Introduction: To assess the neurological deficit associated with the surgical resection of brain lesions that involve the eloquent cortex using brain stimulation in order to achieve wider resections with safer margins.

Methods: Follow-up to patients with brain injury related to the premotor eloquent area was made; nine patients who underwent resection of the lesion with standard anesthetic technique, intra operative cortical stimulation with Ossiris stimulator and neuropsychological protocol; the resected volume assessment was performed with a 3 day postoperative CT and follow-up at 3 months with MRI, standardized neuropsychological tests were performed to assess neurological deficit. Initial and monitoring data were recorded and monitored in an Excel 2010 database for further statistical analysis.

Results: Complete resection of the lesion was achieved in 64% of patients. In the follow-up visit three months after surgery, 73% of patients had no neurological deficit associated with the procedure, only three patients (27%) had mild deficit.

Conclusions: Although advances made in anatomic location of brain lesions related to eloquent areas with improving MRI and neuronavigation technology, surgical resection of these lesions poses a high risk of postoperative neurological deficit. Cortical stimulation has been developed as an increasingly useful tool for this type of injury as it opens up the possibility of using it not only to establish a real-time functional map of the cerebral cortex that allows the surgeon to define a safe edge for resection of the lesion but also stimulation of intracranial or intra lesional electrodes can be carried out in epilepsy surgery to determine whether a specific injury is the initial foci for specific seizures. Our results support the usefulness of this tool. Cortical stimulation for resection of brain lesions in eloquent areas is a good tool to preserve neurological function. Moreover, the preoperative cortical stimulation of intra lesion and intracranial electrodes in epilepsy surgery is highly useful to verify location of epileptogenic focus.

Patient Care: Cortical stimulation for resection of brain lesions in eloquent areas is a good tool to preserve neurological function

Learning Objectives: assess the neurological deficit associated with the surgical resection of brain lesions that involve the eloquent cortex using brain stimulation

