Strategies for resection of lesions in the motor area: preliminary results in 42 surgical patients

Abstract

-In recent years considerable technological advances have been made with the purpose of i m p roving the surgical results in the treatment of eloquent lesions. The overall aim of this study is to evaluate the postoperative surgical outcome in 42 patients who underwent surg e ry to remove lesions aro u n d the motor cortex, in which preoperative planning by using neuroimaging exams, anatomical study, appropriate micro s u rg e ry technique and auxiliary methods such as cortical stimulation were perf o rmed. Tw e n t ytwo patients (52.3%) presented a normal motor function in the preoperative period. Of these, six developed transitory deficit. Twenty patients (47.6%) had a motor deficit pre o p e r a t i v e l y, nevertheless 90% of these improved postoperatively. Surg e ry in the motor area becomes safer and more effective with pre o perative localization exams, anatomical knowledge and appropriate micro s u rg e ry technique. Cortical stimulation is important because it made possible to maximize the resection reducing the risk of a motor deficit. Stereotaxy method was useful in the location of subcortical lesions.KEY WORDS: motor cortex, mapping, stimulation, stereotaxic techniques, preoperative planning.Estratégias para ressecção de lesões em área motora: resultados pre l i m i n a resem 42 pacientes operados RESUMO -Nos últimos anos, consideráveis avanços tecnológicos, principalmente métodos de localização funcional do córtex cerebral, têm surgido no sentido de melhorar os resultados cirúrgicos no tratamento de lesões em áreas eloqüentes. O objetivo deste estudo é avaliar os resultados pós-operatórios em 42 pacientes submetidos à ressecção de lesões em área motora, utilizando-se de planejamento com exames de neuroimagem, conhecimento anatômico, técnica micro c i r ú rgica adequada e métodos auxiliares a exemplo do estimulador cortical. Vinte e dois pacientes (52,3%) apresentavam força muscular normal no pré-operatório. Destes, seis apresentaram déficit motor transitório. Vinte pacientes (47,6%) tinham déficit motor no pré-operatório, mas 90% destes apresentaram melhora no pós-operatório. A ciru rgia em áre a motora se torna mais segura e eficaz com a utilização de planejamento pré-operatório baseado nos exames de imagem, conhecimento anatômico e técnica micro c i r ú rgica adequada. A utilização de estimulador c o rtical é importante para maximizar a ressecção minimizando o risco de déficit motor. A estereotaxia foi útil na localização de lesões subcorticais.PA L AV R A S -C H AVE: c ó rtex motor, mapeamento, estimulação, técnicas estereotáxicas, planejamento pré-operatório.

Relationship between the coronal suture and the central lobe: how important is it and how can we use it in surgical planning?

“…There are many ways to identify this important landmark 1,5,[7][8][9] . The use of the coronal suture as a point of reference, and especially, its relationship to the sulcus of the lateral surface of the frontal lobe, allows to estimate the assessment of the projection on the cranium of the superficial cerebral lesions, with the purpose of delimiting the surgical access and to guide the approach to the cerebral convexity.…”

“…However, manipulation in an eloquent area increases the risk of pos surgical complications and deficits. A knowledge of the morphological relationship of this lobe and its relationship to the craniometric points and sutures facilitates the approach to the lesion preserving neurovascular structures [1][2][3][4][5][6] . exact and correct localization of the central sulcus becomes crucial.…”

The Role of the Intraoperative Auxiliary Methods in the Resection of Motor Area Lesions

“…Although technology already offers modern intraoperative localization tools such as MRI and neuronavigation, anatomical knowledge remains an important part of surgical planning. [12][13][14][15] Craniotomy planning is an essential step in approaching motor area lesions. Paul Broca (1824-1880) was the first neurosurgeon to perform a craniotomy based on anatomical localization.…”

“…19 Radiological data and anatomical landmarks can provide a projected image of the lesion on the scalp, which influences patient position, the size and conformation of the surgical incision, and the location and extent of the craniotomy. 12,20,21 Exposure of brain surface is necessary to identify the relationship between the lesion and the motor gyrus, veins, and arteries (►Fig. 6a).…”

“…[9][10][11] Despite increased use of such techniques, the anatomical knowledge and the use of precise neurosurgical techniques still play a decisive role in the attempt to preserve the full integrity of vascular structures and decrease the risk of functional deficits. [12][13][14][15] The aim of this study was to explore which of the abovementioned methods is best in the resection of motor area lesions. We also investigated the relationship between methods used and the development of postoperative motor deficits.…”