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Multimodal Surgical Treatment of High-Grade Gliomas in the Motor Area: The Impact of the Combination of Navigated Transcranial Magnetic Stimulation and Fluorescein-Guided Resection.

Al's Comment:

 This study shows a way to increase the chances of a gross total resection and at the same time getting less neurologic damage, by combining methods that were previously used by themselves! Great work!


Posted on: 01/21/2020

World Neurosurg. 2019 Aug;128:e378-e390. doi: 10.1016/j.wneu.2019.04.158. Epub 2019 Apr 25.
Multimodal Surgical Treatment of High-Grade Gliomas in the Motor Area: The Impact of the Combination of Navigated Transcranial Magnetic Stimulation and Fluorescein-Guided Resection.
Raffa G1, Scibilia A2, Conti A3, Cardali SM3, Rizzo V4, Terranova C4, Quattropani MC5, Marzano G5, Ricciardo G3, Vinci SL6, Germanò A3.
 
Author information:
1. Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy. Electronic address: giovanni.raffa@unime.it.
2. Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy; Division of Neurosurgery, University of Strasbourg, Strasbourg, France.
3. Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy.
4. Division of Neurology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
5. Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
6. Division of Neuroradiology, BIOMORF Department, University of Messina, Messina, Italy.
Abstract
BACKGROUND:
 
Fluorescein-guided surgery of high-grade gliomas (HGGs) increases the extent of tumor resection but its efficacy has been questioned, especially for tumors located close to functional networks. In these cases, navigated transcranial magnetic stimulation (nTMS) may be used to plan and guide a safe resection. The aim of this study was to assess the impact of these techniques combined with intraoperative neurophysiologic mapping (IONM) to achieve the maximal safe resection of tumors located in the motor area.
METHODS:
 
We collected data of patients operated using a multimodal combination of sodium fluorescein-guided resection, nTMS motor planning, and IONM for HGGs in the motor area. The nTMS planning accuracy, extent of resection, and postoperative motor and functional status were compared with a matched control group of patients with HGG operated on only by IONM-guided resection.
RESULTS:
 
Forty-one patients treated by multimodal approach (group A) and 41 controls (group B) were included. The nTMS-based planning reliably identified the tumor/motor pathway spatial relationship (accuracy, 92.68%). We obtained in group A versus controls a higher gross total resection rate (73.17% vs. 51.22%; P = 0.04), and a reduction of cases with new permanent motor deficits (9.75% vs. 29.27%; P = 0.04) or Karnofsky Performance Status worsening (12.19% vs. 31.71%; P = 0.03).
CONCLUSIONS:
 
This study supports the role of the combination of sodium fluorescein-guided resection and nTMS-based planning for surgery of HGGs close to the motor pathway. This multimodal approach in combination with IONM may lead to customized preoperative planning, increased extent of resection, and improved functional outcome, compared with standard IONM-guided surgery.
 
Copyright © 2019 Elsevier Inc. All rights reserved.
PMID: 31029822 [Indexed for MEDLINE]
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