Francesco Vergani

King's College Hospital NHS Foundation Trust · Department of Neurosurgery

Background Diffuse hemispheric glioma, H3 G34-mutant, is a novel paediatric tumour type in the fifth edition of the WHO classification of CNS tumours associated with an invariably poor outcome. We present a comprehensive clinical, imaging and pathological review of this entity. Methods Patients with confirmed H3 G34R-mutant high-grade glioma were...

Safe Trajectory planning for navigation guided biopsy (nBx) of motor eloquent tumours (METs) is important to minimise neurological morbidity. Preliminary clinical data suggest that visualisation of the corticospinal tract (CST) and its relation to the tumour may aid in planning a safe trajectory. In this article we assess the impact of tractography...

Subependymal Giant Cell Astrocytoma (SEGA) is a common diagnosis in patients with Tuberous Sclerosis. Although surgical treatment is often required, resection may entail a significant risk for cognitive function given the anatomical relation with critical structures such as the fornices and subgenual area. Therefore, target subtotal resections usin...

Objectives The study aims to review therapeutic strategies in the management of craniospinal tumours in pregnant patients and the factors that may influence the management along with their influence on maternal & foetal outcomes. Materials and Methods A retrospective single-centre cohort study was performed at a tertiary neurosurgical referral c...

Study Design Retrospective cohort study. Objectives Intraoperative neurophysiological monitoring (IONM) is widely used in spinal neurosurgery, particularly for intramedullary tumours. However, its validity in intradural extramedullary (IDEM) spinal tumours is less clearly defined, this being the focus of this study. Methods We compared outcomes f...

A Proposal for Supplemental Cortical and novel Subcortical Maps to the Motor Homunculus

Introduction Colloid cysts, although benign, may occasionally cause obstructive hydrocephalus and sudden death. Reliable prognostic factors for symptomatic progression have been sought with heterogenous results. Methods We conducted a retrospective review of all cases of colloid cysts of the third ventricle managed at our centre between 2009 and 2...

Background: The role played by the non-dominant parietal lobe in motor cognition, attention and spatial awareness networks has potentiated the use of awake surgery. When this is not feasible, asleep monitoring and mapping techniques should be used to achieve an onco-functional balance. Objective: This study aims to assess the feasibility of a dual-...

Background Epithelioid glioblastoma is a rare subtype of Glioblastoma. We examine two cases who presented acutely with symptoms of headache, neck stiffness and an eye squint. The purpose of this case review is to look at their management, the spread of the disease and propose the availability of BRAF inhibiting agents be made readily available for...

Background Anxiety and depression is prevalent in oncology patients and disproportionately high in neuro-oncology. The screening tools are most frequently used when signs of depression are identified later in the patients pathway. The cognitive impact of a brain tumour means coping mechanisms are harder to integrate and retain. Anti-depressants and...

Background As part of enhanced recovery after surgery in neuro oncology, carbohydrate loading drinks were reviewed to see if there were any benefits in administering this pre operatively, in particularly for patients for awake craniotomy electively. This method is currently used in colorectal and spinal teams within the trust. Carbohydrate loading...

Background: Transsulcal minimally invasive parafasicular (TsMIP) approaches to brain tumor resection use tubular retractors to minimize iatrogenic brain injury. Dynamic cortical and subcortical continuous neurophysiological mapping facilitates safer resection of motor-eloquent tumors. Objective: To describe a new technique to address the challen...

Background: The role played by the non-dominant parietal lobe in motor cognition, attention and spatial awareness networks has potentiated the use of awake surgery. When this is not feasible, asleep monitoring and mapping techniques should be used to achieve an onco-functional balance. Objective: This study aims to assess the feasibility of a du...

Objectives: We aim to demonstrate intraoperative recording of cerebellar to cortical pathways that have not been previously recorded in humans, though imaged. Methods: We report two cases with intraoperative neurophysiological mapping of cerebello-cortical tracts. Direct electrical stimulation of subcortical cerebellum along with recordings of c...

Description of methods and outcomes for awake craniotomy for motor eloquent intrinsic tumours in our practice.

