Name:
Contemporary intraoperative visualization for GBM with use of exoscope, Raman spectroscopy, 5-ALA fluorescence-guided surgery and tractography
Description:
Contemporary intraoperative visualization for GBM with use of exoscope, Raman spectroscopy, 5-ALA fluorescence-guided surgery and tractography
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/cec36c02-0652-44bc-9aeb-181d762cb18f/videoscrubberimages/Scrubber_113.jpg
Duration:
T00H07M08S
Embed URL:
https://stream.cadmore.media/player/cec36c02-0652-44bc-9aeb-181d762cb18f
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/cec36c02-0652-44bc-9aeb-181d762cb18f/21-174.mp4?sv=2019-02-02&sr=c&sig=3rMdVwAKydmSFJSNUj0rOR3K1QfCFi4olAYAdrH7HQs%3D&st=2025-04-30T10%3A32%3A50Z&se=2025-04-30T12%3A37%3A50Z&sp=r
Upload Date:
2021-11-16T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video article shows the key technical aspects of the combined 3D exoscope with DTI tractography and 5-ALA fluorescence for high-grade glioma resection. A 33-year-old male patient presents with refractory seizures, following a prior brain biopsy consistent with a high-grade glioma. His neuro exam was initially significant for mild word-finding difficulties, otherwise nonfocal with no motor or sensory deficits and intact cranial nerves.
SPEAKER: An MRI revealed a left-sided multifocal tumor primarily located on the dominant superior temporal gyrus, with extension to the supermarginal gyrus of the parietal lobe. The patient underwent a stereotactic biopsy, pathology consistent with an IDH1 wildtype glioblastoma, WHO grade IV. And on postoperative day 10, the patient was taken for a left frontotemporoparietal craniotomy for tumor resection. Given the proximity of the tumor to eloquent speech pathways, in addition to his clinical improvement, allowing him to have fluent speech in both Russian and English,
SPEAKER: The surgical team elected to perform an awake craniotomy during the tumor resection portion of the case. Preoperative planning was utilized with the Synaptive Medical software identifying the surgical corridor for the approach. Preoperative MRI with diffusion tensor imaging-- DTI--showing the relationship of the tumor to eloquent brain matter tracts. In this fly-through video, we can see the spatial distribution of the descending corticospinal tracts in blue, the inferior longitudinal fasciculus in neon green, the optic radiations highlighted in forest green, arcuate fasciculus in yellow, corpus callosum in red, the cingulum in orange, and the uncinate fasciculus in pink, with the corona radiata in purple.
SPEAKER: Additionally, the tractography allows the surgical team to select the safest route on entry to the tumor. Therefore, our surgical plan included use of DTI tractography for understanding pathways surrounding the multifocal glioblastoma tumor, performing an awake craniotomy and language mapping for safer resection due to the location of the tumor, use of a voice-controlled 3D surgical exoscope for tumor debulking, and finally, administration of oral 5-ALA and use of fluorescence-guided surgery for maximal resection at the tumor margin, utilizing the new headlamp LED system for fluorescence visualization.
SPEAKER: The patient was positioned supine with his head turned to the right in the Mayfield head clamp, to maximize access to the left temporoparietal lobes. Synaptive navigation was used to plan our incision and tumor margins on the skin. A trapdoor incision was made for the appropriate craniotomy for optimal visualization of the tumor tissue. Raney clips were used for superficial hemostasis, and fishhooks were attached to a Leyla bar to retract the skin flap.
SPEAKER: The skull was removed using four burr holes parallel to the skin incision. 4-0 Nurolon tack-ups were used to close the epidural potential space. The dura was excised in a C-shaped fashion and reflected inferiorly. The frontal and temporal lobes as well as the Sylvian fissure were identified. The Synaptive 3D exoscope was brought into the field.
SPEAKER: And here we see that setup with the dual monitors, the left showing the 3D exoscopic view of the field, with a navigation probe in the resection cavity. On the right, you can see the navigation with a probe tip in the resection cavity. Additionally, the surrounding white matter tracts of interest that were designated prior to the case are highlighted. Here you can see the highly vascular, high-grade glioma tumor tissue using the exoscope.
SPEAKER: There are several advantages to the use of the exoscope in tumor surgery. First, the operator is able to perform the surgery at a low light intensity, 30% in this clip, causing less risk of tissue damage to the surrounding brain. There is a wide range of zoom variability, allowing improved visualization of deep tissue structures, and the 3D wide-angle view allows greater depth perception-- not only for the operator, but for all observers as well-- fostering a positive teaching environment for residents, fellows, and medical students.
SPEAKER: The tumor tissue is removed and sent to pathology. 20 tissue samples in total are taken as part of our clinical trial. After tumor tissue is removed and the tumor core has been debulked, 5-ALA fluorescence-guided surgery is utilized. 5-ALA, a precursor metabolized in the heme biosynthesis pathway to protoporphyn IX, accumulates intracellularly in tumor cells and has a high affinity for high-grade glioma tissue.
SPEAKER: It is administered orally, 4 to 6 hours prior to surgical resection and has a favorable safety profile. Protoporphyn IX absorbs light between 375 to 440 nm and emits a violet-red fluorescence at 635 nm, which you can see here in this video. It is highly sensitive and specific for malignant brain tissue and can help us around the tumor margin to identify tumor from normal brain tissue. 5-ALA was used for the remainder of the tumor resection in this case.
SPEAKER: Of note, we used a new LED headlamp system to visualize tumor fluorescence with the surgical loupes. Therefore, we did not need the microscope for fluorescence visualization. Following tumor resection, meticulous hemostasis was achieved, and the surgical cavity was lined with Surgicel sheets. The dura was closed in a watertight fashion. And the bone flap was reapproximated with four burr hole covers.
SPEAKER: The temporalis muscle was reapproximated, and the galea and skin were subsequently closed with suture. Postoperative MRI shows a gross-total resection. The patient initially had some expressive aphasia following surgery, which improved over several days following surgery. In summary, maximal safe resection is the primary goal of glioma surgery,
SPEAKER: And by incorporating improved intraoperative visualization with the 3D exoscope, 5-ALA fluorescence, neuronavigation, and DTI fiber tracking, we may maximize the safety of resection of tumors in eloquent brain regions.
