Motor tract monitoring during insular glioma surgery

View More View Less
  • Department of Neurosurgery, University of Bonn, Germany
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

Surgery for insular gliomas incurs a considerable risk of motor morbidity. In this study the authors explore the validity and utility of continuous motor tract monitoring to detect and reverse impending motor impairment during insular glioma resection.

Methods

Motor evoked potentials (MEPs) were successfully monitored during 73 operations to remove insular gliomas. Seventy-two cases were assessable, and one patient died during the early postoperative course. In this prospective observational approach, MEP monitoring results were correlated with intraoperative events and perioperative clinical data.

Intraoperative recordings of MEPs remained stable in 40 cases (56%), indicating unimpaired motor outcome and allowing safe completion of the hazardous steps of the procedure. Deterioration of MEPs occurred in 32 cases (44%). This deterioration was reversible after intervention in 21 cases (29%), and there was no new motor deficit except for transient paresis in nine of these cases (13%). Surgical measures could not prevent irreversible MEP deterioration in 11 cases (15%). Transient mild or moderate paresis occurred if complete MEP loss was avoided. Irreversible MEP loss in seven cases (10%) occurred after completion of resection in four of these seven cases, and was consistently an indicator of both a stroke within the deep motor pathways and permanent paresis, which remained severely disabling in three patients (4%). In contrast, permanently severe paresis occurred in two (18%) of 11 cases without useful MEP monitoring.

Conclusions

Continuous MEP monitoring is a valid indicator of motor pathway function during insular glioma surgery. This method indicates that remote ischemia, in this study the leading cause of impending motor deterioration, helps to avert definitive stroke of the motor pathways and permanent new paresis in the majority of cases. The rate of permanently severe new deficit appears to be greater in unmonitored cases.

Abbreviations used in this paper:GBM = glioblastoma multiforme; LSA = lenticulostriate artery; MEP = motor evoked potential; MR = magnetic resonance; SSEP = somatosensory evoked potential; WHO = World Health Organization.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address reprint requests to: Georg Neuloh, M.D., Department of Neurosurgery, University of Bonn, D-53105 Bonn, Germany. email: neuloh@ukb.uni-bonn.de.
  • 1

    Berger MS: Functional mapping-guided resection of low-grade gliomas. Clin Neurosurg 42:437452, 1995

  • 2

    Berger MS, & Rostomily RC: Low grade gliomas: functional mapping resection strategies, extent of resection, and outcome. J Neurooncol 34:85101, 1997

    • Search Google Scholar
    • Export Citation
  • 3

    Berman JI, , Berger MS, , Mukherjee P, & Henry RG: Diffusion-tensor imaging-guided tracking of fibers of the pyramidal tract combined with intraoperative cortical stimulation mapping in patients with gliomas. J Neurosurg 101:6672, 2004

    • Search Google Scholar
    • Export Citation
  • 4

    Cedzich C, , Taniguchi M, , Schafer S, & Schramm J: Somatosensory evoked potential phase reversal and direct motor cortex stimulation during surgery in and around the central region. Neurosurgery 38:962970, 1996

    • Search Google Scholar
    • Export Citation
  • 5

    Deletis V: Intraoperative monitoring of the functional integrity of the motor pathways. Adv Neurol 63:201214, 1993

  • 6

    Deletis V, & Kothbauer K, Intraoperative neurophysiology of the corticospinal tract. Staalberg E, , Sharma HS, & Olsson Y: Spinal Cord Monitoring Wien, Springer, 1998. 421444

    • Search Google Scholar
    • Export Citation
  • 7

    Duffau H, , Bauchet L, , Lehericy S, & Capelle L: Functional compensation of the left dominant insula for language. Neuroreport 12:21592163, 2001

    • Search Google Scholar
    • Export Citation
  • 8

    Duffau H, & Capelle L: Preferential brain locations of low-grade gliomas. Cancer 100:26222626, 2004

  • 9

    Duffau H, , Capelle L, , Denvil D, , Sichez N, , Gatignol P, & Lopes M, : Functional recovery after surgical resection of low grade gliomas in eloquent brain: hypothesis of brain compensation. J Neurol Neurosurg Psychiatry 74:901907, 2003

    • Search Google Scholar
    • Export Citation
  • 10

    Duffau H, , Capelle L, , Lopes M, , Bitar A, , Sichez JP, & van Effenterre R: Medically intractable epilepsy from insular low-grade gliomas: improvement after an extended lesionectomy. Acta Neurochir (Wien) 144:563572, 2002

