week 3. neurosurgical planning with multimodal imaging
TRANSCRIPT
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Multimodal imaging in neurosurgical planning
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• Requirements of modern neurosurgery– Maximum removal while preserving neurological function– Precise spatial visualization, localization– Information beyond structure: blood supply, function– Neuronavigation and „augmented reality”
Introduction
Neuronavigation and „augmented reality
Trepanatio
Modern? NeurosurgeryModern? Neurosurgery
Modern neurosurgery
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• Most common indications• Tumors
– MeningeomaMetastasis
The main indications of neurosurgery and planning
– Metastasis– Glioma (low-grade, high-grade), PCBL– Pediatric tumors (medulloblastoma, PNET)
• AVM• Cortical dysplasia, degeneratio• Epilepsy surgery
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• Location of craniotomy?• Tumor localization, cortical eloquent areas• Vessels structure• Eloquent areas
What clinicians should ask
• Eloquent areas– White matter fibers– Functional domains
• Function laterality (speech, movement)• Tumor characterization• Post operative imaging + controll
MultimodalMultimodal imagingimaging forfor neurosurgeryneurosurgery
Anatomy
Tumor localization
Vessels
El t t t
Conventional MRI (Gd!)
DTI, Eloquent tracts
Function, laterality
Tumor metabolism
Stereotacticplanning
Localization
tractography
fMRI
PET, MR spectroscopy
CT
Neuronavigation systems
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Multimodal– Parallel / fused display of different imaging
modalities– Their benefits multiply
IntroductionBasics of multimodal imaging
– New information– Image processing
• Spatial alignment• Standard space• Normalization
10• Conventional MRI sequences to display anatomy:• T1-weighted / post-Gd (vessels) or TOF time of flight• T2-weighted / flair• Segmentation of cortical structure, vasculature• Segmentation of lesion / tumor
MRI sequences
• Segmentation of markers
11• Skin, muscles, skin markers for neurosurgery
Information fromconventional MR images 12
• Vessels: (1) Contrast MRI (2) TOF
Information fromconventional MR images
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13• Cortex• tumor
Information fromconventional MR images 14 Diffusion information:
DTI and fibertracking
• Displaying white matter tracts• Tumor adjacent tracts• Diffusion mapping• Characterizing pathologies
15• Térbeli illesztés, regisztráció• Tenzorterek regisztrációja a strukturális felvételekhez (CT,MRI)
Diffusion information:DTI and fibertracking
–
• Eredmény: kevesebb torzítás, pontosabb térbeli leképzés, koordináta
rendszer.
16• Fibertracking: the method to display brain
tracts in vivo by MRI• Representation: line / tubes / probabilities
Diffusion information:DTI and fibertracking
17• Segmenting and localizing main structures of the WM (pl. tr. cortico-
spinalis, FLS, cc)
Diffusion information:DTI and fibertracking 18 Diffusion information:
DTI and fibertracking
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19• DTI acquisitions are distorted• DTI has to be aligned with the T1-weighted brain image
Diffusion information:DTI and fibertracking
• .
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40 BevezetésA multimodális képalkotás alapjai
41 BevezetésA multimodális képalkotás alapjai 42 Bevezetés
A multimodális képalkotás alapjai
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43 BevezetésA multimodális képalkotás alapjai 44 Bevezetés
A multimodális képalkotás alapjai
45 BevezetésA multimodális képalkotás alapjai 46 Bevezetés
A multimodális képalkotás alapjai
47 BevezetésA multimodális képalkotás alapjai 48 Bevezetés
A multimodális képalkotás alapjai
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49 BevezetésA multimodális képalkotás alapjai 50 Bevezetés
A multimodális képalkotás alapjai
51 Functional MRISecond step: the actual fMRI acquisition
T2*-weighted images• Image contrast relates to neuronal activity• Low spatial resolution (3x3x5 mm)• One volume of the brain is acquired in 2 seconds!• We acquire many volumes in time (4D), ie. 150• Repeated scanning
first volume(2 sec to acquire)
…
Paradigm and block design~2 sec
Functional images
Time
fMRIsignal(% change
ROI Time Course
Tasks
Statisticalactivation map on T1 image
Time
~ 5 minutesRegion of interest kijelölés (ROI)
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• fMRI also distorts, image alignment necessary– To patients anatomical (T1) images– To standard neuroimaging spaces / atlases:– Talairach atlas /MNI atlas
fMRI
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Right hand activation (finger-tapping test)
Forrás: Katona P., DEOEC
Lesion in left precentral gyrus. Question: CST?
