Publique en esta revista
Información de la revista
Vol. 14. Núm. 6.Enero 2003Páginas 483-538
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Vol. 14. Núm. 6.Enero 2003Páginas 483-538
DOI: 10.1016/S1130-1473(03)70507-7
Estimulación cortical intraoperatoria en el tratamiento quirúrgico de los gliomas de bajo grado situados en áreas elocuentes
Intraoperative cortical mapping in the surgical resec-tion of low-grade gliomas located in eloquent áreas
Visitas
3734
M. Brell, G. Conesa, J.J. Acebes??
Servicio de Neurocirugía. Hospital Universitári de Bellvitge. Barcelona
Este artículo ha recibido
3734
Visitas
Información del artículo
Resumen
Bibliografía
Descargar PDF
Estadísticas
Resumen
Introducción

La selección de pacientes para cirugía en los gliomas de bajo grado, basada en criterios radiológicos, es, en ocasiones, insuficiente, dada la variabilidad individual en la localización de las áreas elocuentes y la preservación de función en el tejido cerebral infiltrado. Evaluamos la seguridad de la técnica de estimulación cortical intraoperatoria en un subgrupo de pacientes con tumores gliales de bajo grado, analizando en qué medida la aplicación de ésta modifica la posibilidad de resecciones completas y la aparición de déficits postquirúrgicos.

Material y métodos

Veinticinco pacientes con gliomas de bajo grado (II/IV OMS) localizados en áreas cerebrales elocuentes fueron intervenidos para exéresis guiada con estimulación cortical intraoperatoria. La cirugía se efectuó bajo anestesia local y sedación o bajo anestesia general sin relajación muscular, en dependencia de la función a explorar. Todas las intervenciones se efectuaron desde una perspectiva oncológica, buscando la resección tumoral máxima, y deteniéndose al hallar tejido cerebral funcionante en la lesión o próximo a ella.

Resultados

Se logró una exéresis completa o parcial máxima en 16 pacientes (64%); en cinco casos (20%) la resección fue parcial, y en el resto (16%), sólo pudo efectuarse biopsia. Los tumores de área motora suplementaria (AMS) y los de la región fronto-opercular, fueron los que con más frecuencia pudieron resecarse completamente. Trece pacientes (52%) presentaron un empeoramiento de su situación neurológica previa, pero en ocho de ellos se observó mejoría progresiva durante los días siguientes, con práctica resolución de la clínica a los 6 meses.

Conclusiones

La estimulación cortical intraoperatoria permite optimizar el grado de resección minimizando las secuelas postoperatorias. La existencia de áreas funcionales y vías subcorticales en el seno de estos tumores es una realidad a tener en cuenta. La localización en región fronto-opercular izquierda y AMS permiten mayor grado de exéresis con menor morbilidad, mientras que las lesiones insulares continúan siendo un reto incluso con el apoyo de esta técnica.

Palabras clave:
Glioma de bajo grado
Estimulación cortical intraoperatoria
Complicaciones
Área cerebral elocuente
Resección quirúrgica
Summary
Introduction

Surgical selection of patients harbo-ring low-grade gliomas based on radiological criteria may be insufficient due to individual variability in eloquent áreas location and to the fact that function can be preserved within infiltrated brain tissue. Brain stimulation mapping safety for patients with low-grade gliomas is evaluated, analyzing whether this technique modifies the extent of resection and minimizes postope-rative déficits.

Material and methods

Twenty-five patients with low-grade gliomas (II/IV WHO) located in eloquent áreas underwent tumor resection with the aid of intraoperative mapping. Patients underwent surgery under local or general anesthesia depending on the neurological function to be explored. All procedures were performed from an oncological point of view, trying to achieve a radical tumor resection but stopping removal whenever functional tissue was found within or near the lesión.

