Brain Tumor Resection

The patients who benefit the most from AMIGO are in whom the distinction between tumor and brain and between different critical brain regions is most difficult. This occurs particularly in patients who have low grade gliomas, because although visible on certain imaging sequences, these tumors are nearly indistinguishable from surrounding brain during surgery even through the operating microscope. Moreover, visually all of the cortex and white matter look the same, and the surgeon can not discern the presence of white matter tracts or important areas during resection. In the AMIGO suite we can tie together preoperative mapping, accomplish intraoperative electrophysiology mapping, and obtain new US, MR, CT and PET images as needed.

Brain Tumor Resection Workflow in AMIGO

Craniotomy. Image guidance is used to perform a minimal craniotomy with optimized exposure of the lesion.
Ultrasound. When the dura is exposed, US is performed prior to making any incisions. US provides a fast initial orientation, including the location of major blood vessels. On left, the surgeon is using the BrainLab navigation system integrated with the BK US, and on the right is US with color doppler mode.
ECS. In a very small subset of cases, after the dura is opened and the cortex is exposed, intracranial electrical stimulation testing (ECS) is performed. ECS uses voltage applied directly to the cortex to map important functional areas. This is valuable in confirming and applying preoperative fMRI findings.
Navigation. Throughout the procedure, the pre-operative multimodal image data is used to navigate.
Navigation. Information is available to the surgeon about location and trajectory of her tools.
Tractography. Visualization of the tumor relative to the arcuate fasciculus white matter tract.
Gross Mass Removal. Gross tumor removal is performed using conventional tools aided by iterative neuro navigation. A cauterizer is shown in the picture.
Gross Mass Removal. Ablation and aspiration of tissue is shown.
Gross Mass Removal. Image guidance makes effective tumor resection possible.
Intraoperative MR. Prior to intraoperative MRI, a temporary closure is performed.
Intraoperative MR. A ceiling mounted high field (3T) MR scanner is then brought into the OR.
Tumor assessment. The tumor is contoured in green on the pre-op MRI image.
Assessment of residual tumor. The residual tumor is contoured in red.
Closure and post operative confirmatory imaging. Once the surgeon is satisfied with the extent of tumor resection, the dura is stitched, skull plate replaced, and skin stitched. Post-operative MR scans are obtained to confirm that there are no intraoperative complications and to set a new baseline. Once conscious, the patient is immediately asked to demonstrate motor control, such as foot movement. This confirms that resection has not affected at-risk areas of the motor cortex.

Publications

  1. Dolati-Ardejani P., Norton I., Wells III W.M., Horowitz P., Golby A. Ultrasound Imaging for Navigated Brain Tumor Resection: A Prospective Validation Study. AANS Conference 2014 April, San Francisco, CA.
  2. Dolati-Ardejani P., Olubiyi O., Ozdemir A., Inceckara F., Golby A. The Effect of Intraoperative MRI on the Extent of Resection of the Glioma. AANS Conference 2014 April, San Francisco, CA.
  3. Calligaris D., Feldman D.R., Norton I., Brastianos P.K., Dunn I.F., Santagata S., Agar N.Y.R. Molecular Typing of Meningiomas by Desorption Electrospray Ionization Mass Spectrometry Imaging for Surgical Decision-Making. Int J Mass Spectrom. 2015 Feb 1;377:690-8. PMID: 25844057. PMC4379512.
  4. Calligaris D., Caragacianu D., Liu X., Norton I., Thompson C.J., Richardson A.L., Golshan M., Easterling M.L., Santagata S., Dillon D.A., Jolesz F.A., Agar N.Y.R. Application of Desorption Electrospray Ionization Mass Spectrometry Imaging in Breast Cancer Margin Analysis. Proc Natl Acad Sci U S A. 2014 Oct 21;111(42):15184-9. PMID: 25246570. PMC4210338.
  5. Santagata S, Eberlin LS, Norton I, Calligaris D, Feldman DR, Ide JL, Liu X, Wiley JS, Vestal ML, Ramkissoon SH, Orringer DA, Gill KK, Dunn IF, Dias-Santagata D, Ligon KL, Jolesz FA, Golby AJ, Cooks RG, Agar NY. Intraoperative mass spectrometry mapping of an onco-metabolite to guide brain tumor surgery. Proc Natl Acad Sci. 2014;111(30) 11121-6. PMID: 24982150. PMC4121790.
  6. Calligaris, D., Feldman, D.R., Norton, I., Brastianos, P., Dunn, I.F., Santagata, S., and Agar, N.Y.R.  Molecular Typing of Meningiomas by Desorption Electrospray Ionization Mass Spectrometry Imaging for Surgical Decision-Making. Proc Natl Acad Sci U S A. 2014 Oct 21;111(42):15184-9. PMID:25246570. PMC4210338.
  7. Agar N.Y. R., Santagata S., Eberlin L., Norton I., Calligaris D., Feldman D., Ide J., Liu X., Wiley J., Vestal M., Ramkissoon S., Ian D., Dias-Santagata D., Ligon K., Jolesz F.A., Golby A., Cooks G. Intraoperative Mass Spectrometry Imaging of an Onco-metabolite to Guide Brain Tumor Surgery. AANS Conference 2014 April, San Francisco, CA.
  8. Eberlin L.S., Norton I., Orringer D., Dunn I.F., Liu X., Ide J.L., Jarmusch A.K., Ligon K.L., Jolesz F.A., Golby A.J., Santagata S., Agar N.Y.R., Cooks R.G. Ambient Mass Spectrometry for the Intraoperative Molecular Diagnosis of Human Brain Tumors. Proc Natl Acad Sci U S A. 2013 Jan 29;110(5):1611-6. PMID: 23300285. PMC3562800.
  9. Ovalioglu A., Olubiyi O., Rigolo L., Golby A. The Utility of fMRI for Language Mapping in Patients with High Grade Gliomas. AANS Conference 2014 April, San Francisco, CA.

Book

  1. Golby, Alexandra J, ed. Image-Guided Neurosurgery. 1st ed. Vol. Image-Guided Neurosurgery. Academic Press, 2015. p. 536. Print.

Book Chapters

  1. Ferenc A. Jolesz, Alexandra J. Golby, Daniel A. Orringer. Magnetic Resonance Image-Guided Neurosurgery. Ch.32. Part V. Image-Guided Clinical Applications. In Ferenc A. Jolesz (Ed.), Intraoperative Imaging and Image-Guided Therapy. New York, NY: Springer; 2014. pp. 451-64.
  2. Isaiah H. Norton, Daniel A. Orringer, Alexandra J. Golby. Image-Guided Neurosurgical Planning. Ch.37. Part V. Image-Guided Clinical Applications. In Ferenc A. Jolesz (Ed.), Intraoperative Imaging and Image-Guided Therapy. New York, NY: Springer; 2014. pp. 507-18.
  3. Nobuhiko Hata, Paul R. Morrison, Zsolt Cselik, Ron Kikinis, Peter McL. Black, and Ferenc A. Jolesz. MRI-Guided and Controlled Laser-Induced Interstitial Thermal Therapy of Brain Tumors Using Integrated Navigation and Thermal Mapping Ch.42. Part V. Image-Guided Clinical Applications. In Ferenc A. Jolesz (Ed.), Intraoperative Imaging and Image-Guided Therapy. New York, NY: Springer; 2014. pp. 567-74.