Analogous Three-Dimensional Constructive Interference in Steady State Sequences Enhance the Utility of Three-Dimensional Time of Flight Magnetic Resonance Angiography in Delineating Lenticulostriate Arteries in Insular Gliomas: Evidence from a Prospective Clinicoradiologic Analysis of 48 Patients

Abstract

Three-dimensional (3D) time of flight (TOF) imaging is the current gold standard for noninvasive, preoperative localization of lenticulostriate arteries (LSAs) in insular gliomas; however, the utility of this modality depends on tumor intensity. Over a 3-year period, 48 consecutive patients with insular gliomas were prospectively evaluated. Location of LSAs and their relationship with the tumor were determined using a combination of contrast-enhanced coronal 3D TOF magnetic resonance angiography and coronal 3D constructive interference in steady state (CISS) sequences. These findings were analyzed with respect to extent of tumor resection and early postoperative motor outcome. Tumor was clearly visualized in 29 (60.4%) patients with T1-hypointense tumors using 3D TOF and in all patients using CISS sequences. Using combined 3D TOF and CISS, LSA-tumor interface was well seen in 47 patients, including all patients with T1-heterointense or T1-isointense tumors. Extent of resection was higher in the LSA-pushed group compared with the LSA-encased group. In the LSA-encased group, 6 (12.5%) patients developed postoperative hemiparesis; 2 (4.2%) cases were attributed to LSA injury. Contrast-enhanced 3D TOF can delineate LSAs in almost all insular gliomas but is limited in identifying the LSA-tumor interface. This limitation can be overcome by addition of analogous CISS sequences that delineate the LSA-tumor interface regardless of tumor intensity. Combined 3D TOF and 3D CISS is a useful tool for surgical planning and safer resections of insular tumors and may have added surgical relevance when included as an intraoperative adjunct.