Brain Tumor Surgery Research Articles

Effect of Tranexamic Acid on Blood Loss in Brain Tumour Resection Surgery

INTRODUCTION: Intraoperative blood loss is considered to be one of the major complications in neurosurgical operations and neurosurgical procedures and is directly related to the postoperative morbidity and mortality. Administration of Tranexamic acid [TXA] by reducing blood loss has resulted in survival benefits in Traumatic Brain Injury [TBI] population, as shown in two recent meta-analysis. AIMS AND OBJECTIVES: To study the effect of tranexamic acid on blood loss in brain tumor resection surgery. MATERIAL AND METHODS: Patients of either sex, aged 18-65 years who were undergoing brain tumour resection were randomly allocated to either group - the study group and the control group (30 patients in each group). Patients in the study group received tranexamic acid intravenously @10 mg/kg body weight over 10 minutes after induction and then maintenance of continuous infusion @ 1mg/kg/hr intraoperatively till skin closure. Patients in the control group received the same volume of saline per kg body weight as the volume of tranexamic acid in study group. RESULTS: The average drop in haemoglobin and HCT was significantly lower in TXA group. Accordingly, amount of blood loss was less in TXA group compared to saline group. (332ml vs 576 ml; p = 0.011). CONCLUSION: From our study, it was concluded that the administration of TXA resulted in a significant reduction in blood loss. TXA can thus be suggested as a cost effective method of reducing mortality due to hemorrhage in brain tumor surgery. Keywords: Tranexamic acid [TXA], Traumatic Brain Injury [TBI].

Clinical Effects and Adverse Events Associated With Desflurane Use in Adult Patients Undergoing Supratentorial Craniotomy: A Systematic Review.

Desflurane is an inhalational anesthetic agent with an appealing recovery profile. The present systematic review investigates the clinical effects and adverse events associated with desflurane use during supratentorial craniotomy for brain tumor resection in adults in comparison with other inhalational and intravenous anesthetic agents. A literature search was conducted across the MEDLINE, Library of Congress and LISTA (EBSCO) databases from January 2001 to January 2021. Twelve studies published between 2003 and 2020 were included in this systematic review. Desflurane was compared with either isoflurane, sevoflurane, or propofol for anesthesia maintenance. Brain relaxation scores showed no statistically significant difference between desflurane and the other anesthetic agents. Recovery timepoints, such as time to recovery, time to eye opening, time to extubation, time to follow commands, and time to reach a modified Aldrete score ≥9 were significantly shorter with desflurane in the majority of studies. Systemic hemodynamic variables (mean arterial pressure and heart rate) and cerebral hemodynamics (intracranial pressure and cerebrospinal fluid pressure) were comparable between desflurane and other anesthetic agents in each study. The results of this systematic review demonstrate that desflurane is associated with few adverse events when used for anesthesia maintenance in adult patients undergoing supratentorial brain tumor surgery. Large, prospective, comprehensive studies, utilizing standardized parameter evaluation could provide higher levels of evidence to support these findings.

Mapping Resection Progress by Tool-Tip Tracking during Brain Tumor Surgery for Real-Time Estimation of Residual Tumor.

Surgical resection continues to be the primary initial therapeutic strategy in the treatment of patients with brain tumors. Computerized cranial neuronavigation based on preoperative imaging offers precision guidance during craniotomy and early tumor resection but progressively loses validity with brain shift. Intraoperative MRI (iMRI) and intraoperative ultrasound (iUS) can update the imaging used for guidance and navigation but are limited in terms of temporal and spatial resolution, respectively. We present a system that uses time-stamped tool-tip positions of surgical instruments to generate a map of resection progress with high spatial and temporal accuracy. We evaluate this system and present results from 80 cranial tumor resections. Regions of the preoperative tumor segmentation that are covered by the resection map (True Positive Tracking) and regions of the preoperative tumor segmentation not covered by the resection map (True Negative Tracking) are determined for each case. We compare True Negative Tracking, which estimates the residual tumor, with the actual residual tumor identified using iMRI. We discuss factors that can cause False Positive Tracking and False Negative Tracking, which underestimate and overestimate the residual tumor, respectively. Our method provides good estimates of the residual tumor when there is minimal brain shift, and line-of-sight is maintained. When these conditions are not met, surgeons report that it is still useful for identifying regions of potential residual.

