Brain Mapping: Real-Time Neuropsychological Testing Experience during Low-Grade Tumor Resection

Abstract BACKGROUND Cognitive deficit was frequently observed in glioma patients, especially for those on the eloquent area. Considering the increased life expectancy, brain mapping during awake craniotomy was preferentially applied to exacerbate neurocognitive deficits. The aim of the current study was to evaluate the neurocognitive changes during the perioperative period of resection of low-grade glioma (LGG) in the left side eloquent area with awake craniotomy in a major neurosurgical center in China for 5 years. MATERIAL AND METHODS We retrospectively analyzed patients with left-sided glioma in eloquent areas, who received awake craniotomy during 2016–2020. Montreal Cognitive Assessment Scale, BN-20, and EORTC-QLQ-C30 questionnaire were applied for neurological cognitive assessment. We performed a correlation analysis between changes in cognitive performance and tumor characteristics, including tumor location, pathological grade. Treatment-related factors were also analyzed, such as the extent of resection (EOR), preoperative and postoperative Karnofsky Performance Score (KPS), postoperative treatment strategy (chemo- and radiotherapy), progression-free survival (PFS), overall survival (OS). RESULTS 68 patients were included in our current study. For the language domain, memory domain, and executive functions, 7.4% (5/68) patients presented mild postoperative cognitive performance deterioration compared to preoperative. Tumor location was the only factor that greatly influenced the postoperative cognitive performance, while other features (EOR, KPS, pathological grades) and treatment strategy were found no effect on cognitive change. The extent of tumor resection ranged from 81% to 100%. CONCLUSION Our study underlines the importance of the application of brain mapping during awake craniotomy, which helps to maximize extent of tumor resection while preserving cognitive function in individuals with LGG in eloquent regions.

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Real-Time Neuropsychological Testing Protocol for Left Temporal Brain Tumor Surgery: A Technical Note and Case Report

Frontiers in Human Neuroscience ◽

10.3389/fnhum.2021.760569 ◽

2021 ◽

Vol 15 ◽

Author(s):

Barbara Tomasino ◽

Ilaria Guarracino ◽

Tamara Ius ◽

Marta Maieron ◽

Miran Skrap

Keyword(s):

Case Report ◽

Real Time ◽

Short Term Memory ◽

Diffusion Tensor ◽

Neuropsychological Testing ◽

Cognitive Status ◽

Awake Surgery ◽

Low Grade ◽

Normal Range ◽

Essential Information

Background: The risk of surgery in eloquent areas is related to neuropsychological dysfunctions. Maximizing the extent of resection increases the overall survival. The onco-functional balance is mandatory when surgery involves cognitive areas, and maximal information on the cognitive status of patients during awake surgery is needed. This can be achieved using direct cortical stimulation mapping and, in addition to this, a neuropsychological monitoring technique called real-time neuropsychological testing (RTNT). The RTNT includes testing protocols based on the area where the surgery is performed. We reported on tests used for left temporal lobe surgery and our RTNT decision tree.Case Report: We reported our RTNT experience with a 25-year-old right-handed man with 13 years of schooling. He reported daily partial seizures. MRI revealed the presence of a low-grade glioma involving the temporo-insular cortex. The neuropsychological status presurgery which was within the normal range was combined with functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) information. Awake surgery plus RTNT was performed. Direct electrical stimulation during object naming elicited a motor speech arrest. Resection was continuously accompanied by the RTNT. The RTNT provided enriched information to the surgeon. Performance never dropped. A slight decrement in accuracy emerged for pseudoword repetition, short-term memory and working memory, phonological processing, and verbal comprehension. Total resection was performed, and the histological examination confirmed the nature of the lesion. Immediate postsurgery performance was within the normal range as it was the fMRI and DTI assessment.Conclusion: The RTNT provides essential information that can be used online, during surgery, for clinical aims to provide the surgeon with useful feedback on the cognitive status of patients.

