Resection of malignant brain tumors in eloquent cortical areas: a new multimodal approach combining 5-aminolevulinic acid and intraoperative monitoring

2010 ◽  
Vol 113 (2) ◽  
pp. 352-357 ◽  
Author(s):  
Guenther C. Feigl ◽  
Rainer Ritz ◽  
Mario Moraes ◽  
Jan Klein ◽  
Kristofer Ramina ◽  
...  
Keyword(s):  
Brain Tumors ◽  
Intraoperative Monitoring ◽  
Aminolevulinic Acid ◽  
Diffusion Tensor ◽  
Imaging Data ◽  
Eloquent Areas ◽  
Cortical Areas ◽  
Malignant Brain Tumors ◽  
Fiber Tracts ◽  
Functional Areas

Object Several studies have revealed that the gross-total resection (GTR) of malignant brain tumors has a significant influence on patient survival. Frequently, however, GTR cannot be achieved because the borders between healthy brain and diseased tissue are blurred in the infiltration zones of malignant brain tumors. Especially in eloquent cortical areas, resection is frequently stopped before total removal is achieved to avoid causing neurological deficits. Interestingly, 5-aminolevulinic acid (5-ALA) has been shown to help visualize tumor tissue intraoperatively and, thus, can significantly improve the possibility of achieving GTR of primary malignant brain tumors. The aim of this study was to go one step further and evaluate the utility and limitations of fluorescence-guided resections of primary malignant brain tumors in eloquent cortical areas in combination with intraoperative monitoring based on multimodal functional imaging data. Methods Eighteen patients with primary malignant brain tumors in eloquent areas were included in this prospective study. Preoperative neuroradiological examinations included MR imaging with magnetization-prepared rapid gradient echo (MPRAGE), functional MR, and diffusion tensor imaging sequences to visualize functional areas and fiber tracts. Imaging data were analyzed offline, loaded into a neuronavigational system, and used intraoperatively during resections. All patients received 5-ALA 6 hours before surgery. Fluorescence-guided tumor resections were combined with intraoperative monitoring and cortical as well as subcortical stimulation to localize functional areas and fiber tracts during surgery. Results Twenty-five procedures were performed in 18 consecutive patients. In 24% of all surgeries, resection was stopped because a functional area or cortical tract was identified in the resection area or because motor evoked potential amplitudes were reduced in an area where fluorescent tumor cells were still seen intraoperatively. Grosstotal resection could be achieved in 16 (64%) of the surgeries with preservation of all functional areas and fiber tracts. In 2 patients presurgical hemiparesis became accentuated postoperatively, and 1 of these patients also suffered from a new homonymous hemianopia following a second resection. Conclusions The authors' first results show that tumor resections with 5-ALA in combination with intraoperative cortical stimulation have the advantages of both methods and, thus, provide additional safety for the neurosurgeon during resections of primary malignant brain tumors in eloquent areas. Nonetheless, more cases and additional studies are necessary to further prove the advantages of this multimodal strategy.

CNTM-01. Evaluating Traditional and Non-Traditional Eloquent Areas in Patients with Brain Tumors: Large-scale Network Analysis Using a Machine Learning-Based Platform

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi224-vi224
Author(s):  
Alexis Morell ◽  
Daniel Eichberg ◽  
Ashish Shah ◽  
Evan Luther ◽  
Victor Lu ◽  
...  
Keyword(s):  
Machine Learning ◽  
Brain Tumors ◽  
Large Scale ◽  
Diffusion Tensor ◽  
Brain Networks ◽  
Tumor Resection ◽  
Central Executive ◽  
Default Mode ◽  
Eloquent Areas ◽  
Neurologic Deficits

