Impact of Multi-modality Monitoring Using Direct Electrical Stimulation to Determine Corticospinal Tract Shift and Integrity in Tumors using the Intraoperative MRI

2019 ◽  
Author(s):  
Daria Krivosheya ◽  
Ganesh Rao ◽  
Sudhakar Tummala ◽  
Vinodh Kumar ◽  
Dima Suki ◽  
...  
Keyword(s):  
Electrical Stimulation ◽  
Corticospinal Tract ◽  
Diffusion Tensor ◽  
Tumor Resection ◽  
Similar Degree ◽  
Low Grade ◽  
Direct Electrical Stimulation ◽  
Resection Cavity ◽  
Group 4 ◽  
The Impact

Abstract Introduction Preserving the integrity of the corticospinal tract (CST) while maximizing the extent of tumor resection is one of the key principles of brain tumor surgery to prevent new neurologic deficits. Our goal was to determine the impact of the use of perioperative diffusion tensor imaging (DTI) fiber-tracking protocols for location of the CSTs, in conjunction with intraoperative direct electrical stimulation (DES) on patient neurologic outcomes. The role of combining DES and CST shift in intraoperative magnetic resonance imaging (iMRI) to enhance extent of resection (EOR) has not been studied previously. Methods A total of 53 patients underwent resection of tumors adjacent to the motor gyrus and the underlying CST between June 5, 2009, and April 16, 2013. All cases were performed in the iMRI (BrainSuite 1.5 T). Preoperative DTI mapping and intraoperative cortical and subcortical DES including postoperative DTI mapping were performed in all patients. There were 32 men and 21 women with 40 high-grade gliomas (76%), 4 low-grade gliomas (8%), and 9 (17%) metastases. Thirty-four patients (64%) were newly diagnosed, and 19 (36%) had a previous resection. There were 31 (59%) right-sided and 22 (42%) left-sided tumors. Eighteen patients (34%) had a re-resection after the first intraoperative scan. Most patients had motor-only mapping, and one patient had both speech and motor mapping. Relative to the resection margin, the CST after the first iMRI was designated as having an outward shift (OS), inward shift (IS), or no shift (NS). Results A gross total resection (GTR) was achieved in 41 patients (77%), subtotal resection in 4 (7.5%), and a partial resection in 8 (15%). Eighteen patients had a re-resection, and the mean EOR increased from 84% to 95% (p = 0.002). Of the 18 patients, 7 had an IS, 8 an OS, and in 3 NS was noted. More patients in the OS group had a GTR compared with the IS or NS groups (p = 0.004). Patients were divided into four groups based on the proximity of the tumor to the CST as measured from the preoperative scan. Group 1 (32%) included patients whose tumors were 0 to 5 mm from the CST based on preoperative scans; group 2 (28%), 6 to 10 mm; group 3 (13%), 11 to 15 mm; and group 4 (26%), 16 to 20 mm, respectively. Patients in group 4 had fewer neurologic complications compared with other groups at 1 and 3 months postoperatively (p = 0.001 and p = 0.007, respectively) despite achieving a similar degree of resection (p = 0.61). Furthermore, the current of intraoperative DES was correlated to the distance of the tumor to the CST, and the regression equation showed a close linear relationship between the two parameters. Conclusions Combining information about intraoperative CST and DES in the iMRI can enhance resection in brain tumors (77% had a GTR). The relative relationship between the positions of the CST to the resection cavity can be a dynamic process that could further influence the surgeon's decision about the stimulation parameters and EOR. Also, the patients with an OS of the CST relative to the resection cavity had a GTR comparable with the other groups.

scholarly journals The importance of the preoperative clinical parameters and the intraoperative electrophysiological monitoring in brachial plexus surgery

2011 ◽  
Vol 69 (4) ◽  
pp. 654-659 ◽  
Author(s):  
Leandro Pretto Flores
Keyword(s):  
Electrical Stimulation ◽  
Brachial Plexus ◽  
Intraoperative Monitoring ◽  
Short Interval ◽  
Clinical Parameters ◽  
Direct Electrical Stimulation ◽  
Intraoperative Electrophysiological Monitoring ◽  
Post Traumatic ◽  
Brachial Plexus Surgery ◽  
The Impact

OBJECTIVE: The study aims to demonstrate the impact of some preoperative clinical parameters on the functional outcome of patients sustaining brachial plexus injuries, and to trace some commentaries about the use of intraoperative monitoring techniques. METHOD: A retrospective study one hundred cases of brachial plexus surgery. The analysis regarding postoperative outcomes was performed by comparing the average of the final result of the surgery for each studied cohort. RESULTS: Direct electrical stimulation was used in all patients, EMG in 59%, SEPs in 37% and evoked NAPs in 19% of the cases. Patients in whom the motor function of the hand was totally or partially preserved before surgery, and those in whom surgery was delayed less than 6 months demonstrated significant (p<0.05) better outcomes. CONCLUSION: The preoperative parameters associated to favorable outcomes in reconstruction of the brachial plexus are a good post-traumatic status of the hand and a short interval between injury and surgery.