    • Search Google Scholar
    • Export Citation
  • 11

    Duffau H, , Capelle L, , Lopes M, , Faillot T, , Sichez JP, & Fohanno D: The insular lobe: physiopathological and surgical considerations. Neurosurgery 47:801811, 2000

    • Search Google Scholar
    • Export Citation
  • 12

    Duffau H, , Karachi C, , Gatignol P, & Capelle L: Transient Foix-Chavany-Marie syndrome after surgical resection of a right insulo-opercular low-grade glioma: case report. Neurosurgery 53:426431, 2003

    • Search Google Scholar
    • Export Citation
  • 13

    Duffau H, , Taillandier L, , Gatignol P, & Capelle L: The insular lobe and brain plasticity: lessons from tumor surgery. Clin Neurol Neurosurg 108:543548, 2006

    • Search Google Scholar
    • Export Citation
  • 14

    Ebel H, , Ebel M, , Schillinger G, , Klimek M, , Sobesky J, & Klug N: Surgery of intrinsic cerebral neoplasms in eloquent areas under local anesthesia. Minim Invasive Neurosurg 43:192196, 2000

    • Search Google Scholar
    • Export Citation
  • 15

    Ebeling U, & Kothbauer K: Circumscribed low grade astrocytomas in the dominant opercular and insular region: a pilot study. Acta Neurochir (Wien) 132:6674, 1995

    • Search Google Scholar
    • Export Citation
  • 16

    Guenot M, , Isnard J, & Sindou M: Surgical anatomy of the insula. Adv Tech Stand Neurosurg 29:265288, 2004

  • 17

    Hentschel SJ, & Lang FF: Surgical resection of intrinsic insular tumors. Neurosurgery 57:176183, 2005

  • 18

    Holland NR: Subcortical strokes from intracranial aneurysm surgery: implications for intraoperative neuromonitoring. J Clin Neurophysiol 15:439446, 1998

    • Search Google Scholar
    • Export Citation
  • 19

    Horiuchi K, , Suzuki K, , Sasaki T, , Matsumoto M, , Sakuma J, & Konno Y, : Intraoperative monitoring of blood flow insufficiency during surgery of middle cerebral artery aneurysms. J Neurosurg 103:275283, 2005

    • Search Google Scholar
    • Export Citation
  • 20

    Kombos T, , Suess O, , Ciklatekerlio O, & Brock M: Monitoring of intraoperative motor evoked potentials to increase the safety of surgery in and around the motor cortex. J Neurosurg 95:608614, 2001

    • Search Google Scholar
    • Export Citation
  • 21

    Kreth FW, , Schatz CR, , Faist M, & Ostertag CB: Tumors of the insula. J Neurosurg 86:910911, 1997. (Letter)

  • 22

    Krieger D, , Adams HP, , Albert F, , von Haken M, & Hacke W: Pure motor hemiparesis with stable somatosensory evoked potential monitoring during aneurysm surgery: case report. Neurosurgery 31:145150, 1992

    • Search Google Scholar
    • Export Citation
  • 23

    Lang FF, , Olansen NE, , DeMonte F, , Gokaslan ZL, , Holland EC, & Kalhorn C, : Surgical resection of intrinsic insular tumors: complication avoidance. J Neurosurg 95:638650, 2001

    • Search Google Scholar
    • Export Citation
  • 24

    Mehrkens JH, , Kreth FW, , Muacevic A, & Ostertag CB: Long term course of WHO grade II astrocytomas of the Insula of Reil after I-125 interstitial irradiation. J Neurol 251:14551464, 2004

    • Search Google Scholar
    • Export Citation
  • 25

    Mehrkens JH, , Noachtar S, , Winkler PA, & Kreth FW: In response to: H. Duffau, L. Capelle, M. Lopes, A. Bitar, J.P. Sichez, R. Van Effenterre: Medically intractable epilepsy from insular low-grade gliomas: improvement after extended lesionectomy. Acta Neurochir (2002) 144:563–573. Acta Neurochir (Wien) 145:8790, 2003

    • Search Google Scholar
    • Export Citation
  • 26

    Neuloh G, , Pechstein U, , Cedzich C, & Schramm J: Motor evoked potential monitoring with supratentorial surgery. Neurosurgery 54:10611062, 2004

    • Search Google Scholar
    • Export Citation
  • 27

    Neuloh G, & Schramm J: Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery. J Neurosurg 100:389399, 2004

