XIX Symposium Neuroradiologicum

Neeraj Chepuri, M.D.Neuro Radiologist

Consulting Radiologists, Ltd.Abbott Northwestern HospitalMinneapolis, Minnesota, USA

INTEGRATION OF FUNCTIONAL MRI AND INTRA-OPERATIVE MRI PROVIDES A HIGH

DEGREE OF PRECISION AND CONFIDENCE AT SURGICAL BRAIN TUMOR RESECTION

Objective

To show that high field iMRI, as well as pre-operative fMRI and DTI

has a positive effect on surgical and post-surgical

intracranial neoplasm management

8 October 2010Neeraj Chepuri, MD

Historical Perspective of Intra-operative MRI (iMRI)

8 October 2010Neeraj Chepuri, MD

Historical Perspective of iMRI

Low-field, fixed magnet• Patient moves• Low-image quality• Images not in same position as surgery• Neurosurgeons not as comfortable with non-ferromagnetic tools

8 October 2010Neeraj Chepuri, MD

Historical Perspective of iMRI

High-field, fixed superconducting magnet • Patient moves• Images not in same position as surgery• Surgeons use standard surgical equipment• Better image quality

8 October 2010Neeraj Chepuri, MD

Historical Perspective of iMRI

Low-field, fixed superconducting magnet • Patient does not move• Surgeon must be thin• Surgeon must use non-ferromagnetic tools• Low image quality

8 October 2010Neeraj Chepuri, MD

Historical Perspective of iMRI

High-field, mobile superconducting magnet• Patient does not move• High image quality• Standard surgical equipment• Neurosurgeons of any size

8 October 2010Neeraj Chepuri, MD

High Field Intraoperative MRI (iMRI)

The iMRI suite is equipped with a wide bore Siemens SP Espree (70 cm) ceiling mounted MRI (IMRIS). Field strength is 1.5 tesla. It is located in the main OR suite. It is uniquely dedicated to surgical procedures.

8 October 2010Neeraj Chepuri, MD

High Field Intraoperative MRI (iMRI)

8 October 2010Neeraj Chepuri, MD

High Field Intraoperative MRI (iMRI)

8 October 2010Neeraj Chepuri, MD

Material and Methods

Surgical material is from June 2007 to October 2009.

• 314 patients were surgically treated in the iMRI suite.

• 232 adults and 82 pediatric patients.

8 October 2010Neeraj Chepuri, MD

Adult Patients (232 patients)

Other surgery2%

Other tumor7%

High grade glioma32%

Low grade glioma2%

Meningioma18%

Ependymoma1% Oligodendroglioma

5%

Oligoastrocytoma5%

Chiari Malformation0%Metastatic

9%Vascular malformation

4%

Dermoid cyst0%

Colloid cyst0%

Arachnoid cyst0%

Craniopharyngioma2%

Pituitary adenoma13%

8 October 2010Neeraj Chepuri, MD

Pediatric Patients (82 patients)

Metastatic3%

Chiari Malformation1%

Vascular malformation11%

DNET6%Craniopharyngioma

4%

Ependymoma11%

Medulloblastoma7%

Other tumor11%

Low grade glioma31%

High grade glioma1%

Colloid cyst0%

Arachnoid cyst4%

Dermoid cyst3%

Other surgery3% Meningioma

3%

Oligodendroglioma1%

8 October 2010Neeraj Chepuri, MD

Resection Status

Resection Status

176

97

0

20

40

60

80

100

120

140

160

180

200

GTR

STR

8 October 2010Neeraj Chepuri, MD

Benefits of iMRI

1) Enhances the surgical trajectory definition by accommodating for brain shift

2) Allow for as complete lesion resection as possible.3) Early recognition of intraoperative complications

and early initiation of treatments. 4) Decrease the incidence of “second look” surgeries.5) Decrease the number of post-operative studies.6) No evidence for an increase rate of post-operative

complications (infections, bed sores, infections) related to the prolongation of the operating time.

