Tag: Gliomas

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The Role of Intraoperative Imaging Modalities in Surgical Resection of Supratentorial Gliomas: A Review of 300 Cases

Operative Neurosurgery 30:278–288, 2026

This retrospective study of 300 supratentorial glioma surgeries compares outcomes using intraoperative MRI (iMRI), navigated intraoperative ultrasound (iUS) and no intraoperative imaging. It reports higher gross total resection rates and greater contrast-enhancement extent with iMRI and iUS, with iMRI achieving the highest contrast-enhanced extent of resection (CE-EOR) but longer operative times.

Clinical outcomes show fewer postoperative weaknesses and better overall survival when intraoperative imaging is used. Postoperative cognitive and sensory deficits varied by modality; progression-free survival differences were not significant. Study limitations include a retrospective design, the temporal rollout of modalities and differing surgeon experience.

Gross Total Resection (GTR) Rates: GTR was significantly more common with intraoperative MRI (iMRI, 56.9%) and intraoperative ultrasound (iUS, 57.1%) than without intraoperative imaging guidance (34%) in glioma surgery.

Extent of Resection (EOR): The mean EOR of contrast enhancement was highest with iMRI (96.6%), followed by iUS (93.2%), and lowest without intraoperative imaging (92%).

Postoperative Neurological Deficits: Patients without intraoperative imaging had significantly higher rates of postoperative weakness compared to those with iMRI or iUS (odds ratio = 0.520, CI = 0.272-0.994, P = .048).

Overall Survival (OS): Overall survival was significantly worse in patients without intraoperative imaging guidance (odds ratio = 1.534, CI = 1.058-2.225, P = .024) than in those with iMRI or iUS.

Progression-Free Survival (PFS): No significant differences in progression-free survival were found between the subgroups using iMRI, iUS, or no intraoperative imaging.

Surgery Duration: Mean surgery duration was longest with iMRI (260 minutes), intermediate with iUS (194 minutes), and shortest without intraoperative imaging (175 minutes).

Postoperative Functional Status: Karnofsky Performance Status (KPS) at 1 year was lowest in patients without intraoperative imaging guidance, indicating worse functional outcomes.

Study Limitations: The retrospective design, differing periods of iMRI and iUS use, learning curves, and unequal subgroup sizes limit the ability to fully compare all factors and may affect recurrence rate assessments.

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Risk of Tract Seeding Following Laser Interstitial Thermal Therapy for Brain Tumors

Neurosurgery 93:198–205, 2023

The management of intracranial oncological disease remains a significant challenge despite advances in systemic cancer therapy. Laser interstitial thermal therapy (LITT) represents a novel treatment for local control of brain tumors through photocoagulation with a stereotactically implanted laser fiber. Because the use of laser interstitial thermal therapy continues to increase within neurosurgery, characterization of LITT is necessary to improve outcomes.

OBJECTIVE: To quantify the risk of tumor seeding along the laser fiber tract in patients receiving LITT for primary or metastatic brain tumors at a high-volume treatment center.

METHODS: We retrospectively reviewed all patients receiving LITT from 2015 to 2021 at our medical center. Patients with biopsy-confirmed tumors were included in this study. Tract seeding was identified as discontinuous, newly enhancing tumor along the LITT tract.

RESULTS: Fifty-six patients received LITT for biopsy-confirmed tumors from 2015 to 2021, with tract seeding identified in 3 (5.4%). Twenty-nine (51.8%) patients had gliomas, while the remainder had metastases, of which lung was the most common histology (20 patients, 74%). Tract seeding was associated with ablation proceeding inward from superficial tumor margin closest to the cranial entry point (P = .03). Patients with tract seeding had a shorter median time to progression of 1.1 (0.1-1.3) months vs 4.2 (2.2-8.6) months (P = .03).

CONCLUSION: Although the risk of tract seeding after LITT is reassuringly low, it is associated with decreased progression-free survival. This risk may be related to surgical technique or experience. Follow-up radiosurgery to the LITT tract has the potential to prevent this complication.