Use of ICG to assess effect of tubular retractor surgery on cortical microvasculature

Background: Intraoperative neuromonitoring of motor functions experienced a dramatical revolution in the last years thanks to significant advances in anesthesiology procedures and both preoperative and intraoperative mapping techniques. Asleep, awake, and combined intraoperative mapping techniques were responsible for an improvement in the functio...

Aim • To assess the possibility of a dual strip method to obtain direct cortical stimulation for continuous real-time cortical monitoring and subcortical mapping of motor and visual pathways simultaneously Methods • Prospective single-centre study • Parietal lobe lesions resected with dual subdural strip electrodes for cortical subcortical mapping...

Trilocation of FAT and arcuate with navigated TMS

Does processed EEG (Entropy) correlate with IOM measures: scalp corkscrew EEG and direct cortical electrode ECoG in awake craniotomy for intrinsic tumour?

Background: The benefits of using 5-aminolevulinic acid (5-ALA) in resection of grade IV tumors have been extensively researched. However, few studies have investigated the use of 5-ALA in grade III gliomas. Objective: To discover whether 5-ALA provides significant benefit in assisting resection of grade III gliomas. Methods: A single-center,...

Objective Monitoring biomarkers using machine learning (ML) may determine glioblastoma treatment response. We systematically reviewed quality and performance accuracy of recently published studies. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Diagnostic Test Accuracy, we extracted articles from MEDLINE, EMB...

Deep-seated brain tumours represent a unique neurosurgical challenge as they are often surrounded by eloquent structures. We describe a minimally invasive technique using tubular retractors and intraoperative neurophysiology monitoring for open biopsy of a deep-seated lesion surrounded by the corticospinal tract. We used preoperative functional map...

Sneezing is a poorly understood, protective reflex response. It’s characterized by the following sequence: eye closure, inspiration, glottic closure, forced expiration with sudden glottic opening, and release of an elevated intrathoracic pressure creating a flow of explosive air through the nose.¹ Studies have indicated an anatomic sneezing area of...

To the Editor: We read with great enthusiasm the article published by Khalafallah et al.1 The authors address an utmost point of importance in contemporary glioma surgery: an operational definition for supratotal resection (SpTR) in glioblastoma (GBM). We believe this is a potential landmark article on this subject because it paves the way toward...

Objectives: The study aims to evaluate therapeutic strategies in the management of craniospinal tumours in pregnant patients and the factors that influence the management along with their influence on maternal & foetal outcomes. Materials and Methods: A retrospective single-centre cohort study was performed at a tertiary neurosurgical referral ce...

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Intraoperative neuromonitoring of motor functions experienced a dramatical revolution in the last years due to significant advances in anaesthesiology procedures and both preoperative and intraoperative mapping techniques. Asleep, awake and combined intraoperative mapping techniques were responsible for an improvement in the functional outcomes in...

Aims Primary central nervous system lymphoma (PCNSL) is a rare form of non–Hodgkin lymphoma with exclusive manifestations in the central nervous system, leptomeninges and eyes. It forms around 5% of all primary brain tumours. It is an aggressive tumour which has a poor prognosis if left untreated. It is imperative that diagnosis is made timely so t...

Aims Signs and symptoms that develop in people with brain tumours are often attributed to their tumour. The prevalence and management of functional neurological symptoms in brain tumour patients have received little attention. This is surprising because functional neurological symptoms complicate management greatly and misdiagnosis can lead to inap...

We propose a supplemental map to Penfield motor homunculus in the pre-central cortex and a novel subcortical map of the cortico-spinal tract that are accurate and essential for safe surgery in patients with eloquent brain lesions.

The identification of the visual pathway during surgery for tumors in visual areas is challenging. We present our experience in visual pathway mapping and monitoring, describing the role of direct mapping of the optic radiations and different techniques of VEPs monitoring, employing both Scalp Recording (SR) and the use of strip electrode positione...

Surgery for meningiomas involving dural venous sinuses is challenging. We describe a case of a peritorcular meningioma involving major venous sinuses, which was removed using a venous sparing approach with the aid of intraoperative ultrasound. We found ultrasound to be a useful adjunct as it enabled us to get real-time information about the locatio...

