Ladies and gentlemen, thank you, Chairman. I think it's a good honor, it's a good opportunity for me to be invited here to present our work. And today's topic is about how we do it in Shanghai Huashan Hospital. And I have a whole pattern on brain mapping interactive stimulation system. It will be mentioned afterward. So I agree with the philosophy of Dr. Dufour. Total resection, especially extensive total resection, is reasonable for non-eloquent area brain tumor in accordance with the image boundary, whereas it is not always feasible. Extensive resection of tumor involving eloquent cortex or subcortical critical functional pathway may result in severe functional consequences. In principle, we should weigh in the potential treatment benefit against the related side effect in precision surgery to maximize the extent of tumor resection when feasible, while minimizing the permanent neurological deficits comprising the motor, language, cognition, or any other negative impact on our patient's quality of life. So we emphasize the multimodal approach for individual brain mapping technique. Multimodal approach for individual brain mapping are essential during eloquent area brain tumor resection. First of all is the multimodal brain imaging. So pre-operation multimodal brain imaging allows for improvement in the surgeon's ability to individualize the extent of tumor resection while preserving the eloquent brain area. Functional MRI has been used for cortical mapping for more than 20 years. Task-based BOLD activation is regarded as to be higher precision localization of cortical motor sites, especially for the hand movement area. We may identify different activation of different finger taping area following the task with simultaneous multi-slice acquisition. In general, task-based BOLD functional MRI is now extensively adapted for clinical motor cortical imaging, such as motor in relationship to the tumor. However, the reliability is always being questioned in many aspects. The major one is force negative. So what's the reason for force negative? It is hypothesis that change in cerebrovascular auto-regulation affects BOLD signal. For example, for these three cases, you can see before operation there is no motor deficit for the cases, but on the image we cannot identify the movement activation on the tumor side. So the reason may be the hyperperfusion inside the tumor region and nearby the edema tissue around the tumor. So this slide, we choose the functional brain activation is derived in the tumor region use breath holding task. So use breath holding task method, we expect to be able to uncover Paxil with true activation, which were previous masked by the muted vascular reactivity in gliomas, but were uncovered by the mutilation of BOLD calculation. Secondly, as the cortical language organization is more complex than the motor cortex, either the task-based functional MRI nor the resting state functional MRI is reliable to identify the language site. In our previous study, the sensitivity of BOLD is less than 50%. So we think the functional MRI cortical activation was routinely used to localize the motor cortex. It's okay, especially for hand area, but not for individual language cortex identification. How about the DTI tractography? I think the DTI tractography may be helpful to delineate the functional white matter tract. For example, the subcortical motor pathway, the language pathway, for example, the acute fasciculus, and the optic radiation. So for this case, this is a normal subject. So we can use a DTI tractography to delineate different kinds of language pathway. So how about for the patient? This is a patient with insular low-grade glioma. So in one unpublished study of our group, we found that the projection and endpoints of subcortical language pathway can be used to assist the cortical site localization. For example, this is acute fasciculus projection and endpoint in median frontal gyrus and the inferior frontal gyrus. That area might be the language cortical site. We make a confirmation with intraoperative language mapping. And the final results show the sensitivity and the specificity of acute fasciculus frontal projection localizing speech production center were more than 70 percent, and the specificity is more than 86 percent. A similar situation we can find in superior longitudinal fasciculus. In one prospective cohort study, direct subcortical stimulation validates a high accordance rate with diffusion tensor pyramidal tract. The sensitivity and the specificity of diffusion tensor tractography were 92 percent and 93 percent respectively. And in that study, we found that the safe distance is 8.6 millimeter. That means from the positive subcortical stimulation site to the imaging pyramidal tract, the safe distance might be less than one centimeter. And the value of DTI guided resection of eloquent glioma were assessed clinically nine years before. 