Impact of intraoperative stimulation mapping on high-grade glioma surgery outcome: a meta-analysis

Abstract

BackgroundIntraoperative stimulation mapping (ISM) using electrocortical mapping (awake craniotomy, AC) or evoked potentials has become a solid option for the resection of supratentorial low-grade gliomas in eloquent areas, but not as much for high-grade gliomas. This meta-analysis aims to determine whether the surgeon, when using ISM and AC, is able to achieve improved overall survival and decreased neurological morbidity in patients with high-grade glioma as compared to resection under general anesthesia (GA).MethodsA systematic search was performed to identify relevant studies. Adult patients were included who had undergone craniotomy for high-grade glioma (WHO grade III or IV) using ISM (among which AC) or GA. Primary outcomes were rate of postoperative complications, overall postoperative survival, and percentage of gross total resections (GTR). Secondary outcomes were extent of resection and percentage of eloquent areas.ResultsReview of 2049 articles led to the inclusion of 53 studies in the analysis, including 9102 patients. The overall postoperative median survival in the AC group was significantly longer (16.87 versus 12.04 months; p < 0.001) and the postoperative complication rate was significantly lower (0.13 versus 0.21; p < 0.001). Mean percentage of GTR was significantly higher in the ISM group (79.1% versus 47.7%, p < 0.0001). Extent of resection and preoperative patient KPS were indicated as prognostic factors, whereas patient KPS and involvement of eloquent areas were identified as predictive factors.ConclusionsThese findings suggest that surgeons using ISM and AC during their resections of high-grade glioma in eloquent areas experienced better surgical outcomes: a significantly longer overall postoperative survival, a lower rate of postoperative complications, and a higher percentage of GTR.Electronic supplementary materialThe online version of this article (10.1007/s00701-018-3732-4) contains supplementary material, which is available to authorized users.

Impact of preoperative Karnofsky Performance Scale (KPS) and American Society of Anesthesiologists (ASA) scores on perioperative complications in patients with recurrent glioma undergoing repeated operation

“…In the present study, we assessed the impact of preoperative KPS and ASA scores on perioperative complications in patients undergoing repeated glioma resection. In contrast with the results reported in the literature for patients with newly diagnosed glioma undergoing primary craniotomy [4,[9][10][11], we did not find any significant correlation between low KPS or high ASA score and perioperative complications, including severe complications (death within 30 days or unplanned reoperation within 7 days), CNS complications, and total complications.…”

“…The surgical pathway for the repeated operation was usually primary skin and skull incisions and a similar or same pathway to decrease damage, which was one of the risk factors for wound-related complications, including CSF leakage and intracranial infections [2]. In the literature, low KPS is one of the established risk factors for perioperative complications in patients with glioma who undergo craniotomy [4,[9][10][11]. However, most of these studies focused on primary gliomas or gliomas without clarification of recurrence status.…”

“…KPS is one of the widely studied risk factors for predicting mortality and morbidity in patients with glioma [4][5][6][7][8]. Increased postsurgical complications in patients with glioma with low KPS have been reported by several groups [4,[9][10][11]. In addition, the American Society of Anesthesiologists (ASA) score, which is a widely used clinical preoperative physical status classification, is a well-known risk factor for preoperative mortality and complications after craniotomy in patients with various brain tumors [12][13][14][15][16][17][18].…”

The SAFE-trial: Safe surgery for glioblastoma multiforme: Awake craniotomy versus surgery under general anesthesia. Study protocol for a multicenter prospective randomized controlled trial

“…Only very few studies have reported the use of AC in GBM [26,27]. We recently showed in a meta-analysis and a retrospective matched case-control study that patients with GBM operated with AC had less early postoperative neurological morbidity and significantly higher percentage of total resection [28,29]. AC could thus be of high value in the surgical treatment of GBM in eloquent areas.…”

Functional Ultrasound (fUS) During Awake Brain Surgery: The Clinical Potential of Intra-Operative Functional and Vascular Brain Mapping

“…The widespread introduction of awake craniotomy surgery with ESM has greatly improved the intra-operative identification of eloquent brain areas adjacent to tumors. Intra-operative use of ESM to remove low- (De Witt Hamer et al, 2012) or HGGs (Gerritsen et al, 2019) has been associated with fewer post-operative complications and higher percentages of GTRs. However, ESM also presents with a range of its own inherent limitations, including lack of (sulcus-)depth resolution (Imbault et al, 2017), functional over-estimation due to current leakage (Ritaccio et al, 2018), lack of standardization of stimulation protocols (Pouratian et al, 2004;Ritaccio et al, 2018) and the risk of eliciting epileptic seizures (Su and Ojemann, 2013;Ritaccio et al, 2018).…”