STMO-03 Surgical resection for precentral gyrus glioma

Abstract Primary motor cortex glioma is usually considered unresectable because of its high risk for motor deficit. However, recent reports suggest that surgical resection for primary motor cortex brain tumor is feasible for selected patients. In this study, we analyzed the neurological outcomes for 27 patients who underwent surgical resections for precentral gyrus glioma. Glioma grades for 27 patients were Grade II in 6 cases, Grade III in 7 cases, and Grade IV in 13 cases. 11 patients were recurrent glioma cases and glioma grade for those patients were Grade II in 4 cases, Grade III in 3 cases, and Grade IV in 4 cases. Extent of resection for 27 patients was biopsy in 2 cases, partial resection in 16 cases, and more than 90% of resections in 9 cases. 6 patients underwent awake surgery and glioma grade for those patients were Grade II in 3 cases, Grade III in 2 cases, and Grade IV in 1 case. Median extent of resection for patients who underwent awake surgery was 90%. Transient neurological worsening was observed in 5 patients, however, no patient exhibited permanent neurological deficit. Surgical resections for primary motor cortex glioma were feasible in selected patients without severe neurological complication. Careful intraoperative awake mapping is desirable to achieve maximum resections.

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STMO-10 SURGICAL RESECTION FOR PRIMARY MOTOR CORTEX GLIOMA, TWO CASE REPORTS

Neuro-Oncology Advances ◽

10.1093/noajnl/vdz039.088 ◽

2019 ◽

Vol 1 (Supplement_2) ◽

pp. ii19-ii20

Author(s):

Noriyuki Kijima ◽

Manabu Kinoshita ◽

Ryuichi Hirayama ◽

Tohru Umehara ◽

Chisato Yokota ◽

...

Keyword(s):

Radiation Therapy ◽

Motor Cortex ◽

Neural Plasticity ◽

Primary Motor Cortex ◽

Case Reports ◽

Neurological Complication ◽

Awake Surgery ◽

Motor Deficit ◽

Initial Surgery ◽

Second Surgery

Abstract Primary motor cortex glioma is usually considered unresectable because of its high risk for motor deficit. However recent reports suggest that surgical resections for primary motor cortex brain tumor is feasible for selected patients. In this case report, we report two cases we can successfully resected primary motor cortex glioma by awake surgery without neurological worsening. Case1 was 32 year-old woman with right primary motor cortex oligodendroglioma. We could only perform biopsy at initial surgery, however the patient got worsening of left hemiparesis which were gradually improved by rehabilitation. The patient underwent 50 Gy of radiation therapy and 6 courses of PCV chemotherapy. 60 months after the initial surgery, the tumor recurred and the she underwent 12 courses of temozolomide chemotherapy, but tumor continued to grow. She underwent second surgery 13 years after the initial biopsy. We resected primary motor cortex tumor by awake surgery without neurological complication. Case2 was 31 year-old woman with left primary motor cortex oligodendroglioma. We could only perform biopsy at initial surgery, however the patient got mild right hemiparesis which were improved by rehabilitation. The patient underwent 4 courses of PAV chemotherapy and 54 Gy of Intensity Modulated Radiation Therapy (IMRT). 21 months after IMRT, the tumor recurred and the she underwent second surgery. We resected primary motor cortex tumor by awake motor mapping without severe neurological complication. In conclusion, surgical resections for primary motor cortex glioma is feasible in selected patients without severe neurological complication. Neural plasticity is the reason for this, but careful intraoperative awake mapping is necessary to achieve maximum resections.

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Pre- and Intraoperative Mapping for Tumors in the Primary Motor Cortex: Decision-Making Process in Surgical Resection

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0040-1709729 ◽

2020 ◽

Author(s):

José Pedro Lavrador ◽

Prajwal Ghimire ◽

Christian Brogna ◽

Luciano Furlanetti ◽

Sabina Patel ◽

...

