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( A ) Axial magnetic resonance image showing a cavernous hemangioma in the precentral gyrus. ( B ) Three-dimensional brain image. Notes: In ( B ), the yellow circle represents cortical electric stimulation mapping. The blue octahedron represents the point of TMS mapping. The red cone represents the planned point of transsulcal approach, in the central sulcus behind the vein, an appropriate distance from motor area mapped by TMS and confirmed by DES. Abbreviations: DES, direct cortical electrical stimulation; TMS, transcranial magnetic stimulation.
Source publication
Since the introduction of microscopic techniques, radical surgery for cavernous angiomas has become a recommended treatment option. However, the treatment of motor area cavernous angioma represents a great challenge for the surgical team. Here, we describe an approach guided by frameless neuronavigation and preoperative functional mapping with tran...
Contexts in source publication
Context 1
... navigation, the BrainSight software system was used, for the visualization of the coil location in relation to the cortex. After coregistration, the image of the patient's brain was represented in a coordinate system (defining coordinate X, Y, and Z), such that the position of the coil with respect to the brain could be visualized on the corresponding three dimensional (3D) MR image shown by the navigation system ( Figure 1B). After the TMS mapping, we evaluated the results, and before surgery, we decided on the best approach for each patient. ...
Context 2
... the surgeries, the transsulcal approach (in the medial region of the central sulcus) (Figure 1B) was successfully applied to the lesions, and the areas of motor response iden- tified by the preoperative mapping were carefully avoided. In the surgeries, we also used DES, which confirmed the cortical areas with motor response that were identified with TMS. ...
Context 3
... displayed motor com- ponents in the left hand, without motor deficits. The patient underwent MRI, which revealed a cavernous angioma lesion − approximately 25 mm in diameter -occupying the precentral gyrus subcortical region ( Figure 1A). After an unsuccessful attempt at treating the lesion medically, the patient was referred for surgical treatment. ...
Similar publications
The recent enhanced sophistication of non-invasive mapping of the human motor cortex using MRI-guided Transcranial Magnetic Stimulation (TMS) techniques, has not been matched by refinement of methods for generating maps from motor evoked potential (MEP) data, or in quantifying map features. This is despite continued interest in understanding cortic...
Citations
... This makes the complete removal of the lesion insufficient for patients with epileptic seizures unless the stained tissue is excised. However, the intraoperative surgical decision depends on accounting for all possible complications and postoperative outcomes considering the eloquent area preservation a priority [8]. ...
... The area with the lowest face motor function was chosen to start the dissection. Pavia et al. reported that the complementary use of cortical motor mapping by DES and neuronavigation are the gold standards in deep lesions resection [8]. ...
Introduction: Cavernomas are benign hamartomas of cerebral and spinal vessels, accounting for less than 1% of all arteriovenous malformations. In general, surgical resection is the treatment of choice for enlarging cavernomas or those associated with medically refractory seizures. Herein, we report a case of an enlarged deep precentral gyrus cavernoma, with a discussion of the surgical approach and the impact of intra-operative neurophysiological monitoring on the preservation of motor function.
Case description: A 30-year-old male was referred to our hospital due to 2-month history of focal seizures. Initial magnetic resonance imaging revealed right precentral cavernoma with minimal right parietal subarachnoid haemorrhage. Revealed the location of the cavernoma deep in the right primary motor cortex. Surgery was performed, trans-sulcal dissection was done with the aid of intraoperative ultrasonography neuro-navigation. The cortical motor map was localized by functional mapping with intra-operative neurophysiological monitoring, including somatosensory evoked potentials (SEP) and motor evoked potentials (MEP). Post-operatively, the left side weakness grade was 4/5, and the Glasgow coma scale was 15. Postoperative imaging confirmed successful resection of the cavernoma and associated hemosiderin ring with no SAH.
Conclusion: The use of preoperative MRI and intraoperative ultrasonography supplemented by neurophysiological monitoring utilizing SEP, MEP, and cortical mapping is essential for the safe resection of paracentral cavernomas.
... The spatial resolution is more precise than fMRI. nTMS represents a highly valuable supplement for preoperative functional planning in the clinical routine Krieg et al. (2013) [26] n/a n/a n/a n/a n/a nTMS is as accurate in recurrent gliomas as it is prior to the first operation Paiva et al. (2013) [38] n/a n/a n/a n/a n/a Authors report for the first time TMS mapping in patients with cavernous angioma. The method appears to be a useful preoperative tool Vitikainen et al. (2013) [59] n/a n/a n/a n/a n/a ...
... The spatial resolution is more precise than fMRI. nTMS represents a highly valuable supplement for preoperative functional planning in the clinical routine Krieg et al. (2013) [26] n/a n/a n/a n/a n/a nTMS is as accurate in recurrent gliomas as it is prior to the first operation Paiva et al. (2013) [38] n/a n/a n/a n/a n/a Authors report for the first time TMS mapping in patients with cavernous angioma. The method appears to be a useful preoperative tool Vitikainen et al. (2013) [59] n/a n/a n/a n/a n/a ...
