Cortical and subcortical mapping of language areas: Correlation of functional MRI and tractography in a 3T scanner with intraoperative cortical and subcortical stimulation in patients with brain tumors located in eloquent areas

Background During resection of intrinsic brain tumors in eloquent areas, particularly under awake mapping, subcortical stimulation is mandatory to avoid irreversible deficits by damaging white fiber tracts. The current practice is to alternate between subcortical stimulation with an appropriate probe and resection of tumoral tissue with an ultrasound aspiration device. Switching between different devices induces supplementary movement and possible tissue trauma, loss of time, and inaccuracies in the localization of the involved area. Objective To use one device for both stimulation as well as a resecting tool. Methods The tip of different ultrasound aspiration devices is currently used for monopolar current transmission (e.g., for vessel coagulation in liver surgery). We use the same circuitry for monopolar subcortical stimulation when connected with the usual stimulator devices. Results We have applied this method since 2004 in over 500 patients during tumor resection with cortical and subcortical stimulation, mostly with awake language and motor monitoring. Conclusion A method is presented using existing stimulation and wiring devices by which simultaneous subcortical stimulation and ultrasonic aspiration are applied with the same tool. The accuracy, safety, and speed of intrinsic intracranial lesion resection can be improved when subcortical stimulation is applied.

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Unusual Gliomas

10.1093/med/9780190696696.003.0002 ◽

2018 ◽

Author(s):

Chikezie I. Eseonu ◽

Jordina Rincon-Torroella ◽

Alfredo Quiñones-Hinojosa

Keyword(s):

Magnetic Resonance Imaging ◽

Computed Tomography ◽

Overall Survival ◽

Brain Tumor ◽

Poor Prognosis ◽

Resonance Imaging ◽

Eloquent Areas ◽

Anatomic Location ◽

Subcortical Mapping ◽

Language Areas

Patients with intra-axial brain tumors often present with neurologic symptoms based on the anatomic location of their tumor. Workup for a brain tumor includes cranial imaging such as magnetic resonance imaging and computed tomography, as well as systemic imaging to assess for primary tumor if metastasis is suspected. Maximal safe resection optimizes outcomes including overall survival. Surgical decisions are based on variables such as medical comorbidities and anatomic location of the tumor. Gliomas in eloquent areas may require intraoperative cortical and subcortical mapping of motor and/or language areas to optimize safety and help maximize resection. Adjuvant chemotherapy and radiation lead to a median survival of 14.6 months for patients with glioblastoma. Rapidly recurring glioblastoma after surgery has a poor prognosis.

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A measure of vascular reactivity to overcome neurovascular uncoupling in functional imaging of brain tumors: initial results

10.1101/240085 ◽

2017 ◽

Author(s):

Henning U. Voss ◽

Kyung K. Peck ◽

Nicole M. Petrovich Brennan ◽

Andrei I. Holodny

Keyword(s):

Brain Tumors ◽

Vascular Reactivity ◽

Breath Holding ◽

Low Grade ◽

Bold Response ◽

Independent Measurement ◽

Bold Fmri ◽

Eloquent Areas ◽

Language Areas ◽

Initial Results

AbstractPurposePreoperative functional MRI (fMRI) is limited by a muted BOLD response caused by abnormal vasoreactivity and resultant neurovascular uncoupling adjacent to malignant brain tumors. We propose to overcome this limitation and more accurately identify eloquent areas adjacent to brain tumors by independently assessing vasoreactivity using breath-holding and incorporating these data into the BOLD analysis.MethodsLocal vasoreactivity using a breath-holding paradigm with the same timing as the functional motor and language tasks was determined in 16 patients (9 glioblastomas, 1 anaplastic astrocytoma, 5 low grade astrocytomas, and 1 metastasis). We derived a model based on coherence for analyzing BOLD fMRI that takes into account the altered hemodynamics adjacent to brain tumors.ResultsActivation maps computed using the coherence model were overall similar to standard activation maps. However, the coherence maps demonstrated clinically meaningful areas of activation that were not seen using the standard method in 12/16 cases. This included localization of language areas adjacent to brain tumors, where the coherence method results were confirmed by intra-operative direct cortical stimulation. Enhanced task response maps based on vasoreactivity mapping demonstrated more robust, anatomically-correct activation, in particular adjacent to tumors as compared to maps obtained without vasoreactivity information.ConclusionsThe present preliminary results demonstrate the principle that the neurovascular uncoupling known to affect the accuracy of BOLD fMRI adjacent to brain tumors may be, at least partially, overcome by incorporating an independent measurement of vasoreactivity into the BOLD analysis.

