Intraoperative visualisation of functional structures facilitates safe frameless stereotactic biopsy in the motor eloquent regions of the brain.

BACKGROUND: For stereotactic brain biopsy involving motor eloquent regions, the surgical objective is to enhance diagnostic yield and preserve neurological function. To achieve this aim, we implemented functional neuro-navigation and intraoperative magnetic resonance imaging (iMRI) into the biopsy procedure. The impact of this integrated technique on the surgical outcome and postoperative neurological function was investigated and evaluated. METHOD: Thirty nine patients with lesions involving motor eloquent structures underwent frameless stereotactic biopsy assisted by functional neuro-navigation and iMRI. Intraoperative visualisation was realised by integrating anatomical and functional information into a navigation framework to improve biopsy trajectories and preserve eloquent structures. iMRI was conducted to guarantee the biopsy accuracy and detect intraoperative complications. The perioperative change of motor function and biopsy error before and after iMRI were recorded, and the role of functional information in trajectory selection and the relationship between the distance from sampling site to nearby eloquent structures and the neurological deterioration were further analyzed. RESULTS: Functional neuro-navigation helped modify the original trajectories and sampling sites in 35.90% (16/39) of cases to avoid the damage of eloquent structures. Even though all the lesions were high-risk of causing neurological deficits, no significant difference was found between preoperative and postoperative muscle strength. After data analysis, 3mm was supposed to be the safe distance for avoiding transient neurological deterioration. During surgery, the use of iMRI significantly reduced the biopsy errors (p = 0.042) and potentially increased the diagnostic yield from 84.62% (33/39) to 94.87% (37/39). Moreover, iMRI detected intraoperative haemorrhage in 5.13% (2/39) of patients, all of them benefited from the intraoperative strategies based on iMRI findings. CONCLUSIONS: Intraoperative visualisation of functional structures could be a feasible, safe and effective technique. Combined with intraoperative high-field MRI, it contributed to enhance the biopsy accuracy and lower neurological complications in stereotactic brain biopsy involving motor eloquent areas.

[Integration of metabolism images into multimodal neuronavigation for frameless stereotaxy].

OBJECTIVES: To evaluate the efficacy of integration of metabolism images into multimodal neuronavigation for frameless stereotactic biopsy. METHODS: From January to December 2012, 32 patients with brain lesions underwent frameless stereotactic biopsy guided by positron emission tomograph (PET) and proton magnetic resonance spectroscopy ((1)H-MRS)-based multimodal neuronavigation and intraoperative magnetic resonance imaging (iMRI). The cohort consisted of 16 male and 16 female patients, with a mean age of 45 years (range: 7 - 62 years). Biopsy targets were identified according to PET and (1)H-MRS. Biopsy was performed with Varioguide frameless biopsy system. Diagnostic yield and complications were assessed. RESULTS: Metabolism images-based multimodal neuronavigation and iMRI were successfully implemented in all cases. iMRI confirmed accuracy of biopsy targets. All the specimens obtained pathological diagnosis, the diagnostic yield was 100%. In 1 patient, iMRI found small hematoma (< 5 ml), surgical evacuation wasn't needed with intraoperative complication rate 3.1%. With the help of multimodal neuronavigation, no patients had new or worsened neurologic deficits. CONCLUSIONS: Integration of metabolism images into multimodal neuronavigation provide not only anatomical, but also metabolic and functional information for frameless stereotaxy, increasing diagnostic yield and avoiding postoperative neurologic deficits.

[Application of intraoperative magnetic resonance imaging and multimodal navigation in surgical resection of glioblastoma].

OBJECTIVE: To evaluate the efficacy of intraoperative magnetic resonance imaging (iMRI) and multimodal navigation in surgical resection of glioblastoma. METHODS: Between February 2009 and July 2010, 76 glioblastoma patients underwent surgical resection guided by iMRI and multimodal navigation. The cohort consisted of 43 male and 33 female patients, with a mean age of 49 years (range: 14-79 years). Rates of gross total resection (GTR) and extent of resection (EoR) were calculated at first and final iMRI scans.Pearson χ(2) test was used to compare the rates of GTR. RESULTS: iMRI and multimodal navigation were successfully implemented in all cases. Rates of GTR were misestimated by neurosurgeons in 24 cases (31.6%), which were confirmed by first iMRI. Total tumor resection were achieved in 20 cases (26.3%) as a result of iMRI scan, increasing the rates of gross total resection from 52.6% to 78.9% (χ(2) = 11.692, P = 0.001). Extent of resection in 28 patients who underwent further tumor resection were increased from 81.5% to 98.1%, leading to the overall extent of resection improved from 92.3% to 98.4%. At 3-month follow-up, 3 cases (3.9%) developed permanent neurologic deficits. The mean clinical follow-up was 15.6 months (range 3.0-45.0 months). The 2-year overall survival rate was 19.7%. The median progression-free survival of gross total resection group was 12 months (95% CI: 10.1-13.9 months), compared with 9 months (95%CI: 7.9-10.1 months) of the subtotal resection group (χ(2) = 4.756, P = 0.029). The overall survival of gross total resection group was 16 months (95% CI: 13.7-18.3 months), compared with 12 months (95% CI: 9.7-14.3 months) of the subtotal resection group (χ(2) = 7.885, P = 0.005). CONCLUSION: Combined with multimodal navigation, iMRI helps maximize surgical resection of glioblastoma, preserving neurological function while increasing progression-free survival and overall survival.

