scholarly journals Combined Use of Diffusion Tractography and Advanced Intraoperative Imaging for Resection of Cervical Intramedullary Spinal Cord Neoplasms: A Case Series and Technical Note

2019 ◽  
Vol 17 (5) ◽  
pp. 525-530 ◽  
Author(s):  
Carolina Gesteira Benjamin ◽  
Anthony Frempong-Boadu ◽  
Michael Hoch ◽  
Mary Bruno ◽  
Timothy Shepherd ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Diffusion Tensor ◽  
Intraoperative Imaging ◽  
Case Series ◽  
Technical Note ◽  
Surface Registration ◽  
Integrated Navigation ◽  
Total Resection ◽  
Intramedullary Spinal Cord ◽  
Spinal Cord Neoplasms

Abstract BACKGROUND Intramedullary spinal cord neoplasms (ISCN) pose significant management challenges. Advances in magnetic resonance imaging (MRI) (such as diffusion tensor imaging, DTI) have been utilized to determine the infiltrative nature and resectability of ISCN. However, this has not been applied to intraoperative decision making. OBJECTIVE To present a case series of 2 patients with ISCN, the first to combine use of DTI, pre- and intraoperative 3-dimensional (3D) virtual reality imaging, and microscope integrated navigation with heads-up display. METHODS Two patients who underwent surgery for ISCN were included. DTI images were obtained and 3D images were created using Surgical Theater (Surgical Theater SRP, Version 7.4.0, Cleveland, Ohio). Fiducials were used to achieve accurate surface registration to C4. Navigation confirmed the levels of laminectomy necessary. The microscope was integrated with Brainlab (Brainlab AG Version 3.0.5, Feldkirchen, Germany) and the tumor projected in the heads-up display. Surgical Theater was integrated with Brainlab to allow for real time evaluation of the 3D tractography. RESULTS Case 1: All tracts were pushed away from the tumor, suggesting it was not infiltrative. Surgical Theater and Brainlab assisted in confirming midline despite the abnormal swelling of the cord so the myelotomy could be performed. The heads-up display outline demonstrated excellent correlation to the tumor. Gross total resection was achieved. Diagnosis of ependymoma was confirmed. Case 2: Some tracts were going through the tumor itself, suggesting an infiltrative process. Surgical Theater and Brainlab again allowed for confirmation of the midline raphe. Near total resection of the enhancing portion was achieved. Diagnosis of glioblastoma was confirmed. CONCLUSION This is a proof of concept application where multi-modal imaging technology was utilized for safest maximal ISCN resection.

scholarly journals Resection of cerebral gangliogliomas causing drug-resistant epilepsy: short- and long-term outcomes using intraoperative MRI and neuronavigation

2015 ◽  
Vol 38 (1) ◽  
pp. E5 ◽  
Author(s):  
Björn Sommer ◽  
Cornelia Wimmer ◽  
Roland Coras ◽  
Ingmar Blumcke ◽  
Bogdan Lorber ◽  
...  
Keyword(s):  
Diffusion Tensor ◽  
Intraoperative Imaging ◽  
Intractable Epilepsy ◽  
Complete Resection ◽  
Blood Oxygenation ◽  
Seizure Outcome ◽  
Incomplete Resection ◽  
Brain Areas ◽  
Total Resection

OBJECT Cerebral gangliogliomas (GGs) are highly associated with intractable epilepsy. Incomplete resection due to proximity to eloquent brain regions or misinterpretation of the resection amount is a strong negative predictor for local tumor recurrence and persisting seizures. A potential method for dealing with this obstacle could be the application of intraoperative high-field MRI (iopMRI) combined with neuronavigation. METHODS Sixty-nine patients (31 female, 38 male; median age 28.5 ± 15.4 years) suffering from cerebral GGs were included in this retrospective study. Five patients received surgery twice in the observation period. In 48 of the 69 patients, 1.5-T iopMRI combined with neuronavigational guidance was used. Lesions close to eloquent brain areas were resected with the implementation of preoperative diffusion tensor imaging tractography and blood oxygenation level–dependent functional MRI (15 patients). RESULTS Overall, complete resection was accomplished in 60 of 69 surgical procedures (87%). Two patients underwent biopsy only, and in 7 patients, subtotal resection was accomplished because of proximity to critical brain areas. Excluding the 2 biopsies, complete resection using neuronavigation/iopMRI was documented in 33 of 46 cases (72%) by intraoperative imaging. Remnant tumor mass was identified intraoperatively in 13 of 46 patients (28%). After intraoperative second-look surgery, the authors improved the total resection rate by 9 patients (up to 91% [42 of 46]). Of 21 patients undergoing conventional surgery, 14 (67%) had complete resection without the use of iopMRI. Regarding epilepsy outcome, 42 of 60 patients with seizures (70%) became completely seizure free (Engel Class IA) after a median follow-up time of 55.5 ± 36.2 months. Neurological deficits were found temporarily in 1 (1.4%) patient and permanently in 4 (5.8%) patients. CONCLUSIONS Using iopMRI combined with neuronavigation in cerebral GG surgery, the authors raised the rate of complete resection in this series by 19%. Given the fact that total resection is a strong predictor of long-term seizure control, this technique may contribute to improved seizure outcome and reduced neurological morbidity.

