Functional magnetic resonance imaging as a management tool for cerebral arteriovenous malformations.

The location of eloquent cortex, such as the motor strip, the visual cortex, or Broca's area, may be difficult to predict even with multiprojectional magnetic resonance imaging (MRI). Distortion and displacement of this cortex may occur with a congenital lesion, such as an arteriovenous malformation, or by an acquired disease, such as a neoplasm. A desire to avoid damaging these eloquent areas by conventional surgery, radiosurgery, or endovascular surgery makes their accurate identification an important part of the pretherapeutic planning process. Blood oxygen level dependent functional MRI is a technique that uses the local increase of oxyhemoglobin concentration in the patient that occurs as a result of the increase in flow rate and blood volume in eloquent cortex undergoing stimulation from, for example, flashing lights, hand movements, or speech. We have used the blood oxygen level dependent technique to localize eloquent cortex relative to arteriovenous malformations and tumors. Using a 4.0-T magnetic resonance (MR) system, there is a sufficiently high degree of spatial resolution of the MR signal intensity changes during stimulation to allow the identification of eloquent cortex. Alternative, non-MR, invasive techniques for functional localization include electrocorticography and stimulation from subdural grids and strips. Noninvasive, non-MR technologies, such as positron emission tomography and magnetoencephalography, can also provide functional localization of eloquent cortex. However, the perfection of functional MRI at the 1.5-T field strength and the large number of such MR systems in operation mean that a highly accurate cerebral cortical localization technique can be available to most neuroscientists without the need to purchase alternative expensive technology.