Diffusion-tensor imaging—guided tracking of fibers of the pyramidal tract combined with intraoperative cortical stimulation mapping in patients with gliomas

2004 ◽  
Vol 101 (1) ◽  
pp. 66-72 ◽  
Author(s):  
Jeffrey I. Berman ◽  
Mitchel S. Berger ◽  
Pratik Mukherjee ◽  
Roland G. Henry
Keyword(s):  
Mr Imaging ◽  
Diffusion Tensor ◽  
Tumor Resection ◽  
Cortical Stimulation ◽  
Surgical Morbidity ◽  
Content Type ◽  
Motor Pathways ◽  
Cortical Motor ◽  
Cortical Stimulation Mapping ◽  
Fine Print

Object. The goal of this study was to use diffusion-tensor (DT) magnetic resonance (MR) imaging to track fibers combined with cortical stimulation mapping to delineate descending motor pathways. Subcortical localization of motor pathways in relation to a glioma may provide critical information to guide tumor resection and prevent surgical morbidity. Methods. Eleven adult patients harboring gliomas underwent MR imaging 1 day prior to image-guided intraoperative cortical motor mapping and tumor resection. Screens depicting 27 cortical motor sites on a surgical navigation system were saved to launch DT imaging of fiber tracks of descending motor pathways. The position and organization of motor tracts were visualized by fiber tracking. Tracks from 16 motor stimulation sites followed descending pathways from the precentral gyrus, through the corona radiata and internal capsule, and into the cerebral peduncle. These tracks were also observed on DT images to diverge along crossing white matter bundles (four patients) and to terminate or deviate in regions of peritumoral vasogenic edema (five patients). Conclusions. The use of precise intraoperative cortical mapping information and DT images of fiber tracks can reveal the course of motor pathways beneath the cortex. The subcortical fiber tracks generated are consistent with the known anatomical course and somatotopic organization of the motor tract in relation to its cortical origins. Tracking fibers by using DT imaging in combination with functional localization has the potential to reduce surgical morbidity by revealing subcortical connections of the functional cortex.

Intraoperative magnetic resonance imaging during transsphenoidal surgery

2001 ◽  
Vol 95 (3) ◽  
pp. 381-390 ◽  
Author(s):  
Rudolf Fahlbusch ◽  
Oliver Ganslandt ◽  
Michael Buchfelder ◽  
Werner Schott ◽  
Christopher Nimsky
Keyword(s):  
Magnetic Resonance ◽  
Mr Imaging ◽  
Early Stage ◽  
Intraoperative Imaging ◽  
Tumor Resection ◽  
Tumor Removal ◽  
Content Type ◽  
Early Evaluation ◽  
Flexible Coil ◽  
Fine Print

Object. The aim of this study was to evaluate whether intraoperative magnetic resonance (MR) imaging can increase the efficacy of transsphenoidal microsurgery, primarily in non—hormone-secreting intra- and suprasellar pituitary macroadenomas. Methods. Intraoperative imaging was performed using a 0.2-tesla MR imager, which was located in a specially designed operating room. The patient was placed supine on the sliding table of the MR imager, with the head placed near the 5-gauss line. A standard flexible coil was placed around the patient's forehead. Microsurgery was performed using MR-compatible instruments. Image acquisition was started after the sliding table had been moved into the center of the magnet. Coronal and sagittal T1-weighted images each required over 8 minutes to acquire, and T2-weighted images were obtained optionally. To assess the reliability of intraoperative evaluation of tumor resection, the intraoperative findings were compared with those on conventional postoperative 1.5-tesla MR images, which were obtained 2 to 3 months after surgery. Among 44 patients with large intra- and suprasellar pituitary adenomas that were mainly hormonally inactive, intraoperative MR imaging allowed an ultra-early evaluation of tumor resection in 73% of cases; such an evaluation is normally only possible 2 to 3 months after surgery. A second intraoperative examination of 24 patients for suspected tumor remnants led to additional resection in 15 patients (34%). Conclusions. Intraoperative MR imaging undoubtedly offers the option of a second look within the same surgical procedure, if incomplete tumor resection is suspected. Thus, the rate of procedures during which complete tumor removal is achieved can be improved. Furthermore, additional treatments for those patients in whom tumor removal was incomplete can be planned at an early stage, namely just after surgery.

