scholarly journals Revisiting Intraoperative 2D USG with Saline–Air Mixture as Contrast for Resection of Eloquent Area Glioma in Resource-Deficient Countries

2021 ◽  
Author(s):  
Sushanta K. Sahoo ◽  
Pravin Salunke ◽  
Chirag Kamal Ahuja
Keyword(s):  
High Grade Glioma ◽  
Extent Of Resection ◽  
Brain Parenchyma ◽  
Low Grade ◽  
Glioma Surgery ◽  
Residual Lesion ◽  
Resection Cavity ◽  
Resource Limited ◽  
Eloquent Area ◽  
Magnetic Resonance Imaging Mri

Abstract Background Advanced ultrasound, intraoperative magnetic resonance imaging (MRI), neuromonitoring, and aminolevulenic acid have improved the resection and safety of eloquent area gliomas. However, availability of these modern gadgets is a major concern in resource-deficient countries. A two-dimensional ultrasonography 2D USG is cheaper, provides real-time imaging, and is already established but underutilized instrument. Objective Here, we revisited the principles of 2D USG and used it for eloquent-area glioma surgery. Materials and Methods Fifty-eight patients with eloquent area gliomas were operated in last 2 years with the aid of 2D USG with 6-13 MHz curvilinear probe. Preoperative diagnosis was high-grade glioma in 38 and low-grade glioma (LGG) in 20 patients. Tumors were categorized as predominantly hyperechoic (27), uniformly hyperechoic (7), mixed echogenicity (21), and cystic (3). Results Intraoperatively, 2D USG could define the tumor margins in 46 cases. Of these, USG suggested gross total excision in 38 patients and subtotal in 8 patients. The findings matched with follow-up MRI in 34 patients who showed hyperechogenicity (predominant/uniform). Injecting saline with air in to the resection cavity and insinuating through adjacent brain parenchyma helped in detecting residual lesion in three cystic gliomas and in two LGG where the tumor cavity collapsed. Conclusion 2D USG is a helpful tool in eloquent area glioma surgery, especially in resource-limited countries. Visualization through adjacent parenchyma and injection of saline–air mixture in to the resection cavity helped in delineating residual lesion. Extent of resection is best monitored by 2D USG when tumor appeared hyperechoic (predominant/uniform).

scholarly journals Contribution of combined intraoperative electrophysiological investigation with 3-T intraoperative MRI for awake cerebral glioma surgery: comprehensive review of the clinical implications and radiological outcomes

2016 ◽  
Vol 40 (3) ◽  
pp. E14 ◽  
Author(s):  
Diana Ghinda ◽  
Nan Zhang ◽  
Junfeng Lu ◽  
Cheng-Jun Yao ◽  
Shiwen Yuan ◽  
...  
Keyword(s):  
Learning Curve ◽  
High Grade Glioma ◽  
Awake Craniotomy ◽  
Low Grade ◽  
High Grade ◽  
Short Term ◽  
Glioma Surgery ◽  
Eloquent Area ◽  
Short And Long Term

