Mario M. Bonsanto

Intraoperative diagnostic and interventional magnetic resonance imaging in neurosurgery

OBJECTIVE The benefits of intraoperative magnetic resonance (MR) imaging for diagnostic and therapeutic measures are as follows: 1) intraoperative update of data sets for navigational systems, 2) intraoperative resection control of brain tumors, and 3) frameless and frame-based on-line MR-guided interventions. The concept of an intraoperative MR scanner in the sterile environment of operating theater is presented, and its advantages, disadvantages, and limitations are discussed. METHODS A 0.2-tesla magnet (Magnetom Open; Siemens AG, Erlangen, Germany) inside a radiofrequency cabin with a radiofrequency-shielded sliding door was installed adjacent to one of the operating theaters. A specially designed patient transport system carried the patient in a fixed position on an air cushion to the scanner and back to the surgeon. RESULTS In a series of 27 patients, intraoperative resection control was performed in 13 cases, with intraoperative reregistration in 4 cases. Biopsies, cyst aspirations, and catheter placements (mainly frameless) were performed under direct MR visualization with fast image sequences. The MR-compatible equipment and the patient transport system are safe and reliable. CONCLUSION Intraoperative MR imaging is a safe and successful tool for surgical resection control and is clearly superior to computed tomography. Intraoperative acquisition of data sets eliminates the problem of brain shift in conventional navigational systems. Finally, on-line MR-guided interventional procedures can be performed easily with this setting. As with all MR systems, individual testing with phantoms, application of correction programs, and determination of the optimal amount of contrast media are absolute prerequisites to guarantee patient safety and surgical success.

Intraoperative Magnetic Resonance Imaging to Update Interactive Navigation in Neurosurgery: Method and Preliminary Experience

We report on the first successful intraoperative update of interactive image guidance based on an intraoperatively acquired magnetic resonance imaging (MRI) date set. To date, intraoperative imaging methods such as ultrasound, computerized tomography (CT), or MRI have not been successfully used to update interactive navigation. We developed a method of imaging patients intraoperatively with the surgical field exposed in an MRI scanner (Magnetom Open; Siemens Corp., Erlangen, Germany). In 12 patients, intraoperatively acquired 3D data sets were used for successful recalibration of neuronavigation, accounting for any anatomical changes caused by surgical manipulations. The MKM Microscope (Zeiss Corp., Oberkochen, Germany) was used as navigational system. With implantable fiducial markers, an accuracy of 0.84 +/- 0.4 mm for intraoperative reregistration was achieved. Residual tumor detected on MRI was consequently resected using navigation with the intraoperative data. No adverse effects were observed from intraoperative imaging or the use of navigation with intraoperative images, demonstrating the feasibility of recalibrating navigation with intraoperative MRI.

Clinical impact and functional aspects of tenascin-C expression during glioma progression.

The extracellular matrix protein tenascin‐C is expressed in processes like embryogenesis and wound healing and in neoplasia. Tenascin‐C expression in gliomas has been described previously; however, the relation to clinical data remains inconsistent. Generally, analysis of tenascin‐C function is difficult due to different alternatively spliced isoforms. Our studies focus on changes in tenascin‐C expression in human gliomas, correlating these changes with tumor progression and elucidating the functional role of the glioma cell‐specific tenascin‐C isoform pool. Eighty‐six glioma tissues of different World Health Organization (WHO) grades were analyzed immunohistochemically for tenascin‐C expression. The influence of the specific tenascin‐C isoforms produced by glioblastoma cells on proliferation and migration was examined in vitro using blocking antibodies recognizing all isoforms. In general, tenascin‐C expression increased with tumor malignancy. Perivascular staining of tenascin‐C around tumor‐supplying blood vessels was observed in all glioblastoma tissues, whereas in WHO II and III gliomas, perivascular tenascin‐C staining appeared less frequently. The appearance of perivascular tenascin‐C correlated significantly with a shorter disease‐free time. Analysis of proliferation and migration in the presence of blocking antibodies revealed an inhibition of proliferation by around 30% in all 3 glioblastoma cell cultures, as well as a decrease in migration of 30.6–46.7%. Thus we conclude that the endogenous pool of tenascin‐C isoforms in gliomas supports both tumor cell proliferation and tumor cell migration. In addition, our data on the perivascular staining of tenascin‐C in WHO II and III gliomas and its correlation with a shorter disease‐free time suggest that tenascin‐C may be a new and potent prognostic marker for an earlier tumor recurrence.

Image-guided neurosurgery with intraoperative MRI : update of frameless stereotaxy and radicality control

Intraoperative shifts and resulting inaccuracies have been a concern in frame based and frameless stereotactically guided interventions, particularly in open microsurgical procedures. Trying to solve this problem, we developed a method to perform intraoperative MRI (0.2 tesla, Magnetom Open) and use intraoperatively acquired data sets to update neuronavigation. In 21 patients, intraoperative images could be used to reference navigation (mean accuracy of 0.83 +/- 0.31 mm). The operation was continued in 10 cases to resect detected tumor remnants using navigation, leaving 4 patients (19%) with residual tumor postoperatively. We showed that update of frameless stereotaxy to compensate for brain shift is feasible and might increase the number of cases where radiologically complete resection can be achieved.

Intraoperative Computer-Assisted Neuronavigation in Functional Neurosurgery

The clinical experience with a frameless computer-assisted neuronavigational system (ISG. Canada) used in functional neurosurgery is described. The advantage of image-guided surgery is stressed for functional procedures of the cortex with delineation of the gyral pattern, e.g. motor cortex stimulation and procedures at the base of the skull with triplanar and three-dimensional reconstruction of the bony landmarks. A general use of the device for aiming at subcortical targets cannot be recommended. Limitations are the accuracy (< or = 2.2 mm) and software deficiencies and the lack of a reliable fixation of the position sensing arm (wand).