Combined use of tractography-integrated functional neuronavigation and direct fiber stimulation

2005 ◽  
Vol 102 (4) ◽  
pp. 664-672 ◽  
Author(s):  
Kyousuke Kamada ◽  
Tomoki Todo ◽  
Yoshitaka Masutani ◽  
Shigeki Aoki ◽  
Kenji Ino ◽  
...  
Keyword(s):  
Diffusion Tensor ◽  
Motor Evoked Potentials ◽  
Tumor Resection ◽  
Brain Structures ◽  
Magnetic Resonance Images ◽  
Content Type ◽  
Neuronavigation System ◽  
Functional Neuronavigation ◽  
Fiber Stimulation ◽  
Fine Print

Object. The aim of this study was better preoperative planning and direct application to intraoperative procedures through accurate coregistration of diffusion-tensor (DT) imaging—based tractography results and anatomical three-dimensional magnetic resonance images and subsequent importation of the combined images to a neuronavigation system (functional neuronavigation). Methods. Six patients with brain lesions adjacent to the corticospinal tract (CST) were studied. During surgery, direct fiber stimulation was used to evoke motor responses to confirm the accuracy of CST depicted on functional neuronavigation. In three patients, stimulation of the supposed CST elicited the expected motor evoked potentials. In the other three, stimulation at the resection borders more than 1 cm away from the supposed CST showed no motor response. All patients underwent appropriate tumor resection with preservation of the CST. Conclusions. Integration of the DT imaging—based tractography information into a traditional neuronavigation system demonstrated spatial relationships between lesions and the CST, allowing for the avoidance of tract injury during lesion resection. Direct fiber stimulation was used for real-time reliable white matter mapping, which served to adjust for any discrepancy between the neuronavigation system data and potentially shifted positions of the brain structures. The combination of these techniques enabled the authors to identify accurate positions of the CST during surgery and to accomplish optimal tumor resections.

Fluorescence-guided resection of glioblastoma multiforme utilizing 5-ALA-induced porphyrins: a prospective study in 52 consecutive patients

2000 ◽  
Vol 93 (6) ◽  
pp. 1003-1013 ◽  
Author(s):  
Walter Stummer ◽  
Alexander Novotny ◽  
Herbert Stepp ◽  
Claudia Goetz ◽  
Karl Bise ◽  
...  
Keyword(s):  
Glioblastoma Multiforme ◽  
Mr Imaging ◽  
Aminolevulinic Acid ◽  
Univariate Analysis ◽  
Tumor Resection ◽  
Mr Images ◽  
Content Type ◽  
Tissue Fluorescence ◽  
Solid Fluorescence ◽  
Fine Print

