Neuronavigation and functional MRI for surgery in patients with lesion in eloquent brain areas.

OBJECTIVE: Surgery in patients with lesions in eloquent areas is still a challenge for the neurosurgeon. The aim of surgical interventions should be the radical removal of the lesions with functional preservation. Functional brain imaging methods provide the preoperative demonstration of those brain areas and their relationship to pathologic structures. MATERIAL: Twenty-seven patients with pathologic lesions in or near eloquent regions were investigated with functional magnetic resonance imaging (fMRI). Nineteen patients were neurologically intact preoperatively, and presented only with headache and/or seizure. Eight patients had a minor neurological deficit. Twenty-five patients underwent surgery. Preoperatively a computed tomography (CT) scan or a magnetic resonance imaging procedure with five skin fiducials was performed. The data were transferred to the neuronavigation workstation. The tumour was lined out in colours, and reconstruction in a triplanar format as well as three-dimensionally was implemented. The information from the fMRI concerning the functional areas was transferred into the images manually to account for EPI distortions. Fifteen patients were operated on using the combination fMRI/neuronavigation. Diagnoses included eleven gliomas, two meningeomas, one metastasis and one cavernoma. RESULTS: In seven patients the tumour was removed completely, eight patients had residual tumour, demonstrated by early postoperative MRI. All patients with residual tumour had gliomas that involved functional areas. Postoperatively no patient had an additional neurological deficit. CONCLUSION: Functional MRI provides important additional information in patients with lesions in eloquent brain areas. In combination with neuronavigation this is a very helpful technique for surgical interventions on these patients to reduce morbidity. Nonetheless, there are still open questions concerning accuracy of display of the functional areas and integration into a neuronavigation system.