Abstract BACKGROUND Developing mapping tools that allow identification of traditional or non-traditional eloquent areas is necessary to minimize the risk of postoperative neurologic deficits. The objective of our study is to evaluate the use of a novel cloud-based platform that uses machine learning to identify cerebral networks in patients with brain tumors. METHODS We retrospectively included all adult patients who underwent surgery for brain tumor resection or thermal ablation at our Institution between the 16th of February and the 15th of May of 2021. Pre and postoperative contrast-enhanced MRI with T1-weighted and high-resolution Diffusion Tensor Imaging (DTI) sequences were uploaded into the Quicktome platform. After processing the data, we categorized the integrity of seven large-scale brain networks: sensorimotor, visual, ventral attention, central executive, default mode, dorsal attention and limbic. Affected networks were correlated with pre and postoperative clinical data, including neurologic deficits. RESULTS Thirty-five (35) patients were included in the study. The average age of the sample was 63.2 years, and 51.4% (n=18) were females. The most affected network was the central executive network (40%), followed by the dorsal attention and default mode networks (31.4%), while the least affected were the visual (11%) and ventral attention networks (17%). Patients with preoperative deficits showed a significantly higher number of altered networks before the surgery (p=0.021), compared to patients without deficits. In addition, we found that patients without neurologic deficits had an average of 2.06 large-scale networks affected, with 75% of them not being related to traditional eloquent areas as the sensorimotor, language or visual circuits. CONCLUSIONS The Quicktome platform is a practical tool that allows automatic visualization of large-scale brain networks in patients with brain tumors. Although further studies are needed, it may assist in the surgical management of traditional and non-traditional eloquent areas.

Subcortical Stimulation with Tip of Ultrasound Aspirator

2021 ◽  
Author(s):  
Henry Colle ◽  
David Colle ◽  
Bonny Noens ◽  
Bob Dhaen ◽  
Giovanni Alessi ◽  
...  
Keyword(s):  
Brain Tumors ◽  
Current Practice ◽  
Tumor Resection ◽  
Intracranial Lesion ◽  
Eloquent Areas ◽  
Fiber Tracts ◽  
Current Transmission ◽  
Subcortical Stimulation ◽  
Tissue Trauma ◽  
White Fiber

Background During resection of intrinsic brain tumors in eloquent areas, particularly under awake mapping, subcortical stimulation is mandatory to avoid irreversible deficits by damaging white fiber tracts. The current practice is to alternate between subcortical stimulation with an appropriate probe and resection of tumoral tissue with an ultrasound aspiration device. Switching between different devices induces supplementary movement and possible tissue trauma, loss of time, and inaccuracies in the localization of the involved area. Objective To use one device for both stimulation as well as a resecting tool. Methods The tip of different ultrasound aspiration devices is currently used for monopolar current transmission (e.g., for vessel coagulation in liver surgery). We use the same circuitry for monopolar subcortical stimulation when connected with the usual stimulator devices. Results We have applied this method since 2004 in over 500 patients during tumor resection with cortical and subcortical stimulation, mostly with awake language and motor monitoring. Conclusion A method is presented using existing stimulation and wiring devices by which simultaneous subcortical stimulation and ultrasonic aspiration are applied with the same tool. The accuracy, safety, and speed of intrinsic intracranial lesion resection can be improved when subcortical stimulation is applied.

Magnetoencephalography in Neurosurgery

Neurosurgery ◽  
2006 ◽  
Vol 59 (3) ◽  
pp. 493-511 ◽  
Author(s):  
Jyrki P. Mäkelä ◽  
Nina Forss ◽  
Juha Jääskeläinen ◽  
Erika Kirveskari ◽  
Antti Korvenoja ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Diffusion Tensor ◽  
Brain Plasticity ◽  
Epileptiform Activity ◽  
Intractable Epilepsy ◽  
Imaging Data ◽  
Resonance Imaging ◽  
Cortical Areas ◽  
Neurosurgical Patients