Object. It has been established that 5-aminolevulinic acid (5-ALA) induces the accumulation of fluorescent porphyrins in glioblastoma multiforme (GBM), a phenomenon potentially exploitable to guide tumor resection. In this study the authors analyze the influence of fluorescence-guided resection on postoperative magnetic resonance (MR) imaging and survival in a series of patients who underwent surgery in the authors' department.Methods. Fifty-two consecutive patients with GBM received oral doses of 5-ALA (20 mg/kg body weight) 3 hours before induction of anesthesia. Intraoperatively, tumor fluorescence was visualized using a modified operating microscope. Fluorescing tissue was removed whenever it was considered safely possible. Residual enhancement on early postoperative MR imaging was quantified and related to each patient's characteristics to determine which factors influenced resection. Survival was analyzed using the Kaplan—Meier method and multivariate analysis was performed in which the Karnofsky Performance Scale (KPS) score, residual fluorescence, patient age, and residual enhancement on MR images were considered.Intraoperatively, two fluorescence qualities were perceived: solid fluorescence generally reflected coalescent tumor, whereas vague fluorescence mostly corresponded to infiltrative tumor. Complete resection of contrast-enhancing tumor was accomplished in 33 patients (63%). Residual intraoperative tissue fluorescence left unresected for safety reasons predicted residual enhancement on MR images in 18 of the 19 remaining patients. Age, residual solid fluorescence, and absence of contrast enhancement in MR imaging were independent explanatory factors for survival, whereas the KPS score was significant only in univariate analysis. No perioperative deaths and one case of permanent morbidity were encountered.Conclusions. The observations in this study indicate the usefulness of 5-ALA—induced tumor fluorescence for guiding tumor resection. The completeness of resection, as determined intraoperatively from residual tissue fluorescence, was related to postoperative MR imaging findings and to survival in patients suffering from GBM.

Cortical stimulation mapping of language cortex by using a verb generation task: effects of learning and comparison to mapping based on object naming

2002 ◽  
Vol 97 (1) ◽  
pp. 33-38 ◽  
Author(s):  
Jeffrey G. Ojemann ◽  
George A. Ojemann ◽  
Ettore Lettich
Keyword(s):  
Functional Neuroimaging ◽  
Cortical Stimulation ◽  
Object Naming ◽  
Generation Task ◽  
Content Type ◽  
Cortical Stimulation Mapping ◽  
Verb Generation ◽  
Language Areas ◽  
Language Cortex ◽  
Fine Print

Object. Cortical stimulation mapping has traditionally relied on disruption of object naming to define essential language areas. In this study, the authors reviewed the use of a different language task, verb generation, in mapping language. This task has greater use in brain imaging studies and may be used to test aspects of language different from those of object naming. Methods. In 14 patients, cortical stimulation mapping performed using a verb generation task provided a map of language areas in the frontal and temporoparietal cortices. These verb generation maps often overlapped object naming ones and, in many patients, different areas of cortex were found to be involved in the two functions. In three patients, stimulation mapping was performed during the initial performance of the verb generation task and also during learned performance of the task. Parallel to findings of published neuroimaging studies, a larger area of stimulated cortex led to disruption of verb generation in response to stimulation during novel task performance than during learned performance. Conclusions. Results of cortical stimulation mapping closely resemble those of functional neuroimaging when both implement the verb generation task. The precise map of the temporoparietal language cortex depends on the task used for mapping.

Meningiomas of the posterior petrous bone: functional outcome after microsurgery

2004 ◽  
Vol 100 (6) ◽  
pp. 1014-1024 ◽  
Author(s):  
Hischam Bassiouni ◽  
Anja Hunold ◽  
Siamak Asgari ◽  
Dietmar Stolke
Keyword(s):  
Mr Imaging ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Petrous Bone ◽  
Surgical Anatomy ◽  
Impaired Hearing ◽  
Imaging Data ◽  
Content Type ◽  
Hearing Function ◽  
Fine Print