Goal-Directed Fluid Therapy and major postoperative complications in elective craniotomy. A retrospective analysis of a before-after multicentric study

BackgroundGoal-Directed Fluid Therapy (GDFT) is recommended to decrease major postoperative complications. However, data are lacking in intra-cranial neurosurgery.MethodsWe evaluated the efficacy of a GDFT protocol in a before/after multi-centre study in patients undergoing elective intra-cranial surgery for brain tumour. Data were collected during 6 months in each period (before/after). GDFT was performed in high-risk patients: ASA score III/IV and/or preoperative Glasgow Coma Score (GCS) < 15 and/or history of brain tumour surgery and/or tumour greater size ≥ 35 mm and/or mid-line shift ≥ 3 mm and/or significant haemorrhagic risk. Major postoperative complication was a composite endpoint: re-intubation after surgery, a new onset of GCS < 15 after surgery, focal motor deficit, agitation, seizures, intra-cranial haemorrhage, stroke, intra-cranial hypertension, hospital-acquired related pneumonia, surgical site infection, cardiac arrythmia, invasive mechanical ventilation ≥ 48 h and in-hospital mortality.ResultsFrom July 2018 to January 2021, 344 patients were included in 3 centers: 171 in the before and 173 in the after (GDFT) period. Thirty-six (21.1%) patients displayed a major postoperative complication in the Before period, and 50 (28.9%) in the After period (p = 0.1). In the propensity score analysis, we matched 48 patients in each period: 9 (18.8%) patients in the After period and 14 (29.2%) patients in the Before period displayed a major perioperative complication (p = 0.2). Sixty-two (35.8%) patients received GDFT in the After period, with great heterogeneity among centers (p < 0.05).ConclusionsIn our before-after study, GDFT was not associated with a decrease in postoperative major complications in elective intra-cranial neurosurgery.

Status epilepticus after brain tumor surgery

Status epilepticus (SE) is characterized by continuous course of clinical and/or electrographic epileptic seizures. There are little data on the course and outcomes of SE after resection of brain tumors. To analyze clinical and electrographic manifestations of SE, its course and outcomes in short-term period after resection of brain tumors. We analyzed medical records of 18 patients over 18 years old between 2012 and 2019. All patients underwent resection of brain tumor and developed SE after surgery. Clinical criteria were repeated epileptic seizures without interictal recovery of consciousness, stereotypical motor phenomena, impaired consciousness with continued epileptic activity according to video-EEG data. We analyzed EEG data, neurological status, CT and laboratory data. Metastases (33%) and meningiomas (16%) prevailed. Supratentorial tumors were observed in 61% of patients. Two patients had preoperative seizures. Non-convulsive SE was diagnosed in 62% of patients. SE was successfully treated in 77% of cases. Mortality rate in patients with SE was 44%. Early postoperative SE is rare after brain tumor surgery (about 0.09%). Nevertheless, this complication is associated with high mortality. Non-convulsive SE is common (62%) that should be considered in postoperative management.

Functional Magnetic Resonance Imaging and Diffusion Tensor Imaging for Language Mapping in Brain Tumor Surgery: Validation With Direct Cortical Stimulation and Cortico-Cortical Evoked Potential.

