Intraoperative Seizures in Awake Craniotomy for Perirolandic Glioma Resections That Undergo Cortical Mapping

2018 ◽  
Vol 79 (03) ◽  
pp. 239-246 ◽  
Author(s):  
Chikezie Eseonu ◽  
Jordina Rincon-Torroella ◽  
Young Lee ◽  
Karim ReFaey ◽  
Punita Tripathi ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Cortical Stimulation ◽  
Awake Craniotomy ◽  
Motor Area ◽  
Perioperative Outcomes ◽  
Motor Deficits ◽  
Precentral Gyrus ◽  
Motor Mapping ◽  
Direct Cortical Stimulation ◽  
Motor Region

Background Perirolandic motor area gliomas present invasive eloquent region tumors within the precentral gyrus that are difficult to resect without causing neurologic deficits. Study Aims This study evaluates the role of awake craniotomy and motor mapping on neurologic outcome and extent of resection (EOR) of tumor in the perirolandic motor region. It also analyzes preoperative risk factors for intraoperative seizures. Methods We evaluated 57 patients who underwent an awake craniotomy for a perirolandic motor area eloquent region glioma. Patients who had positive mapping (PM) or intraoperative identification of motor regions in the cortex using direct cortical stimulation were compared with patients with no positive motor mapping following direct cortical stimulation and negative mapping (NM). Preoperative risks, intraoperative seizures, perioperative outcomes, tumor characteristics, and EOR were also compared. A logistic regression model was used to evaluate the predictors for intraoperative seizures in this patient cohort. Results Overall, 33 patients were in the PM cohort; 24 were in the NM cohort. Our study showed an 8.8% incidence of intraoperative seizures during cortical and subcortical mapping for awake craniotomies in the perirolandic motor area, none of which aborted the case. PM patients had significantly more intraoperative and postoperative seizures (15.5% and 30.3%, respectively) compared with the NM patients (0% and 8.3%, respectively; p = 0.046 and 0.044). New transient postoperative motor deficits were found more often in the PM group (51.5%) versus the NM group (12.5%; p = 0.002). A univariate logistic regression showed that PM (odds ratio [OR]: 1.16; 95% confidence interval [CI], 1.01–1.34; p = 0.035) and preoperative tumor volume (OR: 0.998; 95% CI, 0.996–0.999; p = 0.049) were significant predictors for intraoperative seizures in patients with perirolandic gliomas. Conclusion Awake craniotomies in the perirolandic motor region can be safely performed with a similar incidence of intraoperative seizures as reported for the language cortex. PM in this region may increase the likelihood of perioperative seizures or motor deficits compared with NM. Craniotomies that minimize cortical exposure for perirolandic gliomas that may not localize motor regions can still allow for extensive tumor resection with a good postoperative outcome.

Impact of Navigated Task-specific fMRI on Direct Cortical Stimulation

2020 ◽  
Vol 81 (06) ◽  
pp. 555-564
Author(s):  
Joao Leote ◽  
Ricardo Loução ◽  
Catarina Viegas ◽  
Martin Lauterbach ◽  
António Perez-Hick ◽  
...  
Keyword(s):  
Picture Naming ◽  
Cortical Stimulation ◽  
Awake Craniotomy ◽  
Awake Surgery ◽  
Precentral Gyrus ◽  
Direct Cortical Stimulation ◽  
Language Tests ◽  
Verb Generation ◽  
The Impact ◽  
Decision Tasks

