Typical 3-D localization of tumor remnants of WHO grade II hemispheric gliomas--lessons learned from the use of intraoperative high-field MRI control

Application Value of 3.0-T Multivoxel 1H-MR Spectroscopy in the Peritumoral Tissue of Brain Astrocytic Tumors

Objective

This study aimed to explore metabolic features in the peritumoral tissue of different-rank brain astrocytic tumors using multivoxel proton magnetic resonance spectroscopy (¹H-MRS) and to estimate its application value in the MRS quantitative ratio of brain astrocytic tumors.

Materials and Methods

A total of 82 patients with brain astrocytic tumors, confirmed by postoperative pathological evaluation, were divided into low-grade astrocytic tumors [World Health Organization (WHO) grade I-II; 32 cases] and high-grade astrocytic tumors (WHO grade III-IV; 50 cases). The semi-quantitative and relative quantitative metabolite ratios of the parenchyma area, peritumoral tissue area, and normal area were measured. The P value was set as <0.05.

Results

The relative quantitative ratios of choline (Cho)/creatine (Cr) and Cho/N-acetyl aspartate (NAA) significantly differed in the peritumoral tissues of the high-grade astrocytic tumors and low-grade astrocytic tumors (P < 0.05), but NAA/Cr showed no significant difference.

Conclusions

The changes in the metabolite ratio of the peritumoral tissue area in brain astrocytic tumors reflect the biological behavior of different tumors. They have a significant clinical value in classifying brain astrocytic tumors and indicating the scope of invasion.

Multimodal neuronavigation-guided precision bypass in adult ischaemic patients with moyamoya disease: study protocol for a randomised controlled trial

INTRODUCTION

Revascularisation surgery is an important treatment of moyamoya disease (MMD). Several general methods of revascularisation had been used: direct, indirect and combined techniques. However, there had been no reports about the criteria of recipient arteries selection in bypass surgery for MMD. Surgeons usually choose the recipient arteries by their own experiences. Their choices of the recipient arteries are various and may contribute the different outcome of patients. The purpose is to identify utility and efficacy of precision bypass guided by multimodal neuronavigation of MMD in a prospective randomised controlled trial.

METHOD AND ANALYSIS

This study is a prospective randomised controlled clinical trial. This study will enrol a total of 100 eligible patients. These eligible patients will be randomised to the empirical bypass group and the multimodal neuronavigation-guided precision bypass group in a 1:1 ratio. Patient baseline characteristics and MMD characteristics will be described. In the multimodal neuronavigation-guided group, the blood velocity and blood flow of the recipient arteries will be identified. Surgical complications and outcomes at pretreatment, post-treatment, at discharge and at 3 month, 6 month, 12 month and end of trial will be analysed with CT perfusion, MRI, digital subtraction angiography, modified Rankin Scale, National Institute of Health Stroke Scale and modified Barthel Scale. This trial will determine whether multimodal neuronavigation-guided precision bypass is superior to empirical bypass in patients with MMD and identify the safety and efficacy of multimodal neuronavigation-guided precision bypass.

ETHICS AND DISSEMINATION

The study protocol and written informed consent were reviewed and approved by the Clinical Research Ethics Committee of Peking University International Hospital. Study findings will be disseminated in the printed media. The study started in August, 2018 and expected to be completed in December, 2020.

TRIAL REGISTRATION NUMBER

NCT03516851; Pre-results.

Clinical application of 3.0 T intraoperative magnetic resonance combined with multimodal neuronavigation in resection of cerebral eloquent area glioma

Glioma is the most common tumor among central nervous system tumors; surgical intervention presents difficulties. This is especially the case for gliomas in so-called "eloquent areas," as surgical resection threatens vital structures adjacent to the tumor. Intraoperative magnetic resonance imaging (iMRI) combined with multimodal neuronavigation may prove beneficial during surgery. This study explored the applicability of 3.0 T high field iMRI combined with multimodal neuronavigation in the resection of gliomas in eloquent brain areas.We reviewed 40 patients with a glioma located in the eloquent brains areas who underwent treatment in the Neurosurgery Department of Peking University International Hospital between December 2015 and August 2017. The experimental group included 20 patients treated using iMRI assistance technology (iMRI group). The remaining 20 patients underwent treatment by conventional neuronavigation (non-iMRI group). Tumor resection degree, preoperative and postoperative ability of daily living scale (Barthel index), infection rate, and operative time were compared between the 2 groups.No difference in infection rate was observed between the 2 groups. However, compared with the non-iMRI group, the iMRI group had a higher resection rate (96.55 ± 4.03% vs 87.70 ± 10.98%, P = .002), postoperative Barthel index (90.75 ± 12.90 vs 9.25 ± 16.41, P = .018), as well as a longer operation time (355.85 ± 61.40 vs 302.45 ± 64.09, P = .011).The use of iMRI technology can achieve a relatively higher resection rate among cases of gliomas in eloquent brain areas, with less incidence of postoperative neurological deficits. Although the operative time using iMRI was longer than that taken to perform conventional navigation surgery, the surgical infection rate in these 2 procedures showed no significant difference.

