Technology in context: A holistic care approach

Journal Pre-proofs Letter to the Editor Technology in context: A holistic care approach José Pedro Lavrador, Sabina Patel, Richard Gullan, Ranjeev Bhangoo, Francesco Vergani, Keyoumars Ashkan PII: DOI: Reference: S1388-2457(19)31292-1 https://doi.org/10.1016/j.clinph.2019.10.026 CLINPH 2009036 To appear in: Clinical Neurophysiology Received Date: Accepted Date: 13 October 2019 15 October 2019 Please cite this article as: Pedro Lavrador, J., Patel, S., Gullan, R., Bhangoo, R., Vergani, F., Ashkan, K., Technology in context: A holistic care approach, Clinical Neurophysiology (2019), doi: https://doi.org/10.1016/ j.clinph.2019.10.026 This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V. on behalf of International Federation of Clinical Neurophysiology. Technology in context: a holistic care approach José Pedro Lavrador*, Sabina Patel, Richard Gullan, Ranjeev Bhangoo, Francesco Vergani, Keyoumars Ashkan Neurosurgical Department, King’s College Hospital Foundation Trust, London, United Kingdom * Correspondence We read with great enthusiasm the paper published by Seidel et al. (2019). To our knowledge, this is the first published series where navigated transcranial magnetic stimulation (nTMS) was used to predict the motor recovery in patients with motor deficit after surgery for a supratentorial brain tumor. Building on the previous work performed by this group where 25% of patients with intraoperative loss of motor evoked potentials (MEPs) still recovered the motor function after surgery (Seidel et al., 2013), the post-operative nTMS revealed a negative predictive value of 100% (no motor recovery at 1 month if no MEPs elicited with nTMS) and a positive predictive value of 91% (motor recovery at 1 month if MEPs elicited with TMS). Post-operative nTMS was therefore able to enhance the prognostic information provided by the intraoperative direct cortical stimulation. We agree with the authors that nTMS is particularly useful in patients with lesions in the supplementary motor and ventral premotor areas (SMA and VPM), where the interpretation of motor deficits is challenging and a source of significant anxiety, to efficiently differentiate between the temporary deficits produced by the surgical resection from the permanent deficits. Our group routinely uses the post-operative diffusion tensor imaging (DTI)-tractography to assess the integrity of the corticospinal tract (CST) after surgical resection in patients with post-operative motor deficits (Figure 1). Results presented in this paper encourage a combined strategy, nTMS and tractography, to further improve prediction of post-operative motor recovery in these patients. In our view a critical point to highlight though is the importance of intensive post-operative physiotherapy and neurorehabilitation in patients with deficits despite the results of functional and structural data such as nTMS and tractography, as it happened with the patients described by Seidel et al. (2019). There is now ample evidence across the age groups that taking part in physical rehabilitation programs has far reaching benefits beyond motor recovery, including improving the patients’ well-being and adhesion to the treatments (Riggs et al., 2017). The authors discuss the importance of having realistic expectations about post-operative motor recovery by both the patient and the multidisciplinary team (MDT) members (neurosurgeons, oncologists, physiotherapists) (McGirt et al., 2009). This however needs to be balanced against the potential psychological stresses caused to the patient by this information, at a critical time in their journey when motivation is paramount, thus hindering recovery from surgery and engagement with further treatment (Cormie et al., 2015). Moreover, there is a risk that the perceived permanency of the post-operative deficit biases the further management of the patient by the MDT, not only in terms of rehabilitation but provision of timely adjuvant therapy. These considerations should be framed within each cultural and social background as well as regional and national policies for adjuvant oncological treatment. Seidel et al. need to be congratulated on their efforts to push forward the clinical applications of nTMS and pave the way for new and better postoperative motor recover predictability scores. Such information, however, will need to be integrated as part of the holistic approach towards the patients’ best interests. Physical rehabilitation should be considered to all patients regardless of the postoperative functional-structural data as it may improve the motor recovery in those with favorable postoperative parameters (MEPs elicited with post-operative nTMS and / or integrity of the CST in the post-operative DTI), and the psychological well-being and a sense of value in all affected by this terrible disease. Conflict of Interest None of the authors have potential conflicts of interest to be disclosed and the authors had no funding source to write this manuscript. References Cormie P, Nowak AK, Chambers SK, Galvão DA, Newton RU. The potential role of exercise in neurooncology. Front Oncol. 2015;5:85. McGirt MJ, Mukherjee D, Chaichana KL, Than KD, Weingart JD, Quinones-Hinojosa A. Association of surgically acquired motor and language deficits on overall survival after resection of glioblastoma multiforme. Neurosurgery. 2009;65:463-9; discussion 469-70. Riggs L, Piscione J, Laughlin S, Cunningham T, Timmons BW, Courneya KS, Bartels U, Skocic J, de Medeiros C, Liu F, Persadie N, Scheinemann K, Scantlebury N, Szulc KU, Bouffet E, Mabbott DJ. Exercise training for neural recovery in a restricted sample of pediatric brain tumor survivors: a controlled clinical trial with crossover of training versus no training. Neuro Oncol. 2017;19:440-450. Seidel K, Beck J, Stieglitz L, Schucht P, Raabe A. The warning-sign hierarchy between quantitative subcortical motor mapping and continuous motor evoked potential monitoring during resection of supratentorial brain tumors. J Neurosurg. 2013;118:287-96. Seidel K, Häni L, Lutz K, Zbinden C, Redmann A, Consuegra A, Raabe A, Schucht P. Postoperative navigated transcranial magnetic stimulation to predict motor recovery after surgery of tumors in motor eloquent areas. Clin Neurophysiol. 2019;130:952-959. Figure Caption Figure 1 – Pre-Operative (blue box) and Post-Operative (orange box) tractography in a patient with a right side supplementary motor area WHO Grade IV Glioma – A (coronal), B (sagittal), C (axial) and D (3D reconstruction) of preoperative tractography. E (coronal), F (sagittal), G (axial) and H (3D reconstruction) of postoperative tractography. Green – Upper Limb streamlines. Red – Lower Limb streamlines. StealthViz MEDTRONIC® Software