Ponowne operacje chorych z glejakami wysoko zróżnicowanymi położonymi w okolicach elokwentnych mózgu lub w pobliżu okolic elokwentnych mózgu

Background and purpose Reoperations of patients with recurrent low-grade gliomas (LGG) are not always recommended due to a higher risk of neurological deficits when compared to initial surgery. The purpose of the present study was to evaluate surgical outcomes of patients operated on for recurrent LGG. Material and methods Sixteen patients who had surgery for recurrent LGG out of 68 LGG patients who underwent surgery at the Department of Neurosurgery in Sosnowiec, Poland between 2005 and 2011 were enrolled in the study. Results A large tumour volume prior to the initial surgery was the most significant parameter influencing LGG progression (96.6 cm3 vs. 47.9 cm3, p = 0.01). Increased incidence of epileptic seizures and decreased mental ability according to Karnofsky score were the most common symptoms associated with tumour recurrence. In the group of patients with malignant transformation, the relative cerebral blood volume (rCBV) was considerably increased (1.21 vs. 2.41, p < 0.01). No statistically significant difference was found in terms of the extent of resection between initial surgery and reoperation. Similarly, no significant difference was found in the number of patients with a permanent neurological deficit after initial surgery and reoperation. Conclusions Reoperations of the patients with recurrent LGG are not burdened with a higher risk of neurological sequelae when compared to initial surgery. The extent of resection during the surgery for LGG recurrence is comparable to initial surgery. The increase of rCBV seems to be a significant biomarker that indicates malignant transformation.Wstęp i cel pracy Ponowne operacje chorych z odrostem wysoko zróżnicowanego glejaka mózgu (WGM), zwłaszcza zlokalizowanego w obszarach elokwentnych mózgu, nie zawsze są zalecane. Powodem tego jest przekonanie, że ryzyko wystąpienia deficytów neurologicznych jest większe niż podczas pierwszej operacji. Celem pracy była ocena wyników leczenia chorych operowanych ponownie z powodu odrostu WGM. Materiał i metody W okresie od 2005 r. do 2011 r. w Klinice Neurochirurgii w Sosnowcu operowanych było 68 chorych z rozpoznaniem WGM. Do analizy włączono 16 chorych operowanych ponownie z powodu odrostu guza. Wyniki Jednym z najistotniejszych parametrów decydujących o progresji WGM była duża objętość guza przed pierwszą operacją (96,6 cm3 vs 47,9 cm3; p = 0,01). Głównym objawem odrostu guza była zwiększona częstość napadów padaczkowych oraz pogorszenie sprawności intelektualnej ocenianej w skali Karnofsky'ego. Wśród guzów, w przypadku których doszło do zezłośliwienia odrostu, obserwowano istotny wzrost względnej mózgowej objętości krwi (rCBV) (1,21 vs 2,41; p < 0,01). Nie stwierdzono statystycznie istotnej różnicy pod względem doszczętności resekcji między pierwszą i ponowną operacją. Nie stwierdzono statystycznie istotnej różnicy w liczbie chorych z utrwalonym deficytem neurologicznym po pierwszym zabiegu i po ponownej operacji. Wnioski Ponowne operacje chorych z odrostem WGM, również tych zlokalizowanych w obszarach elokwentnych mózgu, nie są obarczone większym ryzykiem powikłań neurologicznych w porównaniu z pierwszą operacją. Stopień resekcji osiągany przy operacjach odrostu WGM jest porównywalny z zakresem resekcji po pierwszej operacji. Istotnym parametrem wskazującym na zezłośliwienie procesu nowotworowego jest wzrost rCBV