Functional magnetic resonance imaging (fMRI) and diffusion tensor imaging-derived tractography (DTI-t) contribute to the localization of language areas, but their accuracy remains controversial. This study aimed to investigate the diagnostic performance of preoperative fMRI and DTI-t obtained with a simultaneous multi-slice technique using intraoperative direct cortical stimulation (DCS) or corticocortical evoked potential (CCEP) as reference standards. This prospective study included 26 patients (23-74 years; male:female, 13:13) with tumors in the vicinity of Broca's area who underwent preoperative fMRI and DTI-t. A site-by-site comparison between preoperative (fMRI and DTI-t) and intraoperative language mapping (DCS or CCEP) was performed for 226 cortical sites to calculate the sensitivity and specificity of fMRI and DTI-t for mapping Broca's areas. For sites with positive signals on fMRI or DTI-t, the true-positive rate (TPR) was calculated based on the concordance and discordance between fMRI and DTI-t. Among 226 cortical sites, DCS was performed in 100 sites and CCEP was performed in 166 sites. The specificities of fMRI and DTI-t ranged from 72.4% (63/87) to 96.8% (122/126), respectively. The sensitivities of fMRI (except for verb generation) and DTI-t were 69.2% (9/13) to 92.3% (12/13) with DCS as the reference standard, and 40.0% (16/40) or lower with CCEP as the reference standard. For sites with preoperative fMRI or DTI-t positivity (n = 82), the TPR was high when fMRI and DTI-t were concordant (81.2% and 100% using DCS and CCEP, respectively, as the reference standards) and low when fMRI and DTI-t were discordant (≤ 24.2%). fMRI and DTI-t are sensitive and specific for mapping Broca's area compared with DCS and specific but insensitive compared with CCEP. A site with a positive signal on both fMRI and DTI-t represents a high probability of being an essential language area.

Relation between Lower Urinary Tract Dysfunction and Functional Outcome in Patients After Brain Tumor Resection.

This study aimed to compare functional outcomes after rehabilitation with initial degree of urinary retention (UR) in patients operated on for brain tumors. Medical records of 61 patients transferred to the Department of Rehabilitation Medicine of single center, from January 2011 to December 2021, were reviewed retrospectively. Patient data included post-void residual (PVR) urine, tumor characteristics, and functional status. Functional status was evaluated on the Mini-Mental Status Examination (MMSE), Modified Barthel Index (MBI), Functional Ambulation Category (FAC), Modified Rankin Scale (mRS), Motricity Index (MI)-lower limb, and Berg Balance Scale (BBS). MMSE, FAC, mRS, and MI-lower limb were re-evaluated 3 weeks after standard inpatient rehabilitation. Twenty-four patients were in the UR group and 37 in the non-UR group. Initial MMSE, MBI, BBS, FAC, and mRS were significantly worse in the UR group, and both groups showed significant functional improvement after rehabilitation. After rehabilitation, MMSE, FAC, MRS, MI-lower were still worse in the UR group, but the degree of improvement between the groups was not significantly different. Rehabilitation was shown to be effective for brain tumor patients regardless of UR. Initial UR after brain tumor surgery is significantly associated with poor functional status in both the early stages of rehabilitation and after rehabilitation.

Comparison of anatomical-based vs. nTMS-based risk stratification model for predicting postoperative motor outcome and extent of resection in brain tumor surgery

BackgroundTwo statistical models have been established to evaluate characteristics associated with postoperative motor outcome in patients with glioma associated to the motor cortex (M1) or the corticospinal tract (CST). One model is based on a clinicoradiological prognostic sum score (PrS) while the other one relies on navigated transcranial magnetic stimulation (nTMS) and diffusion-tensor-imaging (DTI) tractography. The objective was to compare the models regarding their prognostic value for postoperative motor outcome and extent of resection (EOR) with the aim of developing a combined, improved model. MethodsWe retrospectively analyzed a consecutive prospective cohort of patients who underwent resection for motor associated glioma between 2008 and 2020, and received a preoperative nTMS motor mapping with nTMS-based diffusion tensor imaging tractography. The primary outcomes were the EOR and the motor outcome (on the day of discharge and 3 months postoperatively according to the British Medical Research Council (BMRC) grading). For the nTMS model, the infiltration of M1, tumor-tract distance (TTD), resting motor threshold (RMT) and fractional anisotropy (FA) were assesed. For the PrS score (ranging from 1 to 8, lower scores indicating a higher risk), we assessed tumor margins, volume, presence of cysts, contrast agent enhancement, MRI index (grading white matter infiltration), preoperative seizures or sensorimotor deficits. ResultsTwo hundred and three patients with a median age of 50 years (range: 20–81 years) were analyzed of whom 145 patients (71.4%) received a GTR. The rate of transient new motor deficits was 24.1% and of permanent new motor deficits 18.8%. The nTMS model demonstrated a good discrimination ability for the short-term motor outcome at day 7 of discharge (AUC = 0.79, 95 %CI: 0.72–0.86) and the long-term motor outcome after 3 months (AUC = 0.79, 95 %CI: 0.71–0.87). The PrS score was not capable to predict the postoperative motor outcome in this cohort but was moderately associated with the EOR (AUC = 0.64; CI 0.55–0.72). An improved, combined model was calculated to predict the EOR more accurately (AUC = 0.74, 95 %CI: 0.65–0.83). ConclusionThe nTMS model was superior to the clinicoradiological PrS model for potentially predicting the motor outcome. A combined, improved model was calculated to estimate the EOR. Thus, patient counseling and surgical planning in patients with motor-associated tumors should be performed using functional nTMS data combined with tractography.