Abstract OBJECTIVE: To present applications of magnetoencephalography (MEG) in studies of neurosurgical patients. METHODS: MEG maps magnetic fields generated by electric currents in the brain, and allows the localization of brain areas producing evoked sensory responses and spontaneous electromagnetic activity. The identified sources can be integrated with other imaging modalities, e.g., with magnetic resonance imaging scans of individual patients with brain tumors or intractable epilepsy, or with other types of brain imaging data. RESULTS: MEG measurements using modern whole-scalp instruments assist in tailoring individual therapies for neurosurgical patients by producing maps of functionally irretrievable cortical areas and by identifying cortical sources of interictal and ictal epileptiform activity. The excellent time resolution of MEG enables tracking of complex spaciotemporal source patterns, helping, for example, with the separation of the epileptic pacemaker from propagated activity. The combination of noninvasive mapping of subcortical pathways by magnetic resonance imaging diffusion tensor imaging with MEG source localization will, in the near future, provide even more accurate navigational tools for preoperative planning. Other possible future applications of MEG include the noninvasive estimation of language lateralization and the follow-up of brain plasticity elicited by central or peripheral neural lesions or during the treatment of chronic pain. CONCLUSION: MEG is a mature technique suitable for producing preoperative “road maps” of eloquent cortical areas and for localizing epileptiform activity.

Quantifying accuracy and precision of diffusion MR tractography of the corticospinal tract in brain tumors

2014 ◽  
Vol 121 (2) ◽  
pp. 349-358 ◽  
Author(s):  
Maria Luisa Mandelli ◽  
Mitchel S. Berger ◽  
Monica Bucci ◽  
Jeffrey I. Berman ◽  
Bagrat Amirbekian ◽  
...  
Keyword(s):  
Brain Tumors ◽  
Corticospinal Tract ◽  
Diffusion Tensor ◽  
Fiber Tracking ◽  
Subcortical White Matter ◽  
Motor Pathways ◽  
Motor Mapping ◽  
Fiber Tracts ◽  
Accuracy And Precision ◽  
Dti Fiber Tracking

Object The aim of this paper was to validate the diffusion tensor imaging (DTI) model for delineation of the corticospinal tract using cortical and subcortical white matter electrical stimulation for the location of functional motor pathways. Methods The authors compare probabilistic versus deterministic DTI fiber tracking by reconstructing the pyramidal fiber tracts on preoperatively acquired DTI in patients with brain tumors. They determined the accuracy and precision of these 2 methods using subcortical stimulation points and the sensitivity using cortical stimulation points. The authors further explored the reliability of these methods by estimation of the potential that the found connections were due to a random chance using a novel neighborhood permutation method. Results The probabilistic tracking method delineated tracts that were significantly closer to the stimulation points and was more sensitive than deterministic DTI fiber tracking to define the tracts directed to the motor sites. However, both techniques demonstrated poor sensitivity to finding lateral motor regions. Conclusions This study highlights the importance of the validation and quantification of preoperative fiber tracking with the aid of electrophysiological data during the surgery. The poor sensitivity of DTI to delineate lateral motor pathways reported herein suggests that DTI fiber tracking must be used with caution and only as adjunctive data to established methods for motor mapping.

Use of 5-ALA fluorescence guided endoscopic biopsy of a deep-seated primary malignant brain tumor

2011 ◽  
Vol 114 (5) ◽  
pp. 1410-1413 ◽  
Author(s):  
Rainer Ritz ◽  
Guenther C. Feigl ◽  
Martin U. Schuhmann ◽  
André Ehrhardt ◽  
Soeren Danz ◽  
...  
Keyword(s):  
Brain Tumors ◽  
Aminolevulinic Acid ◽  
Protoporphyrin Ix ◽  
Endoscopic Biopsy ◽  
Combined Approach ◽  
Malignant Brain Tumors ◽  
Dichroic Filter ◽  
Microsurgical Resection ◽  
New Strategies ◽  
Primary Malignant Brain Tumor

