Lessons from Brain Mapping in Surgery for Low-Grade Gliomas: Study of Cerebral Connectivity and Plasticity

  • Hugues Duffau
Part of the Lecture Notes in Computer Science book series (LNCS, volume 4091)


Radical surgical removal of WHO grade II glioma, when possible, appears currently the first treatment to delay the risk of anaplastic transformation. The goal of surgery is to maximize the quality of resection, while minimizing the risk of permanent neurological deficit. Thus, due to the frequent location of these lesions in eloquent areas, and because of an important interindividual anatomofunctional variability, it is important to study the cortical functional organization, the effective connectivity and the brain plastic potential for each patient, in order to taylor the resection according to both oncological and cortico-subcortical functional boundaries, then to optimize the benefit / risk ratio of surgery.

Consequently, in addition to preoperative functional neuroimaging, useful for the surgical indications and the surgical planning, intraoperative electrical stimulations can be used during the resection, under local anesthesia on awake patient if language and other cognitive functions need to be mapped. Indeed, this is an easy, accurate, reliable and safe technique of detection of both cortical and subcortical structures essential for the function.

Indeed, intraoperative electrostimulations have many interests:

– to understand the individual cortical functional organization of each patient before the beginning of the resection;

– to improve the knowledge of the pathophysiology of brain areas involved by the glioma, such as the supplementary motor area, insula, premotor cortex, supramarginal or angular gyri (i.e. participation in sensorimotor function, vision, language, spatial awareness, calculation, ...);

– to continue to map the subcortical structures all along the resection, allowing a direct study of the anatomo-functional connectivity (i.e. a tracking of the cortico-cortical and cortico-subcortical loops);

– to study the mechanisms of on-line short-term plasticity, using repeated cortical stimulations;

– to perform the resection according to functional boundaries, enabling to optimize the quality of tumor removal while minimizing the risk to induce a permanent postoperative neurological deficit.

Moreover, intraoperative stimulations can be combined with peri-operative functional neuroimaging methods (fMRI, PET, MEG, DTI), before and after surgery, in order to improve the reliability of the pre-operative planning (validation of the non-invasive techniques), but also with the goal to better understand both the short-term and long-term plasticity mechanisms based on functional cortical reshaping and connectivity changes – due initially to the tumor growth, then to its surgical resection. Such an individual knowledge may enable to increase the quality of tumor resection during a second surgery performed some years after the first procedure, while it was not possible to remove to entire glioma during the first surgery due its location in “eloquent” areas – reorganized following the initial operation.

Such a strategy has enabled both to increase the impact of the surgery on the natural history of low-grade glioma, and also to improve the quality of life of the patients.