scholarly journals Diffusion tensor imaging to guide surgical planning in intramedullary spinal cord tumors in children

2014 ◽  
Vol 56 (2) ◽  
pp. 169-174 ◽  
Author(s):  
Asim F. Choudhri ◽  
Matthew T. Whitehead ◽  
Paul Klimo ◽  
Blake K. Montgomery ◽  
Frederick A. Boop
Keyword(s):  
Spinal Cord ◽  
Diffusion Tensor Imaging ◽  
Surgical Planning ◽  
Diffusion Tensor ◽  
Spinal Cord Tumors ◽  
Intramedullary Spinal Cord

Intraoperative Computed Tomography Navigation-Assisted Resection of Symptomatic Intramedullary Spinal Cord Cavernoma: A Technical Note and Case Report

2019 ◽  
Vol 129 ◽  
pp. 311-317
Author(s):  
Krisztina Moldovan ◽  
Sanjay Konakondla ◽  
Sean M. Barber ◽  
Jonathan Nakhla ◽  
Jared S. Fridley ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Spinal Cord ◽  
Case Report ◽  
Technical Note ◽  
Intramedullary Spinal Cord ◽  
Intraoperative Computed Tomography

scholarly journals Intramedullary Spinal Cord Metastases: MRI and Relevant Clinical Features from a 13-Year Institutional Case Series

2013 ◽  
Vol 34 (10) ◽  
pp. 2043-2049 ◽  
Author(s):  
J.B. Rykken ◽  
F.E. Diehn ◽  
C.H. Hunt ◽  
K.M. Schwartz ◽  
L.J. Eckel ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Clinical Features ◽  
Case Series ◽  
Intramedullary Spinal Cord

scholarly journals Nerve root biopsy in intramedullary spinal cord lymphoma: Technical note and case report

2020 ◽  
Vol 19 ◽  
pp. 100599
Author(s):  
Georgios Α. Maragkos ◽  
Rouzbeh Motiei-Langroudi ◽  
German Pihan ◽  
Eric T. Wong ◽  
Efstathios Papavassiliou
Keyword(s):  
Spinal Cord ◽  
Case Report ◽  
Nerve Root ◽  
Technical Note ◽  
Intramedullary Spinal Cord

Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data

2014 ◽  
Vol 21 (4) ◽  
pp. 662-676 ◽  
Author(s):  
Jetan H. Badhiwala ◽  
Forough Farrokhyar ◽  
Waleed Alhazzani ◽  
Blake Yarascavitch ◽  
Mohammed Aref ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Individual Patient Data ◽  
Clinical Course ◽  
Meta Analysis ◽  
Single Center ◽  
Total Resection ◽  
Intramedullary Spinal Cord ◽  
Cavernous Malformations ◽  
Neurological Outcomes ◽  
History Of

Object Information pertaining to the natural history of intramedullary spinal cord cavernous malformations (ISCCMs) and patient outcomes after surgery is scarce. To evaluate factors associated with favorable outcomes for patients with surgically and conservatively managed ISCCMs, the authors performed a systematic review and metaanalysis of the literature. In addition, they included their single-center series of ISCCMs. Methods The authors searched MEDLINE, EMBASE, CINAHL, Google Scholar, and The Cochrane Library for studies published through June 2013 that reported cases of ISCCMs. Data from all eligible studies were used to examine the epidemiology, clinical features, and neurological outcomes of patients with surgically managed and conservatively treated ISCCMs. To evaluate several variables as predictors of favorable neurological outcomes, the authors conducted a meta-analysis of individual patient data and performed univariate and multivariate logistic regression analyses. Variables included patient age, patient sex, lesion spinal level, lesion size, cerebral cavernomas, family history of cavernous malformations, clinical course, presenting symptoms, treatment strategy (operative or conservative), symptom duration, surgical approach, spinal location, and extent of resection. In addition, they performed a meta-analysis to determine a pooled estimate of the annual hemorrhage rate of ISCCMs. Results Eligibility criteria were met by 40 studies, totaling 632 patients, including the authors' institutional series of 24 patients. Mean patient age was 39.1 years (range 2–80 years), and the male-to-female ratio was 1.1:1. Spinal levels of cavernomas were cervical (38%), cervicothoracic (2.4%), thoracic (55.2%), thoracolumbar (0.6%), lumbar (2.1%), and conus medullaris (1.7%). Average cavernoma size was 9.2 mm. Associated cerebral cavernomas occurred in 16.5% of patients, and a family history of cavernous malformation was found for 11.9% of evaluated patients. Clinical course was acute with stepwise progression for 45.4% of patients and slowly progressive for 54.6%. Symptoms were motor (60.5%), sensory (57.8%), pain (33.8%), bladder and/or bowel (23.6%), respiratory distress (0.5%), or absent (asymptomatic; 0.9%). The calculated pooled annual rate of hemorrhage was 2.1% (95% CI 1.3%–3.3%). Most (89.9%) patients underwent resection, and 10.1% underwent conservative management (observation). Outcomes were better for those who underwent resection than for those who underwent conservative management (OR 2.79, 95% CI 1.46–5.33, p = 0.002). A positive correlation with improved neurological outcomes was found for resection within 3 months of symptom onset (OR 2.11, 95% CI 1.31–3.41, p = 0.002), hemilaminectomy approach (OR 3.20, 95% CI 1.16–8.86, p = 0.03), and gross-total resection (OR 3.61, 95% CI 1.24–10.52, p = 0.02). Better outcomes were predicted by an acute clinical course (OR 1.72, 95% CI 1.10–2.68, p = 0.02) and motor symptoms (OR 1.76, 95% CI 1.08–2.86, p = 0.02); poor neurological recovery was predicted by sensory symptoms (OR 0.58, 95% CI 0.35–0.98, p = 0.04). Rates of neurological improvement after resection were no higher for patients with superficial ISCCMs than for those with deep-seated ISCCMs (OR 1.36, 95% CI 0.71–2.60, p = 0.36). Conclusions Intramedullary spinal cord cavernous malformations tend to be clinically progressive. The authors' findings support an operative management plan for patients with a symptomatic ISCCM. Surgical goals include gross-total resection through a more minimally invasive hemilaminectomy approach within 3 months of presentation.