Morbidity profile following aggressive resection of parietal lobe gliomas

2012 ◽  
Vol 116 (6) ◽  
pp. 1182-1186 ◽  
Author(s):  
Nader Sanai ◽  
Juan Martino ◽  
Mitchel S. Berger
Keyword(s):  
Classification System ◽  
Tumor Volume ◽  
Parietal Lobe ◽  
Tumor Resection ◽  
High Rate ◽  
Low Grade ◽  
High Grade ◽  
Language Pathways ◽  
The Impact ◽  
Glioma Classification

Object The impact of parietal lobe gliomas is typically studied in the context of parietal lobe syndromes. However, critical language pathways traverse the parietal lobe and are susceptible during tumor resection. The authors of this study reviewed their experience with parietal gliomas to characterize the impact of resection and the morbidity associated with language. Methods The study population included adults who had undergone resection of parietal gliomas of all grades. Tumor location was identified according to a proposed classification system for parietal region gliomas. Low- and high-grade tumors were volumetrically analyzed using FLAIR and T1-weighted contrast-enhanced MR imaging. Results One hundred nineteen patients with parietal gliomas were identified—34 with low-grade gliomas and 85 with high-grade gliomas. The median patient age was 45 years, and most patients (53) presented with seizures, whereas only 4 patients had an appreciable parietal lobe syndrome. The median preoperative tumor volume was 31.3 cm3, the median extent of resection was 96%, and the median postoperative tumor volume was 0.9 cm3. Surprisingly, the most common early postoperative neurological deficit was dysphasia (16 patients), not weakness (12 patients), sensory deficits (14 patients), or parietal lobe syndrome (10 patients). A proposed parietal glioma classification system, based on surgical anatomy, was predictive of language deficits. Conclusions This is the largest reported experience with parietal lobe gliomas. The findings suggested that parietal language pathways are compromised at a surprisingly high rate. The proposed parietal glioma classification system is predictive of postoperative morbidity associated with language and can assist with preoperative planning. Taken together, these data emphasize the value of identifying language pathways when operating within the parietal lobe.

scholarly journals Acute changes in diffusion tensor-derived metrics and its correlation with the motor outcome in gliomas adjacent to the corticospinal tract

2021 ◽  
Vol 12 ◽  
pp. 51
Author(s):  
Santiago Cepeda ◽  
Sergio García-García ◽  
Ignacio Arrese ◽  
María Velasco-Casares ◽  
Rosario Sarabia
Keyword(s):  
Corticospinal Tract ◽  
Diffusion Tensor ◽  
Premotor Cortex ◽  
Motor Impairment ◽  
Mean Diffusivity ◽  
Motor Deficits ◽  
Low Grade ◽  
Contralateral Hemisphere ◽  
Motor Outcome ◽  
Acute Changes

Background: This study involves analysis of the relationship between variables obtained using diffusion tensor imaging (DTI) and motor outcome in gliomas adjacent to the corticospinal tract (CST). Methods: Histologically confirmed glioma patients who were to undergo surgery between January 2018 and December 2019 were prospectively enrolled. All patients had a preoperative magnetic resonance imaging (MRI) study that included DTI, a tumor 2 cm or less from the CST, and postsurgical control within 48 h. Patients with MRI that was performed at other center, tumors with primary and premotor cortex invasion, postsurgical complications directly affecting motor outcome and tumor progression <6 months were excluded in the study. In pre- and post-surgical MRI, we measured the following DTI-derived metrics: fractional anisotropy (FA), mean diffusivity, axial diffusivity, and radial diffusivity of the entire CST and peritumoral CST regions and in the contralateral hemisphere. The motor outcome was assessed at 1, 3, and 6 months using the Medical Research Council scale. Results: Eleven patients were analyzed, and six corresponded to high-grade gliomas and five to low-grade gliomas. Four patients had previous motor impairment and seven patients had postsurgical motor deficits (four transient and three permanent). An FA ratio of 0.8 between peritumoral CST regions and the contralateral hemisphere was found to be the cutoff, and lower values were obtained in patients with permanent motor deficits. Conclusion: Quantitative analysis of DTI that was performed in the immediate postsurgery period can provide valuable information about the motor prognosis after surgery for gliomas near the CST.

