COT-31 Risk Factors for the Development of Skin Rash with Levetiracetam and Lacosamide in Patients with Glioma

Introduction: Seizure control of in glioma patients is essential for quality of life. The new generation anti-seizure drug (ASD) is represented by lacosamide (LCM) and levetiracetam (LEV), and is said to have few side effects of eruption. We retrospectively analyzed the incidence of rash and related factors of the ASD, evaluated the safety of patients with glioma, and conducted a comparison with the evaluation of patients with meningioma. Method: We calculated the incidence of rash in patients who underwent glioma resection at our Hospital from January 2017 to December 2019 and were prescribed LEV or LCM, and compared it with the same incidence in meningioma patients. Multivariate logistic regression analysis was used to analyze the risk factors for the ASD-related eruption. Result: The subjects were 353 gliomas and 125 meningiomas who received LEV or LCM.The median ages are 44 ± 14.8 and 58 ± 13.2, respectively, and the male-female ratio is 203/150 and 53/72. There was no difference in the incidence of eruptions between the two groups, LEV and LCM, and the incidence of ASD-related eruptions was 11% (39/353) for gliomas, significantly higher than 1.6% (2/125) for meningiomas (p = 0.006). The incidence of ASD-related eruptions in glioma patients was not significantly different between the LEV group (10% (21/216)) and the LCM group (13% (20/154)) (p = 0.53). In a multivariate analysis of risk factors for eruption, chemoradiotherapy (p = 0.01), history of drug allergy (p = 0.039) was significantly higher. Conclusion: The incidence of LEV and LCM eruptions in glioma patients was higher than that in meningioma patients, and it was speculated that the treatment course specificity was more important than the disease-specific factors. Patients with glioma, especially those who have undergone chemoradiotherapy or have a history of drug allergies, require careful confirmation of the eruption.

STMO-9 Maximal safe glioma resection using high resolution exoscope

INTRODUCTION: Maximal safe glioma resection should be achieved using neuronavigation, electrophysiological monitoring, fluorescence visual system, and so on. Heads-up surgery with exoscope is suitable for the multimodal glioma surgery because multi-monitors come in our sights simultaneously. We introduce our glioma surgery using a latest exoscope and neuronavigation system. METHODS: We attempted maximal safe resection for the patients with high grade glioma using 3D/4K exoscope with 5-ALA-induced fluorescence, neuronavigation, and electrophysiological monitoring or awake mapping. An extent of resection, morbidity, and postoperative infarction were retrospectively reviewed. RESULTS: Twenty-one patients (age 26–79, male 11/female 10, glioblastoma 10/lower grade glioma 11, general anesthesia 16/awake craniotomy 5) underwent exoscopic tumor removal. Neuronavigation and electrophysiological monitoring were displayed in sub-monitors close to the main screen. Navigation could be recognized continuously using electromagnetic navigation technology. Intraoperative fluorescence was observed in 100% of the tumor with gadolinium enhancement. Surrounding structures such as white matter, vessels and nerves were clearly visualized under blue light. Supra-total resection or gross total resection was achieved in 8 (80%) of the patients with glioblastoma. Surgical morbidity included hemiparesis in 1 (4.8%) patient, hemianopsia in 1 (4.8%) patient. Postoperative infarction was observed in 2 (9.5%) patients, which was significantly lower compared to 23 of 77 (29.9%) patients with glioblastoma who underwent tumor resection with fluorescence-equipped microscope (p<0.05). CONCLUSION: High resolution exoscope surgery is effective for patients undergoing glioma surgery with respect to higher extent of resection and lower ischemic complication. Further studies are needed to assess direct comparisons between exoscope and microscope glioma resection.

Curative Effect of Tumor Resection under Microscope for Brain Glioma based on Humanized Nursing Model

Previous studies have shown that microsurgery has two main roles in glioma resection, that is, the nerve function is well protected and the degree of tumor resection is improved. On the basis of this experiment, the curative effect of tumor resection under microscope for glioma was studied based on humanized nursing model. By randomly dividing 64 patients into two steps and comparing them in many aspects, the study mainly obtained two inspirations: microglioma resection has good effect, and humanized nursing mode has good effect on postoperative recovery. Finally, some Suggestions and principles for microglioma resection were put forward: the principle of timely operation after diagnosis, the principle of complete resection for nonfunctional areas, the principle of protection for important functional areas, and the principle of recovery plan confirmed by disease examination after surgery. In addition, in terms of the influence of humanized nursing mode on the treatment of glioma under the microscope, the data statistics and SPSS tests show that humanized nursing mode can effectively improve the satisfaction of patients and their families. Relieve anxiety and depression and help patients recover; Lower scores in pain rating statistics, etc. In addition, this experiment has a good basis for development, and all the 64 patients successfully completed the operation without serious complications, which further verified the above conclusions, namely, the maturity and reliability of the technique of microscopic tumor resection for glioma. The technique of tumor resection under microscope can be used in combination with humanized nursing mode, which has good promotion value.

