Impact of combined use of intraoperative MRI and awake microsurgical resection on patients with gliomas: a systematic review and meta-analysis

Abstract

Microsurgical resection of primary brain tumors located within or near eloquent areas is challenging. Primary aim is to preserve neurological function, while maximizing the extent of resection (EOR), to optimize long-term neurooncological outcomes and quality of life. Here, we review the combined integration of awake craniotomy and intraoperative MRI (IoMRI) for primary brain tumors, due to their multiple challenges. A systematic review of the literature was performed, in accordance with the Prisma guidelines. Were included 13 series and a total number of 527 patients, who underwent 541 surgeries. We paid particular attention to operative time, rate of intraoperative seizures, rate of initial complete resection at the time of first IoMRI, the final complete gross total resection (GTR, complete radiological resection rates), and the immediate and definitive postoperative neurological complications. The mean duration of surgery was 6.3 h (median 7.05, range 3.8–7.9). The intraoperative seizure rate was 3.7% (range 1.4–6; I^2 = 0%, P heterogeneity = 0.569, standard error = 0.012, p = 0.002). The intraoperative complete resection rate at the time of first IoMRI was 35.2% (range 25.7–44.7; I^2 = 66.73%, P heterogeneity = 0.004, standard error = 0.048, p < 0.001). The rate of patients who underwent supplementary resection after one or several IoMRI was 46% (range 39.8–52.2; I^2 = 8.49%, P heterogeneity = 0.364, standard error = 0.032, p < 0.001). The GTR rate at discharge was 56.3% (range 47.5–65.1; I^2 = 60.19%, P heterogeneity = 0.01, standard error = 0.045, p < 0.001). The rate of immediate postoperative complications was 27.4% (range 15.2–39.6; I^2 = 92.62%, P heterogeneity < 0.001, standard error = 0.062, p < 0.001). The rate of permanent postoperative complications was 4.1% (range 1.3–6.9; I^2 = 38.52%, P heterogeneity = 0.123, standard error = 0.014, p = 0.004). Combined use of awake craniotomy and IoMRI can help in maximizing brain tumor resection in selected patients. The technical obstacles to doing so are not severe and can be managed by experienced neurosurgery and anesthesiology teams. The benefits of bringing these technologies to bear on patients with brain tumors in or near language areas are obvious. The lack of equipoise on this topic by experienced practitioners will make it difficult to do a prospective, randomized, clinical trial. In the opinion of the authors, such a trial would be unnecessary and would deprive some patients of the benefits of the best available methods for their tumor resections.

Fibre tract segmentation for intraoperative diffusion MRI in neurosurgical patients using tract-specific orientation atlas and tumour deformation modelling

“…In addition, tractography has poor reproducibility, with results depending on numerous factors [ 5 ]. All considered, it is perhaps unsurprising that there is hesitancy within the neurosurgical community to adopt intraoperative tractography [ 6 ], even as interest in intraoperative MRI [ 7 , 8 ] and tractography for surgical planning and navigation [ 9 , 10 ] grows. Currently intraoperative streamline tractography is mostly limited to the often outdated tools available in commercial navigation software [ 3 ].…”

Full-course resection control strategy in glioma surgery using both intraoperative ultrasound and intraoperative MRI

“…Scherer et al (7) and Ghinda et al (15) reported two large iMRI case series. Tuleeasca et al conducted a meta-analysis using the latest iMRI data (26). In the studies using iUS, Shetty et al (23) and Munkvold et al (24) recruited large, unselected cohorts of gliomas at neurological centers with extensive iUS experience.…”

“…The reduction of iMRI scans was due to fewer patients requiring further resections. Further resection was recorded in 17.5% of patients, compared to 46% in the previous iMRI case series (13)(14)(15)26). One iMRI scan session needs about 30-70 minutes when using the high field iMRI system (13)(14)(15)39).…”

“…This study suggested that combining iUS and iMRI might make the quality of resection control more stable during glioma surgery. There was a wide variation in the reported results of glioma surgeries in the literature, no matter whether iUS or iMRI was used (20,25,26) (30). Mostly, this variability was due to the heterogeneous nature of gliomas (20).…”

Advantages of Using 3D Intraoperative Ultrasound and Intraoperative MRI in Glioma Surgery

“…The authors did not give specific data about the number of iMRI scans. While In the reported iMRI case series, around 46% (26.1-52.2%) (14)(15)(16)23) patients needed multiple iMRI scans. Reducing the number of iMRI scans also might effectively decrease the complexity of the iMRi-assisted surgeries.…”