In this post, psychologist Cristian Francisco Liébanas Vega talks about the intraoperative brain mapping technique and its contributions to disease diagnosis.

Intraoperative brain mapping is a specialized technique used during brain surgery to optimize the balance between tumor removal and preservation of important brain functions. This technique is mainly used in patients with tumors or lesions located near important functional brain regions such as language, movement, vision, and emotions. The main objective of intraoperative brain mapping is to identify and avoid critical brain areas during tumor removal.

How is the study of brain mapping performed?

The study of intraoperative brain mapping is carried out using electrodes to stimulate different parts of the brain while the patient is awake. During the procedure, different language, movement, visual field, and emotion expression tasks specifically designed for each patient by neuropsychologists are performed.

These tasks allow neurosurgeons and clinical neuropsychologists to assess the patient’s responses and create a personalized map of brain areas with functions to preserve. This functional map is compared with the anatomical map of the tumor obtained through intraoperative ultrasound and neuronavigation, allowing for a better understanding of higher brain functions and the performance of surgical resections with a lower risk of neurological damage.

Diseases detectable through brain mapping

In addition to brain tumors, brain mapping can also be used in the diagnosis and treatment of other neurological diseases, such as epilepsy and movement disorders. Intraoperative brain mapping can provide crucial information about the brain areas responsible for seizures in patients with epilepsy, allowing for precise surgical removal planning of the affected area.

The role of the neuropsychologist in brain mapping

The neuropsychologist plays a fundamental role in the study of intraoperative brain mapping. They are responsible for designing and carrying out specific neuropsychological tasks to evaluate the patient’s brain functions during the procedure.

The neuropsychologist works closely with the surgeon and the medical team to identify critical brain areas and create a personalized map of functions to be preserved during surgery. Additionally, the neuropsychologist can also conduct pre- and post-operative assessments to evaluate potential changes in brain functions after surgery.

Contributions of brain mapping in disease diagnosis

Intraoperative brain mapping has proven to be a valuable tool in the diagnosis of neurological diseases.

In addition to determining the anatomical and functional boundaries of tumors as we have just seen, brain mapping can also be used in the diagnosis and treatment of other neurological diseases such as, in the case of epilepsy, helping to determine the areas responsible for seizures and guiding the surgery planning to remove the affected areas.

Clinical psychological and neuropsychological assessment

In awake neurosurgery patients, identifying changes in mood, cognition, behavior, and personality is a challenge, and only a thorough and comprehensive assessment process can determine whether these changes are caused by the tumor or are a psychological response to secondary stress, diagnosis, or treatment (Madhusoodanan, Ting, Farah, & Ugur, 2015). In this regard, the literature emphasizes the careful and individualized selection of the patient through a detailed and objective preoperative neuropsychological evaluation, which can reduce risks and increase the chances of a good diagnosis.

Neuropsychological predictors of high surgical risk

1. Personal factors

It is important to take into account all those personal factors that can positively or negatively influence a person’s surgical performance. Personal resources include personality type, emotional maturity, coping strategies, and previous experiences. Previous experiences related to cancer or the death of a family member due to a tumor are related to a higher emotional burden for the patient at the beginning of the process, while social and familial resources are considered protective factors in the disease process.

Variables such as excessive alcohol or drug consumption and chronic pain disorders are known risk factors for sedation failure (Chui, 2015). Additionally, stress levels, patient expectations, and how they cope with stressful situations are considered in various studies and are considered important variables.

2. Decision-making capacity

Assessing the ability to understand the treatment is a necessary part of the care process. According to Palmer & Harmell (2016) and Lutters & Broekman (2019), the formal assessment of decision-making capacity is not only an ethical and legal obligation of the responsible team but also constitutes a patient’s right to autonomy. Palmer & Harmell (2016) argue that the patient’s decision-making capacity should be defined based on four dimensions:

• Understanding: refers to the ability to accept and understand the illness, the information provided, the risks, benefits, and possible treatments.
• Appreciation: described as the ability to apply the information provided to oneself and one’s own situation.
• Reasoning: refers to the evidence that decisions reflect the presence of a comparative process and manipulation of information.
• Expression of decision: understood as the ability to communicate a clear and consistent decision.

At this point, it must be taken into consideration that, in the disease processes, the decision-making capacity becomes more complex, so it is common for both the patient and the family to have difficulties in deciding about their own health (Mattavelli, Casarotti, Forgiarini, Riva, Bello, & Papagno, 2012). In addition to this, patients with brain tumors often experience cognitive impairment, which is related in some cases to severe impairments in everyday decision-making skills (Ouerchefani, Ouerchefani, Allain, Rejeb, & Le Gall, 2017, Lutters & Broekman, 2019).

