Functional neuronavigation—risk grading for surgery in close proximity to eloquent motor cortex

Abstract

BACKGROUNDTumor removal, brain swelling, the use of brain retractors, and cerebrospinal-fluid drainage all result in an intraoperative brain deformation that is known as brain shift. Thus, neuronavigation systems relying on preoperative image data have a decreasing accuracy during the surgical procedure. Intraoperative image data represent the correct anatomic situation, so their use may compensate for the effects of brain shift.METHODSIn a series of 16 brain tumor patients, we used intraoperative magnetic resonance (MR) imaging to obtain 3-D data, which were then transferred to the microscope-based neuronavigation system. With the help of bone fiducial markers these images were registered intraoperatively, updating the neuronavigation system.RESULTSIn all patients the updating of the neuronavigation system with the intraoperative MR data was successful. It led to reliable neuronavigation with high accuracy; the mean registration error of the update procedure in all patients was 1.1 mm. The updating procedure added about 15 minutes to the operation time. In all patients the area suggestive of remaining tumor was reached and the additional tumor could be resected, resulting in a complete tumor removal in 14 patients. In the remaining patients extension of the tumor into eloquent brain areas prevented a complete excision.CONCLUSIONSThe update of a neuronavigation system with intraoperative MR images reliably compensates for the effects of brain shift. This method allows completion of tumor removal in some difficult brain tumors.