[ca] Aquest estudi tracta el dilema en la neurocirurgia de tumors cerebrals: extirpar la major part del tumor per reduir el risc de recurrència, amb el perill de danyar el teixit cerebral sa, o preservar la funció cerebral deixant cèl·lules tumorals que podrien provocar una ràpida recurrència. La Prehabilitació Cortical Induïda per Neuromodulació (NICP) intenta resoldre aquest conflicte optimitzant la neurocirurgia mitjançant l'ampliació dels marges funcionals per a una extirpació segura del tumor. La NICP combina neuromodulació i entrenament específic en tasques per inhibir àrees eloqüents peritumorals i activar altres zones cerebrals, fomentant la plasticitat neuronal. Encara que hi ha pocs estudis previs, els enfocaments invasius de la NICP han demostrat ser eficaços però arriscats, mentre que els no invasius (com l'Estimulació Magnètica Transcranial, TMS) són més segurs però menys efectius. A l'Institut Guttmann (Barcelona), es va desenvolupar un protocol innovador de NICP no invasiva amb entrenament intensiu. Aquest protocol es va validar en un estudi pilot amb 10 pacients dins la tesi 'PREHABILITA', seguit d'un assaig en curs amb 20 pacients més. La intervenció incloïa entre 10 i 20 sessions d'estimulació cerebral no invasiva (TMS o tDCS) amb entrenament motor, del llenguatge o cognitiu, segons el risc individual. Es van realitzar avaluacions clíniques i neurofisiològiques abans, durant i després de la cirurgia. Els resultats preliminars van mostrar que el protocol és viable, amb altes taxes d'adherència i sense esdeveniments adversos. No es va observar deteriorament funcional, i els pacients van expressar satisfacció amb el tractament. Les neuroimatges van mostrar un augment de la distància entre les àrees eloqüents i el tumor, suggerint canvis neuroplàstics en alguns pacients. No obstant això, aquests resultats van variar, amb alguns casos mostrant canvis menors o no desitjats. Es va observar que els canvis neuroplàstics més consistents es produïen quan la neuromodulació es dirigia a àrees de màxima activitat identificades per fMRI. Aquesta investigació representa la major sèrie de casos de NICP fins ara, demostrant que la NICP no invasiva combinada amb entrenament intensiu és factible i pot induir canvis neuroplàstics clínicament rellevants abans de la cirurgia. Tot i que els resultats són prometedors, cal validar-los amb estudis de cohorts més grans.

[en] This study addresses a critical dilemma in brain tumor (BT) neurosurgery, where surgeons must balance the goal of removing as much of the tumor as possible with the need to preserve healthy brain tissue. On the one hand, gross or supratotal resection of the tumor helps to reduce the risk of recurrence, but it may increase the likelihood of damaging surrounding healthy brain tissue, which could lead to functional impairments. On the other hand, a less radical resection may protect brain function, but it leaves behind cancerous cells that could cause the tumor to reoccur. To address this challenge, novel approaches like Neuromodulation-Induced Cortical Prehabilitation (NICP) have been explored as a way to optimize neurosurgical outcomes by expanding the functional margins that allow for safe, radical tumor removal. NICP combines neuromodulation and task-specific training to influence brain plasticity. Neuromodulation aims to inhibit activity in peritumoral eloquent areas, while task-specific training encourages alternative brain regions to take over these functions. This strategy helps to shift the brain's functional load away from eloquent areas at risk during surgery, thus reducing the likelihood of functional deficits. Although previous studies of NICP are limited to just a few cases, the findings suggest that invasive approaches are more effective than non-invasive ones in inducing neuroplastic changes. However, the invasive methods come with higher risks, including infection and seizures. In contrast, non-invasive techniques such as Transcranial Magnetic Stimulation (TMS) are safer but have shown limited effectiveness, possibly due to insufficient task-specific training. In response to these findings, the Institut Guttmann in Barcelona developed a novel protocol for non-invasive NICP, combining it with intensive task training in a pilot study involving 10 patients as part of the 'PREHABILITA' thesis. This was followed by a larger ongoing trial with 20 more patients. The intervention included 10 to 20 sessions of non-invasive brain stimulation (TMS or transcranial Direct Current Stimulation (tDCS)), focused on upper limb motor function, language, or cognitive abilities depending on the patient's needs. Before, during, and after surgery, comprehensive neuroimaging and clinical assessments were conducted to monitor changes in brain function, quality of life, and neuroplasticity. The primary goal of the study was to assess the feasibility of the protocol in terms of patient adherence, safety, and satisfaction. Additionally, the study sought to explore the effectiveness of the intervention and identify key factors that contribute to successful outcomes. The results were promising: the intervention was feasible, with high adherence and retention rates, and no adverse events attributable to the treatment. All patients completed the program without experiencing functional decline, and they expressed satisfaction with the therapy. Neuroimaging data revealed an overall trend for increased distance between eloquent brain areas and both the neuromodulation target and the tumor, suggesting a shift in brain activity away from areas at risk during surgery. However, outcomes varied on a case-by-case basis, with some patients showing substantial neuroplastic changes and others experiencing minimal or even undesirable changes. Additional analyses indicated that the most consistent neuroplastic changes occurred when the neuromodulation target was focused on areas of peak activity as identified by functional MRI (fMRI), particularly when targeting the eloquent area itself rather than more distant brain regions. This research represents the largest case series of NICP to date and demonstrates that non-invasive NICP, combined with intensive task training, is both feasible and capable of inducing meaningful neuroplastic changes before neurosurgery. While these early results are encouraging, larger cohort studies are needed to validate the findings and further refine the methodology developed in this study.