Keyword(s):

Decision Making ◽

Motor Cortex ◽

Surgical Resection ◽

Process Model ◽

Primary Motor Cortex ◽

Treatment Plan ◽

Motor Deficit ◽

Decision Making Process ◽

Total Resection ◽

Intraoperative Mapping

Abstract Background Lesions within the primary motor cortex (M1) and the corticospinal tract (CST) represent a significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centered treatment plan. Methods Patients with lesions within the M1 and CST with preoperative cortical and subcortical mapping (navigated transcranial magnetic stimulation [nTMS] and tractography), intraoperative mapping, and intraoperative provisional histologic information (smear with and without 5-aminolevulinic acid [5-ALA]) were included. This independently acquired information was integrated in a decision-making process model to determine the intraoperative extent of resection. Results A total of 10 patients (6 patients with metastatic precentral tumor; 1 patient with grade III and 2 patients with grade IV gliomas; 1 patient with precentral cavernoma) were included in the study. Most of the patients (60%) had a preoperative motor deficit. The nTMS documented M1 invasion in all cases, and in eight patients, the lesions were embedded within the CST. Overall, 70% of patients underwent gross total resection; 20% of patients underwent near-total resection of the lesions. In only one patient was no surgical resection possible after both preoperative and intraoperative mapping. Overall, 70% of patients remained stable postoperatively, and previous motor weakness improved in 20%. Conclusion The independently acquired anatomical (anatomical MRI) and functional (nTMS and tractography) tests in patients with CST lesions provide a useful guide for resection. The inclusion of histologic information (smear with or without 5-ALA) further allows the surgical team to balance the potential functional risks within the global treatment plan. Therefore, the patient is kept at the center of the informed decision-making process.

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Resection of primary motor cortex tumors: feasibility and surgical outcomes

Journal of Neurosurgery ◽

10.3171/2017.5.jns163045 ◽

2018 ◽

Vol 129 (4) ◽

pp. 961-972 ◽

Cited By ~ 13

Author(s):

Stephen T. Magill ◽

Seunggu J. Han ◽

Jing Li ◽

Mitchel S. Berger

Keyword(s):

Motor Cortex ◽

General Anesthesia ◽

Motor Response ◽

Primary Motor Cortex ◽

Extent Of Resection ◽

Motor Deficit ◽

Motor Deficits ◽

Motor Mapping ◽

Postoperative Mri ◽

Significant Difference

OBJECTIVEBrain tumors involving the primary motor cortex are often deemed unresectable due to the potential neurological consequences that result from injury to this region. Nevertheless, we have challenged this dogma for many years and used asleep, as well as awake, intraoperative stimulation mapping to maximize extent of resection. It remains unclear whether these tumors can be resected with acceptable morbidity, whether performing the surgery with the patient awake or asleep impacts extent of resection, and how stimulation mapping influences outcomes.METHODSA retrospective chart review was performed on the senior author’s cohort to identify patients treated between 1998 and 2016 who underwent resection of tumors that were located within the primary motor cortex. Clinical notes, operative reports, and radiographic images were reviewed to identify intraoperative stimulation mapping findings and functional outcomes following tumor resection. Extent of resection was quantified volumetrically. Characteristics of patients were analyzed to identify factors associated with postoperative motor deficits.RESULTSForty-nine patients underwent 53 resections of tumors located primarily within the motor cortex. Stimulation mapping was performed in all cases. Positive cortical sites for motor response were identified in 91% of cases, and subcortical sites in 74%. Awake craniotomy was performed in 65% of cases, while 35% were done under general anesthesia. The mean extent of resection was 91%. There was no statistically significant difference in extent of resection in cases done awake compared with those done under general anesthesia. New or worsened postoperative motor deficits occurred in 32 patients (60%), and 20 patients (38%) had a permanent deficit. Of the permanent deficits, 14 were mild, 4 were moderate, and 2 were severe (3.8% of cases). Decreased intraoperative motor response and diffusion restriction on postoperative MRI were associated with permanent deficit. Awake motor mapping surgery was associated with increased diffusion signal on postoperative MRI.CONCLUSIONSResection of tumors from the primary motor cortex is associated with an increased risk of motor deficit, but most of these deficits are transient or mild and have little functional impact. Excellent extent of resection can be achieved with intraoperative stimulation mapping, suggesting that these tumors are indeed amenable to resection and should not be labeled unresectable. Injury to small perforating or en passage blood vessels was the most common cause of infarction that led to moderate or severe deficits. Awake motor mapping was not superior to mapping done under general anesthesia with regard to long-term functional outcome.

