Novel Strategies for Surgery of Brain Tumors in Eloquent Areas

A special issue of Brain Sciences (ISSN 2076-3425). This special issue belongs to the section "Neurosurgery and Neuroanatomy".

Deadline for manuscript submissions: closed (15 June 2023) | Viewed by 12469

Special Issue Editors

Division of Neurosurgery, BIOMORF Department, University of Messina, 98124 Messina, Italy
Interests: neuro-oncology; gliomas; preoperative planning; navigated transcranial magnetic stimulation (nTMS); DTI tractography
Special Issues, Collections and Topics in MDPI journals
Associate Professor, Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
Interests: neuro-oncological surgery; intraoperative tumor visualization; cell–cell communication
Special Issues, Collections and Topics in MDPI journals
Karolinska Institutet, 171 77 Stockholm, Sweden
Interests: brain tumors; gliomas; brain mapping; image-guided surgery
Servicio de Neurocirugía, Hospital Universitario La Paz, 28046 Madrid, Spain
Interests: neurosurgy; brain tumors; gliomas; image-guided surgery

Special Issue Information

Dear Colleagues,

The modern surgical treatment of intrinsic brain tumors located in or close to eloquent areas consists of a “maximal safe resection” of the lesion, aiming to obtain the maximal removal of neoplastic tissue while preserving surrounding functional brain networks to reduce postoperative neurological morbidity. In recent years, several novel strategies, mainly combining advanced technology with neuroimaging and neurophysiology, have been introduced to neurosurgical practice to plan and guide the surgical resection of these tumors. The use of such novel strategies helps neurosurgeons to achieveme maximal safe resection.

The aim of this Special Issue is to summarize the state-of-the-art of modern preoperative, intraoperative and postoperative strategies used in neuro-oncology to improve the surgical treatment and outcome of patients affected by brain tumors located in or close to eloquent areas. Moreover, the aim is also to describe, for the first time, novel techniques based on modern technologies that could help neurosurgeons to achieve the maximal safe resection of these tumors.

We are looking for studies focusing on the following modern strategies in intrinsic brain tumor surgery located in or close to eloquent areas

  • Novel neuroimaging strategies, including nTMS, fMRI, MEG, and tractography, allowing for preoperative brain mapping and the identification of brain networks at risk during surgery on intrinsic brain tumors located in eloquent areas;
  • Advanced intraoperative neurophysiology strategies for the brain mapping and monitoring of complex functions;
  • Modern approaches based on simulation, augmented reality, mixed reality and virtual reality for intrinsic brain tumor surgery located in eloquent areas;
  • Novel imaging strategies as an alternative to standard microscopy for the intraoperative visualization of intrinsic brain tumors (exoscope, endoscope, robotics, etc.);
  • Intraoperative image-guided strategies to identify neoplastic tissue based on the use of fluorescent dyes (e.g., sodium fluoresceine, 5-ALA), on novel software-based analysis of the fluorescent signal, or on advanced histological analysis (e.g., intraoperative confocal microscopy);
  • Novel approaches based on intraoperative imaging to assess the extent of tumor resection (e.g., iMRI, iCT, iUS).

We welcome original articles, review, minireview, editorials, commentary, technical notes, and case reports.

Dr. Giovanni Raffa
Dr. Christian Freyschlag
Prof. Dr. Jiri Bartek Jr
Guest Editors

Dr. María Luisa Gandía-González
Guest Editor Assistant

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Keywords

  • brain tumors
  • image-guided neurosurgery
  • gliomas
  • eloquent areas
  • brain mapping
  • augmented/mixed/virtual reality
  • robotics

Published Papers (6 papers)