Results

Total or subtotal resection was achieved in 16 patients (64%); in five cases (20%) resection was partial, and in the remaining (16%) only a biopsy was obtained. Tumors located in the supplementary motor área (SMA) or in the operculum were those which could be more often totally resected. Thirteen patients (52%) experienced neurological worsening immediately after surgery but eight of them had almost completely reco- vered six months after the procedure.

Conclusions

Intraoperative functional mapping can optimize extent of resection minimizing permanent morbidity. Functional tissue can be found within the inñltrated brain and this must be considered in the pre-surgical planning. SMA and opercular tumors allow radical resection with low morbidity whereas insular tumors remain a challenge even with the aid of this technique.

Key words:
Low-grade glioma
Intraoperative cortical mapping
Complications
Eloquent brain regions
Surgical resection
El Texto completo solo está disponible en PDF
Bibliografía
[1.]
J. Bampoe,M. Bernstein
The role of surgery in low grade gliomas
J Neurooncol, 42 (1999), pp. 259-269
[2.]
M.S. Berger
Functional mapping-guided resection of low-grade gliomas
Clin Neurosurg, 42 (1995), pp. 437-452
[3.]
M.S. Berger,A.V. Deliganis,J. Dobbins,G.E. Keles
The effect of extent of resection on recurrence in patients with low grade cerebral hemisphere gliomas
Cancer, 74 (1994), pp. 1784-1791
[4.]
M.S. Berger,R.C. Rostomily
Low grade gliomas: Functional mapping resection strategies, extent of resection, and outcome
J Neurooncol, 34 (1997), pp. 85-101
[5.]
R.G. Bittar,A. Olivier,A.F. Sadikot
Localization of somatosensory function by using positron emission tomography scanning: a comparison with intraoperative cortical stimulation
J Neurosurg, 90 (1999), pp. 478-483 http://dx.doi.org/10.3171/jns.1999.90.3.0478
[6.]
A.M. Cabantog,M. Bernstein
Complications of first craniotomy for intra-axial brain rumors
Can J Neurol Sci, 21 (1994), pp. 213-218
[7.]
C. Cedzich,M. Taniguchi,S. Schafer,J. Schramm
Somatosensory evoked potential phase reversal and direct motor cortex stimulation during surgery in and around the central región
Neurosurgery, 38 (1996), pp. 962-970
[8.]
R.A. Danks,L.S. Aglio,L.D. Gugino,P. Black
McL.: Craniotomy under local anesthesia and monitored conscious sedation for the resection of rumors involving eloquent cortex
J Neurooncol, 49 (2000), pp. 131-139
[9.]
H. Duffau
Acute functional reorganization of the human motor cortex during resection of central lesions: a study using intraoperative brain mapping
J Neurol Neurosurg Psychiatry, 20 (2001), pp. 2159-2163
[10.]
H. Duffau,L. Capelle,D. Denvil
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, 98 (2003), pp. 764-778 http://dx.doi.org/10.3171/jns.2003.98.4.0764
[11.]
H. Duffau,L. Capelle,M. Lopes,A. Bitar,J.P. Sichez,R. Van Effenterre
Medically intractable epilepsy from insular low-grade gliomas: improvement after extended lesionectomy
Acta Neurochir, 144 (2002), pp. 563-573 http://dx.doi.org/10.1007/s00701-002-0941-6
[12.]
H. Duffau,L. Capelle,J. Sichez
Intra-operative direct electrical stimulations of the central nervous system: the Salpetriere experience with 60 patients
Acta Neurochir (Wien), 141 (1999), pp. 1157-1167