OBJECTIVE This study aimed to assess the clinical efficiency of combined awake craniotomy with 3-T intraoperative MRI (iMRI)–guided resection of gliomas adjacent to eloquent cortex performed at a single center. It also sought to explore the contribution of iMRI to surgeons' learning process of maximal safe resection of gliomas. METHODS All patients who underwent an awake craniotomy and iMRI for resection of eloquent area glioma during the 53 months between January 2011 and June 2015 were included. The cases were analyzed for short- and long-term neurological outcome, progression-free survival (PFS), overall survival (OS), and extent of resection (EOR). The learning curve was assessed after dividing the cohort into Group A (first 27 months) and Group B (last 26 months). Statistical analyses included univariate logistic regression analysis on clinical and radiological variables. Kaplan-Meier and Cox regression models were used for further analysis of OS and PFS. A p value < 0.05 was considered statistically significant. RESULTS One hundred six patients were included in the study. Over an average follow-up period of 24.8 months, short- and long-term worsening of the neurological function was noted in 48 (46.2%) and 9 (8.7%) cases, respectively. The median and mean EOR were 100% and 92%, respectively, and complete radiographic resection was achieved in 64 (60.4%) patients. The rate of gross-total resection (GTR) in the patients with low-grade glioma (89.06% ± 19.6%) was significantly lower than that in patients with high-grade glioma (96.4% ± 9.1%) (p = 0.026). Thirty (28.3%) patients underwent further resection after initial iMRI scanning, with a 10.1% increase of the mean EOR. Multivariate Cox proportional hazards modeling demonstrated that the final EOR was a significant predictor of PFS (HR 0.225, 95% CI 0.070–0.723, p = 0.012). For patients with high-grade glioma, the GTR (p = 0.033), the presence of short-term motor deficit (p = 0.027), and the WHO grade (p = 0.005) were independent prognostic factors of OS. Performing further resection after the iMRI (p = 0.083) and achieving GTR (p = 0.05) demonstrated a PFS benefit trend for the patients affected by a low-grade glioma. Over time, the rate of performing further resection after an iMRI decreased by 26.1% (p = 0.005). A nonsignificant decrease in the rate of short-term (p = 0.101) and long-term (p = 0.132) neurological deficits was equally noted. CONCLUSIONS Combined awake craniotomy and iMRI is a safe and efficient technique allowing maximal safe resection of eloquent area gliomas with possible subsequent OS and PFS benefits. Although there is a learning curve for applying this technique, it can also improve the surgeon's ability in eloquent glioma surgery.

scholarly journals STMO-11 CLINICAL EFFICACY OF AWAKE SURGERY: ANALYSIS OF 335 CASE ON EXTENT OF RESECTION AND SURVIVAL TIME

2019 ◽  
Vol 1 (Supplement_2) ◽  
pp. ii20-ii20
Author(s):  
Atsushi Fukui ◽  
Yoshihiro Muragaki ◽  
Takashi Maruyama ◽  
Taiichi Saito ◽  
Masayuki Nitta ◽  
...  
Keyword(s):  
Overall Survival ◽  
Multivariate Analysis ◽  
General Anesthesia ◽  
Extent Of Resection ◽  
Awake Surgery ◽  
Significant Prognostic Factor ◽  
Glioma Surgery ◽  
Long Term Outcome ◽  
Significant Difference ◽  
Eloquent Area

Abstract INTRODUCTION Awake craniotomy (AS) with intraoperative mapping can be compatible to obtain maximal resection and preserve neurological function for glioma surgery. However, there is less evidence to improve overall survival for glioma patients. We compared the long-term outcome of glioma resection during AS and general anesthesia (GA). METHODS Continuous 335 patients with newly diagnosed glioma of WHO grade2 (G2) or higher who underwent surgery with intraoperative MRI between 2000 and 2013 were reviewed. Three-dimensional volumetric tumor measurements before and after operation were made. Multivariate analysis was used to evaluate the effect of awake surgery on overall survival (OS). RESULTS The mean age of all cases was 46 years, male: female 199: 136, mean preoperative tumor volume (PTV) 44.5cc, mean extent of resection (EOR) 88.31%, and median survival (MST) 82.6 months. MST of G4 was significantly longer in the AS group (AS 38.9 months vs. GA group 22.0 months: p = 0.03), while multivariate analysis showed that age and KPS was a significant prognostic factor, but AS was not. There was no significant difference in the EOR of G3 (AS group 80.1% vs. general anesthesia 84.2%: p = 0.365), and MST was also not significantly different (AS group 134.8 months vs. GA group 117.9 months: p = 0.338). G2 also had no significant difference in the EOR (AS group 84.6% vs. GA group 86.7%; p = 0.92), and MST was also not significantly different (AS group 152.9 months vs. GA group 135.1 months: p = 0.235). Analysis of G2 or G3 showed no significant differences in PTV, KPS, and age at the surgery between two groups. CONCLUSION Even if a glioma is located close to or within the eloquent area, AS can lead to EOR and OS equivalent to the removal of the non-eloquent area under GA.