Object. The aim of this study was to analyze a subgroup of patients harboring cerebellopontine angle meningiomas originating from the posterior petrous bone in regard to clinical presentation, surgical anatomy, complications, and long-term functional postoperative results. Methods. Data in a series of 51 patients with meningiomas of the posterior petrous bone who had undergone microsurgical treatment at the authors' institution between 1989 and 2002 were retrospectively reviewed. The patient population consisted of 46 women and five men with a mean age of 53 years (range 22–70 years). The main symptom on first admission was impaired hearing in 41%, dizziness in 20%, and tinnitus in 18% of the patients. Results of physical examination and audiological testing revealed hypacusis in 65% of patients, cerebellar ataxia in 31%, and impairment of the fifth cranial nerve in 26%. All patients underwent surgical treatment via a lateral suboccipital approach. Intraoperatively, the tumor was found to be attached to the postmeatal dura in 37%, the premeatal dura in 27.5%, the suprameatal dura in 19.6%, the inframeatal dura in 7.8%, and centered on the porus acusticus in 5.9% of cases. Tumor extension into the internal acoustic meatus was present in seven patients. Tumor resection was categorized as Grade I in 14 patients, Grade II in 29, Grade III in six, and Grade IV in two patients, according to the Simpson classification system. The site of displacement of the cranial nerves was predictable in up to 84% of patients, depending on the dural origin of the tumor as depicted on preoperative magnetic resonance (MR) imaging studies. Postoperatively, a new and permanent facial paresis was observed in five patients (9.8%). In 38 patients in whom both pre- and postoperative audiological data were available, hearing function deteriorated after surgery in 18.4% and improved in 7.9%. Clinical and MR imaging postsurgical data from a mean period of 5.8 years (range 13 months–13 years) were available in all patients. Forty-four patients (86%) resumed normal daily activity. Tumor recurrence was observed in two patients (3.9%), and both underwent a second surgery. Conclusions. Preoperative detailed analysis of MR imaging data gives the surgeon a clue about the dislocation of critical neurovascular structures, particularly the cranial nerves. Nonetheless, the exact relationship of the cranial nerves to the tumor (dislocation, adherence, infiltration, and splaying of nerves) can only be fully appreciated during surgery.

Neuroradiographic changes following convection-enhanced delivery of the recombinant cytotoxin interleukin 13—PE38QQR for recurrent malignant glioma

2005 ◽  
Vol 102 (2) ◽  
pp. 267-275 ◽  
Author(s):  
Ian F. Parney ◽  
Sandeep Kunwar ◽  
Michael McDermott ◽  
Mitchel Berger ◽  
Michael Prados ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Malignant Glioma ◽  
Tumor Resection ◽  
Therapeutic Agents ◽  
Grading System ◽  
Recurrent Malignant Glioma ◽  
Mr Images ◽  
Convection Enhanced Delivery ◽  
Content Type ◽  
Fine Print

Object. Convection-enhanced delivery (CED) is a novel method for delivering therapeutic agents to infiltrative brain tumor cells. For agents administered by CED, changes on magnetic resonance (MR) imaging directly resulting from catheter placement, infusion, and the therapeutic compound may confound any interpretation of tumor progression. As part of an ongoing multiinstitutional Phase I study, 14 patients with recurrent malignant glioma underwent CED of interleukin (IL) 13—PE38QQR, a recombinant cytotoxin consisting of human IL-13 conjugated with a truncated Pseudomonas exotoxin. Serial neuroradiographic changes were assessed in this cohort of patients. Methods. Patients were treated in two groups: Group 1 patients received IL13—PE38QQR before and after tumor resection; Group 2 patients received infusion only after tumor resection. Preoperative and postinfusion MR images were obtained prospectively at specified regular intervals. Changes were noted along catheter tracks on postresection MR images obtained in all patients. A simple grading system was developed to describe these changes. When MR imaging changes appeared to be related to IL13—PE38QQR, patients were followed up without instituting new antitumor therapy. Conclusions. As CED of therapeutic agents becomes more common, clinicians and investigators must become aware of associated neuroimaging changes that should be incorporated into toxicity assessment. We have developed a simple grading system to facilitate communication about these changes among investigators. Biological imaging modalities that could possibly distinguish these changes from recurrent tumor should be evaluated. In this study the authors demonstrate the challenges in determining efficacy when surrogate end points such as time to tumor progression as defined by new or progressive contrast enhancement on MR imaging are used with this treatment modality.

