you hope will never happen to you this
is a patient who came to our department
with a new epilepsy this epilepsy was
due to a brain tumor and the location of
this tumor is in a very essential region
which is called Broca’s area which is
known for the production or conception
of language so what brain tumors have in
common is that they’re not only consist
of tumor cells but they are highly
infiltrative which means that the tumor
consists of tumor cells but also has
incited humor working brain cells and in
a lot of cases this brain tissue is
still highly essential for the patient
itself and for some of his most
essential functions so what do you tell
such a patient about the therapeutic
options of his tumor should it be
resected or i afraid just by the
location and you counsel him and tell
him he shouldn’t be operated on so for
doctor and for me as a surgeon it’s
quite hard to tell your patient that you
can’t help them because you’re not sure
if there is function or it is not of
course when we operate on the brain we
roughly know where function is located
for instance motor functions look at
tier two so called precentral gyrus like
for a movement of your body this is the
understanding of language as I told you
this is Broca’s area for language
production mainly social behavior
arithmetic processing which means the
ability to calculate and memory however
this is in the healthy brain we know the
brain tumors actually impair the
function of the brain and kind of caused
a reorganization in some patients and
some it does not
this means that motor function doesn’t
need to be here it can also be here the
language doesn’t need
you can also hear so how do you know
before surgery
greatest functions located and what do
you tell your patient that make search
reasons at all or not so that’s why in
2010 we decided to leap forward and
actually test a brand new application of
an actually old technique for mapping
brain function which is called a long
name navigated transcranial magnetic
stimulation or short but easier and TMS
and what an TM has does is that it has a
stimulation coil which is put on the
patient’s head it’s handheld and induces
a magnetic field which penetrates the
skull it then hits the brain and where
it is in the brain it elicits an
electric field and this electric field
then stimulates or inhibits neurons and
the newest thing is that we can actually
navigate in the brain and visualize
which point and small area in the brain
we’re actually stimulating or inhibiting
is to see here between the red and blue
arrows so we can really see in
high-resolution MRIs where we stimulate
the brain and if you then examine the
response of the brain by electrodes of
the muscle or by observing the language
of the patient or even the ability to
perform some little and easy calculation
tasks you can make a map of the brain so
it’s quite powerful technique so in the
last six years we learned a lot new
things are about our brain tumor patient
and their functional anatomy this is the
fusion of the maps of the motor system
of 100 brain tumor patients you see in
light blue the motor area for the arm
and the hand and in dark purple for the
leg and in pink I draw in for you again
the Prasad gyrus which is the
traditionally thought region for motor
function and as to see here that the
actual region in brain tumor patients
where motor function can be is far more
spread so you can’t just buy anatomies
tell a patient if you should operate him
or not even if you separate these
hundred patients in five different
groups so that each group only has
patients with the tumor in the same
location is to see here you see that the
region of the motor area is totally
different depending on the tumor so even
a tumor location then determines in a
way how your motor cortex is reorganized
in the brain
and the same is true for language I
showed you earlier the yellow blue
regions but as you see here in this heat
map where that blue means a high rate of
patients have motor function inside this
area it shows you how much more spread
language function can be in brain tumor
patients so coming back to a patient as
I showed you at the beginning whom we
couldn’t tell where function is located
because we assume this by location this
is a tumor we might not operate and
actually that still happens today we’re
able to perform individual maps for each
patient which we actually do a lot of
times a week it takes us 2 to 4 hours
for each patient and we can then counsel
patients and tell them about the risks
and benefits of surgery if it makes
sense or not if he has a high risk to
lose some part of his language or motor
function or not and the same is true for
children
beginning at age of 2 we’re able to also
perform naps for them this is actually
the case of a smart kid who has two
brain tumors as you see here in orange
in blue you’ll see again the motor areas
and in yellow and blue you see the
fibrous which are kind of the cables
which bring the information down to a
spinal cord and as you can imagine on
these slides with such detailed images
you can tell the parents much easier but
the problem of the therapy is
and if they want to do surgery or truth
another treatment and you can show them
in a way that they really understand the
problem three years ago did a study on
which we analyzed patients who came to
our department for a second opinion
because they were told they tumors not
removal or the 51 patients we operated
on forty-seven seventy-four percent of
those had complete tumor resection which
means we resected all tumor you saw an
MRI scan none of the patients with their
first brain surgery in our department
had any new deficit although they were
told they have high risk and you
shouldn’t operate the tumor in another
study we compared tations were operated
on without preoperative TMS data and
those with TMS data and we saw that the
rate of complete tumor removal increased
from 58 to 78% however there’s actually
just the beginning of using TMS in the
surgery there are some specialties who
already used TMS also non levitated
since decades for pain tinnitus a
depression but also a stroke and what
patients with stroke have has main
problem in many cases is that they’ll
suffer from a weakness of one side of
the body and we know today that if you
have a injured half of the brain half of
the brains called hemisphere so if you
have an intern hemisphere the healthy
hemisphere has inhibitory pathways which
even makes the hell injured hemisphere
even worse so it inhibits the inert
atmosphere what we can do with TMS is
that we apply inhibitory pulses which is
kind of an overstimulation so the
healthy hemisphere and avoid that makes
the injured one universe and it works
actually well most drug patients and a
lot of studies and we actually do that
study now on our brain tumor patients
which is ongoing who suffer actually
after surgery from a problem with moving
arm or leg
and we have really amazing cases some of
them matriz we don’t all a patient who
could move his right arm and hand for
five weeks after surgery and then we did
treatment on hand with TMS and after
some sessions his talent or show moved
in his hand in another case we had a
young woman who could write the day
after surgery not move her left side of
the body and at the seventh day of
treatment she actually walked to the
treatment room so it’s what not only for
us especially for the family it was kind
of a miracle for effort was also like a
very strong treatment effect at thinking
even one step further this is a PET scan
a PET scan shows you biological activity
of tissue which means it shows you where
the tissue is most highly active and
also where the tumor is highly active
and this is again a two men so called
Broca’s area and I told you before we
don’t know where language is usually so
we did a mapping on him and
unfortunately the mapping showed us
right inside the tumor this is actually
a tree lingual patient it showed us for
every of his three languages that he has
essential language function inside a
tumor so what do you do with such a
patient do you tell them well we won’t
operate at all do we tell him why we
remove some part of it we try to remove
everything and can happen that you
cannot speak anymore after surgery we
can then try some tumors treatment it
might work might not or you think one
step further and you apply to these
highly essential brain areas inside the
tumor you apply inhibitory TMS treatment
and make it much harder for the brain to
actually produce language and then you
force the brain to find new solutions
so finally coming back to our knowledge
about the functional anatomy of brain
tumor patients we know that this
different from healthy people so we
shouldn’t treat them like they have a
normal function atomy but we also do not
have to because today we’re able to
perform individual Maps we actually do
that on a routine basis in our
department several times a week and we
do that with a powerful help of brain
stimulation and as I showed you today
this is just the beginning of this
technique thank you very much [Applause]