Forrás: Katona P., Jakab A. DEOEC
Summary – multimodality inneurosurgery
• Locate anatomy• Locate vessels• Locate eloquent (neighbouring) areas
L t hit tt t t• Locate white matter tracts• Locate functional domains
• Plan treatment
Case 1Case 1.
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Focal cortical dysplasias•Cortical dysplasia is a congenital abnormality where the neurons in an area of the brain failed to migrate in the proper formation in utero. •Occasionally neuronswill develop that are larger than normal in certain areas. •This causes the signals sent through the neurons in these areas to misfire, which sends an incorrect signal. It is commonly found near the cerebral cortex and is associated with seizures.•Cortical dysplasia is estimated to be present in 1 in 2,500 newborns, making it one of the most common cortical malformations.
Dysplasia - Dysgenesis
• Greenfield’s Neuropathology – Dysplasia of cerebral cortex– Agyria
Pachygiria– Pachygiria– Polymicrogyria– Heterotopia– Focal cortical dysplasia (FCD)
• Neuronal migration disorder
J Neurol Neurosurg Psychiatry. 1971 August; 34(4): 369–387. Palmini A, Najm I, Avanzini G, et al. Terminology and classification of the cortical dysplasias. Neurology 2004;62(6 suppl 3):S2–S8.
Abnormal proliferationFocal cortical dysplasia FCD Type I
• Abnormal cells anywhere from the ventricular wall to the cortex
• Broadened gyrus, slightly irregular sulcus• Non enhancingNon enhancing• Adjacent cortex slightly thickened• Temporal localisation is common• Marked by slightly broadened sulcus• Hasznos a kontrollok során a fokozott figyelem,
mert a korral egyértelmübbé válhat
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67 Case 1.
Infant, generalized epileptic seizures. CT negative. Background: focalcortical dysplasia
68 Case 1.
Case 2Case 2.
Pontine gliomas•Brain stem tumors account for 10 percent of pediatric brain tumors. The peak incidence is between ages 5 and 10.
Pontine Gliomas - The patients' symptoms often improve dramatically during or after six weeks of irradiation. Unfortunately, problems usually recur after six to nine months, and progress rapidly. Survival past 12 to 14 months is uncommon, and new approaches to treating these tumors are urgently needed.Midbrain/Medullary Gliomas - With the use of radiation therapy, these patients often to well. Long-term survival ranges from 65 to 90 percent for brain stem tumors that arise from the midbrain or medulla.
Case 2.
3 yr, F, ICP signs, cerebellum – tonsillar herniation
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Jobb oldali nézetJobb oldali nézet
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Elülső nézet
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felülnézet
Baljobb
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Hátsó nézet a IV. agykamra felől
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Case 3.Case 3.
Glioblastoma multiforme•Glioblastoma multiforme (GBM) is the most common and most aggressive malignant primary brain tumor in humans, involving glial cells and accounting for 52% of all functional tissue brain tumor cases and 20% of all intracranial tumors. Despite being the most prevalent form of primary brain tumor, GBM incidence is only 2–3 cases per 100,000 , y p ,people in Europe and North America. According to the WHO classification of the tumors of the central nervous system, the standard name for this brain tumor is "glioblastoma"; it presents two variants: giant cell glioblastoma and gliosarcoma.•Treatment can involve chemotherapy, radiation, radiosurgery, corticosteroids, antiangiogenic therapy, surgery[1] and experimental approaches such as gene transfer.[2]
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Case 4Case 4.
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Case 5Case 5.
Low grade gliomasGliomas are named according to the specific type of cell they share histologicalfeatures with, but not necessarily originate from. The main types of gliomas are:Ependymomas — ependymal cells.Astrocytomas — astrocytes (glioblastoma multiforme is the most commonastrocytoma).Oligodendrogliomas — oligodendrocytes.Mixed gliomas, such as oligoastrocytomas, contain cells from different types of g , g y , ypglia.
