Artikel
Intraoperative MRI-guidance in pediatric low grade glioma surgery – Advantages and challenges
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Veröffentlicht: | 13. Mai 2014 |
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Gliederung
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Objective: A unique feature of pediatric low-grade glioma (LGG) surgery is, that complete tumor resection carries a high likelihood of permanent cure. While advantages of intraoperative MRI guidance in the surgical therapy of gliomas are well described for adults, only scarce evidence is available on the value of this technology in pediatric patients.
Method: 1.5T iMRI-guided operations of children and adolescents with LGGs were analyzed retrospectively. Main parameters included feasibility, extent of resection, histology, perioperative data, clinical outcome, as well postoperative blood analysis to identify possible systemic harm of extended surgery time and repeat contrast medium application.
Results: 25 pediatric patients (mean 11.7 y (2–17)) underwent iMRI-guided resection of 9 gangliogliomas, 7 pilocytic astrocytomas, 4 astrocytoma WHO°II, 3 DNET, 1 oligodendroglioma WHO°II, and 1 cortical dysplasia. Quality of 1.5T standard and functional intraoperative MR imaging with closed and open skull had full diagnostic quality in all cases. Resection was continued due to intraoperative residual tumor findings 56% of the cases. Electrophysiological changes demanding termination of resections was always given priority over tumor residual in imaging. In 15 of 17 cases (88%) with intended total resections no residual tumor was found in the diagnostic imaging 3 months postoperatively. No postoperative neurological deficits at discharge were found in 12, mild ones in 11 and severe in 2 patients. Positioning of the children was easily possible in supine, prone and lateral position. The integration of IOM, neuronavigation, endoscopy and ultrasound was uncomplicated. Postoperative blood-analysis revealed no systemic changes caused by extended surgery times (mean 418 (201–610) minutes) or repeat contrast medium application. Two patients had skin decubitus, no ferromagnetic incidents and no postoperative infections were noticed.
Conclusions: iMRI-guided glioma surgery in pediatric patients is safe and effective to increase the rate of intended total resections in LGGs with diffuse tumor margins close to 90%. Due to the easy integration of all supportive surgical tools and high flexibility in positioning of patients, surgeons do not suffer drawbacks compared to conventional operations. Acquisition of preoperative planning as well as postoperative MRI within the same session eliminates the usual need for additional anesthesia to perform these examinations pre- and postoperatively in small children.