Search Results (11)

Background: Awake craniotomy (AC) surgeries are less common in the pediatric population in comparison to their adult counterparts. Nonetheless, they can be considered for selected cases whereby speech preservation is paramount during maximal safe resection of intracranial lesions. We describe a case of AC for the excision of a brain arteriovenous malformation (bAVM) with language mapping in a pediatric patient. Methods: A previously well 16-year-old male presented with a spontaneous left frontal intracranial hemorrhage. Neuroimaging confirmed the cause to be a left antero-temporal bAVM centered in the insula. A decision was made for AC bAVM excision with language mapping for speech preservation. Results: As part of the pre-operative preparation, the patient and his caregivers were reviewed by a multidisciplinary team. For the conduct of the AC, the asleep–awake–asleep technique was used with processed EEG to guide anesthesia management. Additional modifications to make the patient comfortable included the avoidance of rigid cranial skull pins, urinary catheterization and central line insertion at the start of the surgery. Conclusions: Our experience concurs with the evidence that AC in children is a feasible option for select individuals. To our knowledge, this is the first detailed case description of a pediatric patient undergoing AC with language mapping for a bAVM. Emphases include a strong rapport between the patient and the managing multidisciplinary team, flexibility to adjust conventional workflows and limitations of neuroimaging adjuncts. Full article

Objective: Navigated transcranial magnetic stimulation (nTMS) has seldom been used to study visuospatial (VS) circuits so far. Our work studied (I) VS functions in neurosurgical oncological patients by using repetitive nTMS (rnTMS), (II) the possible subcortical circuits underneath, and (III) the correspondence between nTMS and direct cortical stimulation (DCS) during awake procedures. Methods: We designed a monocentric prospective study, adopting a protocol to use rnTMS for preoperative planning, including VS functions for lesions potentially involving the VS network, including neurosurgical awake and asleep procedures. nTMS-based-DTI tractography allowed the visualization of subcortical circuits. Statistical analyses on nTMS/DCS points were performed. Clinical results were collected pre- and postoperatively. Results: Finally, 27 patients with primitive intra-axial brain lesions were enrolled between April 2023 and March 2024. Specific tests and an experimental integrated VS test (VISA) were used. The clinical evaluation (at 5 ± 7, 30 ± 10, 90 ± 10 days after surgery) documented 33% of patients with neglect in the left hemisphere four days after surgery and, during the 3-month follow-up, preservation of visuospatial function/clinical recovery (90.62% in MMSE, 98.86% in the bell test, 80% in the clock test, and 98% in the OCS test). The surgical strategy was modulated according to the nTMS map. Subcortical bundles were traced to identify those most involved in these functions: SFLII > SLFII > SLFI. A comparison of the nTMS and DCS points in awake surgery (n = 10 patients) documented a sensitivity (Se) of 12%, a specificity (Sp) of 91.21%, a positive predictive value (PPV) of 42%, a negative predictive value (NPV) of 66%, and an accuracy of ~63.7%. Conclusions: Based on our preliminary results, nTMS is advantageous for studying cognitive functions, minimising neurological impairment. Further analyses are needed to validate our data. Full article

