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1.
Clin Neurol Neurosurg ; 229: 107685, 2023 06.
Artículo en Inglés | MEDLINE | ID: mdl-37105067

RESUMEN

INTRODUCTION: Cortical and subcortical motor mapping has advanced the notion of maximal safe resection of intra-axial brain tumours, thereby preserving neurological functions as well as improving survival. Despite being an age-old and established neurosurgical procedure across the world, the strategy and techniques involved in motor mapping have a gamut of variation due to a lack of defined standard protocols. METHODS: We disseminated a structured survey among focused group of neurosurgeons with established practices involving brain mapping. It consisted of 40 questions, split into five sections assessing the practice description, general approach for motor mapping, preference for asleep versus awake mapping, operative techniques and approach to representative tumor cases. Practice-patterns during primary motor mapping for brain tumours were analysed from responses of 51 neurosurgeons. RESULTS: 60.8 % felt that any lesion even near (without infiltration) was suffice to define "involvement" of the cortical/subcortical motor pathways. 82.4 % felt that motor mapping was necessary for brain tumours involving motor pathways, irrespective of the tumor histology or patient age. 90.2 % opined that tumor location was the predominant factor affecting their choice between awake or asleep mapping. 31.4 % believed that all cases should be performed awake unless patient-related medical, psychological, or anaesthetic contraindications exist, whereas 45.1 % felt that all cases should be performed asleep unless language mapping is required. MRI, DTI-based tractography and intra-operative fluorescence were the most commonly employed surgical adjuncts. CONCLUSIONS: The data from this survey may serve as a preliminary foundation for a more standardized approach to patient selection and the approach to motor mapping for brain tumors.


Asunto(s)
Neoplasias Encefálicas , Humanos , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/cirugía , Neoplasias Encefálicas/patología , Procedimientos Neuroquirúrgicos/métodos , Imagen por Resonancia Magnética , Selección de Paciente , Mapeo Encefálico/métodos , Vigilia/fisiología
2.
Neurosurg Focus ; 52(6): E8, 2022 06.
Artículo en Inglés | MEDLINE | ID: mdl-35921187

RESUMEN

OBJECTIVE: Despite growing evidence on the benefits of outpatient oncological neurosurgery (OON), it is only performed in a few specialized centers and there are no previous descriptions of established OON programs in Europe. Moreover, increasing application of telemedicine strategies, especially after the start of the coronavirus disease 2019 (COVID-19) pandemic, is drastically changing neurosurgical management, particularly in the case of vulnerable populations such as neuro-oncological patients. In this context, the authors implemented an OON program in their hospital with telematic follow-up. Herein, they describe the protocol and qualitatively analyze the barriers and facilitators of the development process. METHODS: An OON program was developed through the following steps: assessment of hospital needs, specific OON training, multidisciplinary team organization, and OON protocol design. In addition, the implementation phase included training sessions, a pilot study, and continuous improvement sessions. Finally, barriers and facilitators of the protocol's implementation were identified from the feedback of all participants. RESULTS: An OON protocol was successfully designed and implemented for resection or biopsy of supratentorial lesions up to 3 cm in diameter. The protocol included the patient's admission to the day surgery unit, noninvasive anesthetic monitoring, same-day discharge, and admission to the hospital-at-home (HaH) unit for telematic and on-site postoperative care. After a pilot study including 10 procedures in 9 patients, the main barriers identified were healthcare provider resistance to change, lack of experience in outpatient neurosurgery, patient reluctance, and limitations in the recruitment of patients. Key facilitators of the process were the patient education program, the multidisciplinary team approach, and the HaH-based telematic postoperative care. CONCLUSIONS: Initiating an OON program with telematic follow-up in a European clinical setting is feasible. Nevertheless, it poses several barriers that can be overcome by identifying and maximizing key facilitators of the process. Among them, patient education, a multidisciplinary team approach, and HaH-based postoperative care were crucial to the success of the program. Future studies should investigate the cost-effectiveness of telemedicine to assess potential cost savings, from reduced travel and wait times, and the impact on patient satisfaction.


