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  • Author or Editor: Juan A Barcia x
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Paola A. Rivera-Rivera, Marcos Rios-Lago, Sandra Sanchez-Casarrubios, Osman Salazar, Miguel Yus, Mercedes González-Hidalgo, Ana Sanz, Josué Avecillas-Chasin, Juan Alvarez-Linera, Alvaro Pascual-Leone, Antonio Oliviero and Juan A. Barcia

OBJECTIVE

The extent of resection is the most important prognostic factor following brain glioma surgery. However, eloquent areas within tumors limit the extent of resection and, thus, critically affect outcomes. The authors hypothesized that presurgical suppression of the eloquent areas within a tumor by continuous cortical electrical stimulation, coupled with appropriate behavioral training (“prehabilitation”), would induce plastic reorganization and enable a more extensive resection.

METHODS

The authors report on 5 patients harboring gliomas involving eloquent brain areas within tumors as identified on intraoperative stimulation mapping. A grid of electrodes was placed over the residual tumor, and continuous cortical electrical stimulation was targeted to the functional areas. The stimulation intensity was adjusted daily to provoke a mild functional impairment while the function was intensively trained.

RESULTS

The stimulation intensity required to impair function increased progressively in all patients, and all underwent another operation a mean of 33.6 days later (range 27–37 days), when the maximal stimulation voltage in all active contacts induced no functional deficit. In all cases, a substantially more extensive resection of the tumor was possible. Intraoperative mapping and functional MRI demonstrated a plastic reorganization, and most previously demonstrated eloquent areas within the tumor were silent, while there was new functional activation of brain areas in the same region or toward the contralateral hemisphere.

CONCLUSIONS

Prehabilitation with continuous cortical electrical stimulation and appropriate behavioral training prior to surgery in patients with WHO Grade II and III gliomas affecting eloquent areas accelerate plastic changes. This can help maximize tumor resection and, thus, improve survival while maintaining function.

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Jaime Broseta, José Barberá, J. A. de Vera, Juan Luis Barcia-Salorio, Guillermo Garcia-March, José González-Darder, Francisco Rovaina and Vicente Joanes

✓ Percutaneous epidural Stimulation of the low thoracic spinal cord was carried out in 41 patients with pain from peripheral arterial disease of the lower limbs. Results are reported relating to pain, claudication distance, peripheral blood flow, and trophic lesion changes. Following a trial period of stimulation, 37 patients had stimulators permanently implanted. After a mean poststimulation follow-up period of 25 months, substantial pain relief (75% to 100%) was obtained in 29 cases; claudication distance significantly increased in 15 cases; Doppler ultrasound recordings of lower-limb distal arteries showed a tendency toward normalization of pulse-wave morphology, with increase of amplitude in 12 of the 23 patients studied; a rise in skin temperature was also detected by thermography. Distal arterial blood pressure remained unchanged with stimulation. Ischemic cutaneous trophic lesions of less than 3 sq cm healed, but gangrenous conditions were not benefited. A placebo effect or the natural history of the disease can be excluded as the reason for these improvements. It is concluded that spinal cord stimulation is a valid alternative treatment for moderate peripheral arterial disorders when direct arterial surgery is not possible or has been unsuccessful.