Article
Presurgical navigated TMS motor cortex mapping improves surgical outcome in brain tumor surgery: a pseudo-randomized observational study
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Authors
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Thomas Picht
- Klinik für Neurochirurgie, Charité - Universitätsmedizin Berlin
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Dietmar Frey
- Klinik für Neurochirurgie, Charité - Universitätsmedizin Berlin
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Stefan Thieme
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin
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Stefan Kliesch
- Klinik für Radiologie, Charité - Universitätsmedizin Berlin
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Peter Vajkoczy
- Klinik für Neurochirurgie, Charité - Universitätsmedizin Berlin
| Published: | June 2, 2015 |
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Outline
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Objective: The purpose of this pseudo-randomized observational study was to examine and compare surgical and neurological outcome in two population-based, parallel cohorts from two campuses of the same university hospital, served by a single neurosurgical department, where the only identifiable differentiating characteristic between the two cohorts was a variation in the availability of nTMS mapping and nTMS based tractography for the preoperative work-up.
Method: All brain tumors that were operated on between April 2011 and April 2014 with the aid of intraoperative neurophysiological mapping (IOM) were identified. Only patients with diagnosis of glioma or metastases in the vicinity of the primary motor cortex and/or the pyramidal tract were retained. Key endpoints of the study were a) extent of tumor resection, based on a re-reading of all pre- and postoperative MRI scans by an experienced neuroradiologist and b) functional outcome at three months compared to the presurgical motor status.
Results: Of the 181 cases eligible for study inclusion, 139 were investigated by nTMS and designated the "nTMS & IOM" arm of the study. The 42 patients not pre-operatively investigated by nTMS were designated the "IOM-only" arm. Both study arms were almost identical in terms of patient characteristics, tumor type and location, preoperative motor status and treating physician experience. For patients with metastases (n=38), gross total resection was achieved in all patients. For patients with gliomas (n=127), a significantly greater rate of gross total resections was achieved for patients in the nTMS & IOM arm (61%) compared to the those in the IOM-only arm (45%) and the average residual volume was significantly smaller at 5.9 ml (SD 8.4; range 0-25.2) in the nTMS & IOM cohort vs. 9.6 ml (SD 17.2; range 0-77.9) in the "IOM-only" arm (p < 0.05). With respect to "motor outcome" in the glioma group 13% of patients in the nTMS & IOM and 15% in the IOM-only arm had a new or increased permanent motor deficit.
Conclusions: This study is the first to demonstrate that the improved surgical outcomes after the implementation of nTMS observed in previous historical case-control studies are not caused by any overall improvement in patient care or a paradigm shift toward more aggressive resection but by the additional functional data provided by presurgial nTMS.
