Glioma resection in a shared-resource magnetic resonance operating room after optimal image-guided frameless stereotactic resection

OBJECTIVE: We describe a shared-resource intraoperative magnetic resonance imaging (MRI) design that allocates time for both surgical procedures and routine diagnostic imaging. We investigated the safety and efficacy of this design as applied to the detection of residual glioma immediately after an optimal image-guided frameless stereotactic resection (IGFSR). METHODS: Based on the twin operating rooms (ORs) concept, we installed a commercially available Hitachi AIRIS II, 0.3-tesla, vertical field, open MRI unit in its own specially designed OR (designated the magnetic resonance OR) immediately adjacent to a conventional neurosurgical OR. Between May 1998 and October 1999, this facility was used for both routine diagnostic imaging (969 diagnostic scans) and surgical procedures (50 craniotomies for tumor resection, 27 transsphenoidal explorations, and 5 biopsies). Our study group, from which prospective data were collected, consisted of 40 of these patients who had glioma (World Health Organization Grades II-IV). These 40 patients first underwent optimal IGFSRs in the adjacent conventional OR, where resection continued until the surgeon believed that all of the accessible tumor had been removed. Patients were then transferred to the magnetic resonance OR to check the completeness of the resection. If accessible residual tumor was observed, then a biopsy and an additional resection were performed. To validate intraoperative MRI findings, early postoperative MRI using a 1.5-tesla magnet was performed. RESULTS: Intraoperative images that were suitable for interpretation were obtained for all 40 patients after optimal IGFSRs. In 19 patients (47%), intraoperative MRI studies confirmed that adequate resection had been achieved after IGFSR alone. Intraoperative MRI studies showed accessible residual tumors in the remaining 21 patients (53%), all of whom underwent additional resections. Early postoperative MRI studies were obtained in 39 patients, confirming that the desired final extent of resection had been achieved in all of these patients. One patient developed a superficial wound infection, and no hazardous equipment or instrumentation problems occurred. CONCLUSION: Use of an intraoperative MRI facility that permits both diagnostic imaging and surgical procedures is safe and may represent a more cost-effective approach than dedicated intraoperative units for some hospital centers. Although we clearly demonstrate an improvement in volumetric glioma resection as compared with IGFSR alone, further study is required to determine the impact of this approach on patient survival.