Giovanni Muscas1, Simone Orlandini2, Camilla Bonaudo2, Maddalena Dardo2, Alice Esposito2, Luca Campagnaro2, Riccardo Carrai3, Enrico Fainardi4, Pietro Ciccarino5, Alessandro Della Puppa2. 1. Neurosurgery Clinic, Academic Neurosurgery, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Largo Palagi 1, 50139, Florence, Italy. muscasgi@aou-careggi.toscana.it. 2. Neurosurgery Clinic, Academic Neurosurgery, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Largo Palagi 1, 50139, Florence, Italy. 3. Neurophysiopathology Unit, Careggi University Hospital, Florence, Italy. 4. Neuroradiology Unit, Careggi University Hospital and University of Florence, Florence, Italy. 5. Neurosurgery Unit, Department of Neuroscience, Padova University Hospital, Padua, Italy.
Abstract
BACKGROUND: 5-Aminolevulinic acid (5-ALA) fluorescence can maximize perirolandic glioblastoma (GBM) resection with low rates of postoperative sequelae. Our purpose was to present the outcomes of our experience and compare them with other literature reports to investigate the potential influence of different intraoperative monitoring strategies and to evaluate the role of intraoperative data on neurological and radiological outcomes in our series. METHODS: We retrospectively analyzed our prospectively collected database of GBM involving the motor pathways. Each patient underwent tumor exeresis with intraoperative 5-ALA fluorescence visualization. Our monitoring strategy was based on direct stimulation (DS), combined with cortical or transcranial MEPs. The radiological outcome was evaluated with CRET vs. residual tumor, and the neurological outcome as improved, unchanged, or worsened. We also performed a literature review to compare our results with state-of-the-art on the subject. RESULTS: Sixty-five patients were included. CRET was 63.1%, permanent postoperative impairment was 1.5%, and DS's lowest motor threshold was 5 mA. In the literature, CRET was 25-73%, permanent postoperative impairment 3-16%, and DS lowest motor threshold was 1-3 mA. Our monitoring strategy identified a motor pathway in 60% of cases in faint fluorescent tissue, and its location in bright/faint fluorescence was predictive of CRET (p < 0.001). A preoperative motor deficit was associated with a worse clinical outcome (p < 0.001). Resection of bright fluorescent tissue was stopped in 26%, and fluorescence type of residual tumor was associated with higher CRET grades (p < 0.001). CONCLUSIONS: Based on the data presented and the current literature, distinct monitoring strategies can achieve different onco-functional outcomes in 5-ALA-guided resection of a glioblastoma (GBM) motor pathway. Intraoperatively, functional and fluorescence data close to a bright/vague interface could be helpful to predict onco-functional outcomes.
BACKGROUND: 5-Aminolevulinic acid (5-ALA) fluorescence can maximize perirolandic glioblastoma (GBM) resection with low rates of postoperative sequelae. Our purpose was to present the outcomes of our experience and compare them with other literature reports to investigate the potential influence of different intraoperative monitoring strategies and to evaluate the role of intraoperative data on neurological and radiological outcomes in our series. METHODS: We retrospectively analyzed our prospectively collected database of GBM involving the motor pathways. Each patient underwent tumor exeresis with intraoperative 5-ALA fluorescence visualization. Our monitoring strategy was based on direct stimulation (DS), combined with cortical or transcranial MEPs. The radiological outcome was evaluated with CRET vs. residual tumor, and the neurological outcome as improved, unchanged, or worsened. We also performed a literature review to compare our results with state-of-the-art on the subject. RESULTS: Sixty-five patients were included. CRET was 63.1%, permanent postoperative impairment was 1.5%, and DS's lowest motor threshold was 5 mA. In the literature, CRET was 25-73%, permanent postoperative impairment 3-16%, and DS lowest motor threshold was 1-3 mA. Our monitoring strategy identified a motor pathway in 60% of cases in faint fluorescent tissue, and its location in bright/faint fluorescence was predictive of CRET (p < 0.001). A preoperative motor deficit was associated with a worse clinical outcome (p < 0.001). Resection of bright fluorescent tissue was stopped in 26%, and fluorescence type of residual tumor was associated with higher CRET grades (p < 0.001). CONCLUSIONS: Based on the data presented and the current literature, distinct monitoring strategies can achieve different onco-functional outcomes in 5-ALA-guided resection of a glioblastoma (GBM) motor pathway. Intraoperatively, functional and fluorescence data close to a bright/vague interface could be helpful to predict onco-functional outcomes.
Authors: Elke Hattingen; Julian Rathert; Alina Jurcoane; Stefan Weidauer; Andrea Szelényi; George Ogrezeanu; Volker Seifert; Friedhelm E Zanella; Thomas Gasser Journal: Neurosurg Rev Date: 2009-05-13 Impact factor: 3.042
Authors: Seunggu J Han; Ramin A Morshed; Irene Troncon; Kesshi M Jordan; Roland G Henry; Shawn L Hervey-Jumper; Mitchel S Berger Journal: J Neurosurg Date: 2018-08-17 Impact factor: 5.115