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Intraoperative MRI with a Rotating, Tiltable Surgical Table: A Time–Use Study and Clinical Results in 122 Patients

¹ Department of Radiology, University Hospitals of Cleveland/Case Western Reserve University, Cleveland, OH 44106.
² Present address: Department of Radiology, Johns Hopkins University, Outpatient Center, 601 N Caroline St., Rm. 4210, Baltimore, MD 21287.
³ Department of Neurosurgery, University Hospitals of Cleveland/Case Western Reserve University, Cleveland, OH.
⁴ Present address: New Mexico Neurosurgery, Albuquerque, NM.
⁵ Siemens Medical Engineering Group, Erlangen, Germany.

View larger version (44K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Schematic drawing of floor plan shows location of MRI-equipped operating room among standard surgical suites.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Overview of setup of operating room equipped with open low-field MRI unit. Photographs show prototype surgical table that permits wide range of spatial freedom. Table can be rotated back and forth between imaging (A) and operating (B) positions. It also allows height adjustment and tilting to both Trendelenburg and reverse Trendelenburg positions. Color codes are marked on floor to define different zones of fringe field strength. Arrow in A indicates in-room LCD monitor that allows tableside imager control and image viewing.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Overview of setup of operating room equipped with open low-field MRI unit. Photographs show prototype surgical table that permits wide range of spatial freedom. Table can be rotated back and forth between imaging (A) and operating (B) positions. It also allows height adjustment and tilting to both Trendelenburg and reverse Trendelenburg positions. Color codes are marked on floor to define different zones of fringe field strength. Arrow in A indicates in-room LCD monitor that allows tableside imager control and image viewing.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —Overview of setup of operating room equipped with open low-field MRI unit. Photograph shows MR–surgical table has been rotated to bring patient's head in operating position where surgeons can implement their conventional surgical approaches. Standard operating microscopes, electrocautery instruments, and fiberoptic headlamps were used.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —Overview of setup of operating room equipped with open low-field MRI unit. Photograph shows patient repositioned into scanner for intraoperative imaging. Any MR-incompatible instruments are removed from surgical field. Prototype sterilizable solenoidal coil with surgical pin head fixation (Heidelberg Neurosurgical Research Group) is placed around patient's head, and table is moved into draped scanner for imaging. Time necessary to position patient's head at magnet isocenter and tune system ranges from 30 to 90 seconds.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Gadolinium-enhanced 2D FLASH images (TR/TE, 418/9; flip angle, 90°; number of signals averaged, 2; acquisition time, 3 minutes 36 seconds) in 60-year-old woman with glioblastoma multiforme. Coronal (A) and axial (B) images obtained during resection of right frontal lobe glioblastoma multiforme. Area of focal nodular enhancement (arrow, A) is noted at base of resection bed that is consistent with incomplete tumor resection. Contrast level (arrow, B) within operative bed denotes blood pooling within area of resection.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Gadolinium-enhanced 2D FLASH images (TR/TE, 418/9; flip angle, 90°; number of signals averaged, 2; acquisition time, 3 minutes 36 seconds) in 60-year-old woman with glioblastoma multiforme. Coronal (A) and axial (B) images obtained during resection of right frontal lobe glioblastoma multiforme. Area of focal nodular enhancement (arrow, A) is noted at base of resection bed that is consistent with incomplete tumor resection. Contrast level (arrow, B) within operative bed denotes blood pooling within area of resection.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Gadolinium-enhanced 2D FLASH images (flip angle, 90°; number of signals averaged, 2) in 71-year-old woman during resection of temporal lobe glioblastoma. Axial (A) (TR/TE, 418/9; acquisition time, 3 minutes 36 seconds) and coronal (B) (330/9; acquisition time, 2 minutes 30 seconds) images obtained after craniotomy show faintly enhancing partially ill-defined lesion (arrowheads) involving left-sided mesial temporal lobe and extending superiorly into inferior aspect of ipsilateral lentiform nucleus. Adjacent edema is responsible for mass effect exerted on left lateral ventricle, sylvian fissure, and overlying cortical sulci.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Gadolinium-enhanced 2D FLASH images (flip angle, 90°; number of signals averaged, 2) in 71-year-old woman during resection of temporal lobe glioblastoma. Axial (A) (TR/TE, 418/9; acquisition time, 3 minutes 36 seconds) and coronal (B) (330/9; acquisition time, 2 minutes 30 seconds) images obtained after craniotomy show faintly enhancing partially ill-defined lesion (arrowheads) involving left-sided mesial temporal lobe and extending superiorly into inferior aspect of ipsilateral lentiform nucleus. Adjacent edema is responsible for mass effect exerted on left lateral ventricle, sylvian fissure, and overlying cortical sulci.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —Gadolinium-enhanced 2D FLASH images (flip angle, 90°; number of signals averaged, 2) in 71-year-old woman during resection of temporal lobe glioblastoma. Axial (C) (418/9; acquisition time, 3 minutes 36 seconds) and coronal (B) (330/9; acquisition time, 2 minutes 30 seconds) images obtained after resection show minimal residual enhancement along deep aspect of resection bed and small nodule (arrows) medially, denoting residual neoplastic tissue. Further resection was subsequently performed based on these intraoperative imaging findings.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —Gadolinium-enhanced 2D FLASH images (flip angle, 90°; number of signals averaged, 2) in 71-year-old woman during resection of temporal lobe glioblastoma. Axial (C) (418/9; acquisition time, 3 minutes 36 seconds) and coronal (B) (330/9; acquisition time, 2 minutes 30 seconds) images obtained after resection show minimal residual enhancement along deep aspect of resection bed and small nodule (arrows) medially, denoting residual neoplastic tissue. Further resection was subsequently performed based on these intraoperative imaging findings.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Axial gadolinium-enhanced 2D FLASH images (TR/TE, 418/9; flip angle, 90°; number of signals averaged, 2; acquisition time, 3 minutes 36 seconds) obtained during resection of glioblastoma multiforme in 66-year-old woman. Image obtained after patient has undergone left craniotomy shows complex cystic neoplastic lesion with predominant marginal enhancement involving left temporal lobe and left operculum.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Axial gadolinium-enhanced 2D FLASH images (TR/TE, 418/9; flip angle, 90°; number of signals averaged, 2; acquisition time, 3 minutes 36 seconds) obtained during resection of glioblastoma multiforme in 66-year-old woman. Image obtained after resection at location corresponding to A shows complete resection of enhancing component of glioblastoma multiforme. Intraoperative edema has caused effacement of left lateral ventricle and basilar cisterns.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Coronal gadolinium-enhanced 2D FLASH images (TR/TE, 418/9; flip angle, 90°; number of signals averaged, 2; acquisition time, 3 minutes 36 seconds) in 39-year-old man with left frontal gemistocytic anaplastic astrocytoma (World Health Organization grade II). Image shows left frontoparietal craniotomy exposing partially cystic, partially solid neoplastic mass that involves underlying left frontoparietal lobe and extends deeply to involve body of corpus callosum. Vasogenic edema is seen compressing left lateral ventricle and effacing ipsilateral cortical sulci and sylvian fissure.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Coronal gadolinium-enhanced 2D FLASH images (TR/TE, 418/9; flip angle, 90°; number of signals averaged, 2; acquisition time, 3 minutes 36 seconds) in 39-year-old man with left frontal gemistocytic anaplastic astrocytoma (World Health Organization grade II). Image obtained intraoperatively after tumor resection shows residual rind of enhancement (arrowheads) surrounding margins of resection bed, reflecting incomplete tumor resection.

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