Polarimetric Markers for Delineation of Lesional Margins during Brain Tumor Surgery

Polarimetric Markers for Delineation of Lesional Margins during Brain Tumor Surgery

Indications and Limitations of Transcranial Microsurgery/Endoscopic Surgery for Benign Brain Tumors

Indications and Limitations of Transcranial Microsurgery/Endoscopic Surgery for Benign Brain Tumors

Surgical Treatment of Mesial Temporal Lobe Epilepsy Focusing on Anatomical Understanding

Surgical treatment is an effective option for medically intractable epilepsy. Amygdalohippocampectomy for mesial temporal lobe epilepsy is a surgically remediable epileptic syndrome. It is a well-established surgery and various approaches to the mesial temporal lobe have been reported. To reduce the complication rate, surgeons should have sufficient knowledge of anatomy in the mesial temporal region. Here, we summarize the surgical treatments for mesial temporal lobe epilepsy, focusing on anatomical understanding. We described in detail the surgical anatomy of amygdalohippocampectomy and various approaches to the mesial temporal region. In addition, we describe hippocampal transection aimed at preserving memory function, which is an alternative surgery in patients without hippocampal sclerosis. An anatomical understanding of the mesial temporal region helps surgeons not only in the field of epilepsy surgery, but also in other fields of neurosurgery, such as brain tumor and vascular surgery.

Artificial Intelligence Applications in Clinical Neurosurgery

: An emerging area of computer science is artificial intelligence (AI), which involves creating machines capable of learning, reasoning, and solving problems in the same way as humans. There is increasing use of machine learning techniques in the medical field, along with image recognition, language processing, and data mining, ranging from automated image analysis to disease prediction. Neurosurgery is frequently regarded as a pioneer in developing disruptive and innovative technologies that have significantly altered the course of acute and chronic disorders, such as epilepsy and brain tumors. Artificial intelligence platforms have been developed in recent decades to contribute to the paradigm shift in brain tumor surgery. Artificial intelligence platforms can result in safer and more effective brain tumor surgery. Artificial intelligence will soon be used to evaluate, analyze, and provide high-quality medical care. Robots will also become more prevalent in neurosurgery. Hence, physicians must keep up with this revolution to personalize patient care and deliver meaningful outcomes. For neurosurgeons to continue providing high-quality care in the future, they must understand artificial intelligence and utilize it effectively.

A prospective study of shared decision-making in brain tumor surgery

PurposeShared decision-making (SDM) is a key tenet of personalized care and is becoming an essential component of informed consent in an increasing number of countries. The aim of this study is to analyze patient and healthcare staff satisfaction with the SDM process before and after SDM was officially introduced as the standard of care. Decision grids are important tools in the SDM process, and we developed them for three different types of intracranial tumors.MethodsThis prospective study was conducted in a high-volume neuro-oncological center on all consecutive eligible patients undergoing consideration of treatment for intracranial glioma and metastases. Twenty-two patients participated before and 74 after the introduction of SDM. Six and 5 staff members respectively participated in the analysis before and after team training and the introduction of SDM. The main outcome was patient and healthcare staff satisfaction with the SDM process.ResultsPatients reported high satisfaction with the SDM process before (mean CollaboRATE score 26 of 27 points) and after (mean CollaboRATE score 26.3 of 27 points, p = 0.23) the introduction of SDM. Interestingly, staff attitude toward SDM improved significantly from 61.68 before to 90.95% after the introduction of SDM (p-value < 0.001). Decision grids that were developed for three different types of intracranial tumors are presented.ConclusionsTeam training in SDM and the introduction of techniques into daily practice can increase staff satisfaction with the SDM process. High levels of patient satisfaction were observed before, with a non-significant increase after the introduction of SDM. Decision grids are an important tool to facilitate the conveyance and understanding of complex information and to achieve SDM in daily clinical practice.

