Image-Guided Removal of Supratentorial Cavernomas in Critical Brain Areas: Application of Neuronavigation and Intraoperative Magnetic Resonance Imaging

Abstract

In a retrospective study the postoperative results of 26 patients operated on for supratentorial cavernous hemangiomas either deep-seated or near eloquent brain areas are summarized. An exact surgical approach to these lesions is essential to prevent neurological deterioration. Three different navigation systems were used and compared according to their clinical applicability. Complete removal of the lesion was obtained in all patients of this series. In six cases (23 %) functional data from magnetoencephalography or functional magnetic resonance imaging were integrated into the navigational setup. In 14 cases (54 %) intraoperative magnetic resonance imaging was performed. The follow-up time was 3 - 26 months (mean: 10 months). In the postoperative course one patient (3.8 %) developed a hemiparesis, another one developed quadrantopia. Nineteen patients presented with preoperative seizure history, 16 of these (84 %) had no further or rare seizures after surgery. The better results in seizure control were achieved in those patients with shorter duration of seizure history before surgery. The study indicates that the application of neuronavigation allows surgery on supratentorial cavernous hemangiomas in critical brain areas with low morbidity. The intraoperative visualization of eloquent cortex areas by integration of functional data allows a fast identification and exemption of eloquent brain areas, preventing neurological deterioration. Furthermore, the intraoperative MR resection control ensures a complete resection and illustrates the minimal invasive approach.

Non-rigid alignment of pre-operative MRI, fMRI, and DT-MRI with intra-operative MRI for enhanced visualization and navigation in image-guided neurosurgery

“…Moreover, cortical stimulation is a demanding, time consuming, and costly procedure and as such is often not possible during surgery. Therefore, because fMRI of motor and language tasks is feasible in patients with cerebral tumors (Mueller et al 1996), several groups have proposed the integration of functional data into the neuronavigation system in recent years (Krishnan et al 2004, Gralla et al 2003, Jannin et al 2002, Roessler et al 2005, Reithmeier et al 2003, Talos et al 2003, O'Shea et al 2006. And strong evidence that a more radical tumor resection may be achieved by using fMRI information during neurosurgery has been demonstrated by Krishnan et al 2004, Haberg et al 2004 Diffusion tensor imaging (DTI) has recently emerged as a potentially valuable tool for preoperative planning (Tummala et al 2004, Field et al 2004, Clark et al 2003, Wieshmann et al 2000, Moller-Hartmann et al 2002, Coenen et al 2003 and postoperative follow-up (Alexander et al 2003) of surgically treated brain tumors and vascular malformations.…”

Surgical management of epilepsy due to cerebral cavernomas using neuronavigation and intraoperative MR imaging

“…15 However, only 63% of those patients were seizure free after a mean follow-up of 10 months, partly due to 0.2T iopMRI being not capable to visualize hemosiderin as high field (1.5T) MRI does. At the time of installation of an intraoperative 1.5T high field MR suite at our clinic in 2002, we started to test the hypothesis that 1.5T iopMRI in combination with neuronavigation may extend the resection amount of CMs and lead to a higher percentage of seizure free patients with less complications for those in eloquent brain areas.…”

“…13,15,22 Furthermore, DTI was used for reconstruction and visualization of the neuronal fiber tracts with the navigation planning software iPlan 2.6 (BrainLab, Feldkirchen, Germany). The procedure of localizing fiber bundles was demonstrated previously by our group.…”

“…In these patients, intraoperative MRI (iopMRI) and functional neuronavigation (FN) may be helpful to achieve successful surgical treatment. [15][16][17] Resections adjacent to eloquent brain regions can be performed more safely by applying FN and incomplete resection can be detected by iopMRI. 18 This concept was termed 'multimodal navigation' as reported earlier by our group.…”

Tailored keyhole surgery for basal ganglia cavernous malformation with preoperative three-dimensional pyramidal tracts assessment and intraoperative electrophysiological monitoring

“…Surgical removal of basal ganglia cavernous malformations is technically challenging [1,2]. Although the introduction and further development of image-guided neurosurgical system has greatly facilitated the challenges encountered in approaching the lesion [3,4], the high risk of paresis due to damage to the perilesional pyramidal tracts during lesion resection continues to make this procedure controversial [1,5].…”