Asunto(s)
Neoplasias Encefálicas , COVID-19 , Telemedicina , Neoplasias Encefálicas/cirugía , Humanos , Pacientes Ambulatorios , Proyectos Piloto
3.
Acta Neurochir (Wien) ; 164(11): 2841-2849, 2022 11.
Artículo en Inglés | MEDLINE | ID: mdl-35809147

RESUMEN

PURPOSE: Selective amygdalohippocampectomy (SelAH) is one of the most common surgical treatments for mesial temporal sclerosis. Microsurgical approaches are associated with the risk of cognitive and visual deficits due to damage to the cortex and white matter (WM) pathways. Our objective is to test the feasibility of an endoscopic approach through the anterior middle temporal gyrus (aMTG) to perform a SelAH. METHODS: Virtual simulation with MRI scans of ten patients (20 hemispheres) was used to identify the endoscopic trajectory through the aMTG. A cadaveric study was performed on 22 specimens using a temporal craniotomy. The anterior part of the temporal horn was accessed using a tubular retractor through the aMTG after performing a 1.5 cm corticectomy at 1.5 cm posterior to the temporal pole. Then, an endoscope was introduced. SeIAH was performed in each specimen. The specimens underwent neuronavigation-assisted endoscopic SeIAH to confirm our surgical trajectory. WM dissection using Klingler's technique was performed on five specimens to assess WM integrity. RESULTS: This approach allowed the identification of collateral eminence, lateral ventricular sulcus, choroid plexus, inferior choroidal point, amygdala, hippocampus, and fimbria. SelAH was successfully performed on all specimens, and CT neuronavigation confirmed the planned trajectory. WM dissection confirmed the integrity of language pathways and optic radiations. CONCLUSIONS: Endoscopic SelAH through the aMTG can be successfully performed with a corticectomy of 15 mm, presenting a reduced risk of vascular injury and damage to WM pathways. This could potentially help to reduce cognitive and visual deficits associated with SelAH.


Asunto(s)
Epilepsia del Lóbulo Temporal , Lóbulo Temporal , Humanos , Estudios de Factibilidad , Lóbulo Temporal/cirugía , Epilepsia del Lóbulo Temporal/cirugía , Amígdala del Cerebelo/diagnóstico por imagen , Amígdala del Cerebelo/cirugía , Hipocampo/diagnóstico por imagen , Hipocampo/cirugía , Cadáver
4.
World Neurosurg ; 164: 353-366, 2022 08.
Artículo en Inglés | MEDLINE | ID: mdl-35697231

RESUMEN

Homonymous hemianopia has been reported after brain tumor resection with a significant effect on quality of life. Nevertheless, no standardized methods exist for intraoperative optical radiation mapping. The purpose of this article is to describe a new intraoperative task for visual mapping and to review the existing literature. A Central and Peripheral Image task was used to map optic radiations during brain tumor resection in 3 patients. A systematic review was performed following PRISMA 2020 guidelines, with 25 of 449 articles included. Optic radiations were identified in all patients and preserved in all but one, in whom the extent of resection prevailed. The literature review exposed 2 methods to assess visual function: visual evoked potentials (VEP) and direct electric stimulation (DES), with 13 and 12 articles and 341 and 63 patients, respectively. Hemianopia was developed in 13.49% of patients with VEP versus 1.59% of patients with DES. The use of DES might be associated with a better outcome (level IV evidence). However, standardization of intraoperative tasks during DES could be improved. In this context, the Central and Peripheral Image task might be an adequate tool for the resection of tumors affecting the optic radiations.


Asunto(s)
Neoplasias Encefálicas , Potenciales Evocados Visuales , Mapeo Encefálico/métodos , Neoplasias Encefálicas/complicaciones , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/cirugía , Craneotomía/métodos , Hemianopsia/complicaciones , Humanos , Calidad de Vida
5.
Oper Neurosurg (Hagerstown) ; 21(6): E561-E562, 2021 Nov 15.
Artículo en Inglés | MEDLINE | ID: mdl-34561696

RESUMEN

Transopercular approach to the insula is indicated for resection of insular low-grade gliomas, particularly for Yasargil's 3B, 5A, and 5B types. Nevertheless, the infrequent location and its challenging approach make it difficult to master the surgery. Consequently, a realistic laboratory training model might help to acquire key surgical skills. In this video, we describe a cadaveric-based model simulating the resection of a temporo-insular low-grade glioma. Kingler's fixation technique was used to fix the cadaver head before injecting red and blue colorants for a realistic vascular appearance. Hemisphere was frozen for white matter tract dissection. Tractography and intraoperative eloquent areas were extrapolated from a glioma patient by using a neuronavigation system. Then, a fronto-temporal craniotomy was performed through a question mark incision, exposing from inferior temporal gyrus up to middle frontal gyrus. After cortical anatomic landmark identification, eloquent areas were extrapolated creating a simulated functional cortical map. Then, transopercular noneloquent frontal and temporal corticectomies were performed, followed by subpial resection. Detailed identification of Sylvian vessels and insular cortex was demonstrated. Anatomic resection limits were exposed, and implicated white matter bundles, uncinate and fronto-occipital fascicles, were identified running through the temporal isthmus. Finally, a temporo-mesial resection was performed. In summary, this model provides a simple, cost-effective, and very realistic simulation of a transopercular approach to the insula, allowing the development of surgical skills needed to treat insular tumors in a safe environment. Besides, the integration of simulated navigation has proven useful in better understanding the complex white matter anatomy involved. Cadaver donation, subject or relatives, includes full consent for publication of the images. For the purpose of this video, no ethics committee approval was needed. Images correspond to a cadaver head donation. Cadaver donation, subject or relatives, includes full consent for any scientific purposes involving the corpse. The consent includes image or video recording. Regarding the intraoperative surgical video and tractography, the patient gave written consent for scientific divulgation prior to surgery.