Abstract Background and Study Aims Cortical mapping (CM) with direct cortical stimulation (DCS) in awake craniotomy is used to preserve cognitive functions such as language. Nevertheless, patient collaboration during this procedure is influenced by previous neurological symptoms and growing discomfort with DCS duration. Our study aimed to evaluate the impact of navigated task-specific functional magnetic resonance imaging (nfMRI) on the practical aspects of DCS. Material and Methods We recruited glioma patients scheduled for awake craniotomy for prior fMRI-based CM, acquired during motor and language tasks (i.e., verb generation, semantic and syntactic decision tasks). Language data was combined to generate a probabilistic map indicating brain regions activated with more than one paradigm. Presurgical neurophysiological language tests (i.e., verb generation, picture naming, and semantic tasks) were also performed. We considered for subsequent study only the patients with a minimum rate of correct responses of 50% in all tests. These patients were then randomized to perform intraoperative language CM either using the multimodal approach (mCM), using nfMRI and DCS combined, or electrical CM (eCM), with DCS alone. DCS was done while the patient performed picture naming and nonverbal semantic decision tasks. Methodological features such as DCS duration, number of stimuli, total delivered stimulus duration per task, and frequency of seizures were analyzed and compared between groups. The correspondence between positive responses obtained with DCS and nfMRI was also evaluated. Results Twenty-one surgeries were included, thirteen of which using mCM (i.e., test group). Patients with lower presurgical neuropsychological performance (correct response rate between 50 and 80% in language tests) showed a decreased DCS duration in comparison with the control group. None of the compared methodological features showed differences between groups. Correspondence between DCS and nfMRI was 100/84% in the identification of the precentral gyrus for motor function/opercular frontal inferior gyrus for language function, respectively. Conclusion Navigated fMRI data did not influence DCS in practice. Presurgical language disturbances limited the applicability of DCS mapping in awake surgery.

scholarly journals Correlation between localization of supratentorial glioma to the precentral gyrus and difficulty in identification of the motor area during awake craniotomy

2020 ◽  
pp. 1-10 ◽  
Author(s):  
Taiichi Saito ◽  
Yoshihiro Muragaki ◽  
Manabu Tamura ◽  
Takashi Maruyama ◽  
Masayuki Nitta ◽  
...  
Keyword(s):  
Motor Function ◽  
Pyramidal Tract ◽  
Motor Evoked Potential ◽  
Extent Of Resection ◽  
Awake Craniotomy ◽  
Motor Area ◽  
Precentral Gyrus ◽  
Motor Mapping ◽  
Supratentorial Glioma ◽  
Evoked Potential Monitoring

OBJECTIVEIdentification of the motor area during awake craniotomy is crucial for preservation of motor function when resecting gliomas located within or close to the motor area or the pyramidal tract. Nevertheless, sometimes the surgeon cannot identify the motor area during awake craniotomy. However, the factors that influence failure to identify the motor area have not been elucidated. The aim of this study was to assess whether tumor localization was correlated with a negative cortical response in motor mapping during awake craniotomy in patients with gliomas located within or close to the motor area or pyramidal tract.METHODSBetween April 2000 and May 2019 at Tokyo Women’s Medical University, awake craniotomy was performed to preserve motor function in 137 patients with supratentorial glioma. Ninety-one of these patients underwent intraoperative cortical motor mapping for a primary glioma located within or close to the motor area or pyramidal tract and were enrolled in the study. MRI was used to evaluate whether or not the tumors were localized to or involved the precentral gyrus. The authors performed motor functional mapping with electrical stimulation during awake craniotomy and evaluated the correlation between identification of the motor area and various clinical characteristics, including localization to the precentral gyrus.RESULTSThirty-four of the 91 patients had tumors that were localized to the precentral gyrus. The mean extent of resection was 89.4%. Univariate analyses revealed that identification of the motor area correlated significantly with age and localization to the precentral gyrus. Multivariate analyses showed that older age (≥ 45 years), larger tumor volume (> 35.5 cm3), and localization to the precentral gyrus were significantly correlated with failure to identify the motor area (p = 0.0021, 0.0484, and 0.0015, respectively). Localization to the precentral gyrus showed the highest odds ratio (14.135) of all regressors.CONCLUSIONSIdentification of the motor area can be difficult when a supratentorial glioma is localized to the precentral gyrus. The authors’ findings are important when performing awake craniotomy for glioma located within or close to the motor area or the pyramidal tract. A combination of transcortical motor evoked potential monitoring and awake craniotomy including subcortical motor mapping may be needed for removal of gliomas showing negative responses in the motor area to preserve the motor-related subcortical fibers.