The objective of this systematic review is to create an overview of the literature on the comparison of navigated transcranial magnetic stimulation (nTMS) as a mapping tool to the current gold standard, which is (intraoperative) direct cortical stimulation (DCS) mapping. A search in the databases of PubMed, EMBASE, and Web of Science was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations were used. Thirty-five publications were included in the review, describing a total of 552 patients. All studies concerned either mapping of motor or language function. No comparative data for nTMS and DCS for other neurological functions were found. For motor mapping, the distances between the cortical representation of the different muscle groups identified by nTMS and DCS varied between 2 and 16 mm. Regarding mapping of language function, solely an object naming task was performed in the comparative studies on nTMS and DCS. Sensitivity and specificity ranged from 10 to 100% and 13.3–98%, respectively, when nTMS language mapping was compared with DCS mapping. The positive predictive value (PPV) and negative predictive value (NPV) ranged from 17 to 75% and 57–100% respectively. The available evidence for nTMS as a mapping modality for motor and language function is discussed.
... Navigated transcranial magnetic stimulation (nTMS) has become in recent years a commonly used tool in the preoperative planning for neurosurgical patients [8]. nTMS is now being widely used as an important pre-operative tool for motor and speech mapping in eloquent glioma surgery (awake/asleep), brain metastasis, cavernoma, and vascular malformations [5,7,14,15,17,20,23,25] and is a useful adjunct to impact the surgical indications, guide the surgical approach, and estimate and reduce the risk of inducing postsurgical deficits [26,27]. It has further been highlighted in recent studies that the preoperative nTMS motor mapping/ speech mapping provides improved outcome in patients with glioblastoma [24] and is also useful in language-eloquent tumour surgery in awake-ineligible patients [25]. ...
Background
Patient-reported experience measures (PREMs) are a unique measure of experience of patients which can help address the quality of care of the patients.Objective
Our aim of the study is to collect quality of care outcomes with our newly navigated transcranial magnetic stimulation patient-reported experience measure (nTMS-PREMs) questionnaire among neurosurgical patients undergoing nTMS.MethodsA single-centre prospective nTMS-PREMs 19-item questionnaire study was performed between February 2018 and December 2018 on patient referred for nTMS at our hospital. The Data was analysed using Likert scale, linear and logistic regression using statistical software (STATA 13.0®).ResultsFifty patient questionnaires were collected (30 males, 20 females, mean age of 47.6 ± 2.1 years) among which 74% of patients underwent both motor and language mapping with a mean duration of 103.3 ± 5.1 min. An overall positive response was noted from the results of the questionnaire, tiredness and anxiety being the common effects noted. Patients with the left-sided disease appreciated more the conditions provided in our laboratory (Q4, p = 0.040) and increasing age was related to less confidence and trust (Q6, p = 0.038) in the staff performing the exam. Younger patients tolerated nTMS better than older patients (> 65 years). PubMed literature search resulted in no relevant articles on the use of PREMs in nTMS patients.ConclusionnTMS is a well-tolerated non-invasive tool and nTMS-PREMS provides a promising role in identifying the unmet needs of the patients and improving the quality of their care.
... DES has always been accepted as the gold standard for motor mapping and language mapping [35]. It was reported that motor activation points detected by nTMS were closely associated with those found in DES [36,37]. One meta-analysis reviewed six studies with a total of 81 patients and summarized that the mean distance of motor cortex identified on DES and nTMS was 6.18 mm [37]. ...
... Functional mapping with nTMS is available not only in tumorous brain lesions, but also within hypervascularized cortical areas [56]. Many studies had shown that nTMS can serve as a powerful tool to schedule planning prior to surgery for patients with arteriovenous malformation and cavernous angiomas, and it can also help optimize treatment planning [36,57]. ...
Abstract Transcranial magnetic stimulation (TMS) is a noninvasive neurophysiologic technique that can stimulate the human brain. Positioning of the coil was often performed based merely on external landmarks on the head, meaning that the anatomical target in the cortex remains inaccurate. Navigated transcranial magnetic stimulation (nTMS) combines a frameless stereotactic navigational system and TMS coil and can provide a highly accurate delivery of TMS pulses with the guidance of imaging. Therefore, many novel utilities for TMS could be explored due to the ability of precise localization. Many studies have been published, which indicate nTMS enables presurgical functional mapping. This review aimed to provide a comprehensive literature review on nTMS, especially the principles and clinical applications of nTMS. All articles in PubMed with keywords of “motor mapping,” “presurgical mapping,” “navigated transcranial magnetic stimulation,” and “language mapping” published from 2000 to 2018 were included in the study. Frequently cited publications before 2000 were also included. The most valuable published original and review articles related to our objective were selected. Motor mapping of nTMS is validated to be a trustful tool to recognize functional areas belonging to both normal and lesioned primary motor cortex. It can offer reliable mapping of speech and motor regions at cortex prior to operation and has comparable accuracy as direct electrical cortical stimulation. nTMS is a powerful tool for mapping of motor and linguistic function prior to operation, has high application value in neurosurgery and the treatment of neurological and psychiatric diseases, and has gained increasing acceptance in neurosurgical centers across the world.