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Brain connectomics applied to oncological neuroscience: from a traditional surgical strategy focusing on glioma topography to a meta-network approach

Acta Neurochirurgica (2021) 163:905–917

The classical way for surgical selection and planning in cerebral glioma mainly focused on tumor topography. The emerging science of connectomics, which aims of mapping brain connectivity, resulted in a paradigmatic shift from a modular account of cerebral organization to a meta-network perspective. Adaptive behavior is actually mediated by constant changes in interactions within and across large-scale delocalized neural systems underlying conation, cognition, and emotion.

Here, to optimize the onco-functional balance of glioma surgery, the purpose is to switch toward a connectome-based resection taking account of both relationships between the tumor and critical distributed circuits (especially subcortical pathways) as well as the perpetual instability of the meta-network. Such dynamic in the neural spatiotemporal integration permits functional reallocation leading to neurological recovery after massive resection in structures traditionally thought as “inoperable.” This better understanding of connectome increases benefit/risk ratio of surgery (i) by selecting resection in areas deemed “eloquent” according to a localizationist dogma; (ii), conversely, by refining intraoperative awake cognitive mapping and monitoring in so-called non-eloquent areas; (iii) by improving preoperative information, enabling an optimal selection of intrasurgical tasks tailored to the patient’s wishes; (iv) by developing an “oncological disconnection surgery”; (v) by defining a personalized multistep surgical strategy adapted to individual brain reshaping potential; and (vi) ultimately by preserving environmentally and socially appropriate behavior, including return to work, while increasing the extent of (possibly repeated) resection(s).

Such a holistic vision of neural processing can enhance reliability of connectomal surgery in oncological neuroscience and may also be applied to restorative neurosurgery.

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Comparison of 5-aminolevulinic acid and sodium fluorescein for intraoperative tumor visualization in patients with high-grade gliomas

J Neurosurg 133:1324–1331, 2020

Maximal safe resection is an important surgical goal in the treatment for high-grade gliomas. Fluorescent dyes help the surgeon to distinguish malignant tissue from healthy. The aims of this study were 1) to compare the 2 fluorescent dyes 5-aminolevulinic acid (5-ALA) and sodium fluorescein (fluorescein) regarding extent of resection, progression- free survival, and overall survival; and 2) to assess the influence of other risk factors on clinical outcome and screen for potential disadvantages of the dyes.

METHODS A total of 209 patients with high-grade gliomas were included in this retrospective study. Resections were performed in the period from 2012 to 2017 using 5-ALA or fluorescein. Extent of resection was assessed as the difference in tumor volume between early postoperative and preoperative MRI studies. Tumor progression–free survival and overall survival were analyzed using an adjusted Cox proportional hazards model.

RESULTS One hundred fifty-eight patients were operated on with 5-ALA and 51 with fluorescein. The median duration of follow-up was 46.7 and 21.2 months, respectively. Covariables were evenly distributed. There was no statistically significant difference in volumetrically assessed median extent of resection (96.9% for 5-ALA vs 97.4% for fluorescein, p = 0.46) or the percentage of patients with residual tumor volume less than 0.175 cm3 (29.5% for 5-ALA vs 36.2% for fluorescein, p = 0.39). The median overall survival was 14.8 months for the 5-ALA group and 19.7 months for the fluorescein group (p = 0.06). The median adjusted progression-free survival was 8.7 months for the 5-ALA group and 9.2 months for the fluorescein group (p = 0.03).

CONCLUSIONS Fluorescein can be used as a viable alternative to 5-ALA for intraoperative fluorescent guidance in brain tumor surgery. Comparative, prospective, and randomized studies are much needed.