[13.]
H. Duffau,L. Capelle,N. Sichez
Intraoperative mapping of the subcortical language pathways using direct stimulations An anatomo-functional study
Brain, 125 (2002), pp. 199-214
[14.]
H. Duffau,D. Denvil,L. Capelle
Long tenn reshaping of language, sensory, and motor maps after glioma resection: a new parameter to intégrate in the surgical strategy
J Neurol Neurosurg Psychiatry, 72 (2002), pp. 511-516
[15.]
D.M. Eddy
Clinical decisión making: from therapy to practice Designing a practice policy. Standards, guidelines, and options
Jama, 263 (1990), pp. 3077-3084
[16.]
D.B. Fitzerald,G.R. Cosgrove,S. Ronner
Location of language in the cortex: a comparison between functional MR Imaging and electrocortical stimulation
Ajnr, 18 (1997), pp. 1529-1539
[17.]
D. Fontaine,L. Capelle,H. Duffau
Somatotopy of the supplementary motor área: evidence from correlation of the extent of surgical resection with the clinical patterns of déficit
Neurosurgery, 50 (2002), pp. 297-305
[18.]
M.M. Haglund,M.S. Berger,M. Shamseldin,E. Lettich,G.A. Ojemann
Cortical localization of temporal lobe language sites in patients with gliomas
Neurosurgery, 34 (1994), pp. 567-576
[19.]
K. Herholz,H.J. Reulen,H.M. von Stockhausen
Preoperative activation and intraoperative stimulation of language related áreas in patients with glioma
Neurosurgery, 41 (1997), pp. 1253-1260
[20.]
G.E. Keles,K.R. Lamborn,M.S. Berger
Low-grade hemispheric gliomas in adults: a critical review of extent of resection as a factor influencing outcome
J Neurosurg, 95 (2001), pp. 735-745 http://dx.doi.org/10.3171/jns.2001.95.5.0735
[21.]
A. Krainik,S. Lehéricy,H. Duffau
Postoperative speech disorder after medial frontal surgery Role of the supplementary motor área
Neurology, 60 (2003), pp. 587-594
[22.]
W.L. Lanier
Brain tumor resection in the awake patient (editorial)
Mayo Clin Proc, 76 (2001), pp. 670-672 http://dx.doi.org/10.4065/76.7.670
[23.]
P.G. Matz,C. Cobbs,M.S. Berger
Intraoperative cortical mapping as a guide to the surgical resection of glioma
JNeurooncol, 42 (1999), pp. 233-245
[24.]
F.B. Meyer,L.M. Bates,S.J. Goerss
Awake craniotomy for aggressive resection of primary gliomas located in eloquent brain
Mayo Clin Proc, 76 (2001), pp. 677-687 http://dx.doi.org/10.4065/76.7.677
[25.]
R. Miralbell,J. Balart,J. Matías-Guiu,J. Molet,A. Ariza,J. Craven-Bartle
Radiotherapy for supratentorial low-grade gliomas: results and prognostic factors with special focus on tumor volume parameters
Radiother Oncol, 27 (1993), pp. 112-116
[26.]
J.G. Ojemann,J.W. Mille, r,D.L. Silbergeld
Preserved function in brain invaded by tumor
Neurosurgery, 39 (1996), pp. 253-258
[27.]
A. Peraud,M. Meschede,W. Eisner,J. Ilmberger,H.J. Reulen
Surgical Resection of grade II astrocytomas in the superior frontal gyrus
Neurosurgery, 50 (2002), pp. 966-977
[28.]
J. Pujol,G. Conesa,J. Deus,L. Lopez-Obarrio,F. Isamat,A. Capdevila
Clinical application of functional magnetic resonance imaging in presurgical identification of the central sulcus
J Neurosurg, 88 (1998), pp. 863-869 http://dx.doi.org/10.3171/jns.1998.88.5.0863
[29.]
L.D. Recht,R. Lew,T.W. Smith
Suspected low-grade glioma: Is deferring treatment safe?
Ann Neurol, 46 (1989), pp. 1238-1239
[30.]
F.E. Roux,K. Boulanouar,J.P. Ranjeva