... 1,2 The phenomenon of neural plasticity in corticalsubcortical circuits in response to various clinical situations and the variability among individuals with different hodological features make it difficult to establish a treatment guided solely by anatomy. [3][4][5] As such, the use of mapping by direct electrical stimulation of the cerebral cortex proposed by Penfield became the standard method to guide the brain tumor resections. 1,6 Although innovative preoperative mapping methods, such as functional transcranial magnetic stimulation and positron emission tomography, have become more widely available, direct electrical stimulation continues to be the standard method. ...
Introduction Surgical treatment of brain tumors in eloquent areas has always been considered a major challenge because removal-related cortical damage can cause serious functional impairment. However, few studies have investigated the association between small craniotomies and the higher risk of incidence of motor deficits and prolonged recovery time. Here, we analyzed neurologic deficits and the prognostic variables after surgery guided by navigation for motor cortex tumors under general anesthesia.
Methods This was a prospective study that included 47 patients with tumors in the precentral gyrus. All surgeries were performed with neuronavigation and cortical mapping, with direct electrical stimulation of the motor cortex. We evaluated the prognostic evolution of patients with pre- and postoperative Karnofsky Performance Scale using the Eastern Cooperative Oncology Group scale.
Results Complete resection was verified in all 18 cases of metastasis, 13 patients with glioblastoma multiforme, and 5 patients with low-grade gliomas. An analysis of the motor deficits revealed that 11 patients experienced worsening of the deficit on the first day after surgery. Only four patients developed new deficits in the immediate postoperative period, and these improved after 3 weeks. After 3 months, only two patients had deficits that were worse those experienced prior to surgery; both patients had glioblastoma multiforme.
Conclusion In our series, motor deficits prior to surgery were the most important factors associated with persistent postoperative deficits. Small craniotomy with navigation associated with intraoperative brain mapping allowed a safe resection and motor preservation in patients with motor cortex brain tumor.
... 11 Even if the placement of the coil is not satisfactory, it can be replaced or removed easily and safely. Covered stents 15,16 and flow-diverting stents 17,18 are being used as another alternative methods for CCFs treatment. If there is no artificial cranioplasty history, this patient can also be treated by clipping the PComA via craniotomy. ...
Carotid-cavernous fistulas (CCFs) are an abnormal vascular shunt between the carotid artery and the cavernous sinus, and were traditionally classified into four subtypes based on the detailed fistulas anatomy and arterial supply. CCFs are frequently encountered in patients with traumatic skull base fractures. In this report, we present one such case caused by two head traumas. Computed tomography and digital subtraction angiography confirmed that this CCF arose from posterior communicating artery of the internal carotid artery, which is not included in the traditional Barrow et al’s categorization. The possible mechanisms include laceration of dural mater of posterior clinoid process and laceration or pseudoaneurysm formation of posterior communicating artery. This case was successfully treated with endovascular coil embolization.
Cerebral cavernous malformations (CCMs) are vascular lesions associated with seizures, hemorrhage, and neurologic deficits. The familial form of CCM constitutes ≈20% of cases and presents with multifocal lesions in the brain and spinal cord, whereas the more common sporadic form typically involves a single lesion. Treatments of CCM include surgical resection and stereotactic radiosurgery, as well as management of symptoms (eg, seizures). Surgical resection or irradiation of lesions in eloquent areas requires careful consideration because of the potential for morbidity and mortality, and these treatments are not advised for asymptomatic lesions. The purpose of this narrative review is to describe the current state of treatments for CCM, with an emphasis on potential clinically relevant pharmacologic treatments aimed at targeting aberrant molecular signaling associated with CCM. Literature was identified through PubMed using search terms related to treatments of CCMs. In endothelial cells, overactivation of RhoA/Rho‐associated kinase contributes to disruption of cell‐cell junctions and a shift to a senescence‐associated secretory phenotype, which leads to inflammation, migration, and invasiveness of mutant endothelial cells. Specific (NRL‐1049) and nonspecific (fasudil, statins) inhibition of Rho‐associated kinase has shown effectiveness to reduce lesion burden in mouse models of CCM. A phase 1/2 clinical trial is currently underway to investigate the efficacy of atorvastatin in patients with CCM, and a first‐in‐human clinical trial to evaluate safety, tolerability, and pharmacokinetic parameters of NRL‐1049 began in 2023. The β‐blocker propranolol and the superoxide dismutase mimetic REC‐994 have also shown effectiveness in attenuating lesion burden in preclinical studies. Results from a pilot phase 2 clinical trial of propranolol support further investigation in an adequately powered trial, and the safety, pharmacokinetics, and potential efficacy of REC‐994 are currently being evaluated in a phase 2 clinical trial. Additional agents have been used solely in preclinical models and require clinical evaluation.