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Awake mapping for resection of cavernous angioma and surrounding gliosis in the left dominant hemisphere: surgical technique and functional results

Journal of Neurosurgery ◽

10.3171/2012.9.jns12662 ◽

2012 ◽

Vol 117 (6) ◽

pp. 1076-1081 ◽

Cited By ~ 23

Author(s):

Ryosuke Matsuda ◽

Alejandro Fernández Coello ◽

Alessandro De Benedictis ◽

Matteo Martinoni ◽

Hugues Duffau

Keyword(s):

Electrical Stimulation ◽

Cavernous Angioma ◽

Functional Results ◽

Awake Surgery ◽

Consecutive Series ◽

Dominant Hemisphere ◽

Eloquent Areas ◽

Valuable Adjunct ◽

Subcortical Stimulation ◽

Subcortical Mapping

Object Maximal resection of symptomatic cavernous angioma (CA), including its surrounding gliosis if possible, has been recommended to minimize the risk of seizures or (re)bleeding. However, despite recent neurosurgical advances, such extensive CA removal is still a challenge in eloquent areas. The authors report a consecutive series of patients who underwent awake surgery for CA within the left dominant hemisphere in which intraoperative cortical–subcortical electrical stimulation was used. Methods Nine patients harboring a CA that was revealed by seizures in 6 cases and bleeding in 3 cases underwent resection. All CAs were located in the left dominant hemisphere: 3 temporal, 2 insular, 2 parietal, and 2 in the parietotemporal region. Awake mapping was performed in all cases by using intraoperative cortical–subcortical electrical stimulation and ultrasonography (except in 1 insular CA in which a neuronavigation system was used). Results Total removal of the CA was achieved in all patients, with identification and preservation of language and sensory-motor structures. In addition, the pericavernomatous gliosis was removed in 7 cases, according to the functional boundaries provided by intraoperative subcortical stimulation. In 2 cases, subcortical mapping revealed eloquent areas within the surrounding gliosis, which was voluntarily avoided. There was no postsurgical permanent deficit, no rebleeding, and no epilepsy in 7 cases (2 patients had rare seizures in the 1st year or two after surgery, and then complete arrest), with a mean follow-up of 28.5 months (range 3–64 months). Conclusions These results suggest that intraoperative cortical–subcortical stimulation in awake patients represents a valuable adjunct to image-guided surgery with the aim of selecting the safer surgical approach for CAs involving eloquent areas. Moreover, such online mapping can be helpful when removing the pericavernomatous gliosis while preserving functional structures, which can persist within the hemosiderin rim. Thus, the authors propose that awake surgery be routinely considered, both to optimize the resection and to improve the quality of life through seizure control and avoidance of (re)bleeding for CAs located in the left dominant hemisphere.

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Group Independent Component Analysis and Functional MRI Examination of Changes in Language Areas Associated with Brain Tumors at Different Locations

PLoS ONE ◽

10.1371/journal.pone.0059657 ◽

2013 ◽

Vol 8 (3) ◽

pp. e59657 ◽

Cited By ~ 25

Author(s):

Liya Wang ◽

Dandan Chen ◽

Xiaofeng Yang ◽

Jeffrey J. Olson ◽

Kaundinya Gopinath ◽

...

Keyword(s):

Brain Tumors ◽

Independent Component Analysis ◽

Functional Mri ◽

Component Analysis ◽

Independent Component ◽

Mri Examination ◽

Language Areas ◽

Group Independent Component Analysis

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Neurophysiologic Mapping of Thalamocortical Tract in Asleep Craniotomies: Promising Results From an Early Experience

Operative Neurosurgery ◽

10.1093/ons/opaa330 ◽

2020 ◽

Author(s):

Mirela V Simon ◽

Daniel K Lee ◽

Bryan D Choi ◽

Pratik A Talati ◽

Jimmy C Yang ◽

...