Neurosurgical Options for Glioma

Glioma surgery has been the main component of glioma treatment for decades. The surgical approach changed over time, making it more complex and more challenging. With molecular knowledge and diagnostic improvement, this challenge became maximally safe resection of tumor, which resulted in prolonged overall survival, progression-free period, and a better quality of life. Today, the standard glioma treatment includes maximally safe resection, if feasible, administration of temozolomide, radiotherapy, and chemotherapy. Surgical resection is performed as subtotal resection, gross total resection, and supratotal resection. Subtotal resection is the resection where a part of tumor is left. Gross total resection is a complete removal of the magnetic resonance imaging (MRI) visible tumor tissue. Supratotal resection is performed as gross total resection with excising the MRI visible tumor tissue borders into the unaffected brain tissue. Before we make final decision on which type of resection should be performed, many factors have to be considered. The main question has to be answered: what the actual impact of resection on the progression of glioma is and what the functional risk of resection is

Surgical management of Glioma Grade 4: technical update from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®): a systematic review

Purpose: The extent of resection (EOR) is an independent prognostic factor for overall survival (OS) in adult patients with Glioma Grade 4 (GG4). The aim of the neuro-oncology section of the Italian Society of Neurosurgery (SINch®) was to provide a general overview of the current trends and technical tools to reach this goal. Methods: A systematic review was performed. The results were divided and ordered, by an expert team of surgeons, to assess the Class of Evidence (CE) and Strength of Recommendation (SR) of perioperative drugs management, imaging, surgery, intraoperative imaging, estimation of EOR, surgery at tumor progression and surgery in elderly patients. Results: A total of 352 studies were identified, including 299 retrospective studies and 53 reviews/meta-analysis. The use of Dexamethasone and the avoidance of prophylaxis with anti-seizure medications reached a CE I and SR A. A preoperative imaging standard protocol was defined with CE II and SR B and usefulness of an early postoperative MRI, with CE II and SR B. The EOR was defined the strongest independent risk factor for both OS and tumor recurrence with CE II and SR B. For intraoperative imaging only the use of 5-ALA reached a CE II and SR B. The estimation of EOR was established to be fundamental in planning postoperative adjuvant treatments with CE II and SR B and the stereotactic image-guided brain biopsy to be the procedure of choice when an extensive surgical resection is not feasible (CE II and SR B). Conclusions: A growing number of evidences evidence support the role of maximal safe resection as primary OS predictor in GG4 patients. The ongoing development of intraoperative techniques for a precise real-time identification of peritumoral functional pathways enables surgeons to maximize EOR minimizing the post-operative morbidity

Multiformni glioblastom lokaliziran u motornom korteksu: specifičnosti u odnosu na gliome niskog stupnja iste lokalizacije - analiza serije od šezdeset bolesnika