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Intraoperative contrast-enhanced ultrasound for cerebral glioma resection and the relationship with microvessel density

10.1101/528281 ◽

2019 ◽

Author(s):

Jia Wang ◽

Xi Liu ◽

Yilin Yang ◽

Yunyou Duan

Keyword(s):

Real Time ◽

Microvessel Density ◽

Color Doppler ◽

Tumor Resection ◽

Low Grade ◽

Contrast Enhanced Ultrasound ◽

Contrast Enhanced ◽

Cerebral Gliomas ◽

Before And After ◽

The Relationship

ABSTRACTPurposeWe studied the value of intraoperative contrast-enhanced ultrasound (iCEUS) for real-time monitoring of resection of cerebral gliomas, and analyzed the relationship between CEUS parameters and microvessel density (MVD) of different pathologic grades of cerebral gliomas.Materials and MethodsICEUS was performed in 49 patients with cerebral gliomas. The enhancement characteristics of cerebral gliomas were observed before and after tumor resection. The number of microvessels was counted by immunostaining with anti-CD34. Differences in these quantitative parameters in cerebral gliomas were compared and subjected to a correlation analysis with MVD.ResultsThe color Doppler flow classification within lesions were significantly different before and after iCEUS (p<0.05). The assessment of iCEUS parameters and tumor MVD showed that cerebral gliomas of different pathological grades had different characteristics. The time-to-peak (Tmax) was significantly shorter, the peak intensity (PI) and MVD were significantly higher in high-grade cerebral gliomas than in low-grade cerebral gliomas (p<0.05). According to the immunostaining, PI was positively (r=0.637) correlated with MVD and Tmax was negatively (r=–0.845) correlated with MVD.ConclusionICEUS may determine the borders of lesions more clearly, indicate the microvascular perfusion in real time, and be helpful in understanding the cerebral gliomas grade.

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Challenges and Opportunities of Intraoperative 3D Ultrasound With Neuronavigation in Relation to Intraoperative MRI

Frontiers in Oncology ◽

10.3389/fonc.2021.656519 ◽

2021 ◽

Vol 11 ◽

Author(s):

Dhiego Chaves De Almeida Bastos ◽

Parikshit Juvekar ◽

Yanmei Tie ◽

Nick Jowkar ◽

Steve Pieper ◽

...

Keyword(s):

Real Time ◽

Tumor Resection ◽

Intraoperative Ultrasound ◽

Residual Tumor ◽

Intraoperative Mri ◽

Recent Experience ◽

Low Grade ◽

Challenges And Opportunities ◽

Real Time Information ◽

Time Information

IntroductionNeuronavigation greatly improves the surgeon’s ability to approach, assess and operate on brain tumors, but tends to lose its accuracy as the surgery progresses and substantial brain shift and deformation occurs. Intraoperative MRI (iMRI) can partially address this problem but is resource intensive and workflow disruptive. Intraoperative ultrasound (iUS) provides real-time information that can be used to update neuronavigation and provide real-time information regarding the resection progress. We describe the intraoperative use of 3D iUS in relation to iMRI, and discuss the challenges and opportunities in its use in neurosurgical practice.MethodsWe performed a retrospective evaluation of patients who underwent image-guided brain tumor resection in which both 3D iUS and iMRI were used. The study was conducted between June 2020 and December 2020 when an extension of a commercially available navigation software was introduced in our practice enabling 3D iUS volumes to be reconstructed from tracked 2D iUS images. For each patient, three or more 3D iUS images were acquired during the procedure, and one iMRI was acquired towards the end. The iUS images included an extradural ultrasound sweep acquired before dural incision (iUS-1), a post-dural opening iUS (iUS-2), and a third iUS acquired immediately before the iMRI acquisition (iUS-3). iUS-1 and preoperative MRI were compared to evaluate the ability of iUS to visualize tumor boundaries and critical anatomic landmarks; iUS-3 and iMRI were compared to evaluate the ability of iUS for predicting residual tumor.ResultsTwenty-three patients were included in this study. Fifteen patients had tumors located in eloquent or near eloquent brain regions, the majority of patients had low grade gliomas (11), gross total resection was achieved in 12 patients, postoperative temporary deficits were observed in five patients. In twenty-two iUS was able to define tumor location, tumor margins, and was able to indicate relevant landmarks for orientation and guidance. In sixteen cases, white matter fiber tracts computed from preoperative dMRI were overlaid on the iUS images. In nineteen patients, the EOR (GTR or STR) was predicted by iUS and confirmed by iMRI. The remaining four patients where iUS was not able to evaluate the presence or absence of residual tumor were recurrent cases with a previous surgical cavity that hindered good contact between the US probe and the brain surface.ConclusionThis recent experience at our institution illustrates the practical benefits, challenges, and opportunities of 3D iUS in relation to iMRI.