scholarly journals STEM-12. INCREASING INDUCED NEURAL STEM CELL PERSISTENCE IN THE TUMOR RESECTION CAVITY

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi236-vi236
Author(s):  
Hunter Bomba ◽  
Kevin Sheets ◽  
Abigail Carey-Ewend ◽  
Morgan Goetz ◽  
Juli Bago ◽  
...  
Keyword(s):  
Stem Cells ◽  
Neural Stem Cells ◽  
Direct Injection ◽  
Tumor Resection ◽  
Therapeutic Window ◽  
Current Standard ◽  
Light Sheet Microscopy ◽  
Resection Cavity ◽  
The Impact

Abstract Glioblastoma multiforme (GBM) is the most common primary brain cancer in adults. Afflicted patients have a median survival rate of only 15 months, and patient survival statistics have remained stagnant for over three decades. Current standard of care includes maximal safe tumor resection, chemotherapy, and radiation. Nevertheless, GBM is aggressive, making recurrence and deeper tumor infiltration inevitable. Neural stem cells transdifferentiated from a skin biopsy, i.e. induced neural stem cells (iNSCs), have the innate ability to home to tumors, and, when engineered with cytotoxic proteins, can actively kill cancer cells. However, direct injection of these cells into the hostile immune environment of the tumor resection cavity results in an accelerated clearance rate and therefore a shortened therapeutic window. To combat this clearance issue, we investigated the FDA-approved hemostatic matrix, Floseal, as a cell delivery platform to increase iNSC persistence. In vitro, SEM imaging showed homogeneous iNSC distribution throughout Floseal. Using our surgical resection model of GBM in mice, we delivered iNSCs into the post-surgical cavity in Floseal and by direct injection to model current clinical delivery strategies. Serial kinetic imaging showed that human iNSC persistence delivered into the cavity in Floseal persisted over 90 days, while cells directly injected into the brain parenchyma persist less than 20 days. When we investigated the impact on tumor kill, we found the increase in persistence increased survival of GBM-bearing mice more than 30 days compared to control cells. Light-sheet microscopy showed wild-type neural stem cells migrate into invasive GBM-8 tumors in the contralateral hemisphere, and we are now using this approach to validate the homing of iNSCs delivered via Floseal. Administration of iNSCs encapsulated in the biocompatible Floseal matrix offers a promising, clinically-translatable therapeutic strategy for GBM.

Pre- and Intraoperative Tractographic Evaluation of Corticospinal Tract Shift

Neurosurgery ◽  
2011 ◽  
Vol 69 (3) ◽  
pp. 696-705 ◽  
Author(s):  
Andrea Romano ◽  
Giancarlo D'Andrea ◽  
Luigi Fausto Calabria ◽  
Valeria Coppola ◽  
Camilla Rossi Espagnet ◽  
...  
Keyword(s):  
Corticospinal Tract ◽  
Diffusion Tensor ◽  
Tumor Resection ◽  
Brain Lesions ◽  
Peritumoral Edema ◽  
Brain Shift ◽  
Neuronavigation System ◽  
Dural Opening ◽  
Glioma Resection ◽  
The Brain

Abstract BACKGROUND: Magnetic resonance with diffusion tensor image (DTI) may be able to estimate trajectories compatible with subcortical tracts close to brain lesions. A limit of DTI is brain shifting (movement of the brain after dural opening and tumor resection). OBJECTIVE: To calculate the brain shift of trajectories compatible with the corticospinal tract (CST) in patients undergoing glioma resection and predict the shift directions of CST. METHODS: DTI was acquired in 20 patients and carried out through 12 noncollinear directions. Dedicated software “merged” all sequences acquired with tractographic processing and the whole dataset was sent to the neuronavigation system. Preoperative, after dural opening (in 11) and tumor resection (in all) DTI acquisitions were performed to evaluate CST shifting. The extent of shifting was considered as the maximum distance between the preoperative and intraoperative contours of the trajectories. RESULTS: An outward shift of CST was observed in 8 patients and an inward shift in 10 patients during surgery. In the remaining 2 patients, no intraoperative displacement was detected. Only peritumoral edema showed a statistically significant correlation with the amount of shift. In those patients in which DTI was acquired after dural opening as well (11 patients), an outward shifting of CST was evident in that phase. CONCLUSION: The use of intraoperative DTI demonstrated brain shifting of the CST. DTI evaluation of white matter tracts can be used during surgical procedures only if updated with intraoperative acquisitions.