The verified presence of a glioblastoma multiforme (GBM ) tumor in the motor area of the brain, in a patient lacking preoperative neurological deficit, offers no certainty that the tumor can be radically removed without the possibility of causing postoperative motor deficit. We present a series of 60 patients hospitalized at the Clinical Department of Neurosurgery, Clinical Center of Serbia in Belgrade between October 2011 and February 2015, harboring tumors located within and in the vicinity of the motor zone of the brain. By using Karnofsky‘s index (KI), the pre- and postoperative conditions of the patients were evaluated. Regarding electrical stimulation of the motor cortex, significantly lower values of the electrical current intensity, frequency, and pulse wave duration (p<0.01) were needed for triggering motor response in case of GBM tumor compared to a slowly growing tumor (low-grade). Patients with low-grade gliomas (LGG) had statistically significantly higher KI values pre- and postoperatively than patients with GBM (p<0.01). Using electrical stimulation of the cortex, a higher grade of resection of LGG could be achieved as compared with the group presenting with GBM (c2=5.281; df=1; p<0.05). Our findings and review of the results reported by other authors underline the necessity of routine application of electrical stimulation of the cerebral cortex in order to identify the primary motor field (M1).Jasna prezentacija tumora mozga u području motorne zone kod bolesnika koji prijeoperacijski nisu imali slabost ekstremiteta nije jamstvo da se on može radikalno odstraniti bez poslijeoperacijskog neurološkog deficita. Prikazujemo niz od 60 ispitanika sa supratentorijalnim tumorima lokaliziranim u i oko motorne zone mozga, koji su hospitalizirani na Institutu za neurokirurgiju KCS u Beogradu u razdoblju od listopada 2011. do veljače 2015. godine. Procjena prije- i poslijeoperacijskog stanja bolesnika je vrednovana ljestvicom Karnofski indeksa (KI). Iz serije su isključeni bolesnici s recidivom tumora i bolesnici čiji je KI kod prijma bio manji od 70. Tijekom procedure elektrostimulacije motornog korteksa potrebne su značajno manje vrijednosti jačine struje, frekvencije i pulsnog vala (p<0,01) za izazivanje motornog odgovora u slučaju postojanja tipa tumora multiformnog glioblastoma (glioblastoma multiforme, GBM ) u odnosu na spororastuće gliome (niskog stupnja) mozga. Nađena je statistički značajna razlika u prije- i poslijeoperacijskim vrijednostima KI (F=48,856; df=1; p<0,01; Eta2=0,457), naime, bolesnici s gliomima niskog stupnja imali su statistički značajno veću vrijednost KI prije- i poslijeoperacijski u odnosu na vrijednosti KI kod skupine bolesnika s GBM (p<0,01). Uporabom elektrostimulacije korteksa postignut je veći stupanj radikalnosti kirurške resekcije glioma niskog stupnja u odnosu na skupinu bolesnika s GBM (c2=5,281; df=1; p<0,05). Kirurgija tumora lokaliziranih u motornom korteksu predstavlja izazov zbog pratećeg rizika od de novo nastanka motornog deficita. Naši rezultati kao i rezultati drugih autora pokazuju neophodnost rutinske primjene direktne elektrostimulacije moždane kore radi identifikacije primarnog motornog polja (M1)

Motor Evoked Potentials in Supratentorial Glioma Surgery

Primary brain tumors, that is gliomas, are frequently located close to or within functional motor areas and motor tracts and therefore represent a major neurosurgical challenge. Preservation of the patients’ motor functions, while achieving a maximum resection of tumor, can be only achieved by monitoring and locating motor areas and motor tracts intraoperatively. The intraoperative use of motor evoked potentials (MEPs) represents the current gold standard to do so. However, intraoperative MEP monitoring and mapping can be quite challenging and require a profound knowledge of the MEP technique, brain anatomy and physiology and anesthesia. In this chapter, a systematic review of PubMed listed literature on MEP monitoring and mapping in glioma surgery is presented. The benefits, limitations, technical pearls and pitfalls are discussed from the perspective of an experienced neurosurgical/neurophysiological team

Practical prognostic score for predicting the extent of resection and neurological outcome of gliomas in the sensorimotor area

OBJECTIVE: In this prospective study, we assessed the utility of a novel prognostic score (PS) in guiding the surgical strategy of patients with sensorimotor area gliomas. PATIENTS AND METHODS: Form December 2012 to April 2016, we collected data from patients diagnosed with brain gliomas in the sensorimotor area. All the patients had intraoperatively confirmed contiguity or continuity with sensorimotor cortical and subcortical structures. Several clinical and radiological factors were analyzed to generate a PS for each patient (range 1-8). The end-points included the extent of resection (EOR) and neurological outcome (modified Rankin Score; mRS). We assessed the predictive power of the PS using different analyses. Crosstabs analyses and Fisher's exact test (Fet) were used to evaluate the possible predictive parameters, and for the classification of positive or negative outcomes for the chosen proxies; the significance threshold was set at p<0.05. RESULTS: Using independent t-tests, we compared the mRS at different time points (pre, post, and at 6 months) for 2 subgroups from the total sample using a cut-off PS value of 4. For the EOR, a PS value of ≥5 was predictive of successful outcome, a value of 4 indicated an uncertain outcome, and a value of ≤3 predicted a worse outcome. CONCLUSIONS: This PS value can be easily used in clinical settings to help predict the functional outcome and EOR in sensorimotor area tumors. Integration with information from fMRI, DTI, and TMS, along with MRI spectroscopy could further enhance the value of this P