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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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Clinical Utility of Real-Time Targeted Molecular Profiling in the Clinical Management of Ovarian Cancer: The ALLOCATE Study

JCO Precision Oncology ◽

10.1200/po.19.00019 ◽

2019 ◽

pp. 1-18

Author(s):

Olga Kondrashova ◽

Gwo-Yaw Ho ◽

George Au-Yeung ◽

Leakhena Leas ◽

Tiffany Boughtwood ◽

...

Keyword(s):

Ovarian Cancer ◽

Real Time ◽

Targeted Therapies ◽

Clinical Management ◽

Clinical Utility ◽

Advanced Ovarian Cancer ◽

Molecular Profiling ◽

Molecular Testing ◽

Low Grade ◽

Ovarian Carcinomas

PURPOSE The ALLOCATE study was designed as a pilot to demonstrate the feasibility and clinical utility of real-time targeted molecular profiling of patients with recurrent or advanced ovarian cancer for identification of potential targeted therapies. PATIENTS AND METHODS A total of 113 patients with ovarian cancer of varying histologies were recruited from two tertiary hospitals, with 99 patient cases suitable for prospective analysis. Targeted molecular and methylation profiling of fresh biopsy and archived tumor samples were performed by screening for mutations or copy-number variations in 44 genes and for promoter methylation of BRCA1 and RAD51C. RESULTS Somatic genomic or methylation events were identified in 85% of all patient cases, with potentially actionable events with defined targeted therapies (including four resistance events) detected in 60% of all patient cases. On the basis of these findings, six patients received molecularly guided therapy, three patients had unsuspected germline cancer–associated BRCA1/ 2 mutations and were referred for genetic counseling, and two intermediate differentiated (grade 2) serous ovarian carcinomas were reclassified as low grade, leading to changes in clinical management. Additionally, secondary reversion mutations in BRCA1/ 2 were identified in fresh biopsy samples of two patients, consistent with clinical platinum/poly (ADP-ribose) polymerase inhibitor resistance. Timely reporting of results if molecular testing is done at disease recurrence, as well as early referral for patients with platinum-resistant cancers, were identified as factors that could improve the clinical utility of molecular profiling. CONCLUSION ALLOCATE molecular profiling identified known genomic and methylation alterations of the different ovarian cancer subtypes and was deemed feasible and useful in routine clinical practice. Better patient selection and access to a wider range of targeted therapies or clinical trials will further enhance the clinical utility of molecular profiling.

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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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Three-dimensional Force Perception of Robotic Bipolar Forceps for Brain Tumor Resection

Journal of Medical Devices ◽

10.1115/1.4051361 ◽

2021 ◽

Author(s):

Xiu-Heng Zhang ◽

Heng Zhang ◽

Zhen Li ◽

Gui-Bin Bian

Keyword(s):

Brain Tumor ◽

Real Time ◽

Force Measurement ◽

Measurement Techniques ◽

Tumor Resection ◽

Three Dimensional ◽

Contact Forces ◽

Surgical Instruments ◽

Force Perception ◽

Brain Tumor Resection

Abstract Three-dimensional force perception is critically important in the enhancement of human force perception to minimize brain injuries resulting from excessive forces applied by surgical instruments in robot-assisted brain tumor resection. And surgeons are not responsive enough to interpret tool-tissue interaction forces. In previous studies, various force measurement techniques have been published. In neurosurgical scenarios, there are still some drawbacks to these presented approaches to forces perception. Because of the narrow, and slim configuration of bipolar forceps, three-dimensional contact forces on forceps tips is not easy to be traced in real-time. Five fundamental acts of handling bipolar forceps are poking, opposing, pressing, opening, and closing. The first three acts independently correspond to the axial force of z, x, y. So, in this paper, typical interactions between bipolar forceps and brain tissues have been analyzed. A three-dimensional force perception technique to collect force data on bipolar forceps tips by installing three Fiber Bragg Grating Sensors (FBGs) on each prong of bipolar forceps in real-time is proposed. Experiments using a tele-neurosurgical robot were performed on an in-vitro pig brain. In the experiments, three-dimensional forces were tracked in real-time. It is possible to experience forces at a minimum of 0.01 N. The three-dimensional force perception range is 0-4 N. The calibrating resolution on x, y, and z, is 0.01, 0.03, 0.1 N, separately. According to our observation, the measurement accuracy precision is over 95%.

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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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