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DOI 10.1007/s00701-012-1357-6
CASE REPORT
Received: 16 February 2012 / Accepted: 6 April 2012 / Published online: 4 May 2012
# Springer-Verlag 2012
Introduction
Literature regarding monitoring of visual functions during
awake resection (AR) of infiltrative gliomas is sparse [2, 3,
12, 17, 18].
We report a case of right-sided temporal grade II oligodendroglioma infiltrating the optic radiation (OR). Direct
electrical stimulation (DES) of OR and navigated threedimensional intraoperative ultrasound (3D-iUS) contributed
to the achievement of an extensive resection and to a satisfactory functional result.
Clinical report
Presentation and examination A 43-year-old man, a medical doctor, initially presented with an epileptic seizure.
Magnetic resonance imaging (MRI) revealed a nonenhancing, hyperintense tumor in his right temporal lobe
(Fig. 1a, b). Digital tensor imaging (DTI) fused with fluidattenuated inversion recovery (FLAIR) MRI sequence
showed infiltration of inferior portion of OR at the level of
atrium of lateral ventricle (Fig. 2a, b). Ophthalmologic
investigation showed no visual deficit. The patients wish
was to preserve as much visual function as possible. An AR
with DES of OR and navigated 3D-iUS was proposed.
Operating procedure General anesthesia was inducted by
using intravenously administered remifentanil and propofol.
A laryngeal mask was used to secure airways. The patient
was positioned on his left side, and his head was fixed in a
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Discussion
For significant improvement of patients prognosis, the resection of LGG tissue should be at least subtotal [11]. However,
surgery of LGG is complicated by frequent infiltration of
cortical and subcortical structures that still may be functional
[1, 4, 16, 20]. Subcortical injuries are often far more devastating than cortical injuries of comparable volume [7]. Therefore,
the eloquent subcortical tracts must be intraoperatively
detected in order to preserve the anatomo-functional connectivity while optimizing the extent of resection [5].
Intraoperative detection of optic radiation
Literature regarding intraoperative neuromonitoring of OR
is sparse, despite the fact that some level of visual field
defect is a frequent occurrence after resection close to this
structure [6, 22].
At the level of atrium of lateral ventricle, all three bundles of OR (anterior bundle, i.e., Mayers loop, central
bundle, and posterior bundle) form the lateral ventricular
wall; resection of this part of OR causes a complete homonymous hemianopia [6].
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Apart from OR tractography implemented into conventional neuronavigation (which can become inaccurate due to
the brainshift) there are three methods of detection and/or
neuromonitoring of the OR during a glioma resection: monitoring of cortically recorded VEPs [9, 13], intraoperatively
updated OR tractography [21, 22], and subcortical OR stimulation in an awake patient [3]. Subcortical stimulation of
OR during AR was first reported by Duffau et al. [3]. OR
constituted the posterior and deep functional boundary of
the resection. The detection of OR helped the surgeon to
avoid postoperative hemianopia in spite of a quadrantopia.
Mapping of visual functions in awake patients without
stating whether visual cortex or visual pathways were stimulated was documented by Serletis and Bernstein [17] and
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Fig. 5 a Initial 3D-iUS image scanned from the dural surface showing
the lower part of the tumor. b 3D-iUS scan performed from the dural
surface during the resection. Center of the yellow cross AEAs. c
Eliminated AEAs. 3D-iUS data were acquired with a miniature probe
inserted within the resection cavity. The tumor was removed; only a
thin rim of edematous brain tissue is present at the bottom of the
resection cavity (center of the yellow cross)
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Fig. 7 Postoperative
automated perimetry. Two days
after surgery: left eye (a), right
eye (b). Three months after
surgery: left eye (c), right eye
(d)
Contrary to older systems, newer 3D-iUS systems provide image quality comparable to high-field MRI [25].
Depiction of glioma tissue is at least as accurate as T2weighted MRI sequences [25]. Intraoperative fusion with
preoperative MRI, and the possibility of intraoperative image rendering in axial, coronal, and sagittal planes make
recognition of brain structures relatively simple [10]; application of anatomical knowledge is rather straightforward.
Presented case
To the best of our knowledge, our case is the second
reported case of DES of OR. Subcortical stimulation
allowed detection of OR. In general, the current intensity
adapted to each patient is determined at eloquent cortex by
progressively increasing the amplitude by 1-mA increments
from a baseline of 2 mA until a functional response is
elicited, with 6 mA as the upper limit for an awake patient
[4, 5]. Subsequently, the same current intensity is used for
subcortical stimulation in the given patient. However, as no
visual (or any other eloquent) cortex was approachable for
DES in our patient, we selected the current intensity
explained by the fact that visual field of the left eye was
minimally affected. Because the visual field was tested with
both eyes open (in order to preserve effective visual
functions), the sparsely affected visual field in the left eye
could preclude the detection of the scotoma in the left upper
hemifield of the right eye.
The method of ultrasound artifact elimination via intracavitary 3D-iUS data acquisition has not been reported
before. In this way of scanning, the column of water between the tip of the miniature probe and scanned tissue at
the bottom of resection cavity was naturally much smaller
than in scanning with a larger probe placed on the brain
surface. AEAs at the bottom of resection cavity were successfully eliminated, and the structures in the medial part of
resection cavity were distinctly depicted.
Conclusions
DES of OR repeatedly elicited phosphenes, and thus
allowed intraoperative OR identification. The intracavitary
3D-iUS data acquisition enabled distinct depiction of the
structures at the median part of resection cavity. Resection
of the residuum involving part of OR would lead to a more
profound visual deficit than the partial quadrantopia. The
patient does not report any change in his visual functions
when compared to the preoperative status. Although a new
visual field deficit could not be completely avoided, the
functional result was satisfactory. However, studies with a
larger number of patients are needed to validate the presented methodology.
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Conflicts of interest None.
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