Techniken/Möglichkeiten des präoperativen Mappings · Jeder Hirntumor beeinflusst die...

U N I V E R S I T Ä T S M E D I Z I N B E R L I N

Seeheim 2014 33. Fort- und Weiterbildungstagung der DGNC

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Techniken/Möglichkeiten des präoperativen Mappings

Neurochirurgische Klinik

Oberflächenanatomie

1. Funktionelle Neuroanatomie

Vorführender

Präsentationsnotizen

Warum präoperatives mapping?


Oberflächenanatomie


Dept. of Neurosurgery

Ius et al. Evidence for potentials and limitations of brain plasticity using an atlas of functional resectability of WHO grade II gliomas: towards a "minimal common brain". Neuroimage, 2011

„Essentielle“ Funktion?



A Raumforderung

Einfluss von Läsionen



A Raumforderung B Funktionelle Reorganisation


18 Monate später





18 Monate später





Takahashi et al. Plastic relocation of motor cortex in a patient with LGG confirmed by NBS. Acta Neurochir. 2012





9 Monate später





9 Monate später

Kawashima A et al. Plastic reshaping of cortical language areas evaluated by nTMS in a surgical case of GBM. Clin Neurol Neurosurg, 2013



Jeder Hirntumor beeinflusst die funktionelle Anatomie

Duffau H, Taillandier L. New concepts in the management of diffuse low-grade glioma: Proposal of a multistage and individualized therapeutic approach. Neuro Oncol. 2014 Aug 2

18 Monate später 9 Monate später 18 Monate später



1. “…patients should not be considered ineligible for surgical intervention based on anatomical considerations alone.”

2. “… neurosurgeons need to take advantage of modern technology and mapping techniques.”

3. “… an individualized approach allows one to expand the number of patients who are considered for surgical intervention.”

Pouratian N, Bookheimer SY. The reliability of neuroanatomy as a predictor of eloquence: a review. Neurosurg Focus, 2010

Schlussfolgerungen



2. Präoperative Funktionsdiagnostik

Methoden

Vorführender


„Best available evidence for making treatment decisions with our patients“


DTI fMRT MEG nTMS


Methoden

Vorführender




1. Zuverlässigkeit Sensitivität und Spezifität wie IOM

2. Integrierbarkeit intuitive Interpretation

3. Verfügbarkeit billig, schnell, einfach

Anforderungen



Faserbahndarstellung DTI





Isotropie




Isotropie Anisotropie




Isotropie Anisotropie Tensor




Frey D et al. A new approach for corticospinal tract reconstruction based on nTMS and standardized fractional anisotropy values. Neuroimage, 2012

Krieg SM et al. Diffusion tensor imaging fiber tracking using navigated brain stimulation--a feasibility study. Acta Neurochir, 2012


Fehlerquellen




fMRT

Ruhe

Aktivierung


BOLD (Blood Oxygen Level Dependent contrast)


Ruhe Aktivierung

p = 0.0001



fMRT


p = 0.0001

Picht T, Suess O et al. fMRI and cortical mapping in motor cortex tumor surgery: complementary methods. Zentralbl Neurochir. 2008


fMRT



p = 0.0001 p = 0.000001

Picht T, Suess O et al. fMRI and cortical mapping in motor cortex tumor surgery: complementary methods. Zentralbl Neurochir. 2008


fMRT



MEG

Tarapore PE, Berger MS et al. Preoperative multimodal motor mapping: a comparison of MEG, nTMS and direct cortical stimulation. J Neurosurg. 2012


Vorführender


FT, 10-15 Tesla Die Magnetenzephalografie (MEG) ist ein nicht-invasives Verfahren zur Messung von magnetischen Feldkomponenten, die durch die Informationsverarbeitung im menschlichen Gehirn entstehen. Durch die sehr hohe zeitliche Auflösung des MEG im Bereich von Millisekunden können auch sehr schnell ablaufende elektrophysiologische Prozesse aufgespürt und analysiert werden


nTMS


neuronale

Aktivierung/Hemmung

elektrisches Feld

Magnet Feld

Spulenstrom


nTMS


Picht T, Suess O et al. nTMS for preoperative functional diagnostics in brain tumor surgery. Neurosurgery. 2009