Usefulness of motor functional MRI correlated to cortical mapping in Rolandic low-grade astrocytomas
Acta Neurochir. (Wien), 141 (1999), pp. 71-79
[31.]
S.M. Russell,P.J. Kelly
Incidence and clinical evolution of postoperative deficits after volumetric stereotactic resection of glial neoplasms involving the supplementary motor área
Neurosurgery, 52 (2003), pp. 506-516
[32.]
R. Sawaya,M. Hammoud,D. Schoppa
Neu- rosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors
Neurosurgery, 42 (1998), pp. 1044-1055
[33.]
H. Schiffbauer,M.S. Berger,P. Ferrari,D. Freudenstein,H.A. Rowley,T.P. Roberts
Preoperative magnetic source imaging for brain tumor surgery: a quantitative comparison with intraoperative sensory and motor mapping
J Neurosurg, 97 (2002), pp. 1333-1342 http://dx.doi.org/10.3171/jns.2002.97.6.1333
[34.]
H. Schiffbauer,P. Ferrari,H.A. Rowley,M.S. Berger,T.P. Roberts
Functional activity within brain tumors: a magnetic source imaging study
Neurosurgery, 49 (2001), pp. 1313-1320
[35.]
Y. Shibamoto,Y. Kitakabu,M. Takahashi
Supratentorial low-grade astrocytoma Correlation of computed tomography findings with effect of radiation therapy and prognostic variables
Cancer, 72 (1993), pp. 190-195
[36.]
D.C. Shrieve,E.I.I.L. Alexander,P.M. Black
Treatment of patients with primary glioblastoma multiforme with standard postoperative radiotherapy and radiosurgical boost: prognostic factors and long-term outcome
J Neurosurg, 90 (1999), pp. 72-77 http://dx.doi.org/10.3171/jns.1999.90.1.0072
[37.]
S. Skirboll,G.A. Ojemann,M.S. Berger,E. Lettich,H.R. Winn
Functional cortex and subcortical white matter located within gliomas
Neurosurgery, 38 (1996), pp. 678-685
[38.]
M.D. Taylor,M. Bernstein
Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases
J Neurosurg, 90 (1999), pp. 35-41 http://dx.doi.org/10.3171/jns.1999.90.1.0035
[39.]
J.L. Ulmer,H.G. Krouwer,W.M. Mueller,M.S. Ugurel,M. Kocak,L.P. Mark
Pseudo-Reorganization of lan guage cortical function at fMR imaging: a consequence of tumor-induced neurovascular uncoupling
AJNR, 24 (2003), pp. 213-217
[40.]
K.P. Vives,J.M. Piepmeier
Complications and expected outcome of glioma surgery
J Neurooncol, 42 (1999), pp. 289-302
[41.]
G. Wunderlich,U. Knorr,H. Herzog,J.C. Kiwit,H.J. Freund,R.J. Seitz
Precentral glioma location determines the displacement of cortical hand representation
Neuro- Estimulación cortical surgery, 42 (1998), pp. 18-26
[42.]
M.G. Yasargil,K. von Ammon,E. Cavazos,T. Doczi,J.D. Reeves,R. Roth
Tumors of the limbic and paralimbic systems
Acta Neurochir. (Wien), 118 (1992), pp. 40-52
[43.]
J. Zentner,B. Meyer,A. Stangl,J. Schramm
Intrinsic tumors of the Ínsula: a prospective surgical study of 30 patients
J Neurosurg, 85 (1996), pp. 263-271 http://dx.doi.org/10.3171/jns.1996.85.2.0263

Brell, M.; Conesa, G.; Acebes, J.J.: Estimulación cortical mtraoperatoria en el tratamiento quirúrgico de los gliomas de bajo grado situados en áreas elocuentes. Neurocirugía 2003; 14:491–503.

Copyright © 2003. Sociedad Española de Neurocirugía
Idiomas
Neurocirugía

Suscríbase al Newsletter

Opciones de artículo
Herramientas
Política de cookies
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí.

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?