Intraoperative magnetic resonance imaging–guided tractography with integrated monopolar subcortical functional mapping for resection of brain tumors

Clinical article

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Object

The object of this study was to describe the utility and safety of using a single probe for combined intraoperative navigation and subcortical mapping in an intraoperative MR (iMR) imaging environment during brain tumor resection.

Methods

The authors retrospectively reviewed those patients who underwent resection in the iMR imaging environment, as well as functional electrophysiological monitoring with continuous motor evoked potential (MEP) and direct subcortical mapping combined with diffusion tensor imaging tractography.

Results

As a navigational tool the monopolar probe used was safe and accurate. Positive subcortical fiber MEPs were obtained in 10 (83%) of the 12 cases. In 10 patients in whom subcortical MEPs were recorded, the mean stimulus intensity was 10.4 ± 5.2 mA and the mean distance from the probe tip to the corticospinal tract (CST) was 7.4 ± 4.5 mm. There was a trend toward worsening neurological deficits if the distance to the CST was short, and a small minimum stimulation threshold was recorded indicating close proximity of the CST to the resection margins. Gross-total resection (95%–100% tumor removal) was achieved in 11 cases (92%), whereas 1 patient (8%) had at least a 90% tumor resection. At the end of 3 months, 2 patients (17%) had persistent neurological deficits.

Conclusions

The monopolar probe can be safely implemented in an iMR imaging environment both for navigation and stimulation purposes during the resection of intrinsic brain tumors. In this study there was a trend toward worsening neurological deficits if the distance from the probe to the CST was short (< 5 mm) indicating close proximity of the resection cavity to the CST. This technology can be used in the iMR imaging environment as a surgical adjunct to minimize adverse neurological outcomes.

Abbreviations used in this paper: CST = corticospinal tract; DTI = diffusion tensor imaging; GTR = gross-total resection; iMR = intraoperative MR; MEP = motor evoked potential; ROI = region of interest.

Article Information

Address correspondence to: Sujit S. Prabhu, M.D., F.R.C.S.(Ed), The University of Texas M. D. Anderson Cancer Center, Department of Neurosurgery, 1515 Holcombe Boulevard, Unit 442, Houston, Texas 77030-4009. email: sprabhu@mdanderson.org.

Please include this information when citing this paper: published online October 22, 2010; DOI: 10.3171/2010.9.JNS10481.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photograph of the 1-mm ball tip monopolar probe with the star link and the 3 reflection spheres attached to the handle. After registration the probe is used both for navigation and direct subcortical stimulation.

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    Case 11. Intraoperative images obtained during resection of a right frontal WHO Grade II oligodendroglioma. A: Preoperative axial FLAIR sequence showing the fibers of the CST stretched out at the back of the tumor. B: Following initial resection, the first intraoperative axial FLAIR sequence shows residual tumor. At this point the measured distance between the probe tip and the CST was 20 mm and fiber MEPs were obtained at 20 mA. C: The patient underwent additional resection of the residual tumor and the second intraoperative scan shows the CST in close proximity to the posterior resection margin. D and E: Screen shot of sagittal (D) and axial (E) images during intraoperative navigation after the residual tumor was resected. These images show the segmented tumor cavity in green and purple and the segmented CST in light brown adjacent to the resection cavity. The measured distance between the tip of the probe (yellow line) and the CST was approximately 1 mm. While the iMR image accounts for the shift, the short distance between the probe and the CST (1 mm) along with the small amplitude of current (5 mA) to generate a fiber MEP alerted the surgeon to the proximity of the CST.

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    Case 8. Preoperative (A) and intraoperative (B) Gd-enhanced T1-weighted axial MR images. A: Image showing minimal enhancement of a deep-seated right parietal glioblastoma outlined in black. B: Intraoperative image obtained after resection shows the greater part of the tumor resected with residual tumor outlined in black. The posterior part of the CST was approximately 12 mm from the resection cavity, and fiber MEPs were obtained at 14 mA in the upper extremities and 18 mA in the lower extremities, respectively. Because of the infiltrative nature of this residual tumor and its proximity to the CST, further resection was not undertaken.

  • View in gallery

    Sagittal iMR images obtained before (A) and after (B) resection of a recurrent glioblastoma adjacent to the motor cortex. Note the significant edema at the posterior aspect of the mass prior to resection (A) with the posterior margin of the tumor 19.4 mm from the CST. Following resection (B) the CST moved forward toward the resection cavity and appeared less compressed and was located 11 mm from the resection cavity.

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