title: Cortical plasticity catalyzed by prehabilitation enables extensive resection of brain tumors in eloquent areas.
abstract: OBJECTIVE The extent of resection is the most important prognostic factor following brain glioma surgery. However, eloquent areas within tumors limit the extent of resection and, thus, critically affect outcomes. The authors hypothesized that presurgical suppression of the eloquent areas within a tumor by continuous cortical electrical stimulation, coupled with appropriate behavioral training ("prehabilitation"), would induce plastic reorganization and enable a more extensive resection. METHODS The authors report on 5 patients harboring gliomas involving eloquent brain areas within tumors as identified on intraoperative stimulation mapping. A grid of electrodes was placed over the residual tumor, and continuous cortical electrical stimulation was targeted to the functional areas. The stimulation intensity was adjusted daily to provoke a mild functional impairment while the function was intensively trained. RESULTS The stimulation intensity required to impair function increased progressively in all patients, and all underwent another operation a mean of 33.6 days later (range 27-37 days), when the maximal stimulation voltage in all active contacts induced no functional deficit. In all cases, a substantially more extensive resection of the tumor was possible. Intraoperative mapping and functional MRI demonstrated a plastic reorganization, and most previously demonstrated eloquent areas within the tumor were silent, while there was new functional activation of brain areas in the same region or toward the contralateral hemisphere. CONCLUSIONS Prehabilitation with continuous cortical electrical stimulation and appropriate behavioral training prior to surgery in patients with WHO Grade II and III gliomas affecting eloquent areas accelerate plastic changes. This can help maximize tumor resection and, thus, improve survival while maintaining function.
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Paola A
authors.initials: PA
authors.lastname: Rivera-Rivera
authors.affiliation: Department of Radiology, Hospital Ruber Internacional, Madrid.|Department of Basic Psychology II, UNED, Madrid.|Brain Damage Unit, Hospital Beata María Ana, Madrid, Spain.
authors.forename: Marcos
authors.initials: M
authors.lastname: Rios-Lago
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Sandra
authors.initials: S
authors.lastname: Sanchez-Casarrubios
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Osman
authors.initials: O
authors.lastname: Salazar
authors.affiliation: Radiology, and.
authors.forename: Miguel
authors.initials: M
authors.lastname: Yus
authors.affiliation: Neurophysiology, San Carlos Institute of Health Research (IdISSC), Hospital Clínico San Carlos de Madrid, Universidad Complutense de Madrid.
authors.forename: Mercedes
authors.initials: M
authors.lastname: González-Hidalgo
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Ana
authors.initials: A
authors.lastname: Sanz
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Josué
authors.initials: J
authors.lastname: Avecillas-Chasin
authors.affiliation: Department of Radiology, Hospital Ruber Internacional, Madrid.
authors.forename: Juan
authors.initials: J
authors.lastname: Alvarez-Linera
authors.affiliation: Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.|Institut Guttmann, Universitat Autonoma, Barcelona; and.
authors.forename: Alvaro
authors.initials: A
authors.lastname: Pascual-Leone
authors.affiliation: Department of Neurology and FENNSI group, Hospital Nacional de Parapléjicos, Toledo, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Oliviero
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Juan A
authors.initials: JA
authors.lastname: Barcia
mesh_terms: D000328:Adult; D001931:Brain Mapping; D001932:Brain Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D002540:Cerebral Cortex / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D004599:Electric Stimulation Therapy; D005260:Female; D005910:Glioma / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D009434:Neural Pathways / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology / Q000601:surgery; D000066530:Neurological Rehabilitation / Q000379:methods*; D009473:Neuronal Plasticity / Q000502:physiology; D019635:Neurosurgical Procedures; D011183:Postoperative Complications / Q000517:prevention & control; D011300:Preoperative Care / Q000379:methods; D016896:Treatment Outcome
keywords: ECSM = extraoperative cortical stimulation mapping; ICSM = intraoperative cortical stimulation mapping; brain plasticity; cCES = continuous cortical electrical stimulation; cortical stimulation; diagnostic and operative techniques; eloquent cortical areas; fMRI = functional MRI; glioma surgery; neurooncology; oncology; preservation of brain functions; rTMS = repetitive transcranial magnetic stimulation; sMRI = structural MRI