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Research

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16 pages, 1653 KiB  
Article
Resection of Eloquent Located Brain Tumors by Mapping Only—A Feasibility Study
by Franziska Staub-Bartelt, Marion Rapp and Michael Sabel
Brain Sci. 2023, 13(10), 1366; https://doi.org/10.3390/brainsci13101366 - 25 Sep 2023
Viewed by 811
Abstract
Background: Patients with eloquently located cerebral lesions require surgery that usually employs mapping and monitoring techniques for the preservation of motor and language function. However, in many cases, mapping only might be sufficient, reducing the need for technical and personnel logistics. Here, we [...] Read more.
Background: Patients with eloquently located cerebral lesions require surgery that usually employs mapping and monitoring techniques for the preservation of motor and language function. However, in many cases, mapping only might be sufficient, reducing the need for technical and personnel logistics. Here, we report our experiences using a device that can be operated by the surgeon independently, providing mapping techniques but omitting monitoring techniques. Methods: For monopolar and bipolar cortical/subcortical stimulation, pre-set programs were available and intraoperatively used—two enabling EMG real-time tracking of eight muscles for monopolar (cortical/subcortical) mapping, and two programs for 60 Hz stimulation, one with EMG and one without. Motor mapping was performed under continuous observation of the screened EMG signal and acoustic feedback by the surgeon. For the 60 Hz stimulation, a standard bipolar stimulation probe was connected through a second port. The preoperative application of the subdermal EMG needles, as well as the intraoperative handling of the device, were performed by the surgeons independently. Postoperatively, an evaluation of the autonomous handling and feasibility of the device for the chosen test parameters was conducted. Results: From 04/19–09/21, 136 procedures in patients with eloquently located cerebral lesions were performed by using the “mapping-only” device. Mapping was performed in 82% of the monopolar cases and in 42% of the bipolar cases. Regarding the setup and sufficiency for the cortical/subcortical mapping, the device was evaluated as independently usable for motor and language mapping in 129 procedures (95%). Gross total resection was achieved, or functional limit throughout resection was reached, in 79% of the patients. 13 patients postoperatively suffered from a new neurological deficit. At the 3–6-month follow-up, three patients showed persistent deficit (2%). All of them had language disturbances. The setup time for the device was less than 7 min. Conclusions: The device was evaluated as sufficient in over 90% of cases concerning monopolar and bipolar mapping, and the setup and handling was sufficient in all patients. With the present data we show that in well-selected cases, a very simple system providing mapping only is sufficient to achieve gross total resection with the preservation of functionality. Full article
(This article belongs to the Special Issue Novel Strategies for Surgery of Brain Tumors in Eloquent Areas)
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13 pages, 2736 KiB  
Article
A Novel Intraoperative Mapping Device Detects the Thermodynamic Response Function
by Michael Iorga, Nils Schneider, Jaden Cho, Matthew C. Tate and Todd B. Parrish
Brain Sci. 2023, 13(7), 1091; https://doi.org/10.3390/brainsci13071091 - 19 Jul 2023
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Abstract
Functional activation leads to an increase in local brain temperature via an increase in local perfusion. In the intraoperative setting, these cortical surface temperature fluctuations may be imaged using infrared thermography such that the activated brain areas are inferred. While it is known [...] Read more.
Functional activation leads to an increase in local brain temperature via an increase in local perfusion. In the intraoperative setting, these cortical surface temperature fluctuations may be imaged using infrared thermography such that the activated brain areas are inferred. While it is known that temperature increases as a result of activation, a quantitative spatiotemporal description has yet to be achieved. A novel intraoperative infrared thermography device with data collection software was developed to isolate the thermal impulse response function. Device performance was validated using data from six patients undergoing awake craniotomy who participated in motor and sensory mapping tasks during infrared imaging following standard mapping with direct electrical stimulation. Shared spatiotemporal patterns of cortical temperature changes across patients were identified using group principal component analysis. Analysis of component time series revealed a thermal activation peak present across all patients with an onset delay of five seconds and a peak duration of ten seconds. Spatial loadings were converted to a functional map which showed strong correspondence to positive stimulation results for similar tasks. This component demonstrates the presence of a previously unknown impulse response function for functional mapping with infrared thermography. Full article
(This article belongs to the Special Issue Novel Strategies for Surgery of Brain Tumors in Eloquent Areas)
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13 pages, 1056 KiB  
Article
Exoscopic Microsurgery: A Change of Paradigm in Brain Tumor Surgery? Comparison with Standard Operative Microscope
by Andrea Di Cristofori, Francesca Graziano, Chiara Benedetta Rui, Paola Rebora, Diego Di Caro, Gaia Chiarello, Giovanni Stefanoni, Chiara Julita, Santa Florio, Davide Ferlito, Gianpaolo Basso, Giuseppe Citerio, Paolo Remida, Giorgio Carrabba and Carlo Giussani
Brain Sci. 2023, 13(7), 1035; https://doi.org/10.3390/brainsci13071035 - 06 Jul 2023
Cited by 1 | Viewed by 1255
Abstract
Background: The exoscope is a high-definition telescope recently introduced in neurosurgery. In the past few years, several reports have described the advantages and disadvantages of such technology. No studies have compared results of surgery with standard microscope and exoscope in patients with glioblastoma [...] Read more.
Background: The exoscope is a high-definition telescope recently introduced in neurosurgery. In the past few years, several reports have described the advantages and disadvantages of such technology. No studies have compared results of surgery with standard microscope and exoscope in patients with glioblastoma multiforme (GBM). Methods: Our retrospective study encompassed 177 patients operated on for GBM (WHO 2021) between February 2017 and August 2022. A total of 144 patients were operated on with a microscope only and the others with a 3D4K exoscope only. All clinical and radiological data were collected. Progression-free survival (PFS) and overall survival (OS) have been estimated in the two groups and compared by the Cox model adjusting for potential confounders (e.g., sex, age, Karnofsky performance status, gross total resection, MGMT methylated promoter, and operator’s experience). Results: IDH was mutated in 9 (5.2%) patients and MGMT was methylated in 76 (44.4%). Overall, 122 patients received a gross total resection, 14 patients received a subtotal resection, and 41 patients received a partial resection. During follow-up, 139 (73.5%) patients experienced tumor recurrence and 18.7% of them received a second surgery. After truncation to 12 months, the median PFS for patients operated on with the microscope was 8.82 months, while for patients operated on with the exoscope it was >12 months. Instead, the OS was comparable in the two groups. The multivariable Cox model showed that the use of microscope compared to the exoscope was associated with lower progression-free survival (hazard ratio = 3.55, 95%CI = 1.66–7.56, p = 0.001). Conclusions: The exoscope has proven efficacy in terms of surgical resection, which was not different to that of the microscope. Furthermore, patients operated on with the exoscope had a longer PFS. A comparable OS was observed between microscope and exoscope, but further prospective studies with longer follow-up are needed. Full article