238 cases was enrolled in that trial. In conclusion, the DTI-based functional neural navigation contributes to maximal safe resection of eloquent gliomas, thereby decreasing the postoperative motor deficit for both high-grade and low-grade glioma while increasing the survival for high-grade gliomas. We think the preoperative multimodal imaging may not replace the intraoperative neurophysiological monitoring to identify the functional cortical and subcortical pathway for a much more safe tumor resection. So this is the intraoperative neurophysiological monitoring protocol for eloquent surgery in Huashan Hospital. So as I was trained in Mayo Clinic by Dr. Panning, and Dr. Panning used to be the fellow of Dr. Mitschberg, so I think the protocol is following the guidance of Dr. Mitschberg in UCSF. Initially, we preferred the SSEP for central circus localization, and after the strict electrode insertion beneath the dura, we may remain the electrode there. It can be remained there for two purpose. One purpose for continuous transcortical MEP monitoring. The second purpose was used for after discharge monitoring. So for this case, we can identify the central circus. And for cortical mapping, and this is one case for cortical mapping, not only for motor mapping but also for language mapping. Of course, if we want to do the language cortical mapping, we should do the awake craniotomy. And also subcortical mapping, we can perform subcortical mapping along the surgical margin. So for this case, the stimulation site will be noted by a tag P. When I stimulate there, you can see the face, hand, and the leg, the positive EMG potential. But to my experience, we prefer to use transcortical continuous MEP for some deep-seated brain tumor surgery. We think it is much convenient and with no interruption for the surgical resection procedure. For example, for this case, during tumor resection, my technician allowed me that the MEP potential decreased rapidly. So that might be something had happened. So I performed the intraoperative MI scanning and also performed the diffusion tensor for motor pathway delineation. So we can find out, figure out that the resection cavity is so close to the subcortical motor pathway. So we stopped that direction and adjusted the direction of the surgical approach to inferior. So finally, the tumor was totally resected and the potential recovered before wound closure. So after operation, for that case, there is no motor deficit at all. For language mapping, awakened autoimmune is essential. So for this case, this is a case that can speak Chinese and English. So if we do the language mapping, we can find that there's dissemination of different language positive site. The American flag means English-speaking site, and the Chinese flag means Chinese-speaking, Mandarin-speaking positive site. Awakened autoimmune cannot only be used for language mapping. It is also very practical for motor mapping, especially for the posterior frontal lobe. We can resect the tumor much safer than ever. So for some complicated cases, the combination use of multimodal intraoperative neurophysiological monitoring technique may be used in one operation. For example, for this high-grade deep-seated insular lobe glomer, we can combine the different modality of intraoperative neurophysiological monitoring technique in one cases. So during the past four years, almost 1,000 of eloquent area glomer was operated in my team. So I suppose that might be the largest personal case areas in Chinese. So among them, 165 cases performed awakened autoimmune. So this is the profile of different kinds of intraoperative neurophysiological monitoring. You can see most of them used SSEP for central circuits localization. And two-thirds of the cases performed continuous transcortical MEP monitoring. And for language mapping, language mapping was only performed for the awake craniotomy person. And for the else, maybe subcortical motor mapping and cortical motor mapping. I have no experience about language pathway subcortical mapping. How about the functional outcome? The permanent motor deficit is about 3.7 percent. And the permanent language deficit is much more than 60 percent. So we talk about awake craniotomy. That is a small video chip about acupuncture anesthesia in the past of China. In 1958, the first time using acupuncture anesthesia for a surgery was successfully performed in Shanghai. It became extremely popular throughout China. In 1972, former U.S. President Nixon asked for an inspection of acupuncture anesthesia during his visit. It was gradually known by the world. Now we see a patient lay on the operation table, except for the difference, as using acupuncture anesthesia, he lay on his side and consciously reach both of his hands out of the table. In that time, acupuncture anesthesia was used widely in different kinds of surgeries, including craniotomy. So acupuncture anesthesia originates from the planned relief theory