Name:
Microscope-based augmented reality with diffusion tensor imaging and fluorescein in insular glioma resection
Description:
Microscope-based augmented reality with diffusion tensor imaging and fluorescein in insular glioma resection
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/61aacebf-0b68-471c-942a-93408a348287/videoscrubberimages/Scrubber_379.jpg
Duration:
T00H07M56S
Embed URL:
https://stream.cadmore.media/player/61aacebf-0b68-471c-942a-93408a348287
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/61aacebf-0b68-471c-942a-93408a348287/21-57.mp4?sv=2019-02-02&sr=c&sig=CjjRz8PLB7cZFefnZBLZiJQJHd4jA6AIyzehMCyiNhY%3D&st=2024-05-06T10%3A49%3A15Z&se=2024-05-06T12%3A54%3A15Z&sp=r
Upload Date:
2021-12-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
This video article aims to show the technical key aspects of the microscope based augmented reality with diffusion tensor imaging and fluorescein in insular glioma resection.
A 63-year-old female patient suffering from a progressive decline in learning and memory and new-onset epilepsy. The neurological exam revealed the neurocognitive and visual spatial impairment. Past medical history was unremarkable. MRI revealed the right insular Berger-Sanai type I+IV high-grade glioma. The tumor arose at the level of the extreme capsule and it involved the short and long gyri. The claustrum and the lentiform nucleus were pushed medially and the medial part of the lesion was in contact with the putamen.
In their progressive growth, insular gliomas tend to encase the lenticulostriate arteries, this aspect being the major cause of morbidity of insular glioma surgery. 3D-rendered MRI showed in more detail the anatomical relationships between the tumor, circular sulcus of the insula, and putamen. Preoperative DTI fiber tracking showed the spatial distribution of the corticospinal tract, occipitofrontal fasciculus, posterior thalamic peduncle, and the optic radiation compared to the tumor.
It also allows for the selection of the surgical approach. A pterional transylvian approach was selected. And noteworthy transylvanian route allows for multiple working corridors. The different vascular supply of the basal ganglia and the insular cortex from the lenticulostriate arteries and MCA, respectively, is to be taken into account during the planning of surgery.
Total intravenous anesthesia target-controlled diffusion was used to allow the neuromonitoring. Cortical subcortical mapping was performed with the transcranial electrical stimulation motor evoked potentials, while subcortical mapping was carried out with the high-frequency bipolar stimulation technique. Asleep craniotomy was performed. A one-layer submuscular pterional approach was carried out with the full exposure of the lateral part of the sylvian fissure.
Brain mapping is recommended since DTI provides only anatomical information but no data about the function. The first step of surgery consisted of the opening of the carotid cistern, Liliequist membrane, chiasmatic cistern, along with the fenestration of the laminar terminalis. Meticulous sharp dissection of the arachnoid membranes is of utmost importance in avoiding any damage to the neurovascular structures of the basal cisterns.
It is also essential to keep clean the surgical field. A wide opening of the basal cisterns, Liliequist membrane included, allows for CSF withdrawal. This is the key point to avoid the use of a fixed brain retraction in the transylvian approach. The dynamic retraction by the surgical instruments is a less traumatizing and more effective in allowing for the progressive recognition and exposure of the anatomical structures.
The visualization of the lenticular striate arteries is a crucial since they mark the most media limit of surgery. Microscope-based augmented reality fiber orthography provided for virtual view of the anatomical relationship between the lateral lenticulostriate arteries and white matter fiber tracts. The splitting of the lateral and anterior insular compartment of the sylvian fissure and the opening of the sylvian cistern allowed to expose the M1 segment of the middle cerebral artery (MCA), MCA bifurcation, superior and inferior limiting sulcus of the insula, limen insula and the entire insular cortex.
In this case, the middle trunk of the originated from the superior trunk. The insular cortex shows the fluorescein enhancement. The cortical branches of the MCA were coagulated and the tumor was resected in a piecemeal fashion.
The use of fluorescein filter aided the recognition of the tumor boundaries. Care must be taken during tumor removal in avoiding mechanical vasospasm of the MCA or its branches caused by an excessive retraction of the vessels. The use of the cavitron ultrasonic aspirator facilitated the tumor resection.
DTI allowed for a constant awareness of the spatial location of the corticospinal tract, front- occipital fasciculus, and optic radiation. The accuracy of the augmented reality fiber tract tomography was checkered at the cortical and subcortical level having the motor strip as a landmark. At the cortical level, the matching between the visual corticospinal tract and the opercular part of the motor area was tested.
At the subcortical level the matching was verified through the subcortical mapping. DTI navigation was extremely useful during the resection of the deepest part of the lesion, close to the putamen. At this step, the lack of fluorescence confirmed the gross-total resection of the tumor. At the end of surgery, the check of the blood flow ruled out spasm of the MCA and its branches.
ICG videoangiography showed the patency of the MCA. Gross-total resection of the glioma was achieved as confirmed by the postoperative MRI. Postoperative DTI documented the preserved structural anatomical connectivity of the corticospinal tract, IFOF, and optic radiation.
It was basically an anatomical confirmation of a functional check which has been already obtained operatively by means of a cortical-subcortical mapping of the motor pathway. The patient was discharged without deficits on the seventh postoperative day. The relatively longer perioperative follow-up was justified by the known risk of delayed ischemic complications.
Urinary tract infection occurred at the third postop day, required the administration of intravenous antibiotic therapy. Pathology revealed in anaplastic astrocytoma. Standard Stupp protocol was employed and no recurrence occurred at the 21st month follow-up. In conclusion, DTI- fluorescein microscope-. based augmented reality resulted safe and effective in maximizing the extent of the section of the reported insular high-grade glioma. Its association with brain mapping is recommended. Further theoretical advantages may also come from its use during awake surgery.