Reference n comparisons of nTMS and DES

Method of Measurement

Distance (mm) between muscle representations

Other Modalities Compared

Kantelhardt , 2010 1 single hotspots <5 fMRI

Forster, 2011 10 single hotspots (SD) 10.49 (5.67) fMRI

Krieg, 2012 14 stimulation area mean (SD) 4.4 (3.4) fMRI

Tarapore, 2012 8 single hotspots median (SE) 2.13 (0.19) MEG

Coburger, 2012 30 semiquantative - fMRI

Krieg, 2013 24 single hotspots mean (SD)

mean (SD) 4.4 (3.4) fMRI

Mangraviti, 2013 8 single hotspots mean (CI)

APB, FCR, TA 8.47 (4.6) fMRI

Genauigkeit



Test-/Retest Reliability

Reference Modality (no. of comparisons)

Method of Measurement

Distance (mm) between muscle representations

intraobserver interobserver

Havel et al., 2006

fMRI (15 volunteers)

Hand, foot, mouth, tongue

RC 0.06 to 0.62 reproducibility varied with statistical threshold

Rau et al., 2007

fMRI (13 volunteers)

overt naming, + noun generation

overt naming “not reproducible” + noun gen.”reproducible to a certain degree”

Weiss et al., 2012

nTMS (10 volunteers)

APB, mentalis, plantaris, tongue hotspots 10.8±1.9 -

Sollmann et al., 2013

nTMS (10 volunteers) APB hotspots 8.1 ± 3.3 10.3 ± 3.3

Zdunczyk et al., 2013

nTMS (20 volunteers/ patients) APB CoG 4.4 ± 0.46

- 4.89 ± 2.5 5.99 ± 2.7

Sollmann et al., 2013

nTMS (10 volunteers) 7 error types CCC -0.047 to 0.356 CCC -0.135 to 0.559

Forster et al., 2014

nTMS (12 volunteers)

FDI, APB, ED, TA, AH CoG 5.7 ± 3.2 -


Vorführender


highly reliable when mapping the core region of a given target muscle, especially for the hand representation area. In contrast, mapping the spatial extent of a cortical representation area was only little reliable for both nTMS and fMRI Proving the accuracy is only one part of the story. The other question which makes a mapping technology useful in the clinical routine is what about the reliability of the method in non-expert hands and what about its test retest reliability? For that reason we conducted a study where the motor cortex of volunteers and tumor patients was mapped independetly by an expert and by a beginner. The beginner having no experience with motor mapping whatsoever. In addition the mapping was repeated in the healthy volunteers after a week to analyze the repeatability of the mappings. For comparison we used the hot spot as well as the CoG. We foud an excellent repeatability of the results over time and – even more important – we also observed a very good concordance of the mapping results between expert and beginner. In this example it can be seen that although the mapping clusters are quite different, the end result in this case the CoG shows an almost perfect agreement.



Vorführender


highly reliable when mapping the core region of a given target muscle, especially for the hand representation area. In contrast, mapping the spatial extent of a cortical representation area was only little reliable for both nTMS and fMRI Proving the accuracy is only one part of the story. The other question which makes a mapping technology useful in the clinical routine is what about the reliability of the method in non-expert hands and what about its test retest reliability? For that reason we conducted a study where the motor cortex of volunteers and tumor patients was mapped independetly by an expert and by a beginner. The beginner having no experience with motor mapping whatsoever. In addition the mapping was repeated in the healthy volunteers after a week to analyze the repeatability of the mappings. For comparison we used the hot spot as well as the CoG. We foud an excellent repeatability of the results over time and – even more important – we also observed a very good concordance of the mapping results between expert and beginner. In this example it can be seen that although the mapping clusters are quite different, the end result in this case the CoG shows an almost perfect agreement.


3. Einfluss auf Therapieplanung

Vorführender




n = 50

Sentence completion and hand squeeze task

Questionnaires before/after fMRI

► 46% more aggressive approach recommended

► reduced surgical time 16-60 min in 53%

Petrella JR, Shah LM, et al.: Preoperative fMRI localization of language and motor areas: effect on therapeutic decision making in patients with potentially resectable brain tumors. Radiology. 2006


fMRT

Vorführender




n = 60 (53 language, 33 motor) ► altered treatment planning in 35 cases (58%) ► IOM was altered in 31 cases (52%)