[Implementation of VarioGuide in stereotactic brain biopsy: a preliminary experience].

OBJECTIVE: To evaluate the clinical value of VarioGuide in stereotactic brain biopsy. METHODS: Fifteen patients with brain lesions underwent frameless stereotactic brain biopsy guided by VarioGuide and multimodal neuronavigation. Intraoperative magnetic resonance imaging (iMRI) was used to confirm the accuracy of biopsy. And the VarioGuide-related adverse events, operative duration, surgical outcomes and postoperative complications were recorded respectively. RESULTS: In all patients, VarioGuide and multimodal neuronavigation were successfully integrated into the biopsy procedure. No VarioGuide-related adverse events were reported. The mean operative duration was (65 ± 8) min. The biopsy accuracy was confirmed by iMRI in all cases. And the postoperative histological diagnostic rate was 100%. No mortality and morbidity occurred postoperatively. CONCLUSION: The combined approach of VarioGuide and multimodal neuronavigation is accurate, safe and efficient. It may improve the histological diagnostic rate without postoperative neurological deficits in stereotactic brain biopsy.

[Influences of high-field intraoperative magnetic resonance imaging on the extent of resection in low-grade gliomas].

OBJECTIVE: To evaluate the influences of high-field intraoperative magnetic resonance imaging (iMRI) on the extent of resection (EoR) in low-grade gliomas. METHODS: Fifty-nine patients with low-grade gliomas underwent microsurgeries under the guidance of high-field iMRI and functional neuro-navigation. The rates of gross total removal and EoR were recorded after initial and final iMRI scans and neurological performances were evaluated peri-operatively and at follow-up. RESULTS: iMRI and functional neuronavigation were successfully performed in all patients. Initial iMRI found that the rates of gross total removal were misestimated in 21 cases (35.6%). In 17 cases (28.8%), initial iMRI revealed resectable residual tumors and further resection achieved gross total removal in 8 cases (13.6%). iMRI boosted the level of EoR from 90% ± 15% to 94% ± 12% (P < 0.001) in all cases and from 78% ± 17% to 91% ± 12% in 17 cases undergoing further tumor resections. At 3-month follow-up, 2 cases (3.4%) developed neurological deficits. CONCLUSION: The combination of iMRI and functional neuronavigation helped maximize safe tumor resection in low-grade gliomas.

[High-field intraoperative magnetic resonance imaging suite with neuronavigation system: implementation and preliminary experience in the pituitary adenoma operation with transsphenoidal approach].

OBJECTIVES: To review the preliminary clinical experience with high-field-strength intraoperative magnetic resonance imaging (iMRI) suite with neuronavigation system in the pituitary adenoma operation with transsphenoidal approach. METHODS: From March 2009 to December 2010, 31 patients [range, 29 - 76 years, mean age (47 ± 11) years]of pituitary adenoma were operated with transsphenoidal approach and intraoperatively with a movable 1.5 T high-field-strength iMRI suite in combination with neuronavigation system. Tumor size was 1.8 - 7.3 cm, mean (3.5 ± 1.2) cm. Twenty-five cases were non-functional pituitary adenoma, 4 cases were prolactin-secreting pituitary adenoma, 2 cases were growth hormone-secreting pituitary adenoma. Thirty patients' resection with transnasal transsphenoidal approach were performed, one patient with transoral transsphenoidal approach was performed. RESULTS: In 12 cases of 30 patients who planed to totally remove tumor, iMRI had revealed residual lesions and resulted in the change of the surgical strategy, 2 invasive cavernous sinus cases no further resection of the tumor because of internal carotid artery encasement, the other 10 cases resected further, eventually. Finally, 8 cases were totally removed. The ratio of total removal tumor was enhanced to 86.7% (26/30) from 60.0% (18/30). There was no perioperative mortality. CONCLUSIONS: High-field-strength iMRI suite with neuronavigation system provides valuable information of tumor resection that allows intraoperative modification of the surgical strategy. It could be very helpful to maximize the resection of the pituitary adenoma and minimize the injury to neurological function.