The warning-sign hierarchy between quantitative subcortical motor mapping and continuous motor evoked potential monitoring during resection of supratentorial brain tumors

2013 ◽  
Vol 118 (2) ◽  
pp. 287-296 ◽  
Author(s):  
Kathleen Seidel ◽  
Jürgen Beck ◽  
Lennart Stieglitz ◽  
Philippe Schucht ◽  
Andreas Raabe
Keyword(s):  
Evoked Potential ◽  
Tumor Resection ◽  
Motor Evoked Potential ◽  
Cortical Stimulation ◽  
Motor Deficits ◽  
Warning Sign ◽  
Motor Mapping ◽  
Direct Cortical Stimulation ◽  
Monopolar Stimulation ◽  
Signal Changes

Object Mapping and monitoring are believed to provide an early warning sign to determine when to stop tumor removal to avoid mechanical damage to the corticospinal tract (CST). The objective of this study was to systematically compare subcortical monopolar stimulation thresholds (1–20 mA) with direct cortical stimulation (DCS)–motor evoked potential (MEP) monitoring signal abnormalities and to correlate both with new postoperative motor deficits. The authors sought to define a mapping threshold and DCS-MEP monitoring signal changes indicating a minimal safe distance from the CST. Methods A consecutive cohort of 100 patients underwent tumor surgery adjacent to the CST while simultaneous subcortical motor mapping and DCS-MEP monitoring was used. Evaluation was done regarding the lowest subcortical mapping threshold (monopolar stimulation, train of 5 stimuli, interstimulus interval 4.0 msec, pulse duration 500 μsec) and signal changes in DCS-MEPs (same parameters, 4 contact strip electrode). Motor function was assessed 1 day after surgery, at discharge, and at 3 months postoperatively. Results The lowest individual motor thresholds (MTs) were as follows (MT in mA, number of patients): > 20 mA, n = 12; 11–20 mA, n = 13; 6–10 mA, n = 20; 4–5 mA, n = 30; and 1–3 mA, n = 25. Direct cortical stimulation showed stable signals in 70 patients, unspecific changes in 18, irreversible alterations in 8, and irreversible loss in 4 patients. At 3 months, 5 patients had a postoperative new or worsened motor deficit (lowest mapping MT 20 mA, 13 mA, 6 mA, 3 mA, and 1 mA). In all 5 patients DCS-MEP monitoring alterations were documented (2 sudden irreversible threshold increases and 3 sudden irreversible MEP losses). Of these 5 patients, 2 had vascular ischemic lesions (MT 20 mA, 13 mA) and 3 had mechanical CST damage (MT 1 mA, 3 mA, and 6 mA; in the latter 2 cases the resection continued after mapping and severe DCS-MEP alterations occurred thereafter). In 80% of patients with a mapping MT of 1–3 mA and in 75% of patients with a mapping MT of 1 mA, DCS-MEPs were stable or showed unspecific reversible changes, and none had a permanent motor worsening at 3 months. In contrast, 25% of patients with irreversible DCS-MEP changes and 75% of patients with irreversible DCS-MEP loss had permanent motor deficits. Conclusions Mapping should primarily guide tumor resection adjacent to the CST. DCS-MEP is a useful predictor of deficits, but its value as a warning sign is limited because signal alterations were reversible in only approximately 60% of the present cases and irreversibility is a post hoc definition. The true safe mapping MT is lower than previously thought. The authors postulate a mapping MT of 1 mA or less where irreversible DCS-MEP changes and motor deficits regularly occur. Therefore, they recommend stopping tumor resection at an MT of 2 mA at the latest. The limited spatial and temporal coverage of contemporary mapping may increase error and may contribute to false, higher MTs.

