Enhanced resection of primary high-grade gliomas using a combination of intraoperative magnetic resonance imaging and intraoperative fluorescence (5-aminolevulinic acid): A single-centre experience

• Published in: Neurology India 2018-05, Vol.66 (3), p.747-752
• Main Authors: Sharma, Vikas, Kedia, Rishabh, Narang, Karanjit, Jha, Ajaya
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aminolevulinic Acid; Brain Neoplasms - surgery; Diagnosis; Female; Fluorescent Dyes; Glioma; Glioma - surgery; Gliomas; Humans; Levulinic Acids; Magnetic resonance imaging; Magnetic Resonance Imaging - methods; Male; Middle Aged; Neuroimaging - methods; Neurosurgical Procedures - methods; Prognosis; Risk factors; Surgery, Computer-Assisted - methods
• ISSN: 0028-3886; 1998-4022
• DOI: 10.4103/0028-3886.232334

Background: The extent of resection (EOR) of a tumor is a proven prognostic factor in patients undergoing surgery for suspected high grade glioma. A few recent publications have shown the importance of intraoperative magnetic resonance imaging (iMRI) with 5-aminolevulinic acid (5-ALA) fluorescence-guidance in order to maximally increase the EOR. Aim: The objective of our study was to calculate the effect on survival of patients with high grade gliomas of resection using both iMRI and 5-ALA fluorescence-guidance as intraoperative adjuncts. Methods: Thirty-seven patients with gadolinum-enhancing high gliomas on preoperative MRI undergoing surgical excision were included in a prospective study. Surgeries began under white-light conditions. Intermittently, a blue light filter was switched on to search for remaining tumor tissue not visible to the naked eye. When gross total resection (GTR) was thought to have been achieved, iMRI was done to check for any contrast-enhancing part left behind. Surgery was concluded or resumed based on the iMRI findings. Histopathological examination of the tumor tissue was done. All patients underwent immediate postoperative MRI at the end of the surgery to calculate the EOR. Results: Our results showed that out of the total of 37 patients, 17 patients died during the follow up period and 11 patients were still alive. The mean survival was 587.1 days and median survival was 491 days with a range of 342 to 943 days. When we compared these figures with the average survival in patients with a high grade glioma, i.e., 9 to 14 months, it showed that both the above mentioned modalities were very helpful in increasing the EOR, and in turn, the overall survival. Conclusions: The use of iMRI as well as fluorescence-guidance are appropriate methods to improve the extent of resection in surgery of contrast-enhancing gliomas. Best results can be achieved by the complementary use of both modalities.