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Intraoperative MRI: a Moving Magnet

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Intraoperative MRI: a Moving Magnet Nov. 16, 1999 CMAJ Specialty Spotlight Table of Contents Neurosurgery Intraoperative MRI: a moving magnet Garnette R. Sutherland, MD; Deon F. Louw, MD Technology: Intraoperative MRI Use: This mobile, 1.5 Tesla MRI system is placed into a stan- dard neurosurgical operating room. It is used to plan accurate surgical corridors, confirm the accomplishment of operative objectives and detect acute complications such as hemorrhage and ischemia. History: Lesion localization is paramount for safe neuro- surgery. Until the late 19th century phrenologic considera- tions dictated drill sites for cranial trephinations. In 1861 Paul Broca1 studied stroke patients and nurtured the concept of cortical compartmentation of function. Presumptive clinical localization, however, required imaging confirmation, the first Ceiling-mounted mobile 1.5 Tesla MRI magnet being moved of which was pneumoencephalography. Walter Dandy into position. serendipitously discovered this in the early part of this century. A leak of cerebrospinal fluid (CSF) accompanying a skull frac- intraoperative magnet is the risk of entraining ferric objects at ture allowed entrainment of air into the patient’s ventricular high speed into its bore, with serious consequences to the pa- system, which was clearly outlined on the skull radiograph. tient. Although not necessarily a problem, the use of intraop- Egas Moniz perfected cerebral angiography shortly there- erative MRI requires a collaboration between physicists, after. However, it was the inventions of CT and MRI scan- image-processing scientists, MRI technicians, neuroradiolo- ning that heralded the modern era of neurosurgery. gists, neurosurgeons and other OR personnel. Promise: MRI scanners generate exquisitely detailed images of Prospects: The future of intraoperative MRI is exciting. brain and spinal cord anatomy and pathology. Moreover, they Through pilot studies, functional MRI has been shown to en- are multiplanar and radiation free and have a greater sensitivity able the mapping of brain anatomy in the pre-, intra- and and specificity than either CT or ultrasonography. Although postoperative phases. Placement of a radiofrequency coil di- an engineering challenge, the placement of MRI systems in rectly on the brain may generate more accurate images than the operating room will revolutionize neurosurgical care.2–5 are available with conventional techniques. Magnetic reso- This technology enables neurosurgeons to improve the accu- nance spectroscopy and angiography will also greatly increase racy of craniotomy placement and to reduce the size of bone the understanding of neuropathology, while enhancing opera- flaps. The result is minimalist surgery and maximum technical tive outcomes. We believe that within a decade intraoperative outcome. Surgical navigation can be repeatedly updated by in- MRI will become the standard of care in neurosurgery. traoperative images that detect brain shift resulting from CSF leakage. In contrast, navigation systems currently rely on Competing interests: Dr. Sutherland received travel assistance from an MRI manufacturer to attend meetings. archived images only. Intraoperative MRI has also identified a significant number of patients who harboured unsuspected, References residual tumour at the end of surgery, thus sparing them the 1. Broca P: Nouvelle observation d’aphemie produite par une lésion de la moitic postérieure des deuxième et troisième circonvolutions frotales gauches. Bull discomfort and expense of reoperation. It is also reassuring to Soc Anat Paris 1861;6:398-407. perform MRI before wound closure to rule out hematoma, es- 2. Black PM, Moriarty T, Alexander E III, Steig P, Woodard EJ, Gleason PL, et pecially in patients with arteriovenous malformations. al. Development and implementation of intraoperative magnetic resonance imaging and its neurosurgical applications. Neurosurgery 1997;41:831-42. Problems: Intraoperative MRI technology is expensive. A sin- 3. Steinmeier R, Fahlbusch R, Ganslandt O, Nimsky C, Buchfelder M, Kaus M, gle system costs $2–3 million. However, using the equipment et al. Intraoperative magnetic resonance imaging with the magnetom open scanner: concepts, neurosurgical indications, and procedures: a preliminary for conventional diagnostic imaging when it is not required in report. Neurosurgery 1998;43:739-48. the operating room can largely offset this cost. The mobile, 4. Hall WA, Martin AJ, Jiu H, Nussbaum ES, Maxwell RE, Truwit CL: Brain biopsy using high-field strength interventional magnetic resonance imaging. ceiling-mounted design is ideal for this purpose, because it Neurosurgery 1999;44:807-14. permits the magnet to move from the operating room to an 5. Sutherland GR, Kaibara T, Kouw D, Hoult DI, Tomanek B, Saunders J: A mobile high-field magnetic resonance system for neurosurgery. J Neurosurg adjacent radiology suite. Older systems had wide magnetic 1999;91:804-13. fields, necessitating the acquisition of MRI-compatible micro- scopes and drills at a substantial cost. The new mobile mag- The authors are with the Department of Clinical Neuro- net, however, is self-shielded. An important concern with an sciences, University of Calgary, Calgary, Alta. CMAJ • NOV. 16, 1999; 161 (10) 1293 © 1999 Canadian Medical Association or its licensors.
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