scholarly journals Clinical and pathological outcomes after resection of intramedullary spinal cord tumors: a single-institution case series

2016 ◽  
Vol 41 (2) ◽  
pp. E8 ◽  
Author(s):  
Nardin Samuel ◽  
Lindsay Tetreault ◽  
Carlo Santaguida ◽  
Anick Nater ◽  
Nizar Moayeri ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Tumor Progression ◽  
Functional Outcomes ◽  
Univariate Analysis ◽  
Case Series ◽  
Progression Free Survival ◽  
Spinal Cord Tumors ◽  
Intramedullary Spinal Cord ◽  
Free Survival ◽  
Tumor Pathology

OBJECTIVE The objective of this study was to identify clinically relevant predictors of progression-free survival and functional outcomes in patients who underwent surgery for intramedullary spinal cord tumors (ISCTs). METHODS An institutional spinal tumor registry and billing records were reviewed to identify adult patients who underwent resection of ISCTs between 1993 and 2014. Extensive data were collected from patient charts and operative notes, including demographic information, extent of resection, tumor pathology, and functional and oncological outcomes. Survival analysis was used to determine important predictors of progression-free survival. Logistic regression analysis was used to evaluate the association between an “optimal” functional outcome on the Frankel or McCormick scale at 1-year follow-up and various clinical and surgical characteristics. RESULTS The consecutive case series consisted of 63 patients (50.79% female) who underwent resection of ISCTs. The mean age of patients was 41.92 ± 14.36 years (range 17.60–75.40 years). Complete microsurgical resection, defined as no evidence of tumor on initial postoperative imaging, was achieved in 34 cases (54.84%) of the 62 patients for whom this information was available. On univariate analysis, the most significant predictor of progression-free survival was tumor histology (p = 0.0027). Patients with Grade I/II astrocytomas were more likely to have tumor progression than patients with WHO Grade II ependymomas (HR 8.03, 95% CI 2.07–31.11, p = 0.0026) and myxopapillary ependymomas (HR 8.01, 95% CI 1.44–44.34, p = 0.017). Furthermore, patients who underwent radical or subtotal resection were more likely to have tumor progression than those who underwent complete resection (HR 3.46, 95% CI 1.23–9.73, p = 0.018). Multivariate analysis revealed that tumor pathology was the only significant predictor of tumor progression. On univariate analysis, the most significant predictors of an “optimal” outcome on the Frankel scale were age (OR 0.94, 95% CI 0.89–0.98, p = 0.0062), preoperative Frankel grade (OR 4.84, 95% CI 1.33–17.63, p = 0.017), McCormick score (OR 0.22, 95% CI 0.084–0.57, p = 0.0018), and region of spinal cord (cervical vs conus: OR 0.067, 95% CI 0.012–0.38, p = 0.0023; and thoracic vs conus: OR 0.015: 95% CI 0.001–0.20, p = 0.0013). Age, tumor pathology, and region were also important predictors of 1-year McCormick scores. CONCLUSIONS Extent of tumor resection and histopathology are significant predictors of progression-free survival following resection of ISCTs. Important predictors of functional outcomes include tumor histology, region of spinal cord in which the tumor is present, age, and preoperative functional status.

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