Subcortical mapping and monitoring during insular tumor surgery

Kombos, Theodoros; Süss, Olaf; Vajkoczy, Peter

doi:10.3171/2009.8.focus09140

Cited by 59 publications

(48 citation statements)

References 64 publications

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“…25,52 The reference electrode was placed at Fzp. 10 Identical stimulation parameters as described above for DCS were applied (TOF stimuli, interstimulus interval 4 msec, pulse duration 500 µsec).…”

Section: Standard Mapping Using a Fingerstick Probementioning

confidence: 99%

“…22,25,36,37,39 We recently showed that a safe mapping corridor for mechanical injury of the CST exists between high and low MTs, and that both significant signal changes in motor evoked potential (MEP) monitoring and permanent motor deficits do not occur before very low MTs of < 1-2 mA. 45 We also provided data supporting the hypothesis that the interruptive and punctiform technique of mapping with insufficient spatial and temporal coverage of the surgical site may be a cause of motor deficits despite higher and apparently safe MTs (3-6 mA).…”

mentioning

confidence: 99%

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Continuous dynamic mapping of the corticospinal tract during surgery of motor eloquent brain tumors: evaluation of a new method

Raabe¹,

Beck²,

Schucht³

et al. 2014

JNS

164

127

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Object The authors developed a new mapping technique to overcome the temporal and spatial limitations of classic subcortical mapping of the corticospinal tract (CST). The feasibility and safety of continuous (0.4–2 Hz) and dynamic (at the site of and synchronized with tissue resection) subcortical motor mapping was evaluated. Methods The authors prospectively studied 69 patients who underwent tumor surgery adjacent to the CST (< 1 cm using diffusion tensor imaging and fiber tracking) with simultaneous subcortical monopolar motor mapping (short train, interstimulus interval 4 msec, pulse duration 500 μsec) and a new acoustic motor evoked potential alarm. Continuous (temporal coverage) and dynamic (spatial coverage) mapping was technically realized by integrating the mapping probe at the tip of a new suction device, with the concept that this device will be in contact with the tissue where the resection is performed. Motor function was assessed 1 day after surgery, at discharge, and at 3 months. Results All procedures were technically successful. There was a 1:1 correlation of motor thresholds for stimulation sites simultaneously mapped with the new suction mapping device and the classic fingerstick probe (24 patients, 74 stimulation points; r2 = 0.98, p < 0.001). The lowest individual motor thresholds were as follows: > 20 mA, 7 patients; 11–20 mA, 13 patients; 6–10 mA, 8 patients; 4–5 mA, 17 patients; and 1–3 mA, 24 patients. At 3 months, 2 patients (3%) had a persistent postoperative motor deficit, both of which were caused by a vascular injury. No patient had a permanent motor deficit caused by a mechanical injury of the CST. Conclusions Continuous dynamic mapping was found to be a feasible and ergonomic technique for localizing the exact site of the CST and distance to the motor fibers. The acoustic feedback and the ability to stimulate the tissue continuously and exactly at the site of tissue removal improves the accuracy of mapping, especially at low (< 5 mA) stimulation intensities. This new technique may increase the safety of motor eloquent tumor surgery.

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Section: Standard Mapping Using a Fingerstick Probementioning

confidence: 99%

mentioning

confidence: 99%

Continuous dynamic mapping of the corticospinal tract during surgery of motor eloquent brain tumors: evaluation of a new method

Raabe¹,

Beck²,

Schucht³

et al. 2014

JNS

164

127

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“…A safe window has been described for monopolar high-frequency TOF mapping between 20 mA and 3-5 mA 16,19,25,27,28,47 or even 1-3 mA. 38 An MT within this range excludes mechanical damage of the CST and permanent motor deficit, provided that the measured MT is indeed the lowest in the resection cavity, the surgeon does not continue resection after mapping, and no vascular injury has occurred.…”

Section: How Close To the Cst Can We Safely Resect Tumor Tissue?mentioning

confidence: 99%

“…31,37 An MT-to-distance relationship exists for subcortical monopolar TOF mapping of the CST. 16,19,27 As a rule of thumb, 1 mA of current corresponds to 1 mm remaining distance to the CST. 27,28 We previously demonstrated a safe window between high and low MTs for mechanical injury to the CST and showed that significant signal changes in MEP monitoring and permanent motor deficits do not occur above very low MTs of less than 1-2 mA.…”

mentioning

confidence: 99%

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Intraoperative monopolar mapping during 5-ALA–guided resections of glioblastomas adjacent to motor eloquent areas: evaluation of resection rates and neurological outcome

Schucht¹,

Seidel²,

Beck³

et al. 2014

FOC

102

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Object Resection of glioblastoma adjacent to motor cortex or subcortical motor pathways carries a high risk of both incomplete resection and postoperative motor deficits. Although the strategy of maximum safe resection is widely accepted, the rates of complete resection of enhancing tumor (CRET) and the exact causes for motor deficits (mechanical vs vascular) are not always known. The authors report the results of their concept of combining monopolar mapping and 5-aminolevulinic acid (5-ALA)–guided surgery in patients with glioblastoma adjacent to eloquent tissue. Methods The authors prospectively studied 72 consecutive patients who underwent 5-ALA–guided surgery for a glioblastoma adjacent to the corticospinal tract (CST; < 10 mm) with continuous dynamic monopolar motor mapping (short-train interstimulus interval 4.0 msec, pulse duration 500 μsec) coupled to an acoustic motor evoked potential (MEP) alarm. The extent of resection was determined based on early (< 48 hours) postoperative MRI findings. Motor function was assessed 1 day after surgery, at discharge, and at 3 months. Results Five patients were excluded because of nonadherence to protocol; thus, 67 patients were evaluated. The lowest motor threshold reached during individual surgery was as follows (motor threshold, number of patients): > 20 mA, n = 8; 11–20 mA, n = 13; 6–10 mA, n = 10; 4–5 mA, n = 13; and 1–3 mA, n = 23. Motor deterioration at postsurgical Day 1 and at discharge occurred in 30% (n = 20) and 10% (n = 7) of patients, respectively. At 3 months, 3 patients (4%) had a persisting postoperative motor deficit, 2 caused by vascular injury and 1 by mechanical injury. The rates of intra- and postoperative seizures were 1% and 0%, respectively. Complete resection of enhancing tumor was achieved in 73% of patients (49/67) despite proximity to the CST. Conclusions A rather high rate of CRET can be achieved in glioblastomas in motor eloquent areas via a combination of 5-ALA for tumor identification and intraoperative mapping for distinguishing between presumed and actual motor eloquent tissues. Continuous dynamic mapping was found to be a very ergonomic technique that localizes the motor tissue early and reliably.

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Surgical Tools and Techniques

Zentner¹

2020

Surgical Treatment of Epilepsies

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Subcortical mapping and monitoring during insular tumor surgery

Cited by 59 publications

References 64 publications

Continuous dynamic mapping of the corticospinal tract during surgery of motor eloquent brain tumors: evaluation of a new method

Continuous dynamic mapping of the corticospinal tract during surgery of motor eloquent brain tumors: evaluation of a new method

Intraoperative monopolar mapping during 5-ALA–guided resections of glioblastomas adjacent to motor eloquent areas: evaluation of resection rates and neurological outcome

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