Functional MRI-guided microsurgery of intracranial arteriovenous malformations: study protocol for a randomised controlled trial

INTRODUCTION

Intracranial arteriovenous malformations (AVMs) are associated with high morbidity and mortality. Modern microsurgery has improved the results of surgical treatment of AVMs; however, the treatment of AVMs, particularly eloquently located AVMs, still carries a high risk. Functional MRI (fMRI) has been reported to be used for the preoperative evaluation of AVMs in small case series. The purpose is to identify the utility and efficacy of fMRI-guided microsurgery of AVMs in a large randomised controlled trial.

METHODS AND ANALYSIS

The study is a prospective, randomised controlled clinical trial. This study will enrol a total of 600 eligible patients. These eligible patients will be randomised to the standard microsurgery group and the fMRI-guided microsurgery group in a 1:1 ratio. Patient baseline characteristics and AVM architecture and characteristics will be described. In the fMRI-guided group, fMRI mapping of an eloquent cortex in all AVMs will be identified. Surgical complications and outcomes at pretreatment, post-treatment, at discharge and at 1-month, 3-month and 6-month follow-up intervals will be analysed using the modified Rankin Scale (mRS). This trial will determine whether fMRI-guided microsurgery could improve outcomes in patients with AVMs and also identify the safety and efficacy of fMRI-guided microsurgery.

ETHICS AND DISSEMINATION

The study protocol and written informed consent were reviewed and approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (ky2012-016-02). Study findings will be disseminated in the printed media.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01758211.

Feasibility of cervical intramedullary diffuse glioma resection using intraoperative magnetic resonance imaging

Intraoperative magnetic resonance imaging (iopMRI) actually has an important role in the surgery of brain tumors, especially gliomas and pituitary adenomas. The aim of our work was to describe the advantages and drawbacks of this tool for the surgical treatment of cervical intramedullary gliomas. We describe two explicative cases including the setup, positioning, and the complete workflow of the surgical approach with intraoperative imaging. Even if the configuration of iopMRI equipment was originally designed for cranial surgery, we have demonstrated the feasibility of cervical intramedullary glioma resection with the aid of high-field iopMRI. This tool was extremely useful to evaluate the extent of tumor removal and to obtain a higher resection rate, but still need some enhancement in the configuration of the headrest coil and surgical table to allow better patient positioning.

[First intraoperative magnetic resonance imaging in a Spanish hospital of the public healthcare system: initial experience, feasibility and difficulties in our environment]

OBJECTIVE

Intraoperative MRI is considered the gold standard among all intraoperative imaging technologies currently available. Its main indication is in the intraoperative detection of residual disease during tumour resections. We present our initial experience with the first intraoperative low-field MRI in a Spanish hospital of the public healthcare system. We evaluate its usefulness and accuracy to detect residual tumours and compare its intraoperative results with images obtained postoperatively using conventional high-field devices.

MATERIAL AND METHODS

We retrospectively reviewed the first 21 patients operated on the aid of this technology. Maximal safe resection was the surgical goal in all cases. Surgeries were performed using conventional instrumentation and the required assistance in each case.

RESULTS

The mean number of intraoperative studies was 2.3 per procedure (range: 2 to 4). Intraoperative studies proved that the surgical goal had been achieved in 15 patients (71.4%), and detected residual tumour in 6 cases (28.5%). After comparing the last intraoperative image and the postoperative study, 2 cases (9.5%) were considered as "false negatives".

CONCLUSIONS

Intraoperative MRI is a safe, reliable and useful tool for guided resection of brain tumours. Low-field devices provide images of sufficient quality at a lower cost; therefore their universalisation seems feasible.