 

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Resection of tumors within the primary motor cortex using high-frequency stimulation

J Neurosurg 133:642–654, 2020

Brain mapping techniques allow one to effectively approach tumors involving the primary motor cortex (M1). Tumor resectability and maintenance of patient integrity depend on the ability to successfully identify motor tracts during resection by choosing the most appropriate neurophysiological paradigm for motor mapping. Mapping with a highfrequency (HF) stimulation technique has emerged as the most efficient tool to identify motor tracts because of its versatility in different clinical settings. At present, few data are available on the use of HF for removal of tumors predominantly involving M1.

METHODS The authors retrospectively analyzed a series of 102 patients with brain tumors within M1, by reviewing the use of HF as a guide. The neurophysiological protocols adopted during resections were described and correlated with patients’ clinical and tumor imaging features. Feasibility of mapping, extent of resection, and motor function assessment were used to evaluate the oncological and functional outcome to be correlated with the selected neurophysiological parameters used for guiding resection. The study aimed to define the most efficient protocol to guide resection for each clinical condition.

RESULTS The data confirmed HF as an efficient tool for guiding resection of M1 tumors, affording 85.3% complete resection and only 2% permanent morbidity. HF was highly versatile, adapting the stimulation paradigm and the probe to the clinical context. Three approaches were used. The first was a “standard approach” (HF “train of 5,” using a monopolar probe) applied in 51 patients with no motor deficit and seizure control, harboring a well-defined tumor, showing contrast enhancement in most cases, and reaching the M1 surface. Complete resection was achieved in 72.5%, and 2% had permanent morbidity. The second approach was an “increased train approach,” that is, an increase in the number of pulses (7–9) and of pulse duration, using a monopolar probe. This second approach was applied in 8 patients with a long clinical history, previous treatment (surgery, radiation therapy, chemotherapy), motor deficit at admission, poor seizure control, and mostly high-grade gliomas or metastases. Complete resection was achieved in 87.5% using this approach, along with 0% permanent morbidity. The final approach was a “reduced train approach,” which was the combined use of train of 2 or train of 1 pulses associated with the standard approach, using a monopolar or bipolar probe. This approach was used in 43 patients with a long clinical history and poorly controlled seizures, harboring tumors with irregular borders without contrast enhancement (low or lower grade), possibly not reaching the cortical surface. Complete resection was attained in 88.4%, and permanent morbidity was found in 2.3%.

CONCLUSIONS Resection of M1 tumors is feasible and safe. By adapting the stimulation paradigm and probe appropriately to the clinical context, the best resection and functional results can be achieved.

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Correlation between glioma location and preoperative seizures: a systematic review and meta-analysis

Epilepsy is a common manifestation of glioma patients and negatively impacts on quality of life and neurocognitive function. The risk of preoperative seizures in patients with glioma is currently under discussion.

We aimed to evaluate the relationship between tumor locations in the cerebrum and preoperative seizures in patients with glioma. PubMed, EMBASE, Web of Science, China Biology Medicine, and the Cochrane Library were systematically searched from inception to July 15, 2017, for original studies including reports of preoperative seizures in patients with gliomas in different brain regions. The pooled odds ratio (OR) and 95% confidence interval (CI) of the meta-analysis for preoperative seizure risk stratified by cerebrum regions were calculated. The quality of evidence was assessed per outcome, using the approach of the Grades of Recommendation, Assessment, Development and Evaluation.

Overall, 4323 participants in 16 population-based studies were included in this meta-analysis. The meta-analysis indicated that gliomas in the frontal lobe (OR = 1.51, 95% CI = 1.09–2.09, P = 0.013) were associated with a higher risk for preoperative seizure compared to occipital lobe involved (OR = 0.53, 95% CI = 0.32–0.88, P = 0.014). Regarding the other three lobe involved gliomas, no difference was found between the incidence of preoperative seizures and tumor location.

Current limited data suggest that frontal gliomas were associated with a higher risk of preoperative seizures, while gliomas in the occipital lobe were associated with a lower seizure risk. Further RCT studies recruiting larger sample sizes are required to validate these results and guide clinical practice.

