Functional Image-Guided Surgery For Brain Tumors
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 For patients with brain tumors, surgical resection is often the ideal first treatment; in some tumor types,  such as meningiomas,  surgery may be curative.  However, the proximity of vital brain structures may limit the ideal goal of complete tumor removal with preservation of function.  Surgery may not be offered to patients who might benefit from it on the assumption that their tumor is too close to so-called "eloquent" brain, such as the areas responsible for controlling movement or speech.

 Recent advances in imaging techniques allow for nonivasive brain "mapping", by which the precise relationship of areas controlling brain function to a nearby tumor can be determined.  One such method is functional MRI, or fMRI.

How can functional image-guided surgery be done?

 When an fMRI scan is done, the patient is asked to perform certain repetitive tasks, or "paradigms", such as finger tapping, reading a word list, or even to think about certain types of objects.  Areas of the brain that control these functions will show "increased activation" on the scan, which can be turned into an image showing the anatomical location of interest.  This functional scan is then "registered" or combined directly with a conventional MRI scan, in which an injection of a contrast medium is used to show the outline of a tumor.

 Next, this combined scan is transferred to a surgical navigation computer in the operating room.  Using this device, neurosurgeons routinely can guide incisions, skull openings, and brain tumor removal by the use of a special pointer whose position on a patient’s head is matched to the corresponding point on an MRI or CT scan.  With functional image-guided surgery, not only the location of the tumor can be noted, but that of critical brain areas as well.

How accurate is it?

 We have compared the predicted location of motor cortex (the part of the brain where movement on the opposite side of the body is initiated) with conventional techniques of brain mapping, wherein at the time of surgery a grid is placed on the brain, and sensory stimulation on the opposite arm or leg used to identify the location of the motor cortex.  In some cases the motor cortex was mapped by direct stimulation with a weak electric current.

 In every patient we have found the location of the motor cortex to be predicted accurately by functional image guidance.  Maximal tumor resection was achieved, and no new neurological deficit resulted.

What are the advantages of this type of surgery?

 Functional image guidance can give the neurosurgeon increased confidence that total tumor removal may be accomplished without giving a patient new neurological deficits, such as weakness on the opposite side of the body or difficulty speaking.  In some cases, it may prevent inappropriately aggressive surgery that may injure a patient.

 While the conventional methods of brain mapping described above are widely available, functional image guidance with fMRI allows for accurate, noninvasive preoperative assessment and planning for brain tumor surgery.

Who can benefit from functional image-guided surgery?

 Any patient who has a tumor near a critical area of cerebral cortex, especially areas involved in controlling movement, sensation, speech, or vision.  There are no additional risks, and no added inconvenience except for the relatively minor one of the functional MRI scan, which takes less than one hour to perform.

 We have also begun to use functional image-guidance for patients undergoing stereotactic radiosurgery.  This allows for the mapping of critical cortex on the radiosurgery planning computer, so that the delivery of potentially dangerous radiation doses to eloquent brain will be avoided.

Patient no.1

 This 35-year-old man had been diagnosed as having a low-grade glioma in his right motor cortex.  He was treated with radiation therapy, and told that surgery would leave him paralyzed on left side.  Functional image-guided surgery demonstrated that his tumor was actually in front of the motor cortex.  After exposing the brain at surgery, the stereotactic probe demonstrated the location of the motor cortex, as seen on the surgical navigation computer (figures 1 and 2).  The tumor was removed, as seen on postoperative MRI (figure 3); the patient is neurologically intact.

Figure 1
Figure 1
 
Figure 2
Figure 2
 
Figure 2
Figure 3
 

Patient no.2

 A 69-year-old woman was found to have a left-sided meningioma, in the region of the motor cortex, that enlarged on serial scans (figure 4).  She elected to undergo stereotactic radiosurgery.  Functional MRI showed the motor cortex to be behind the tumor; this scan was "fused" with a stereotactic CT scan.  Figure 5 shows the relative dose lines, surrounding the tumor and supplying a very low dose to the motor cortex.

Figure 4
Figure 4
 
Figure 5
Figure 5


For questions or comments, contact:
Michael Schulder, M.D.
Director, Image-Guided Neuosurgery
Section of Neurosurgery
New Jersey Medical School
90 Bergen Street, Suite 7300
Newark, NJ 07103
tel.: 973-972-2323
fax: 973-972-2333
email: schulder@umdnj.edu




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