scholarly journals SURG-32. THE USE OF 5-AMINOLEVULINIC ACID IN LOW-GRADE GLIOMA RESECTION: A SYSTEMATIC REVIEW

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi246-vi246
Author(s):  
Ahmad Almekkawi ◽  
Tarek El Ahmadieh ◽  
Karl Abi-Aad ◽  
Salah Aoun ◽  
Najib EL Tecle ◽  
...  
Keyword(s):  
Systematic Review ◽  
Quality Index ◽  
Aminolevulinic Acid ◽  
High Grade Glioma ◽  
Extent Of Resection ◽  
Low Grade Glioma ◽  
Low Grade ◽  
High Grade ◽  
Visualization Technology ◽  
Glioma Resection

Abstract BACKGROUND 5-aminolevulinic acid is a reliable tool for optimizing high-grade glioma resection. However, its efficacy in low-grade glioma resection remains unclear. OBJECTIVE To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and effect on the extent of resection. METHODS A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. Quality index of the selected papers using the Downs and Black criteria checklist was provided. RESULTS Twelve articles met the selection criteria with 244 histologically-confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n=60/244; 24.5%) demonstrated visual intra-operative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies, however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10–17) which correlated with an overall good quality. CONCLUSION There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

scholarly journals Navigated Intraoperative 2-Dimensional Ultrasound in High-Grade Glioma Surgery: Impact on Extent of Resection and Patient Outcome

2019 ◽  
Author(s):  
Alessandro Moiraghi ◽  
Francesco Prada ◽  
Alberto Delaidelli ◽  
Ramona Guatta ◽  
Adrien May ◽  
...  
Keyword(s):  
Real Time ◽  
Karnofsky Performance Status ◽  
Performance Status ◽  
Intraoperative Ultrasound ◽  
High Grade Glioma ◽  
Extent Of Resection ◽  
High Grade ◽  
Glioma Surgery ◽  
Supratentorial Gliomas ◽  
The Impact

Abstract BACKGROUND Maximizing extent of resection (EOR) and reducing residual tumor volume (RTV) while preserving neurological functions is the main goal in the surgical treatment of gliomas. Navigated intraoperative ultrasound (N-ioUS) combining the advantages of ultrasound and conventional neuronavigation (NN) allows for overcoming the limitations of the latter. OBJECTIVE To evaluate the impact of real-time NN combining ioUS and preoperative magnetic resonance imaging (MRI) on maximizing EOR in glioma surgery compared to standard NN. METHODS We retrospectively reviewed a series of 60 cases operated on for supratentorial gliomas: 31 operated under the guidance of N-ioUS and 29 resected with standard NN. Age, location of the tumor, pre- and postoperative Karnofsky Performance Status (KPS), EOR, RTV, and, if any, postoperative complications were evaluated. RESULTS The rate of gross total resection (GTR) in NN group was 44.8% vs 61.2% in N-ioUS group. The rate of RTV > 1 cm3 for glioblastomas was significantly lower for the N-ioUS group (P < .01). In 13/31 (42%), RTV was detected at the end of surgery with N-ioUS. In 8 of 13 cases, (25.8% of the cohort) surgeons continued with the operation until complete resection. Specificity was greater in N-ioUS (42% vs 31%) and negative predictive value (73% vs 54%). At discharge, the difference between pre- and postoperative KPS was significantly higher for the N-ioUS (P < .01). CONCLUSION The use of an N-ioUS-based real-time has been beneficial for resection in noneloquent high-grade glioma in terms of both EOR and neurological outcome, compared to standard NN. N-ioUS has proven usefulness in detecting RTV > 1 cm3.

scholarly journals Functional preoperative and intraoperative mapping and monitoring: increasing safety and efficacy in glioma surgery