Surgery for insular low-grade glioma: predictors of postoperative seizure outcome

2014 ◽  
Vol 120 (1) ◽  
pp. 12-23 ◽  
Author(s):  
Tamara Ius ◽  
Giada Pauletto ◽  
Miriam Isola ◽  
Giorgia Gregoraci ◽  
Riccardo Budai ◽  
...  
Keyword(s):  
Seizure Control ◽  
Tumor Resection ◽  
Low Grade Glioma ◽  
Seizure Outcome ◽  
Low Grade ◽  
Class Iii ◽  
The Difference ◽  
Drug Resistant Epilepsy ◽  
Postoperative Seizure ◽  
The Impact

Object Although a number of recent studies on the surgical treatment of insular low-grade glioma (LGG) have demonstrated that aggressive resection leads to increased overall patient survival and decreased malignant progression, less attention has been given to the results with respect to tumor-related epilepsy. The aim of this investigation was to evaluate the impact of volumetric, histological, and intraoperative neurophysiological factors on seizure outcome in patients with insular LGG. Methods The authors evaluated predictors of seizure outcome with special emphasis on both the extent of tumor resection (EOR) and the tumor's infiltrative pattern quantified by computing the difference between the preoperative T2- and T1-weighted MR images (ΔVT2T1) in 52 patients with preoperative drug-resistant epilepsy. Results The 12-month postoperative seizure outcome (Engel class) was as follows: seizure free (Class I), 67.31%; rare seizures (Class II), 7.69%; meaningful seizure improvement (Class III), 15.38%; and no improvement or worsening (Class IV), 9.62%. Poor seizure control was more common in patients with a longer preoperative seizure history (p < 0.002) and higher frequency of seizures (p = 0.008). Better seizure control was achieved in cases with EOR ≥ 90% (p < 0.001) and ΔVT2T1 < 30 cm3 (p < 0.001). In the final model, ΔVT2T1 proved to be the strongest independent predictor of seizure outcome in insular LGG patients (p < 0.0001). Conclusions No or little postoperative seizure improvement occurs mainly in cases with a prevalent infiltrative tumor growth pattern, expressed by high ΔVT2T1 values, which consequently reflects a smaller EOR.

scholarly journals SURG-36. IMPACT OF MULTIMODALITY MONITORING USING DIRECT ELECTRICAL STIMULATION TO DETERMINE CORTICOSPINAL TRACT SHIFT AND INTEGRITY IN THE iMRI suite

2016 ◽  
Vol 18 (suppl_6) ◽  
pp. vi198-vi198
Author(s):  
Daria Krivosheya ◽  
Ganesh Rao ◽  
Sudhakar Tummala ◽  
Vinodh Kumar ◽  
Dima Suki ◽  
...  
Keyword(s):  
Electrical Stimulation ◽  
Corticospinal Tract ◽  
Direct Electrical Stimulation ◽  
Multimodality Monitoring

scholarly journals The impact of susceptibility correction on diffusion metrics in adolescents

2021 ◽  
Author(s):  
Katri Lahti ◽  
◽  
Riitta Parkkola ◽  
Päivi Jääsaari ◽  
Leena Haataja ◽  
...  
Keyword(s):  
Corpus Callosum ◽  
Fractional Anisotropy ◽  
Corticospinal Tract ◽  
Diffusion Tensor ◽  
Length Distribution ◽  
Mean Diffusivity ◽  
Imaging Method ◽  
Brain White Matter ◽  
Significant Difference ◽  
The Impact

Abstract Background Diffusion tensor imaging is a widely used imaging method of brain white matter, but it is prone to imaging artifacts. The data corrections can affect the measured values. Objective To explore the impact of susceptibility correction on diffusion metrics. Materials and methods A cohort of 27 healthy adolescents (18 boys, 9 girls, mean age 12.7 years) underwent 3-T MRI, and we collected two diffusion data sets (anterior–posterior). The data were processed both with and without susceptibility artifact correction. We derived fractional anisotropy, mean diffusivity and histogram data of fiber length distribution from both the corrected and uncorrected data, which were collected from the corpus callosum, corticospinal tract and cingulum bilaterally. Results Fractional anisotropy and mean diffusivity values significantly differed when comparing the pathways in all measured tracts. The fractional anisotropy values were lower and the mean diffusivity values higher in the susceptibility-corrected data than in the uncorrected data. We found a significant difference in total tract length in the corpus callosum and the corticospinal tract. Conclusion This study indicates that susceptibility correction has a significant effect on measured fractional anisotropy, and on mean diffusivity values and tract lengths. To receive reliable and comparable results, the correction should be used systematically.

