Tailoring neurophysiological strategies with clinical context enhances resection and safety and expands indications in gliomas involving motor pathways.
BACKGROUND
Resection of motor pathway gliomas requires the intraoperative recognition of essential cortical-subcortical motor structures. The degree of involvement of motor structures is variable, and increases as result of treatments patients are submitted to. Intraoperative neurophysiology offers various stimulation modalities, which efficiency is based on the ability to recognize essential sites with the highest possible resolution in most clinical conditions. Two stimulation paradigms evolved for intraoperative guidance of motor tumors removal: the 60 Hz-technique [low frequency (LF)] and the pulse-technique [high frequency-(HF)], delivered by bipolar or monopolar probe respectively. Most surgical teams rely on to either of the 2 techniques. The key point is the integration of the choice of the stimulation modality with the clinical context.


METHODS
In 591 tumors involving the corticospinal tract, the use of HF and LF was tailored to the clinical context defined by patient clinical history and tumor features (by imaging). The effect was evaluated on the feasibility of mapping, the impact on immediate and permanent morbidity, the extent of resection, and the number of patients treated.


RESULTS
By integrating the choice of the probe and the stimulation protocol with patient clinical history and tumor characteristics, the best probe-frequency match was identified for the different sets of clinical conditions. This integrative approach allows increasing the extent of resection and patient functional integrity, and greatly expands the number of patients who could benefit from surgery.


CONCLUSIONS
The integration of stimulation modalities with clinical context enhances the extent and safety of resection and expands the population of patients who could benefit from surgical treatment.
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Lorenzo
L
Bello
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Marco
M
Riva
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Enrica
E
Fava
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Valentina
V
Ferpozzi
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Antonella
A
Castellano
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Fabio
F
Raneri
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Federico
F
Pessina
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Alberto
A
Bizzi
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Andrea
A
Falini
Neurosurgical Oncology, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Humanitas Clinical and Research Center, Milan, Italy (L.B., M.R., E.F., F.R., F.P.); Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, University of Milan, Humanitas Clinical and Research Center, Milan, Italy (V.F., G.C.); Scientific Institute and University, Ospedale San Raffaele IRCCS, Neuroradiology, CERMAC, Milan, Italy (A.C., A.F.); Neuroradiology, Humanitas Clinical and Research Center, Milan, Italy (A.B.).
Gabriella
G
Cerri
D000293:Adolescent; D000328:Adult; D001931:Brain Mapping; D001932:Brain Neoplasms / Q000473:pathology / Q000601:surgery*; D004525:Efferent Pathways / Q000601:surgery*; D005260:Female; D005910:Glioma / Q000150:complications / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D009044:Motor Cortex / Q000473:pathology / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods; D011712:Pyramidal Tracts / Q000473:pathology / Q000601:surgery; D055815:Young Adult
brain mapping; extent of resection; gliomas; intraoperative neurophysiology; motor pathways; outcome