Ki67 is a marker for proliferation of a given cell population. Low expression of Ki67 may be associated with a favourable outcome. We investigate how the proliferation index correlates with the location, morphology and behaviour of WHO grade II ependymomas with a single-centre cohort study of adult patients admitted for surgery of WHO grade II epen...

Penfield's motor homunculus describes a caricaturised yet useful representation of the map of various body parts on the pre-central cortex. We propose a supplemental map of the clinically represented areas of human body in pre-central cortex and a novel subcortical corticospinal tract map. We believe this knowledge is essential for safe surgery in...

To the Editor: Keeble et al from our institution recently reported on the reliability and feasibility of combining electromagnetic (EM) neuronavigation systems and intraoperative neuromonitoring (IONM). Strategies to minimize the electrical interference from the EM navigation system to allow accurate recording of intra- operative somatosensory evok...

In this review, we summarise the current knowledge regarding the Superior Longitudinal Fasciculus(SLF) I and II. These fibres represent a longitudinal association tract between the parietal and frontal lobes of the brain. We highlight the anatomical representation of the SLF I and II in the primate and in the human brain. The fibres of the SLF I e...

Objective The aim of this work is to define competencies and entrustable professional activities (EPAs) to be imparted within the framework of surgical neuro-oncological residency and fellowship training as well as the education of medical students. Improved and specific training in surgical neuro-oncology promotes neuro-oncological expertise, qual...

Objective: The study analyzes the monitoring and subcortical mapping techniques for intra-axial visual eloquent tumors and their impact in the visual outcome. Design: It is a single-center prospective study from 2018- 2020. Subjects: Patients with intra-axial visual eloquent tumors(n=34) were included in the study. Methods: Single-center prospec...

Objectives: The study aims to evaluate craniospinal tumours in pregnant patients and the therapeutic strategies that influence maternal and foetal outcomes along with the challenges faced in management Design: A retrospective single-centre cohort study was performed at a tertiary neurosurgical referral centre. Subjects: Pregnant patients referre...

Abstract Objective: We summarise our experience and challenges faced with the non-navigated intraoperative ultrasound in cranial neuro-oncological surgery at a tertiary neurosurgical centre in UK. Design: It is a retrospective single-centre cohort study for a period of 2 years between Dec 2017-Dec 2019. Subjects: Adult patients(n=90) referred t...

Abstract Objective: The study aims to propose a supplemental map of the clinically represented areas of human body in pre-central cortex and a novel subcortical corticospinal tract map that are accurate and essential for safe surgery in patients with eloquent brain lesions. Design: It is a 5-year single-centre retrospective cohort study between 2...

We have recently introduced a full sized operative table beanbag surgical positioner (Vacuform 2.0©) to our operating theatres. • The operative beanbag is able to be positioned while soft, mould to the patients position and then solidify with vacuum suction. • Benefits include: speed, avoiding pressure complications, achieving maximal surgical acce...

Background 5-Aminolevulic Acid guided surgery (5-ALA-GS) improves the extent of resection and progression free survival in patients with glioblastoma multiforme (GBM). Methods Single-center retrospective cohort study of adult patients with GBM who had surgical resection between 2013 and 2019, 5-ALA guided versus a non 5-ALA cohort. Primary outcome...

Letter to Editor: We write to you with an example of a scenario regarding the use of pre-operative imaging and intraoperative techniques for mapping in insular glioma surgery and its relation to improved surgical outcome in the current context.

Background: The simplistic approaches to language circuits are continuously challenged by new findings in brain structure and connectivity. The posterior middle frontal gyrus and area 55b (pFMG/area55b), in particular, has gained a renewed interest in the overall language network. Methods: This is a retrospective single-center cohort study of patie...

Background Low-grade gliomas (LGG) are a heterogeneous group with significant changes in their management during the last decade. Objective To assess how our multidisciplinary team approach to the management of LGG has evolved over the past 10 years and its implications for outcomes. Methods Retrospective single-center cohort study of adult patie...

