Sulci and gyri are topological cerebral landmarks in individual subjects: a study of brain navigation during tumour resection

NEUROANATOMY TO NEUROSURGEONS IN THE AI / ROBOTIC ERA

Evidence-based medicine is currently the foundation of precision medicine, either in clinical or surgical treatments. Regarding Central Nervous System (CNS) malignant Gliomas, an optimal maximal safe resection surgery followed by adjuvant therapies are the standard of care.

The last decades brought an unprecedented development of technology devices. Magnetic Resonance Images (MRI) reveals with high resolution anatomical brain landmarks related to functional areas, that may be also defined by means of tractography; NeuroNavigators systems are  very useful to indicate sub-cortical and deep-seated lesions; awake surgery with brain mapping, the use of fluorescent agents and intraoperative post-resection MRI  contributes to ensure safe gross total resection with minimal or none morbidity, resulting in better quality of life to majority of patients treated under this protocolar method.

However, some sporadic personal and published reports about pitfalls and troubles using such devices raises the question about how dependable physicians and surgeons became to perform a very precise diagnosis followed by a (truly!) gross total resection. Perhaps it seems that all those tools may lead some physicians to an exaggerated confidence accompanied by a certain negligence with some of brain landmarks.

Dr. Tomaiuolo and their colleagues cast doubt wether technology ensure precise and accurate procedures without the ancient knowledge of microsurgical NeuroAnatomy, a medical field structured step-by-step for our ancestors since ancient Edwin Smith Surgical Papyrus (1600 BC), the anatomical studies of Haerophilus of Chalcedony (335-280 BC) Galen (129 – c. 216 AD), Andreas Vesalius (1514 –1564), Leonardo da Vinci (1452–1519), Thomas Willis (1621 –1675) until the modern microsurgical anatomy work developed by Dr. Yaşargil (1925-2025), Dr. Rhoton (1932-2016), Dr. De Oliveira (1946-2021) and many others who applied so well neuroanatomic principles to neurosurgery, with impressive results.

Medical confidence must be gained by means of a classical careful examination of complaints, signs, symptoms, laboratory and image studies by the surgeon-in-chief, which must further review the most relevant informations to a team of colleagues, during the needful tumor board sections, seeking for a consensus about the most precise and safe approach to that particular patient .

Maybe the most important message from Dr. Tomaiuolo and their colleagues is that any detail about individual anatomical, physiological or even clinical aspects of a particular person are relevant, and that patient’s “fingerprints”characteristics – as well his or her neuroanatomic landmarks - must be recognized during  the surgical planning phase.

Finally, probably new upgraded generations of machines guided by AI will perform more precise and effective procedures than we do today, however, it is out of discussion that even the most advanced AI available must possess the consolidate knowledge about constant brain sulci and gyri landmarks in order to successfully accomplish a maximal or even Supra-maximal total malignant glioma resection in a more efficient manner. Journal: EJN - European Journal of NeuroScience | FENS - Federation of European NeuroScience Societie

Author: Edmundo Luís Rodrigues Pereira, MD, MSc, PhD.

Mini-CV: Oncological NeuroSurgeon - Associate Professor |Neurosurgical Division, Federal University of Pará