Romanian Neurosurgery (Mar 2021)
The impact and causes of negative cortical mapping in primary motor area tumours
Abstract
Introduction: Intraoperative neurophysiological monitoring is the golden standard for lesions located in eloquent areas of the brain. On the one hand, positive mapping offers a view of the relationship between the anatomo-functional cortical organisation of the patient and the lesion, facilitating the choice of the cerebrotomy entry point and the resection until the functional borders are found. On the other hand, negative mapping does not offer certainty that the absence of the motor response, from the operative field, is the real feedback or is the result of the false-negative response. In such a situation, a differentiation between those two must be done. Materials and methods: We evaluated the results of direct cortical stimulation of lesion located in or near the primary motor area, which were diagnosticated with contrast-enhancement head MRI and admitted to the Third Department of Neurosurgery, "Prof. Dr N. Oblu” Emergency Clinical Hospital, Iasi, Romania, between January 2014 and July 2018. Special attention was given especially to the negative mapping cases, regarding the histological type, imagistic localisation, symptoms and neurological outcome immediate postoperative, at 6 months and one-year follow-up. Results: From all 66 patients meeting the inclusion and exclusion criteria in 9,09% (6 cases) we did not obtain any motor response after direct cortical stimulation. The imagistic localisations of those cases were: 3 – Rolandic, 2 – pre-Rolandic and one retro-Rolandic. Tumors histological types were: glioblastoma, anaplastic astrocytoma, oligoastrocytoma and oligodendroglioma each one case and two cases of fibrillary astrocytoma. The intensity range was between 6 – 18mA, the mode – 12mA and the median – 10mA. Postoperatively the neurological condition of 3 patients worsened (4,54% from all the cases), while 3 had a favourable evolution with symptom remission. At 6monts and one-year follow-up in one case (1,51%), we observed no improvement in contrast with the other two, where dysfunction remission was highlighted. Conclusion: The possible technical, surgical and anesthesiologic causes of false-negative motor response must be eliminated to be able to differentiate from the real absence of the functional area from the operative field. In the first scenario, the resection may be associated with permanent postoperative neurologic deficit and major life quality alteration while in the second one the patient presents no motor dysfunction after surgery and the resection may be extensive with multiple oncological benefits.