References: 1. Brell M, Conesa G, Acebes JJ. [Intraoperative cortical mapping in the surgical resection of low-grade gliomas located in eloquent areas]. Neurocirugia (Astur). 2003 Dec;14(6):491-503. 2. Gupta DK, Chandra PS, Ojha BK, Sharma BS, Mahapatra AK, Mehta VS. Awake craniotomy versus surgery under general anesthesia for resection of intrinsic lesions of eloquent cortex--a prospective randomised study. Clin Neurol Neurosurg. 2007 May;109(4):335-43. 3. Holodny AI, Shevzov-Zebrun N, Brennan N, Peck KK. Motor and sensory mapping. Neurosurg Clin N Am. 2011 Apr;22(2):207-18, viii. 4. Bello L, Gallucci M, Fava M, Carrabba G, Giussani C, Acerbi F, et al. Intraoperative subcortical language tract mapping guides surgical removal of gliomas involving speech areas. Neurosurgery. 2007 Jan;60(1):67-80; discussion -2. 5. Kim SS, McCutcheon IE, Suki D, Weinberg JS, Sawaya R, Lang FF, et al. Awake craniotomy for brain tumors near eloquent cortex: correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients. Neurosurgery. 2009 May;64(5):836-45; discussion 345-6. 6. Szelenyi A, Bello L, Duffau H, Fava E, Feigl GC, Galanda M, et al. Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice. Neurosurg Focus. 2010 Feb;28(2):E7. 7. Nabavi A, Goebel S, Doerner L, Warneke N, Ulmer S, Mehdorn M. Awake craniotomy and intraoperative magnetic resonance imaging: patient selection, preparation, and technique. Top Magn Reson Imaging. 2009 Jan;19(4):191-6. 8. Roland J, Brunner P, Johnston J, Schalk G, Leuthardt EC. Passive real-time identification of speech and motor cortex during an awake craniotomy. Epilepsy Behav. 2010 May;18(1-2):123-8. 9. July J, Manninen P, Lai J, Yao Z, Bernstein M. The history of awake craniotomy for brain tumor and its spread into Asia. Surg Neurol. 2009 May;71(5):621-4; discussion 4-5. 10. Kerr PB, Caputy AJ, Horwitz NH. A history of cerebral localization. Neurosurg Focus. 2005 Apr 15;18(4):e1. 11. Boling W, Olivier A, Fabinyi G. Historical contributions to the modern understanding of function in the central area. Neurosurgery. 2002 Jun;50(6):1296-309, discussion 309-10. 12. Phillips CG. Proceedings: Hughlings Jackson Lecture. Cortical localization and "sensori motor processes" at the "middle level" in primates. Proc R Soc Med. 1973 Oct;66(10):987-1002. 13. Bonhomme V, Franssen C, Hans P. Awake craniotomy. Eur J Anaesthesiol. 2009 Nov;26(11):906-12. 14. Pendleton C, Zaidi HA, Chaichana KL, Raza SM, Carson BS, Cohen-Gadol AA, et al. Harvey Cushing's contributions to motor mapping: 1902-1912. Cortex. 2012 Jan;48(1):7-14. 15. Conte V, Baratta P, Tomaselli P, Songa V, Magni L, Stocchetti N. Awake neurosurgery: an update. Minerva Anestesiol. 2008 Jun;74(6):289-92. 16. Schott GD. Penfield's homunculus: a note on cerebral cartography. J Neurol Neurosurg Psychiatry. 1993 Apr;56(4):329-33. 17. Sacko O, Lauwers-Cances V, Brauge D, Sesay M, Brenner A, Roux FE. Awake craniotomy vs surgery under general anesthesia for resection of supratentorial lesions. Neurosurgery. 2011 May;68(5):1192-8; discussion 8-9. 18. Gonzalez-Darder JM, Gonzalez-Lopez P, Talamantes F, Quilis V, Cortes V, Garcia-March G, et al. Multimodal navigation in the functional microsurgical resection of intrinsic brain tumors located in eloquent motor areas: role of tractography. Neurosurg Focus. 2010 Feb;28(2):E5. 19. Tan TK, Leong KW. Awake craniotomy in an intra-operative MRI environment. Anaesthesia. 2009 May;64(5):575-6. 20. Picht T, Kombos T, Gramm HJ, Brock M, Suess O. Multimodal protocol for awake craniotomy in language cortex tumour surgery. Acta Neurochir (Wien). 2006 Feb;148(2):127-37; discussion 37-8. 21. Hoosein S. Eyes wide open: the awake craniotomy for tumour resection: a review. Axone. 2006 Fall;28(1):15-8. 22. Klimek M, Verbrugge SJ, Roubos S, van der Most E, Vincent AJ, Klein J. Awake craniotomy for glioblastoma in a 9-year-old child. Anaesthesia. 2004 Jun;59(6):607-9. 23. Kurimoto M, Asahi T, Shibata T, Takahashi C, Nagai S, Hayashi N, et al. Safe removal of glioblastoma near the angular gyrus by awake surgery preserving calculation ability--case report. Neurol Med Chir (Tokyo). 2006 Jan;46(1):46-50. 24. Manninen PH, Tan TK. Postoperative nausea and vomiting after craniotomy for tumor surgery: a comparison between awake craniotomy and general anesthesia. J Clin Anesth. 2002 Jun;14(4):279-83. 25. Parney IF, Goerss SJ, McGee K, Huston J, 3rd, Perkins WJ, Meyer FB. Awake craniotomy, electrophysiologic mapping, and tumor resection with high-field intraoperative MRI. World Neurosurg. 2010 May;73(5):547-51. 26. Shinoura N, Yoshida M, Yamada R, Tabei Y, Saito K, Suzuki Y, et al. Awake surgery with continuous motor testing for resection of brain tumors in the primary motor area. J Clin Neurosci. 2009 Feb;16(2):188-94. 27. Whittle IR, Borthwick S, Haq N. Brain dysfunction following 'awake' craniotomy, brain mapping and resection of glioma. Br J Neurosurg. 2003 Apr;17(2):130-7. 28. Bollo RJ, Carlson C, Schevon C, Wisoff JH, Devinsky O, Weiner HL. Extraoperative functional mapping and staged resection of supratentorial tumors near eloquent cortex in children. Pediatr Neurosurg. 2009;45(3):175-80. 29. De Benedictis A, Moritz-Gasser S, Duffau H. Awake mapping optimizes the extent of resection for low-grade gliomas in eloquent areas. Neurosurgery. 2010 Jun;66(6):1074-84; discussion 84. 30. Duffau H, Capelle L, Denvil D, Sichez N, Gatignol P, Taillandier L, et al. Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients. J Neurosurg. 2003 Apr;98(4):764-78. 31. Gil-Robles S, Duffau H. Surgical management of World Health Organization Grade II gliomas in eloquent areas: the necessity of preserving a margin around functional structures. Neurosurg Focus. 2010 Feb;28(2):E8. 32. Olsen KS. The asleep-awake technique using propofol-remifentanil anaesthesia for awake craniotomy for cerebral tumours. Eur J Anaesthesiol. 2008 Aug;25(8):662-9. 33. Manninen PH, Balki M, Lukitto K, Bernstein M. Patient satisfaction with awake craniotomy for tumor surgery: a comparison of remifentanil and fentanyl in conjunction with propofol. Anesth Analg. 2006 Jan;102(1):237-42. 34. Shinoura N, Yamada R, Tabei Y, Saito K, Suzuki Y, Yagi K. Advantages and disadvantages of awake surgery for brain tumours in the primary motor cortex: institutional experience and review of literature. Br J Neurosurg. 2011 Apr;25(2):218-24. 35. Khu KJ, Ng WH. Intraoperative swelling leading to neurological deterioration: an argument for large craniotomy in awake surgery for glioma resection. J Clin Neurosci. 2009 Jul;16(7):886-8. 36. Sato K, Kato M. Intraoperative neurological monitoring in awake craniotomy. J Anesth. 2008;22(4):493-7. 37. Carrabba G, Venkatraghavan L, Bernstein M. Day surgery awake craniotomy for removing brain tumours: technical note describing a simple protocol. Minim Invasive Neurosurg. 2008 Aug;51(4):208-10. 38. Costello TG, Cormack JR. Anaesthesia for awake craniotomy: a modern approach. J Clin Neurosci. 2004 Jan;11(1):16-9.