“Cerebellar lesions after low-grade tumor resection can induce memory impairment in children, similar to that observed in patients with frontal lesions”

Abstract BACKGROUND: Use of diffusion tensor imaging (DTI) in brain tumor resection has been limited in part by a perceived difficulty in implementing the techniques into neurosurgical practice. OBJECTIVE: To demonstrate a simple DTI postprocessing method performed without a neuroscientist and to share results in preserving patient function while aggressively resecting tumors. METHODS: DTI data are obtained in all patients with tumors located within presumed eloquent cortices. Relevant white matter tracts are mapped and integrated with neuronavigation by a nonexpert in < 20 minutes. We report operative results in 43 consecutive awake craniotomy patients from January 2014 to December 2014 undergoing resection of intracranial lesions. We compare DTI-expected findings with stimulation mapping results for the corticospinal tract, superior longitudinal fasciculus, and inferior fronto-occipital fasciculus. RESULTS: Twenty-eight patients (65%) underwent surgery for high-grade gliomas and 11 patients (26%) for low-grade gliomas. Seventeen patients had posterior temporal lesions; 10 had posterior frontal lesions; 8 had parietal-temporal-occipital junction lesions; and 8 had insular lesions. With DTI-defined tracts used as a guide, a combined 65 positive maps and 60 negative maps were found via stimulation mapping. Overall sensitivity and specificity of DTI were 98% and 95%, respectively. Permanent speech worsening occurred in 1 patient (2%), and permanent weakness occurred in 3 patients (7%). Greater than 90% resection was achieved in 32 cases (74%). CONCLUSION: Accurate DTI is easily obtained, postprocessed, and implemented into neuronavigation within routine neurosurgical workflow. This information aids in resecting tumors while preserving eloquent cortices and subcortical networks.

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NI-01 Usefulness of preoperative evaluation of glioma elasticity by the magnetic resonance elastography

Neuro-Oncology Advances ◽

10.1093/noajnl/vdaa143.054 ◽

2020 ◽

Vol 2 (Supplement_3) ◽

pp. ii12-ii13

Author(s):

Shinichiro Koizumi ◽

Kazuhiko Kurozumi

Keyword(s):

Elastic Modulus ◽

Magnetic Resonance ◽

Preoperative Evaluation ◽

Tumor Resection ◽

High Grade Glioma ◽

Magnetic Resonance Elastography ◽

Low Grade ◽

Intracranial Tumors ◽

Grade 3 ◽

Malignant Grade

Abstract Introduction: The elasticity of intracranial tumors is difficult to assess non-invasively because the lesion is surrounded by the skull. Therefore, intracranial tumors have not been verified before surgery in terms of elastic modulus. Magnetic resonance elastography (MRE) is an epoch-making method capable of non-invasively imaging the elasticity of internal organs. We have examined the elasticity of meningiomas and pituitary adenomas and reported their usefulness. This time, we measured the glioma elasticity and verified usefulness of MRE. Method: Twenty-four gliomas (mean age 51.8±15.7 years, male: female = 17: 7) who underwent tumor resection after MRE imaging from July 2017 to May 2020 were targeted. The average elasticity was measured as an evaluation of tumor elastic modulus by MRE. Gliomas were divided into a low-grade glioma group (LGG: Grade 1, 2) and a high-grade glioma group (HGG: Grade 3, 4). Then, a comparative statistical study was conducted. Results: The average values of the average elasticity of LGG group (9 cases) and HGG group (15 cases) were 1.8±0.8 kPa and 2.5±0.8 kPa, respectively. The average elasticity was significantly higher in the HGG group (p=0.023). In the ROC analysis, the cutoff value was 2.1 kPa (sensitivity 70%, specificity 70%). Therefore, it was suggested that the tumor is likely to be HGG when the average elasticity is 2.1 kPa or more. Discussion: The glioma elasticity by preoperative MRE was significantly higher in the HGG group. Based on actual surgical experience, the tumor seems to be hard in the HGG group, and it was judged to be consistent with this our MRE research. The preoperative evaluation of glioma elasticity by MRE was considered useful, and it might help in planning a surgical strategy considering malignant grade.

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Predictors of tumor progression among children with gangliogliomas

Journal of Neurosurgery Pediatrics ◽

10.3171/2009.2.peds0861 ◽

2009 ◽

Vol 3 (6) ◽

pp. 461-466 ◽

Cited By ~ 25

Author(s):

Mostafa El Khashab ◽

Lynn Gargan ◽

Linda Margraf ◽

Korgun Koral ◽

Farideh Nejat ◽

...

Keyword(s):

