Abstract
Many studies have established a link between extent of resection and survival in patients with gliomas. Surgeons must optimize the oncofunctional balance by maximizing the extent of resection and minimizing postoperative neurological morbidity. Preoperative functional imaging modalities are important tools for optimizing the oncofunctional balance. Transcranial magnetic stimulation (TMS) and functional magnetic resonance imaging (fMRI) are non-invasive imaging modalities that can be used for preoperative functional language mapping. Scarce data exist evaluating the accuracy of these preoperative modalities for language mapping compared with gold standard intraoperative data in the same cohort. This study compares the accuracy of fMRI and TMS for language mapping compared with intraoperative direct cortical stimulation (DCS). We also identified significant predictors of preoperative functional imaging accuracy, as well as significant predictors of functional outcomes. Evidence from this study could inform clinical judgment as well as provide neuroscientific insight. We used geometric distances to determine copositivity between preoperative data and intraoperative data. Twenty-eight patients were included who underwent both preoperative fMRI and TMS procedures, as well as an awake craniotomy and intraoperative language mapping. We found that TMS shows significantly superior correlation to intraoperative DCS compared with fMRI. TMS also showed significantly higher sensitivity and negative predictive value than specificity and positive predictive value. Poor cognitive baseline was associated with decreased TMS accuracy as well as increased risk for worsened aphasia postoperatively. TMS has emerged as a promising preoperative language mapping tool. Future work should be done to identify the proper role of each imaging modality in a comprehensive, multimodal approach to optimize the oncofunctional balance.
Highlights
MATERIALS AND METHODSSeveral studies have established a survival advantage to gross total resection in patients with intracranial malignancies (Molinaro et al, 2020)
Results for Transcranial magnetic stimulation (TMS) from our cohort showed an negative predictive value (NPV) exceeding 99% and a sensitivity of 83%, indicating that TMS consistently identifies language-positive sites defined by intraoperative mapping
Sanai et al (2008) were the first to report that intraoperative negative direct cortical stimulation (DCS) mapping was sufficient to minimize long-term neurological deficits
Summary
MATERIALS AND METHODSSeveral studies have established a survival advantage to gross total resection in patients with intracranial malignancies (Molinaro et al, 2020). Various factors including young age, mental illness, and conscious sedation intolerance exclude patients for consideration for an awake craniotomy (Picht et al, 2013; Tarapore et al, 2013). This approach is invasive and associated with a risk of intraoperative seizures that can lead to an aborted operation (Serletis and Bernstein, 2007; Nossek et al, 2013a,b; Gonen et al, 2014; Eseonu et al, 2018). These considerations indicate the need for accurate preoperative mapping modalities
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