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Intraoperative Magnetic Resonance Imaging-Guided Glioma Resections in Awake or Asleep Settings and Feasibility in the
Angelo Pichierri1, Marcus Bradley2, Venkat Iyer1
1Department of Neurosurgery, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom.
Background:
Despite the most recent surgical aids and tools, surgical removal of infiltrating brain tumors remains a challenge. Unclear margins, edematous areas, and infiltrative behavior are the main causes for failing gross total removals. Also, excessive resection of peri-tumoral tissue often carries risks of damaging the nearby functioning cortical and subcortical structures with an unacceptable decrease in patient's quality of life and postoperative functional status, and the risk of making patients not eligible to adjuvant treatments. Awake surgery and intraoperative magnetic resonance imaging (ioMRI) are among the most effective aids in preventing damage to functional brain while maximizing the extent of resection.
Methods:
We present our series of 46 patients operated on at Southmead Hospital (North Bristol NHS Trust) in between July 2014 and February 2017 using ioMRI plus or minus awake surgery. Setting, patient features, indications, type and size of tumors, surgical times, extent of resection, morbidity, and survival are analyzed and discussed.
Results:
Overall, ioMRI check led to a +43% resections in Group 1 and +58% in Group 2. In grade 2 tumors, GTR was 46% in Group 1 and 55% in Group 2 (41% in control group). In grade 3 tumors, GTR was 57% in Group 1 and 66% in Group 2 (30% in control group). In Grade 4 tumors, GTR was 63% in Group 1, 66% in Group 2 (36% in control group). In terms of theatre occupation, the use of ioMRI added 1/2 operative session; the addition of awake surgery implied the use of another 1/2 operative session. Morbidity did not differ among the groups, with low incidence of permanent post-operative deficits (<5%). Group 2 OS was statistically longer when compared to the control group.
Conclusions:
Using ioMRI together with awake surgery is demanding for the anesthetic team, staff nurses, and for the patient. Nevertheless, low morbidity, greater total resections rates, and longer survival suggest its use is effective in making more approachable gliomas of all grades that we would consider "complex" due to their intrinsic features or locations.
Insights
Intraoperative MRI (ioMRI) combined with awake surgery improves gross total resection rates for complex brain tumors, leading to longer survival with low morbidity. This approach enhances surgical outcomes for challenging glioma cases.
Area of Science:
- Neurosurgery
- Oncology
- Medical Imaging
Background:
- Surgical removal of infiltrating brain tumors is challenging due to unclear margins and infiltrative growth.
- Excessive resection risks neurological damage, impacting quality of life and eligibility for adjuvant treatments.
- Awake surgery and intraoperative MRI (ioMRI) are key aids for maximizing resection while preserving function.
Purpose of the Study:
- To evaluate the effectiveness of ioMRI with or without awake surgery in improving resection extent and patient outcomes.
- To analyze surgical times, morbidity, and survival rates in patients undergoing these advanced surgical techniques.
Main Methods:
- A series of 46 patients were operated on using ioMRI, with or without awake surgery.
- Data collected included patient features, tumor types/sizes, surgical duration, resection extent, morbidity, and survival.
- Outcomes were compared to a control group to assess the impact of ioMRI and awake surgery.
Main Results:
- ioMRI use increased resection rates by +43% (Group 1) and +58% (Group 2).
- Gross total resection (GTR) rates were significantly higher across all tumor grades (2, 3, and 4) compared to the control group.
- Morbidity remained low (<5% permanent deficits), and overall survival (OS) was statistically longer in Group 2 (ioMRI + awake surgery).
Conclusions:
- Combining ioMRI with awake surgery is demanding but highly effective for complex gliomas.
- This approach achieves greater total resection rates and longer survival with acceptable morbidity.
- The technique makes challenging brain tumors more approachable, improving patient prognosis.
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