Introduction: Bariatric surgery is the mainstay of treatment of obesity, with a proven, long-lasting effect on body weight reduction and remission of co-morbidities. Sleep disorders, including insomnia, and deteriorated sleep quality and duration are associated with obesity, and a reduction in body weight can be associated with a reduction in prevalence of sleep disorders. The purpose of this study was to assess the influence of laparoscopic sleeve gastrectomy (LSG) on the prevalence and intensity of different sleep disturbances. Methods: This observational prospective study included 80 patients qualified for bariatric surgery who filled in a questionnaire with a set of structured questions about different sleep disturbances, such as difficulties in falling asleep, night awakenings, early morning awakenings, snoring, and nightmares, as well as eating at night and daytime dysfunction, supplemented with Athens Insomnia Scale (AIS), before and 6 months after bariatric surgery. Results: There was a statistically significant reduction in incidence of night awakenings, with 40.00% of participants reporting night awakenings before surgery and, respectively, 25.00% after surgery. A significant reduction was also observed in the rate of patients who reported snoring, with 60.00% before the surgery and 38.75% after the surgery (p < 0.05). There was a correlation present between estimated weight loss % (EWL%) and reduction in snoring (p < 0.05). The mean total AIS score before surgery was 7.21 and 5.99 after surgery, and the change was statistically significant (p < 0.05). A total AIS score of 8 or more, the cutoff score for insomnia diagnosis according to the Polish validation of the Athens Insomnia Scale, was present in 44.16% of cases before surgery and in 38.00% after surgery (p = 0.52). There was a significant difference in the incidence of awakening during the night score before and after surgery (p < 0.05; CI 0.022–0.341), sleep quality (p < 0.05; CI 0.0105–0.4311), well-being during the day (p < 0.05; CI 0.0273–0.4143), and sleepiness during the day (p < 0.05; CI 0.101–0.444). Conclusions: LSG is observed to have a positive effect on selected sleep disturbances and insomnia remission in patients with obesity, measured by a significant reduction in Athens Insomnia Scale scores in follow-up 6 months after surgery. Additionally, patients after bariatric surgery reported less night awakenings and there was a lower rate of snoring. Therefore, LSG can be considered an effective therapeutic tool for insomnia in patients with obesity. Full article

Brain tumour surgery in visual eloquent areas poses significant challenges to neurosurgeons and has reported inconsistent results. This is a single-centre prospective cohort study of patients admitted for asleep surgery of intra-axial lesions in visual eloquent areas. Demographic and clinical information, data from tractography and visual evoked potentials (VEPs) monitoring were recorded and correlated with visual outcomes. Thirty-nine patients were included (20 females, 19 males; mean age 52.51 ± 14.08 years). Diffuse intrinsic glioma was noted in 61.54% of patients. There was even distribution between the temporal, occipital and parietal lobes, while 55.26% were right hemispheric lesions. Postoperatively, 74.4% remained stable in terms of visual function, 23.1% deteriorated and 2.6% improved. The tumour infiltration of the optic radiation on tractography was significantly related to the visual field deficit after surgery (p = 0.016). Higher N75 (p = 0.036) and P100 (p = 0.023) amplitudes at closure on direct cortical VEP recordings were associated with no new postoperative visual deficit. A threshold of 40% deterioration of the N75 (p = 0.035) and P100 (p = 0.020) amplitudes correlated with a risk of visual field deterioration. To conclude, direct cortical VEP recordings demonstrated a strong correlation with visual outcomes, contrary to transcranial recordings. Invasion of the optic radiation is related to worse visual field outcomes. Full article

Gliomas are infiltrative primary brain tumors that often invade functional cortical and subcortical regions, and they mandate individualized brain mapping strategies to avoid postoperative neurological deficits. It is well known that maximal safe resection significantly improves survival, while postoperative deficits minimize the benefits associated with aggressive resections and diminish patients’ quality of life. Although non-invasive imaging tools serve as useful adjuncts, intraoperative stimulation mapping (ISM) is the gold standard for identifying functional cortical and subcortical regions and minimizing morbidity during these challenging resections. Current mapping methods rely on the use of low-frequency and high-frequency stimulation, delivered with monopolar or bipolar probes either directly to the cortical surface or to the subcortical white matter structures. Stimulation effects can be monitored through patient responses during awake mapping procedures and/or with motor-evoked and somatosensory-evoked potentials in patients who are asleep. Depending on the patient’s preoperative status and tumor location and size, neurosurgeons may choose to employ these mapping methods during awake or asleep craniotomies, both of which have their own benefits and challenges. Regardless of which method is used, the goal of intraoperative stimulation is to identify areas of non-functional tissue that can be safely removed to facilitate an approach trajectory to the equator, or center, of the tumor. Recent technological advances have improved ISM’s utility in identifying subcortical structures and minimized the seizure risk associated with cortical stimulation. In this review, we summarize the salient technical aspects of which neurosurgeons should be aware in order to implement intraoperative stimulation mapping effectively and safely during glioma surgery. Full article