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P04.18 Management of diffuse gliomas using hypnosis-aided awake surgery: oncological and functional preliminary results in a series of 16 cases

Neuro-Oncology ◽

10.1093/neuonc/noz126.113 ◽

2019 ◽

Vol 21 (Supplement_3) ◽

pp. iii33-iii33

Author(s):

T Picart ◽

G Pardey Bracho ◽

R Ameli ◽

L Berner ◽

L Thomas ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Awake Surgery ◽

Motor Deficit ◽

Resonance Imaging ◽

Preliminary Results ◽

Diffuse Gliomas ◽

Grade Ii ◽

Awake Resection ◽

Grade Iii

Abstract BACKGROUND Awake resection of diffuse gliomas aims to find a tailored onco-functional balance for each patient. Hypnosis represents an innovative technique able to optimize the comfort and well-being of the patient during such procedures. The aim of the present study is to analyse the oncological and functional outcome in a cohort of patients operated on with hypnosis-aided awake surgery. MATERIAL AND METHODS All consecutive adult patients that underwent hypnosis-aided resection for a diffuse glioma between January 2018 and January 2019 were recorded. Neurological and cognitive status were assessed preoperatively and at 3 months postoperatively. Extent of tumor resection was quantified by a radiologist on magnetic resonance imaging. RESULTS Sixteen patients (6 males and 10 females), with a mean age of 39 years, were included. Gliomas were revealed by epileptic seizures (62.5%), motor deficit (6.25%) or incidentally discovered (31.25%) and were either located in the right hemisphere (50%) or in the left hemisphere (50%), with a mean initial volume of 42 mL. Histologically, there were six grade II-astrocytomas, three grade III-astrocytomas, five grade II-oligodendroglioma, one grade III-oligodendroglioma and one ganglioglioma. Under HAS, the awake-time after the anaesthesia drugs stop was short, because low doses of drugs were required thanks to the hypnotic state. All patients were able to reliably performed the different tests until functional subcortical limits were reached. Postoperative magnetic resonance imaging showed complete resection in 8 cases (50%), subtotal resection in 2 cases (12.5%) and partial resection in 6 cases (37.5%), with a mean resection rate of 84.6%. At 3 months after surgery, there was only a new motor deficit (6.25%). The language and neuropsychological assessments were improved in 7 patients (43.75%), stable in 7 patients (43.75%) and deteriorated in some tests in 2 patients (12.5%). After surgery, no patient reported negative emotion concerning the awake glioma resection and all patient declared being ready for a second awake resection in the future, if indicated. CONCLUSION According to these preliminary results, hypnosis-aided awake resection of diffuse gliomas appears to be safe and effective from an onco-functional viewpoint and parallelly contributes to decrease intra-operative pain, anxiety and major discomfort.

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Intraoperative Motor Evoked Potential Alteration in Intracranial Tumor Surgery and Its Relation to Signal Alteration in Postoperative Magnetic Resonance Imaging

Neurosurgery ◽

10.1227/01.neu.0000371973.46234.46 ◽

2010 ◽

Vol 67 (2) ◽

pp. 302-313 ◽

Cited By ~ 67

Author(s):

Andrea Szelényi ◽

Elke Hattingen ◽

Stefan Weidauer ◽

Volker Seifert ◽

Ulf Ziemann

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Motor Cortex ◽

Evoked Potential ◽

Corticospinal Tract ◽

Motor Evoked Potential ◽

Motor Deficit ◽

Warning Sign ◽

Precentral Gyrus ◽

Resonance Imaging

Abstract OBJECTIVE To determine the degree to which the pattern of intraoperative isolated, unilateral alteration of motor evoked potential (MEP) in intracranial surgery was related to motor outcome and location of new postoperative signal alterations on magnetic resonance imaging (MRI). METHODS In 29 patients (age, 42.8 ± 18.2 years; 15 female patients; 25 supratentorial, 4 infratentorial procedures), intraoperative MEP alterations in isolation (without significant alteration in other evoked potential modalities) were classified as deterioration (> 50% amplitude decrease and/or motor threshold increase) or loss, respectively, or reversible and irreversible. Postoperative MRI was described for the location and type of new signal alteration. RESULTS New motor deficit was present in all 5 patients with irreversible MEP loss, in 7 of 10 patients with irreversible MEP deterioration, in 1 of 6 patients with reversible MEP loss, and in 0 of 8 patients with reversible MEP deterioration. Irreversible compared with reversible MEP alteration was significantly more often correlated with postoperative motor deficit (P < .0001). In 20 patients, 22 new signal alterations affected 29 various locations (precentral gyrus, n = 5; corticospinal tract, n = 19). Irreversible MEP alteration was more often associated with postoperative new signal alteration in MRI compared with reversible MEP alteration (P = .02). MEP loss was significantly more often associated with subcortically located new signal alteration (P = .006). MEP deterioration was significantly more often followed by new signal alterations located in the precentral gyrus (P = .04). CONCLUSION MEP loss bears a higher risk than MEP deterioration for postoperative motor deficit resulting from subcortical postoperative MR changes in the corticospinal tract. In contrast, MEP deterioration points to motor cortex lesion. Thus, even MEP deterioration should be considered a warning sign if surgery close to the motor cortex is performed.