Prosopagnosia following nonlanguage dominant inferior temporal lobe low-grade glioma resection in which the inferior longitudinal fasciculus was disrupted preoperatively: illustrative case

BACKGROUND Prosopagnosia is a rare neurological condition characterized by the impairment of face perception with preserved visual processing and cognitive functioning and is associated with injury to the fusiform gyrus and inferior longitudinal fasciculus (ILF). Reports of this clinical impairment following resection of right temporal lobe diffuse gliomas in the absence of contralateral injury are exceedingly scarce and not expected as a complication of surgery. OBSERVATIONS The authors describe the case of a young female patient found to have an incidental diffuse glioma in the right inferior temporal lobe despite evidence of preoperative ILF disruption by the tumor. Following resection of the lesion, despite the preoperative disruption to the ILF by the tumor, the patient developed prosopagnosia. There was no evidence of contralateral, left-sided ILF injury. LESSONS Given the significant functional impairment associated with prosopagnosia, neurosurgeons should be aware of the exceedingly rare possibility of a visual-processing deficit following unilateral and, in this case, right-sided inferior temporal lobe glioma resections. More investigation is needed to determine whether preoperative testing can determine dominance of facial-processing networks for patients with lesions in the right inferior posterior temporooccipital lobe and whether intraoperative mapping could help prevent this complication.

P14.23 Relation between neurological deficits and location of postsurgical ischemia in glioma resection

BACKGROUND Postoperative ischemia is a known complications of glioma resection and can lead to neurological deficits. New or worsened postoperative deficits are often transient, but some patients experience persisting effects after surgery. Neuroanatomical location of ischemia is suspected to play an important role in the development as well as persistence of neurological deficits. Therefore, the aim of this study was to investigate the spatial relation between postoperative ischemia and short-term and long-term neurological deficits. MATERIAL AND METHODS Postoperative ischemia was defined as new confluent areas of diffusion restriction on DWI in a retrospective database of 144 adult WHO grade II-IV supratentorial glioma patients, who received MRI within 3 days after resection in 2012–2014. New or worsened neurological deficits of any grade at discharge and after 3 months was assessed in relation to postoperative ischemia by an experienced neuro-oncologist. We manually delineated ischemic lesions and spatially normalized these to stereotaxic MNI space. Next, we performed voxel-based analysis (VBA) to identify locations of ischemia associated with new or worsened neurological deficits and corrected for multiple comparisons using family-wise error correction to eliminate false positive results. Delineations were labeled using the Harvard-Oxford cortical and subcortical atlases and a white matter atlas (XTRACT). RESULTS Any new or worsened neurological deficits were present in 44 (30.5%) cases at discharge and in 27 (20.9%) cases after 3 months, of which respectively 26 (18%) and 21 (16.3%) were related to ischemia. Volume of ischemia was significantly associated with deficits at discharge (P = 0.003) and after 3 months (P = 0.039). No areas of ischemia were associated with a lack of new or worsened deficits. A statistically significant cluster of 42.96cc was associated with deficits at discharge and encompassed the right frontal, insular and tempo-occipital regions. Voxels associated only with deficits at discharge included lateral occipital cortices and supramarginal gyri. A cluster of 17.68cc in the right frontal and insular lobes was significantly associated with deficits after 3 months. Overlapping areas included the right thalamus, caudate nucleus, putamen, globus pallidum, insular cortex, middle and inferior temporal gyri, corticospinal tract and superior thalamic radiation. CONCLUSION Transient and persisting new or worsened deficits after glioma resection were significantly associated with volume of postoperative ischemia. Ischemic lesions in right frontal and insular regions, including the basal nuclei, corticospinal tract and superior thalamic radiation were significantly associated with persisting neurological deficits after 3 months, while temporo-occipital lesions were associated with transient deficits only found at discharge.

Focal gamma activity in frontal control regions revealed using intraoperative electrocorticography

How the frontal cortex is anatomically and functionally organized to control cognition remains puzzling. Numerous non-invasive brain imaging studies relate cognitive control to a localized set of frontal regions, part of a wider fronto-parietal network (FPN), that show increases in functional MRI (fMRI) signal during the performance of multiple cognitively demanding tasks. Lesions implicating frontal control regions lead to disorganized behaviour. However, the fMRI BOLD signal is an indirect measure of neuronal activity and represents evidence from a single modality. This has led to limited clinical translation of fMRI findings e.g. to guide the surgical resection of brain tumours. Here we sought supporting evidence for lateral frontal control regions using electrocorticography (ECoG). We recorded electrophysiological activity from electrodes placed on the lateral frontal cortex in patients undergoing awake craniotomy for glioma resection. During surgery, patients performed two verbal executive-related counting tasks with a difficulty level manipulation, closely adapting difficulty manipulations in fMRI studies of cognitive control. We performed spectral analysis focusing on the gamma range (30-250 Hz) due to mounting evidence of its value as an index of local cortical processing. Comparing hard versus easy demands revealed circumscribed frontal regions with power increases in the gamma range. This contrasted with spatially distributed power decreases in the beta range (12-30 Hz). Further, electrodes showing significant gamma power increases were more likely to occur within a canonical fMRI-defined FPN and showed stronger gamma power increases compared to electrodes outside the FPN, even at the single patient level. Reinforcing the need for careful task manipulation, an easy versus baseline comparison, which includes factors such as speech output, produced gamma changes over a wider area. Thus, using similar task difficulty manipulations, ECoG and fMRI signals converged on delineating lateral frontal control regions. These findings open the door for extending clinical functional mapping to the domain of cognitive control during awake neurosurgery.