Identification of risk factors for poor language outcome in surgical resection of glioma involving the arcuate fasciculus: an observational study.

The arcuate fasciculus is a critical component of the neural substrate of human language function. Surgical resection of glioma adjacent to the arcuate fasciculus likely damages this region. In this study, we evaluated the outcome of surgical resection of glioma adjacent to the arcuate fasciculus under the guidance of magnetic resonance imaging and diffusion tensor imaging, and we aimed to identify the risk factors for postoperative linguistic deficit. In total, 54 patients with primary glioma adjacent to the arcuate fasciculus were included in this observational study. These patients comprised 38 men and 16 women (aged 43 ± 11 years). All patients underwent surgical resenction of glioma under the guidance of magnetic resonance imaging and diffusion tensor imaging. Intraoperative images were updated when necessary for further resection. The gross total resection rate of the 54 patients increased from 38.9% to 70.4% by intraoperative magnetic resonance imaging. Preoperative language function and glioma-to-arcuate fasciculus distance were associated with poor language outcome. Multivariable logistic regression analyses showed that glioma-to-arcuate fasciculus distance was the major independent risk factor for poor outcome. The cutoff point of glioma-to-arcuate fasciculus distance for poor outcome was 3.2 mm. These findings suggest that intraoperative magnetic resonance imaging combined with diffusion tensor imaging of the arcuate fasciculus can help optimize tumor resection and result in the least damage to the arcuate fasciculus. Notably, glioma-to-arcuate fasciculus distance is a key independent risk factor for poor postoperative language outcome. This study was approved by the Ethics Committee of the Chinese PLA General Hospital, China (approval No. S2014-096-01) on October 11, 2014.

Resveratrol improves prostate fibrosis during progression of urinary dysfunction in chronic prostatitis.

AIM: We investigated whether prostate fibrosis was associated with urinary dysfunction in chronic prostatitis (CP) and whether resveratrol improved urinary dysfunction and the underlying molecular mechanism. METHODS: Rat model of CP was established via subcutaneous injections of DPT vaccine and subsequently treated with resveratrol. Bladder pressure and volume tests investigated the effect of resveratrol on urinary dysfunction in CP rats. Western blotting and immunohistochemical staining examined the expression level of C-kit/SCF and TGF-ß/Wnt/ß-catenin. RESULTS: Compared to the control group, the maximum capacity of the bladder, residual urine volume and maximum voiding pressure, the activity of C-kit/SCF and TGF-ß/Wnt/ß-catenin pathways were increased significantly in the CP group. Resveratrol treatment significantly improved these factors. CONCLUSION: CP induced significantly prostate fibrosis, which exhibits a close relationship with urinary dysfunction. Resveratrol improved fibrosis, which may be associated with the suppression of C-kit/SCF and TGF-ß/Wnt/ß-catenin pathway.

Image-guided endoscopic surgery for spontaneous supratentorial intracerebral hematoma.

OBJECTIVE Endoscopic removal of intracerebral hematomas is becoming increasingly common, but there is no standard technique. The authors explored the use of a simple image-guided endoscopic method for removal of spontaneous supratentorial hematomas. METHODS Virtual reality technology based on a hospital picture archiving and communications systems (PACS) was used in 3D hematoma visualization and surgical planning. Augmented reality based on an Android smartphone app, Sina neurosurgical assist, allowed a projection of the hematoma to be seen on the patient's scalp to facilitate selection of the best trajectory to the center of the hematoma. A obturator and transparent sheath were used to establish a working channel, and an endoscope and a metal suction apparatus were used to remove the hematoma. RESULTS A total of 25 patients were included in the study, including 18 with putamen hemorrhages and 7 with lobar cerebral hemorrhages. Virtual reality combined with augmented reality helped in achieving the desired position with the obturator and sheath. The median time from the initial surgical incision to completion of closure was 50 minutes (range 40-70 minutes). The actual endoscopic operating time was 30 (range 15-50) minutes. The median blood loss was 80 (range 40-150) ml. No patient experienced postoperative rebleeding. The average hematoma evacuation rate was 97%. The mean (± SD) preoperative Glasgow Coma Scale (GCS) score was 6.7 ± 3.2; 1 week after hematoma evacuation the mean GCS score had improved to 11.9 ± 3.1 (p < 0.01). CONCLUSIONS Virtual reality using hospital PACS and augmented reality with a smartphone app helped precisely localize hematomas and plan the appropriate endoscopic approach. A transparent sheath helped establish a surgical channel, and an endoscope enabled observation of the hematoma's location to achieve satisfactory hematoma removal.