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Gross Total Resection of a Grade IV Astrocytoma Adjacent to the Precentral Gyrus With Nonawake Motor Mapping and Motor-Evoked Potential Monitoring: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz185 ◽

2019 ◽

Cited By ~ 1

Author(s):

Burak Ozaydin ◽

Ihsan Dogan ◽

Bryan J Wheeler ◽

Mustafa K Baskaya

Keyword(s):

Motor Cortex ◽

Evoked Potential ◽

Primary Motor Cortex ◽

Motor Evoked Potential ◽

Gross Total Resection ◽

Precentral Gyrus ◽

Total Resection ◽

Motor Mapping ◽

3 Dimensional ◽

Intraoperative Adjuncts

Abstract Surgical treatment of the gliomas located in or adjacent to the eloquent areas poses significant challenge to neurosurgeons. The main goal of the surgery is to achieve maximal safe resection while preserving the neurological function. This might be possible with utilizing pre- and intraoperative adjuncts such as functional magnetic resonance imaging (MRI), image guidance, mapping of the function of interest, intraoperative MRI, and neurophysiological monitoring. In this video, we demonstrate the utilization of nonawake mapping and motor-evoked potential (MEP) monitoring for the resection of a right-sided posterior superior frontal gyrus grade IV astrocytoma adjacent to the primary motor cortex. The patient is a 69-yr-old woman presented with multiple episodes of simple partial seizures involving her left leg and spreading to the left arm. MRI and functional MRI examinations showed a heterogeneously enhancing mass with peritumoral edema adjacent to the primary motor cortex. Because the patient did not want to undergo an awake craniotomy, a decision was made to perform the resection of the tumor with nonawake motor mapping and continuous MEP monitoring. Nonawake motor mapping and MEP monitoring enabled us to perform gross total resection. Because it has been shown that supratotal resection may provide improved survival outcome,1,2 we extended the white matter resection beyond the contrast enhancing area in noneloquent parts of the tumor. Surgical steps in dealing with vascular anatomy as well as utilizing intraoperative adjuncts such as motor mapping and MEP monitoring to enhance the extent of resection while preserving the function are demonstrated in this 3-dimensional surgical video. The patient consented to publication of her operative video.

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Shared functional connectivity between the dorso-medial and dorso-ventral streams in macaques

Scientific Reports ◽

10.1038/s41598-020-75219-x ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

R. Stefan Greulich ◽

Ramina Adam ◽

Stefan Everling ◽

Hansjörg Scherberger

Keyword(s):

Functional Connectivity ◽

Motor Cortex ◽

Primary Motor Cortex ◽

Rhesus Macaques ◽

Premotor Cortex ◽

Network Connectivity ◽

Insular Cortex ◽

Resting State Fmri ◽

Precentral Gyrus ◽

Related Information

Abstract Manipulation of an object requires us to transport our hand towards the object (reach) and close our digits around that object (grasp). In current models, reach-related information is propagated in the dorso-medial stream from posterior parietal area V6A to medial intraparietal area, dorsal premotor cortex, and primary motor cortex. Grasp-related information is processed in the dorso-ventral stream from the anterior intraparietal area to ventral premotor cortex and the hand area of primary motor cortex. However, recent studies have cast doubt on the validity of this separation in separate processing streams. We investigated in 10 male rhesus macaques the whole-brain functional connectivity of these areas using resting state fMRI at 7-T. Although we found a clear separation between dorso-medial and dorso-ventral network connectivity in support of the two-stream hypothesis, we also found evidence of shared connectivity between these networks. The dorso-ventral network was distinctly correlated with high-order somatosensory areas and feeding related areas, whereas the dorso-medial network with visual areas and trunk/hindlimb motor areas. Shared connectivity was found in the superior frontal and precentral gyrus, central sulcus, intraparietal sulcus, precuneus, and insular cortex. These results suggest that while sensorimotor processing streams are functionally separated, they can access information through shared areas.

