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Cortical plasticity catalysed by a prehabilitation protocol enables extensive resection of brain tumours in eloquent areas

Paola Rivera-Rivera, Department of Neurosurgery San Carlos Institute of Health Research (IdisSC) Hospital Clínico San Carlos de Madrid University Complutense of Madrid Spain; Marcos Rios-Lago, Department of Radiology Hospital Ruber Internacional Madrid Spain and Brain Damage Unit Hospital Beata María Ana Madrid Spain; Sandra Sancgez-Casarrubios, Department of Neurosurgery San Carlos Institute of Health Research (IdisSC) Hospital Clínico San Carlos de Madrid University Complutense of Madrid Spain; Miguel Yus, Department of Radiology San Carlos INstitute of Health Research (IdisSC) Hospital Clínico San Carlos de Madrid University Complutense of Madrid Spain; Mercedes González-Hidalgo, Department of Neurophysiology San Carlos Institute of Healrch Research (IdisSC) Hosptial Clínico San Carlos de Madrid University Complutense of Madrid Spain; Ana Sanz, Departmente of Neurosurgery San Carlos Institute of Health Research (IdisSC) Hospital Clínico San Carlos de Madrid University Complutense of Madrid Spain; Osman Salazar, Department of Neurosurgery San Carlos INstitute of Health Research (IdisSC) Hospital Clínico San Carlos de Madrid University Complutense of Madrid Sapin; Josué Avecillas-Chasin, Department of Neurosurgery San Carlos Institute of Health Research (IdisSC) Hospital Clínico San Carlos de Madrid University Complutense of Madrid Sapin; Juan Alvarez-Linera, Department of Radiology Hospital Ruber Internacional Madrid Sapin; Alvaro Pascual-Leone, Berenson-Allen Center for Noninvasive Brain Stimulation Division of Cognitive Neurology Department of Neurology Beth Israel Deaconess Medical Centre and Harvard Medical School Boston MA USA; Antonio Olivero, Department of Neurology and FENNSI group Hospital Nacional de Paraplégicos Toledo Spain; Juan A. Barcia, Department of Neurosurgery San Carlos INstitute of Health Research (IdisSC) Hospital Clínico San Carlos de Madrid University Complutense of Madrid Spain


The extent of resection is the most important prognostic factor following brain gliomas surgery. However, eloquent areas within tumours limit the extent of resection and, thus, critically affect outcomes. We hypothesized that pre-surgical suppression of the eloquent areas within a tumour by continuous cortical electrical stimulation,, coupled with appropriate behavioural training (prehabilitation), would induce plastic reorganization which enables a more extensive resection. We present a study on five patients with gliomas involving eloquent brain areas within or near the tumour, identified using intraoperative cortical stimulation mapping in a first surgery. A cortical grid of electrodes was placed over the residual tumour, and continuous cortical electrical stimulation was targeted to the functional areas. The stimulation intensity was adjusted daily to provoke a mild functional impairment while the function was intensively practiced. The required stimulation intensity to impair function increased progressively in all patients, and all underwent another surgery a mean of 33.6 days (range: 27–37) later, when the maximal stimulation voltage in all active contacts induced no functional deficit. In all cases, a substantially more extensive resection of the tumour was possible. Intraoperative cortical stimulation mapping and functional magnetic resonance imaging demonstrated a plastic reorganization, and all previously demonstrated eloquent areas within the tumour were silent, while there was new functional activation of brain areas in the same or the contralateral hemisphere. Prehabilitation with continuous cortical electrical and appropriate behavioural training prior to surgery in patients with WHO grade 2 and 3 gliomas affecting eloquent areas, can help maximize tumour resection and, thus, improve survival while maintaining function.

Format: Oral communication

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