1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
2Department of Neurosurgery, University Medical Center, Utrecht, The Netherlands.
Neurosurg Focus. 2020 Feb 1;48(2):E11. doi: 10.3171/2019.11.FOCUS19779.
Functional MRI (fMRI) is increasingly being investigated for use in neurosurgical patient care. In the current study, the authors characterize the clinical use of fMRI by surveying neurosurgeons' use of and attitudes toward fMRI as a surgical planning tool in neurooncology patients.
A survey was developed to inquire about clinicians' use of and experiences with preoperative fMRI in the neurooncology patient population, including example case images. The survey was distributed to all neurosurgical departments with a residency program in the US.
After excluding incomplete surveys and responders that do not use fMRI (n = 11), 50 complete responses were included in the final analysis. Responders were predominantly from academic programs (88%), with 20 years or more in practice (40%), with a main area of practice in neurooncology (48%) and treating an adult population (90%). All 50 responders currently use fMRI in neurooncology patients, mostly for low- (94%) and high-grade glioma (82%). The leading decision factors for ordering fMRI were location of mass in dominant hemisphere, location in a functional area, motor symptoms, and aphasia. Across 10 cases, language fMRI yielded the highest interrater reliability agreement (Fleiss' kappa 0.437). The most common reasons for ordering fMRI were to identify language laterality, plan extent of resection, and discuss neurological risks with patients. Clinicians reported that fMRI results were not obtained when ordered a median 10% of the time and were suboptimal a median 27% of the time. Of responders, 70% reported that they had ever resected an fMRI-positive functional site, of whom 77% did so because the site was "cleared" by cortical stimulation. Responders reported disagreement between fMRI and awake surgery 30% of the time. Overall, 98% of responders reported that if results of fMRI and intraoperative mapping disagreed, they would rely on intraoperative mapping.
Although fMRI is increasingly being adopted as a practical preoperative planning tool for brain tumor resection, there remains a substantial degree of discrepancy with regard to its current use and presumed utility. There is a need for further research to evaluate the use of preoperative fMRI in neurooncology patients. As fMRI continues to gain prominence, it will be important for clinicians to collectively share best practices and develop guidelines for the use of fMRI in the preoperative planning phase of brain tumor patients.
功能磁共振成像（fMRI）在神经外科患者护理中的应用越来越受到关注。在本研究中，作者通过调查神经外科医生在神经肿瘤患者中使用 fMRI 作为手术计划工具的情况及其对 fMRI 的态度来描述 fMRI 的临床应用。
开发了一项调查，以询问临床医生在神经肿瘤患者人群中使用和经历术前 fMRI 的情况，包括示例病例图像。该调查分发给美国所有有住院医师培训计划的神经外科部门。
排除不完整的调查和不使用 fMRI 的应答者（n=11）后，最终分析包括 50 份完整的应答。应答者主要来自学术项目（88%），实践经验 20 年或以上（40%），主要实践领域为神经肿瘤学（48%），治疗成人人群（90%）。所有 50 名应答者目前在神经肿瘤患者中使用 fMRI，主要用于低级别（94%）和高级别胶质瘤（82%）。订购 fMRI 的主要决策因素是肿块在优势半球的位置、功能区的位置、运动症状和失语症。在 10 例病例中，语言 fMRI 的观察者间信度最高（Fleiss'kappa 0.437）。订购 fMRI 的最常见原因是确定语言偏侧性、计划切除范围和与患者讨论神经风险。临床医生报告说，在订购 fMRI 的情况下，中位数有 10%的时间无法获得结果，中位数有 27%的时间结果不理想。在应答者中，70%的人报告曾切除过 fMRI 阳性的功能部位，其中 77%是因为皮质刺激“清除”了该部位。应答者报告说，在 30%的情况下，fMRI 与清醒手术之间存在分歧。总体而言，98%的应答者表示，如果 fMRI 和术中映射的结果不一致，他们将依赖于术中映射。
尽管 fMRI 作为脑肿瘤切除的一种实用术前规划工具越来越受到重视，但在其当前使用和预期用途方面仍存在相当大的差异。需要进一步研究评估神经肿瘤患者术前 fMRI 的使用情况。随着 fMRI 的地位不断提高，临床医生将重要的是共同分享最佳实践，并为脑肿瘤患者术前规划阶段 fMRI 的使用制定指南。