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The concept of the “Hexahedron” in the supratotal resection of the frontal gliomas: A technical note

10.21203/rs.3.rs-926821/v1 ◽

2021 ◽

Author(s):

Pu Cai ◽

Gang Bai ◽

Jun Peng ◽

Yun Li ◽

Shanli Che ◽

...

Keyword(s):

Tumour Volume ◽

Extent Of Resection ◽

Technical Note ◽

Subtotal Resection ◽

Diffuse Astrocytoma ◽

Who Grade ◽

Grade Ii ◽

Supratotal Resection ◽

Who Grade Iii ◽

Grade Iii

Abstract OBJECTIVE To evaluate the value of the concept of the “Hexahedron” in the supratotal resection (SPTR) of frontal gliomas in both dominant and nondominant hemispheres . METHODS All consecutive patients who underwent SPTR for frontal gliomas under the guidance from the concept of the “Hexahedron” were retrospectively analysed for lesion location, pathology, extent of resection (EOR), and complications from May 2020 to June 2021. Volumetric EOR was measured and classified as SPTR, (in which the volume of the postoperative cavity was larger than the preoperative tumour volume), gross total resection (GTR, > 95% by volume) or subtotal resection (STR, ≤ 95% by volume) after independent radiological review. RESULTS Six men and two women (mean age: 47.13 years; range: 26–69 years) were included. All eight patients underwent frontal craniotomy combined frontotemporal craniotomy for resection of frontal gliomas. Neuropathological examination confirmed a diagnosis of glioblastoma WHO Grade IV in 4 patients, anaplastic oligodendroglioma WHO Grade III in 1, anaplastic astrocytoma WHO Grade III in 2 and diffuse astrocytoma WHO Grade II in 1. SPTR was achieved in six patients and STR was achieved in two. The main postoperative complications were contralateral paresis in 2 patients and memory disturbances in 1 patient. There were no cases of rebleeding or secondary operation during hospitalization. CONCLUSIONS In the presented eight cases the concept of the “Hexahedron” allowed for safe surgical supratotal resection of frontal gliomas.

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Brain mapping for lesions in primary motor cortex: integrated surgical approach

Neuro-Oncology ◽

10.1093/neuonc/noz167.078 ◽

2019 ◽

Vol 21 (Supplement_4) ◽

pp. iv18-iv18

Author(s):

José Lavrador ◽

Prajwal Ghimire ◽

Christian Brogna ◽

Luciano Furlanetti ◽

Sabina Patel ◽

...

Keyword(s):

Decision Making ◽

Process Model ◽

Primary Motor Cortex ◽

Treatment Plan ◽

Extent Of Resection ◽

Motor Deficit ◽

Decision Making Process ◽

Total Resection ◽

Intraoperative Mapping ◽

Subcortical Mapping

Abstract Background Lesions within the corticospinal tract (CST) represent significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centred treatment plan. Methods Patients with lesions within the CST with preoperative cortical and subcortical mapping (nTMS and tractography), intraoperative mapping and intraoperative provisional histological information (smear +- 5-ALA) were included. This independently acquired information was integrated in a decision-making process model to determine the intraoperative extent of resection. Results 10 patients (6 patients with metastatic precentral tumour; 1 patient with Grade III and 2 patients with grade IV gliomas; 1 patient with precentral vascular malformation) were included in the study. Majority of the patient had pre-operative motor deficit (60%). 50% patients underwent gross total resection and 40% patients underwent near total resection of the lesions. In only one patient, no surgical resection was possible after both pre-operative and intraoperative mapping. 70% of patients remained stable postoperatively and 20% improved from previous motor weakness. Conclusion The independently acquired anatomical (anatomical MRI) and functional (nTMS and tractography) in patients with CST lesions provide a more accurate guide for resection. The inclusion of the histological information (smear +- 5-ALA) further allows the surgical team to balance the potential functional risks within the global treatment plan. Therefore, the patient is kept at the centre of the informed decision making process.

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