ABSTRACT
OBJECTIVES: The role of the microsurgical management of intrinsic brain tumors is to maximize the volumetric resection of the tumoral tissue minimizing the postoperative morbidity. The purpose of our paper has been to study the benefits of an original protocol developed for the microsurgical treatment of tumors located in eloquent motor areas where the navigation and electrical stimulation of motor subcortical pathways have been implemented. MATERIALS AND METHODS: A total of 17 patients operated on for resection of cortical or subcortical tumors in motor areas were included in the series. Preoperative planning for multimodal navigation was done integrating anatomic studies, motor functional MRI (f-MRI) and subcortical pathways volumes generated by diffusion tensor imaging (DTI). Intraoperative neuromonitorization included motor mapping by direct cortical and subcortical electrical stimulation (CS and sCS) and localization of the central sulcus using cortical multipolar electrodes and the N20 wave inversion technique. The location of all cortical and subcortical stimulated points with positive motor response was stored in the navigator and correlated with the cortical or subcortical motor functional structures defined preoperatively. RESULTS: The mean tumoral volumetric resection was 89.1±14.2% of the preoperative volume, with a total resection (≥100%) in twelve patients. Preoperatively a total of 58.8% of the patients had some motor deficit, increasing 24 hours after surgery to 76.5% and decreasing to 41.1% a month later. There was a great correlation between anatomic and functional data, both cortically and subcortically. However, in six cases it was not possible to identify the central sulcus and in many cases fMRI gave contradictory information. A total of 52 cortical points submitted to CS had positive motor response, with a positive correlation of 83.7%. Also, a total of 55 subcortical points had positive motor response, being in these cases 7.3±3.1 mm the mean distance from the stimulated point to the subcortical tract. CONCLUSIONS: The integration of preoperative and intraoperative anatomic and functional studies allows a safe functional resection of the brain tumors located in eloquent areas, compared to the tumoral resection based on anatomic imaging studies. Multimodal navigation allows the integration and correlation among preoperative and intraoperative anatomic and functional data. Cortical motor functional areas are anatomically and functionally located preoperatively thanks to MRI and fMRI and subcortical motor pathways with TDI and tractography. Intraoperative confirmation is done with CS and N20 inversion wave for cortical structures and with sCS for subcortical pathways. With this protocol we achieved a mean of 90% of volumetric resection in cortical and subcortical tumors located in eloquent motor areas with an increase of neurological deficits in the immediate postoperative period that significantly decreased one month later. Ongoing studies will define the safe limits for functional resection taking into account the intraoperative brain shift. Finally, it must be demonstrated if this protocol has any benefit for patients concerning disease free or overall survival.
Subject(s)
Brain Neoplasms/pathology , Brain Neoplasms/surgery , Microsurgery/methods , Motor Cortex/pathology , Motor Cortex/surgery , Neurosurgical Procedures/methods , Adult , Aged , Brain Mapping/methods , Electric Stimulation , Female , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Motor Cortex/anatomy & histology , Preoperative Period , Survival RateABSTRACT
Objetivos. El papel actual del tratamiento microquirúrgicode los tumores cerebrales intrínsecos se basaen alcanzar la máxima resección volumétrica del tumorminimizando la morbilidad postoperatoria. El propósitodel trabajo es estudiar los beneficios de un protocolodiseñado para tratar tumores localizados en áreaselocuentes motoras, en el que se incluye la navegación yla estimulación de tractos motores subcorticales.Material y métodos. Se han incluido 17 pacientescon tumores corticales y subcorticales de área motoratratados quirúrgicamente. Para la planificación preoperatoriase fusionaron en el sistema de navegaciónestudios anatómicos, de resonancia funcional motora(RNM-f) y los tractos subcorticales generados porestudios de tensor de difusión (DTI). La monitorizaciónintraoperatoria incluía el mapeo motor por estimulacióncortical y subcortical directa (ECD y EsCD) e identificacióndel surco central por inversión de la onda N20con electrodos corticales multipolares. La localizaciónde los puntos con respuesta positiva a la ECD o EsCD secorrelacionaba con las áreas corticales o tractos funcionalesmotores definidos en los estudios preoperatoriosgracias al navegador.Resultados. La resección volumétrica tumoral mediafue del 89.1±14.2% del volumen tumoral calculado enlos estudios preoperatorios, con resección total (≥100%)en doce pacientes. En el preoperatorio había focalidadneurológica deficitaria motora en el 58.8% de lospacientes, que aumentó al 76.5% a las 24 horas de lacirugía y se redujo a los 30 días al 41.1%. Hubo una (..) (AU)
Objectives. The role of the microsurgical managementof intrinsic brain tumors is to maximize the volumetricresection of the tumoral tissue minimizing thepostoperative morbidity. The purpose of our paper hasbeen to study the benefits of an original protocol developedfor the microsurgical treatment of tumors locatedin eloquent motor areas where the navigation and electricalstimulation of motor subcortical pathways havebeen implemented.Materials and methods. A total of 17 patients operatedon for resection of cortical or subcortical tumors inmotor areas were included in the series. Preoperativeplanning for multimodal navigation was done integratinganatomic studies, motor functional MRI (f-MRI)and subcortical pathways volumes generated by diffusiontensor imaging (DTI). Intraoperative neuromonitorizationincluded motor mapping by direct corticaland subcortical electrical stimulation (CS and sCS) andlocalization of the central sulcus using cortical multipolarelectrodes and the N20 wave inversion technique.The location of all cortical and subcortical stimulatedpoints with positive motor response was stored in thenavigator and correlated with the cortical or subcorticalmotor functional structures defined preoperatively.Results. The mean tumoral volumetric resection (..) (AU)
Subject(s)
Humans , Brain Neoplasms/surgery , Cerebral Cortex/surgery , Craniotomy/methods , Monitoring, Physiologic/methods , Surgery, Computer-Assisted/methods , Efferent Pathways/surgery , Motor Cortex/surgery , Informed ConsentABSTRACT
Percutaneous radiofrequency lesion of the Gasserian ganglion was performed between 1974 and 1984 in ninety-eight patients for the relief of trigeminal neuralgia. The average follow-up period was 4.5 years. Age, sex, and duration of illness were unrelated to outcome. Satisfactory analgesia was achieved in 68 patients. Thirty-one percent had return of pain (30 cases). Recurrent neuralgia occurred most frequently during first postoperative year (46%). Patients with marked sensory deficits had a reduced risk of recurrence. Postoperative complications included: reduced or absent corneal reflex (18 cases), corneal keratitis (3 cases) and anesthesia dolorosa (2 cases).
