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Johannes Herta, Fabian Winter, Ekaterina Pataraia, Martha Feucht, Thomas Czech, Barbara Porsche, Ulrike Leiss, Irene Slavc, Andreas Peyrl, Gregor Kasprian, Karl Rössler, and Christian Dorfer

OBJECTIVE

The goal of this study was to evaluate the feasibility, benefit, and safety of awake brain surgery (ABS) and intraoperative language mapping in children and adolescents with structural epilepsies. Whereas ABS is an established method to monitor language function in adults intraoperatively, reports of ABS in children are scarce.

METHODS

A retrospective chart review of pediatric patients ≤ 18 years of age who underwent ABS and cortical language mapping for supratentorial tumors and nontumoral epileptogenic lesions between 2008 and 2019 was conducted. The authors evaluated the global intellectual and specific language performance by using detailed neuropsychological testing, the patient’s intraoperative compliance, results of intraoperative language mapping assisted by electrocorticography (ECoG), and postsurgical language development and seizure outcomes. Descriptive statistics were used for this study, with a statistical significance of p < 0.05.

RESULTS

Eleven children (7 boys) with a median age of 13 years (range 10–18 years) underwent ABS for a lesion in close vicinity to cortical language areas as defined by structural and functional MRI (left hemisphere in 9 children, right hemisphere in 2). Patients were neurologically intact but experiencing seizures; these were refractory to therapy in 9 patients. Compliance during the awake phase was high in 10 patients and low in 1 patient. Cortical mapping identified eloquent language areas in 6/10 (60%) patients and was concordant in 3/8 (37.5%), discordant in 3/8 (37.5%), and unclear in 2/8 (25%) patients compared to preoperative functional MRI. Stimulation-induced seizures occurred in 2 patients and could be interrupted easily. ECoG revealed that afterdischarge potentials (ADP) were involved in 5/9 (56%) patients with speech disturbances during stimulation. None of these patients harbored postoperative language dysfunction. Gross-total resection was achieved in 10/11 (91%) patients, and all were seizure free after a median follow-up of 4.3 years. Neuropsychological testing using the Wechsler Intelligence Scale for Children and the verbal learning and memory test showed an overall nonsignificant trend toward an immediate postoperative deterioration followed by an improvement to above preoperative levels after 1 year.

CONCLUSIONS

ABS is a valuable technique in selected pediatric patients with lesions in language areas. An interdisciplinary approach, careful patient selection, extensive preoperative training of patients, and interpretation of intraoperative ADP are pivotal to a successful surgery.

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Ichiro Okano, Stephan N. Salzmann, Fabian Winter, Erika Chiapparelli, Yushi Hoshino, Jennifer Shue, John A. Carrino, Andrew A. Sama, Frank P. Cammisa, Federico P. Girardi, and Alexander P. Hughes

OBJECTIVE

Medial migration of the vertebral artery (VA) can be a risk factor for injury during anterior procedures. CT angiography (CTA) has been considered the gold standard for the evaluation of various areas of the arterial anatomy. MRI and nonenhanced CT are more commonly used as routine preoperative imaging studies, but it is unclear if these modalities can safely exclude the anomalous course of the VA. The aims of this cross-sectional observational study were to investigate risk factors for medially migrated VA on CTA and to evaluate the diagnostic accuracy of MRI and nonenhanced CT for high-risk VA anatomy in the subaxial cervical spine.

METHODS

The records of 248 patients who underwent CTA for any reason at a single academic institution between 2007 and 2018 were reviewed. The authors included MRI and nonenhanced CT taken within 1 year before or after CTA. An axial VA position classification was used to grade VA anomalies in the subaxial cervical spine. The multivariable linear regression analysis with mixed models was performed to identify the risk factors for medialized VA. The sensitivity and specificity of MRI and nonenhanced CT for high-risk VA positions were calculated.

RESULTS

A total of 175 CTA sequences met the inclusion criteria. The mean age was 63.8 years. Advanced age, disc and pedicle levels, lower cervical levels, and left side were independent risk factors for medially migrated VA. The sensitivities of MRI and nonenhanced CT for the detection of grade 1 or higher VA position were only fair, and the sensitivity of MRI was lower than that of nonenhanced CT (0.31 vs 0.37, p < 0.001), but the specificities were similarly high for both modalities (0.97 vs 0.97). With the combination of MRI and nonenhanced CT, the sensitivity significantly increased to 0.50 (p < 0.001 vs MRI and vs CT alone) with a minimal decrease in specificity.

CONCLUSIONS

Axial images of MRI and nonenhanced CT demonstrated high specificities but only fair sensitivities. Nonenhanced CT demonstrated better diagnostic value than MRI. When combining both modalities the sensitivity improved, but a substantial proportion of medialized VAs could not be diagnosed.

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Ichiro Okano, Stephan N. Salzmann, Fabian Winter, Erika Chiapparelli, Yushi Hoshino, Jennifer Shue, John A. Carrino, Andrew A. Sama, Frank P. Cammisa, Federico P. Girardi, and Alexander P. Hughes

OBJECTIVE

Medial migration of the vertebral artery (VA) can be a risk factor for injury during anterior procedures. CT angiography (CTA) has been considered the gold standard for the evaluation of various areas of the arterial anatomy. MRI and nonenhanced CT are more commonly used as routine preoperative imaging studies, but it is unclear if these modalities can safely exclude the anomalous course of the VA. The aims of this cross-sectional observational study were to investigate risk factors for medially migrated VA on CTA and to evaluate the diagnostic accuracy of MRI and nonenhanced CT for high-risk VA anatomy in the subaxial cervical spine.

METHODS

The records of 248 patients who underwent CTA for any reason at a single academic institution between 2007 and 2018 were reviewed. The authors included MRI and nonenhanced CT taken within 1 year before or after CTA. An axial VA position classification was used to grade VA anomalies in the subaxial cervical spine. The multivariable linear regression analysis with mixed models was performed to identify the risk factors for medialized VA. The sensitivity and specificity of MRI and nonenhanced CT for high-risk VA positions were calculated.

RESULTS

A total of 175 CTA sequences met the inclusion criteria. The mean age was 63.8 years. Advanced age, disc and pedicle levels, lower cervical levels, and left side were independent risk factors for medially migrated VA. The sensitivities of MRI and nonenhanced CT for the detection of grade 1 or higher VA position were only fair, and the sensitivity of MRI was lower than that of nonenhanced CT (0.31 vs 0.37, p < 0.001), but the specificities were similarly high for both modalities (0.97 vs 0.97). With the combination of MRI and nonenhanced CT, the sensitivity significantly increased to 0.50 (p < 0.001 vs MRI and vs CT alone) with a minimal decrease in specificity.

CONCLUSIONS

Axial images of MRI and nonenhanced CT demonstrated high specificities but only fair sensitivities. Nonenhanced CT demonstrated better diagnostic value than MRI. When combining both modalities the sensitivity improved, but a substantial proportion of medialized VAs could not be diagnosed.