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Parietal association deficits in patients harboring parietal lobe gliomas

J Neurosurg 130:773–779, 2019

Although the parietal lobe is a common site for glioma formation, current literature is scarce, consists of retrospective studies, and lacks consistency with regard to the incidence, nature, and severity of parietal association deficits (PADs).

The aim of this study was to assess the characteristics and incidence of PADs in patients suffering from parietal lobe gliomas through a prospective study and a battery of comprehensive neuropsychological tests.

METHODS Between 2012 and 2016 the authors recruited 38 patients with glioma confined in the parietal lobe. Patients were examined for primary and secondary association deficits with a dedicated battery of neuropsychological tests. The PADs were grouped into 5 categories: visuospatial attention, gnosis, praxis, upper-limb coordination, and language. For descriptive analysis tumors were divided into high- and low-grade gliomas and also according to patient age and tumor size.

RESULTS Parietal association deficits were elicited in 80% of patients, thus being more common than primary deficits (50%). Apraxia was the most common PAD (47.4%), followed by anomic aphasia and subcomponents of Gerstmann’s syndrome (34.2% each). Other deficits such as hemineglect, stereoagnosia, extinction, and visuomotor ataxia were also detected, albeit at lower rates. There was a statistically nonsignificant difference between PADs and sex (72.2% males, 85% females) and age (77.8% at ≤ 60 years, 80% at age > 60 years), but a statistically significant difference between the > 4 cm and the ≤ 4 cm diameter group (p = 0.02, 94.7% vs 63.2%, respectively). There was a tendency (p = 0.094) for low-grade gliomas to present with fewer PADs (50%) than high-grade gliomas (85.7%). Tumor laterality showed a strong correlation with hemineglect (p = 0.004, predilection for right hemisphere), anomia (p = 0.001), and Gerstmann’s symptoms (p = 0.01); the last 2 deficits showed a left (dominant) hemispheric preponderance.

CONCLUSIONS This is the first study to prospectively evaluate the incidence and nature of PADs in patients with parietal gliomas. It could be that the current literature may have underestimated the true incidence of deficits. Dedicated neuropsychological examination detects a high frequency of PADs, the most common being apraxia, followed by anomia and subcomponents of Gerstmann’s syndrome. Nevertheless, a direct correlation between the clinical deficit and its anatomical substrate is only possible to a limited extent, highlighting the need for intraoperative cortical and subcortical functional mapping.

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Minimally invasive subfrontal route for the resection of medial temporal region intrinsic tumors

Minimally invasive subfrontal route for the resection of medial temporal region intrinsic tumors

Acta Neurochir (2015) 157:1971–1974

The mesial temporal region (MTR) comprises important components of the limbic system, as well as vital neurovascular structures. Because of its important functional role, as much healthy brain tissue as possible must be preserved while targeting resection of MTR lesions.

Methods A frontal minicraniotomy is used to access the MTR through a subfrontal approach. By opening the most medial part of the Sylvian fissure, the uncus-amygdala complex is exposed, and through this, the head of the hippocampus can be reached and removed as well.

Conclusions This approach is extremely suitable for MTR lesions, as it provides the advantage of sparing the most important functional structures of the temporal lobe, the temporal stem, and the limen insulae, as well as the optic radiations and the fronto-occipital connections.

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Trends in Fluorescence Image-Guided Surgery for Gliomas

Trends in Fluorescence Image-Guided Surgery for Gliomas

Neurosurgery 75:61–71, 2014

Mounting evidence suggests that a more extensive surgical resection is associated with an improved life expectancy for both low-grade and high-grade glioma patients. However, radiographically complete resections are not often achieved in many cases because of the lack of sensitivity and specificity of current neurosurgical guidance techniques at the margins of diffuse infiltrative gliomas.

Intraoperative fluorescence imaging offers the potential to improve the extent of resection and to investigate the possible benefits of resecting beyond the radiographic margins.