Brain mapping Connectivity Plasticity Electrical stimulation Brain Tumor Surgery 


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  1. 1.
    Mandonnet, E., Delattre, J.Y., Tanguy, M.L., et al.: Continuous growth of mean tumor diameter in a subset of grade II gliomas. Ann. Neurol. 53, 524–528 (2003)CrossRefGoogle Scholar
  2. 2.
    Duffau, L., Capelle, L.: Preferential brain locations of low-grade gliomas. Cancer 100, 2622–2626 (2004)CrossRefGoogle Scholar
  3. 3.
    Duffau, H., Lopes, M., Arthuis, F., et al.: Contribution of intraoperative electrical stimulations in surgery of low grade gliomas: a comparative study between two series without (1985-1996) and with (1996-2003) functional mapping in the same institution. J. Neurol Neurosurg Psychiatry 76, 845–851 (2005)CrossRefGoogle Scholar
  4. 4.
    Roux, F.E., Boulanouar, K., Lotterie, J.A., et al.: Language functional magnetic resonance imaging in preoperative assessment of language areas: correlation with direct cortical stimulation. Neurosurgery 52, 1335–1345 (2003)CrossRefGoogle Scholar
  5. 5.
    Aubert, A., Costalat, R., Duffau, H., et al.: Modeling of pathophysiological coupling between brain electrical activation, energy metabolism and hemodynamics: insights for the interpretation of intracerebral tumor imaging. Acta Biotheor. 50, 281–295 (2002)CrossRefGoogle Scholar
  6. 6.
    Duffau, H., Capelle, L., Sichez, J.P., et al.: Intraoperative direct electrical stimulations of the central nervous system: the Salpêtrière experience with 60 patients. Acta Neurochir (Wien) 141, 1157–1167 (1999)CrossRefGoogle Scholar
  7. 7.
    Duffau, H.: Peroperative functional mapping using direct electrical stimulations. Methodological considerations. Neurochirurgie 50, 474–483 (2004)CrossRefGoogle Scholar
  8. 8.
    Fontaine, D., Capelle, L., Duffau, H.: Somatotopy of the supplementary motor area: evidence from correlation of the extent of surgical resection with the clinical patterns of deficit. Neurosurgery 50, 297–303 (2002)CrossRefGoogle Scholar
  9. 9.
    Krainik, A., Lehéricy, S., Duffau, H., et al.: Postoperative speech disorder after medial frontal surgery: role of the supplementary motor area. Neurology 60, 587–594 (2003)Google Scholar
  10. 10.
    Duffau, H., Capelle, L., Lopes, M., et al.: The insular lobe: physiopathological and surgical considerations. Neurosurgery 47, 801–810 (2000)CrossRefGoogle Scholar
  11. 11.
    Duffau, H., Capelle, L., Denvil, D., et al.: The role of dominant premotor cortex in language: a study using intraoperative functional mapping in awake patients. Neuroimage 20, 1903–1914 (2003)CrossRefGoogle Scholar
  12. 12.
    Duffau, H., Denvil, D., Lopes, M., et al.: Intraoperative mapping of the cortical areas involved in multiplication and subtraction: an electrostimulation study in a patient with a left parietal glioma. J. Neurol Neurosurg Psychiatry 73, 733–738 (2002)CrossRefGoogle Scholar
  13. 13.
    Gatignol, P., Capelle, L., Le Bihan, R., Duffau, H.: Double dissociation between picture naming and comprehension: an electrostimulation study. Neuroreport 15, 191–195 (2004)CrossRefGoogle Scholar
  14. 14.
    Milea, D., Lobel, E., Lehéricy, S., et al.: Intraoperative frontal eye field stimulation elicits ocular deviation and saccade suppression. Neuroreport 13, 1359–1364 (2002)CrossRefGoogle Scholar
  15. 15.
    de Schotten, M.T., Urbanski, M., Duffau, H., et al.: Direct evidence for a parietal-frontal pathway subserving spatial awareness in humans. Science 309, 2226–2228 (2005)CrossRefGoogle Scholar
  16. 16.
    Duffau, H.: Intraoperative cortico-subcortical stimulations in surgery of low-grade gliomas. Expert Rev. Neurother 5, 473–485 (2005)CrossRefGoogle Scholar
  17. 17.
    Duffau, H., Capelle, L., Denvil, D., et al.: Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients. J. Neurosurg 98, 764–778 (2003)CrossRefGoogle Scholar
  18. 18.
    Duffau, H., Velut, S., Mitchell, M.C., et al.: Intra-operative mapping of the subcortical visual pathways using direct electrical stimulations. Acta Neurochir (Wien) 146, 265–269 (2004)CrossRefGoogle Scholar
  19. 19.
    Duffau, H., Capelle, L., Sichez, N., et al.: Intraoperative mapping of the subcortical language pathways using direct stimulations. An anatomo-functional study. Brain 125, 199–214 (2002)CrossRefGoogle Scholar
  20. 20.
    Duffau, H., Gatignol, P., Denvil, D., et al.: The articulatory loop: study of the subcortical connectivity by electrostimulation. Neuroreport 14, 2005–2008 (2003)CrossRefGoogle Scholar
