Contribution of combined intraoperative electrophysiological investigation with 3-T intraoperative MRI for awake cerebral glioma surgery: comprehensive review of the clinical implications and radiological outcomes

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>This study aimed to assess the clinical efficiency of combined awake craniotomy with 3-T intraoperative MRI (iMRI)–guided resection of gliomas adjacent to eloquent cortex performed at a single center. It also sought to explore the contribution of iMRI to surgeons' learning process of maximal safe resection of gliomas.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>All patients who underwent an awake craniotomy and iMRI for resection of eloquent area glioma during the 53 months between January 2011 and June 2015 were included. The cases were analyzed for short- and long-term neurological outcome, progression-free survival (PFS), overall survival (OS), and extent of resection (EOR). The learning curve was assessed after dividing the cohort into Group A (first 27 months) and Group B (last 26 months). Statistical analyses included univariate logistic regression analysis on clinical and radiological variables. Kaplan-Meier and Cox regression models were used for further analysis of OS and PFS. A p value &lt; 0.05 was considered statistically significant.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>One hundred six patients were included in the study. Over an average follow-up period of 24.8 months, short- and long-term worsening of the neurological function was noted in 48 (46.2%) and 9 (8.7%) cases, respectively. The median and mean EOR were 100% and 92%, respectively, and complete radiographic resection was achieved in 64 (60.4%) patients. The rate of gross-total resection (GTR) in the patients with low-grade glioma (89.06% ± 19.6%) was significantly lower than that in patients with high-grade glioma (96.4% ± 9.1%) (p = 0.026). Thirty (28.3%) patients underwent further resection after initial iMRI scanning, with a 10.1% increase of the mean EOR. Multivariate Cox proportional hazards modeling demonstrated that the final EOR was a significant predictor of PFS (HR 0.225, 95% CI 0.070–0.723, p = 0.012). For patients with high-grade glioma, the GTR (p = 0.033), the presence of short-term motor deficit (p = 0.027), and the WHO grade (p = 0.005) were independent prognostic factors of OS. Performing further resection after the iMRI (p = 0.083) and achieving GTR (p = 0.05) demonstrated a PFS benefit trend for the patients affected by a low-grade glioma. Over time, the rate of performing further resection after an iMRI decreased by 26.1% (p = 0.005). A nonsignificant decrease in the rate of short-term (p = 0.101) and long-term (p = 0.132) neurological deficits was equally noted.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Combined awake craniotomy and iMRI is a safe and efficient technique allowing maximal safe resection of eloquent area gliomas with possible subsequent OS and PFS benefits. Although there is a learning curve for applying this technique, it can also improve the surgeon's ability in eloquent glioma surgery.</jats:p></jats:sec>

Intraoperative Magnetic Resonance Imaging–Guided Glioma Resections in Awake or Asleep Settings and Feasibility in the Context of a Public Health System

“…We looked with interest at some pioneering papers about the feasibility of combining 2 among the most powerful aids available: the ioMRI (for morphology) and the awake surgery (for function) 18, 20, 31, 32, 33, 34, 35. We were particularly impressed by the recent series of Ghinda et al 35 . of 106 patients with gliomas in eloquent areas, operated on with awake intraoperative mapping and high-field (3T) ioMRI: they reported GTR rates of 89% and 96% for LGG and HGG, respectively.…”

Combined Brain Mapping and Compact Intraoperative MRI for Brain Tumor Resection

“…The largest series to date, published by Ghinda et al [41], demonstrated that the combined use of iMRI with mapping allowed for the safe increase in the extent of resection and suggested a survival benefit from maximal resection of both low-and high-grade gliomas. The majority of studies combining these 2 techniques have used 1.5-T magnets [3,[42][43][44][45][46].…”

Tep1 Regulates Yki Activity in Neural Stem Cells in Drosophila Glioma Model

“…Glioblastoma multiforme (GBM) is a primary malignant adult brain tumor with extremely poor prognosis (Ostrom et al, 2017). Current therapies such as surgery and chemo-and/or radiotherapy only provide palliative care resulting in median GBM patient survival of about 14-15 months (Ghinda et al, 2016). Using patient samples, efforts to identify underlying genetic aberrations that lead to GBM have resulted in the identification of genomic amplification of EGFR, PDGFRA, and FGFR; along with activating mutations and overexpression of Receptor Tyrosine Kinases (RTKs) and genes of the PI3K pathway.…”