AWAKE CRANIOTOMY FOR BRAIN TUMORS NEAR ELOQUENT CORTEX

Neurosurgery ◽  
2009 ◽  
Vol 64 (5) ◽  
pp. 836-846 ◽  
Author(s):  
Stefan S. Kim ◽  
Ian E. McCutcheon ◽  
Dima Suki ◽  
Jeffrey S. Weinberg ◽  
Raymond Sawaya ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Neurological Status ◽  
Extent Of Resection ◽  
Sensory Function ◽  
Neurological Deficits ◽  
Cortical Mapping ◽  
Eloquent Areas ◽  
Eloquent Cortex ◽  
Low Incidence ◽  
Intraoperative Localization

Abstract OBJECTIVE Intraoperative localization of cortical areas for motor and language function has been advocated to minimize postoperative neurological deficits. We report herein the results of a retrospective study of cortical mapping and subsequent clinical outcomes in a large series of patients. METHODS Patients with intracerebral tumors near and/or within eloquent cortices (n = 309) were clinically evaluated before surgery, immediately after, and 1 month and 3 months after surgery. Craniotomy was tailored to encompass tumor plus adjacent areas presumed to contain eloquent cortex. Intraoperative cortical stimulation for language, motor, and/or sensory function was performed in all patients to safely maximize surgical resection. RESULTS A gross total resection (≥95%) was obtained in 64%, and a resection of 85% or more was obtained in 77% of the procedures. Eloquent areas were identified in 65% of cases, and in that group, worsened neurological deficits were observed in 21% of patients, whereas only 9% with negative mapping sustained such deficits (P < 0.01). Intraoperative neurological deficits occurred in 64 patients (21%); of these, 25 (39%) experienced worsened neurological outcome at 1 month, whereas only 27 of 245 patients (11%) without intraoperative changes had such outcomes (P < 0.001). At 1 month, 83% overall showed improved or stable neurological status, whereas 17% had new or worse deficits; however, at 3 months, 7% of patients had a persistent neurological deficit. Extent of resection less than 95% also predicted worsening of neurological status (P < 0.025). CONCLUSION Negative mapping of eloquent areas provides a safe margin for surgical resection with a low incidence of neurological deficits. However, identification of eloquent areas not only failed to eliminate but rather increased the risk of postoperative deficits, likely indicating close proximity of functional cortex to tumor.

scholarly journals Insular Glioma Esoteric Precinct

2020 ◽  
Vol 24 (2) ◽  
Author(s):  
FAUZIA SAJJAD ◽  
MUHAMMAD ASIF SHABBIR ◽  
MUHAMMAD AKMAL ◽  
ZAIN SALEH ◽  
ADEEB-UL- HASSAN
Keyword(s):  
Surgical Resection ◽  
Neurological Deficits ◽  
Total Resection ◽  
Motor Weakness ◽  
Disease Free Interval ◽  
Eloquent Areas ◽  
Free Interval ◽  
Operative Complications ◽  
Grade Ii ◽  
Disease Free

Background and Objective:  The complex insular anatomy and its proximity to eloquent areas make this area almost inaccessible for safe surgical resection of Glioma. Aim of our study is to determine outcome assessment after surgical resection. Materials & Methods:  This was a retrospective analysis of 59 patients over a period of 5 years from July 2013 till June 2018. All patients of insular Glioma were included in our study irrespective of age and sex. Degree of surgical resection, Post-operative neurological deficits and complications were assessed. They were followed in the outpatient department at 3, 6 and 12 months. Results:  Total 59 patients were included 38 (64.40%) male and 21 (35.59%) females. 36 (61%) patients had right sided insular Glioma and 23 (38.98%) have left sided. Seizures were main presentation in 46(77.96%) patients. Trans-sylvian route adopted in 34 (57.6%) patients followed by transcortical route. Near total Resection was Possible in 30 (50.84%) patients and partial in 29 (49.15%) patients. Focal neurological deficits the motor weakness & dysphasia were main post-operative complications in 18 (30.5%) patients. Three (5.08%) patients died. In all grade II and grade III Gliomas no increase in size was discovered on MRI Brain at 6 and 12 months. Conclusion:  Maximum safe resection of insular Glioma with acceptable morbidity is possible with improved overall survival and disease free interval.

