Introduction: Current management of gliomas involves a multidisciplinary approach, including a combination of maximal safe surgical resection, radiotherapy, and chemotherapy. The use of intraoperative magnetic resonance imaging (MRI) helps to maximize extent of resection, and use of awake functioning mapping supports preservation of eloquent areas of the brain. We report here on the concurrent use of these surgical adjuncts.
Methods: We performed a retrospective review of patients with gliomas, who underwent surgical resection in our intraoperative MRI suite (IMRIS) with awake functioning mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume, and intraoperative and postoperative residual volumes was performed.
Results: A total of 61 patients requiring 62 tumor resections met the inclusion criteria for this review. 45.9% of the tumors resected were WHO grade I or II, and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 47 cases (75.8%). 41 of these 47 (87.2%) underwent further resection. 4 cases underwent a second intraoperative MRI with 3 demonstrating residual tumor. Mean EOR on iMRI and final MRI were 85% and 95%, respectively, with a mean difference of 10% (p<0.001). EOR increased by more than 15% in 17 of 62 patients.
Conclusions: In our retrospective case series the combined use of intraoperative MRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows us to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection.
Patient Care: This research will improve patient care by providing neurosurgeons with a combined approach to resection of eloquently located tumors that maximizes extent of resection, and thus the associated survivals benefits, while minimizing functional consequences of resection.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) understand and describe the high degree of coordination and proper technique to successfully combine the use of iMRI, awake functioning mapping, and minimal access craniotomy, 2) Discuss among small groups the feasibility of such coordination in different hospital settings/environments with differing resources, and 3) Identify this technique as a safe and effective approach to tumors located within or around eloquent tissue areas