Our objective is to analyze the difference of microelectrode recording (MER) during awake and asleep subthalamic nucleus deep brain stimulation (STN-DBS) for Parkinson’s disease (PD) and the necessity of MER during “Asleep DBS” under general anesthesia (GA). The differences in MER, target accuracy, and prognosis under different anesthesia methods were analyzed. Additionally, the MER length was compared with the postoperative electrode length by electrode reconstruction and measurement. The MER length of two groups was 5.48 ± 1.39 mm in the local anesthesia (LA) group and 4.38 ± 1.43 mm in the GA group, with a statistical significance between the two groups (p < 0.01). The MER length of the LA group was longer than its postoperative electrode length (p < 0.01), however, there was no significant difference between the MER length and postoperative electrode length in the GA group (p = 0.61). There were also no significant differences in the postoperative electrode length, target accuracy, and postoperative primary and secondary outcome scores between the two groups (p > 0.05). These results demonstrate that “Asleep DBS” under GA is comparable to “Awake DBS” under LA. GA has influences on MER during surgery, but typical STN discharges can still be recorded. MER is not an unnecessary surgical procedure. Full article

Background: The role played by the non-dominant parietal lobe in motor cognition, attention and spatial awareness networks has potentiated the use of awake surgery. When this is not feasible, asleep monitoring and mapping techniques should be used to achieve an onco-functional balance. Objective: This study aims to assess the feasibility of a dual-strip method to obtain direct cortical stimulation for continuous real-time cortical monitoring and subcortical mapping of motor and visual pathways simultaneously in parietal lobe tumour surgery. Methods: Single-centre prospective study between 19 May–20 November of patients with intrinsic non-dominant parietal-lobe tumours. Two subdural strips were used to simultaneously map and monitor motor and visual pathways. Results: Fifteen patients were included. With regards to motor function, a large proportion of patients had abnormal interhemispheric resting motor threshold ratio (iRMTr) (71.4%), abnormal Cortical Excitability Score (CES) (85.7%), close distance to the corticospinal tract—Lesion-To-Tract Distance (LTD)—4.2 mm, Cavity-To-Tract Distance (CTD)—7 mm and intraoperative subcortical distance—6.4 mm. Concerning visual function, the LTD and CTD for optic radiations (OR) were 0.5 mm and 3.4 mm, respectively; the mean intensity for positive subcortical stimulation of OR was 12 mA ± 2.3 mA and 5/6 patients with deterioration of VEPs > 50% had persistent hemianopia and transgression of ORs. Twelve patients remained stable, one patient had a de-novo transitory hemiparesis, and two showed improvements in motor symptoms. A higher iRMTr for lower limbs was related with a worse motor outcome (p = 0.013) and a longer CTD to OR was directly related with a better visual outcome (p = 0.041). At 2 weeks after hospital discharge, all patients were ambulatory at home, and all proceeded to have oncological treatment. Conclusion: We propose motor and visual function boundaries for asleep surgery of intrinsic non-dominant parietal tumours. Pre-operative abnormal cortical excitability of the motor cortex, deterioration of the VEP recordings and CTD < 2 mm from the OR were related to poorer outcomes. Full article