Intraoperative seizures occurrence in cortical mapping of eloquent areas

2021 ◽  
Vol 23 (2) ◽  
pp. 39-44
Author(s):  
Olga A. Toporkova ◽  
Mikhail V. Aleksandrov ◽  
Malik M. Tastanbekov
Keyword(s):  
Cerebral Cortex ◽  
General Anesthesia ◽  
Cortical Mapping ◽  
Motor Mapping ◽  
Eloquent Areas ◽  
Auditory Speech ◽  
Neurophysiological Studies ◽  
Eloquent Cortex ◽  
Structural Epilepsy ◽  
Convulsive Seizures

The effect of structural epilepsy on the frequency of intraoperative convulsive seizures is assessed when mapping functionally significant areas of the cerebral cortex during resection of intracerebral neoplasms. The work is based on the analysis of the results of intraoperative neurophysiological studies at the Polenov Neurosurgical Institute. For the period 20192020 87 intraoperative mappings of eloquent cortex were carried out during resections of intracerebral neoplasms: 79 mappings of the motor cortex and 16 mappings of auditory-speech areas during operations with awakening. When mapping the motor zones of the cortex, the frequency of seizures was 5.1%, while mapping the auditory-speech zones with awakening 18.75%. The division of cases of intraoperative convulsive seizures into two groups: seizures arising from motor mapping and seizures associated with the mapping of auditory zones reflects differences in factors that affect the excitability of the cerebral cortex. In motor mapping, stimulation occurs against the background of general anesthesia, unlike waking operations. The intensity of stimulation in auditory mapping is higher than in motor mapping in motor mapping. Formally, the current used in motor mapping is significantly higher than in mapping auditory zones. In general, with the development of intraoperative convulsive seizures, the current intensity of cortical stimulation does not exceed the average values required to stimulate functionally significant cortical zones. The presence of epileptic syndrome in patients with intracerebral tumors cannot be considered as a predictor of intraoperative seizure development when performing motor mapping under general anesthesia as well as during surgery with awakening for mapping of motor or auditory verbal zones.

Function and organization in dysgenic cortex

1997 ◽  
Vol 87 (1) ◽  
pp. 113-121 ◽  
Author(s):  
Mark C. Preul ◽  
Richard Leblanc ◽  
Fernando Cendes ◽  
Francois Dubeau ◽  
David Reutens ◽  
...  
Keyword(s):  
Developmental Disorders ◽  
Right Hemisphere ◽  
Central Area ◽  
Cortical Dysplasia ◽  
Cortical Reorganization ◽  
Sensory Function ◽  
Neurological Deficits ◽  
Cortical Mapping ◽  
Histological Structure

✓ Cerebral dysgenesis is a subject of interest because of its relationship to cerebral development and dysfunction and to epilepsy. The authors present a detailed study of a 16-year-old boy who underwent surgery for a severe seizure disorder. This patient had dysgenesis of the right hemisphere, which was composed of a giant central frontoparietal nodular gray matter heterotopia with overlying large islands of cortical dysplasia around a displaced central fissure. Exceptional insight into the function, biochemistry, electrophysiology, and histological structure of this lesion was obtained from neurological studies that revealed complementary information: magnetic resonance (MR) imaging, [18]fluoro-2-deoxy-d-glucose positron emission tomography (PET), functional PET scanning, proton MR spectroscopic (1H-MRS) imaging, intraoperative cortical mapping and electrocorticography, in vitro electrophysiology, and immunocytochemistry. These studies demonstrated compensatory cortical reorganization and showed that large areas of heterotopia and cortical dysplasia in the central area may retain normal motor and sensory function despite strikingly altered cytoarchitectonic organization and neuronal metabolism. Such lesions necessitate appropriate functional imaging studies prior to surgery and cortical mapping to avoid creating neurological deficits. Integrated studies, such as PET, 1H-MRS imaging, cortical mapping, immunocytochemistry, and electrophysiology may provide information on the function of developmental disorders of cerebral organization.

scholarly journals Preoperative mapping of the eloquent cortical areas using navigated transcranial magnetic stimulation combined with intraoperative neuronavigation for intracerebral lesions

2018 ◽  
Vol 32 (1) ◽  
pp. 16-24
Author(s):  
G. Petrescu ◽  
Cristina Gorgan ◽  
A. Giovani ◽  
F.M. Brehar ◽  
R.M. Gorgan
Keyword(s):  
Transcranial Magnetic Stimulation ◽  
Surgical Resection ◽  
Magnetic Stimulation ◽  
Neurological Deficits ◽  
Navigated Transcranial Magnetic Stimulation ◽  
Mapping Procedure ◽  
Motor Mapping ◽  
Eloquent Areas ◽  
Preoperative Mapping ◽  
Eloquent Area

