• Giovanni Raffa, Antonino Scibilia, Alfredo Conti, Salvatore Massimiliano Cardali, Vincenzo Rizzo, Carmen Terranova, Maria Catena Quattropani, Giuseppina Marzano, Giuseppe Ricciardo, Sergio Lucio Vinci, and Antonino Germanò.
• Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy. Electronic address: giovanni.raffa@unime.it.
• World Neurosurg. 2019 Aug 1; 128: e378-e390.

BackgroundFluorescein-guided surgery of high-grade gliomas (HGGs) increases the extent of tumor resection but its efficacy has been questioned, especially for tumors located close to functional networks. In these cases, navigated transcranial magnetic stimulation (nTMS) may be used to plan and guide a safe resection. The aim of this study was to assess the impact of these techniques combined with intraoperative neurophysiologic mapping (IONM) to achieve the maximal safe resection of tumors located in the motor area.MethodsWe collected data of patients operated using a multimodal combination of sodium fluorescein-guided resection, nTMS motor planning, and IONM for HGGs in the motor area. The nTMS planning accuracy, extent of resection, and postoperative motor and functional status were compared with a matched control group of patients with HGG operated on only by IONM-guided resection.ResultsForty-one patients treated by multimodal approach (group A) and 41 controls (group B) were included. The nTMS-based planning reliably identified the tumor/motor pathway spatial relationship (accuracy, 92.68%). We obtained in group A versus controls a higher gross total resection rate (73.17% vs. 51.22%; P = 0.04), and a reduction of cases with new permanent motor deficits (9.75% vs. 29.27%; P = 0.04) or Karnofsky Performance Status worsening (12.19% vs. 31.71%; P = 0.03).ConclusionsThis study supports the role of the combination of sodium fluorescein-guided resection and nTMS-based planning for surgery of HGGs close to the motor pathway. This multimodal approach in combination with IONM may lead to customized preoperative planning, increased extent of resection, and improved functional outcome, compared with standard IONM-guided surgery.Copyright © 2019 Elsevier Inc. All rights reserved.

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