Barbara Santini

Cognitive outcome as part and parcel of clinical outcome in brain tumor surgery

Although validated tools (neuropsychological tests, patient reported outcomes, mood and psychological profile) were first introduced many years ago in clinical practice, the impact of the tumor itself on patient cognition has not been extensively studied. Furthermore, while outcome research is evolving in an attempt to adapt the use of different tools to the preoperative and postoperative phases, the standard guidelines for evaluating outcome after brain surgery, by neurological examination and complication assessment, are frequently neglected in the current literature. This article attempts to provide an appraisal of the evidence for the impact of surgical treatment on cognitive function of brain tumor patients within the context of general outcome.

Awake surgery between art and science. Part II: language and cognitive mapping

Direct cortical and subcortical stimulation has been claimed to be the gold standard for exploring brain function. In this field, efforts are now being made to move from intraoperative naming-assisted surgical resection towards the use of other language and cognitive tasks. However, before relying on new protocols and new techniques, we need a multi-staged system of evidence (low and high) relating to each step of functional mapping and its clinical validity. In this article we examine the possibilities and limits of brain mapping with the aid of a visual object naming task and various other tasks used to date. The methodological aspects of intraoperative brain mapping, as well as the clinical and operative settings, were discussed in Part I of this review.

Eligibility criteria and psychological profiles in patient candidates for awake craniotomy: a pilot study.

Background: Although generally well tolerated, awake craniotomy is burdened by non-negligible failure rates. The aim of this pilot study was to verify the feasibility of a wider research scope to define objective criteria for patient exclusion and the risk of intraoperative mapping failures. Methods: Twenty-one patients with brain tumors were subjected to a procedure in 3 steps: neuropsychological criteria for both cognition and language; psychological questionnaires for anxiety, attitude to pain and depression, and psychophysiological monitoring for the candidate’s capacity for self-control; and an intraoperative interview for the patient’s perception during awake procedure. Outcome measures were as follows: (1) patient compliance, defined as patient response to the intraoperative procedure and measured by psychological scale scores for fear and pain, and (2) failure, defined as the impossibility to complete brain mapping (minor) or conversion to general anesthesia (major). Data analysis included the description of preoperative and intraoperative assessments and their evaluation (Spearman &rgr; test), and the prognostic factors for intraoperative compliance and procedure failure (Mann-Whitney test). Results: Three patients were considered ineligible after the first step. In the remaining 18, the responses of 10 patients fell within the normal range and 8 showed some degree of impairment on at least 1 preoperative evaluation, but not enough to be excluded from awake surgery. The data analysis also showed that fear of pain correlated with pain felt during the operation and preoperatively with depression and psychophysiological changes, the latter of which was associated with fear felt during craniotomy. Minor failures occurred in 2 patients. Conclusions: From these preliminary results, we observed that warning signs for minor failure were fear of pain and anxiety, as revealed by psychological questionnaire responses, and the incapability of self-control at psychophysiological monitoring. This assessment may serve to fit mapping modality to the single patient and to avoid complications.

Language testing in brain tumor patients

Neuropsychological testing is not a luxury in the management of patients with brain tumors. Regardless of the therapeutic approach selected in each case (but, especially in the case of awake surgery), it provides information on the status of language and other cognitive functions. This information can be used preoperatively to identify eloquent areas and to provide a baseline against which further examinations can be evaluated, intraoperatively to identify eloquent areas, and post-operatively and at follow-up to ascertain the short-term and long-term consequences of surgery, as well as those of other treatments (chemotherapy and radiotherapy), and to plan and monitor rehabilitative treatments.

Awake surgery between art and science. Part I: clinical and operative settings

Awake surgery requires coordinated teamwork and communication between the surgeon and the anesthesiologist, as he monitors the patient, the neuroradiologist as he interprets the images for intraoperative confirmation, and the neuropsychologist and neurophysiologist as they evaluate in real-time the patients responses to commands and questions. To improve comparison across published studies on clinical assessment and operative settings in awake surgery, we reviewed the literature, focusing on methodological differences and aims. In complex, interdisciplinary medical care, such differences can affect the outcome and the cost-benefit ratio of the treatment. Standardization of intraoperative mapping and related controversies will be discussed in Part II.