NCOG-46. WHITE MATTER TRACT INVOLVEMENT BY INTRA-AXIAL BRAIN TUMORS; DIAGNOSTIC & THERAPEUTIC IMPLICATIONS

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi162-vi162
Author(s):  
Saqib Kamran Bakhshi ◽  
Ayesha Quddusi ◽  
Danish Mahmood ◽  
Muhammad Waqas ◽  
Muhammad Shahzad Shamim ◽  
...  
Keyword(s):  
White Matter ◽  
Brain Tumors ◽  
Functional Outcome ◽  
Diffusion Tensor ◽  
Tumor Resection ◽  
Karnofsky Performance Scale ◽  
Low Grade ◽  
High Grade ◽  
Poor Functional Outcome

Abstract Diffusion tensor imaging (DTI) is a relatively recent modality which aids in visualization of WMT and their relation to intracranial lesions. Despite almost two decades since the beginning of its use in tumor resection, there is still dearth of data on its diagnostic and prognostic value from low- and middle-income countries. We aimed to assess the pattern of involvement of white matter tracts (WMT) by intra-axial brain tumors on DTI. Secondary objectives were to evaluate implications of involvement of WMT on surgical resection, and post-operative functional outcome. This was a retrospective study of 77 consecutive patients, who underwent DTI guided surgery for brain tumors. The involvement of WMT by tumors on DTI was assessed by a radiologist (who was blind to the pathology) using the Witwer classification. The pathology was reported by histopathologists using WHO brain tumor classification. Karnofsky Performance Scale (KPS) was used for assessing patients’ neurological status at admission, and at follow-up. Forty-five (58.4%) out of 77 tumors reviewed, caused infiltration of WMT, whereas only 22 (28.6%) tumors caused displacement of WMT (p = 0.040). Among 32 cases of astrocytoma, involvement of WMTs was influenced by the grade of tumor (p = 0.012), as high-grade tumors caused infiltration (19; 59.4%), unlike low grade tumors which commonly caused displacement (2; 50%). Oligodendroglioma caused infiltration/disruption of WMTs in most cases, irrespective of the grade (19 out of 25 cases; 76%). At last follow-up, 27 (35.1%) patients showed improvement in KPS and 14 (18.2%) reported deterioration, while there was no change observed in 36 (46.8%) patients. Infiltration of WMTs was associated with poor functional outcome. We conclude that intra-axial brain tumors mostly cause infiltration of WMTs, particularly high-grade astrocytoma, and oligodendroglioma of any grade. Infiltration of WMTs is associated with poor functional outcome at follow-up.

scholarly journals Intraoperative mapping of executive function using electrocorticography for patients with low-grade gliomas

2020 ◽  
Author(s):  
Yaara Erez ◽  
Moataz Assem ◽  
Pedro Coelho ◽  
Rafael Romero-Garcia ◽  
Mallory Owen ◽  
...  
Keyword(s):  
Electrical Stimulation ◽  
Executive Function ◽  
Executive Functions ◽  
Neural Activity ◽  
Task Difficulty ◽  
Awake Surgery ◽  
Low Grade ◽  
Direct Electrical Stimulation ◽  
High Gamma ◽  
Gamma Power

Abstract Background Intraoperative functional mapping with direct electrical stimulation during awake surgery for patients with diffuse low-grade glioma has been used in recent years to optimize the balance between surgical resection and quality of life following surgery. Mapping of executive functions is particularly challenging because of their complex nature, with only a handful of reports published so far. Here, we propose the recording of neural activity directly from the surface of the brain using electrocorticography to map executive functions and demonstrate its feasibility and potential utility. Methods To track a neural signature of executive function, we recorded neural activity using electrocorticography during awake surgery from the frontal cortex of three patients judged to have an appearance of diffuse low-grade glioma. Based on existing functional magnetic resonance imaging (fMRI) evidence from healthy participants for the recruitment of areas associated with executive function with increased task demands, we employed a task difficulty manipulation in two counting tasks performed intraoperatively. Following surgery, the data were extracted and analyzed offline to identify increases in broadband high-gamma power with increased task difficulty, equivalent to fMRI findings, as a signature of activity related to executive function. Results All three patients performed the tasks well. Data were recorded from five electrode strips, resulting in data from 15 channels overall. Eleven out of the 15 channels (73.3%) showed significant increases in high-gamma power with increased task difficulty, 26.6% of the channels (4/15) showed no change in power, and none of the channels showed power decrease. High-gamma power increases with increased task difficulty were more likely in areas that are within the canonical frontoparietal network template. Conclusions These results are the first step toward developing electrocorticography as a tool for mapping of executive function complementarily to direct electrical stimulation to guide resection. Further studies are required to establish this approach for clinical use.

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