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Eloquent brain regions11/11/2023 A review of the literature concerning the surgical treatment of cavernous malformations (CM) and arteriovenous malformations (AVM) localized in eloquent brain areas (EBA). To assess the value of magnetic resonance (MR) tractography in deciding on the tactics of surgical treatment of CVM through comparison with morphological studies. The question of whether the surgical procedure is safe is paramount.Īim. We believe, that in the planning of the surgical removal of cerebral vascular malformations (CVM) of eloquent brain areas, a question of whether they include the functionally sustainable brain tissue remains relevant. CSES in an awake patient is a method that produces very good results in terms of resection and neurological outcome.Introduction. Approaching purely subcortical tumors requires microsurgical skills, but in eloquent areas, functional topography monitoring is mandatory to allow safe surgery. Postoperative MRI demonstrated complete resection in all cases. The transient postoperative morbidity was 76.4%, but at last follow-up (range 4-20 months), all the patients regained preoperative status and 2 improved. When a transsulcal route was preferred, CSES documented the presence or absence of function in the deep sulcus. If the transgyral route was chosen, CSES helped to detect a non-eloquent area. Neuronavigation was used to show the most direct route to the tumor (transsulcal or transgyral), but CSES was fundamental to adapt the surgical corridor to the functional topography both cortically and subcortically. The main distance of the tumors from the cortical surface was 18.2mm (range 9-48 mm). Immediate postoperative MRI was used to evaluate the extent of resection. The Rankin modified score was chosen to express the pre and postoperative functional neurological status. Major white matter tracts were investigated by MRI diffusion tensor fiber tracking (DTI-ft). Functional magnetic resonance (fMRI either sensory-motor or language, based on the location) was performed in order to confirm the proximity to functional cortical areas. Prospective analysis of the surgical, neurological, and radiological outcome of patients harboring supratentorial, subcortically located brain tumors or vascular malformations who are operated on through awake surgery and CSES. To analyze the efficacy and safety of cortical and subcortical electrical stimulation CSES and awake surgery to approach purely subcortical tumors in highly functional locations, particularly in guiding the choice of the best transcortical path. This multimodal approach is more aggressive, leads to better outcomes, and should be used routinely for resection of lesions in eloquent brain regions. Intraoperative brain mapping is necessary for safe and maximal resection and to guarantee a satisfying neurological outcome. However, these techniques cannot directly lead the surgeon during resection. Conclusion Preoperative brain mapping is useful when planning awake surgery to estimate the relationship between the tumor and functional brain regions. DTI fiber tracking underestimated the presence of functional fibers surrounding or inside the tumor. Sensorimotor cortex direct mapping correlated 92.3% with fMRI activation, while direct mapping of language cortex correlated 42.8%. Twenty-one patients (77.7%) suffered transient postoperative worsening, but at 6 months follow-up only three (11.1%) patients had persistent neurological impairment. Results Total plus subtotal resection reached 88.8%. We topographically correlated intraoperatively identified sites (cortical and subcortical) with areas of fMRI activation and DTI tractography. Intraand postoperative complications, stimulation effects, extent of resection, and neurological outcome were determined. All subjects underwent preoperative sensorimotor and language fMRI and DTI tractography of major white matter bundles. Patients and methods We prospectively studied 27 patients with eloquent-area tumors who were selected to undergo awake surgery and direct brain mapping. The objective of this study was to assess surgical and functional neurological outputs of awake surgery and intraoperative cortical and subcortical electrical stimulation (CSES) and to use CSES to examine the reliability of preoperative functional magnetic resonance (fMRI) and diffusion tensor imaging fiber tracking (DTI-FT) for surgical planning. The role and integration of these techniques is still a matter of debate. Direct cortical and subcortical stimulation is widely used in routine practice, however, because of its ability to reveal tissue function in eloquent regions. Preoperative functional neuroimaging and diffusion tensor imaging can display cortical functional organization and subcortical anatomy of major white matter bundles. Background Localization of brain function is a fundamental requisite for the resection of eloquent-area brain tumors.
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