Risk Factors ◽

Tumor Progression ◽

Cox Regression ◽

Tumor Resection ◽

Progression Free Survival ◽

Initial Presentation ◽

Subtotal Resection ◽

Low Grade ◽

Cox Regression Analysis ◽

Presenting Symptoms

Object Few reports describe the outcome and prognostic factors for children with gangliogliomas. The objective of this report was to describe the progression-free survival (PFS) for children with low-grade gangliogliomas and identify risk factors for tumor progression. Methods A retrospective study was performed in children with low-grade gangliogliomas who were evaluated and treated in the neuro-oncology department between 1986 and 2006 to determine risk factors for subsequent tumor progression. Results A total of 38 children with newly diagnosed gangliogliomas were included in this report. Thirty-four children were treated with surgery alone, 3 with subtotal resection and radiation therapy, and 1 with subtotal resection and chemotherapy. The follow-up ranged from 4 months to 15.8 years (mean 5.7 ± 4.2 years [± SD]). Seven children have experienced tumor progression, and 1 child died after his tumor subsequently underwent malignant transformation. The 5-year PFS was calculated to be 81.2% using Kaplan-Meier survival analysis. Initial presentation with seizures (p = 0.004), tumor location in the cerebral hemisphere (p = 0.020), and complete tumor resection (p = 0.035) were associated with prolonged PFS. Further analysis of the above significant variables by a Cox regression model identified initial presentation with seizures as being associated with prolonged PFS (p = 0.028). Conclusions The PFS and overall survival of children with gangliogliomas are good. Tumors located in the cerebral hemispheres, the achievement of total resection, and seizures at presentation were associated with prolonged PFS. Cox regression analysis identified presenting symptoms including seizures as significant predictive factors of PFS. Prospective studies with larger numbers of children are needed to define the significant factors of tumor progression.

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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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Low-grade astrocytoma: surgical outcomes in eloquent versus non-eloquent brain areas

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2012005000017 ◽

2013 ◽

Vol 71 (1) ◽

pp. 31-34 ◽

Cited By ~ 7

Author(s):

André de Macedo Bianco ◽

Flavio Key Miura ◽

Carlos Clara ◽

Jose Reynaldo W. Almeida ◽

Clemar Correa da Silva ◽

...

Keyword(s):

Overall Survival ◽

Tumor Resection ◽

Progression Free Survival ◽

Subtotal Resection ◽

Low Grade ◽

Brain Areas ◽

Free Survival ◽

Eloquent Areas ◽

Eloquent Area ◽

Extent Of Surgical Resection

A retrospective study of 81 patients with low-grade astrocytoma (LGA) comparing the efficacy of aggressive versus less aggressive surgery in eloquent and non-eloquent brain areas was conducted. Extent of surgical resection was analyzed to assess overall survival (OS) and progression- free survival (PFS). Degree of tumor resection was classified as gross total resection (GTR), subtotal resection (STR) or biopsy. GTR, STR and biopsy in patients with tumors in non-eloquent areas were performed in 31, 48 and 21% subjects, whereas in patients with tumors in eloquent areas resections were 22.5, 35 and 42.5%. Overall survival was 4.7 and 1.9 years in patients with tumors in non-eloquent brain areas submitted to GTR/STR and biopsy (p=0.013), whereas overall survival among patients with tumors in eloquent area was 4.5 and 2.1 years (p=0.33). Improved outcome for adult patients with LGA is predicted by more aggressive surgery in both eloquent and non-eloquent brain areas.

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Left Pan-Hippocampal Low Grade Glioma—2-Stage Transsylvian Transventricular and Paramedian Supracerebellar Transtentorial Approaches: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy214 ◽

2018 ◽

Vol 16 (3) ◽

pp. E82-E82

Author(s):

Juan C Fernandez-Miranda

Keyword(s):

Tumor Resection ◽

Spatial Relationship ◽

Low Grade Glioma ◽

Parahippocampal Gyrus ◽

Surgical Approaches ◽

Low Grade ◽

Fiber Tractography ◽

High Definition ◽

Posterior Portion ◽

Fiber Tracts

Abstract The surgical goal for low-grade gliomas (LGGs) is to maximize resection while minimizing morbidity. Pan-hippocampal LGGs extend from the hippocampal head to the hippocampal tail, and involve the parahippocampal gyrus and uncus. Given their anteroposterior extension, they cannot be completely removed with 1 single approach, requiring a 2-stage front-to-back operation. In this video, we present the case of a 52-yr-old man with new onset of generalized seizures and a dominant-side, nonenhancing, pan-hippocampal infiltrative lesion compatible with a low-grade glioma. Preoperative high-definition fiber tractography (HDFT) showed the spatial relationship of the tumor with surrounding fiber tracts, such as the arcuate, inferior fronto-occipital, and middle longitudinal fascicles, and optic radiations. Surgical resection was planned in 2 separate stages. The first stage consisted of a transsylvian transinferior insular sulcus approach to the extra- and intraventricular aspects of the uncohippocampal region. The entire anterior and middle portions of the tumor were successfully removed with minimal morbidity, including transient naming difficulties and permanent superior quadrantanopia. Postoperative HDFT showed preservation of all fiber tracts, except for a portion of Meyer's loop and the inferior-most aspect of the inferior fronto-occipital fascicle. The second stage was completed 8 wk later and consisted of a paramedian supracerebellar-transtentorial approach on sitting position. The posterior portion of the tumor was entirely removed to achieve a complete macroscopic tumor resection. The final diagnosis was IDH1-positive LGG. Pan-hippocampal tumors remain a surgical challenge but accurate knowledge of surgical neuroanatomy and surgical approaches facilitates their safe and effective treatment. The patient signed an informed consent including the use of photographic and video material for educational or academic purposes.

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Stereotactic brachytherapy of low-grade cerebral glioma after tumor resection

Neuro-Oncology ◽

10.1093/neuonc/nor100 ◽

2011 ◽

Vol 13 (10) ◽

pp. 1133-1142 ◽

Cited By ~ 27

Author(s):

B. Suchorska ◽

M. Ruge ◽

H. Treuer ◽

V. Sturm ◽

J. Voges

Keyword(s):

Tumor Resection ◽

Low Grade ◽

Cerebral Glioma ◽

Stereotactic Brachytherapy

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

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1698383 ◽

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.

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