Abstract
Intraoperative magnetic resonance imaging (iopMRI) actually has an important role in the surgery of brain tumors, especially gliomas and pituitary adenomas. The aim of our work was to describe the advantages and drawbacks of this tool for the surgical treatment of cervical intramedullary gliomas. We describe two explicative cases including the setup, positioning, and the complete workflow of the surgical approach with intraoperative imaging. Even if the configuration of iopMRI equipment was originally designed for cranial surgery, we have demonstrated the feasibility of cervical intramedullary glioma resection with the aid of high-field iopMRI. This tool was extremely useful to evaluate the extent of tumor removal and to obtain a higher resection rate, but still need some enhancement in the configuration of the headrest coil and surgical table to allow better patient positioning.
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Black PM, Moriarty T, Alexander E 3rd, Stieg P, Woodard EJ, Gleason PL, Martin CH, Kikinis R, Schwartz RB, Jolesz FA (1997) Development and implementation of intraoperative magnetic resonance imaging and its neurosurgical applications. Neurosurgery 41:831–842, discussion 842–835
Steinmeier R, Fahlbusch R, Ganslandt O, Nimsky C, Buchfelder M, Kaus M, Heigl T, Lenz G, Kuth R, Huk W (1998) Intraoperative magnetic resonance imaging with the Magnetom open scanner: concepts, neurosurgical indications, and procedures: a preliminary report. Neurosurgery 43:739–747, discussion 747–738
Fahlbusch R, Keller B, Ganslandt O, Kreutzer J, Nimsky C (2005) Transsphenoidal surgery in acromegaly investigated by intraoperative high-field magnetic resonance imaging. Eur J Endocrinol 153:239–248
Nimsky C, Fujita A, Ganslandt O, Von Keller B, Fahlbusch R (2004) Volumetric assessment of glioma removal by intraoperative high-field magnetic resonance imaging. Neurosurgery 55:358–370, discussion 370–351
Nimsky C, von Keller B, Ganslandt O, Fahlbusch R (2006) Intraoperative high-field magnetic resonance imaging in transsphenoidal surgery of hormonally inactive pituitary macroadenomas. Neurosurgery 59:105–114, discussion 105–114
Gerganov VM, Samii A, Stieglitz L, Giordano M, Luedemann WO, Samii M, Fahbusch R (2011) Typical 3-D localization of tumor remnants of WHO grade II hemispheric gliomas—lessons learned from the use of intraoperative high-field MRI control. Acta Neurochir (Wien) 153:479–487
Fahlbusch R, Ganslandt O, Buchfelder M, Schott W, Nimsky C (2001) Intraoperative magnetic resonance imaging during transsphenoidal surgery. J Neurosurg 95:381–390
Raco A, Piccirilli M, Landi A, Lenzi J, Delfini R, Cantore G (2010) High-grade intramedullary astrocytomas: 30 years’ experience at the Neurosurgery Department of the University of Rome “Sapienza”. J Neurosurg Spine 12:144–153
Raco A, Esposito V, Lenzi J, Piccirilli M, Delfini R, Cantore G (2005) Long-term follow-up of intramedullary spinal cord tumors: a series of 202 cases. Neurosurgery 56:972–981, discussion 972–981
Fahlbusch R, Ganslandt O, Nimsky C (2000) Intraoperative imaging with open magnetic resonance imaging and neuronavigation. Childs Nerv Syst 16:829–831
Nimsky C, Fujita A, Ganslandt O, von Keller B, Kohmura E, Fahlbusch R (2004) Frameless stereotactic surgery using intraoperative high-field magnetic resonance imaging. Neurol Med Chir (Tokyo) 44:522–533, discussion 534
Nimsky C, Ganslandt O, Buchfelder M, Fahlbusch R (2003) Glioma surgery evaluated by intraoperative low-field magnetic resonance imaging. Acta Neurochir Suppl 85:55–63
Hall WA, Liu H, Martin AJ, Pozza CH, Maxwell RE, Truwit CL (2000) Safety, efficacy, and functionality of high-field strength interventional magnetic resonance imaging for neurosurgery. Neurosurgery 46:632–641, discussion 641–632
Senft C, Seifert V, Hermann E, Gasser T (2009) Surgical treatment of cerebral abscess with the use of a mobile ultralow-field MRI. Neurosurg Rev 32:77–84, discussion 84–75
Verheyden P, Katscher S, Schulz T, Schmidt F, Josten C (1999) Open MR imaging in spine surgery: experimental investigations and first clinical experiences. Eur Spine J 8:346–353