in traditional Chinese medicine. It started and widespread in the special historical background of China in 1960s. However, acupuncture anesthesia of the clinical practice in China faded out after cultural revolution rapidly. The major problem of acupuncture is anesthesia, analgesia, analgesic effect is incomplete and it is unsatisfied by our patient. Furthermore, no brain mapping at all in the past. So now we prefer to use the modern awakened craniotomy and in our experience, we prefer to use monitored anesthesia care. So we name this sedation awake and sedation instead of asleep, awake, and asleep. Because our patient will remain moderate sedation when craniotomy, not totally asleep. And 15 minutes before we want to do the brain mapping, the dexamethamidin and the propofol will be stopped and we can awake the patient. Yes, we can awake the patient. And the ramefentanil will be lasted during all the procedure. So for awake language mapping, another important thrust is intraoperative tasks and paradigm display. So we used to use the card, we bring the figure and the phrase on the card and 10 years before we used a laptop and five years before we used iPad. And now we invent equipment named Brain Mapping Interactive Stimulation System. We named her Brain Miss. So on this screen, on this slide, you can see three displays were used for surgeon, patient, technician, respectively. And the other one is used for software manipulation. So the patient's interface is scalable and flexible so we can expand the touch screen, the small touch screen close to the face of our patient. So the patient can identify the figure, identify the phrase much clearly during awake craniotomy. And also our surgeon can monitor my patient clearly on the surgeon's display. So on display we can monitor my patient, the squeeze of the oral pharyngeal and the hand movement and the touch of the feet. So it's very convenient for the surgeon. So operator can choose the brain region on the screen. System will recommend the stimulus tasks for the chosen brain region. The system provide a total of 11 stimulus tasks, counting, picture naming, calculating, line bisection, writing, phrase reading, and something like that. So this is the language task and the paradigm. Maybe this is similar to Dr. Berger's paradigm in UCSF. So this is another video chip about our BRAINMISS system. So we thank the patient to give us the permission to shoot here. This is the layout of our surgical theatre. You can see the patient is performing the damage mapping. When I stimulate on the cortex, speech arrest, you can see speech arrest. And after we perform the motor mapping, you can see the hand movement, hand touch. It will be repeated two or three times to make a confirmation. And all brain mapping procedure will be started as the cognitive assessment one day before operation until the tumor resection. For the baseline of aphasia, the aphasia battery of Chinese was used for our patient. And one day before operation, the patient will be trained for the intraoperative language task to release the possible anxiety of our patient. This is a scalp local anesthesia block. Head rest fixation and mini shave. Incision. During operation, we can... This is my technician for intraoperative physiological monitoring. So this screen is for the surgeon and this screen is for the technician. So this is a touch screen for the patient. So when we do the brain mapping, I can monitor my patient's face, hand, and feet. So after cortical and subcortical mapping, maximum safe resection has been performed for this case. Okay, one minute. So we also use combination used intraoperative MRI, awake craniotomy, and the language mapping in one operating theater. This is the workflow of the routine work. We think the combination used is safe and efficient. It allows the maximum safe resection of eloquent area glioma and it can be used, also be used, to improve the surgeon's ability in eloquent glioma surgery. So this is the last slide, how I do it. So I prefer the functional imaging, especially the diffusion tensor imaging, and motor pathway delineation, because I think it's vivid and reliable. It is recommended to combine used continuous transcortical MEP, because there is no interruption of surgical procedure and will be adapted by the neurosurgeon. And the cortical projection of language pathway can be used to identify the speech production center. And the combination use of awake craniotomy, intraoperative neurophysiological monitoring, and intraoperative MRI is feasible for clinical application. And I also recommended our brain mist system. It is user-friendly for both awake patient and also the surgeon. So I do appreciate the team, all the team members here. Also, I appreciate all the audience here. Thank you so much for your attention.

neurosurgeon

brain mapping

tumor resection

functional magnetic resonance imaging

diffusion tensor imaging

awake craniotomy