Gliomas are further categorized according to their grade, which is determined by pathologic evaluation of the tumor.
Low-grade gliomas [WHO grade II] are well-differentiated (not anaplastic); these are not benign but still portend a better prognosis for the patient.High-grade [WHO grade III-IV] gliomas are undifferentiated or anaplastic; these are malignant and carry a worse prognosis.
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VISUALIZATION OF STRUCTURE
Recidive tumor, 2 foci, purple and magenta
Markers on the skin
removed temporal lobe parts
VISUALIZATION OF FIBERS
OPTIC RADIATION
CORTICOSPINAL TRACT
Case 6Case 6.
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AVMs•Arteriovenous malformation or AVM is an abnormal connection between veins and arteries, usually congenital. This pathology is widely known because of its occurrence in the central nervous system, but can appear in any location. An arteriovenousmalformation is a vascular anomaly. It is a RASopathy. The Spetzler-Martin grading system developed at the Barrow Neurological Institute is utilized by neurosurgeons to determine operative versus nonoperative management when approaching these lesions.
Diagnosis by angiography
Diagnosis by angiography Diagnosis by MRI (T1 and T2-w)
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Case 7. – large GBMT d b lkiTreatment: debulking
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C11 methionine – MRI – DTI fusions
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PET imaging
• fdsfsd
PET imaging
• FDG: F-18 fluorodeoxyglucose positronemission tomography (FDG-PET)– Glucose metabolism, perfusion
Necrosis: no FDG– Necrosis: no FDG
• C11 – methionine– Membrane turnover– Cellular metabolism, tumor activity
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FDG – MRI – DTI fusions
215 Stereotaxic neurosurgery 216
• Modalities:– CT: 1x1x1 mm voxel size with FRAME– MRI:
• 3DT1 (anatomy, vessels)
Planning for Gamma Knife
• T2 (pathology, oedema, tumor etc.)• FIESTA: acoustic neurinomas
– DTI– Multimodal image fusions for planning
DE OEC Gamma Radiosurgery Centre
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Műtéti tervezés
Jelszó: multimodalitás!Sztereotaxia / sugársebészet (gammakés)
Anatómiai kép: 3DT1, de CT, mint koordináta rendszer és geometriai referenciag3DT1 MR – CTMRI – DTICT – DTI / PET / fMRI
CT – 3DT1 MR regisztráció (gammakés)
- Automatic (maximalisation relative entropy)- Manual correction (with internal „landmarks”)To this time, manual correction was necessary in 60% of
the cases- Optimalised automatic registration
CT és T2-súlyozott MR fúziója
0,7x0,7x0,7 mm40-60 slices4 mins
CT - TOF1,2x1,2x1,2 mm190 slices6 minsContrast agent
Képregisztrációk (gammakés)
T1-CT Fiesta-CT TOF-CT2008: approx. 50 patients
Képregisztrációk
(3DT1 + DTI)
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Képregisztrációk (CT + DTI)
CT + ADC map CT + colorized FA map
Case 8Case 8.
Acoustic neurinomas•A vestibular schwannoma, often called an acoustic neuroma,[1] is a benign primary intracranial tumor of the myelin-forming cells of the vestibulocochlearnerve(CN VIII).[2] The term "vestibular schwannoma" involves the vestibular portion of the 8th cranial nerve[3] and arises from Schwann cells, which are responsible for themyelin sheath in the peripheral nervous system. Approximately 3,000 cases are diagnosed each year in the United States with a prevalence of about 1 in 100,000 worldwide. It comprises 5-10% of all intracranial neoplasms in adults. Incidence peaks in the fifth and sixth decades and both sexes are affected equally.the fifth and sixth decades and both sexes are affected equally.
Acoustic neurinomas
28 éves nő
Acousticus neurinoma
Gamma Sugársebészeti Központ
28 éves nő
Acousticus neurinoma
Gamma Sugársebészeti Központ
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Thank you for your attention!Thank you for your attention!