Imaging Case Report
Following is a case report of neurosurgical removal of a low-grade glioma using fMRI–DTI fused images for neuronavigation close to the Wernicke’s area.
Presentation
A 29-year-old man was admitted to the Department of Neurosurgery following a grand mal convulsion. MRI and MR spectroscopy (MRS) revealed an astrocytoma-like tumour within the left middle temporal gyrus. No neurological deficit was found in the otherwise healthy young male patient. As the tumour was close to the Wernicke’s area, an fMRI–DTI-guided frameless navigated microsurgical removal was planned.
Data Acquisition and Image Processing for BOLD and Diffusion Tensor Imaging Exams
MRI was performed on a SIEMENS 3T Trio scanner with a 12-channel phased-array head coil. Three image series were performed: an fMRI (text reading), DTI for tracking fibres within the speech areas and
T1 MP-RAGE for structural imaging. After surgical removal of the lesion, fMRI and structural imaging were repeated. NordicNeuroLab’s nordic fMRI Solution was used to conduct the fMRI exam.
All fMRI image processing was performed using nordicICE software (BOLD module). A standard general linear model (GLM) approach
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was used for statistical analysis. Both BOLD and DTI images were co-registered to the structural images collected during the session. Fibre tracking was performed using the DTI module of nordicICE. The multiplanar reconstruction mode was used for fusing the co-registered fMRI activation information and the DTI fibre data to the structural images. Speech centres were selected as seeds for the fibre tracking. Fibre tractography and BOLD data were saved and exported to surgical navigation (see Figure 2).
Conclusion
During general anaesthesia, a generous left temporal craniotomy was made and the tumour extensions onto the cortical surface were delineated using the navigation system. Tumour resection was performed by microsurgical techniques. Histology revealed World Health Organization (WHO) grade II or III astrocytoma. The post- operative period was uneventful. A control MRI–fMRI confirmed a complete resection (see Figure 2, top image, right side). Functional results were comparable to those of the pre-operative findings, and no aphasia was observed after surgery.
In summary, the use of fMRI–DTI fused structural images for neuronavigation can help substantially in surgical planning and risk assessment when tumours are located close to eloquent brain regions. Thus, brain functions can be preserved and awake craniotomies may be avoided. n
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