Abstract Introduction: Maximal surgical resection with the preservation of cortical functions is the treatment of choice for brain tumors. Achieving these objectives is especially difficult when the tumor is located in an eloquent area. Navigated transcranial magnetic stimulation (nTMS) is a modern non-invasive, preoperative method for defining motor and speech eloquent areas. Material and methods: Patients with tumors located in motor and speech eloquent areas who presented at our institution between March 2017 and December 2017 were prospectively included. Exclusion criteria were frequent generalized epileptic seizures and cranial implants. For lesions involving motor eloquent areas we performed a nTMS motor mapping and for lesions involving speech eloquent areas we supplemented the motor mapping with speech and language mapping. MR images were exported from the nTMS system in a DICOM format and then loaded in the intraoperative neuronavigation system. Based on these findings, the optimal entry point and trajectory were determined, in order to achieve a maximum surgical resection of the lesion, while avoiding new post-operative neurological deficits. Results: Nineteen patients underwent an nTMS brain mapping procedure between March 2017 and December 2017. In all cases a motor mapping procedure was done, but only in eight cases a speech mapping was also performed. Three patients presented new minor postoperatory deficits that consecutively remitted. The rest of the patients presented no added neurological deficits after surgery. In five cases the preexistent deficit was ameliorated after surgery and in three cases the deficit remitted. In one patient there was no improvement in the neurologic deficit after surgery. Conclusion: nTMS is a reliable tool for the preoperative planning of eloquent area lesions. It must be taken into account that functional areas have a high individual variability. Therefore, knowing preoperatively the extent of the eloquent area helps the neurosurgeon adapt the surgical approach in order to obtain a better functional outcome.

scholarly journals Reoperation in Spinal Dysraphism: Does it Help in Reversing the Neurological Deficits?

2017 ◽  
Vol 08 (03) ◽  
pp. 375-380
Author(s):  
Praful Suresh Maste ◽  
Yadhu Kasetti Lokanath ◽  
Shambhulingappa S. Mahantshetti
Keyword(s):  
Primary Repair ◽  
Spinal Dysraphism ◽  
Bowel Function ◽  
Neurological Status ◽  
Sensory Function ◽  
Neurological Deficits ◽  
Limb Weakness ◽  
Repeat Surgery ◽  
Neurological Improvement ◽  
Second Surgery

ABSTRACT Aims: After initial primary repair by inexperienced hands for the spectrum of pathological conditions in spinal dysraphism (SD), a few percentage of patients present with recurrent symptoms and worsening neurological status especially when primarily pathology is not identified and dealt properly. When the primary intradural tethering element is left untouched, worsening of symptoms is common. In this retrospective study, we tried to analyze the symptomatology, functional outcome at 1–2 months after the second surgery and associated complications. Subjects and Methods: All patients underwent second surgery at author’s institution. Pre and post-operative data were evaluated using Necker –Enfants Malades (NEM) neurological and modified Hoffer ambulatory scale. Results: The main presenting complaints were bladder incontinence and limb weakness. Preoperative mean scores for motor and bladder were 3.56 and 2.78 out of 5, 2.67 out of 4, and 2.11 out of 3 for bowel and sensory function, respectively. Postoperative mean score for motor, sensory, bladder, and bowel function revealed good neurological improvement. Statistically neurological improvement in bladder and bowel function was significant. More than 60% of patients had normal ambulation at follow-up. Conclusions: Patients presenting with recurrent symptoms in an operated case of SD need to be investigated, cause of recurrence has to be identified, and if needed repeat surgery is recommended at the earliest. Long-standing neurological deficits can potentially improve, especially bladder and bowel function which gives a good quality of life to the patients. Furthermore, we want to stress the fact that since it is an intradural pathology, these cases should be operated by experienced neurosurgeons, and this fact should be made aware among referring doctors.

Awake Craniotomy for Resection of Left Temporal Cavernoma: 3-Dimensional Operative Video

2018 ◽  
Vol 17 (3) ◽  
pp. E102-E102
Author(s):  
Krunal Patel ◽  
Leonardo Desessards Olijnyk ◽  
Karol P Budohoski ◽  
Thomas Santarius ◽  
Ramez W Kirollos ◽  
...  
Keyword(s):  
Informed Consent ◽  
Medical Treatment ◽  
Seizure Control ◽  
Surgical Excision ◽  
Neurological Deficits ◽  
Awake Surgery ◽  
Cortical Mapping ◽  
3 Dimensional ◽  
Bipolar Stimulation ◽  
Eloquent Cortex

