1. Intraoperative MRI for precise resection of the gliomas maintaining the motor and verbal function Intraoperative MRI for precise resection of the gliomas maintaining the motor and verbal function Yuko Ono Diagnostic Imaging & Nuclear Medicine/Neuroradiology Tokyo Women’s Medical University,Tokyo,Japan XIX Symposium Neuroradiologicum, 2010, Bologna

2. Background For malignant gliomas, more than 95% tumor removal leads to prolongation of the 5 year survival. On the other hand, preservation of the motor and verbal function is necessary for quality of life. years by Brain Tumors Registry of Japan, Neurol Med Chir 43 suppl, 2003 Survival rate% ope(-) w. iMRI Precise, and safe tumor resection preserving the eloquent areas, utilizing multi-modality preoperative and intraoperative images with functional monitoring.

3. arcuate fasciculus part of superior longitudinal fasciculus Conduction aphasia Related fibers to the verbal function

4. Preoperative information Cases: 620 cases of gliomas in grade I-IV  imaging: T1WI, T2WI, FLAIR,Gd-T1WI, DWI, DTI, tractography, PWI by 1.5/3T MR CT, DSA  functional confirmation: fMRI, Wada test  Imaging with metabolism: 1 H-MRS, methionine-PET ★ Comparison of the verbal fMRI and Wada test in 96 cases of gliomas (presented in ESNR 2005) in 96 cases of gliomas (presented in ESNR 2005) dominant hemisphere by Wada test 93/96 (95.8%) clear activation on verbal fMRI 53/75 (67.9%)

5. T1WI T2WI FLAIR Gd-T1WI FMRI with verbal task Preoperative MRI Wada test: left dominance awake craniotomy path. diag.: glioma GII total tumor removal post ope. : no deficits L L L right handed 33 year-old male with convulsion

6. Points of Intraoperative study  Detection of the brain shift and the effects due to operative procedure by iMRI.  Fusion of the preoperative images on the intraoperative images, when necessary.  Confirmation of the somatosensory and motor function by cortical stimulation.  Confirmation of the verbal function by cortical stimulation under awake craniotomy.  Photodynamic diagnosis and photo dynamic therapy.

7. Operative field monitoring Update navigation SEP ・ MEP iMRI histology

8. MR Apparatus: 0.3 T open type routine: 3D volume iT1WI and iT2WI : 3mm thickness FOV 230mm matrix 256x160 (reconstruction to be 15mm) 1 excitation iT1WI: TR/TE 27/10 FA30°imaging time: 3min.36sec iT2WI: TR/TE 1000/140 FA 90 imaging time: 4min.9sec iDWI: MPG-AP, 4 coronal shots, b-value 700 pulse triggered DW-EPI with fat suppression, 8mm thickness, slice interval 3mm with interleaved scan matrix 100x92 (reconstruction to be 256x256) 18 slices (to cover the pyramidal tract), 8 excitations, 5min.(1 min 22 sec x 3) Sequences for iMR

9. 5-ALA(5-Aminolevulinic acid)5-ALA(5-Aminolevulinic acid): administered orally converted intracellularly to the photosensitizer, protoporphyrin IX (PpIX). 5-ALA is accumulated in the tumor cells, and metabolized in heme- biosynthesis and presents strong fluorescence under ultra-violet light illumination. Laserphyrin(mono-L-aspartyl chlorine e6 ・ NPe6)Laserphyrin(mono-L-aspartyl chlorine e6 ・ NPe6): second generation photosensitizer presents fluorescence under laser irradiation and used for photodymanic therapy(FDT). The fluorescent photodynamic diagnosis (PDD)

10. iMRI for the glioma close to the pyramidal tract Cortical stimulation for motor function tumor pyramidal tract iDWI GD-T1WI after craniotomy double dose Gd-DTPA

11. High signal noise ratio and reduced artifacts improvement of the receiver coil with at least 29 % sensitivity of the preoperative MR images. development of head frame to fix the ROI to be in the center of the FOV, maintaining sterility of the coil distortion of the coronal DWI (vs.1.5T MR) craniocaudal distortion : 2.2 ±0.8mm transverse distortion : 1.1±0.4 mm (transverse distance is mainly used for navigation) iDWI for detection of the pyramidal tracts

12. Fusion of preoperative FA images, tractgraphy and iT2WI (developing)

13. 57 year old female with memory loss right dominance on Wada test, Awake craniotomy Photodiagnosis by Laserphyrin Histological diagnosis: Glioma grade 3

14. Resection rate 2000-2001 2002-2010 average G2 93% 96% G3 94% 97% G4 88% 92% 5-year survival of 340 cases in 2002-2010 90% G2 90% 78% G3 78% G4 13% Results of the glioma patients operated by navigation surgery using iMRI

15. Information-guided Surgery Higher resection rate + lower complication rate Anatomincal information preoperative muti-modality images iMRI Metabolic information MRS, PET Functional informati Functional information fMRI, Wada test cortical monitoring(SEP, MEP) awake surgery Histological information Frozen specimen Photodynamic diagnosis Image-guided surgery with update navigation

16. Important points for update navigation surgery 1.Preoperative multi-modality information of the tumors in relation to the eloquent areas. 2.Detection of brain shift and changes by iMRI simultaneously with the operative procedure. 3.Functional monitoring by cortical stimulation, with/without awake craniotomy. 4.More than 95% removal of the gliomas and sparing the motor and verbal functions. 5. Photodymanic Diagnosis and Therapy for the residual tumor. 6. Merits of the low field iMR apparatus: economical, easy and safe magnetic shielding for the equipments and devices for surgery, anesthesia, and monitoring. 7. Developed sensitivity of the receiver coils, a double dose administration of contrast material for better images.

17. Sincere thanks to the President Marco Leonardi and all the members of SNR. Thanks to my colleagues in Tokyo Women’s Medical University. K.Abe 1, Y.Muragaki 2, T.Maruyama 2, Y.Okada 2, H.Iseki 3 Y.Konishi 3, T.Kawamata 4, M.Kohno 1, T.Hayano 1, S.Sakai 1 1) Diagnostic imaging & Nuclear Medicine 1 2) Neurosurgery 2 3) Faculty of Advanced Techno-Surgery(FATS), Institute of Advanced Biomedical Engineering & Science, Graduate School of Medicine 3 4) Neurosurgery, Yachiyo Medical Center 4