Awake Mapping Optimizes the Extent of Resection for Low-Grade Gliomas in Eloquent Areas

Neurosurgery ◽  
2010 ◽  
Vol 66 (6) ◽  
pp. 1074-1084 ◽  
Author(s):  
Alessandro De Benedictis ◽  
Sylvie Moritz-Gasser ◽  
Hugues Duffau
Keyword(s):  
Extent Of Resection ◽  
Low Grade Glioma ◽  
Awake Surgery ◽  
Low Grade ◽  
Functional Sites ◽  
Social Lives ◽  
Eloquent Areas ◽  
Functional Regions ◽  
First Time

Abstract BACKGROUND Awake craniotomy with intraoperative electrical mapping is a reliable method to minimize the risk of permanent deficit during surgery for low-grade glioma located within eloquent areas classically considered inoperable. However, it could be argued that preservation of functional sites might lead to a lesser degree of tumor removal. To the best of our knowledge, the extent of resection has never been directly compared between traditional and awake procedures. OBJECTIVE We report for the first time a series of patients who underwent 2 consecutive surgeries without and with awake mapping. METHODS Nine patients underwent surgery for a low-grade glioma in functional sites under general anesthesia in other institutions. The resection was subtotal in 3 cases and partial in 6 cases. There was a postoperative worsening in 3 cases. We performed a second surgery in the awake condition with intraoperative electrostimulation. The resection was performed according to functional boundaries at both the cortical and subcortical levels. RESULTS Postoperative magnetic resonance imaging showed that the resection was complete in 5 cases and subtotal in 4 cases (no partial removal) and that it was improved in all cases compared with the first surgery (P = .04). There was no permanent neurological worsening. Three patients improved compared with the presurgical status. All patients returned to normal professional and social lives. CONCLUSION Our results demonstrate that awake surgery, known to preserve the quality of life in patients with low-grade glioma, is also able to significantly improve the extent of resection for lesions located in functional regions.

Surgery for low-grade glioma infiltrating the central cerebral region: location as a predictive factor for neurological deficit, epileptological outcome, and quality of life

2013 ◽  
Vol 119 (2) ◽  
pp. 318-323 ◽  
Author(s):  
Philippe Schucht ◽  
Fadi Ghareeb ◽  
Hugues Duffau
Keyword(s):  
Quality Of Life ◽  
Return To Work ◽  
Seizure Control ◽  
Extent Of Resection ◽  
Low Grade Glioma ◽  
Neurological Deficits ◽  
Main Concern ◽  
Low Grade ◽  
Who Grade

Object A main concern with regard to surgery for low-grade glioma (LGG, WHO Grade II) is maintenance of the patient's functional integrity. This concern is particularly relevant for gliomas in the central region, where damage can have grave repercussions. The authors evaluated postsurgical outcomes with regard to neurological deficits, seizures, and quality of life. Methods Outcomes were compared for 33 patients with central LGG (central cohort) and a control cohort of 31 patients with frontal LGG (frontal cohort), all of whom had had medically intractable seizures before undergoing surgery with mapping while awake. All surgeries were performed in the period from February 2007 through April 2010 at the same institution. Results For the central cohort, the median extent of resection was 92% (range 80%–97%), and for the frontal cohort, the median extent of resection was 93% (range 83%–98%; p = 1.0). Although the rate of mild neurological deficits was similar for both groups, seizure freedom (Engel Class I) was achieved for only 4 (12.1%) of 33 patients in the central cohort compared with 26 (83.9%) of 31 patients in the frontal cohort (p < 0.0001). The rate of return to work was lower for patients in the central cohort (4 [12.1%] of 33) than for the patients in the frontal cohort (28 [90.3%] of 31; p < 0.0001). Conclusions Resection of central LGG is feasible and safe when appropriate intraoperative mapping is used. However, seizure control for these patients remains poor, a finding that contrasts markedly with seizure control for patients in the frontal cohort and with that reported in the literature. For patients with central LGG, poor seizure control ultimately determines quality of life because most will not be able to return to work.

