Preoperative and intraoperative diffusion tensor imaging-based fiber tracking in glioma surgery

Intelligent Operating Theater Using Intraoperative Open-MRI

Malignant brain tumors vary among patients and are characterized by their irregular shapes and infiltration. Localization of functional areas in the brain also differs among patients, and excess removal of tumor near eloquent areas may increase the risk of damage of function, such as motor paresis and speech disturbance. Recent progress in magnetic resonance (MR) imaging technology has enabled acquisition of intraoperative images and totally changed the neurosurgery of malignant brain tumors. Before, surgeons could merely speculate about the results of surgical manipulation and have no certainty about procedure outcomes until postoperative examination. Because intraoperative MR images allow visualization of the size of residual tumor(s) and the positional relationship between the tumor(s) and eloquent areas, surgeons are now able to achieve safe and reliable surgery. As an example, positional error on preoperative MR images caused by shifting of the brain (brain shift), a long-standing annoyance for surgeons, has been resolved using intraoperative MR images for surgical navigation, allowing precise resection. Two types of open-MR imaging scanner, a 0.2- or 0.3-tesla hamburger-type scanner with a horizontal gap and a 0.12- or 0.5-tesla double doughnut-type scanner with a vertical gap, are now available in the operating theater, and 1.5-tesla bore-type scanners are available. A 3.0-tesla bore-type scanner is planned. Intraoperative MR imaging includes diffusion-tensor and diffusion-weighted imaging, which allows visualization of nerve fibers in the white matter, especially the pyramidal tract. Such images are valuable aids in the precise resection of residual lesions of malignant brain tumors near eloquent areas without injuring motor function.