Background Lower-grade gliomas may be indolent for many years before developing malignant behaviour. The reasons mechanisms underlying malignant progression remain unclear. Methods We collected blocks of live human brain tissue donated by people undergoing glioma resection. The tissue blocks extended through the peritumoral cortex and into the gli...

Introduction and objectives The novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had drastic effects on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-econo...

Background: A recent influx of intraoperative technology is being used in neurosurgery, but few reports investigate the accuracy and safety of these technologies when used simultaneously. Objective: To assess the ability to use an electromagnetic navigation system alongside multimodal intraoperative neurophysiological monitoring (IONM). Methods...

Introduction: Penfield’s motor homunculus describes a caricaturised yet useful representation of the map of various body parts on the pre-central cortex. We propose a supplemental map of the clinically represented areas of human body in pre-central cortex and a novel subcortical corticospinal tract map that are accurate and essential for safe surge...

In preoperative planning for neurosurgery, both anatomical (diffusion imaging tractography) and functional tools (MR-navigated transcranial magnetic stimulation) are increasingly used to identify and preserve eloquent language structures specific to individuals. Using these tools in healthy adults shows that speech production errors occur mainly in...

Background: Diffuse gliomas have an increased biological aggressiveness across the World Health Organization (WHO) grading system. The implications of glioma grading on the primary motor cortex (M1)-corticospinal tract (CST) excitability is unknown. Objective: To assess the excitability of the motor pathway with navigated transcranial magnetic s...

The COVID-19 pandemic has challenged the delivery of care worldwide, with many outpatient clinics changing from face-to-face to telephone consultations [1]. This is particularly challenging in neuro-oncology, where often complex interventions need to be discussed and where communication can be compromised due to tumour-related language/cognitive de...

Background Patient-reported experience measures (PREMs) are a unique measure of experience of patients which can help address the quality of care of the patients.Objective Our aim of the study is to collect quality of care outcomes with our newly navigated transcranial magnetic stimulation patient-reported experience measure (nTMS-PREMs) questionna...

Background Superior medullary velum cerebral cavernous malformations pose a challenge in terms of appropriate microsurgical approach. Safe access to this deep location as well as preservation of surrounding anatomical structures, in particular the superior cerebellar peduncle just lateral to the superior medullary velum and the dentate nuclei, is p...

Background Lesions within the primary motor cortex (M1) and the corticospinal tract (CST) represent a significant surgical challenge with a delicate functional trade-off that should be integrated in the overall patient-centered treatment plan. Methods Patients with lesions within the M1 and CST with preoperative cortical and subcortical mapping (na...

OBJECTIVE This prospective case-control study was conducted to examine whether spherical deconvolution (SD) can unveil microstructural abnormalities in the corticospinal tract (CST) caused by IDH -mutant gliomas. To determine the significance of abnormal microstructure, the authors investigated the correlation between diffusion parameters and neuro...

Background Paragangliomas are uncommon neuro-endocrine tumours, rarely occurring in the lumbar spine. Primary lumbar paragangliomas are prominently vascularised, can present variably and pose both diagnostic and surgical challenges. We report on a large case series with long-term follow-up and intra-operative footage to characterise the natural his...

Intraoperative mapping and neuromonitoring is an established technique to maximise tumour resection while minimising the risk of inducing permanent postoperative deficit. However, very little is known on how many patients require brain mapping within a general adult neuro-oncology service. A prospective study of all neuro-oncology patients operated...

5-ALA is proven to be effective in high-grade glioma operative resection. The use of 5-ALA in WHO grade I lesions is still controversial. A 49-year-old lady was diagnosed in 2004 with a left temporal lobe lesion as an incidental finding; she was followed up clinically and radiologically. In 2016, the lesion showed contrast enhancement and she was o...

Background The use of intraoperative monitoring (IOM) in glioma surgery is a widely adopted and clinically validated adjunct to define safe zones of resection for the neurosurgeon. However, the role of IOM in cases of a significant preexisting motor deficit is questionable. Case Description We describe a case of a 25-year-old with a recurrent prese...