  21. 21.
    Duffau, H., Gatignol, P., Mandonnet, E., et al.: New insights into the anatomo-functional connectivity of the semantic system: a study using cortico-subcortical electrostimulations. Brain 128, 797–810 (2005)CrossRefGoogle Scholar
  22. 22.
    Gil Robles, S., Gatignol, P., Capelle, L., et al.: The role of dominant striatum in language: a study using intraoperative electrical stimulations. J. Neurol Neurosurg Psychiatry 76, 940–946 (2005)CrossRefGoogle Scholar
  23. 23.
    Spena, G., Gatignol, P., Capelle, L., et al.: Superior longitudinal fascicle subserves vestibular network in humans. NeuroReport (in press)Google Scholar
  24. 24.
    Duffau, H.: Brain plasticity: from pathophysiological mechanisms to therapeutic applications. J. Clin. Neurosci. (in press)Google Scholar
  25. 25.
    Duffau, H.: Lessons from brain mapping in surgery for low-grade glioma: insights into associations between tumour and brain plasticity. Lancet Neurol. 4, 476–486 (2005)CrossRefGoogle Scholar
  26. 26.
    Duffau, H., Capelle, L., Denvil, D., et al.: Functional recovery after surgical resection of low grade gliomas in eloquent brain: hypothesis of brain compensation. J. Neurol Neurosurg Psychiatry 74, 901–907 (2003)CrossRefGoogle Scholar
  27. 27.
    Duffau, H., Sichez, J.P., Lehéricy, S.: Intraoperative unmasking of brain redundant motor sites during resection of a precentral angioma: evidence using direct cortical stimulation. Ann. Neurol. 47, 132–135 (2000)CrossRefGoogle Scholar
  28. 28.
    Duffau, H.: Acute functional reorganisation of the human motor cortex during resection of central lesions: a study using intraoperative brain mapping. J. Neurol Neurosurg Psychiatry 70, 506–513 (2001)CrossRefGoogle Scholar
  29. 29.
    Krainik, A., Duffau, H., Capelle, L., et al.: Role of the healthy hemisphere in recovery after resection of the supplementary motor area. Neurology 62, 1323–1332 (2004)Google Scholar
  30. 30.
    Duffau, H., Denvil, D., Capelle, L.: Long term reshaping of language, sensory, and motor maps after glioma resection: a new parameter to integrate in the surgical strateg. J. Neurol Neurosurg Psychiatry 72, 511–516 (2002)Google Scholar
  31. 31.
    Duffau, H., Taillandier, L., Gatignol, P., Capelle, L.: The insular lobe and brain plasticity: Lessons from tumor surgery. Clin. Neurol. Neurosurg. (in press)Google Scholar
  32. 32.
    Duffau, H., Capelle, L.: Functional recuperation following lesions of the primary somatosensory fields. Study of compensatory mechanisms. Neurochirurgie 47, 557–563 (2001)Google Scholar
  33. 33.
    Duffau, H., Bauchet, L., Lehericy, S., Capelle, L.: Functional compensation of the left dominant insula for language. Neuroreport 12, 2159–2163 (2001)CrossRefGoogle Scholar
  34. 34.
    Duffau, H., Denvil, D., Capelle, L.: Absence of movement disorders after surgical resection of glioma invading the right striatum. J. Neurosurg 97, 363–369 (2002)CrossRefGoogle Scholar
  35. 35.
    Duffau, H., Khalil, I., Gatignol, P., et al.: Surgical removal of corpus callosum infiltrated by low-grade glioma: functional outcome and oncological considerations. J. Neurosurg 100, 431–437 (2004)CrossRefGoogle Scholar
  36. 36.
    Duffau, H.: New concepts in surgery of WHO grade II gliomas : functional brain mapping, connectionism and plasticity. A review. J. Neurooncol (in press)Google Scholar
  37. 37.
    Mandonnet, E., Capelle, L., Duffau, H.: Extension of paralimbic low-grade gliomas: toward an anatomical classification based on white mater invasion patterns. J. Neurooncol (in press)Google Scholar
  38. 38.
    Jbabdi, S., Mandonnet, E., Duffau, H., et al.: Diffusion Tensor Imaging allows anisotropic growth simulations of low-grade gliomas. Mag. Reson Med. 54, 616–624 (2005)CrossRefGoogle Scholar
  39. 39.
    Marrelec, G., Krainik, A., Duffau, H., et al.: Partial correlation for functional brain interactivity investigation in functional MRI. NeuroImage (in press)Google Scholar
  40. 40.
    Krainik, A., Marrelec, G., Duffau, H., et al.: Anatomical and functional premotor correlations in supplementary motor area lesion. Eur. Radiol. 14, 536 (2004)Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2006

Authors and Affiliations

  • Hugues Duffau
    • 1
  1. 1.Department of Neurosurgery and INSERM U678UPMC, Salpêtrière HospitalParisFrance

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