2015 ◽  
Vol 38 (1) ◽  
pp. E3 ◽  
Author(s):  
Malte Ottenhausen ◽  
Sandro M. Krieg ◽  
Bernhard Meyer ◽  
Florian Ringel
Keyword(s):  
Diffusion Tensor ◽  
Imaging Techniques ◽  
Extent Of Resection ◽  
Low Grade ◽  
Glioma Surgery ◽  
Intraoperative Mapping ◽  
Fiber Tracts ◽  
Functional Localization ◽  
Eloquent Cortex ◽  
Cortical Regions

Greater extent of resection (EOR) of low-grade gliomas is associated with improved survival. Proximity to eloquent cortical regions often limits resectability and elevates the risk of surgery-related deficits. Therefore, functional localization of eloquent cortex or subcortical fiber tracts can enhance the EOR and functional outcome. Imaging techniques such as functional MRI and diffusion tensor imaging fiber tracking, and neurophysiological methods like navigated transcranial magnetic stimulation and magnetoencephalography, make it possible to identify eloquent areas prior to resective surgery and to tailor indication and surgical approach but also to assess the surgical risk. Intraoperative monitoring with direct cortical stimulation and subcortical stimulation enables surgeons to preserve essential functional tissue during surgery. Through tailored pre- and intraoperative mapping and monitoring the EOR can be maximized, with reduced rates of surgery-related deficits.

scholarly journals Rationale and Clinical Implications of Fluorescein-Guided Supramarginal Resection in Newly Diagnosed High-Grade Glioma

2021 ◽  
Vol 11 ◽  
Author(s):  
Linda M. Wang ◽  
Matei A. Banu ◽  
Peter Canoll ◽  
Jeffrey N. Bruce
Keyword(s):  
Overall Survival ◽  
Surgical Resection ◽  
Local Treatment ◽  
Standard Of Care ◽  
High Grade Glioma ◽  
Extent Of Resection ◽  
Brain Parenchyma ◽  
Clinical Implications ◽  
Current Standard ◽  
Supramarginal Resection

Current standard of care for glioblastoma is surgical resection followed by temozolomide chemotherapy and radiation. Recent studies have demonstrated that &gt;95% extent of resection is associated with better outcomes, including prolonged progression-free and overall survival. The diffusely infiltrative pattern of growth in gliomas results in microscopic extension of tumor cells into surrounding brain parenchyma that makes complete resection unattainable. The historical goal of surgical management has therefore been maximal safe resection, traditionally guided by MRI and defined as removal of all contrast-enhancing tumor. Optimization of surgical resection has led to the concept of supramarginal resection, or removal beyond the contrast-enhancing region on MRI. This strategy of extending the cytoreductive goal targets a tumor region thought to be important in the recurrence or progression of disease as well as resistance to systemic and local treatment. This approach must be balanced against the risk of impacting eloquent regions of brain and causing permanent neurologic deficit, an important factor affecting overall survival. Over the years, fluorescent agents such as fluorescein sodium have been explored as a means of more reliably delineating the boundary between tumor core, tumor-infiltrated brain, and surrounding cortex. Here we examine the rationale behind extending resection into the infiltrative tumor margins, review the current literature surrounding the use of fluorescein in supramarginal resection of gliomas, discuss the experience of our own institution in utilizing fluorescein to maximize glioma extent of resection, and assess the clinical implications of this treatment strategy.

scholarly journals RTHP-30. DOES THE TEMPORAL LOBECTOMY CAVITY NEED TO BE IRRADIATED? PATTERNS OF RECURRENCE AND IMPLICATIONS FOR POSTOPERATIVE RADIATION TREATMENT FIELD DESIGN FOR TEMPORAL LOBE GLIOMAS.