Intraoperative cortical mapping of visuospatial functions in parietal low-grade tumors: changing perspectives of neurophysiological mapping

OBJECT The aim of this study was to explore the feasibility of intraoperative visuospatial mapping with the same criteria currently used to define essential language areas. METHODS The authors compared surgical procedures in 2 patients with similar tumors (Grade II oligodendroglioma in the right parietal lobe) undergoing awake, image-assisted surgery for lesion removal with intraoperative neurophysiological monitoring. The line bisection task was used in both patients but with different criteria. RESULTS In the first case, the authors respected any area, even within the tumor, where significant interference was found (a stimulation-induced error in 2 of 3 applications defined an essential area). In the second case, they removed 1 essential area located in the tumor and recorded an uneventful clinical response soon thereafter. They continued to monitor the patient without stimulation and stopped the resection when the patient was close to the criteria valid for defining spatial neglect. The signs of spatial neglect were present for 3 days postoperatively and then cleared spontaneously. Subtotal tumor removal was achieved in both cases. CONCLUSIONS Evidence in the present study reveals that areas for visuospatial functions cannot be assessed with the same criteria used for language functions, since essential areas located in the tumor can be safely removed.

Pre- and post-operative assessment of visuo-spatial functions in right hemisphere tumour patients: a pilot study

Patients with neglect fail to report, respond to, or orient to stimuli presented on the opposite side of the brain lesion. Spatial neglect is a multi-componential syndrome and many of its symptoms and signs need specific testing to detect their different clinical manifestations. Given that neglect has a dramatic effect on the outcome of these patients, it is of paramount importance for accurate assessment all its manifestations. Thus, the purpose of this study is to assess visuo-spatial functions with a newly-built neuropsychological battery to determine the incidence of visuo-spatial disorders and spatial neglect in patients with right brain tumour. We tested 14 patients undergoing tumour resection, both pre-operatively and post-operatively. Pre-operatively, we found an incidence of 42.86% for visuo-spatial deficits and of 14.29% specifically for spatial neglect. This incidence increases post-operatively to 57.14% for visuo-spatial deficits and to 42.86% specifically for spatial neglect. The present study has important implications for a better knowledge of the spatial disorders in patients with right-brain tumour, thus providing a clearer picture on the everyday life problems faced by these patients, both within the family and in working contexts.

Mapping nouns and finite verbs in left hemisphere tumors: a direct electrical stimulation study

ABSTRACT Neurosurgical mapping studies with nouns and finite verbs are scarce and subcortical data are nonexistent. We used a new task that uses finite verbs in six Italian-speaking patients with gliomas in the left language-dominant hemisphere. Language-relevant positive areas were detected only with nouns in four patients, with both tasks yet in distinct cortical areas in one patient, and only with finite verbs in another patient. Positive areas and types of errors varied across participants. Finite verbs provide complementary information to nouns, and permit more accurate mapping of language production when nouns are unaffected by electrical stimulation.

Language in individuals with left hemisphere tumors: Is spontaneous speech analysis comparable to formal testing?

ABSTRACT Background: The relationship between spontaneous speech and formal language testing in people with brain tumors (gliomas) has been rarely studied. In clinical practice, formal testing is typically used, while spontaneous speech is less often evaluated quantitatively. However, spontaneous speech is quicker to sample and may be less prone to test/retest effects, making it a potential candidate for assessing language impairments when there is restricted time or when the patient is unable to undertake prolonged testing. Aim: To assess whether quantitative spontaneous speech analysis and formal testing detect comparable language impairments in people with gliomas. Specifically, we addressed (a) whether both measures detected comparable language impairments in our patient sample; and (b) which language levels, assessment times, and spontaneous speech variables were more often impaired in this subject group. Method: Five people with left perisylvian gliomas performed a spontaneous speech task and a formal language assessment. Tests were administered before surgery, within a week after surgery, and seven months after surgery. Performance on spontaneous speech was compared with that of 15 healthy speakers. Results: Language impairments were detected more often with both measures than with either measure independently. Lexical–semantic impairments were more common than phonological and grammatical impairments, and performance was equally impaired across assessment time points. Incomplete sentences and phonological paraphasias were the most common error types. Conclusions: In our sample both spontaneous speech analysis and formal testing detected comparable language impairments. Currently, we suggest that formal testing remains overall the better option, except for cases in which there are restrictions on testing time or the patient is too tired to undergo formal testing. In these cases, spontaneous speech may provide a viable alternative, particularly if automated analysis of spontaneous speech becomes more readily available in the future. These results await replication in a bigger sample and/or other populations.

Surgical Treatment of Supratentorial Glioma in Eloquent Areas

Andrea Talacchi1, Giovanna Maddalena Squintani2, Barbara Santini1, Francesca Casagrande3, Francesco Procaccio3, Franco Alessandrini4, Giada Zoccatelli4, Vincenzo Tramontano1, Aurel Hasanbelliu1 and Massimo Gerosa1 1Institute of Neurosurgery, 2Neurological Unit, Department of Neuroscience; 3Neurosurgical Intensive Care Unit, Department of Emergency and Intensive Care; 4Neuroradiological Unit, Department of Radiology; University Hospital, Verona, Italy