Intraoperative subcortical electrical mapping of optic radiations in awake surgery for glioma involving visual pathways

Clinical article

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Object

Preservation of the visual field in glioma surgery, especially avoidance of hemianopia, is crucial for patients' quality of life, particularly for driving. Recent studies used tractography or cortical occipital stimulation to try to avoid visual deficit. However, optic radiations have not been directly mapped intraoperatively. The authors present, for the first time to their knowledge, a consecutive series of awake surgeries for cerebral glioma with intrasurgical identification and preservation of visual pathways using subcortical electrical mapping.

Methods

Fourteen patients underwent awake resection of a glioma (1 WHO Grade I, 11 WHO Grade II, 2 WHO Grade III) involving the optic radiations. The patients had no presurgical visual field deficit. Intraoperatively, a picture-naming task was used, with presentation of 2 objects situated diagonally on a screen divided into 4 quadrants. An image was presented in the quadrant to be saved and another image was presented in the opposite quadrant. Direct subcortical electrostimulation was repeatedly performed without the patient's knowledge, until optic radiations were identified (transient visual disturbances). All patients underwent an objective visual field assessment 3 months after surgery.

Results

All patients experienced visual symptoms during stimulation. These disturbances led the authors to stop the tumor resection at that level. Postoperatively, only 1 patient had a permanent hemianopia, despite an expected quadrantanopia in 12 cases. The mean extent of resection was 93.6% (range 85%–100%).

Conclusions

Online identification of optic radiations by direct subcortical electrostimulation is a reliable and effective method to avoid permanent hemianopia in surgery for gliomas involving visual pathways.

Article Information

Address correspondence to: Hugues Duffau, M.D., Ph.D., Department of Neurosurgery, Gui de Chauliac Hospital, CHU Montpellier, 80 Avenue Augustin Fliche, 34295 Montpellier, France. email: h-duffau@chu-montpellier.fr.

Please include this information when citing this paper: published online July 13, 2012; DOI: 10.3171/2012.6.JNS111981.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 6, involving a 33-year-old right-handed man who underwent resection of a WHO Grade II oligodendroglioma in the right temporooccipitoparietal junction and had left inferior quadrantanopia postoperatively. a: Intraoperative view before resection. The letter Tags A–G mark the tumor boundaries identified using ultrasonography. The number tags correspond to eloquent sites: Tag 1, within the ventral premotor cortex, and Tag 2, within the retrocentral part of the rolandic operculum, both eliciting speech arrest; Tags 3, 4, and 6, within the primary somatosensory cortex, eliciting left superior lip, left superior limb thumb, and left hand dysesthesia, respectively; Tag 5, within the primary motor cortex of the left hand, eliciting left finger movement; Tag 11, within the anterosuperior part of the supramarginal gyrus, and more posteriorly, Tag 12, within the junction between the middle temporal gyrus and angular gyrus, both eliciting transient spatial cognition impairment during electrical stimulation. b: Preoperative axial FLAIR-weighted and coronal T1-weighted enhanced MR images showing a right-hemisphere diffuse glioma (arrows) involving the temporooccipitoparietal junction, in a patient without any visual defect. c: Intraoperative view after resection. The subcortical mapping allowed the detection of thalamocortical fibers, with induction of dysesthesia of the left hemibody (Tags 48, 49, and 50). More ventrally and lateral to the ventricle, stimulation elicited transient left phosphenes and blurred vision: Tag 46 marks the subcortical optic radiations. d: Postoperative axial FLAIR-weighted and sagittal T1-weighted enhanced MR images obtained 3 months after the surgery, showing the ventrolateral deep edge of the cavity—that is, at the level of the direct bundle of the optic radiations, which were identified and then preserved using intraoperative stimulation (arrow). e: The 4-screen naming task used with the goal of preserving the left upper quadrant. The sacrificed left inferior quadrant is here symbolized by a gray quadrant, and visual symptoms (phosphenes, blurred vision) by black stars. f: Postoperative Octopus perimetric evaluation performed 3 months after surgery, showing a left inferior quadrantanopia. A = anterior; D = dorsal; P = posterior; V = ventral.

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    Case 14, involving a 47-year-old right-handed woman who underwent resection of a WHO Grade II oligodendroglioma in the left temporooccipital junction and had right hemianopia postoperatively. a: Intraoperative view before resection. The letter Tags A and B mark the tumor boundaries identified using ultrasonography. The number tags correspond to eloquent sites: Tag 1, within the posterior part of the superior temporal gyrus, and Tag 3, within the junction between the posterior part of the middle temporal gyrus and the occipital lobe, eliciting anomia and semantic paraphasia, respectively; Tag 2, within the posterior part of the inferior temporal gyrus, eliciting transient pure alexia during stimulation. b: Preoperative axial FLAIR-weighted MR image, showing a left diffuse glioma (arrows) involving the temporooccipital junction in a patient without any visual defect. c: Intraoperative view after resection. The subcortical mapping allowed the detection of the inferior frontooccipital fasciculus (Tag 42, eliciting reproducible transient complete anomia during stimulation). Immediately above, laterally and posteriorly, stimulation elicited transient right phosphenes and blurred vision: Tags 10 and 11 mark the subcortical visual pathways. d: Postoperative axial FLAIR-weighted and coronal T2-weighted MRI performed 3 months following the surgery, showing the dorsomesial deep edge of the cavity—that is, at the level of the visual pathways (arrow), which were identified intraoperatively. e: The 4-screen naming task used in this case with the goal of preserving the right lower quadrant. The sacrificed right superior quadrant is symbolized by a gray quadrant, and visual symptoms (phosphenes, blurred vision) by black stars. f: Postoperative Octopus perimetric evaluation performed 3 months after the surgery showing a right incomplete hemianopia.

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