(This article belongs to the Special Issue Novel Strategies for Surgery of Brain Tumors in Eloquent Areas)
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11 pages, 4555 KiB  
Article
Standardization of Strategies to Perform a Parafascicular Tubular Approach for the Resection of Brain Tumors in Eloquent Areas
by Nadin J. Abdala-Vargas, Giuseppe E. Umana, Javier G. Patiño-Gomez, Edgar Ordoñez-Rubiano, Hernando A. Cifuentes-Lobelo, Paolo Palmisciano, Gianluca Ferini, Anna Viola, Valentina Zagardo, Daniel Casanova-Martínez, Ottavio S. Tomasi, Alvaro Campero and Matias Baldoncini
Brain Sci. 2023, 13(3), 498; https://doi.org/10.3390/brainsci13030498 - 15 Mar 2023
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Abstract
Objective: The aim of this work is to define a methodological strategy for the minimally invasive tubular retractor (MITR) parafascicular transulcal approach (PTA) for the management of brain tumors sited in eloquent areas. Methods: An observational prospective study was designed to evaluate the [...] Read more.
Objective: The aim of this work is to define a methodological strategy for the minimally invasive tubular retractor (MITR) parafascicular transulcal approach (PTA) for the management of brain tumors sited in eloquent areas. Methods: An observational prospective study was designed to evaluate the benefits of PTA associated with MITRs, tractography and intraoperative cortical stimulation. They study was conducted from June 2018 to June 2021. Information regarding white matter tracts was processed, preventing a potential damage during the approach and/or resection. All patients older than 18 years who had a single brain tumor lesion were included in the study. Patients with a preoperative Karnofsky Performance Scale (KPS) score greater than 70% and a Glasgow Coma Scale (GCS) score > 14 points were included. Results: 72 patients were included in the study, the mean age was 49.6, the most affected gender was male, 12.5% presented aphasia, 11.1% presented paraphasia, 41.6% had motor deficit, 9.7% had an affection in the optic pathway, the most frequently affected region was the frontal lobe (26.3%), the most frequent lesions were high-grade gliomas (34.7%) and the measurement of the incisions was on average 5.58 cm. Of the patients, 94.4% underwent a total macroscopic resection and 90.2% did not present new postoperative neurological deficits. In all cases, a PTA was used. Conclusion: Tubular minimally invasive approaches (MIAs) allow one to perform maximal safe resection of brain tumors in eloquent areas, through small surgical corridors. Future comparative studies between traditional and minimally invasive techniques are required to further investigate the potential of these surgical nuances. Full article
(This article belongs to the Special Issue Novel Strategies for Surgery of Brain Tumors in Eloquent Areas)
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10 pages, 4338 KiB  
Article
Supramarginal Gyrus and Angular Gyrus Subcortical Connections: A Microanatomical and Tractographic Study for Neurosurgeons
by Mehmet Hakan Şahin, Mehmet Emin Akyüz, Mehmet Kürşat Karadağ and Ahmet Yalçın
Brain Sci. 2023, 13(3), 430; https://doi.org/10.3390/brainsci13030430 - 02 Mar 2023
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Abstract
Background and Objectives: This article aims to investigate the subcortical microanatomy of the supramarginal gyrus (SMG) and angular gyrus (AnG) using a microfiber dissection technique and diffusion tensor imaging (DTI)/fiber tractography (FT). The cortical and subcortical structures of this region are highly functional, [...] Read more.
Background and Objectives: This article aims to investigate the subcortical microanatomy of the supramarginal gyrus (SMG) and angular gyrus (AnG) using a microfiber dissection technique and diffusion tensor imaging (DTI)/fiber tractography (FT). The cortical and subcortical structures of this region are highly functional, and their lesions often present clinically. For this reason, the possibility of post-surgical deficits is high. We focused on the supramarginal gyrus and the angular gyrus and reviewed their anatomy from a topographic, functional and surgical point of view, and aimed to raise awareness especially for neurosurgeons. Methods: Four previously frozen, formalin-fixed human brains were examined under the operating microscope using the fiber dissection technique. Four hemispheres were dissected from medial to lateral under the surgical microscope. Brain magnetic resonance imaging (MRI) of 20 healthy adults was examined. Pre-central and post-central gyrus were preserved to achieve topographic dominance in dissections of brain specimens. Each stage was photographed. Tractographic brain magnetic resonance imaging of 10 healthy adults was examined radiologically. Focusing on the supramarginal and angular gyrus, the white matter fibers passing under this region and their intersection areas were examined. These two methods were compared anatomically from the lateral view and radiologically from the sagittal view. Results: SMG and AnG were determined in brain specimens. The pre-central and post-central gyrus were topographically preserved. The superior and medial temporal gyrus, and inferior and superior parietal areas were decorticated from lateral to medial. U fibers, superior longitudinal fasciculus II (SLF II), superior longitudinal fasciculus III (SLF III), arcuat fasciculus (AF) and middle longitudinal fasciculus (MdLF) fiber groups were shown and subcortical fiber structures belonging to these regions were visualized by the DTI/FT method. The subcortical fiber groups under the SMG and the AnG were observed anatomically and radiologically to have a dense and complex structure. Conclusions: Due to the importance of the subcortical connections of SMG and AnG on speech function, tumoral lesions and surgeries of this region are of particular importance. The anatomical architecture of the complex subcortical structure, which is located on the projection of the SMG and AnG areas, was shown with a DTI/FT examination under a topographic dominance, preserving the pre-central and post-central gyrus. In this study, the importance of the anatomical localization, connections and functions of the supramarginal and angular gyrus was examined. More anatomical and radiological studies are needed to better understand this region and its connections. Full article
(This article belongs to the Special Issue Novel Strategies for Surgery of Brain Tumors in Eloquent Areas)
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Review