As a consequence of the same disease, many patients only have limited awareness of their symptoms and tend to underestimate the impact on their lives. The lack of self-awareness, which is a consequence of the tumor itself or a psychological defense mechanism, brings difficulties in making informed decisions about their health, which has been identified as a limitation for the patient’s participation in this type of procedure. (Boele et al., 2015).

3. Emotional and psychiatric disorders

According to the literature, a highly anxious patient tends to make more errors and lose their levels of attention-concentration and memory, so neither the baseline nor real-time results would be reliable and would affect both the action plan and the delineation of the resection. (Ruis et al., 2017 y Huget et al, 2019). In awake neurosurgery, it is very important for the patient to manage anxiety and their movements to ensure that they have self-control skills. Self-control is understood as the patient’s ability to voluntarily regulate their behavior during the procedure. (Rughani, Rintel, Desai, Cushing & Florman, 2011; Howie at al., 2016).

4. Neurocognitive disorders

Neuropsychological evaluation is a fundamental procedure that not only allows for establishing a baseline of cognitive functioning but also identifies significant neuropsychological deficits that disable the patient from performing the required tasks during brain mapping (Ruis, Wajer, Robe, & van Zandvoort, 2014).

According to Hervey-Jumper & Berger (2016), severe preoperative cognitive impairment, the presence of aphasias, pronounced neurological disorders, and the inability to be examined due to attention and consciousness problems are considered exclusion factors as they hinder patient cooperation in the operating room.

On the other hand, Becker (2016) mentions some basic cognitive functions that the person must retain to play an active role during awake neurosurgery:

• sufficiently fluent language to express oneself and be able to communicate cognitive, physical alterations and discomfort in the process;

• verbal comprehension for cooperation and following instructions;

• memory to ensure storage of information and instructions to be followed regarding surgery;

• attention for the performance of intraoperative activities;

• and visual skills in case he/she has to name images.

5. Considerations for pre-surgical preparation

In addition to passing clinical and neuropsychological psychological assessment filters, it is necessary for the patient to meet the evaluation requirements typical of pre-surgical preparation to comply with surgery requirements (Rughani et al., 2011). The experience developed at HM has allowed the team to identify that such preparation must involve the family or social network and must contain the two basic aspects that will be developed next:

A. Information regarding the surgery

This type of surgery demands the coordinated participation of each team member. The patient, integrating as an active agent, must know in detail their duties, the procedures to be performed during surgery, and what to expect at each step. Beyond knowing this information, they must understand it.

Authors such as Beez et al. (2013) and Ruis et al. (2014) believe that if the patient shows reluctance or denial to obtain details about the surgery, they cannot be operated on under this modality, as the patient must be aware of the advantages and the need to remain awake at key moments of the operation.

However, in clinical practice, it is identified that the way information is provided must be in line with the patient’s coping style, and some patients require more details than others.

It is necessary to explain what will happen in the operating room, including the procedure, possible complications, the desired level of cooperation, and the tasks to be performed (Carbone et al., 2019). Psychoeducation and preparation sessions with both the patient and the family are essential to achieve this goal.

Psychological preparation for surgery also requires sensory familiarization with the operating room environment and the sensations in one’s body. A previous visit to the operating room or the presentation of visual and auditory stimuli that familiarize the person with the procedure, the physical space, and the instruments, are good tools and help demystify any erroneous beliefs the patient may have about the procedure. Anticipating what will happen or what they will feel in some way will give them a sense of control during the procedure (Ortega, 2013; Ortiz, 2014; Quesada, 2015; Molinari, 2015; Acuña, 2017). Being able to anticipate in some way what will happen or what you will feel will give you a sense of control during the procedure.

B. Connection with the neuropsychology professional and surgical team

One of the most relevant aspects that distinguishes awake surgery from other types of surgeries is the importance of the patient building a trusting relationship with the neuropsychologist.

Due to the demanding nature of the procedure, studies have shown that patients need to have a familiar person available to emotionally support them throughout the surgical procedure (Ruis et al., 2014).

Actions such as explaining what is happening before and during surgery, training them for moments of discomfort or anxiety, providing words of motivation, and holding their hand during surgery, are perceived as highly valuable for patients (Molinari, 2015; Acuña, 2017; Ruis et al., 2014).

For this type of interaction between the patient and the clinician to be possible, it is necessary to invest time in preparation and have the patient’s willingness to work together (Ruis et al., 2014). As part of the preparation, the neuropsychologist professional may try to build a trusting relationship with the entire surgical team, which would be the ideal situation in the operating room.

References

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