Awake Surgery for Nonlanguage Mapping

Neurosurgery ◽  
2010 ◽  
Vol 66 (3) ◽  
pp. 523-529 ◽  
Author(s):  
Hugues Duffau
Keyword(s):  
Language Processing ◽  
Cognitive Deficits ◽  
Extent Of Resection ◽  
Awake Surgery ◽  
Surgical Removal ◽  
Eloquent Areas ◽  
The Past ◽  
Neuropsychological Assessments ◽  
Language Areas

Abstract OBJECTIVE During the past decade, numerous reports have supported the contribution of awake mapping in surgical removal of brain lesions in eloquent areas, with a significant increase of the extent of resection while minimizing the risk of permanent deficit—and even improving quality of life. METHODS Most of these awake procedures were performed in patients with lesions in language areas, to avoid postoperative aphasia. Surprisingly, mapping of nonlanguage functions received less attention, despite the possible consequences of deficits other than aphasia on daily life. Visuospatial and cognitive deficits are reported after brain surgery, because of more objective and extensive neuropsychological assessments. RESULTS AND CONCLUSION This review provides new insights into the indications of awake craniotomies for nonlanguage mapping in surgery for lesions in areas not related to language processing.

Return to Work Following Surgery for Incidental Diffuse Low-Grade Glioma: A Prospective Series With 74 Patients

Neurosurgery ◽  
2019 ◽  
Vol 87 (4) ◽  
pp. 720-729 ◽  
Author(s):  
Sam Ng ◽  
Guillaume Herbet ◽  
Sylvie Moritz-Gasser ◽  
Hugues Duffau
Keyword(s):  
Return To Work ◽  
Extent Of Resection ◽  
Low Grade Glioma ◽  
High Rate ◽  
Awake Surgery ◽  
Prophylactic Surgery ◽  
Low Grade ◽  
Oncological Treatment ◽  
Asymptomatic Patients

Abstract BACKGROUND Therapeutic strategy concerning incidental low-grade glioma (ILGG) is still debated. Early “prophylactic” surgery has been proposed in asymptomatic patients with favorable neurological and oncological outcomes. OBJECTIVE To assess postoperative ability to resume employment following awake surgery in asymptomatic ILGG patients. To assess extent of resection (EOR), timeline for adjuvant oncological treatment, and survival. METHODS A total of 74 patients with ILGG who underwent awake surgery with intraoperative mapping were prospectively included, with a minimum follow-up of 12 mo. All clinicoradiological data were collected, and statistical correlations with return to work (RTW) were performed. RESULTS A total of 66 patients (97.1%) among 68 patients with preoperative professional activities resumed their employment including 62 (91.2%) within 12 mo. Mean time before RTW was 6.8 mo (median: 6 mo, range: 1-36). Two patients experienced seizure-related legal issues impacting their RTW. Clinicoradiological features did not correlate with RTW apart from postoperative seizures (P = .02). Mean EOR was 95.7%. A total of 43 patients (58.1%) underwent supratotal/total resections. All patients recovered from transient deficits at 3 mo. No patients received consecutive adjuvant treatment. A total of 24 patients (32.4%) were reoperated, 24 patients received chemotherapy, and 7 patients (9.5%) received radiotherapy, on average 73.1 mo after surgery. Mean follow-up was 67 mo (range 12-240). Four patients (5.4%) died during the follow-up. CONCLUSION We observed a high rate of RTW (97.1%, including 91.2% within 12 mo) after awake surgery in ILGG patients. Delayed resumption of work was due to employer not clearing them for RTW, personal choice, and, in rare occasions, related to seizures.

Predicting the Extent of Resection in Low-Grade Glioma by Using Intratumoral Tractography to Detect Eloquent Fascicles Within the Tumor

Neurosurgery ◽  
2020 ◽  
Author(s):  
David Mato ◽  
Carlos Velasquez ◽  
Elsa Gómez ◽  
Enrique Marco de Lucas ◽  
Juan Martino
Keyword(s):  
Predictive Value ◽  
Diffusion Tensor ◽  
Extent Of Resection ◽  
Current Treatment ◽  
Low Grade Glioma ◽  
Low Grade ◽  
Seed Region ◽  
Eloquent Areas ◽  
Treatment Paradigm ◽  
Intraoperative Electrical Stimulation

