Intraoperative MR systems. Midfield approaches.

Intraoperative MR imaging provides an unrestricted view of intracranial structures and lesions that has revolutionized the way that neurosurgery is performed in the authors' institution. Intraoperative imaging allows the practitioner to update and adjust the approach to intracranial lesions continuously. With this system, important anatomic and vascular structures can be successfully avoided; boundaries of low-grade tumors can be accurately defined, and foci of possible higher grade within these lesions can be identified; foci of high-grade astrocytomas can be differentiated from radiated brain; hyperacute hemorrhage or infarction during and after procedures can be determined; and the possible communication of cystic collections with CSF can be ascertained. These advantages provide a level of comfort to the surgeon and a presumptive margin of safety to the patient that is unattainable during conventional surgical approaches, and given the choice, the authors' neurosurgeons would prefer to operate in the interventional magnet. Preliminary reports concerning the efficacy and usefulness of MR-guided navigational tools for the performance of neurosurgery are encouraging, as noted earlier, Wirtz et al have shown that the more extensive removal of glioblastomas afforded by intraoperative MR leads to significantly prolonged patient survival compared with conventional surgery. Further outcomes analysis must be performed, however, to determine whether these new techniques significantly decrease overall long-term morbidity or increase survival in those patients who have low-grade astrocytomas.