Time to Re-Think Broca: Extent of Resection and Neurological Outcome in Patients Harboring Tumors in the Dominant Inferior Frontal Gyrus

Introduction/Purpose: There is a general lack of consensus onboth the anatomic definition and function of Broca’s area. Given the belief that this region plays a critical role in expressive language, resective surgery is often avoided topreserve function. However, the putative role of Broca’s area in speech production has been recently challenged.The current study aims to investigatethe feasibilityof glioma resection and neurological outcomes in “Broca’s area” in 15 patients.Methods: We report a feasibility study describing the resection of gliomas within the IFG. Awake brain surgery for resection with mapping and intraoperative neuropsychological evaluation was carried out in all individuals. Results: All included patientshad tumors located in traditional “Broca’s area” and eight patients (53.33%) had tumors that additionally extendedinto the insula and subinsular regions. During stimulation, positive speech-language sites within the IFG were identified in ten patients. Two patients (13.33%) experienced a declinein naming during intraoperative cognitive monitoring and thirteen (86.66%) had a stable performance throughout surgery. With all patients had recovery of language functions at a two-week follow up. Extent of resection was stratified in anatomical regions within the IFG, being the pOr the area with the greatest EOR (97.4%), followed by the pT (84.1%), pOp (83.8%), and vPMC (80%).Conclusion: The belief that Broca’s area is not safe to resect is challenged. Adequate mapping and careful patient selection allow maximum safe resection of tumors located in thetraditional “Broca’s area”,with low risk of postoperative morbidity.

Anatomical aspects of the insula, opercula and peri-insular white matter for a transcortical approach to insular glioma resection

The insula is a lobe located deep in each hemisphere of the brain and is surrounded by eloquent cortical, white matter, and basal ganglia structures. The aim of this study was to provide an anatomical description of the insula and white matter tracts related to surgical treatment of gliomas through a transcortical approach. The study also discusses surgical implications in terms of intraoperative brain mapping. Five adult brains were prepared according to the Klingler technique. Cortical anatomy was evaluated with the naked eye, whereas white matter dissection was performed with the use of a microscope. The widest exposure of the insular surface was noted through the temporal operculum, mainly in zones III and IV according to the Berger-Sanai classification. By going through the pars triangularis in all cases, the anterior insular point and most of zone I were exposed. The narrowest and deepest operating field was observed by going through the parietal operculum. This method provided a suitable approach to zone II, where the corticospinal tract is not covered by the basal ganglia and is exposed just under the superior limiting sulcus. At the subcortical level, the identification of the inferior frontoocipital fasciculus at the level of the limen insulae is critical in terms of preserving the lenticulostriate arteries. Detailed knowledge of the anatomy of the insula and subcortical white matter that is exposed through each operculum is essential in preoperative planning as well as in the intraoperative decision-making process in terms of intraoperative brain mapping.

Cortical and Subcortical Anatomy of the Orbitofrontal Cortex: A White Matter Microfiberdissection Study and Case Series

ABSTRACT BACKGROUND The literature on white matter anatomy underlying the human orbitofrontal cortex (OFC) is scarce in spite of its relevance for glioma surgery. OBJECTIVE To describe the anatomy of the OFC and of the underlying white matter fiber anatomy, with a particular focus on the surgical structures relevant for a safe and efficient orbitofrontal glioma resection. Based on anatomical and radiological data, the secondary objective was to describe the growth pattern of OFC gliomas. METHODS The study was performed on 10 brain specimens prepared according to Klingler's protocol and dissected using the fiber microdissection technique modified according to U.T., under the microscope at high magnification. RESULTS A detailed stratigraphy of the OFC was performed, from the cortex up to the frontal horn of the lateral ventricle. The interposed neural structures are described together with relevant neighboring topographic areas and nuclei. Combining anatomical and radiological data, it appears that the anatomical boundaries delimiting and guiding the macroscopical growth of OFC gliomas are as follows: the corpus callosum superiorly, the external capsule laterally, the basal forebrain and lentiform nucleus posteriorly, and the gyrus rectus medially. Thus, OFC gliomas seem to grow ventriculopetally, avoiding the laterally located neocortex. CONCLUSION The findings in our study supplement available anatomical knowledge of the OFC, providing reliable landmarks for a precise topographical diagnosis of OFC lesions and for perioperative orientation. The relationships between deep anatomic structures and glioma formations described in this study are relevant for surgery in this highly interconnected area.