Metabolic navigation during brain tumor surgery: analysis of a series of 403 patients

Introduction. Metabolic navigation with 5‑ALA is one of methods for intraoperative imaging in neuro‑oncology.Aim. To perform a comparative analysis of sensitivity of metabolic navigation with 5‑ALA during surgery of primary and secondary brain tumors of various histological nature and degree of malignancy.Materials and methods. During the period from 2013 to 2020, our group have performed surgery to 403 patients using metabolic navigation: microsurgical resections were performed in 384 people with brain tumors, 220 of them were with glial tumors, 101 were with intracranial meningiomas, 63 were with metastatic brain damage. Among patients with metastases, 39 patients had a solitary injury, 16 had a multi‑focal injury, so 72 cases of metastatic nodes were considered in this group. Stereotactic biopsies with 5‑ALA‑assistance were performed in 19 people. Metabolic navigation was performed with the drug 5‑ALA, which was taken orally at a dose of 20 mg/kg 2 hours before surgery. Intraoperative fluorescence was evaluated using microscope with a fluorescent module.Results. Metabolic navigation using microscope has a high sensitivity when employed during microsurgery (including repeated implementation of surgery) in cases of anaplastic gliomas (65 % in total, 58 % with bright glow), glioblastomas (94 % in total, 53 % with bright glow), intracranial meningiomas (94 % in total, 64 % – with bright glow). The use of 5‑ALA has significant limitations in sensitivity in cases of diffuse gliomas (46 % – in total, 27 % – with bright glow) and brain metastases (in total 87 % – for the solid part, 52 % – for the bed, with bright glow – 51 %). In diffuse gliomas, the glow areas had significantly higher proliferative index and cell nuclei density than the fluoronegative zones. Among the most important factors affecting the glow of gliomas it can be noted: the status of the IDH1 mutation, the volume of the contrasting part of the glioma according to MRI data, the methionine accumulation index according to positron emission tomography, the tumor blood flow indicators according to the arterial spin marking method – ASL perfusion.Conclusions. Implementation of 5‑ALA navigation with the use of microscope provides high sensitivity in cases of glioblastomas, anaplastic gliomas (especially for detecting of non‑contrasting part of tumor that is not visually altered in the white light of operating microscope) and brain meningiomas. The method is less effective in low‑grade gliomas and intracranial metastases.

Impact of COVID-19 Epidemic on Psycho-Oncological Distress in Neuro-Oncological Patients.

Up to 40% of neuro-oncological patients already deal with high levels of distress under conventional circumstances. Due to COVID-19, pandemic hospital visitor rules have been restricted and patients did not receive the same level of supporting caregiver network as before COVID. The aim of the present study was to analyse the impact of the COVID pandemic on the prevalence of distress, anxiety and depression in neuro-oncological patients. Patients admitted for brain tumour surgery were screened regarding distress, anxiety and depression. Furthermore, aspects of patients' quality of life and clinical data were covered. Retrospectively available data of patients treated pre-pandemic (group A) and throughout the COVID-19 pandemic (group B) were statistically analysed using Chi-square tests and independent-sample t-tests, and regression analysis was performed to support statistical findings. Data from 110 patients were available. In all, 48 patients were included pre-COVID-19 and 62 during the COVID-19 pandemic. The authors found no significant difference between pre-COVID-19 prevalence of distress (p = 0.112), anxiety (p = 0.385) or depression (p = 0.084). Regression analyses additionally did not show any significant influence of COVID-19 on the above analysed parameter. Analyses of our cohort's data could not underline the negative impact of COVID-19 restrictions, shortcuts of professional and remodelled caregiver support on psycho-oncological outcomes.

Distance travelled for brain tumour surgery: An Low and Middle Income Country's perspective.

