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Marcos V. C. Maldaun, Shumaila N. Khawja, Nicholas B. Levine, Ganesh Rao, Frederick F. Lang, Jeffrey S. Weinberg, Sudhakar Tummala, Charles E. Cowles, David Ferson, Anh-Thuy Nguyen, Raymond Sawaya, Dima Suki and Sujit S. Prabhu

areas requires an understanding of both the anatomical and functional limits of the tissues involved. Awake craniotomy with electrophysiological monitoring is currently the gold standard to achieve the functional limits of resection. 8 , 16 , 20 Intraoperative MRI (iMRI) has been successfully used to maximize the resection of gliomas and improve patient survival. 4 , 19 By compensating for brain shift during surgery, iMRI improves accurate anatomical visualization of residual tumor and functional tissue. Besides tumor resection, awake craniotomy procedures in the

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Benjamin B. Whiting, Bryan S. Lee, Vaidehi Mahadev, Hamid Borghei-Razavi, Sanchit Ahuja, Xuefei Jia, Alireza M. Mohammadi, Gene H. Barnett, Lilyana Angelov, Shobana Rajan, Rafi Avitsian and Michael A. Vogelbaum

progressively lose their accuracy as CSF is displaced and tumor is resected, resulting in brain shift and tissue deformation. The use of intraoperative MRI (iMRI) can overcome the navigational challenge associated with these brain deformations by allowing repeat images to be obtained after initial resection is completed, which can then be added to the navigation system to provide an updated “map.” 18 , 21 , 26 The iMRI cannot be used, however, to routinely produce new maps of functional cortex. Although preoperative functional imaging is widely accepted as necessary

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Constantin Roder, Martin Breitkopf, MS, Sotirios Bisdas, Rousinelle da Silva Freitas, Artemisia Dimostheni, Martin Ebinger, Markus Wolff, Marcos Tatagiba and Martin U. Schuhmann

I t is well known that in pediatric low-grade glioma (LGG) surgery, total resection has the potential to cure patients. However, since these patients have a high overall survival rate, the cost of total resection must not include an increased risk of iatrogenic neurological deficits. 8 , 10 One of the most important neurosurgical tools in achieving the goal of safe, complete resection (CR) of an intraaxial lesions is, together with intraoperative electrophysiological monitoring (IOM), surgical guidance via intraoperative MRI (iMRI), which has become more

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Moritz Scherer, Christine Jungk, Alexander Younsi, Philipp Kickingereder, Simon Müller and Andreas Unterberg

undesired partial resection (PR) despite an intended GTR prior to surgery. 12 In this regard, larger tumors, those with proximity to eloquent areas, and deep-seated tumors have been shown to have a higher likelihood of being resected incompletely. 1 , 12 , 19 Bringing together intraoperative MRI (iMRI) with multimodal neuronavigation forms a state-of-the-art concept for image-guided neurosurgery, facilitating the tightrope walk of achieving a radical but safe resection of gliomas. A proof of this concept has been delivered through a randomized controlled study in HGG by

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Manish N. Shah, Jeffrey R. Leonard, Gabrielle Inder, Feng Gao, Michael Geske, Devon H. Haydon, Melvin E. Omodon, John Evans, Diego Morales, Ralph G. Dacey, Matthew D. Smyth, Michael R. Chicoine and David D. Limbrick

A lthough there are few randomized controlled trials, it is generally accepted that maximizing the extent of resection increases survival for patients with many CNS tumors. 1 , 10 , 16 , 17 , 22–24 , 27 Recent advances in MR imaging technology have permitted the application of high-field intraoperative imaging modalities as an adjunct to neurosurgical procedures. 3 , 6 , 9 , 14 , 15 , 21 In adult patients, iMRI has been linked to enhanced glioma resection and longer survival. 2 , 7 , 12 , 18 Several series also have shown the benefit of iMRI

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Jan Coburger, Ralph König, Klaus Seitz, Ute Bäzner, Christian Rainer Wirtz and Michal Hlavac

postoperative changes, reliable detection of residual tumor with MRI cannot be achieved earlier than 3 months after surgery. 17 Despite the introduction of neuronavigation to facilitate precise intraoperative anatomical orientation, complete resection of adenomas is not always achieved. The application of intraoperative imaging methods such as CT (iCT) and MRI (iMRI) 30 seems to have improved resection rates, not only in gliomas but also in transsphenoidal pituitary surgery. 2 , 6 , 8 First introduced as a low-field technique 31 improving resection, especially in

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Sven Berkmann, Sven Schlaffer, Christopher Nimsky, Rudolf Fahlbusch and Michael Buchfelder

tools have been introduced, starting with Hardy and Wigser's use of radiofluoroscopy in 1965, 32 to increase the efficiency of this procedure. Intraoperative MRI (iMRI) has been used in pituitary surgery for more than a decade. 45 , 71 It allows evaluation of progress during transsphenoidal tumor resection, an update of images for intraoperative navigation tools, and the exclusion of imminent complications, such as hemorrhage, before the site is closed. 17 Five decades of transsphenoidal pituitary surgery have left a legacy of thousands of patients with remnants

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Jan Coburger, Jens Engelke, Angelika Scheuerle, Dietmar R. Thal, Michal Hlavac, Christian Rainer Wirtz and Ralph König

S everal studies have shown that the extent of resection (EOR) correlates with increased survival in patients with high-grade gliomas (HGGs). 3 , 5 , 11 , 12 , 14 , 16 , 20 , 32 For 5-aminolevulinic acid (5-ALA) fluorescence and for low-field intraoperative MRI (iMRI), Class I evidence exists to increase EOR. 22 , 24 The outline of contrast enhancement in Gd-DPTA–enhanced MRI is the most widely accepted target area of HGG and metastasis (MET) surgery. Most large trials, including the above-mentioned publications, are based on the EOR calculated on pre

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Zhiqiang Cui, Longsheng Pan, Huifang Song, Xin Xu, Bainan Xu, Xinguang Yu and Zhipei Ling

microelectrode recording (MER), intraoperative MRI (iMRI), temporary efficacy during the operation, postoperative MRI, and sustained effect during the postoperative period. Typically, a combination of anatomical and physiological methods is used in the localization of the STN. Electrophysiological recording of the STN can be obtained intraoperatively via microelectrodes. Real-time physiological confirmation of the target has been reported to be particularly useful, especially as an adjunct to current advanced brain imaging techniques. 1 , 21 , 27 Intraoperative

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Yosuke Masuda, Hiroyoshi Akutsu, Eiichi Ishikawa, Masahide Matsuda, Tomohiko Masumoto, Takashi Hiyama, Tetsuya Yamamoto, Hidehiro Kohzuki, Shingo Takano and Akira Matsumura

authors have stated that benign and nonneoplastic postoperative reactive findings, such as benign enhancement or T2 high-intensity area (HIA) expansion, were seen even on MRIs that were obtained earlier than 72 hours after surgery for glioma, including epMRI. Thus, the EOR can be misdiagnosed due to postoperative reactive changes on epMRI. 1 , 26 , 28 Intraoperative MRI (iMRI)–guided surgery, however, is more effective than conventional neuronavigation-guided surgery in maximizing the EOR, enhancing the patient’s quality of life, and prolonging survival after resection