- Department of Computer Science, Washington University, St. Louis, Missouri, USA
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University, St. Louis, Missouri, USA
- Center for Innovation in Neuroscience and Technology, Washington University School of Medicine, St. Louis, Missouri, USA
S. Kathleen Bandt
Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
Department of Biomedical Engineering, Washington University, St. Louis, Missouri, USA
Center for Innovation in Neuroscience and Technology, Washington University School of Medicine, St. Louis, Missouri, USA
DOI:10.4103/2152-7806.175885Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Batra P, Bandt SK, Leuthardt EC. Resting state functional connectivity magnetic resonance imaging integrated with intraoperative neuronavigation for functional mapping after aborted awake craniotomy. Surg Neurol Int 05-Feb-2016;7:13
How to cite this URL: Batra P, Bandt SK, Leuthardt EC. Resting state functional connectivity magnetic resonance imaging integrated with intraoperative neuronavigation for functional mapping after aborted awake craniotomy. Surg Neurol Int 05-Feb-2016;7:13. Available from: http://surgicalneurologyint.com/surgicalint_articles/resting-state-functional-connectivity-magnetic-resonance-imaging-integrated-with-intraoperative-neuronavigation-for-functional-mapping-after-aborted-awake-craniotomy/
Background:Awake craniotomy is currently the gold standard for aggressive tumor resections in eloquent cortex. However, a significant subset of patients is unable to tolerate this procedure, particularly the very young or old or those with psychiatric comorbidities, cardiopulmonary comorbidities, or obesity, among other conditions. In these cases, typical alternative procedures include biopsy alone or subtotal resection, both of which are associated with diminished surgical outcomes.
Case Description:Here, we report the successful use of a preoperatively obtained resting state functional connectivity magnetic resonance imaging (MRI) integrated with intraoperative neuronavigation software in order to perform functional cortical mapping in the setting of an aborted awake craniotomy due to loss of airway.
Conclusion:Resting state functional connectivity MRI integrated with intraoperative neuronavigation software can provide an alternative option for functional cortical mapping in the setting of an aborted awake craniotomy.
Keywords: Awake craniotomy, functional mapping, intraoperative neuronavigation, resting state functional connectivity magnetic resonance imaging
The goal of an awake craniotomy for tumor resection is to remove as much pathologic tissue as possible while preserving cortical structures subserving functions such as speech and motor control.[
Clinical history and physical examination
Our patient was a 57-year-old right-handed gentleman with a remote history of colon cancer who presented with increasing headache frequency and severity with new onset complex partial seizures. MRI identified a left posterior frontotemporal tumor suggestive of a high-grade glioma [
Preoperative anatomic magnetic resonance imaging. (a) Sagittal T1-weighted contrasted magnetic resonance imaging demonstrating a rim enhancing peri-sylvian mass consistent with primary glial neoplasm. (b) Axial fluid attenuated inversion recovery magnetic resonance imaging sequence demonstrating the same peri-sylvian mass with significant surrounding edema
The patient was placed in the three-quarter lateral position exposing the left side for craniotomy. He was mildly sedated with remifentanil and midazolam by the anesthesia team for surgical exposure. Supraorbital and posterior occipital nerve blocks were performed prior to fixing his head in an MRI compatible Mayfield cranial fixation device (Integra Life Sciences, Plainsboro NJ, USA). A circumferential field block was then performed, and the patient's head was coregistered with the intraoperative stereotactic navigation system (StealthStation, Medtronic, Inc., Minneapolis, MN, USA). Following coregistration, the surgical team was notified by anesthesia that the patient was vomiting and had aspirated, and they would need to place an endotracheal tube to protect the patient's airway moving forward. At this juncture, the following options were considered: Aborting the procedure, proceeding with biopsy alone or proceeding with surgical resection based on previously integrated preoperative resting state functional connectivity MRI.
The patient's preoperative resting state functional connectivity MRI suggested that there was a corridor through the parietal lobe that would allow for surgical resection without damage to adjacent eloquent cortex [Figures
Since its introduction in the 1990s, task-based fMRI has shown tremendous potential as an adjunctive tool to delineate areas of eloquent cortex for preoperative planning.[
Currently, the gold standard for mapping eloquent cortex for neurosurgical procedures involves ECS testing during an awake craniotomy.[
Preoperative fMRI has been extensively compared to intraoperative ECS, generally with favorable results.[
In conclusion, preoperative resting state functional connectivity MRI is a viable alternative for the management of eloquently located brain tumors when an awake craniotomy isn’t feasible or is poorly tolerated. Since resting state functional connectivity, MRI is both noninvasive and nonparticipatory, it is more broadly applicable than both task-based fMRI and awake ECS for mapping of the functional cortex. Its use for this purpose would allow tumor resections within eloquent cortex to be performed under a wider variety of circumstances. This, in turn, could lead to improved neurosurgical outcomes. The successful resection of our patient's left temporoparietal high-grade glioma using integrated preoperative fMRI instead of awake cortical stimulation in the setting of an aborted awake craniotomy supports the use of preoperatively acquired resting state functional connectivity MRI as an effective alternative to an awake cortical mapping.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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