Background: Although awake resection using intraoperative cortico-subcortical functional brain mapping is the benchmark technique for diffuse gliomas within eloquent brain areas, it is still rarely proposed for IDH-wildtype glioblastomas. We have assessed the feasibility, safety, and efficacy of awake resection for IDH-wildtype glioblastomas. Methods: Observational single-institution cohort (2012–2018) of 453 adult patients harboring supratentorial IDH-wildtype glioblastomas who benefited from awake resection, from asleep resection, or from a biopsy. Case matching (1:1) criteria between the awake group and asleep group: gender, age, RTOG-RPA class, tumor side, location and volume and neurosurgeon experience. Results: In patients in the awake resection subgroup (n = 42), supratotal resections were more frequent (21.4% vs. 3.1%, p < 0.0001) while partial resections were less frequent (21.4% vs. 40.1%, p < 0.0001) compared to the asleep (n = 222) resection subgroup. In multivariable analyses, postoperative standard radiochemistry (aHR = 0.04, p < 0.0001), supratotal resection (aHR = 0.27, p = 0.0021), total resection (aHR = 0.43, p < 0.0001), KPS score > 70 (HR = 0.66, p = 0.0013), MGMT promoter methylation (HR = 0.55, p = 0.0031), and awake surgery (HR = 0.54, p = 0.0156) were independent predictors of overall survival. After case matching, a longer overall survival was found for awake resection (HR = 0.47, p = 0.0103). Conclusions: Awake resection is safe, allows larger resections than asleep surgery, and positively impacts overall survival of IDH-wildtype glioblastoma in selected adult patients. Full article

Microelectrode recording (MER) in deep brain stimulation (DBS) surgery has long been a recognized and efficient method for defining a target. However, in recent decades, imaging techniques, including DBS surgery, have experienced significant growth. There is convincing evidence that imaging-guided surgery can be helpful for targeting anatomically well-defined nuclei (e.g., subthalamic nucleus (STN) or internal globus pallidus (GPi)), and reductions in secondary effects have also been claimed. It has even been proposed that MER is not necessary to perform DBS, identifying in this way asleep surgery and imaging-guided DBS. However, there are several reasons why this is not the case. Neurophysiological techniques can efficiently and safely help to identify neural structures even in sleeping patients (e.g., different types of evoked potentials or motor stimulation). Deep nuclei are not homogeneous structures (even STN), so it is important to identify different places inside the putative target. Evidently, this is more relevant in the case of thalamic or hypothalamic surgery. Moreover, it is important to remember that the clinical and scientific knowledge acquired during DBS surgery can be important to gain further insight into pathologies and develop more effective treatments. Finally, the cost/efficiency of medical technology should be considered. Full article

Gliomas are the most common primary malignant brain tumours in adults, representing nearly 80%, with poor prognosis in their high-grade forms. Several variables positively affect the prognosis of patients with high-grade glioma: young age, tumour location, radiological features, recurrence, and the opportunity to perform post-operative adjuvant therapy. Low-grade gliomas are slow-growing brain neoplasms of adolescence and young-adulthood, preferentially involving functional areas, particularly the eloquent ones. It has been demonstrated that early surgery and higher extent rate ensure overall longer survival time regardless of tumour grading, but nowadays, functional preservation that is as complete as possible is imperative. To achieve the best surgical results, along with the best functional results, intraoperative mapping and monitoring of brain functions, as well as different anaesthesiology protocols for awake surgery are nowadays being widely adopted. We report on our experience at our institution with 28 patients affected by malignant brain tumours who underwent brain mapping-aided surgical resection of neoplasm: 20 patients underwent awake surgical resection and 8 patients underwent asleep surgical resection. An analysis of the results and a review of the literature has been performed. Full article

Advancements in neuroimaging have led to a trend toward direct, image-based targeting under general anesthesia without the use of microelectrode recording (MER) or intraoperative test stimulation, also referred to as “asleep” deep brain stimulation (DBS) surgery. Asleep DBS, utilizing imaging in the form of intraoperative computed tomography (iCT) or magnetic resonance imaging (iMRI), has demonstrated reliable targeting accuracy of DBS leads implanted within the globus pallidus and subthalamic nucleus while also improving clinical outcomes in patients with Parkinson’s disease. In lieu, of randomized control trials, retrospective comparisons between asleep and awake DBS with MER have shown similar short-term efficacy with the potential for decreased complications in asleep cohorts. In lieu of long-term outcome data, awake DBS using MER must demonstrate more durable outcomes with fewer stimulation-induced side effects and lead revisions in order for its use to remain justifiable; although patient-specific factors may also be used to guide the decision regarding which technique may be most appropriate and tolerable to the patient. Full article