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Takahiro Ota, Kensuke Kawai, Kyousuke Kamada, Taichi Kin, and Nobuhito Saito
Intraoperative monitoring of visual evoked potentials (VEPs) has been regarded as having limited significance for the preservation of visual function during neurosurgical procedures, mainly due to its poor spatial resolution and signal-to-noise ratio. The authors evaluated the usefulness of cortically recorded VEPs, instead of the usual scalp VEPs, as intraoperative monitoring focusing on the posterior visual pathway.
In 17 consecutive patients who underwent microsurgical procedures for lesions near the posterior visual pathway, cortical responses were recorded using 1-Hz flashing light-emitting diodes and subdural strip electrodes after induction of general anesthesia with sevoflurane or propofol. The detectability and waveform of the initial response, stability, and changes during microsurgical manipulations were analyzed in association with the position of electrodes and postoperative changes in visual function.
Initial VEPs were detected in 82% of all patients. The VEPs were detected in 94% of patients without total hemianopia in whom electrodes were placed sufficiently near the occipital pole; in these cases the recordings were not significantly affected by anesthesia. The detectability rates of the negative peak before 100 msec (N1), positive peak ~ 100 msec (P100), and negative peak after 100 msec (N2) were 36, 50, and 100%, respectively. The mean latencies and amplitudes of N1, P100, and N2 were 90.0 ± 15.9 msec and 61.0 ± 64.0 μV, 103.9 ± 13.5 msec and 34.3 ± 38.6 μV, and 125.7 ± 12.2 msec and 44.9 ± 48.9 μV, respectively, showing great variability. In 11 patients, the initial waveforms of VEP remained stable during microsurgical procedures, and the visual status did not change postoperatively, while it disappeared in 2 patients who presented with postoperative hemianopia.
Direct recording from the visual cortices under general anesthesia achieved satisfactory detectability of the visual response to a light-emitting diode flashing light. Although the initial waveforms varied greatly among patients, they were stable during microsurgical procedures, and the changes were consistent with postoperative visual function. Intraoperative cortical VEP monitoring is a potentially useful procedure to monitor the functional integrity of the posterior visual pathway.
Kyousuke Kamada, Tomoki Todo, Takahiro Ota, Kenji Ino, Yoshitaka Masutani, Shigeki Aoki, Fumiya Takeuchi, Kensuke Kawai, and Nobuhito Saito
To validate the corticospinal tract (CST) illustrated by diffusion tensor imaging, the authors used tractography-integrated neuronavigation and direct fiber stimulation with monopolar electric currents.
Forty patients with brain lesions adjacent to the CST were studied. During the operation, the motor responses (motor evoked potential [MEP]) elicited at the hand by the cortical stimulation to the hand motor area were continuously monitored, maintaining the consistent stimulus intensity (mean 15.1 ± 2.21 mA). During lesion resection, direct fiber stimulation was applied to elicit MEP (referred to as fiber MEP) to identify the CST functionally. The threshold intensity for the fiber MEP was determined by searching for the best stimulus point and changing the stimulus intensity. The minimum distance between the resection border and illustrated CST was measured on postoperative isotropic images.
Direct fiber stimulation demonstrated that tractography accurately reflected anatomical CST functioning. There were strong correlations between stimulus intensity for the fiber MEP and the distance between the CST and the stimulus points. The results indicate that the minimum stimulus intensity of 20, 15, 10, and 5 mA had stimulus points ~ 16, 13.2, 9.6, and 4.8 mm from the CST, respectively. The convergent calculation formulated 1.8 mA as the electrical threshold of the CST for the fiber MEP, which was much smaller than that of the hand motor area.
The investigators found that diffusion tensor imaging–based tractography is a reliable way to map the white matter connections in the entire brain in clinical and basic neuroscience applications. By combining these techniques, investigating the cortical-subcortical connections in the human CNS could contribute to elucidating the neural networks of the human brain and shed light on higher brain functions.
Arcuate fasciculus tractography integrated into Gamma Knife surgery
Keisuke Maruyama, Tomoyuki Koga, Kyousuke Kamada, Takahiro Ota, Daisuke Itoh, Kenji Ino, Hiroshi Igaki, Shigeki Aoki, Yoshitaka Masutani, Masahiro Shin, and Nobuhito Saito
To prevent speech disturbances after Gamma Knife surgery (GKS), the authors integrated arcuate fasciculus (AF) tractography based on diffusion tensor (DT) MR imaging into treatment planning for GKS.
Arcuate fasciculus tractography was retrospectively integrated into planning that had been previously performed by neurosurgeons and radiation oncologists. This technique was retrospectively applied to 12 patients with arteriovenous malformations adjacent to the AF. Diffusion tensor images were acquired before the frame was affixed to the patient's head and DT tractography images of the AF were created using the authors' original software. The data from DT tractography and stereotactic 3D imaging studies obtained after frame fixation were transported to a treatment planning workstation for GKS and coregistered so that the delivered doses and incidence of posttreatment aphasia could be assessed.
The AF could not be depicted in 2 patients who initially presented with motor aphasia caused by hemorrhaging from arteriovenous malformations. During the median follow-up period of 29 months after GKS, aphasia developed in 2 patients: 30 Gy delivered to the frontal portion of the AF caused conduction aphasia in 1 patient, and 9.6 Gy to the temporal portion led to motor aphasia in the other. Speech dysfunction was not observed after a maximum radiation dose of 10.0–16.8 Gy was delivered to the frontal fibers in 4 patients, and 3.6–5.2 Gy to the temporal fibers in 3.
The authors found that administration of a 10-Gy radiation dose during GKS was tolerated in the frontal but not the temporal fibers of the AF. The authors recommend confirmation of the dose by integration of AF tractography with GKS, especially in lesions located near the temporal language fibers.