Objective:Navigated transcranial magnetic stimulation (nTMS) has seldom been used to study visuospatial (VS) circuits so far. Our work studied (I) VS functions in neurosurgical oncological patients by using repetitive nTMS (rnTMS), (II) the possible subcortical circuits underneath, and (III) the correspondence between nTMS and direct cortical stimulation (DCS) during awake procedures.Methods:We designed a monocentric prospective study, adopting a protocol to use rnTMS for preoperative planning, including VS functions for lesions potentially involving the VS network, including neurosurgical awake and asleep procedures. nTMS-based-DTI tractography allowed the visualization of subcortical circuits. Statistical analyses on nTMS/DCS points were performed. Clinical results were collected pre- and postoperatively.Results:Finally, 27 patients with primitive intra-axial brain lesions were enrolled between April 2023 and March 2024. Specific tests and an experimental integrated VS test (VISA) were used. The clinical evaluation (at 5 ± 7, 30 ± 10, 90 ± 10 days after surgery) documented 33% of patients with neglect in the left hemisphere four days after surgery and, during the 3-month follow-up, preservation of visuospatial function/clinical recovery (90.62% in MMSE, 98.86% in the bell test, 80% in the clock test, and 98% in the OCS test). The surgical strategy was modulated according to the nTMS map. Subcortical bundles were traced to identify those most involved in these functions: SFLII > SLFII > SLFI. A comparison of the nTMS and DCS points in awake surgery (n = 10 patients) documented a sensitivity (Se) of 12%, a specificity (Sp) of 91.21%, a positive predictive value (PPV) of 42%, a negative predictive value (NPV) of 66%, and an accuracy of ~63.7%.Conclusions:Based on our preliminary results, nTMS is advantageous for studying cognitive functions, minimising neurological impairment. Further analyses are needed to validate our data.
目的：目前导航经颅磁刺激（nTMS）在视空间（VS）环路研究中的应用尚少。本研究通过重复性nTMS（rnTMS）探讨：（I）神经外科肿瘤患者的视空间功能；（II）潜在的皮层下神经环路；（III）清醒手术中nTMS与直接皮层电刺激（DCS）的对应关系。 方法：我们设计了一项单中心前瞻性研究，采用rnTMS术前规划方案，针对可能累及视空间网络的病灶进行视空间功能评估，涵盖清醒与睡眠神经外科手术。基于nTMS的弥散张量成像纤维束示踪技术实现了皮层下环路可视化。对nTMS/DCS刺激点进行统计分析，并收集术前及术后临床结果。 结果：2023年4月至2024年3月期间，最终纳入27例原发性脑实质内病变患者。采用特异性测试及实验性综合视空间测试（VISA）进行评估。临床评估（术后5±7天、30±10天、90±10天）显示：33%左半球病变患者术后四天出现忽视症状；三个月随访期间视空间功能保持/临床恢复情况良好（MMSE评分90.62%、钟声测试98.86%、画钟测试80%、OCS测试98%）。手术策略根据nTMS图谱进行调整。通过纤维束示踪识别出与视空间功能最相关的皮层下束：SFLII > SLFII > SLFI。清醒手术中nTMS与DCS刺激点对比分析（n=10例）显示：灵敏度12%、特异度91.21%、阳性预测值42%、阴性预测值66%、准确率约63.7%。 结论：基于初步研究结果，nTMS在研究认知功能、最小化神经功能损伤方面具有优势，但需进一步分析验证数据。
肿瘤(癌症)患者之家