Intraoperative MRI versus 5-ALA in high-grade glioma resection: a network meta-analysis

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  • 1 Departments of Neurosurgery and
  • 2 Radiology, New York University School of Medicine, New York, New York;
  • 3 NYU Health Sciences Library, New York University School of Medicine, New York, New York;
  • 4 Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York;
  • 6 Departments of Neurosurgery, Otolaryngology, and Neuroscience, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York; and
  • 5 Department of Science, Technology, Engineering and Math, Sweet Briar College, Sweet Briar, Virginia
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High-grade gliomas (HGGs) continue to carry poor prognoses, and patient outcomes depend heavily on the extent of resection (EOR). The utility of conventional image-guided surgery is limited by intraoperative brain shift. More recent techniques to maximize EOR, including intraoperative imaging and the use of fluorescent dyes, combat these limitations. However, the relative efficacy of these two techniques has never been systematically compared. Thus, the authors performed an exhaustive systematic review in conjunction with quantitative network meta-analyses to evaluate the comparative effectiveness of 5-aminolevulinic acid (5-ALA) and intraoperative MRI (IMRI) in optimizing EOR in HGG. They secondarily analyzed associated progression-free and overall survival and performed subgroup analyses by level of evidence.


PubMed, Embase, Cochrane Central, and Web of Science were searched for studies evaluating conventional neuronavigation, IMRI, and 5-ALA in HGG resection. The primary study endpoint was the proportion of patients attaining gross-total resection (GTR), defined as 100% elimination of contrast-enhancing lesion on postoperative MRI. Secondary endpoints included overall and progression-free survival and subgroup analyses for level of evidence. Comparative efficacy analysis of IMRI and 5-ALA was performed using Bayesian network meta-analysis models.


This analysis included 11 studies. In a classic meta-analysis, both IMRI (OR 4.99, 95% CI 2.65–9.39, p < 0.001) and 5-ALA (OR 2.866, 95% CI 2.127–3.863, p < 0.001) were superior to conventional navigation in achieving GTR. Bayesian network analysis was employed to indirectly compare IMRI to 5-ALA, and no significant difference in GTR was found between the two (OR 1.9 favoring IMRI, 95% CI 0.905–3.989, p = 0.090). A handful of studies additionally suggested that the use of either IMRI (2 and 4 studies, respectively) or 5-ALA (2 and 2 studies, respectively) improves progression-free and overall survival.


IMRI and 5-ALA are individually superior to conventional neuronavigation for achieving GTR of HGG. Between IMRI and 5-ALA, neither method is clearly more effective. Future studies evaluating the comparative cost and surgical time associated with IMRI and 5-ALA will better inform any cost-benefit analysis.

ABBREVIATIONS 5-ALA = 5-aminolevulinic acid; EOR = extent of resection; GTR = gross-total resection; HGG = high-grade glioma; IMRI = intraoperative MRI; LGG = low-grade glioma; QALY = quality-adjusted life year; RCT = randomized controlled trial; SDM = standard difference in means.

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Contributor Notes

Correspondence Danielle Golub: New York University School of Medicine, New York, NY.

INCLUDE WHEN CITING Published online February 21, 2020; DOI: 10.3171/2019.12.JNS191203.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this study.


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