BRMP-05. Intraoperative neural tract positioning method for the maximal safe resection of tumors

Brain mapping is a gold standard for the surgery of tumors in eloquent area. Especially subcortical mapping is an essential method for the preservation of important neural fibers conveying motor, sensory and even higher brain functions such as language control. The efforts to estimate the fiber localizations in brain white matter sometimes result in the unprecise identification that is caused by several factors including electrical heterogeneity of brain tissues. To solve this long-standing problem, NY Tract Finder (Yamaguchi Tract Finder) was invented and has been used for intraoperative brain mappings. Now this electrode and method is used in more than 30 major hospitals in Japan, China, Taiwan and Russia. The novel and unique neural fiber positioning technique and our efforts for the maximal preservation of patients’ QOL will be introduced.

Revisiting Intraoperative 2D USG with Saline–Air Mixture as Contrast for Resection of Eloquent Area Glioma in Resource-Deficient Countries

Background Advanced ultrasound, intraoperative magnetic resonance imaging (MRI), neuromonitoring, and aminolevulenic acid have improved the resection and safety of eloquent area gliomas. However, availability of these modern gadgets is a major concern in resource-deficient countries. A two-dimensional ultrasonography 2D USG is cheaper, provides real-time imaging, and is already established but underutilized instrument. Objective Here, we revisited the principles of 2D USG and used it for eloquent-area glioma surgery. Materials and Methods Fifty-eight patients with eloquent area gliomas were operated in last 2 years with the aid of 2D USG with 6-13 MHz curvilinear probe. Preoperative diagnosis was high-grade glioma in 38 and low-grade glioma (LGG) in 20 patients. Tumors were categorized as predominantly hyperechoic (27), uniformly hyperechoic (7), mixed echogenicity (21), and cystic (3). Results Intraoperatively, 2D USG could define the tumor margins in 46 cases. Of these, USG suggested gross total excision in 38 patients and subtotal in 8 patients. The findings matched with follow-up MRI in 34 patients who showed hyperechogenicity (predominant/uniform). Injecting saline with air in to the resection cavity and insinuating through adjacent brain parenchyma helped in detecting residual lesion in three cystic gliomas and in two LGG where the tumor cavity collapsed. Conclusion 2D USG is a helpful tool in eloquent area glioma surgery, especially in resource-limited countries. Visualization through adjacent parenchyma and injection of saline–air mixture in to the resection cavity helped in delineating residual lesion. Extent of resection is best monitored by 2D USG when tumor appeared hyperechoic (predominant/uniform).

JS01.4.A The neurocognitive function changes with awake craniotomy for low-grade glioma in the left hemispheric eloquent regions

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.

Awake Surgery for Arteriovenous Malformations (AVM) in Eloquent Area: Risk and Outcome Analysis in the Most Complete Case-Collection

Background: Artero-venous malformations (AVMs) located in eloquent area are associated with significant risk of neurological deterioration, especially in patients presenting with unruptured AVMs and minimal or no neurological deficits. Awake-surgery allows a better identification of eloquent gyrus, but its feasibility and application in resection of eloquent AVMs is controversial and mostly limited to small case series.Methods: A total of 31 patients suffering from intracranial AVMs have been operated on in our Department. Patients were stratified into two groups: patients submitted to Asleep Surgery and patients submitted to Awake surgery. We implemented the Awake Group with results from the most complete case series reported in the literature to obtain a complete uni and multivariate analysis of surgical risks and outcome.Results: Awake craniotomy was performed in 19,35% of the AVMs treated in our centre. Considering the reported cases from all other series published in the literature, we obtained a comparison between the asleep group of 25 patients derived from our series and the awake group of 34 patients. No statistically significant differences were identified regarding the risk of postoperative complications, surgical radicality, presence of residual, and need for adjuvant treatment. Interestingly, however, improvement in performance status was more rapid and effective during follow-up in patients treated with awake surgery compared with asleep surgery.Conclusions: In contrast to what is commonly believed, applying awake surgery in this type of lesions does not involve increased intra-operative risks, but rather it seems to determine a greater improvement in the outcome of patients from the thirtieth postoperative day. Awake patients allow for more precise brain mapping and superior clinical neurologic monitoring, which facilitates resection by defining the safe margins without an increased risk.

