Neuroplasticity and Epilepsy Surgery in Brain Eloquent Areas: Case Report

Abstract

Introduction: Neuronal plasticity includes changes in any component of the central nervous system in response to intrinsic or extrinsic stimuli. Brain functions that depend on the epileptogenic cortex pose a challenge in epilepsy surgery because many patients are excluded from pre-surgical evaluation for fear of the possible sequelae. Some of these patients may be rescued by enhancing neuronal plasticity with brain neuromodulation techniques. Case Report: We describe a 6-year-old child with refractory focal motor seizures symptomatic to a neuroepithelial dysembryoblastic tumor in the left temporo-parietal region. He underwent limited resection of the lesion in order to avoid sequelae in his language function. A functional study at age of 17 years revealed an overlap of Wernicke's area with the tumor and areas of incipient language reorganization in the contralateral hemisphere. An invasive neuromodulation procedure was designed to enhance neuroplasticity. After craniotomy, he underwent language training and simultaneous electrical inhibition of language using an electrode grid placed over the lesion. The intensity of the language inhibitory stimulus was increased every day to force the use of accessory language areas in the right hemisphere by neuroplasticity. Results: The language of the patient improved for six consecutive days until he was able to speak and understand while undergoing maximum electrical inhibition. The tumor was resected using a cortical mapping guide. Discussion: Application of direct cortical stimulation techniques and language pre-habilitation before epilepsy surgery can be useful to rescue patients excluded from resective surgery, especially young patients with long-term lesions.

Neuromodulation-induced prehabilitation to leverage neuroplasticity before brain tumor surgery: a single-cohort feasibility trial protocol

“…Pioneering efforts have been made in the field, with the publication of four articles (three case reports and one case series) where NICP was undertaken by a total of seven patients with brain tumor ( 2 , 5 – 7 ). A common element was neuromodulation coupled with behavioral training: Neuromodulation provokes temporary inhibition (virtual lesion) of eloquent areas, while behavioral training (cognitive/speech or motor training) promotes the activation of alternative brain resources.…”

“…However, the main limitations were the need to perform two surgeries and the relatively high rate of adverse events (focal seizure, osteomyelitis, epidural abscess, intermittent myoclonus, and subdural hematoma) caused by surgery and by the presence of intracranial electrodes. More recently, Serrano-Castro et al ( 7 ) published a case report of a 17-year-old patient with a neuroepithelial dysembryoblastic tumor in the left temporo-parietal region provoking refractory focal motor seizures ( 7 ), who undertook a similar protocol as described by Rivera-Rivera et al ( 2 ) (first surgery, placement of intracranial electrodes for invasive neuromodulation during subsequent prehabilitation, and second definitive surgery to remove the tumor and the electrodes). However, the first craniotomy was intended specifically for placing electrodes, and NICP was performed for only 6 days, during which language training was provided very intensively (6 h a day).…”

Commentary: Predictors and Impact of Postoperative 30-Day Readmission in Glioblastoma

“…Finally, the authors 1 postulated prehabilitation programs as an opportunity to reduce risk factors for readmission. Prehabilitation programs have been reported for several diseases including epilepsy, 22 coronary artery bypass grafting, 23 esophageal cancer, 24 and thoracoscopic lobectomy for lung cancer. 25 Although,…”

“…Finally, the authors 1 postulated prehabilitation programs as an opportunity to reduce risk factors for readmission. Prehabilitation programs have been reported for several diseases including epilepsy, 22 coronary artery bypass grafting, 23 esophageal cancer, 24 and thoracoscopic lobectomy for lung cancer. 25 Although, cortical stimulation plasticity prehabilitation has been reported for eloquent grade 2 and 3 gliomas, 26 delaying glioblastoma resection could be counterproductive given the aggressiveness and rapid growth of these tumors.…”