Surgical treatment of superior sulcus tumors with spinal and brachial plexus involvement

2002 ◽  
Vol 97 (3) ◽  
pp. 301-309 ◽  
Author(s):  
Mark H. Bilsky ◽  
Todd W. Vitaz ◽  
Patrick J. Boland ◽  
Manjit S. Bains ◽  
Viswanathan Rajaraman ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Brachial Plexus ◽  
Tumor Resection ◽  
Incomplete Resection ◽  
Content Type ◽  
Superior Sulcus Tumors ◽  
Epidural Compression ◽  
Superior Sulcus ◽  
Complete Tumor ◽  
Fine Print

Object. Non—small cell lung carcinomas with spinal and brachial plexus involvement have traditionally been considered to be Stage IIIb lesions and therefore unresectable. Advances in spinal surgery, the application of magnetic resonance (MR) imaging, and improvements in neoadjuvant therapy require a reassessment of the potential for complete resection. Methods. The authors conducted a retrospective review of all procedures involving the resection of superior sulcus tumors with spinal or brachial plexus involvement performed between 1985 and 1999. Assessment or resectability and operative planning were based on an MR imaging classification scheme in which the extent of spinal involvement was considered. Class A tumors involved the periosteum of the vertebral body (VB) (16 patients); Class B, distal neural foramen without epidural compression (eight patients); Class C, proximal neural foramen with epidural compression (four patients); and Class D, bone involvement (VB or posterior elements) with or without epidural involvement (14 patients). Brachial plexus involvement was present in 21 patients, including 17 with T-1 nerve root only and four with C-8 or lower-trunk infiltration. Complete tumor resection was achieved in 27 patients and incomplete resection in 15. Complications occurred in 14 patients, two of which were related to instrumentation failures. The overall median survival was 1.44 years. The median survival for the complete and incomplete resection groups were 2.84 and 0.79 years, respectively (p = 0.0001). There was no statistical difference in survival among classification groups. Conclusions. Complete tumor resection of superior sulcus tumors is possible in selected patients in whom involvement of the spinal column and/or brachial plexus is present. Preoperative MR imaging is essential for evaluation of the spine and surgical planning. Survival and cure are dependent on complete resection, regardless of the extent of spinal involvement.

Diffuse axonal injury in mild traumatic brain injury: a diffusion tensor imaging study

2005 ◽  
Vol 103 (2) ◽  
pp. 298-303 ◽  
Author(s):  
Matilde Inglese ◽  
Sachin Makani ◽  
Glyn Johnson ◽  
Benjamin A. Cohen ◽  
Jonathan A. Silver ◽  
...  
Keyword(s):  
Diffusion Tensor Imaging ◽  
Mr Imaging ◽  
Fractional Anisotropy ◽  
Diffusion Tensor ◽  
Axonal Injury ◽  
Diffuse Axonal Injury ◽  
Mean Diffusivity ◽  
Internal Capsule ◽  
Content Type ◽  
Fine Print

Object. Diffuse axonal injury (DAI) is a major complication of traumatic brain injury (TBI) that leads to functional and psychological deficits. Although DAI is frequently underdiagnosed by conventional imaging modalities, it can be demonstrated using diffusion tensor imaging. The aim of this study was to assess the presence and extent of DAI in patients with mild TBI. Methods. Forty-six patients with mild TBI and 29 healthy volunteers underwent a magnetic resonance (MR) imaging protocol including: dual—spin echo, fluid-attenuated inversion recovery, T2-weighted gradient echo, and diffusion tensor imaging sequences. In 20 of the patients, MR imaging was performed at a mean of 4.05 days after injury. In the remaining 26, MR imaging was performed at a mean of 5.7 years after injury. In each case, mean diffusivity and fractional anisotropy were measured using both whole-brain histograms and regions of interest analysis. No differences in any of the histogram-derived measures were found between patients and control volunteers. Compared with controls, a significant reduction of fractional anisotropy was observed in patients' corpus callosum, internal capsule, and centrum semiovale, and there were significant increases of mean diffusivity in the corpus callosum and internal capsule. Neither histogram-derived nor regional diffusion tensor imaging metrics differed between the two groups. Conclusions. Although mean diffusivity and fractional anisotropy abnormalities in these patients with TBI were too subtle to be detected with the whole-brain histogram analysis, they are present in brain areas that are frequent sites of DAI. Because diffusion tensor imaging changes are present at both early and late time points following injury, they may represent an early indicator and a prognostic measure of subsequent brain damage.