Treatment strategy for the tumor cyst of the medulla in an eloquent area: a case report and review of the literature

This is a clinical case of a 24-year-old woman with the unrescetable cystic tumor of the medulla because of eloquent area involved and severe neurological symptoms caused by the recurrent cystic component. The patient underwent emptying the cyst twice previously by means of safe entry zone myelotomy. Later there was a recurrence of the cyst with a significant neurological and oweral deterioration which is typical for such neoplasms. Recurrent cystic mass-effect was resolved with the help of newly designed device implanted. It provided simultaneous stable cisternal drainage and an opportunity for active aspiration via Ommaya reservoir.

Recurrent high-grade glioma surgery: a multimodal intraoperative protocol to safely increase extent of tumor resection and analysis of its impact on patient outcome

OBJECTIVENo consensus exists on the best treatment for recurrent high-grade glioma (HGG), particularly in terms of surgical indications, and scant data are available on the integrated use of multiple technologies to overcome intraoperative limits and pitfalls related to artifacts secondary to previous surgery and radiotherapy. Here, the authors report on their experience with the integration of multiple intraoperative tools in recurrent HGG surgery, analyzing their pros and cons as well as their effectiveness in increasing the extent of tumor resection. In addition, they present a review of the relevant literature on this topic.METHODSThe authors reviewed all cases in which recurrent HGG had been histologically diagnosed after a first surgery and the patient had undergone a second surgery involving neuronavigation with MRI, intraoperative CT (iCT), 11C-methionine–positron emission tomography (11C-MET-PET), 5-aminolevulinic acid (5-ALA) fluorescence, intraoperative neurophysiological monitoring (IONM), and intraoperative navigated ultrasound (iUS). All cases were classified according to tumor functional grade (1, noneloquent area; 2, near an eloquent area; 3, eloquent area).RESULTSTwenty patients with recurrent HGG were operated on using a multimodal protocol. The recurrent tumor functional grade was 1 in 4 patients, 2 in 8 patients, and 3 in the remaining 8 patients. In all patients but 2, 100% EOTR was obtained. Intraoperative 5-ALA fluorescence and navigated iUS showed low specificity and sensitivity. iCT detected tumor remnants in 3 cases. Postoperatively, 6 patients (30%) had worsening neurological conditions: 4 recovered within 90 days, 1 partially recovered, and 1 experienced a permanent deficit. The median Karnofsky Performance Status remained substantially unchanged over the follow-up period. The mean progression-free survival after the second surgery was 7.7 months (range 2–11 months). The mean overall survival was 25.4 months (range 10–52 months), excluding 2 long survivors. Two patients died within 60 days after surgery, and 3 patients were still under follow-up at the end of this study.CONCLUSIONSThis is the first study reporting the integration of neuronavigation, 5-ALA fluorescence, iUS, iCT, 11C-MET-PET, and IOM during microsurgical resection of recurrent glioma. The authors believe that the proposed multimodal protocol is useful to increase the safety, effectiveness, and EOTR in patients with recurrent HGG and brain alterations secondary to radio- and chemotherapy.

MET-10 Preliminary report of radiotherapy for brain metastases from breast and kidney using mask system of Leksell Gamma Knife Icon

