fmri and Pre-operative Planning for CNS tumors

Transcription

1 fmri and Pre-operative Planning for CNS tumors Miami Brain Symposium Andrei I. Holodny, M.D. Chief of Neuroradiology Director of the fmri Lab Memorial Sloan-Kettering Cancer Center Disclosures: 1. NIH-NIBIB 1R01EB Holodny A (MPI with Hernan Makse) Graph theoretical analysis of the effect of brain tumors on functional MRI networks Role: MPI $1, NIH-NCI Holodny A (MPI with Hernan Makse) Graph theoretical analysis of pre-operative fmri data in bilingual and English as a second language (ESL) patients with brain tumors. as part of NIH/NCI. U54 CA (Ahles, PI) CCNY/MSK Partnership for Cancer Research Training and Community Outreach Role: PI $200, NIH-NCI 1 R21 CA Holodny A (MPI with Kyung Peck) Identification of Essential Areas of the Brain in Pre-Operative Brain Tumor Patients Using BOLD fmri and Independent Physiological Parameters Role: PI $830, NIH-NCI R25CA Wolchok (PI) Bayer Pharmaceuticals Peck (PI) MSKCC Department of Radiology Miloushev V (PI) The Dana Foundation Keshari (PI) Disclosures: fmri Consultants LLC exclusively educational, runs the Hands-on fmri and DTI course in New York. Next course Dec 11-13, 2017 (SOLD OUT) Hands-on Clinical fmri and Diffusion Tractography June 8-10, 2015 Course Director: Andrei I. Holodny, M.D. 22 CME and 3 SAM credits EDUCATIONAL OBJECTIVES Understand the fundamental principles behind fmri and diffusion tractography Choose the optimal fmri paradigms appropriate for the patient and clinical situation Deliver fmri paradigms correctly and monitor the patient for adequate compliance Hands on experience so that the attendee will be able to analyze fmri and diffusion tractography Understand how data is delivered to a neurosurgical navigational system and used by the neurosurgeon Avoid pitfalls in the interpretation of clinical fmri and diffusion tractography Optimize fmri billing and coding For further information Please contact Andrei Holodny, MD Conference Location Belfer Research Building Weill Medical College of Cornell University 69 th Street and York Avenue 1

2 55 year old lawyer Broca s area Boston naming test 59/60 Broca s area From Grays s Anatomy Broca s area Pars triangularis Pars orbitalis Pars opercularis 2

3 Wernicke s area Wernicke s area Posterior aspect of the superior temporal gyrus Other language areas SMA 3

4 fmri improves my ability to read routine brain MRI scans Superior Frontal Sulcus Pre-Central Sulcus Middle Frontal Gyrus Inferior Frontal Gyrus Central Sulcus Inferior Frontal Sulcus 62 year-old righthanded man Expected location of Wernicke s area 4

5 Sanai et al NEJM 2008 Sanai et al NEJM 2008 Functional MRI (fmri) Brain Mapping using MR imaging to measure the quick and small metabolic changes that take place in an active part of the brain. Provides not only closer look at the brain, but determines precisely which part of the brain is handling thought, movement, sensation and speech Anatomy (MRI) vs. Function (fmri) 5

6 Fe Superficial or extra-axial circumscribed tumor Risk of postop deficit (injury, bleed, stroke, etc.) Where to exercise caution Central sulcus Courtesy of Cameron Brennan Location of pre-central gyrus? Courtesy of Cameron Brennan 6

7 Normal organization of language Broca s area Wernicke s areas 55 year old lawyer Pars triangularis Pars opercualris Boston naming test 59/60 Semantic fluency:?split Broca s area 7

8 Intraoperative MRI Post-operative MRI 1. No language deficits 2. No residual enhancement 3. Mostly grade II with focal areas of anaplasia Metastasis to primary motor cortex fmri Resection Disease free 3 years later 8

9 True reorganization 57-year-old man, low grade glioma 100% right handed, 57/60 on BNT Pre-operative fmri Broca s Wernicke s Pre-operative fmri #2 Broca s Wernicke s 9

10 Resection of Broca s area No language deficit Intra-operative Exposure Exposed brain during operation Screen seen by neurosurgeon Intra-operative Exposure Tip of pointer 10

11 Intra-operative Exposure Tumor Motor cortex speech arrest Phase reversal speech delay sensation hand movement Courtesy of Cameron Brennan Conclusion and Take Home Message: Pre-operative fmri: - Helps in pre-operative mapping of essential brain areas in gliomas - Can be done on standard MR scanners. - Software is analysis of fmri data is easy to use. 11

12 Acknowledgments: fmri Lab: Kyung Peck Nicole Brennan Bob Hou Mehrnaz Jenabi Ethan Jost Arka Mallela Connie Chen Nina Shevzov Dimitri Bogomolni JH Kim Artem Beyaev Neurosurgery: Philip Gutin Viviane Tabar Cameron Brennan Neuroradiology: Robert Young Sasan Karimi John Lyo Vaios Hatzoglou Eric Lis Michelle Bradbury Other institutions: Bharat Biswal Joseph Maldjian A John Tsiouris Rebecca Jones John Ulmer Michael Schulder Andrew Kalnin Thank you! holodnya@mskcc.org 12