6.
Neurosurgery ; 88(2): E190-E202, 2021 01 13.
Artículo en Inglés | MEDLINE | ID: mdl-33313812

RESUMEN

BACKGROUND: An early maximal safe surgical resection is the current treatment paradigm for low-grade glioma (LGG). Nevertheless, there are no reliable methods to accurately predict the axonal intratumoral eloquent areas and, consequently, to predict the extent of resection. OBJECTIVE: To describe the functional predictive value of eloquent white matter tracts within the tumor by using a pre- and postoperative intratumoral diffusion tensor imaging (DTI) tractography protocol in patients with LGG. METHODS: A preoperative intratumoral DTI-based tractography protocol, using the tumor segmented volume as the only seed region, was used to assess the tracts within the tumor boundaries in 22 consecutive patients with LGG. The reconstructed tracts were correlated with intraoperative electrical stimulation (IES)-based language and motor subcortical mapping findings and the extent of resection was assessed by tumor volumetrics. RESULTS: Identification of intratumoral language and motor tracts significantly predicted eloquent areas within the tumor during the IES mapping: the positive predictive value for the pyramidal tract, the inferior fronto-occipital fasciculus, the arcuate fasciculus and the inferior longitudinal fasciculus positive was 100%, 100%, 33%, and 80%, respectively, whereas negative predictive value was 100% for all of them. The reconstruction of at least one of these tracts within the tumor was significantly associated with a lower extent of resection (67%) as opposed to the extent of resection in the cases with a negative intratumoral tractography (100%) (P < .0001). CONCLUSION: Intratumoral DTI-based tractography is a simple and reliable method, useful in assessing glioma resectability based on the analysis of intratumoral eloquent areas associated with motor and language tracts within the tumor.


Asunto(s)
Mapeo Encefálico/métodos , Neoplasias Encefálicas/diagnóstico por imagen , Imagen de Difusión Tensora/métodos , Glioma/diagnóstico por imagen , Cirugía Asistida por Computador/métodos , Adulto , Neoplasias Encefálicas/cirugía , Femenino , Glioma/cirugía , Humanos , Masculino , Márgenes de Escisión , Persona de Mediana Edad
7.
Kidney Int ; 99(4): 986-998, 2021 04.
Artículo en Inglés | MEDLINE | ID: mdl-33166580

RESUMEN

A cyclical corticosteroid-cyclophosphamide regimen is recommended for patients with primary membranous nephropathy at high risk of progression. We hypothesized that sequential therapy with tacrolimus and rituximab is superior to cyclical alternating treatment with corticosteroids and cyclophosphamide in inducing persistent remission in these patients. This was tested in a randomized, open-label controlled trial of 86 patients with primary membranous nephropathy and persistent nephrotic syndrome after six-months observation and assigned 43 each to receive six-month cyclical treatment with corticosteroid and cyclophosphamide or sequential treatment with tacrolimus (full-dose for six months and tapering for another three months) and rituximab (one gram at month six). The primary outcome was complete or partial remission of nephrotic syndrome at 24 months. This composite outcome occurred in 36 patients (83.7%) in the corticosteroid-cyclophosphamide group and in 25 patients (58.1%) in the tacrolimus-rituximab group (relative risk 1.44; 95% confidence interval 1.08 to 1.92). Complete remission at 24 months occurred in 26 patients (60%) in the corticosteroid-cyclophosphamide group and in 11 patients (26%) in the tacrolimus-rituximab group (2.36; 1.34 to 4.16). Anti-PLA2R titers showed a significant decrease in both groups but the proportion of anti-PLA2R-positive patients who achieved immunological response (depletion of anti-PLA2R antibodies) was significantly higher at three and six months in the corticosteroid-cyclophosphamide group (77% and 92%, respectively), as compared to the tacrolimus-rituximab group (45% and 70%, respectively). Relapses occurred in one patient in the corticosteroid-cyclophosphamide group, and three patients in the tacrolimus-rituximab group. Serious adverse events were similar in both groups. Thus, treatment with corticosteroid-cyclophosphamide induced remission in a significantly greater number of patients with primary membranous nephropathy than tacrolimus-rituximab.