Abstract 3734: Presurgical fMRI and Morbidity Outcomes in Patients with Vascular Lesions

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Andrew C Radtke ◽  
Joshua Pankratz ◽  
Ryan Holdsworth ◽  
Dovile Baniulis ◽  
Nicole Kornder ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Preoperative Planning ◽  
Binary Logistic Regression ◽  
Vascular Lesion ◽  
Vascular Lesions ◽  
Motor Deficits ◽  
Binary Logistic Regression Analysis ◽  
Language Mapping ◽  
Motor Mapping ◽  
The Relationship

Background fMRI is being increasingly used as an adjunct imaging technique for preoperative planning for patients with various brain lesions. The proximity of the lesion to eloquent cortex is a major factor in guiding surgical planning. Our group has previously reported significant association between the distance between brain tumor periphery and area of fMRI activation (Lesion-Activation Distance; LAD) and morbidity and mortality outcomes. This study investigated the relationship between vascular lesion LAD and morbidity. Methods This study was a retrospective analysis of data from patients with vascular lesions [arteriovenous malformations (AVMs) (n=49), and cavernomas (n=57)], who had received fMRI as part of their preoperative planning. The preoperative fMRI included motor mapping (n=87) and/or language mapping (n=102). The fMRI paradigms were chosen based on observed preoperative weakness (aphasia, paresis) and anticipated functional areas of the brain that may be affected by treatment. Results Multiple logistic regression analyses showed that a model that combines Age and Language LAD was a significant predictor of postoperative deficits (p= 0.04). Broca’s LAD(1-2 cm) X Age was a significant predictor of postoperative deficits (change in odds ratio (OR) =0.82, CI:0.68-0.98). The relationship between Brocas’s LAD and postoperative aphasia and Broca’s LAD and pre and postoperative aphasia trended towards significance (p = .08 and p =.07 respectively). Wernicke’s LAD, independently or combined with Age, was not a significant predictor of postoperative deficits. Binary logistic regression analysis for SMC LAD and postop deficits did not reach significance (p =.10). There were no significant differences in postoperative language or motor deficits as a function of gender or handedness. Conclusions These results suggest that both age and the proximity of a vascular lesion to language LAD are factors that can help predict postoperative outcomes, especially for Broca’s LAD. The lack of similar results when investigating the relationship between Wernicke’s LAD and postoperative deficits suggests potential brain reorganization and/or robustness of this brain region. These results have implications for the potential use of fMRI as a presurgical tool for language mapping in patients with vascular lesions.

scholarly journals Surgical management of Rolandic area meningioma in the era of intraoperative neurophysiological monitoring

2020 ◽  
pp. 488-494
Author(s):  
Mihaela Coșman ◽  
Ionuț Mihail Panțiru ◽  
Andrei Ionuț Cucu ◽  
Andreea Lenuța Atomei ◽  
Gabriela Florența Dumitrecu ◽  
...  
Keyword(s):  
Cortical Stimulation ◽  
Motor Area ◽  
Intraoperative Neurophysiological Monitoring ◽  
Motor Deficit ◽  
Cortical Mapping ◽  
Neurophysiological Monitoring ◽  
Direct Cortical Stimulation ◽  
One Year ◽  
The Impact

Introduction: The advantages and the necessity of intraoperative neurophysiological monitoring (IOM) in the surgery of motor area infiltrative tumours is well known. The use of this technique for Rolandic meningioma is still debatable. The absence or the loss of the cleavage plan and an infiltrative border make the dissection exceedingly difficult and increase the risk of new postoperative motor disfunction. Materials and methods: We evaluated the impact of IOM, especially direct cortical stimulation on the degree of resection, new postoperative deficits, symptom remission and clinical-imagistic aspects at one-year follow up of 19 cases of Rolandic meningioma admitted in Third Department of Neurosurgery,” Prof. Dr N. Oblu” Emergency Clinical Hospital, Yassi, Romania, between January 2014 and July 2018. Results: More than half of the cases (57,88%) had epileptic manifestations as the main clinical symptom with the Jacksonian seizures being on the first place (31,57%), followed by progressive paresis (26,31%) and other nonspecific symptoms. Intraparenchymal preoperative oedema was observed in 36,84% of patients. The intensity of direct cortical stimulation was between 6-13 mA (median = 9mA; mode = 12mA). Simpson degree of resection was dominated by S3– 47,36% and S4 was obtained in 15,78% of cases. Postoperative the outcome was favourable for 73,68% patients with 5,26% motor aggravation and 10,52% new deficits. At one-year follow up no imagistic recurrence was observed and the permanent motor deficit was maintained in one of the three cases (5,26%). Conclusion: Even though meningiomas are extranevraxial lesions and those located on the convexity have a low risk of complication, the absence of a clear dissection plan between the tumour and the adjacent motor cortex is associated with a high risk for new postoperative neurological deficits. Therefore, it is important to perform cortical mapping for Rolandic meningioma, to determine the location of the primary motor area and to protect it from mechanical and vascular trauma, during tumour resection.