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi216-vi216
Author(s):  
Achiraya Teyateeti ◽  
Connie Geno ◽  
Paul Brown ◽  
Krishan Jethwa ◽  
Scott Stafford ◽  
...  
Keyword(s):  
Temporal Lobe ◽  
Radiation Treatment ◽  
Progression Free Survival ◽  
Tumor Grade ◽  
Brain Parenchyma ◽  
Temporal Lobectomy ◽  
Low Grade ◽  
Who Grade ◽  
Resection Cavity ◽  
Target Volumes

Abstract BACKGROUND Treatment of temporal lobe glioma (TLG) frequently includes partial or complete temporal lobectomy (TL) followed by radiotherapy (RT). However, there are two approaches for temporal resection cavity RT, 1) standard target volumes (STV) targeting the entire TL resection cavity, dura, and peri-tumoral brain parenchyma or 2) modified target volumes (MTV) targeting only the adjacent peri-tumoral brain parenchyma. We report patterns of failure and a dosimetric comparison of these approaches. MATERIALS AND METHODS This was a retrospective review of 49 patients with WHO grade II-IV TLG who underwent partial or complete TL and post-operative RT between 1998 and 2018. Progression-free survival (PFS) was estimated using the Kaplan-Meier method. RESULTS The median patient age was 56 years (range,21–76). Patients were diagnosed with glioblastoma (n=32,65%), anaplastic glioma (n=10,20%) and low-grade glioma (n=7,14%). Treatment included partial TL with STV (n=33,67%), partial TL with MTV (n=5,10%), complete TL with STV (n=8,16%) and complete TL with MTV (n=3,6%). Mean RT dose was 60 Gy (range,40–76) in 30 fractions (range,15–39). At median follow-up time of 18 months (range, 3–161), 44 patients (90%) experienced recurrence: 34 (77%) in-field, 5 (11%) out-of-field, and 5 (11%) both in- and out-of-field. Among the 39 in-field failures, the location of recurrence included brain parenchyma (n=38,97%), ventricle (n=6,15%), and dura (n=5,13%). No patient experienced isolated dural recurrence regardless of tumor grade, extent of TL, or radiation volume. Median PFS was 20 months (95% confidence interval [CI]: 15–24). RT volume (STV vs. MTV) was not associated with worsened PFS (hazard ratio: 1.1, 95% CI: 0.5–2.6). MTV was associated with significant reductions in mean or max doses to brain stem, optic chiasm, optic nerves, hippocampus, and pituitary compared to STV. CONCLUSION Omitting RT to the entire TL cavity may reduce dose to multiple normal tissues with no detriments in dural recurrence or PFS.

scholarly journals Extent of Glioma Resection on Intraoperative Ultrasound Correlates Well with Postoperative MRI Results

2019 ◽  
pp. 1-7
Author(s):  
Ahmed Aly ◽  
Radwan Noubi ◽  
Mahmoud Ragab ◽  
Khalid Abdelaziz ◽  
Simon Howarth ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Intraoperative Imaging ◽  
Intraoperative Ultrasound ◽  
Extent Of Resection ◽  
Control Group ◽  
P Value ◽  
Low Grade ◽  
Ultrasound Images ◽  
Glioma Surgery ◽  
Number Of Patients

Background: Maximal surgical resection is thought to confer survival benefit for both high- and low-grade gliomas. Intraoperative imaging assists with achieving maximal surgical resection. Different intraoperative imaging modalities have been implemented, but intra-operative MRI has a high cost that may limit its uptake in resource scarce healthcare systems. Objectives: This study aims to evaluate intraoperative ultrasound as a surrogate for intra and post-operative MRI for assessing the extent of resection of glioma. Methods: A partially prospective comparative study, which compares a prospective cohort group with a historical control group. We evaluated 74 glioma patients, who all underwent surgery in a regional UK Neurosurgical centre between October 2013 and October 2017. The study population was divided into 2 groups based on the use of ultrasound to guide the resection. We compared the size of the lesion prior and after excision to evaluate the extent of resection and undertook comparison with post-operative MRI. Results: The mean extent of resection on the ultrasound images was 96.1 % and 97.7 % on the postoperative MR. Using Spearman’s correlation; extent of resection on the ultrasound images was strongly correlated with the extent of resection on the postoperative MR images (P=value <0.001). The use of intraoperative ultrasound was associated with a significant increase in the number of patients in whom 95% or greater extent of resection was achieved (Fisher’s exact test P= value 0.033). Conclusion: Intra-operative ultrasonography could provide a reliable and cheaper alternative to intraoperative MRI to improve the extent of resection in glioma surgery.

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