Medina LS, et al. Seizure disorders: functional MR imaging for diagnostic evaluation and surgical treatment--prospective study. Radiology. 2005


fMRT

Schulz J et al. Assessment of the influence of nTMS on surgical planning for tumors in or near the motor cortex. Neurosurgery. 2012


nTMS

Vorführender


„8mm rule“ „no-M1“



Kategorie 1: Bestätigung (22%)


Kato et al. Functional Brain Mapping of the Patients with Arteriovenous Malformations using Navigated Transcranial Magnetic Stimulation: First Experience in 11 Patients. Acta Neurochir, 2014


Kategorie 1: Bestätigung (22%)



Kategorie 2: Erkenntnisgewinn ohne Einfluss (23%)



Kategorie 3: Erkenntnisgewinn – IOM Durchführung (27%)



Kategorie 4: Änderung Zugang (17%)



Kategorie 5: geplantes Resektionsausmaß (8%)



Kategorie 6: Indikation (3%)


Schilt et al. Integration of navigated brain stimulation data into radiosurgical planning: potential benefits and dangers. Acta Neurochir, 2014


Kategorie 6: Indikation (3%)


4. Einfluss auf Behandlungsergebnis

Vorführender




Wu JS et al. Clinical evaluation and follow-up outcome of DTI-based functional neuronavigation: a prospective, controlled study in patients with gliomas involving pyramidal tracts. Neurosurgery. 2007

n = 238

gliomas involving pyramidal tract

randomized for DTI (118) vs. no-DTI (120)

► gross total resection 74.4% vs. 33.3%

► permanent motor deficit 15.3% vs. 32.8%

► survival 21.2mt vs. 14.0mt

DTI


Vorführender



Frey et al. Navigated Transcranial Magnetic Stimulation Improves the Treatment Outcome for Tumours in Presumed Motor Eloquent Location . Neuro-Oncology, 2014

nTMS

12.4 mt

15.4 mt 95%

8%

78%

10%

115 non-TMS cases

2005-2007

250 TMS cases

2007-2012


Krieg et al. Preoperative motor mapping by navigated transcranial magnetic brain stimulation improves outcome for motor eloquent lesions. Neuro-Oncology, 2014

26.7cm2

22.4cm2

78%

13%

58%

18%

100 non-TMS cases

2006-2010

100 TMS cases

2010-2013

nTMS


Vorführender


Size of craniotomy nTMS: 22.4+8.3 cm2 non-TMS: 26.7+11.3 cm2 (P = 0.0023) Gross total resection nTMS: 78% non-TMS: 58% (OR 0.3828) New fixed deficit nTMS: 13% nTMS non-TMS: 18% (P = 0.0057)

Neuro Klinik

Zusammenfassung

Vorführender



Neuro Klinik

Zusammenfassung

1.Funktionelle Anatomie nicht anhand Morphologie bestimmbar

2.Tumore induzieren Plastizität 1.DTI: standardisieren, validieren

2.fMRI/MEG: hohe zeitliche Auflösung, Netzwerkanalyse

3.nTMS: gezielte Testung wie IOM, Outcome Verbesserung

Vorführender



Heike Schneider Dietmar Frey Anna Zdunczyk Güliz Acker Brendon Bagley

AG perioperative Funktionsdiagnostik Charité

Sarah Schilt Tizian Rosenstock Nataliia Kulchytska Vera Schwarzer Ina Bährend


Chang EF, Berger MS et al. Functional mapping-guided resection of LGGs in eloquent brain areas: improvement of long-term survival. J Neurosurg. 2011


Vorführender


Part of the risk stratification into eloquent versus non-eloquent lcation can be done outside thr OR!


62% 38%



Vorführender




73%

62% 38%

27%



Vorführender




73%

62% 38%

27%

64% 36%



Vorführender




73%

62% 38%

27%

64% 36%

Months survival



Vorführender




Roessler K, et al. Evaluation of preoperative high magnetic field motor functional MRI (3 Tesla) in glioma patients by navigated electrocortical stimulation and postoperative outcome. J Neurol Neurosurg Psychiatry. 2005

n = 22

(all motor)

→ fMRI identified the primary motor cortex in 100%

→ IOM identified the primary motor cortex in 77% (n=17)


fMRT


„Essentielle“ Funktion?


Techniken/Möglichkeiten des präoperativen Mappings · Jeder Hirntumor beeinflusst die...

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