MRI for Surgical Planning
Priti Balchandani1

1Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States

Synopsis

This talk discusses the role of MRI in neurosurgical planning and guidance. Specific examples included are the application of ultrahigh field MRI and multi-modal MRI to improved surgical treatment of epilepsy and skull base tumors.

Title

Application of advanced pre-operative multi-modal MRI for planning and guidance of neurosurgery

Target Audience

Clinicians and basic scientists who want to learn about the role of new MRI techniques in neurosurgical planning and guidance.

Outcomes/objectives

Learners will be able to identify the utility of pre-operative MRI in different stages of neurosurgical treatment. They will become familiar with the most advanced pre-operative MR imaging sequences and will learn how these methods may be integrated into surgical treatment of a wide range of neurological diseases. Neurosurgeons may identify ways to better utilize MRI in patient care and researchers will learn ways to to build MRI protocols to meet the needs of surgeons.

Purpose

There is surprisingly low adoption of high-resolution, multi-modal neuroimaging in the operating room. It is necessary to bridge the gap between advanced imaging and surgical care. This talk will focus on two examples for which more advanced MRI, employing multiple modalities and ultrahigh field scanners, could substantially improve planning and guidance of surgery: epilepsy and tumors of the skull base. In epilepsy, invasive methods are currently used to identify abnormal areas of the brain for surgical targeting, when these could be replaced with improved, non-invasive MRI techniques to reveal subtle focal abnormalities and lesion boundaries (1). For tumors of the skull base, patients may be candidates for less invasive surgical methods such as endoscopic endonasal approaches, however high resolution MRI is critical to provide clear visualization of adjacent or encased vessels and nerves, in order to avoid complications (2,3).

Methods

Integration of novel imaging methods with modern equipment for surgical guidance will provide a fully integrated, high-tech operating room (OR) environment and improve the quality of a wide range of neurosurgical procedures.

Use of ultrahigh field MRI scanners, such as those operating at 7 Tesla, may substantially improve the depiction of lesions and surrounding anatomy for better surgical guidance. (4-6).

Development of MR pulse sequences that use specialized adiabatic RF pulses and efficient readout mechanisms may be applied to improve surgical planning for a wide range of neurological diseases including epilepsy and brain tumors (7-9).

Results

The value of applying more advanced multi-modal and ultrahigh field MRI to better delineate lesion boundaries and avoid damage to adjacent neurovascular structures as well as cranial nerves is an ongoing area of research. The use of ultrahigh and multi-modal MRI has shown utility for improved surgical treatment of epilepsy, skull base tumors and trigeminal neuralgia (10-13). Anatomical and functional MRI is also valuable to guide minimally invasive surgical procedures such as deep brain stimulation and neuromodulation (14,15).

Discussion

Systematic integration of multimodal imaging data into neurosurgical decision making and evaluation through quantitative metrics, will be required to assess improvements in surgical treatment efficacy and outcome. High resolution anatomical MRI needs to be fused and co-registered with vascular imaging methods such as time-of-flight angiography to provide most benefit in the operating room.

Combined development of imaging methods with improved visualization software for neuronavigation systems in operating rooms may be necessary to best provide surgical guidance.

Advanced image analysis methods, leveraging graph theory, to intelligently combine these data from multiple MRI modalities may be powerful methods in neurological diseases such as epilepsy to identify the primary seizure onset zone, as well as other areas of the brain affected by and involved in seizure activity(16,17).

Conclusion

Multi-modal and ultrahigh field MRI meet the critical need of providing precise and detailed anatomical imaging to the surgeon preoperatively, allowing for better tumor/patient selection, planning of approach, and intraoperative decision making. Every one of these features has a high impact on patient safety and clinical outcome.

Acknowledgements

No acknowledgement found.

References

1. Duncan JS, Winston GP, Koepp MJ, Ourselin S. Brain imaging in the assessment for epilepsy surgery. Lancet Neurol 2016;15:420–433. doi: 10.1016/S1474-4422(15)00383-X.