Here, we provide a review of wide-field and high-resolution fluorescence-imaging strategies that are being developed for neurosurgical guidance, with a focus on emerging imaging technologies and clinically viable contrast agents. The strengths and weaknesses of these approaches will be discussed, as well as issues that are being addressed to translate these technologies into the standard of care.

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Intraoperative visualisation of language fascicles by diffusion tensor imaging-based tractography in glioma surgery

Intraop visualization language fascicles-3

Acta Neurochir (2013) 155:437–448

For gliomas, the goal of surgery is to maximise the extent of resection (EOR) while minimising the postoperative morbidity. The purpose of this study was to evaluate the benefits of a protocol developed for the surgical management of gliomas located in language areas, where tractography-integrated navigation was used in conjunction with direct electrical stimulations (DES).

Methods and materials The authors included ten patients suffering of gliomas located in language areas. The preoperative planning for multimodal navigation was done by integrating anatomical magnetic resonance images and subcortical pathway volumes generated by diffusion tensor imaging. Six white matter fascicles implicated in language functions were reconstructed in each patient, including fibres for phonological processing (i.e. the arcuate fasciculus), fibres for lexical-semantic processing (i.e. the inferior frontooccipital fasciculus, inferior longitudinal fasciculus and uncinate fasciculus), and two premotor fasciculi involved in the preparation of speech movements (the subcallosal medialis fasciculus and cortical fibres originating from the medial and lateral premotor areas). During surgery, language fascicles were identified by direct visualisation on tractography-integrated navigation images and by observing transient language inhibition after subcortical DES. Language deficits were evaluated preoperatively and postoperatively, and compared with the EOR.

Results Tractography was successfully performed in all patients, preoperatively demonstrating the relationships between the tumours to resect and the language fascicles to preserve from injury. With the use of the tractographyintegrated navigation system and intraoperative DES, language functions were preserved in all patients. The mean volumetric resection was 93.0±10.4 % of the preoperative tumour volume, with a gross total resection in 60 % of patients.

Conclusion The intraoperative combination of tractography and DES contributed to maximum safe resection of gliomas located in language areas.

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ELTD1, a Potential New Biomarker for Gliomas

ELTD1, a Potential New Biomarker for Gliomas

Neurosurgery 72:77–91, 2013

Glioblastoma multiforme (GBM), a high-grade glioma, is characterized by being diffuse, invasive, and highly angiogenic and has a very poor prognosis. Identification of new biomarkers could help in the further diagnosis of GBM.

OBJECTIVE: To identify ELTD1 (epidermal growth factor, latrophilin, and 7 transmembrane domain-containing protein 1 on chromosome 1) as a putative gliomaassociated marker via a bioinformatic method.

METHODS: We used advanced data mining and a novel bioinformatics method to predict ELTD1 as a potential novel biomarker that is associated with gliomas. Validation was done with immunohistochemistry, which was used to detect levels of ELTD1 in human high-grade gliomas and rat F98 glioma tumors. In vivo levels of ELTD1 in rat F98 gliomas were assessed using molecular magnetic resonance imaging.

RESULTS: ELTD1 was found to be significantly higher (P = .03) in high-grade gliomas (50 patients) compared with low-grade gliomas (21 patients) and compared well with traditional immunohistochemistry markers including vascular endothelial growth factor, glucose transporter 1, carbonic anhydrase IX, and hypoxia-inducible factor 1a. ELTD1 gene expression indicates an association with grade, survival across grade, and an increase in the mesenchymal subtype. Significantly high (P , .001) in vivo levels of ELTD1 were additionally found in F98 tumors compared with normal brain tissue.

CONCLUSION: Results of this study strongly suggests that associative analysis was able to accurately identify ELTD1 as a putative glioma-associated biomarker. The detection of ELTD1 was also validated in both rodent and human gliomas and may serve as an additional biomarker for gliomas in preclinical and clinical diagnosis of gliomas.

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