The introduction of fluorescence-guided resection of primary malignant brain tumors was a milestone in neurosurgery. Deep-seated malignant brain tumors are often not approachable for microsurgical resection. For diagnosis and therapy, new strategies are recommended. The combination of endoscopy and 5-aminolevulinic acid–induced protoporphyrin IX (5-ALA-induced Pp IX) fluorescence–guided procedures supported by neuronavigation seems an interesting option. Here the authors report on a combined approach for 5-ALA fluorescence–guided biopsy in which they use an endoscopy system based on an Xe lamp (excitation approximately λ = 407 nm; dichroic filter system λ = 380–430 nm) to treat a malignant tumor of the thalamus and perform a ventriculostomy and septostomy. The excitation filter and emission filter are adapted to ensure that the remaining visible blue remission is sufficient to superimpose on or suppress the excited red fluorescence of the endogenous fluorochromes. The authors report that the lesion was easily detectable in the fluorescence mode and that biopsy led to histological diagnosis.

5-Aminolevulinic Acid-induced Protoporphyrin IX Levels in Tissue of Human Malignant Brain Tumors

2010 ◽  
Vol 86 (6) ◽  
pp. 1373-1378 ◽  
Author(s):  
Ann Johansson ◽  
Gesa Palte ◽  
Oliver Schnell ◽  
Jörg-Christian Tonn ◽  
Jochen Herms ◽  
...  
Keyword(s):  
Brain Tumors ◽  
Aminolevulinic Acid ◽  
Protoporphyrin Ix ◽  
Malignant Brain Tumors

Abstract 1531: Altered Brain Fiber Tracts in Heart Failure

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Mary A Woo ◽  
Paul M Macey ◽  
Rajesh Kumar ◽  
Stacy L Serber ◽  
Rebecca Cross ◽  
...  
Keyword(s):  
Heart Failure ◽  
Frontal Cortex ◽  
Diffusion Tensor ◽  
Multiple Comparisons ◽  
Brain Regions ◽  
Imaging Data ◽  
Permutation Testing ◽  
Control Subjects ◽  
Fiber Tracts ◽  
Limbic Regions

Introduction: Heart failure (HF) patients show neuronal brain injury which contributes to cognitive, affective, and autonomic symptoms. However, earlier studies did not consistently report injury within cognitive sites (e.g., frontal cortex) or limbic structures linked to affective and autonomic function. The inconsistent signs of injury in these neuronal structures may result from compromised communication between cognitive and limbic regions from damaged axons. Methods: We studied axon integrity between these regions using tract-based spatial statistics (TBSS; allows study of white matter tracts) in 17 HF (age 54 ± 8 years; 12 males; LVEF 0.28 ± 0.07) and 51 control subjects (age 50 ± 7 years, 29 males). We collected diffusion tensor imaging data using a 3T MRI scanner, from which we calculated fractional anisotropy (FA), an index of axonal integrity. Whole-brain FA “maps” for each subject were processed using TBSS, giving estimated axonal tracts co-localized across subjects. FA values throughout the tracts were compared between groups using 2-sample t-tests, controlling for multiple comparisons by permutation testing (form of randomization test). Results: Fiber tracts in HF showed reduced FA values across multiple brain regions (Figure ), including the anterior corona radiata (projecting to and from frontal cortex) and the superior and inferior cingulum bundle (communicating to and from the cingulate, hippocampus and other limbic regions), and cerebellum (dampens blood pressure changes). Discussion: Cognitive and affective symptoms in HF patients may arise from a combination of damaged structural areas and poor communication between brain regions. Regions of reduced fiber tract integrity (lower FA) in 17 HF versus 51 control subjects indicated in white ( p < 0.05, false discovery rate correction for multiple comparisons). Background image is a reference anatomical scan, with detected fiber tracts as found with TBSS in black. Orientation: images left of image is left of person; locations relative to standard reference (anterior commusure is origin): from left to right, 48 mm anterior, 7 mm left, 39 mm posterior.

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