To examine the effect of distance travelled for brain tumour surgery on patient outcomes in an LMIC. Data were collected as part of the Pakistan Brain Tumour Epidemiology Study (PBTES) for brain tumour patients who underwent surgery in 2019. Mapping software was used to calculate the distance travelled by each patient from their primary address to the hospital. This was analysed in correlation with outcomes (change in KPS score, current status) and demographic variables. Of 2366 patients, the median distance travelled across the country was 104 km (IQR: 9.07 - 304). Only 970 (41%) patients had access to brain tumour surgical care within 50 km of their primary address. A total of 372 (15.7%) patients requiring brain tumour surgery had to travel more than 500 km to reach their primary care hospital. Patients travelling more than 50 km for brain tumour surgery had better pre- and post-surgery Karnofsky performance scores (p<0.001) than those travelling less than 50 km. The overall survival for these patients was also better (82.4% vs 75.7%, p= 0.002) compared to patients travelling less than 50 km. The distance to a hospital dictates a patient's access to continuity of care through adjuvant chemoradiotherapy and regular follow-ups. Less than half of brain tumour patients in Pakistan had access to brain tumour surgery care within 50 km of their homes. Overall outcomes were significantly better in patients travelling more than 50km for neurosurgical care - suggesting a distance bias effect.

Time to surgery after radiological diagnosis of brain tumours in Pakistan: A nationwide cross-sectional study.

To investigate waiting times for brain tumour surgery in Pakistan from a nationwide sample and highlight specific affected patient populations. A nationwide study was conducted as part of the Pakistan Brain Tumour Epidemiology Study; data from 32 high-volume neurosurgical centres were collected. The national sample included 2,750 patients. Time to surgery was calculated by the difference in dates recorded for radiological diagnosis and the date of the first surgery. This was further stratified according to demographic factors, histopathological diagnosis, type of surgical procedure performed and survival outcomes. The data of 1,474 patients for time to surgery was available. Patients travelling to public hospitals had significantly longer mean wait times (94.07 (CI: 85.29, 102.84) vs 75.14 (CI: 54.72, 95.56) days, p<0.001). Significant differences were seen between patients of various age groups, as adolescents (116.63 (CI: 65.27, 167.98) days) and young adults (103.34 (CI: 85.96, 120.72) days) had higher waiting times compared to middle-aged (72.44 (CI: 61.26, 83.61) days) and older (48.58 (CI: 31.17, 65.98) days) adults. No difference was seen between the genders. A significantly longer time to surgery was observed for middle- and lower-socioeconomic class patients. Those undergoing gross total resection of the tumour had significantly (p<0.001) longer waiting times for surgery when compared to STR (sub-total resection), biopsy, and CSF-diversion procedures, for all tumour types. Patients diagnosed with meningioma had the most prolonged waiting periods (106 (CI: 76, 95) days). Gliomas had a mean waiting period of 88 (CI: 73, 103) days across the country. Low-grade gliomas had significantly (p=0.031) longer mean waiting times (99.73 (CI: 61.91, 127.36) days) in comparison to high-grade gliomas (70.13 (CI: 43.39, 89.69 ) days). A significant difference was seen between waiting times for patients who survived surgical procedures for a brain tumour on the most recent follow-up and those who had expired (91.87 (CI: 79, 107.74) vs 77.41 (CI: 59.90, 94.91) days, p<0.001). Prolonged delays to surgery are a significant barrier within low-and-middle-income countries, leading to adverse outcomes for patients. Patients undergoing brain tumour surgery at public hospitals from lower or middle SES and electing for gross resections were more likely to have longer delays.

STMO-4 INITIAL EXPERIENCE WITH BRAIN TUMOR SURGERY USING STEALTH AUTOGUIDE

Abstract Tissue sampling of brain tumors is generally performed by biopsy with large or small craniotomy and stereotaxic brain biopsy. Recently, Stealth Autoguide, a robotic system for stereotactic deep electrode implantation and brain tumor biopsy in epilepsy, has become available. We report the initial experience of brain tumor surgery using stealth Autoguide in our hospital.Case: A man in his 70s. Left paralysis occurred during chemotherapy for esophageal cancer. Magnetic resonance imaging (MRI) revealed a ring-enhanced lesion from the right basal ganglia to the coronal radiatum. Because he was under steroid administration, he was diagnosed with metastatic brain tumor, malignant lymphoma, malignant glioma, or demyelinating disease. Since paralysis was progressing and MRS was suspected to be a malignant tumor, a stereotactic biopsy using a stealth autoguide was performed. Biopsies were performed with skin incisions of 1 cm or less from two locations that were automatically positioned based on the preoperative planning, and a sufficient amount of tissue was collected from the lesions. No complications such as bleeding were observed. Since the histological diagnosis was glioblastoma, chemotherapy with temozolomide and radiotherapy were promptly started.Brain tumor biopsy using stealth Autoguide allows accurate tissue sampling in a short period of time, and is a very useful tool for brain tumor diagnosis in the future.

