1. XIX Symposium Neuroradiologicum

2. Neeraj Chepuri, M.D. Neuro Radiologist Consulting Radiologists, Ltd. Abbott Northwestern Hospital Minneapolis, Minnesota, USA INTEGRATION OF FUNCTIONAL MRI AND INTRA-OPERATIVE MRI PROVIDES A HIGH DEGREE OF PRECISION AND CONFIDENCE AT SURGICAL BRAIN TUMOR RESECTION

3. Objective To show that high field iMRI, as well as pre-operative fMRI and DTI has a positive effect on surgical and post-surgical intracranial neoplasm management 8 October 2010Neeraj Chepuri, MD

4. Historical Perspective of Intra-operative MRI (iMRI) 8 October 2010Neeraj Chepuri, MD

5. Historical Perspective of iMRI Low-field, fixed magnet Patient moves Low-image quality Images not in same position as surgery Neurosurgeons not as comfortable with non-ferromagnetic tools 8 October 2010Neeraj Chepuri, MD

6. Historical Perspective of iMRI High-field, fixed superconducting magnet Patient moves Images not in same position as surgery Surgeons use standard surgical equipment Better image quality 8 October 2010Neeraj Chepuri, MD

7. Historical Perspective of iMRI Low-field, fixed superconducting magnet Patient does not move Surgeon must be thin Surgeon must use non-ferromagnetic tools Low image quality 8 October 2010Neeraj Chepuri, MD

8. Historical Perspective of iMRI High-field, mobile superconducting magnet Patient does not move High image quality Standard surgical equipment Neurosurgeons of any size 8 October 2010Neeraj Chepuri, MD

9. High Field Intraoperative MRI (iMRI) The iMRI suite is equipped with a wide bore Siemens SP Espree (70 cm) ceiling mounted MRI (IMRIS). Field strength is 1.5 tesla. It is located in the main OR suite. It is uniquely dedicated to surgical procedures. 8 October 2010Neeraj Chepuri, MD

10. High Field Intraoperative MRI (iMRI) 8 October 2010Neeraj Chepuri, MD

11. High Field Intraoperative MRI (iMRI) 8 October 2010Neeraj Chepuri, MD

12. Material and Methods Surgical material is from June 2007 to October 2009. 314 patients were surgically treated in the iMRI suite. 232 adults and 82 pediatric patients. 8 October 2010Neeraj Chepuri, MD

13. Adult Patients (232 patients) 8 October 2010Neeraj Chepuri, MD

14. Pediatric Patients (82 patients) 8 October 2010Neeraj Chepuri, MD

15. Resection Status 8 October 2010Neeraj Chepuri, MD

16. Benefits of iMRI 1) Enhances the surgical trajectory definition by accommodating for brain shift 2) Allow for as complete lesion resection as possible. 3) Early recognition of intraoperative complications and early initiation of treatments. 4) Decrease the incidence of “second look” surgeries. 5) Decrease the number of post-operative studies. 6) No evidence for an increase rate of post-operative complications (infections, bed sores, infections) related to the prolongation of the operating time. 7) Overall decrease in cost of neurosurgical care ** 8 October 2010Neeraj Chepuri, MD

17. Value of iMRI update of Neuro-Navigation data to account for Brain Shift 8 October 2010Neeraj Chepuri, MD

18. Value of iMRI update of Neuro-Navigation data to account for Brain Shift 8 October 2010Neeraj Chepuri, MD

19. Value of Following Tumor Resection Progress by Multiple iMRI Functional MRI Tongue movement Activations Fiber Tracking Right corticospinal tract not disrupted 8 October 2010Neeraj Chepuri, MD

20. Value of Following Tumor Resection Progress by Multiple iMRI #1 #2 Intra-operative Monitoring 8 October 2010Neeraj Chepuri, MD

21. Case 2: Fiber tracking: Corticospinal tract intact Value of Following Tumor Resection Progress by Multiple iMRI 8 October 2010Neeraj Chepuri, MD

22. Value of Pre-operative fMRI Functional MRI: The integration of fMRI to the preoperative planning in both the adult and pediatric age group has helped define the “surgical corridor”. 8 October 2010Neeraj Chepuri, MD

23. Value of Pre-operative fMRI Functional MRI: The integration of fMRI to the preoperative planning in both the adult and pediatric age group has helped define the “surgical corridor”. 8 October 2010Neeraj Chepuri, MD

24. 17-year-old female presented with headaches and difficulty with speech Vision? Value of Pre-operative fMRI 8 October 2010Neeraj Chepuri, MD

25. Value of Pre-operative fMRI and DTI Functional MRI Visual and Language Activations Fiber Tracking Left Optic Radiation Displacement 8 October 2010Neeraj Chepuri, MD

26. Surface rendering 8 October 2010Neeraj Chepuri, MD

27. Pre-op vs. post-op 8 October 2010Neeraj Chepuri, MD

28. tongue Value of Pre-operative fMRI 8 October 2010Neeraj Chepuri, MD

29. Value of Early Identification of Complications by High Field iMRI Acute ischemia Acute hematoma Sinus thrombosis 8 October 2010Neeraj Chepuri, MD

30. Early Acute Ischemia Pre-op Post-op 8 October 2010Neeraj Chepuri, MD

31. Confirmation of No Complication The patient woke up from surgery weak in his leg. However; there were no abnormalities on the DWI scan. Therefore; the prognosis was good and the patient made a full recovery. 8 October 2010Neeraj Chepuri, MD

32. 5 year-old male with headaches, progressive in intensity over a 12 week duration and intractable emesis of one week duration Pre-operative MRI Value of Early Identification of Complications by High Field iMRI 8 October 2010Neeraj Chepuri, MD

33. iMRI demonstrates acute epidural hematoma Value of Early Identification of Complications by High Field iMRI 8 October 2010Neeraj Chepuri, MD

34. Pre-operative images Value of Early Identification of Complications by High Field iMRI 8 October 2010Neeraj Chepuri, MD

35. Post-operative images Neeraj Chepuri, MD Value of Early Identification of Complications by High Field iMRI 8 October 2010

36. Pre-op Post-op Value of Early Identification of Complications by High Field iMRI 8 October 2010Neeraj Chepuri, MD

37. Drawback of High Field iMRI 1) Undoubtedly iMRI lengthens the surgical procedure duration. ~ 30 min – 1 hr 2) Surgical procedure costs are increased: use of MRI compatible surgical equipment training of surgical personnel lengthens the surgical procedure 8 October 2010Neeraj Chepuri, MD

38. Benefits of iMRI 1) Enhances the surgical trajectory definition by accommodating for brain shift 2) Allow for as complete lesion resection as possible. 3) Early recognition of intraoperative complications and early initiation of treatments. 4) Decrease the incidence of “second look” surgeries. 5) Decrease the number of post-operative studies. 6) No evidence for an increase rate of post-operative complications (infections, bed sores, infections) related to the prolongation of the operating time. 7) Overall decrease in cost of neurosurgical care ** 8 October 2010Neeraj Chepuri, MD

39. Acknowledgements Douglas Yock, M.D. - Neuroradiologist Mahmoud Nagib, M.D. – Neurosurgeon Koi Kainth, M.D. – Neurosurgeon Marie Gura, R.N. - Nursing David Lori, R.N. - Nursing 8 October 2010Neeraj Chepuri, MD

40. Acknowledgements 8 October 2010Neeraj Chepuri, MD Ravi ChepuriSujit Chepuri Carolyn Chou