Woodard EJ, Leon SP, Moriarty TM, Quinones A, Zamani AA, Jolesz FA (2001) Initial experience with intraoperative magnetic resonance imaging in spine surgery. Spine (Phila Pa 1976) 26:410–417
Mastronardi L, Elsawaf A, Roperto R, Bozzao A, Caroli M, Ferrante M, Ferrante L (2007) Prognostic relevance of the postoperative evolution of intramedullary spinal cord changes in signal intensity on magnetic resonance imaging after anterior decompression for cervical spondylotic myelopathy. J Neurosurg Spine 7:615–622
Hall WA, Nimsky C, Truwit CL (2011) Intraoperative MRI-guided neurosurgery. Thieme, New York, pp 186–195
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Xiaolei Chen, Bejing, China
Giordano et al. reported their preliminary experience on the surgical treatment of cervical intramedullary diffuse gliomas with intraoperative high-field-strength magnetic resonance imaging. This well-written paper has proved the technical feasibility of this technique.
Intraoperative MRI (ioMRI) has been widely propagated in recent years. The main indications are intracranial gliomas, pituitary adenomas, and other intracranial lesions. The use of this technique for the treatment of spinal intramedullary lesions was rarely reported. The major obstacle, as the authors pointed out in their paper, is the patient positioning and the placement of the RF coils. In our experience, it is almost impossible to place the RF coils below the C5-6 level. For patients with short necks, the situation will be even worse. Therefore, I do agree with the authors that new RF coils designed exclusively to cover the neck or, even better, the spinal column will be very helpful for the future application of ioMRI for the treatment of spinal lesions.
Another problem is the poor image quality of ioMRI for cervical spinal cord. Because the operation site is usually at the edge of the RF coils, while there are fluid and air inside after the resection, there will be severe image distortion and artifact. This problem will hopefully be solved with newly designed RF coils.
Because intramedullary spinal lesions seldom involve cortex and nuclei, the main purpose of the protection of the neurologic function is to protect the major fiber tracts. Intraoperative diffusion tensor-based fiber tracking and fiber navigation may be helpful to intraoperatively decide the incision of the spinal cord pia between the fiber tracts and during the dissection of the intramedullary lesions. The authors involved DTI sequence in their routine intraoperative scanning protocol. However, they did not report their results for intraoperative fiber tracking. It will be interesting if they can further this study and involve more intraoperative multimodal functional imaging for spinal lesions.
After all, the authors proved that it is feasible to apply high-field-strength ioMRI for the treatment of intramedullary cervical spinal lesions. Multimodality functional imaging navigation will support this technique better in the future. And a larger cohort study will be needed to prove the real role of this technique.
Andreas K. Demetriades, Edinburgh, UK
The authors demonstrate the feasibility of iopMRI for the surgical treatment of cervical and cervicothoracic intramedullary gliomas.
The perceived advantages are, on the one hand, the evaluation of the extent of tumour resection, and therefore, on the other hand, the capability of an increased resection rate. In both illustrative cases presented, these two advantages were achieved.
While cranial iopMRI has been present for more than two decades and is now in widespread use, spinal iopMRI is still only sporadically available.
The authors provide useful information on the setup and surgical workflow. The time required for a preoperative on-table scan, an intraoperative check scan, plus a final check scan after further resection seems to amount to an extra hour; this is, however, worthwhile if the extra resection achieved avoids further reoperations and their accompanying costs, delays and anxiety.