Localizing hand motor area using resting-state fMRI: validated with direct cortical stimulation

2014 ◽  
Vol 156 (12) ◽  
pp. 2295-2302 ◽  
Author(s):  
Tian-ming Qiu ◽  
Chao-gan Yan ◽  
Wei-jun Tang ◽  
Jin-song Wu ◽  
Dong-xiao Zhuang ◽  
...  
Keyword(s):  
Resting State ◽  
Resting State Fmri ◽  
Cortical Stimulation ◽  
Motor Area ◽  
Direct Cortical Stimulation ◽  
Hand Motor Area

Nonlesional central lobule seizures: use of awake cortical mapping and subdural grid monitoring for resection of seizure focus

2003 ◽  
Vol 98 (6) ◽  
pp. 1255-1262 ◽  
Author(s):  
Aaron A. Cohen-Gadol ◽  
Jeffrey W. Britton ◽  
Frederic P. Collignon ◽  
Lisa M. Bates ◽  
Gregory D. Cascino ◽  
...  
Keyword(s):  
Seizure Frequency ◽  
Sensorimotor Cortex ◽  
Cortical Stimulation ◽  
Limited Resection ◽  
Awake Craniotomy ◽  
Sensory Loss ◽  
Precentral Gyrus ◽  
Content Type ◽  
Postcentral Gyrus ◽  
Fine Print

Object. Surgical treatment options for intractable seizures caused by a nonlesional epileptogenic focus located in the central sulcus region are limited. The authors describe an alternative surgical approach for treating medically refractory nonlesional perirolandic epilepsy. Methods. Five consecutive patients who were treated between 1996 and 2000 for nonlesional partial epilepsy that had originated in the central lobule were studied. The patients' ages ranged from 16 to 56 years (mean 28.6 years; there were four men and one woman). The duration of their epilepsy ranged from 8 to 39 years (mean 20.2 years), with a mean seizure frequency of 19 partial seizures per week. Preoperative assessment included video electroencephalography (EEG) and subtracted ictal—interictal single-photon emission computerized tomography coregistered with magnetic resonance imaging (SISCOM). Patients underwent an awake craniotomy stereotactically guided by the ictal EEG and SISCOM studies. Cortical stimulation was used to identify the sensorimotor cortex and to reproduce the patient's aura. A subdural grid was then implanted based on these results. Subsequent postoperative ictal electrocorticographic recordings and cortical stimulation further delineated the site of seizure onset and functional anatomy. During a second awake craniotomy, a limited resection of the epileptogenic central lobule region was performed while function was continuously monitored intraoperatively. One resection was limited to the precentral gyrus, two to the postcentral gyrus, and in two the excisions involved regions of both the pre- and postcentral gyri. In three patients a hemiparesis occurred postsurgery but later resolved. In the four patients whose resection involved the postcentral gyrus, transient cortical sensory loss and apraxia occurred, which completely resolved in three. Two patients are completely seizure free, two have experienced occasional nondisabling seizures, and one patient has benefited from a more than 75% reduction in seizure frequency. The follow-up period ranged from 2 to 5.5 years (mean 3.5 years). Conclusions. A limited resection of the sensorimotor cortex may be performed with acceptable neurological morbidity in patients with medically refractory perirolandic epilepsy. This procedure is an alternative to multiple subpial transections in the surgical management of intractable nonlesional epilepsy originating from the sensorimotor cortex.

