses of our cohort’s data suggest that planned awake surgery might not have a negative impact on patients concerning the prevalence and severity of manifestation of distress, anxiety, or depression in psychooncological screening. Patients undergoing recurrent surgery tend to demonstrate increased distress, although results were not significant.

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Evidence of a large-scale network underlying language switching: a brain stimulation study

Journal of Neurosurgery ◽

10.3171/2009.4.jns081587 ◽

2009 ◽

Vol 111 (4) ◽

pp. 729-732 ◽

Cited By ~ 36

Author(s):

Sylvie Moritz-Gasser ◽

Hugues Duffau

Keyword(s):

Large Scale ◽

Tumor Resection ◽

Posterior Part ◽

Surgical Care ◽

Naming Task ◽

Awake Surgery ◽

Language Switching ◽

Superior Longitudinal Fasciculus ◽

Temporal Area ◽

French And English

This 47-year-old, right-handed bilingual (French and English) man underwent awake surgery for a glioma in the left dominant posterior temporal lobe. During intraoperative picture naming, direct electrostimulation of a discrete cortical area within the posterior part of the superior temporal sulcus elicited an involuntary language switching (French to English). Moreover, during tumor resection, subcortical electrical mapping again generated reproducible language switching (French to English) when stimulating the superior longitudinal fasciculus. After transient immediately postoperative worsening, the patient recovered normal language performance. Both 7 days and 2 months later, however, another language switching episode (French to English) was observed during a naming task. Thus, both intraoperative mapping and transient postsurgical disturbances support involvement of the left dominant posterior temporal area and the superior longitudinal fasciculus in language switching. Interestingly, this pathway is known to connect the posterosuperior temporal gyrus to the Broca center, a region the authors have described as inducing possible switching on stimulation. Therefore, the authors suggest the existence of a large-scale distributed network subserving language switching. Such knowledge may have important clinical implications for the surgical care of a bilingual patient harboring a lesion in the left hemisphere.

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Surgical benefits of combined awake craniotomy and intraoperative magnetic resonance imaging for gliomas associated with eloquent areas

Journal of Neurosurgery ◽

10.3171/2016.9.jns16152 ◽

2017 ◽

Vol 127 (4) ◽

pp. 790-797 ◽

Cited By ~ 14

Author(s):

Kazuya Motomura ◽

Atsushi Natsume ◽

Kentaro Iijima ◽

Shunichiro Kuramitsu ◽

Masazumi Fujii ◽

...

Keyword(s):

Brain Tumors ◽

Tumor Resection ◽

Residual Tumor ◽

Awake Craniotomy ◽

The Other ◽

Intraoperative Mri ◽

Awake Surgery ◽

Eloquent Areas ◽

Mri Studies ◽

The Brain

OBJECTIVEMaximum extent of resection (EOR) for lower-grade and high-grade gliomas can increase survival rates of patients. However, these infiltrative gliomas are often observed near or within eloquent regions of the brain. Awake surgery is of known benefit for the treatment of gliomas associated with eloquent regions in that brain function can be preserved. On the other hand, intraoperative MRI (iMRI) has been successfully used to maximize the resection of tumors, which can detect small amounts of residual tumors. Therefore, the authors assessed the value of combining awake craniotomy and iMRI for the resection of brain tumors in eloquent areas of the brain.METHODSThe authors retrospectively reviewed the records of 33 consecutive patients with glial tumors in the eloquent brain areas who underwent awake surgery using iMRI. Volumetric analysis of MRI studies was performed. The pre-, intra-, and postoperative tumor volumes were measured in all cases using MRI studies obtained before, during, and after tumor resection.RESULTSIntraoperative MRI was performed to check for the presence of residual tumor during awake surgery in a total of 25 patients. Initial iMRI confirmed no further tumor resection in 9 patients (36%) because all observable tumors had already been removed. In contrast, intraoperative confirmation of residual tumor during awake surgery led to further tumor resection in 16 cases (64%) and eventually an EOR of more than 90% in 8 of 16 cases (50%). Furthermore, EOR benefiting from iMRI by more than 15% was found in 7 of 16 cases (43.8%). Interestingly, the increase in EOR as a result of iMRI for tumors associated mainly with the insular lobe was significantly greater, at 15.1%, than it was for the other tumors, which was 8.0% (p = 0.001).CONCLUSIONSThis study revealed that combining awake surgery with iMRI was associated with a favorable surgical outcome for intrinsic brain tumors associated with eloquent areas. In particular, these benefits were noted for patients with tumors with complex anatomy, such as those associated with the insular lobe.

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