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13 pages, 4504 KiB  
Review
Advances in Intraoperative Glioma Tissue Sampling and Infiltration Assessment
by Nadeem N. Al-Adli, Jacob S. Young, Katie Scotford, Youssef E. Sibih, Jessica Payne and Mitchel S. Berger
Brain Sci. 2023, 13(12), 1637; https://doi.org/10.3390/brainsci13121637 - 25 Nov 2023
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Abstract
Gliomas are infiltrative brain tumors that often involve functional tissue. While maximal safe resection is critical for maximizing survival, this is challenged by the difficult intraoperative discrimination between tumor-infiltrated and normal structures. Surgical expertise is essential for identifying safe margins, and while the [...] Read more.
Gliomas are infiltrative brain tumors that often involve functional tissue. While maximal safe resection is critical for maximizing survival, this is challenged by the difficult intraoperative discrimination between tumor-infiltrated and normal structures. Surgical expertise is essential for identifying safe margins, and while the intraoperative pathological review of frozen tissue is possible, this is a time-consuming task. Advances in intraoperative stimulation mapping have aided surgeons in identifying functional structures and, as such, has become the gold standard for this purpose. However, intraoperative margin assessment lacks a similar consensus. Nonetheless, recent advances in intraoperative imaging techniques and tissue examination methods have demonstrated promise for the accurate and efficient assessment of tumor infiltration and margin delineation within the operating room, respectively. In this review, we describe these innovative technologies that neurosurgeons should be aware of. Full article
(This article belongs to the Special Issue Novel Strategies for Surgery of Brain Tumors in Eloquent Areas)
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