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Background: Tractography allows the in vivo study of subcortical white matter, and it is a potential tool for providing predictive indices on post-operative outcomes. We aim at establishing whether there is a relation between cognitive outcome and the status of the inferior fronto-occipital fasciculus's (IFOF's) microstructure., Methods: The longitudinal neuropsychological data of thirty young (median age: 35 years) patients operated on for DLGG in the left temporo-insular cortex along with pre-surgery tractography data were processed., Results: A degraded integrity of the left (vs. right) IFOF (lower fractional anisotropy and length, p < 0.001; higher mean and axial diffusivity, p < 0.01) was found, with lower microstructural variables in the infiltration (vs. dislocation) group. Significant decreases immediately post-surgery vs. pre-surgery mainly occurred in lexico-semantics ( p < 0.001), with significant improvements at follow-up in all the tests ( p < 0.01 to p < 0.001), despite values in the range of 44% to 47.82% of patients with below cut-off scores regarding naming verbs and making visual lexical decisions. The status of left and right IFOFs is predictive of a decrease in immediate post-surgery performance for several tests ( p < 0.05); similarly, it is predictive of better recovery in the follow-up performance for naming nouns, naming verbs, making phonological fluency lexical decisions, and the token test ( p < -0.05). For the ROC analysis, a significant result was obtained for the verb-naming test, with a cut-off of 79%., Conclusions: This study supports the role of the predictive value of pre-operative tractography for assessing the immediate post-operative result and at follow-up the risk of developing a cognitive deficit.

Background: Executive functions are multi-component and are based on large-scale brain networks. For patients undergoing brain surgery in the prefrontal cortex, resection in the anterior prefrontal sites is assisted by continuous monitoring of their performance on several tasks measuring components of executive functions. In this study, we did not test patients during direct cortical stimulation, but during resection itself. We chose tests routinely used to assess executive functions and included them in a protocol for left (LH) and right (RH) hemisphere prefrontal resections. This protocol is meant to be used during real-time neuropsychological testing (RTNT)-an already established monitoring technique., Methods: We retrospectively reviewed a consecutive series of 29 adult patients with glioma in the superior and middle frontal areas who performed the RTNT sequence throughout the resection phase. The testing protocol comprised 10 tests for LH frontal resections and 9 tests for RH frontal resections., Results: RH patients showed a median performance on RTNT with significantly lower scores for visuo-spatial attention and emotion processing (95% Confidence Interval Lower bound of 66.55 and 82.57, respectively, χ2 (7) = 32.8, p < 0.001). LH patients showed a median performance on RTNT, with significantly lower scores for selective attention and working memory (95% Confidence Interval Lower bound of 51.12, χ2 (5) = 20.31 p < 0.001) and minimum scores for the same task and for the Stroop test (χ2 (5) = 17.86, p < 0.005). The delta for accuracy between the first and the last RTNT run was not statistically significant (RH patients: χ2 (7) = 10.49, p > 0.05, n.s.; LH patients: χ2 (5) = 3.35, p > 0.05, n.s.). Mean extent of resection was 95.33% ± 9.72 for the RH group and 94.64% ± 6.74 for the LH group. Patients showed good performance post- vs. pre-surgery. The greater difference in the number of LH patients scoring within the normal range was found for the symbol-digit modality test (83.3% to 62%), Stroop test (100% to 77%) and short-term memory (84.61% to 72.72%) and working memory (92.3% to 63.63%). For RH patients, the main changes were observed on the clock drawing test (100% to 77.7%) and cognitive estimation (100% to 72.7%)., Conclusions: Frontal RTNT offers continuous and reliable feedback on the patients' cognitive status during resection in frontal areas.