Asunto(s)
Glomerulonefritis Membranosa , Tacrolimus , Corticoesteroides/efectos adversos , Ciclofosfamida/efectos adversos , Glomerulonefritis Membranosa/tratamiento farmacológico , Humanos , Inmunosupresores/efectos adversos , Rituximab/efectos adversos , Tacrolimus/efectos adversos , Resultado del Tratamiento
8.
Neurosurg Focus ; 48(2): E7, 2020 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-32006945

RESUMEN

OBJECTIVE: The functional importance of the superior temporal lobe at the level of Heschl's gyrus is well known. However, the organization and function of these cortical areas and the underlying fiber tracts connecting them remain unclear. The goal of this study was to analyze the area formed by the organization of the intersection of Heschl's gyrus-related fiber tracts, which the authors have termed the "Heschl's gyrus fiber intersection area" (HGFIA). METHODS: The subcortical connectivity of Heschl's gyrus tracts was analyzed by white matter fiber dissection and by diffusion tensor imaging tractography. The white matter tracts organized in relation to Heschl's gyrus were isolated in 8 human hemispheres from cadaveric specimens and in 8 MRI studies in 4 healthy volunteers. In addition, these tracts and their functions were described in the surgical cases of left temporal gliomas next to the HGFIA in 6 patients who were awake during surgery and underwent intraoperative electrical stimulation mapping. RESULTS: Five tracts were observed to pass through the HGFIA: the anterior segment of the arcuate fasciculus, the middle longitudinal fasciculus, the acoustic radiation, the inferior fronto-occipital fasciculus, and the optic radiation. In addition, U fibers originating at the level of Heschl's gyrus and heading toward the middle temporal gyrus were identified. CONCLUSIONS: This investigation of the HGFIA, a region where 5 fiber tracts intersect in a relationship with the primary auditory area, provides new insights into the subcortical organization of Wernicke's area. This information is valuable when a temporal surgical approach is planned, in order to assess the surgical risk related to language disturbances.


Asunto(s)
Corteza Auditiva/diagnóstico por imagen , Corteza Auditiva/fisiología , Vías Auditivas/diagnóstico por imagen , Vías Auditivas/fisiología , Percepción Auditiva/fisiología , Lenguaje , Adulto , Anciano , Anciano de 80 o más Años , Corteza Auditiva/anatomía & histología , Vías Auditivas/anatomía & histología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fibras Nerviosas/fisiología , Vías Nerviosas/diagnóstico por imagen , Vías Nerviosas/fisiología
9.
World Neurosurg ; 133: 55, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31562962

RESUMEN

Laughter has a major role in daily social interactions; consequently, its biologic bases have been previously studied. Nevertheless, its cerebral representation remains unclear. The most accepted hypothesis has postulated that laughter has 2 components: mirth, related to the temporal and frontal neocortical areas, and motor aspect, related to the limbic system and brainstem. Furthermore, in prior studies, laughter has been elicited during electric stimulation with depth electrodes in the supplementary motor area and the cingulum. This Video 1 reports resection of a right superior frontal gyrus diffuse astrocytoma (isocitrate dehydrogenase mutant, World Health Organization grade II) with awake intraoperative electric cortical and subcortical stimulation mapping. Diffusion tensor imaging (DTI) tractography, including all the tracts in relation to the tumor, was obtained preoperatively and postoperatively. Stimulation of the cingulum medially and inferiorly to the tumor elicited a patient's smile and laugh without mirth or merriment. Also, this point correlated with the reconstructed cingulum in the intraoperatively navigated DTI tractography. In conclusion, these findings support the anatomic subdivision of the laughter's mechanism and the role of the cingulum in its motor component. Furthermore, smiles and laughter could be useful functional landmarks to identify the cingulum during subcortical mapping. Although it remains unclear whether pursuing resection beyond this point would have caused permanent postoperative deficits, considering laughter's role in social interaction and other emotion-processing functions associated with the cingulum, in the future it could be potentially considered a functional limit of the resection of intrinsic tumors.