Abstract Cavernomas presenting with seizures refractory to medical treatment may require surgical excision for seizure control. If superficial, they can be surgically accessible but can pose additional risks when located in or near eloquent cortex. In this 3D operative video we illustrate the technique for the resection of a left temporal cavernoma located near eloquent cortex for speech with awake surgery and cortical mapping to avoid a speech deficit postoperatively. Informed consent was obtained for this procedure. Navigation is used to localize the cavernoma following which a large craniotomy is performed exposing the temporal lobe, frontal lobe, and sylvian vein. Bipolar stimulation is used to localize speech with the patient awake until speech arrest occurs. The cavernoma is situated immediately inferior to the sulcus over which speech arrest occurs. The sulcus immediately above the cavernoma is opened and adjacent arteries are carefully preserved. The glial plane around the cavernoma is used to dissect the cavernoma from the surrounding cortex. Care is taken to remove the haemosiderin as this can act as a precipitant for ongoing seizures. In this case the patient had no neurological deficits following surgery and was seizure free.

scholarly journals Intraoperative Monitoring with Cortical Estimulation

2018 ◽  
Vol 27 (1) ◽  
pp. 29-38
Author(s):  
Henry Koiti Sato ◽  
Maurício Coelho Neto ◽  
Erasmo Barros Da Silva Jr ◽  
Luis Fernando Moura Da Silva Junior ◽  
Ricardo Ramina
Keyword(s):  
Muscle Strength ◽  
Postoperative Period ◽  
Neurological Deficit ◽  
Neurological Status ◽  
Cortical Stimulation ◽  
Neurological Deficits ◽  
Eloquent Areas ◽  
Main Challenge ◽  
Significant Difference ◽  
Motor Areas

Introduction: Resection of gliomas in eloquent areas such as motor and supplementary motor areas has always been a main challenge for the surgeon due to the risk of severe neurological sequelae. An important tool used during the procedure to avoid postoperative deficits is the intraoperative cortical stimulation of eloquent areas as a safe option of functional area mapping. Methods: In this study, authors examined 50 patients with gliomas located in the motor and supplementary motor area that have undergone surgery with cortical stimulation, using clinical assessment of muscle strength in the pre- and immediate postoperative assessments and three months after surgery as parameters. Results: There was significant difference (p<0.001) between the preoperative and immediate postoperative assessments regarding the occurrence of severe neurological deficit, demonstrating a worsening of the neurological status after surgery. Concerning the comparison between the immediate postoperative period and the assessment performed three months after surgery, it was observed that all the patients who had severe deficit (11 cases) improved (p<0.001). No statistical difference was found between the malignancy grade and the evolution of the neurological deficit in the assessments performed in the three evaluated periods. Conclusion: In the immediate postoperative period following surgical resection of glial tumors in the motor and supplementary motor areas with intraoperative cortical monitoring, most patients have significant alterations in their muscle strength. However, three months after surgery there was significant improvement of these neurological deficits and no patient had severe sequelae. 

scholarly journals Navigated transcranial magnetic stimulation mapping in patients with language-eloquent brain lesions

2021 ◽  
pp. 14-19
Author(s):  
George E. D. Petrescu ◽  
Roxana Radu ◽  
Andrei Giovani ◽  
Cristina Gorgan ◽  
Felix M. Brehar ◽  
...  
Keyword(s):  
Transcranial Magnetic Stimulation ◽  
Surgical Resection ◽  
Error Rate ◽  
Magnetic Stimulation ◽  
Brain Lesions ◽  
Cortical Mapping ◽  
Histopathological Diagnosis ◽  
Navigated Transcranial Magnetic Stimulation ◽  
Functional Deficits ◽  
Eloquent Areas

Introduction: The surgical resection of brain lesions located in language-eloquent areas harbours a great risk for determining new functional deficits. Navigated transcranial magnetic stimulation represents a novel non-invasive cortical mapping method that can be used preoperative to determine language-eloquent areas. Materials and methods: We retrospectively reviewed a prospectively maintained database of patients that underwent preoperative cortical mapping using nTMS between March 2017 and June 2020. Patients older than 18 years old with brain lesions situated in a presumed language eloquent area, that underwent surgical resection of the brain lesion were included in the study. Various parameters such as error rate, number of language-negative sites were assessed. Results: Fourteen patients were included in the study. There were 10 males and 4 females in total. Most of the tumours were in the temporal and frontal lobes (five and four cases, respectively). The histopathological diagnosis was glioblastoma in seven cases, in one case there was an anaplastic astrocytoma and there were two cases of low-grade gliomas. There were three cases of brain metastasis and one cavernoma. The median (range) tumor volume was 25.01 cm3 (0.89 – 86.55 cm3). Gross-total resection (GTR) was achieved in seven cases. The error rate was significantly higher in patients that continued to have an impaired language function after surgical resection (p = 0.016), while the perilesional error rate was higher in patients with preoperative aphasia (p = 0.019). Conclusion: Our findings suggest that a lower tumour volume to perilesional negative stimuli ratio is associated with an extended surgical resection of brain tumours located in language-eloquent areas and that patients that presented with aphasia and have a high error rate have a worse functional prognosis. Through nTMS preoperative cortical mapping of language-eloquent areas, the neurosurgeon has more insight regarding the cortical function and can maximize the surgical resection, while avoiding the onset of new functional deficits.

