Intraoperative Magnetic Resonance Imaging–Guided Glioma Resections in Awake or Asleep Settings and Feasibility in the Context of a Public Health System

Abstract

Background Despite the most recent surgical aids and tools, surgical removal of infiltrating brain tumors remains a challenge. Unclear margins, edematous areas, and infiltrative behavior are the main causes for failing gross total removals. Also, excessive resection of peri-tumoral tissue often carries risks of damaging the nearby functioning cortical and subcortical structures with an unacceptable decrease in patient's quality of life and postoperative functional status, and the risk of making patients not eligible to adjuvant treatments. Awake surgery and intraoperative magnetic resonance imaging (ioMRI) are among the most effective aids in preventing damage to functional brain while maximizing the extent of resection. Methods We present our series of 46 patients operated on at Southmead Hospital (North Bristol NHS Trust) in between July 2014 and February 2017 using ioMRI plus or minus awake surgery. Setting, patient features, indications, type and size of tumors, surgical times, extent of resection, morbidity, and survival are analyzed and discussed. Results Overall, ioMRI check led to a +43% resections in Group 1 and +58% in Group 2. In grade 2 tumors, GTR was 46% in Group 1 and 55% in Group 2 (41% in control group). In grade 3 tumors, GTR was 57% in Group 1 and 66% in Group 2 (30% in control group). In Grade 4 tumors, GTR was 63% in Group 1, 66% in Group 2 (36% in control group). In terms of theatre occupation, the use of ioMRI added 1/2 operative session; the addition of awake surgery implied the use of another 1/2 operative session. Morbidity did not differ among the groups, with low incidence of permanent post-operative deficits (<5%). Group 2 OS was statistically longer when compared to the control group. Conclusions Using ioMRI together with awake surgery is demanding for the anesthetic team, staff nurses, and for the patient. Nevertheless, low morbidity, greater total resections rates, and longer survival suggest its use is effective in making more approachable gliomas of all grades that we would consider “complex” due to their intrinsic features or locations.

Impact of awake mapping on overall survival and extent of resection in patients with adult diffuse gliomas within or near eloquent areas: a retrospective propensity score-matched analysis of awake craniotomy vs. general anesthesia

“…Although there is little objection that AC is superior to general anesthesia (GA) for functional preservation, its ability to improve the EOR is controversial. [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] One reason making such validation di cult is that many studies have not evaluated the OS, despite the proven strong correlation between EOR and OS, owing to the di culty of adjusting the bias induced by the eloquent areas. The lack of an objective de nition of eloquent areas on the image is a factor, but the most critical one is the selection bias of patients who underwent surgery performed under GA despite eloquent lesions.…”

Awake craniotomy for resection of supratentorial glioblastoma: a systematic review and meta-analysis

“…The study by Gerritsen et al was also the only one to find a lower rate of late minor postoperative complications with AC than craniotomy under GA. Survival outcome was similar between AC and craniotomy under GA in the studies by Gerritsen et al 33 and Gravesteijn et al, 36 but higher for the AC group in Pichierri et al 35 (4 out of 6 patients alive at an average of 25 months’ follow-up for the AC group vs 1 out of 8 patients alive at 26 months in the GA group). Notably, both groups in the study by Pichierri et al also had iMRI used.…”

“…PFS and OS were reported in 5 studies, but the reported data were insufficient or too heterogenous to compute pooled mean estimates. Pichierri et al 35 reported an average PFS of 21 months in 6 GBM patients. Among these 6 patients, all 4 patients who underwent GTR had OS of more than 25 months, while the 2 patients who underwent STR died at 12 and 30 months.…”

Cost-Effectiveness of Low-Field Intraoperative Magnetic Resonance in Glioma Surgery

“…Our PFS is superior to this figure in both cohorts probably due to the coexistence of HGG and LGG in each group. Previous reports evaluating the effectiveness of iMR devices failed to demonstrate significant changes on PFS (36). However, positive trends on the improvement of PFS had been linked to the use of intraoperative imaging tools (10,36,37) as a result of an increase in the EoR (35,38,39).…”