Asunto(s)
Astrocitoma/cirugía , Neoplasias Encefálicas/cirugía , Giro del Cíngulo/fisiopatología , Risa/fisiología , Sonrisa/fisiología , Astrocitoma/patología , Astrocitoma/fisiopatología , Mapeo Encefálico , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/fisiopatología , Estimulación Eléctrica , Lóbulo Frontal/patología , Lóbulo Frontal/fisiopatología , Lóbulo Frontal/cirugía , Humanos
10.
Front Oncol ; 9: 1036, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31649891

RESUMEN

The transmembrane protein ODZ1 has been associated with the invasive capacity of glioblastoma (GBM) cells through upregulation of RhoA/ROCK signaling, but the mechanisms triggering the ODZ1 pathway remain elusive. In addition, it is widely accepted that hypoxia is one of the main biological hallmarks of the GBM microenvironment and it is associated with treatment resistance and poor prognosis. Here we show that hypoxic tumor regions express higher levels of ODZ1 and that hypoxia induces ODZ1 expression in GBM cells by regulating the methylation status of the ODZ1 promoter. Hypoxia-induced upregulation of ODZ1 correlates with higher migration capacity of GBM cells that is drastically reduced by knocking down ODZ1. In vitro methylation of the promoter decreases its transactivation activity and we found a functionally active CpG site at the 3'end of the promoter. This site is hypermethylated in somatic neural cells and mainly hypomethylated in GBM cells. Mutagenesis of this CpG site reduces the promoter activity in response to hypoxia. Overall, we identify hypoxia as the first extracellular activator of ODZ1 expression and describe that hypoxia controls the levels of this migration-inducer, at least in part, by regulating the methylation status of the ODZ1 gene promoter.

11.
Neurosurg Focus ; 47(3): E10, 2019 09 01.
Artículo en Inglés | MEDLINE | ID: mdl-31473669

RESUMEN

Throughout history, many scientists have wondered about the reason for neural pathway decussation in the CNS resulting in contralateral forebrain organization. Hitherto, one of the most accepted theories is the one described by the renowned Spanish physician, Santiago Rámon y Cajal at the end of the 19th century. This Nobel Prize winner, among his many contributions to science, gave us the answer to this question: the key lies in the optic chiasm. Based on the fact that the ocular lenses invert the image formed in the retina, Cajal explained how the decussation of the fibers in the optic chiasm is necessary to obtain a continuous image of the outside in the brain. The crossing of the tactile and motor pathways occurred posteriorly as a compensatory mechanism to allow the cortical integration of the sensory, motor, and visual functions. This theory had a great influence on the scientific community of his time, and maintains its importance today, in which none of the theories formulated to date has managed to entirely refute Cajal's. In addition, the decussation of neural pathways plays a significant role in different diseases, especially in the recovery process after a hemispheric lesion and in several congenital pathologies. The advantages of cerebral lateralization have also recently been published, although the evolutionary connection between fiber decussation and cortical function lateralization remains a mystery to be solved. A better understanding of the molecular and genetic substrates of the midline crossing processes might result in significant clinical advances in brain plasticity and repair.


Asunto(s)
Lateralidad Funcional , Neuroanatomía/historia , Quiasma Óptico , Médicos/historia , Historia del Siglo XVII , Historia del Siglo XVIII , Historia del Siglo XIX , Humanos , Vías Nerviosas/anatomía & histología , Vías Nerviosas/fisiología , Plasticidad Neuronal/fisiología , Quiasma Óptico/anatomía & histología , Quiasma Óptico/fisiología , Prosencéfalo/anatomía & histología , Prosencéfalo/fisiología
12.
J Oncol ; 2019: 1740763, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31467533

RESUMEN

The invasive capacity of GBM is one of the key tumoral features associated with treatment resistance, recurrence, and poor overall survival. The molecular machinery underlying GBM invasiveness comprises an intricate network of signaling pathways and interactions with the extracellular matrix and host cells. Among them, PI3k/Akt, Wnt, Hedgehog, and NFkB play a crucial role in the cellular processes related to invasion. A better understanding of these pathways could potentially help in developing new therapeutic approaches with better outcomes. Nevertheless, despite significant advances made over the last decade on these molecular and cellular mechanisms, they have not been translated into the clinical practice. Moreover, targeting the infiltrative tumor and its significance regarding outcome is still a major clinical challenge. For instance, the pre- and intraoperative methods used to identify the infiltrative tumor are limited when trying to accurately define the tumor boundaries and the burden of tumor cells in the infiltrated parenchyma. Besides, the impact of treating the infiltrative tumor remains unclear. Here we aim to highlight the molecular and clinical hallmarks of invasion in GBM.