Objective: The wide use of brain MRI has led to an increased diagnosis of incidental low-grade gliomas (LGGs). There is no consensus regarding the surgical treatment of incidental LGGs, nor even when we deal with a young woman who wants to plan a pregnancy. We performed a literature review on the topic of cognitive testing and pregnancy in LGGs. Results on the patients' cognitive status are poorly addressed: if, after surgery, neuropsychological deficits were to arise, this would greatly complicate the management of a child by a mother who is an oncological patient, and, moreover, has developed cognitive alterations that may compromise the abilities to look after a baby. We also report the case of a 30-years old woman with a diagnosis of incidental LGG who underwent a first surgery for a right-frontal oligodendroglioma METHODS: The patient underwent two awake surgeries and in both performed the Real Time Neuropsychological Testing (RTNT). We acquired clinical and MRI data. This paper also reports a literature review on the topic of cognitive testing and pregnancy in LGGs highlighting a lack of adequate data about this issue., Results: No deterioration of neuropsychological performances was documented during surgery. During the follow-up, she became pregnant and, despite an increased growth rate of the lesion, she did not accuse any symptom or sign of evolution in high-grade glioma (HGG). She underwent a second awake surgery with RTNT. Performance was maintained within the normal range., Conclusions: We concluded that, in our experience, pregnancy could induce an increased growth rate of LGG, not influencing the prognosis., Competing Interests: Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Purpose: In awake surgery, the patient is sedated, but is also required to be sufficiently alert and collaborative during extensive neurocognitive testing. In the present preliminary report of a retrospective single-center study, a continuous series of 168 patients who underwent awake surgery for brain tumor located near eloquent areas, was investigated to observe the effect of dexmedetomidine (n = 58) compared with propofol (n = 110) on vigilance and collaboration required to perform extensive intra-operatory Real Time Neuropsychological Testing (RTNT)., Methods: We assigned a score to each patient, by using a scale that combines vigilance and collaboration in a 5 levels score (the higher score denoting higher level)., Results: The median interquartile range was significantly lower (range 3-5) for the dexmedetomidine group compared to the propofol one (range 4-5, p = .044). Patients with intra-operative seizures (p = .014) and/or electrocorticographic slow/epileptiform activity (p = .042), and patients in the propofol group who showed increased heart rate (p = .032) were those who obtained the lower scores (lower vigilance and collaboration level)., Conclusion: The study shows that the effect of dexmedetomidine or propofol -based conscious sedation on ability to perform Real Time Neuropsychological Testing during awake surgery for supratentorial tumor resection is different. Although both permit high mean levels of vigilance and collaboration, the patient who received dexmedetomidine was more likely to show lower vigilance and collaboration during RTNT., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: For patients undergoing brain surgery, once primary motor and sensory areas are identified by direct electrical stimulation, resection can be performed in the precentral and postsomatosensory areas while monitoring cognition. For this purpose, we developed a real-time neuropsychological testing (RTNT) protocol tapping sensorimotor cognition., Methods: We retrospectively reviewed a consecutive series of 57 adult patients with tumors in the precentral and postsomatosensory areas who performed the RTNT sequence. The testing protocol used continuously throughout resection for excisions comprised action verbs, mental rotation of body parts, action imagery, action semantics, ideomotor praxis, and short-term memory., Results: The patients' median performance on RTNT tests was significantly lower for mental rotation and action imagery (χ 2 (2) = 55.98, P < 0.001), as well as their minimum value of patients' performance (χ 2 (2) = 85.048, P < 0.001) and their delta calculated between the patients' performance at the first versus the last RTNT run (χ 2  (2) = 14.33, P < 0.05). Patients showing such decreases in performance on action imagery had lesions overlapping on the right precentral and postcentral gyrus, the supplementary motor area, and the superior and inferior parietal lobe. For the mental rotation task, their maximum lesion overlay included the right cingulum/supplementary motor area and left superior and inferior parietal lobe and medial precuneus. The mean resection extent was 91.15% ± 17.45 and correlated with the number of motor-related positive sites found by the direct electrical stimulation at cortical (r = -0.279, P = 0.020) and white matter (r = -0.417, P = 0.001) level., Conclusions: The sensory-motor RTNT is performed to assist surgery in the precentral and postsomatosensory areas., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Low-grade gliomas (LGGs) are frequently associated with epilepsy. There are few studies addressing the impact of seizures, antiseizure medications (ASMs), and lesion localization on presurgery cognitive functioning., Methods: We tested the relation between the above-mentioned variables in a continuous series of 73 young patients (mean age 38.3 years ± 11.7) affected by LGGs and epilepsy. The anatomical areas, involved in this sample, were the left insula with surrounding cortical and subcortical areas, the right precentral gyrus/rolandic operculum, and the white matter and cortical regions beneath., Results: Patients' presurgery cognitive status was within the normal range, with borderline performance for some tasks. We tested whether lower scores were related with lesion or with epilepsy-related factors. Multiple regression identified variables that predict test scores. The Token test score was predicted by a model (p = .0078) containing the DT2T1 MRI, corrected for seizure features. Object naming performance was predicted by a model (p = .0113) containing the localization, the DT2T1 MRI, corrected for sex, EEG, and onset. Verbal fluency score was predicted by a model (p = .0056) containing the localization and the DT2T1 MRI, corrected for AEDs and EEG. Working memory score was predicted by a model (p = .0117) containing Engel class, the DT2T1 MRI, corrected for sex. Clock drawing score was predicted by a model (p < .0001) containing the Engel class, AEDs, and EEG. TMT A score was predicted by a model (p = .0022) containing localization, corrected for EEG. TMT B-A score was predicted by a model (p = .0373) containing localization. Voxel Lesion Symptom Mapping analyses carried out on patients' lesion volumes confirmed that patients' level of performance correlated with lesion-related variables., Conclusion: This preliminary study indicates that the presurgical level of performance for language tasks and for cognitive flexibility and shifting is mainly predicted by lesion-related variables, working memory by both lesion and epilepsy-related variables. Epilepsy clinical and instrumental characteristics predicted performance for visuospatial planning., (© 2022 The Authors. Brain and Behavior published by Wiley Periodicals LLC.)