    • Search Google Scholar
    • Export Citation
  • 28

    Neuloh G, & Schramm J: Motor evoked potential monitoring for the surgery of brain tumors and vascular malformations. Adv Tech Stand Neurosurg 29:171228, 2004

    • Search Google Scholar
    • Export Citation
  • 29

    Pechstein U, , Cedzich C, , Nadstawek J, & Schramm J: Transcranial high-frequency repetitive electrical stimulation for recording myogenic motor evoked potentials with the patient under general anesthesia. Neurosurgery 39:335344, 1996

    • Search Google Scholar
    • Export Citation
  • 30

    Quiñones-Hinojosa A, , Alam M, , Lyon R, , Yingling CD, & Lawton MT: Transcranial motor evoked potentials during basilar artery aneurysm surgery: technique application for 30 consecutive patients. Neurosurgery 54:916924, 2004

    • Search Google Scholar
    • Export Citation
  • 31

    Sala F, & Lanteri P: Brain surgery in motor areas: the invaluable assistance of intraoperative neurophysiological monitoring. J Neurosurg Sci 47:7988, 2003

    • Search Google Scholar
    • Export Citation
  • 32

    Schatz CR, , Kreth FW, , Faist M, , Warnke PC, , Volk B, & Ostertag CB: Interstitial 125-iodine radiosurgery of low-grade gliomas of the insula of Reil. Acta Neurochir (Wien) 130:8089, 1994

    • Search Google Scholar
    • Export Citation
  • 33

    Shankar A, & Rajshekhar V: Radiological and clinical outcome following stereotactic biopsy and radiotherapy for low-grade insular astrocytomas. Neurol India 51:503506, 2003

    • Search Google Scholar
    • Export Citation
  • 34

    Suzuki K, , Kodama N, , Sasaki T, , Matsumoto M, , Konno Y, & Sakuma J, : Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery. J Neurosurg 98:507514, 2003

    • Search Google Scholar
    • Export Citation
  • 35

    Szelenyi A, , Bueno de Camargo A, , Flamm E, & Deletis V: Neuro-physiological criteria for intraoperative prediction of pure motor hemiplegia during aneurysm surgery. Case report. J Neurosurg 99:575578, 2003

    • Search Google Scholar
    • Export Citation
  • 36

    Szelenyi A, , Kothbauer K, , de Camargo AB, , Langer D, , Flamm ES, & Deletis V: Motor evoked potential monitoring during cerebral aneurysm surgery: technical aspects and comparison of transcranial and direct cortical stimulation. Neurosurgery 57:331338, 2005

    • Search Google Scholar
    • Export Citation
  • 37

    Taniguchi M, , Cedzich C, & Schramm J: Modification of cortical stimulation for motor evoked potentials under general anesthesia: technical description. Neurosurgery 32:219226, 1993

    • Search Google Scholar
    • Export Citation
  • 38

    Ture U, , Yaşargil DC, , Al-Mefty O, & Yaşargil MG: Topographic anatomy of the insular region. J Neurosurg 90:720733, 1999

  • 39

    Ture U, , Yaşargil MG, , Al-Mefty O, & Yaşargil DC: Arteries of the insula. J Neurosurg 92:676687, 2000

  • 40

    Van Roost D, , Thees C, , Brenke C, , Oppel F, , Winkler PA, & Schramm J: Pseudohypoxic brain swelling: a newly defined complication after uneventful brain surgery, probably related to suction drainage. Neurosurgery 53:13151327, 2003

    • Search Google Scholar
    • Export Citation
  • 41

    Vanaclocha V, , Saiz-Sapena N, & Garcia-Casasola C: Surgical treatment of insular gliomas. Acta Neurochir (Wien) 139:11261134, 1997

  • 42

    Varnavas GG, & Grand W: The insular cortex: morphological and vascular anatomic characteristics. Neurosurgery 44:127138, 1999

  • 43

    Yaşargil DC: Microneurosurgery 4A:Stuttgart, Thieme, 1994

  • 44

    Yaşargil MG, & Reeves JD: Tumours of the limbic and paralimbic system. Acta Neurochir (Wien) 116:147149, 1992

  • 45

    Zentner J, , Meyer B, , Stangl A, & Schramm J: Intrinsic tumors of the insula: a prospective surgical study of 30 patients. J Neurosurg 85:263271, 1996

    • Search Google Scholar
    • Export Citation
  • 46

    Zhou HH, & Kelly PJ: Transcranial electrical motor evoked potential monitoring for brain tumor resection. Neurosurgery 48:10751081, 2001

    • Search Google Scholar
    • Export Citation

Metrics