Functional reorganization oF the primary motor cortex in a patient with a large arteriovenous malFormation involving the precentral gyrus

2013 ◽  
Vol 4 (2) ◽  
Author(s):  
Milan Radoš ◽  
Ines Nikić ◽  
Marko Radoš ◽  
Ivica Kostović ◽  
Patrick Hof ◽  
...  
Keyword(s):  
Motor Cortex ◽  
Primary Motor Cortex ◽  
Right Hemisphere ◽  
Motor Area ◽  
Lower Limbs ◽  
Motor Deficits ◽  
Precentral Gyrus ◽  
Functional Reorganization ◽  
The Right ◽  
The Brain

AbstractIt is known that the brain can compensate for deficits induced by acquired and developmental lesions through functional reorganization of the remaining parenchyma. Arteriovenous malformations (AVM) usually appear prenatally before a functional regional organization of the brain is fully established and patients generally do not present with motor deficits even when the AVM is located in the primary motor area indicating the redistribution of functions in cortical areas that are not pathologically altered. Here we present reorganization of the motor cortex in a patient with a large AVM involving most of the left parietal lobe and the paramedian part of the left precentral gyrus that is responsible for controlling the muscles of the lower limbs. Functional MRI showed that movements of both the right and left feet activated only the primary motor cortex in the right hemisphere, while there was no activation in the left motor cortex. This suggests that complete ipsilateral control over the movements of the right foot had been established in this patient. A reconstruction of the corticospinal tract using diffusion tensor imaging showed a near-complete absence of corticospinal fibers from the part of the left precentral gyrus affected by the AVM. From this clinical presentation it can be concluded that full compensation of motor deficits had occurred by redistributing function to the corresponding motor area of the contralateral

scholarly journals The role of secondary motor and language cortices in morbidity and mortality: a retrospective functional MRI study of surgical planning for patients with intracranial tumors

2013 ◽  
Vol 34 (4) ◽  
pp. E7 ◽  
Author(s):  
Jed Voss ◽  
Timothy B. Meier ◽  
Robert Freidel ◽  
Bornali Kundu ◽  
Veena A. Nair ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Functional Mri ◽  
Brain Regions ◽  
Motor Area ◽  
Morbidity And Mortality ◽  
Motor Deficits ◽  
Language Mapping ◽  
Language Deficits ◽  
The Impact ◽  
The Relationship

Object Functional MRI (fMRI) is commonly used by neurosurgeons preoperatively to identify brain regions associated with essential behaviors, such as language and motor abilities. In this study the authors investigated the relationship between patient morbidity and mortality and the distance from the tumor border area to functional activations in secondary motor and language cortices. Methods Patients with primary or metastatic brain tumors who underwent preoperative fMRI motor and language mapping were selected from a large database of patients with tumors. The lesion-to-activation distance (LAD) was measured in each patient relative to the supplementary motor area (SMA) for motor tasks and the presupplementary motor area (pSMA) for language tasks. The association between LAD and the incidence of deficits was investigated using the Fisher exact tests of significance. The impact of other variables, including age, handedness, sex, and tumor grade, was also investigated. In a subset of patients, logistic regression was performed to identify the likelihood of deficits based on the LAD to primary and secondary regions. Finally, Mantel-Cox log-rank tests were performed to determine whether survival time was significantly related to the LAD to secondary motor and language areas. Results A significant association was observed between the LAD to the SMA and the incidence of motor deficits, with the percentage of patients with deficits dropping for those in the LAD > 2 cm group. The relationship between the LAD to the pSMA and the incidence of language deficits was not significant. Logistic regression demonstrated that the LAD to primary sensorimotor cortex does affect the incidence of motor deficits, but that the LAD to SMA does not. Finally, the authors observed no relationship between the LAD to secondary regions and patient mortality rates. Conclusions These results demonstrate that the LAD to SMA structures does affect morbidity, although not to the extent of LAD to primary structures. In addition, motor deficits are significantly associated with LAD to secondary structures, but language deficits are not. This should be considered by neurosurgeons for patient consultation and preoperative planning.

Sign in / Sign up

Export Citation Format

Share Document