Misleading FLAIR imaging pattern after glioma surgery with intraoperative MRI

Intraoperative MRI (iMRI) allows a more detailed appreciation of the extent of resection than does conventional neurosurgery and results in longer overall survival in patients with malignant glioma. However, it is unknown whether the intraoperative application of contrast agent influences the early postsurgical MRI. The preceding iMRI could alter the signals of MR sequences in the early postsurgical MRI, especially in sequences influenced by T1 contrast. Hereby, we investigate such iMRI-induced influences on the fluid-attenuated inversion recovery (FLAIR) sequence. We retrospectively analyzed postsurgical T2w, T1w, and FLAIR images by visual inspection and by signal measurements in 46 patients with malignant gliomas after tumor resection. Of these, n = 25 patients were operated with conventional microsurgery, and n = 21 patients were operated with contrast-enhanced iMRI-guided microsurgery. We measured signal intensity in the resection cavity, in the cerebrospinal fluid (CSF) of the ventricles, and in the normal brain tissue contralateral to the tumor-bearing hemisphere on axial FLAIR images and T1-weighted and T2-weighted images. In 18 patients, the FLAIR sequence revealed hyperintense signal changes of the CSF in the subarachnoid or ventricular spaces. Seventeen of these 18 patients had received intraoperative MRI. In both FLAIR and T1-weighted images, the signal of the CSF in the ventricles was significantly higher in patients with iMRI than in patients without iMRI. The intraoperative application of contrast agent that is used for iMRI significantly influences postsurgical MRI within the first 72 h. We found hyperintense signal changes of the CSF in the FLAIR sequence in the subarachnoid and intraventricular spaces mimicking subarachnoid hemorrhage. The findings may result in a misdiagnosis of subarachnoid hemorrhage (SAH) in these patients.