13.
World Neurosurg ; 128: e98-e106, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-30980970

RESUMEN

OBJECTIVE: The atrium is the most common location for masses in the lateral ventricle. However, access to this area is limited owing to its deep location and adjacent eloquent neurovascular structures, such as the choroidal arteries, perisylvian white matter (WM) tracts, and optic radiations. We investigated the feasibility and safety of an endoscopic approach to the atrium via the anterior middle temporal gyrus (MTG). METHODS: Radiological assessment of a minimally invasive surgical trajectory to the atrium was achieved in 10 patients. Surgical simulation to assess the feasibility of our endoscopic approach was performed on 24 cadaveric specimens using a transzygomatic corridor and temporal craniotomy. Preoperative computed tomography was performed to confirm the surgical trajectory using neuronavigation. Using Klinger's method, 5 hemispheres were dissected to assess the relationship of our approach to the WM tracts. RESULTS: The optimal entry angle to reach the atrium through the anterior MTG was related to the temporal horn in the axial plane and to the Sylvian fissure in the sagittal plane. Our entry point in the anterior MTG was 19 ± 1.92 mm from the temporal pole. The transparenchymal distance to atrium was 24.55 ± 4.3 mm. The WM dissections confirmed that our approach did not violate the optic radiations, uncinate fasciculus, inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, or superior longitudinal fasciculus. CONCLUSION: Our findings have confirmed the feasibility of an anterior endoscopic approach to the atrium through the anterior MTG, with preservation of the functional integrity of the eloquent cortex and WM tracts.


Asunto(s)
Ventrículos Laterales/cirugía , Neuroendoscopía/métodos , Cadáver , Imagen de Difusión Tensora , Estudios de Factibilidad , Humanos , Imagen por Resonancia Magnética , Procedimientos Quirúrgicos Mínimamente Invasivos , Neuronavegación , Lóbulo Temporal/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Vías Visuales/diagnóstico por imagen , Sustancia Blanca/diagnóstico por imagen
14.
Neurosurgery ; 85(4): E702-E713, 2019 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-30924504

RESUMEN

BACKGROUND: The postoperative outcomes and the predictors of seizure control are poorly studied for supratentorial cavernous angiomas (CA) within or close to the eloquent brain area. OBJECTIVE: To assess the predictors of preoperative seizure control, postoperative seizure control, and postoperative ability to work, and the safety of the surgery. METHODS: Multicenter international retrospective cohort analysis of adult patients benefitting from a functional-based surgical resection with intraoperative functional brain mapping for a supratentorial CA within or close to eloquent brain areas. RESULTS: A total of 109 patients (66.1% women; mean age 38.4 ± 12.5 yr), were studied. Age >38 yr (odds ratio [OR], 7.33; 95% confidence interval [CI], 1.53-35.19; P = .013) and time to surgery > 12 mo (OR, 18.21; 95% CI, 1.11-296.55; P = .042) are independent predictors of uncontrolled seizures at the time of surgery. Focal deficit (OR, 10.25; 95% CI, 3.16-33.28; P < .001) is an independent predictor of inability to work at the time of surgery. History of epileptic seizures at the time of surgery (OR, 7.61; 95% CI, 1.67-85.42; P = .003) and partial resection of the CA and/or of the hemosiderin rim (OR, 12.02; 95% CI, 3.01-48.13; P < .001) are independent predictors of uncontrolled seizures postoperatively. Inability to work at the time of surgery (OR, 19.54; 95% CI, 1.90-425.48; P = .050), Karnofsky Performance Status ≤ 70 (OR, 51.20; 95% CI, 1.20-2175.37; P = .039), uncontrolled seizures postoperatively (OR, 105.33; 95% CI, 4.32-2566.27; P = .004), and worsening of cognitive functions postoperatively (OR, 13.71; 95% CI, 1.06-176.66; P = .045) are independent predictors of inability to work postoperatively. CONCLUSION: The functional-based resection using intraoperative functional brain mapping allows safe resection of CA and the peripheral hemosiderin rim located within or close to eloquent brain areas.


Asunto(s)
Mapeo Encefálico/métodos , Neoplasias Encefálicas/diagnóstico por imagen , Hemangioma Cavernoso/diagnóstico por imagen , Estado de Ejecución de Karnofsky , Convulsiones/diagnóstico por imagen , Adulto , Mapeo Encefálico/tendencias , Neoplasias Encefálicas/cirugía , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Hemangioma Cavernoso/cirugía , Humanos , Internacionalidad , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Convulsiones/cirugía
15.
Artículo en Inglés, Español | MEDLINE | ID: mdl-28676437