Object: Leksell Gamma Knife Icon enables us to apply new methods of immobilization using mask fixation and the option of fractionated treatment. This provides exceptional accuracy and precision of radiosurgery, making it a possibility for many more disease types and many more patients to be treated. Methods: We retrospectively analyzed 97 patients (140 times) with brain metastases from breast (B group) and 26 patients (33 times) with brain metastases from kidney (K group) and who underwent Gamma Knife Icon using mask fixation between September 25th, 2017 and June 30th, 2020 at Rakusai Shimizu Hospital. Patients with small, few, newly diagnosed, and non-eloquent area tumors were treated in a single session. If the tumor volume was larger than 5.0 ml, recurrence, or the location was in an eloquent area, we applied a fractionated schedule. If the tumor number was large, we selected a multisession schedule. Median tumor number was three (1–64) in B group and two (1–31) in K group. Median tumor size was 2.7 (0. 01-58.8) ml in B group and 2.8 (0.02–123.5) ml in K group. We selected fractionated schedules as follows; 7.0 Gy x 5Fr (5–10 ml), 4.2Gy x 10Fr (10-20ml), 3.7Gy x 10Fr (20-30ml), 3.2Gy x 10Fr (30ml-). Results: 32 (B) and 14 (K) cases were treated in a single session, 80 (B) and 17 (K) with fractionation, and 28 (B) and 2 (K) with multiple sessions. Median survival times after Icon treatment was 28.2 (B) and 15.5 (K) months. Local control rates were 89 % (B) and 85% after 12-month Icon treatment. Qualitative survival rates were 91% (B) and 86% (K) after 12-month Icon treatment. There were no statistically differences between two groups. Conclusions: Although these results are limited to short periods, survival rates, local control rates and qualitative survival rates were within the acceptable ranges.

Framed Stereotactic Brain Biopsy Outcome – Single Center Study

stereotactic biopsy. The study was conducted at the Neurospinal & Cancer Care Institute Karachi. Material and Methods: After the approval from the ethical hospital committee, the study was conducted on 34 patients, in which 9 (26.4%) were females, and 25 (73.5%) were males. 34 consecutive patients with biopsy inclusion deep seated lesion, mid line pathology, eloquent area and operated surgery, previous radiation treatment were excluded, and after that, the biopsy report based surgery or radiotherapy treatment was decided. Result: The biopsy underwent histopathological diagnosis proving Astrocytoma in 7 (20.5%) patients out of which four were in the Eloquent area, tuberculosis diagnosed in 5 (14.7%) patient, Oligodendroglioma diagnosed in 3 (8.8%) patients, metastasis in 5 (14.7%), Abscess in 4 (11.7%) patient which was aspirated to maximum and sent for culture, Malignant tumor (grade 3 & 4) 5 (14.7%), Lymphoma in 2 (5.8%) patient both were given radiation therapy Tumor necrosis 1 (2.9%) case, and No tissue obtained in 2 (5.8%) which was repeated later. No major complication or side effects were observed in the patient. Conclusion: Stereotactic Framed biopsy is safe and accurate and can be used in deep seated lesions with high success rate, minimal complication and decrease surgical morbidity for patients, and it is comparable to updated methods.

Multimodality Treatment of Craniopharyngioma: Aspiration of Cystic Contents and Placement of Ommaya Reservoir Stereotactically Followed by Gamma Knife Radiosurgery – Single Center Study of 81 Cases

Objective: The objective of this present study was to assess the accuracy, result, and safety measures of stereotactic biopsy. The study was conducted at the Neurospinal & Cancer Care Institute Karachi. Material and Methods: After the approval from the ethical hospital committee, the study was conducted on 34 patients, in which 9 (26.4%) were females, and 25 (73.5%) were males. 34 consecutive patients with biopsy inclusion deep seated lesion, mid line pathology, eloquent area and operated surgery, previous radiation treatment were excluded, and after that, the biopsy report based surgery or radiotherapy treatment was decided. Result: The biopsy underwent histopathological diagnosis proving Astrocytoma in 7 (20.5%) patients out of which four were in the Eloquent area, tuberculosis diagnosed in 5 (14.7%) patient, Oligodendroglioma diagnosed in 3 (8.8%) patients, metastasis in 5 (14.7%), Abscess in 4 (11.7%) patient which was aspirated to maximum and sent for culture, Malignant tumor (grade 3 & 4) 5 (14.7%), Lymphoma in 2 (5.8%) patient both were given radiation therapy Tumor necrosis 1 (2.9%) case, and No tissue obtained in 2 (5.8%) which was repeated later. No major complication or side effects were observed in the patient. Conclusion: Stereotactic Framed biopsy is safe and accurate and can be used in deep seated lesions with high success rate, minimal complication and decrease surgical morbidity for patients, and it is comparable to updated methods