Raffa Giovanni, Marzano Giuseppina, Curcio Antonello, Espahbodinea Shervin, Germanò Antonino, Angileri Filippo Flavio
1Division of Neurosurgery, BIOMORF Department, University of Messina; and.
2Division of Neurosurgery, A.O.U. Policlinico "G. Martino," Messina, Italy.
Neurosurg Focus. 2022 Dec;53(6):E3. doi: 10.3171/2022.9.FOCUS22415.
OBJECTIVE: Awake surgery represents the gold standard for resection of brain tumors close to the language network. However, in some cases patients may be considered not eligible for awake craniotomy. In these cases, a personalized brain mapping of the language network may be achieved by navigated transcranial magnetic stimulation (nTMS), which can guide resection in patients under general anesthesia. Here the authors describe their tailored nTMS-based strategy and analyze its impact on the extent of tumor resection (EOR) and language outcome in a series of patients not eligible for awake surgery. METHODS: The authors reviewed data from all patients harboring a brain tumor in or close to the language network who were considered not eligible for awake surgery and were operated on during asleep surgery between January 2017 and July 2022, under the intraoperative guidance of nTMS data. The authors analyzed the effectiveness of nTMS-based mapping data in relation to 1) the ability of the nTMS-based mapping to stratify patients according to surgical risks, 2) the occurrence of postoperative language deficits, and 3) the EOR. RESULTS: A total of 176 patients underwent preoperative nTMS cortical language mapping and nTMS-based tractography of language fascicles. According to the nTMS-based mapping, tumors in 115 patients (65.3%) were identified as true-eloquent tumors because of a close spatial relationship with the language network. Conversely, tumors in 61 patients (34.7%) for which the nTMS mapping disclosed a location at a safer distance from the network were identified as false-eloquent tumors. At 3 months postsurgery, a permanent language deficit was present in 13 patients (7.3%). In particular, a permanent deficit was observed in 12 of 115 patients (10.4%) with true-eloquent tumors and in 1 of 61 patients (1.6%) with false-eloquent lesions. With nTMS-based mapping, neurosurgeons were able to distinguish true-eloquent from false-eloquent tumors in a significant number of cases based on the occurrence of deficits at discharge (p < 0.0008) and after 3 months from surgery (OR 6.99, p = 0.03). Gross-total resection was achieved in 80.1% of patients overall and in 69.5% of patients with true-eloquent lesions and 100% of patients with false-eloquent tumors. CONCLUSIONS: nTMS-based mapping allows for reliable preoperative mapping of the language network that may be used to stratify patients according to surgical risks. nTMS-guided asleep surgery should be considered a good alternative for personalized preoperative brain mapping of the language network that may increase the possibility of safe and effective resection of brain tumors in the dominant hemisphere whenever awake mapping is not feasible.
目的：清醒手术是切除靠近语言网络的脑肿瘤的金标准。然而，在某些情况下，患者可能被认为不适合进行清醒开颅手术。在这些情况下，可以通过导航经颅磁刺激（nTMS）实现语言网络的个性化脑图谱绘制，这可以在全身麻醉的患者中指导手术切除。在此，作者描述了他们基于nTMS的定制策略，并分析了其对一系列不适合清醒手术的患者的肿瘤切除范围（EOR）和语言功能结果的影响。 方法：作者回顾了2017年1月至2022年7月期间所有在语言网络内或靠近语言网络且被认为不适合清醒手术并在睡眠手术期间接受手术的脑肿瘤患者的数据，手术在nTMS数据的术中指导下进行。作者分析了基于nTMS的图谱数据在以下方面的有效性：1）基于nTMS的图谱将患者根据手术风险进行分层的能力；2）术后语言功能障碍的发生情况；3）EOR。 结果：共有176例患者接受了术前nTMS皮质语言图谱绘制和基于nTMS的语言束纤维束成像。根据基于nTMS的图谱，115例患者（65.3%）的肿瘤因与语言网络空间关系密切而被确定为真正明确的肿瘤。相反，61例患者（34.7%）的肿瘤经nTMS图谱显示与语言网络的距离较安全，被确定为假明确肿瘤。术后3个月时，13例患者（7.3%）存在永久性语言功能障碍。具体而言，115例真正明确肿瘤患者中有12例（10.4%）出现永久性功能障碍，61例假明确病变患者中有1例（1.6%）出现永久性功能障碍。基于nTMS的图谱，神经外科医生能够在大量病例中根据出院时（p<0.0008）和术后3个月（OR 6.99，p=0.03）功能障碍的发生情况区分真正明确和假明确肿瘤。总体上80.1%的患者实现了全切除，真正明确病变的患者中这一比例为69.5%，假明确肿瘤的患者中这一比例为100%。 结论：基于nTMS的图谱绘制可实现可靠的术前语言网络图谱绘制，可用于根据手术风险对患者进行分层。当清醒图谱绘制不可行时，nTMS引导的睡眠手术应被视为语言网络个性化术前脑图谱绘制的良好替代方法，这可能会增加在优势半球安全有效地切除脑肿瘤的可能性。
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