7) Overall decrease in cost of neurosurgical care **

8 October 2010Neeraj Chepuri, MD

Value of iMRI update of Neuro-Navigation datato account for Brain Shift

8 October 2010Neeraj Chepuri, MD

Value of iMRI update of Neuro-Navigation data

to account for Brain Shift

8 October 2010Neeraj Chepuri, MD

Value of Following Tumor Resection Progress by Multiple iMRI

Functional MRITongue movement Activations

Fiber TrackingRight corticospinal tract not

disrupted

8 October 2010Neeraj Chepuri, MD

Value of Following Tumor Resection Progress by Multiple iMRI

#1 #2Intra-operative Monitoring

8 October 2010Neeraj Chepuri, MD

Case 2:Fiber tracking: Corticospinal tract intact

Value of Following Tumor Resection Progress by

Multiple iMRI

8 October 2010Neeraj Chepuri, MD

Value of Pre-operative fMRI

Functional MRI: The integration of fMRI to the preoperative planning in both the adult and pediatric age group has helped define the “surgical corridor”.

8 October 2010Neeraj Chepuri, MD

Value of Pre-operative fMRI

Functional MRI: The integration of fMRI to the preoperative planning in both the adult and pediatric age group has helped define the “surgical corridor”.

8 October 2010Neeraj Chepuri, MD

17-year-old female presented with headaches and difficulty with speech

Vision?

Value of Pre-operative fMRI

8 October 2010Neeraj Chepuri, MD

Value of Pre-operative fMRI and DTI

Functional MRIVisual and Language Activations

Fiber TrackingLeft Optic Radiation Displacement

8 October 2010Neeraj Chepuri, MD

Surface rendering

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Pre-op vs. post-op

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tongue

Value of Pre-operative fMRI

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Value of Early Identification of Complications by High Field iMRI

Acute ischemiaAcute hematomaSinus thrombosis

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Early Acute Ischemia

Pre-op

Post-op

8 October 2010Neeraj Chepuri, MD

Confirmation of No Complication

The patient woke up from surgery weak in his leg. However; there were no abnormalities on the DWI scan. Therefore; the prognosis was good and the patient made a full recovery.

8 October 2010Neeraj Chepuri, MD

5 year-old male with headaches, progressive in intensity over a 12 week duration and

intractable emesis of one week duration Pre-operative MRI

Value of Early Identification of Complications by High Field iMRI

8 October 2010Neeraj Chepuri, MD

iMRI demonstrates acute epidural hematoma

Value of Early Identification of Complications by High Field iMRI

8 October 2010Neeraj Chepuri, MD

Pre-operative images

Value of Early Identification of Complications by High Field iMRI

8 October 2010Neeraj Chepuri, MD

Post-operative images

Neeraj Chepuri, MD

Value of Early Identification of Complications by High Field iMRI

8 October 2010

Pre-op

Post-op

Value of Early Identification of Complications by High Field iMRI

8 October 2010Neeraj Chepuri, MD

Drawback of High Field iMRI

1) Undoubtedly iMRI lengthens the surgical procedure duration. ~ 30 min – 1 hr

2) Surgical procedure costs are increased:• use of MRI compatible surgical equipment• training of surgical personnel• lengthens the surgical procedure

8 October 2010Neeraj Chepuri, MD

Benefits of iMRI

1) Enhances the surgical trajectory definition by accommodating for brain shift

2) Allow for as complete lesion resection as possible.3) Early recognition of intraoperative complications

and early initiation of treatments. 4) Decrease the incidence of “second look” surgeries.5) Decrease the number of post-operative studies.6) No evidence for an increase rate of post-operative

complications (infections, bed sores, infections) related to the prolongation of the operating time.

7) Overall decrease in cost of neurosurgical care **

8 October 2010Neeraj Chepuri, MD

Acknowledgements

Douglas Yock, M.D. - NeuroradiologistMahmoud Nagib, M.D. – NeurosurgeonKoi Kainth, M.D. – NeurosurgeonMarie Gura, R.N. - NursingDavid Lori, R.N. - Nursing

8 October 2010Neeraj Chepuri, MD

Acknowledgements

8 October 2010Neeraj Chepuri, MDRavi Chepuri Sujit Chepuri

Carolyn Chou