Current Status of Neuromodulation-Induced Cortical Prehabilitation and Considerations for Treatment Pathways in Lower-Grade Glioma Surgery

Ryan P Hamer, Tseng Tsai Yeo, Ryan P Hamer, Tseng Tsai Yeo

Abstract

The infiltrative character of supratentorial lower grade glioma makes it possible for eloquent neural pathways to remain within tumoural tissue, which renders complete surgical resection challenging. Neuromodulation-Induced Cortical Prehabilitation (NICP) is intended to reduce the likelihood of premeditated neurologic sequelae that otherwise would have resulted in extensive rehabilitation or permanent injury following surgery. This review aims to conceptualise current approaches involving Repetitive Transcranial Magnetic Stimulation (rTMS-NICP) and extraoperative Direct Cortical Stimulation (eDCS-NICP) for the purposes of inducing cortical reorganisation prior to surgery, with considerations derived from psychiatric, rehabilitative and electrophysiologic findings related to previous reports of prehabilitation. Despite the promise of reduced risk and incidence of neurologic injury in glioma surgery, the current data indicates a broad but compelling possibility of effective cortical prehabilitation relating to perisylvian cortex, though it remains an under-explored investigational tool. Preliminary findings may prove sufficient for the continued investigation of prehabilitation in small-volume lower-grade tumour or epilepsy patients. However, considering the very low number of peer-reviewed case reports, optimal stimulation parameters and duration of therapy necessary to catalyse functional reorganisation remain equivocal. The non-invasive nature and low risk profile of rTMS-NICP may permit larger sample sizes and control groups until such time that eDCS-NICP protocols can be further elucidated.

Keywords: awake brain mapping; cortical prehabilitation; direct cortical stimulation; lower grade glioma surgery; navigated transcranial magnetic stimulation; neural plasticity.

Conflict of interest statement

Hamer is a clinical consultant and distribution partner of Nexstim OYJ (Finalnd) and inomed medizintechnik gmbh (Germany), whom were not involved in the design or execution of this paper, nor has Hamer received honoraria or incentive of any description for the writing of this paper, which was written as part of his academic appointment at the University of Sydney. Yeo declares no conflict of interest.

Figures

Figure 1
Figure 1
Illustrative example of neuromodulation-induced cortical prehabilitation. (A) Placement of subdural electrode to confirm eloquent cortical topography prior to surgical debulking. (B) End of tumour debulking as distinguished by definition of electrophysiologic or anatomic boundaries, subdural electrode remains for eDCS-NICP towards the pars opercularis/pars triangularis indicated by pre-operative imaging and brain mapping during part-A. (C) rTMS-NICP setup targeting the same cortical region as a non-invasive alternative to extraoperative cortical stimulation. (D) Schematic diagram indicating positive speech related areas (red), and negative areas (green) relating to the lesion (grey oval) prior to NICP. (E) Schematic diagram indicating confirmation of functional reorganisation following NICP as measured by neuroimaging, TMS and/or DCS.

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