Equally importantly, the authors identify certain limitations and points for improvement: the configuration of the headrest coil and operating table to account for the cervical lordosis and the need to adapt coils which will improve image quality at the lower cervical levels and the cervicothoracic junction, where the shoulder and neck anatomical relationship plays a crucial part.
To draw extensive conclusions on only two cases is difficult, but this builds on previously reported experience. Further adaptations of the coil design will help improve the image quality and limit difficulties due to artefacts which may mask the true resection margins, such as from air bubbles trapped within the operating field, which might mimic haemosiderin-containing epidural caps of tumour, and from rapidly increasing contrast enhancement of the resection cavity margins.
Paulo Abdo do Seixo Kadri, Claudio Vinicius Sorrilha, Mato Grosso do Sul, Brasil
Cervical intramedullary glioma presents an extraordinary challenge to the patients and neurosurgeons. The low incidence of these tumors adds an enormous difficulty to define the effectiveness of the treatment. The preoperative neurological status and the tumor’s histology are the most important factors influencing the postoperative neurological outcome. It has been recommended that surgery should be performed as soon as neurological deficits develops [1]. The majority of the surgeons consider that the maintenance of neurological function overrides the benefit of radical resection. Although the extent of surgical resection as a predictor of long-term outcome is still in debate, recent literature has demonstrated a significant impact on survival especially in more aggressive tumors [2, 3]. The acquisition of surgical experience allied to the improvement of preoperative imaging, anatomical knowledge, intraoperative neurophysiological monitoring and surgical devices, such as the intraoperative ultrasonography and delicate ultrasonic aspirators, turn the aim of complete lesionectomy, while maintaining the neurological integrity, into a goal to be pursued. In this manner, we do have to congratulate the Hannover team to add to surgical armamentarium, the use of iopMR. In his article, Dr. Giordano points that the presented technique still needs further refinements; nevertheless, it opens the field and for sure adds in precision and safety.
References
1. Klekamp J (2013) Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results: clinical article J Neurosurg: Spine 19(1):12–26
2. McGirt MJ, Goldstein IM, Chaichana KL, Tobias ME, Kothbauer KF, Jallo GI (2008) Extent of surgical resection of malignant astrocytomas of the spinal cord: outcome analysis of 35 patients. Neurosurgery 63:55–61
3. Raco A, Esposito V, Lenzi J, Piccirilli M, Delfini R, CantoreG (2005) Long-term follow-up of intramedullary spinal cord tumors: a series of 202 cases. Neurosurgery 56:972–981
Christopher Nimsky, Marburg, Germany
The paper by Giordano et al. is one of the rare examples on the use of intraoperative high-field MRI for spinal tumor surgery. As for cranial surgery, also in spinal surgery, immediate intraoperative quality control seems to be beneficial for the individual patient.
Since most of the current intraoperative MR settings are primarily designed to meet the needs for cranial surgery, the authors encountered some challenges mainly attributable to patient positioning and MR coil application. Support by the MR manufacturers for the design of dedicated coils is needed. A coil that is placed close to the spinal cord, i.e., maybe in the approach zone, might lead to much improved image quality. Furthermore, optimized sequences better coping with the special needs of the intraoperative situation, like prevention of imaging artifacts, are also still needed.
The authors are to be congratulated to expand the field of intraoperative MRI beyond the ‘classical’ cranial applications; hopefully, further groups are stimulated by this report, so that then series of patients with spinal tumors can be investigated to actually further analyze the benefits of the applied technology.
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Giordano, M., Gerganov, V.M., Metwali, H. et al. Feasibility of cervical intramedullary diffuse glioma resection using intraoperative magnetic resonance imaging. Neurosurg Rev 37, 139–146 (2014). https://doi.org/10.1007/s10143-013-0510-x
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DOI: https://doi.org/10.1007/s10143-013-0510-x