How Intraoperative MRI Is Transforming Neurosurgery

Atrium Health Carolinas Medical Center recently became the region’s first hospital to utilize intraoperative MRI (iMRI), enabling the neurosurgeons practicing here to capture valuable brain images during surgery. This technique is already improving how these surgeons adapt when the brain shifts during surgery, and it’s making surgery for deep-seated brain tumors and epilepsy even more precise. In turn, iMRI is improving patient outcomes and reducing the need for follow-up surgery.

“We look at every technology through a patient-focused lens so we can be sure it will make a difference in patients’ lives before we make the investment,” says Anthony Asher, MD, FAANS, FAACS, president of Atrium Health Neurosciences Institute. “With iMRI, we’re already seeing significant cost savings, along with a reduction in morbidity, and less surgical and anesthetic exposure.”

Using iMRI to Adapt to “Brain Shift”

The brain’s position can shift as much as a few centimeters as cerebrospinal fluid is released during surgery, rendering preoperative imaging of the location of tumors and other pathologies less accurate. iMRI solves this by letting Dr. Asher and his colleagues capture updated MRI images during surgery.

“iMRI enables us to see deep brain structures in the present state,” Dr. Asher notes. “Now we can be much more confident that we can accomplish our surgical objectives, even if the brain has shifted.”

This makes neurosurgery more accurate and reduces the chances that brain shift will force doctors to end a procedure, obtain another MRI and initiate a second procedure at a later date.

“It means patients are exposed to less anesthesia, spend less time in the hospital and have a lower risk of complications,” says Dr. Asher. “It also makes care more efficient and cost-effective – it’s a win-win.”

Improving Surgery for Skull Base Tumors

Gliomas and other skull-based tumors can be deep-seated and hard to differentiate from normal brain tissue.

“We need almost perfect spatial accuracy to completely and safely remove deep tumors, especially when they’re adjacent to eloquent structures,” Dr. Asher says.

iMRI helps achieve this by allowing neurosurgeons to confirm a tumor’s position and, later, determine whether they’ve removed all cancerous tissue.

“Sometimes our eyes can’t perceive a certain portion of a deeply-seated brain tumor, even with assistance from a high-powered surgical microscope,” Dr. Asher explains. “iMRI enables us to take another image of the brain after initial exposure and determine the relationship of any residual tumor to areas we have already operated in. This helps us ensure that we’ve removed as much of the tumor as possible, as safely as possible, and to continue surgery if needed.”

At Atrium Health Neurosciences Institute, Dr. Asher and his colleagues also use iMRI in conjunction with other imaging modalities that identify the relationship between abnormal tissues and essential brain structures such as blood vessels or motor pathways. These other modalities include MR angiography and Diffusor Tensor Imaging (otherwise known as Brain Fiber Tracking).

“If we overlay the different modalities, we can understand where the tumors are in relation to essential brain connections and protect those connections as much as possible,” he says.

Making Epilepsy Surgery More Precise

Atrium Health Neurosciences Institute utilizes the latest tools and technologies – including functional MRI, stereo EEG, brain mapping and WADA testing – to pinpoint where seizures originate. During surgery, iMRI enables Dr. Asher and his colleagues to confirm the location they’re targeting and to determine whether they’ve removed the appropriate volume of tissue before ending a surgery.

“It’s a tremendous advantage to be able to see where we are making lesions and removing tissue to treat epilepsy with millimeter accuracy, in real time,” notes Dr. Asher, “and it’s just one example of how many areas of functional brain surgery will be significantly transformed by iMRI.”

Using a Team Approach to Decide When iMRI Is Appropriate

Before launching iMRI, Carolinas Medical Center and the neurosurgeons performing surgeries at Atrium Health Neurosciences Institute designed and adopted extensive safety protocols. For example, they had to determine how to segregate MRI from the rest of the operating room, and the team had to train in activities such as how to support the patient while they’re getting an MRI under anesthesia.

Dr. Asher and his colleagues also integrated iMRI into their collaborative, multidisciplinary decision-making process. Nearly every brain tumor case, for example, is reviewed and evaluated by a team that includes experts in pathology, radiology, radiation oncology, medical oncology, surgery, neurophysiology and psychology.

“We all work together to come to a consensus about the best treatment pathway for each individual patient,” Dr. Asher says.

As part of that team evaluation, Dr. Asher and other team members weigh whether iMRI is appropriate.

“We make a determination about whether iMRI is warranted based on everyone’s knowledge of the pathology, the location and what we want to affect,” he explains. “It isn’t just the surgeons determining whether iMRI is the right choice for a particular patient, it’s an entire group. That improves the appropriateness of care, it increases our ability to make the best treatment decisions and it ensures we can deliver the best possible outcomes.”

To learn more about our iMRI technology and/or to refer your patients, watch our iMRI video on YouTube and contact Anthony Asher, MD, president of Atrium Health Neurosciences Institute at NeuroscienceInstitute@AtriumHealth.org