RESUMEN

INTRODUCTION: At least 10% of patients with Obsessive-compulsive Disorder (OCD) are refractory to psychopharmacological treatment. The emergence of new technologies for the modulation of altered neuronal activity in Neurosurgery, deep brain stimulation (DBS), has enabled its use in severe and refractory OCD cases. The objective of this article is to review the current scientific evidence on the effectiveness and applicability of this technique to refractory OCD. METHOD: We systematically reviewed the literature to identify the main characteristics of deep brain stimulation, its use and applicability as treatment for obsessive-compulsive disorder. Therefore, we reviewed PubMed/Medline, Embase and PsycINFO databases, combining the key-words 'Deep brain stimulation', 'DBS' and 'Obsessive-compulsive disorder' 'OCS'. The articles were selected by two of the authors independently, based on the abstracts, and if they described any of the main characteristics of the therapy referring to OCD: applicability; mechanism of action; brain therapeutic targets; efficacy; side-effects; co-therapies. All the information was subsequently extracted and analysed. RESULTS: The critical analysis of the evidence shows that the use of DBS in treatment-resistant OCD is providing satisfactory results regarding efficacy, with assumable side-effects. However, there is insufficient evidence to support the use of any single brain target over another. Patient selection has to be done following analyses of risks/benefits, being advisable to individualize the decision of continuing with concomitant psychopharmacological and psychological treatments. CONCLUSIONS: The use of DBS is still considered to be in the field of research, although it is increasingly used in refractory-OCD, producing in the majority of studies significant improvements in symptomatology, and in functionality and quality of life. It is essential to implement random and controlled studies regarding its long-term efficacy, cost-risk analyses and cost/benefit.


Asunto(s)
Estimulación Encefálica Profunda , Trastorno Obsesivo Compulsivo/terapia , Terapia Combinada , Estimulación Encefálica Profunda/efectos adversos , Estimulación Encefálica Profunda/métodos , Humanos , Calidad de Vida , Medición de Riesgo , Resultado del Tratamiento
16.
Eur Radiol ; 29(4): 1968-1977, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30324390

RESUMEN

OBJECTIVES: We wished to determine whether tumor morphology descriptors obtained from pretreatment magnetic resonance images and clinical variables could predict survival for glioblastoma patients. METHODS: A cohort of 404 glioblastoma patients (311 discoveries and 93 validations) was used in the study. Pretreatment volumetric postcontrast T1-weighted magnetic resonance images were segmented to obtain the relevant morphological measures. Kaplan-Meier, Cox proportional hazards, correlations, and Harrell's concordance indexes (c-indexes) were used for the statistical analysis. RESULTS: A linear prognostic model based on the outstanding variables (age, contrast-enhanced (CE) rim width, and surface regularity) identified a group of patients with significantly better survival (p < 0.001, HR = 2.57) with high accuracy (discovery c-index = 0.74; validation c-index = 0.77). A similar model applied to totally resected patients was also able to predict survival (p < 0.001, HR = 3.43) with high predictive value (discovery c-index = 0.81; validation c-index = 0.92). Biopsied patients with better survival were well identified (p < 0.001, HR = 7.25) by a model including age and CE volume (c-index = 0.87). CONCLUSIONS: Simple linear models based on small sets of meaningful MRI-based pretreatment morphological features and age predicted survival of glioblastoma patients to a high degree of accuracy. The partition of the population using the extent of resection improved the prognostic value of those measures. KEY POINTS: • A combination of two MRI-based morphological features (CE rim width and surface regularity) and patients' age outperformed previous prognosis scores for glioblastoma. • Prognosis models for homogeneous surgical procedure groups led to even more accurate survival prediction based on Kaplan-Meier analysis and concordance indexes.


Asunto(s)
Neoplasias Encefálicas/patología , Glioblastoma/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Encefálicas/mortalidad , Femenino , Glioblastoma/mortalidad , Humanos , Estimación de Kaplan-Meier , Imagen por Resonancia Magnética/métodos , Imagen por Resonancia Magnética/mortalidad , Masculino , Persona de Mediana Edad , Pronóstico , Adulto Joven
17.
Oper Neurosurg (Hagerstown) ; 17(2): 182-192, 2019 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-30418653

RESUMEN

BACKGROUND: The ventral part of the precentral gyrus is considered one of the most eloquent areas. However, little is known about the white matter organization underlying this functional hub. OBJECTIVE: To analyze the subcortical anatomy underlying the ventral part of the precentral gyrus, ie, the ventral precentral fiber intersection area (VPFIA). METHODS: Eight human hemispheres from cadavers were dissected, and 8 healthy hemispheres were studied with diffusion tensor imaging tractography. The tracts that terminate at the ventral part of the precentral gyrus were isolated. In addition, 6 surgical cases with left side gliomas close to the VPFIA were operated awake with intraoperative electrical stimulation mapping. RESULTS: The connections within the VPFIA are anatomically organized along an anteroposterior axis: the pyramidal pathway terminates at the anterior bank of the precentral gyrus, the intermediate part is occupied by the long segment of the arcuate fasciculus, and the posterior bank is occupied by the anterior segment of the arcuate fasciculus. Stimulation of the VPFIA elicited speech arrest in all cases. CONCLUSION: The present study shows strong arguments to sustain that the fiber organization of the VPFIA is different from the classical descriptions, bringing new light for understanding the functional role of this area in language. The VPFIA is a critical neural epicenter within the perisylvian network that may represent the final common network for speech production, as it is strategically located between the termination of the dorsal stream and the motor output cortex that directly control speech muscles.