Abstract BACKGROUND An early maximal safe surgical resection is the current treatment paradigm for low-grade glioma (LGG). Nevertheless, there are no reliable methods to accurately predict the axonal intratumoral eloquent areas and, consequently, to predict the extent of resection. OBJECTIVE To describe the functional predictive value of eloquent white matter tracts within the tumor by using a pre- and postoperative intratumoral diffusion tensor imaging (DTI) tractography protocol in patients with LGG. METHODS A preoperative intratumoral DTI-based tractography protocol, using the tumor segmented volume as the only seed region, was used to assess the tracts within the tumor boundaries in 22 consecutive patients with LGG. The reconstructed tracts were correlated with intraoperative electrical stimulation (IES)-based language and motor subcortical mapping findings and the extent of resection was assessed by tumor volumetrics. RESULTS Identification of intratumoral language and motor tracts significantly predicted eloquent areas within the tumor during the IES mapping: the positive predictive value for the pyramidal tract, the inferior fronto-occipital fasciculus, the arcuate fasciculus and the inferior longitudinal fasciculus positive was 100%, 100%, 33%, and 80%, respectively, whereas negative predictive value was 100% for all of them. The reconstruction of at least one of these tracts within the tumor was significantly associated with a lower extent of resection (67%) as opposed to the extent of resection in the cases with a negative intratumoral tractography (100%) (P &lt; .0001). CONCLUSION Intratumoral DTI-based tractography is a simple and reliable method, useful in assessing glioma resectability based on the analysis of intratumoral eloquent areas associated with motor and language tracts within the tumor.

scholarly journals Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas

2017 ◽  
Vol 126 (2) ◽  
pp. 418-430 ◽  
Author(s):  
Sivashanmugam Dhandapani ◽  
Harminder Singh ◽  
Hazem M. Negm ◽  
Salomon Cohen ◽  
Mark M. Souweidane ◽  
...  
Keyword(s):  
Tumor Volume ◽  
Visual Outcome ◽  
Extent Of Resection ◽  
Endocrine Function ◽  
Subtotal Resection ◽  
Total Resection ◽  
Medical College ◽  
The Impact ◽  
First Time

OBJECTIVE Craniopharyngiomas can be difficult to remove completely based on their intimate relationship with surrounding visual and endocrine structures. Reoperations are not uncommon but have been associated with higher rates of complications and lower extents of resection. So radiation is often offered as an alternative to reoperation. The endonasal endoscopic transsphenoidal approach has been used in recent years for craniopharyngiomas previously removed with craniotomy. The impact of this approach on reoperations has not been widely investigated. METHODS The authors reviewed a prospectively acquired database of endonasal endoscopic resections of craniopharyngiomas over 11 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, performed by the senior authors. Reoperations were separated from first operations. Pre- and postoperative visual and endocrine function, tumor size, body mass index (BMI), quality of life (QOL), extent of resection (EOR), impact of prior radiation, and complications were compared between groups. EOR was divided into gross-total resection (GTR, 100%), near-total resection (NTR, > 95%), and subtotal resection (STR, < 95%). Univariate and multivariate analyses were performed. RESULTS Of the total 57 endonasal surgical procedures, 22 (39%) were reoperations. First-time operations and reoperations did not differ in tumor volume, radiological configuration, or patients' BMI. Hypopituitarism and diabetes insipidus (DI) were more common before reoperations (82% and 55%, respectively) compared with first operations (60% and 8.6%, respectively; p < 0.001). For the 46 patients in whom GTR was intended, rates of GTR and GTR+NTR were not significantly different between first operations (90% and 97%, respectively) and reoperations (80% and 100%, respectively). For reoperations, prior radiation and larger tumor volume had lower rates of GTR. Vision improved equally in first operations (80%) compared with reoperations (73%). New anterior pituitary deficits were more common in first operations compared with reoperations (51% vs 23%, respectively; p = 0.08), while new DI was more common in reoperations compared with first-time operations (80% vs 47%, respectively; p = 0.08). Nonendocrine complications occurred in 2 (3.6%) first-time operations and no reoperations. Tumor regrowth occurred in 6 patients (11%) over a median follow-up of 46 months and was not different between first versus reoperations, but was associated with STR (33%) compared with GTR+NTR (4%; p = 0.02) and with not receiving radiation after STR (67% vs 22%; p = 0.08). The overall BMI increased significantly from 28.7 to 34.8 kg/m2 over 10 years. Six months after surgery, there was a significant improvement in QOL, which was similar between first-time operations and reoperations, and negatively correlated with STR. CONCLUSIONS Endonasal endoscopic transsphenoidal reoperation results in similar EOR, visual outcome, and improvement in QOL as first-time operations, with no significant increase in complications. EOR is more impacted by tumor volume and prior radiation. Reoperations should be offered to patients with recurrent craniopharyngiomas and may be preferable to radiation in patients in whom GTR or NTR can be achieved.