COT-12 ANALYSIS OF 5-ALA STRONGLY POSITIVE FINDINGS USING IMAGE J FOR MALIGNANT BRAIN TUMOR

Abstract For brain tumor surgery using 5-ALA during surgery, we analyze the brightness using image analysis software Image J, we report the results to date for strongly positive findings. Thirty-nine patients who were suspected of having malignant glioma before surgery and who were strongly positive for 5-ALA during surgery were included. (21 malignant glioma, 14 metastatic brain tumor, 3 meningioma, and 1 germ cell tumor.) Intraoperative 5-ALA-positive findings were analyzed with image analysis software Image J (Wayne Rasband: NIH), brightness was measured with histograms, and maximum brightness was compared. The average maximum brightness titer was 106.38 (50-225) in 21 cases of malignant glioma. The brightness titer was 84.5 (28-121) in 14 cases of metastatic brain tumor, 80 (59-97) in meningioma, and 43 in 1 case of germ cell tumor. No clear correlation was found between brightness, tumor grading, and MIB-1 LI. In addition, a clear difference in luminance was observed between the tumor and the ventricle in one case.By analyzing brightness with Image J, it will be possible to obtain informations about tumors from different perspectives.

Personalized surgery of brain tumors in language areas: the role of preoperative brain mapping in patients not eligible for awake surgery.

Awake surgery represents the gold standard for resection of brain tumors close to the language network. However, in some cases patients may be considered not eligible for awake craniotomy. In these cases, a personalized brain mapping of the language network may be achieved by navigated transcranial magnetic stimulation (nTMS), which can guide resection in patients under general anesthesia. Here the authors describe their tailored nTMS-based strategy and analyze its impact on the extent of tumor resection (EOR) and language outcome in a series of patients not eligible for awake surgery. The authors reviewed data from all patients harboring a brain tumor in or close to the language network who were considered not eligible for awake surgery and were operated on during asleep surgery between January 2017 and July 2022, under the intraoperative guidance of nTMS data. The authors analyzed the effectiveness of nTMS-based mapping data in relation to 1) the ability of the nTMS-based mapping to stratify patients according to surgical risks, 2) the occurrence of postoperative language deficits, and 3) the EOR. A total of 176 patients underwent preoperative nTMS cortical language mapping and nTMS-based tractography of language fascicles. According to the nTMS-based mapping, tumors in 115 patients (65.3%) were identified as true-eloquent tumors because of a close spatial relationship with the language network. Conversely, tumors in 61 patients (34.7%) for which the nTMS mapping disclosed a location at a safer distance from the network were identified as false-eloquent tumors. At 3 months postsurgery, a permanent language deficit was present in 13 patients (7.3%). In particular, a permanent deficit was observed in 12 of 115 patients (10.4%) with true-eloquent tumors and in 1 of 61 patients (1.6%) with false-eloquent lesions. With nTMS-based mapping, neurosurgeons were able to distinguish true-eloquent from false-eloquent tumors in a significant number of cases based on the occurrence of deficits at discharge (p < 0.0008) and after 3 months from surgery (OR 6.99, p = 0.03). Gross-total resection was achieved in 80.1% of patients overall and in 69.5% of patients with true-eloquent lesions and 100% of patients with false-eloquent tumors. nTMS-based mapping allows for reliable preoperative mapping of the language network that may be used to stratify patients according to surgical risks. nTMS-guided asleep surgery should be considered a good alternative for personalized preoperative brain mapping of the language network that may increase the possibility of safe and effective resection of brain tumors in the dominant hemisphere whenever awake mapping is not feasible.