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J Neurol Surg A Cent Eur Neurosurg 2021; 82(04): 333-343
DOI: 10.1055/s-0040-1709729
Original Article

Pre- and Intraoperative Mapping for Tumors in the Primary Motor Cortex: Decision-Making Process in Surgical Resection

José Pedro Lavrador
1   Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
,
Prajwal Ghimire 
1   Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
,
Christian Brogna
1   Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
,
Luciano Furlanetti
1   Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
,
Sabina Patel
1   Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
,
Richard Gullan
1   Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
,
Keyoumars Ashkan
1   Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
,
Ranjeev Bhangoo
1   Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
,
Francesco Vergani
1   Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
› Author Affiliations Funding No funding was obtained for the study.
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Abstract

Background Lesions within the primary motor cortex (M1) and the corticospinal tract (CST) represent a significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centered treatment plan.

Methods Patients with lesions within the M1 and CST with preoperative cortical and subcortical mapping (navigated transcranial magnetic stimulation [nTMS] and tractography), intraoperative mapping, and intraoperative provisional histologic information (smear with and without 5-aminolevulinic acid [5-ALA]) were included. This independently acquired information was integrated in a decision-making process model to determine the intraoperative extent of resection.

Results A total of 10 patients (6 patients with metastatic precentral tumor; 1 patient with grade III and 2 patients with grade IV gliomas; 1 patient with precentral cavernoma) were included in the study. Most of the patients (60%) had a preoperative motor deficit. The nTMS documented M1 invasion in all cases, and in eight patients, the lesions were embedded within the CST. Overall, 70% of patients underwent gross total resection; 20% of patients underwent near-total resection of the lesions. In only one patient was no surgical resection possible after both preoperative and intraoperative mapping. Overall, 70% of patients remained stable postoperatively, and previous motor weakness improved in 20%.

Conclusion The independently acquired anatomical (anatomical MRI) and functional (nTMS and tractography) tests in patients with CST lesions provide a useful guide for resection. The inclusion of histologic information (smear with or without 5-ALA) further allows the surgical team to balance the potential functional risks within the global treatment plan. Therefore, the patient is kept at the center of the informed decision-making process.

Keywords

navigated transcranial magnetic stimulation - tractography - corticospinal tract and M1 lesions - intraoperative neuromonitoring - 5-aminolevulinic acid


Publication History

Received: 25 March 2019

Accepted: 30 July 2019

Article published online:
21 May 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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