Brain tumor surgery guided by navigated transcranial magnetic stimulation mapping for arithmetic calculation.

OBJECTIVE: The onco-functional balance represents the primary goal in neuro-oncology. The increasing use of navigated transcranial magnetic stimulation (nTMS) allows the noninvasive characterization of cortical functional anatomy, and its reliability for motor and language mapping has previously been validated. Calculation and arithmetic processing has not been studied with nTMS so far. In this study, the authors present their preliminary data concerning nTMS calculation. METHODS: The authors designed a monocentric prospective study, adopting an internal protocol to use nTMS for preoperative planning, including arithmetic processing. When awake surgery was possible, according to the patients' conditions, nTMS points were used to guide direct cortical stimulation (DCS), i.e., the gold standard for cortical mapping. Navigated TMS-based tractography was used for surgical planning. Statistical analyses on the nTMS and DCS points were performed. RESULTS: From February 2021 to October 2023, 61 procedures for nTMS calculation mapping were performed. The clinical evaluation, including pre- and postoperative evaluations (3 months after surgery), demonstrated a good clinical outcome with preservation of arithmetic function and recovery (92.8% of patients). Between the awake and asleep surgery groups, the postoperative clinical results were comparable at the 3-month follow-up, with > 90% of the patients achieving improved calculation function. The surgical strategy adopted was aimed at sparing nTMS positive points in asleep procedures, whereas nTMS and DCS positive points were not removed in awake procedures. Overall, 62% of the positive points for calculation functions were exposed by craniotomy and 85% were spared during surgery. None of the patients developed nTMS-related seizures. Diffusion tensor imaging fiber tracking based on nTMS positive points for calculation was used. The white matter fiber tracts involved in calculation functions were the arcuate fasciculus (56%) and frontal aslant tract (22%). When nTMS and DCS points were compared in awake surgery (n = 10 patients), a sensitivity of 31.71%, specificity of 85.76%, positive predictive value of 22.41%, negative predictive value of 90.64%, and accuracy of approximately 69% were achieved. CONCLUSIONS: Based on the authors' preliminary data, nTMS can be an advantageous tool to study cognitive functions, aimed at minimizing neurological impairment. The postoperative clinical outcome for patients who underwent operation with nTMS was very good. Considering these results, nTMS has proved to be a feasible method to map cognitive areas including those for calculation functions. Further analyses are needed to validate these data. Finally, other cognitive functions (e.g., visuospatial) may be explored with nTMS.

Heads-Up Micronavigation Reliability of Preoperative Transcranial Magnetic Stimulation Maps for the Motor Function: Comparison With Direct Cortical Stimulation.

BACKGROUND AND OBJECTIVES: We aimed to assess the reliability of preoperative navigated transcranial magnetic stimulation (nTMS) maps for motor function as visualized intraoperatively with augmented reality heads-up display and to assess its accuracy via direct point-by-point comparison with the gold-standard direct cortical stimulation (DCS). METHODS: From January 2022 to January 2023, candidates for surgical removal of lesions involving the motor pathways underwent preoperative nTMS assessment to obtain cortical maps of motor function. Intraoperatively and before tumor removal, nTMS maps were superimposed on the cortical surface, and DCS was performed on positive points with increasing current intensity until obtaining a positive response at 16 mA. The outcome of each stimulation was recorded to obtain discrimination metrics. RESULTS: Twelve patients were enrolled (5 females [42%] vs 7 males [58%], mean age 62.9 ± 12.8 years), for a total of 304 investigated points. Agreement between nTMS and DCS was moderate (κ = 0.43, P < .005), with 0.66 (0.53-0.78) sensitivity, 0.87 (0.82-0.90) specificity, 0.50 (0.39-0.62) positive predictive values, 0.93 (0.89-0.95) negative predictive value, and 0.83 (0.79-0.87) accuracy. A loss of accuracy was observed with higher DCS current intensities. CONCLUSION: We performed a point-by-point validation of preoperative nTMS maps for motor function using augmented reality visualization. The high negative predictive value and low positive predictive values highlight nTMS reliability to visualize safe cortical zones but not to identify critical functional areas, confirming previous findings of nTMS maps for the language function and suggesting the need for combined use of nTMS maps and DCS for optimal maximal safe resection.

Microscope neuronavigation-guided microsurgical fenestration of quadrigeminal cistern arachnoid cysts: how I do it.

BACKGROUND: Management options for treatment of quadrigeminal arachnoid cysts (QAC) include microsurgical/endoscopic fenestration or shunt. There is an open debate about which method is the best. Microsurgical fenestration is well suited for treatment of QAC with predominant infratentorial component and without hydrocephalus making endoscopic procedures more challenging. METHOD: We describe the microsurgical technique and related anatomy to fenestrate infratentorial QAC through supracerebellar infratentorial approach. We also discuss our experiences with this approach, some of the drawbacks and nuances. CONCLUSION: Navigation-guided microsurgical fenestration of infratentorial QAC is the authors' surgical approach of choice for treating these rare challenging lesions when not associated with hydrocephalus.

Functional outcomes, extent of resection, and bright/vague fluorescence interface in resection of glioblastomas involving the motor pathways assisted by 5-ALA.

BACKGROUND: 5-Aminolevulinic acid (5-ALA) fluorescence can maximize perirolandic glioblastoma (GBM) resection with low rates of postoperative sequelae. Our purpose was to present the outcomes of our experience and compare them with other literature reports to investigate the potential influence of different intraoperative monitoring strategies and to evaluate the role of intraoperative data on neurological and radiological outcomes in our series. METHODS: We retrospectively analyzed our prospectively collected database of GBM involving the motor pathways. Each patient underwent tumor exeresis with intraoperative 5-ALA fluorescence visualization. Our monitoring strategy was based on direct stimulation (DS), combined with cortical or transcranial MEPs. The radiological outcome was evaluated with CRET vs. residual tumor, and the neurological outcome as improved, unchanged, or worsened. We also performed a literature review to compare our results with state-of-the-art on the subject. RESULTS: Sixty-five patients were included. CRET was 63.1%, permanent postoperative impairment was 1.5%, and DS's lowest motor threshold was 5 mA. In the literature, CRET was 25-73%, permanent postoperative impairment 3-16%, and DS lowest motor threshold was 1-3 mA. Our monitoring strategy identified a motor pathway in 60% of cases in faint fluorescent tissue, and its location in bright/faint fluorescence was predictive of CRET (p < 0.001). A preoperative motor deficit was associated with a worse clinical outcome (p < 0.001). Resection of bright fluorescent tissue was stopped in 26%, and fluorescence type of residual tumor was associated with higher CRET grades (p < 0.001). CONCLUSIONS: Based on the data presented and the current literature, distinct monitoring strategies can achieve different onco-functional outcomes in 5-ALA-guided resection of a glioblastoma (GBM) motor pathway. Intraoperatively, functional and fluorescence data close to a bright/vague interface could be helpful to predict onco-functional outcomes.