Identification of motor pathways during tumor surgery facilitated by multichannel electromyographic recording

1999 ◽  
Vol 91 (6) ◽  
pp. 922-927 ◽  
Author(s):  
Charles D. Yingling ◽  
Steven Ojemann ◽  
Barbara Dodson ◽  
Margaret J. Harrington ◽  
Mitchel S. Berger
Keyword(s):  
Seizure Activity ◽  
Body Movement ◽  
Tumor Resection ◽  
Internal Capsule ◽  
Visual Observation ◽  
Motor Deficits ◽  
Content Type ◽  
Motor Pathways ◽  
Subcortical Stimulation ◽  
Fine Print

Object. The goal of this study was to determine the usefulness of electromyographic (EMG) recording in locating motor pathways near the central sulcus or internal capsule during surgery.Methods. Multichannel EMG recordings were compared with visual observation of contralateral body movement that was elicited by direct cortical or subcortical stimulation used to identify motor pathways before and during tumor resection.The EMG recordings were more sensitive than visual observation alone in identifying motor responses: in 30% of cases, responses were identified by EMG recording alone at some point during the operation and, in 9% of cases, EMG responses were the only responses observed. Additionally, EMG recordings often detected seizure activity resulting from electrical stimulation of the cortex that could not be appreciated on visual inspection. No new motor deficits were seen postoperatively in 88% of the patients in this series.Conclusions. Using EMG recording in addition to motor pathway mapping results in greater sensitivity, allowing the use of lower stimulation levels and facilitating detection of stimulation-induced seizure activity.

A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival

2001 ◽  
Vol 95 (2) ◽  
pp. 190-198 ◽  
Author(s):  
Michel Lacroix ◽  
Dima Abi-Said ◽  
Daryl R. Fourney ◽  
Ziya L. Gokaslan ◽  
Weiming Shi ◽  
...  
Keyword(s):  
Glioblastoma Multiforme ◽  
Mr Imaging ◽  
Tumor Resection ◽  
Extent Of Resection ◽  
Karnofsky Performance Scale ◽  
Content Type ◽  
Predictive Variables ◽  
Significant Survival ◽  
Performance Scale ◽  
Fine Print

Object. The extent of tumor resection that should be undertaken in patients with glioblastoma multiforme (GBM) remains controversial. The purpose of this study was to identify significant independent predictors of survival in these patients and to determine whether the extent of resection was associated with increased survival time. Methods. The authors retrospectively analyzed 416 consecutive patients with histologically proven GBM who underwent tumor resection at the authors' institution between June 1993 and June 1999. Volumetric data and other tumor characteristics identified on magnetic resonance (MR) imaging were collected prospectively. Conclusions. Five independent predictors of survival were identified: age, Karnofsky Performance Scale (KPS) score, extent of resection, and the degree of necrosis and enhancement on preoperative MR imaging studies. A significant survival advantage was associated with resection of 98% or more of the tumor volume (median survival 13 months, 95% confidence interval [CI] 11.4–14.6 months), compared with 8.8 months (95% CI 7.4–10.2 months; p < 0.0001) for resections of less than 98%. Using an outcome scale ranging from 0 to 5 based on age, KPS score, and tumor necrosis on MR imaging, we observed significantly longer survival in patients with lower scores (1–3) who underwent aggressive resections, and a trend toward slightly longer survival was found in patients with higher scores (4–5). Gross-total tumor resection is associated with longer survival in patients with GBM, especially when other predictive variables are favorable.

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