scholarly journals SURG-14. AWAKE CRANIOTOMY VS CRANIOTOMY UNDER GENERAL ANESTHESIA FOR GLIOBLASTOMAS: EVALUATING THE IMPACT ON OVERALL SURVIVAL AND RISK OF RECURRENCE

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii206-ii206
Author(s):  
Mario Moro
Keyword(s):  
Overall Survival ◽  
General Anesthesia ◽  
Tumor Resection ◽  
Extent Of Resection ◽  
Neurological Deficits ◽  
Awake Surgery ◽  
Tumor Control ◽  
Risk Of Recurrence ◽  
Eloquent Areas ◽  
The Impact

Abstract Maximum safe resection for eloquent glioblastomas (GBMs) is the maximum tumor resection achievable without causing neurological deficits. Although challenging, it must be considered the therapeutic target for GBMs. Indeed, the extension of resection positively correlates with the overall survival and recurrences risk. Awake surgery (AS) has become paramount for achieving maximum safe resection for tumors in eloquent areas. However, there is not a unanimous consensus on the extent of resection of eloquent GBMs, especially for what concerns the so-called supratotal resection (i.e.: resection over the contrast-enhancing limits of the lesion). Recently, several studies focused their attention on the residual tumor volume as estimated from T1-contrast enhanced sequences, but few analyzed the outcomes of patients with a more extended resection. Some authors speculated that increased surgical aggressiveness, thus removing peritumoral edematous area, correlates with improved overall survival and tumor control, without increasing adverse events rates. This study aimed to assess, through quantitative volumetric analysis, the outcomes of a prospectively collected cohort of patients with primary GBM located in eloquent areas. We furtherly subdivided our population into two treatment groups: awake surgery (AS) and general anesthesia (GA) craniotomies. We analyzed the overall outcomes, especially for what concerns MRI T2-Flair signal extent of resection, related to patients’ survival and recurrences formation. Eventually, we stratified our analysis by type of treatment (awake surgery vs. general anesthesia) to rule out any significant differences in survival and postoperative GBMs behaviors. Our data confirmed extensive that T2-Flair resection (EOR≥30%) and AS could improve overall survival and reduce risk of recurrence without, at the same time, causing an increase of surgical and medical complications

scholarly journals MS-1 Surgical strategy for brain tumor based on molecular and functional connectomics profiles

2020 ◽  
Vol 2 (Supplement_3) ◽  
pp. ii2-ii2
Author(s):  
Tatsuya Abe
Keyword(s):  
Overall Survival ◽  
Brain Tumor ◽  
Standard Procedure ◽  
Awake Craniotomy ◽  
Surgical Strategy ◽  
Neurological Deficits ◽  
Cortical Mapping ◽  
Photodynamic Diagnosis ◽  
Tumor Surgery ◽  
Brain Tumor Surgery

Abstract It is reported that the development of new perioperative motor deficits was associated with decreased overall survival despite similar extent of resection and adjuvant therapy. The maximum safe resection without any neurological deficits is required to improve overall survival in patients with brain tumor. Surgery is performed with various modalities, such as neuro-monitoring, photodynamic diagnosis, neuro-navigation, awake craniotomy, intraoperative MRI, and so on. Above all, awake craniotomy technique is now the standard procedure to achieve the maximum safe resection in patients with brain tumor. It is well known that before any treatment, gliomas generate globally (and not only focally) altered functional connectomics profiles, with various patterns of neural reorganization allowing different levels of cognitive compensation. Therefore, perioperative cortical mapping and elucidation of functional network, neuroplasticity and reorganization are important for brain tumor surgery. On the other hand, recent studies have proposed several gene signatures as biomarkers for different grades of gliomas from various perspectives. Then, we aimed to identify these biomarkers in pre-operative and/or intra-operative periods, using liquid biopsy, immunostaining and various PCR methods including rapid genotyping assay. In this presentation, we would like to demonstrate our surgical strategy based on molecular and functional connectomics profiles.

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