Asunto(s)
Lóbulo Frontal/anatomía & histología , Sustancia Blanca/anatomía & histología , Neoplasias Encefálicas/patología , Imagen de Difusión Tensora , Glioma/patología , Humanos , Vías Nerviosas/anatomía & histología
18.
Eur Radiol ; 29(5): 2729, 2019 05.
Artículo en Inglés | MEDLINE | ID: mdl-30547198

RESUMEN

The original version of this article, published on 15 October 2018, unfortunately contained a mistake. The following correction has therefore been made in the original: The name of Mariano Amo-Salas and the affiliation of Ismael Herruzo were presented incorrectly.

19.
Neurosurg Focus ; 45(VideoSuppl2): V8, 2018 10.
Artículo en Inglés | MEDLINE | ID: mdl-30269556

RESUMEN

Parietal lobe functions include somesthesia, language, calculation, self-motion perception, and visuospatial awareness. In this video, the authors show the intraoperative mapping of a left parietal lobe for a low-grade glioma resection. Standard sensory and language mapping were performed. Interestingly, by using the "Line Bisection" task, subcortical stimulation of the gyrus angularis was repeatedly associated with ipsilateral spatial neglect, often described in the right parietal lobe. In a similar way, subcortical stimulation in a more posterior point elicited episodes of vertigo, probably due to stimulation of the superior longitudinal fasciculus. Both findings were useful to define the functional limit of the resection. The video can be found here: https://youtu.be/qgGDRW_6u0A .


Asunto(s)
Mapeo Encefálico/métodos , Neoplasias Encefálicas/diagnóstico por imagen , Glioma/diagnóstico por imagen , Percepción de Movimiento/fisiología , Lóbulo Parietal/diagnóstico por imagen , Percepción Espacial/fisiología , Adulto , Neoplasias Encefálicas/cirugía , Glioma/cirugía , Humanos , Masculino , Lóbulo Parietal/cirugía
20.
Radiology ; 288(1): 218-225, 2018 07.
Artículo en Inglés | MEDLINE | ID: mdl-29924716

RESUMEN

Purpose To evaluate the prognostic and predictive value of surface-derived imaging biomarkers obtained from contrast material-enhanced volumetric T1-weighted pretreatment magnetic resonance (MR) imaging sequences in patients with glioblastoma multiforme. Materials and Methods A discovery cohort from five local institutions (165 patients; mean age, 62 years ± 12 [standard deviation]; 43% women and 57% men) and an independent validation cohort (51 patients; mean age, 60 years ± 12; 39% women and 61% men) from The Cancer Imaging Archive with volumetric T1-weighted pretreatment contrast-enhanced MR imaging sequences were included in the study. Clinical variables such as age, treatment, and survival were collected. After tumor segmentation and image processing, tumor surface regularity, measuring how much the tumor surface deviates from a sphere of the same volume, was obtained. Kaplan-Meier, Cox proportional hazards, correlations, and concordance indexes were used to compare variables and patient subgroups. Results Surface regularity was a powerful predictor of survival in the discovery (P = .005, hazard ratio [HR] = 1.61) and validation groups (P = .05, HR = 1.84). Multivariate analysis selected age and surface regularity as significant variables in a combined prognostic model (P < .001, HR = 3.05). The model achieved concordance indexes of 0.76 and 0.74 for the discovery and validation cohorts, respectively. Tumor surface regularity was a predictor of survival for patients who underwent complete resection (P = .01, HR = 1.90). Tumors with irregular surfaces did not benefit from total over subtotal resections (P = .57, HR = 1.17), but those with regular surfaces did (P = .004, HR = 2.07). Conclusion The surface regularity obtained from high-resolution contrast-enhanced pretreatment volumetric T1-weighted MR images is a predictor of survival in patients with glioblastoma. It may help in classifying patients for surgery.


Asunto(s)
Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/cirugía , Glioblastoma/diagnóstico por imagen , Glioblastoma/cirugía , Imagen por Resonancia Magnética/métodos , Encéfalo/diagnóstico por imagen , Encéfalo/cirugía , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Análisis de Supervivencia , Resultado del Tratamiento
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