Surgical treatment of meningiomas located in the rolandic area: the role of navigated transcranial magnetic stimulation for preoperative planning, surgical strategy, and prediction of arachnoidal cleavage and motor outcome

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OBJECTIVE

Surgical treatment of convexity meningiomas is usually considered a low-risk procedure. Nevertheless, the risk of postoperative motor deficits is higher (7.1%–24.7% of all cases) for lesions located in the rolandic region, especially when an arachnoidal cleavage plane with the motor pathway is not identifiable. The authors analyzed the possible role of navigated transcranial magnetic stimulation (nTMS) for planning resection of rolandic meningiomas and predicting the presence or lack of an intraoperative arachnoidal cleavage plane as well as the postoperative motor outcome.

METHODS

Clinical data were retrospectively collected from surgical cases involving patients affected by convexity, parasagittal, or falx meningiomas involving the rolandic region, who received preoperative nTMS mapping of the motor cortex (M1) and nTMS-based diffusion tensor imaging (DTI) fiber tracking of the corticospinal tract before surgery at 2 different neurosurgical centers. Surgeons’ self-reported evaluation of the impact of nTMS-based mapping on surgical strategy was analyzed. Moreover, the nTMS mapping accuracy was evaluated in comparison with intraoperative neurophysiological mapping (IONM). Lastly, we assessed the role of nTMS as well as other pre- and intraoperative parameters for predicting the patients’ motor outcome and the presence or absence of an intraoperative arachnoidal cleavage plane.

RESULTS

Forty-seven patients were included in this study. The nTMS-based planning was considered useful in 89.3% of cases, and a change of the surgical strategy was observed in 42.5% of cases. The agreement of nTMS-based planning and IONM-based strategy in 35 patients was 94.2%. A new permanent motor deficit occurred in 8.5% of cases (4 of 47). A higher resting motor threshold (RMT) and the lack of an intraoperative arachnoidal cleavage plane were the only independent predictors of a poor motor outcome (p = 0.04 and p = 0.02, respectively). Moreover, a higher RMT and perilesional edema also predicted the lack of an arachnoidal cleavage plane (p = 0.01 and p = 0.03, respectively). Preoperative motor status, T2 cleft sign, contrast-enhancement pattern, and tumor volume had no predictive value.

CONCLUSIONS

nTMS-based motor mapping is a useful tool for presurgical assessment of rolandic meningiomas, especially when a clear cleavage plane with M1 is not present. Moreover, the RMT can indicate the presence or absence of an intraoperative cleavage plane and predict the motor outcome, thereby helping to identify high-risk patients before surgery.

ABBREVIATIONS CST = corticospinal tract; DTI = diffusion tensor imaging; DTI-FT = DTI fiber tracking; DWI = diffusion-weighted imaging; FDI = first dorsal interosseus; IONM = intraoperative neurophysiological mapping; MRC = Medical Research Council; MSO = maximum stimulator output; NPV = negative predictive value; nTMS = navigated transcranial magnetic stimulation; PPV = positive predictive value; RMT = resting motor threshold.

Article Information

Correspondence Giovanni Raffa: University of Messina, Messina, Italy. giovanni.raffa@unime.it.

INCLUDE WHEN CITING Published online June 14, 2019; DOI: 10.3171/2019.3.JNS183411.

G. Raffa and T. Picht contributed equally to this work and share first authorship.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A and B: Two examples of cases of rolandic meningiomas with different spatial relationships with M1. The first lesion was anterior to M1 (A), and resection started from the anterior portion of the meningioma—as far as possible from the motor pathway (red arrow). Conversely, in the second case (B), the lesion was located posterior to M1, and therefore resection started from the posterior portion of the lesion (red arrow). C and D: A third case in which surgery started with identification of the M1 (white spots) and the upper portion of the CST (green fibers from the leg) through navigation and IONM. The motor pathway was found to be posterior to the lesion (C). Lesion debulking started from its anterior portion (D). Figure is available in color online only.

  • View in gallery

    Example of the use of IONM guided by nTMS-based planning at the beginning of surgery. The position of the monopolar stimulator is verified by the navigation probe (blue stylet). This allowed for straightforward identification of the motor cortex. Figure is available in color online only.

  • View in gallery

    Axial MR images showing the neuroimaging parameters evaluated to predict postoperative motor outcome and the presence/absence of an intraoperative arachnoidal cleavage plane: homogeneity versus inhomogeneity of the enhancement on T1-weighted images obtained after gadolinium administration (A); perilesional edema on T2-weighted image (B); presence of the so-called “T2 cleft sign” (red arrows) on T2-weighted image (C). Figure is available in color online only.

  • View in gallery

    Example of nTMS-based planning. The 3D nTMS-based reconstruction disclosed a close relationship between the motor pathway (M1 = white spots, CST = green and red fibers) and the meningioma (yellow) (A); the classic view on axial, sagittal, and coronal planes showed that the M1 was displaced posteriorly and laterally by the meningioma. Also the CST was displaced, but interestingly the leg fibers (green) were moved posteriorly and the arm fibers (red) were moved laterally. This indicated that dissection and tumor resection should be started at the anterior border of the meningioma (red arrow) (B). Figure is available in color online only.

  • View in gallery

    Example of nTMS-based planning. The 3D nTMS-based planning disclosed a safe distance between the meningioma and the motor pathway (A); the motor cortex (white spots) and the whole CST (leg fibers = green, arm fibers = red, face fibers = pink) are far from the tumor. This indicated the possibility of starting a safe dissection and tumor resection at the posterior border of the lesion, where a safe distance from the motor pathway is visible (red arrow) (B). Figure is available in color online only.

  • View in gallery

    Case example of a right parasagittal “rolandic” meningioma. Preoperative axial, coronal, and sagittal contrast-enhanced T1-weighted MR images are shown in panel A. The nTMS cortical mapping of the M1 (B) and the nTMS-based DTI-FT of the CST (C) showed that the motor pathway was posterior and lateral to the meningioma, in close spatial relationship. Therefore, the lesion was considered motor-eloquent and resection started from the anterior portion of the meningioma (red arrow). Figure is available in color online only.

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