2. Cappabianca P, Cavallo LM, Colao A, Del Basso De Caro M, Esposito F, Cirillo S, Lombardi G, de Divitiis E. Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg 2002;45:193–200. doi: 10.1055/s-2002-36197.

3. Cappabianca P, Iaconetta G, Califano L eds. Cranial, Craniofacial and Skull Base Surgery. Milano: Springer Milan; 2010. doi: 10.1007/978-88-470-1167-0.

4. Barrett TF, Dyvorne HA, Padormo F, Pawha PS, Delman BN, Shrivastava RK, Balchandani P. First Application of 7-T Magnetic Resonance Imaging in Endoscopic Endonasal Surgery of Skull Base Tumors. World Neurosurg 2017;103:600–610. doi: 10.1016/j.wneu.2017.03.088.

5. Rutland JW, Feldman RE, Delman BN, Panov F, Fields MC, Marcuse LV, Hof PR, Lin H-M, Balchandani P. Subfield-specific tractography of the hippocampus in epilepsy patients at 7 Tesla. Seizure 2018;62:3–10. doi: 10.1016/j.seizure.2018.09.005.

6. Feldman RE, Delman B, Dyvorne H, yoo J, fields M, Marcuse L, Balchandani P. 7T MRI detection of epileptogenic foci in previously non-lesional patients with focal epilepsy. In: Singapore; 2016.

7. Feldman RE, Balchandani P. A semiadiabatic spectral-spatial spectroscopic imaging (SASSI) sequence for improved high-field MR spectroscopic imaging. Magn Reson Med 2015:n/a–n/a. doi: 10.1002/mrm.26025.

8. Feldman R, fields M, Delman B, Marcuse L, Balchandani P. 3D magnetic resonance spectroscopic imaging at 7 Tesla of patients with medically refractory focal epilepsy with non-lesional or inconclusive clinical MRIs: First Results. In: Hawaii; 2017.

9. Dyvorne H, O'Halloran R, Balchandani P. Ultrahigh field single-refocused diffusion weighted imaging using a matched-phase adiabatic spin echo (MASE). Magn Reson Med 2016;75:1949–1957. doi: 10.1002/mrm.25790.

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11. Barrett TF, Sarkiss CA, Dyvorne HA, Lee J, Balchandani P, Shrivastava RK. Application of Ultrahigh Field Magnetic Resonance Imaging in the Treatment of Brain Tumors: A Meta-Analysis. World Neurosurg 2016;86:450–465. doi: 10.1016/j.wneu.2015.09.048.

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13. Alper J, Shrivastava RK, Balchandani P. Determining the Etiology of Trigeminal Neuralgia using MRI:A Quantitative Review and Meta-analysis (Submitted). World Neurosurg.

14. Stefurak T, Mikulis D, Mayberg H, Lang AE, Hevenor S, Pahapill P, Saint Cyr J, Lozano A. Deep brain stimulation for Parkinson's disease dissociates mood and motor circuits: A functional MRI case study. Movement Disorders 2003;18:1508–1516. doi: 10.1002/mds.10593.

15. Lin Y, Wang Y. Neurostimulation as a promising epilepsy therapy. Epilepsia Open 2017;2:371–387. doi: 10.1002/epi4.12070.

16. Chiang S, Haneef Z. Graph theory findings in the pathophysiology of temporal lobe epilepsy. Clin Neurophysiol 2014;125:1295–1305. doi: 10.1016/j.clinph.2014.04.004.

17. Bernhardt BC, Bonilha L, Gross DW. Network analysis for a network disorder: The emerging role of graph theory in the study of epilepsy. Epilepsy Behav 2015;50:162–170. doi: 10.1016/j.yebeh.2015.06.005.

Proc. Intl. Soc. Mag. Reson. Med. 27 (2019)