Keyword(s):

General Anesthesia ◽

Corticospinal Tract ◽

Sensory Function ◽

Motor Deficit ◽

Motor Deficits ◽

Central Sulcus ◽

Postcentral Gyrus ◽

Subcortical Stimulation ◽

Subcortical Mapping

Abstract BACKGROUND Subcortical mapping of the corticospinal tract has been extensively used during craniotomies under general anesthesia to achieve maximal resection while avoiding postoperative motor deficits. To our knowledge, similar methods to map the thalamocortical tract (TCT) have not yet been developed. OBJECTIVE To describe a neurophysiologic technique for TCT identification in 2 patients who underwent resection of frontoparietal lesions. METHODS The central sulcus (CS) was identified using the somatosensory evoked potentials (SSEP) phase reversal technique. Furthermore, monitoring of the cortical postcentral N20 and precentral P22 potentials was performed during resection. Subcortical electrical stimulation in the resection cavity was done using the multipulse train (case #1) and Penfield (case #2) techniques. RESULTS Subcortical stimulation within the postcentral gyrus (case #1) and in depth of the CS (case #2), resulted in a sudden drop in amplitudes in N20 (case #1) and P22 (case #2), respectively. In both patients, the potentials promptly recovered once the stimulation was stopped. These results led to redirection of the surgical plane with avoidance of damage of thalamocortical input to the primary somatosensory (case #1) and motor regions (case #2). At the end of the resection, there were no significant changes in the median SSEP. Both patients had no new long-term postoperative sensory or motor deficit. CONCLUSION This method allows identification of TCT in craniotomies under general anesthesia. Such input is essential not only for preservation of sensory function but also for feedback modulation of motor activity.

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Combined Utility of Functional MRI, Cortical Mapping, and Frameless Stereotaxy in the Resection of Lesions in Eloquent Areas of Brain in Children

Pediatric Neurosurgery ◽

10.1159/000121167 ◽

1997 ◽

Vol 26 (2) ◽

pp. 68-82 ◽

Cited By ~ 98

Author(s):

Simon R. Stapleton ◽

Elaine Kiriakopoulos ◽

David Mikulis ◽

James M. Drake ◽

Harold J. Hoffman ◽

...

Keyword(s):

Functional Mri ◽

Cortical Mapping ◽

Frameless Stereotaxy ◽

Eloquent Areas

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Subcortical mapping and monitoring during insular tumor surgery

Neurosurgical FOCUS ◽

10.3171/2009.8.focus09140 ◽

2009 ◽

Vol 27 (4) ◽

pp. E5 ◽

Cited By ~ 39

Author(s):

Theodoros Kombos ◽

Olaf Süss ◽

Peter Vajkoczy

Keyword(s):

False Negative ◽

Electrical Stimulus ◽

Morbidity Rate ◽

Stimulus Compound ◽

Motor Pathways ◽

Negative Results ◽

Quantitative Monitoring ◽

False Negative Results ◽

Subcortical Stimulation ◽

Subcortical Mapping

Object The treatment of insular tumors is controversial. Surgical treatment is associated with a higher morbidity rate than other therapies. The present work presents a new method in which the descending motor pathways are monitored during surgery for insular tumors. Methods Intraoperative monitoring was performed in a combination of 2 techniques. The motor cortex was stimulated with a transcranial electrical stimulus. In addition, direct subcortical stimulation was performed with an electrical anodal monopolar stimulus. Compound motor action potentials (CMAPs) were recorded from target muscles. Results Fifteen patients were included in this preliminary study. Following transcranial stimulation, CMAPs were recorded in all cases. Subcortical stimulation was successful in 12 cases. Significant CMAP alterations were recorded in 5 patients. There were no false-negative results in the series. Conclusions The technique presented here is a safe method. It allows a quantitative monitoring of motor function and functional mapping of the pyramidal tract during insular surgery.

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Resting-state functional MRI language network connectivity differences in patients with brain tumors: exploration of the cerebellum and contralesional hemisphere

Brain Imaging and Behavior ◽

10.1007/s11682-021-00498-5 ◽

2021 ◽

Author(s):

Nicholas S. Cho ◽

Kyung K. Peck ◽

Madeleine N. Gene ◽

Mehrnaz Jenabi ◽

Andrei I. Holodny

Keyword(s):

Brain Tumors ◽

Functional Mri ◽

Resting State ◽

Network Connectivity ◽

Language Network

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BRMP-01. Awake cranial surgery with intraoperative language mapping for brain tumors. A single-center experience

Neuro-Oncology ◽

10.1093/neuonc/noab196.894 ◽

2021 ◽

Vol 23 (Supplement_6) ◽

pp. vi223-vi223

Author(s):

Andrés Cervio ◽

Sebastían Giovannini ◽

Sonia Hasdeu ◽

Lucía Pertierra ◽

Blanca Diez

Keyword(s):

Brain Tumors ◽

Functional Mri ◽

Tumor Resection ◽

Awake Surgery ◽

Anesthetic Technique ◽

Low Grade ◽

Safe Procedure ◽

Language Mapping ◽

Cranial Surgery

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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