scholarly journals Profound hearing loss following surgery in pediatric patients with posterior fossa low-grade glioma

2017 ◽  
Vol 5 (2) ◽  
pp. 96-103 ◽  
Author(s):  
Yahya Ghazwani ◽  
Ibrahim Qaddoumi ◽  
Johnnie K Bass ◽  
Shengjie Wu ◽  
Jason Chiang ◽  
...  
Keyword(s):  
Hearing Loss ◽  
Posterior Fossa ◽  
Extent Of Resection ◽  
Tumor Location ◽  
Low Grade Glioma ◽  
Gross Total Resection ◽  
Subtotal Resection ◽  
Low Grade ◽  
Total Resection ◽  
Profound Hearing Loss

Abstract Background Hearing loss may occur in patients with posterior fossa low-grade glioma who undergo surgery. Methods We retrospectively reviewed 217 patients with posterior fossa low-grade glioma, including 115 for whom results of hearing tests performed after surgery and before chemotherapy or radiation therapy were available. We explored the association of UHL with age at diagnosis, sex, race, tumor location, extent of resection, posterior fossa syndrome, ventriculoperitoneal shunt placement, and histology. Results Of the 115 patients, 15 (13.0%: 11 male, 6 black, 8 white, 1 multiracial; median age 7 years [range, 1.3–17.2 years]) had profound UHL after surgery alone or before receiving ototoxic therapy. Median age at tumor diagnosis was 6.8 years (range, 0.7–14.1 years), and median age at surgery was 6.8 years (range, 0.7–14.1 years). Patients with UHL had pathology characteristic of pilocytic astrocytoma (n = 10), ganglioglioma (n = 4), or low-grade astrocytoma (n = 1). Of these 15 patients, 4 underwent biopsy, 1 underwent gross total resection, 1 underwent near-total resection, and 9 underwent subtotal resection. UHL was more frequent in black patients than in white patients (OR 7.3, P = .007) and less frequent in patients who underwent gross total resection or near-total resection than in those who underwent subtotal resection (OR 0.11, P = .02). Conclusions Children undergoing surgery for posterior fossa low-grade glioma are at risk for UHL, which may be related to race or extent of resection. These patients should receive postoperative audiologic testing, as earlier intervention may improve outcomes.

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.

Anesthesia management for low-grade glioma awake surgery: a European Low-Grade Glioma Network survey

2020 ◽  
Vol 162 (7) ◽  
pp. 1701-1707 ◽  
Author(s):  
Jeremy Arzoine ◽  
◽  
Charlotte Levé ◽  
Antonio Pérez-Hick ◽  
John Goodden ◽  
...  
Keyword(s):  
Low Grade Glioma ◽  
Awake Surgery ◽  
Low Grade ◽  
Anesthesia Management

Disrupting the right pars opercularis with electrical stimulation frees the song: case report

2015 ◽  
Vol 123 (6) ◽  
pp. 1401-1404 ◽  
Author(s):  
Guillaume Herbet ◽  
Gilles Lafargue ◽  
Fabien Almairac ◽  
Sylvie Moritz-Gasser ◽  
François Bonnetblanc ◽  
...  
Keyword(s):  
Language Production ◽  
Inferior Frontal Gyrus ◽  
Awake Surgery ◽  
Low Grade ◽  
Speech Impairment ◽  
First Case ◽  
Pars Opercularis ◽  
The Right

The authors report the first case of a strikingly unusual speech impairment evoked by intraoperative electrostimulation in a 36-year-old right-handed patient, a well-trained singer, who underwent awake surgery for a right fronto-temporo-insular low-grade glioma. Functionally disrupting the pars opercularis of the right inferior frontal gyrus led the patient to automatically switch from a speaking to a singing mode of language production. Given the central role of the right pars opercularis in the inhibitory control network, the authors propose that this finding may be interpreted as possible evidence for a competitive and independent neurocognitive subnetwork devoted to the melodically intoned articulation of words (normal language-based vs singing-based) in subjects with high expertise. From a more clinical perspective, such data may have implications for awake neurosurgery, especially to preserve the quality of life for singers.

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