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Preoperative Functional MR Imaging Localization of Language and Motor Areas: Effect on Therapeutic Decision Making in Patients with Potentially Resectable Brain Tumors¹

¹ From the Department of Radiology, Division of Neuroradiology (J.R.P., L.M.S., J.S.P.), Brain Imaging and Analysis Center (K.M.H., J.T.V.), and Department of Surgery, Division of Neurosurgery (A.H.F., T.M.G., J.H.S.), Duke University Medical Center, Box 3808, Durham, NC 27710-3808. Received July 8, 2005; revision requested September 12; revision received October 5; accepted November 4; final version accepted December 19. Address correspondence to J.R.P. (e-mail: jeffrey.petrella{at}duke.edu).

View larger version (110K): [in a new window]   Figure 1: Left temporal lobe metastatic adenocarcinoma in 77-year-old man. Transverse functional MR images derived from series of T2*-weighted echo-planar MR images (2000/40, 24 x 24-cm field of view, 64 x 64 matrix, 5-mm section thickness, no intersection gap) are displayed as thresholded activation maps overlaid in red and yellow on a set of coplanar transverse T2-weighted fast spin-echo MR images (3000/84, 24 x 24-cm field of view, 256 x 192 matrix, 5-mm section thickness, no intersection gap, echo train length of eight). Surgery was not initially planned because of presumed involvement of receptive speech area. Left inferior frontal gyral activation (yellow arrows) is consistent with dominant expressive speech area and is separate from but abuts anterior margin of superior aspect of T2-weighted signal intensity abnormality in left temporal lobe and superior aspect of small left frontal T2 component. Left middle temporal gyrus activation (green arrows) is consistent with dominant receptive speech area and is lateral to midposterior portion of T2 hyperintense component. Craniotomy with mapping was performed, and resection was extended. No postoperative neurologic deficits were documented.

View larger version (125K): [in a new window]   Figure 2: Recurrent left parietal lobe anaplastic astrocytoma in 37-year-old right-handed woman. Transverse functional MR images derived from series of T2*-weighted echo-planar MR images (2000/40, 24 x 24-cm field of view, 64 x 64 matrix, 5-mm section thickness, no intersection gap) are displayed as thresholded activation maps overlaid in red and yellow on a set of coplanar transverse T2-weighted fast spin-echo MR images (3000/84, 24 x 24-cm field of view, 256 x 192 matrix, 5-mm section thickness, no intersection gap, echo train length of eight). Surgery was not initially planned because of presumed involvement of receptive speech area. Left inferior and middle frontal gyral activation (yellow arrows) is consistent with dominant expressive speech area and is located at anterior border of more cephalad component of lesion. Left superior and middle temporal gyral activation (green arrows) is consistent with dominant receptive speech area and abuts inferior border of temporal component of lesion, with superior temporal gyral activation component lying anteroinferior to lesion. Biopsy was performed, and no postoperative neurologic deficits were documented.

View larger version (90K): [in a new window]   Figure 3: Left intraventricular central neurocytoma in 23-year-old left-handed woman. Transverse functional MR images derived from series of T2*-weighted echo-planar MR images (2000/40, 24 x 24-cm field of view, 64 x 64 matrix, 5-mm section thickness, no intersection gap) are displayed as thresholded activation maps overlaid in red and yellow on a set of coplanar transverse T2-weighted fast spin-echo MR images (3000/84, 24 x 24-cm field of view, 256 x 192 matrix, 5-mm section thickness, no intersection gap, echo train length of eight). Preoperative plan included Wada testing and possible craniotomy with mapping. Dominant expressive speech area is shown in left middle and inferior frontal gyri (yellow arrows) and is anterolateral to lateral ventricular component of lesion. Left superior and middle temporal gyral activation (green arrows) is consistent with dominant receptive speech area and is anterior and inferolateral to left atrial component of lesion. Imaging results confirmed left dominant speech; Wada testing was avoided. Lesion was resected during craniotomy with general anesthesia by using right paramedian approach. No postoperative neurologic deficits were documented.

View larger version (118K): [in a new window]   Figure 4: Medial left frontal lobe well-differentiated astrocytoma in 30-year-old man. Transverse functional MR images derived from series of T2*-weighted echo-planar MR images (2000/40, 24 x 24-m field of view, 64 x 64 matrix, 5-m section thickness, no intersection gap) are displayed as thresholded activation maps overlaid in red and yellow on a set of coplanar transverse T2-weighted fast spin-echo MR images (3000/84, 24 x 24-cm field of view, 256 x 192 matrix, 5-mm section thickness, no intersection gap, echo train length of eight). Craniotomy with general anesthesia was planned, with lesion presumed to be sufficiently removed from expressive speech areas. Left inferior frontal gyral activation (yellow arrows) is consistent with dominant expressive speech area located 1 cm inferolateral to posterior margin of left frontal lobe lesion. Left superior and middle temporal gyral activation (green arrows) is consistent with dominant receptive speech area, is located inferiorly, and is separated from left frontal lobe lesion by sylvian fissure. Imaging results helped confirm existing treatment plan. No postoperative neurologic deficits were documented.

View larger version (115K): [in a new window]   Figure 5: Left posterior temporooccipital region pleomorphic xanthoastrocytoma with anaplastic features in 20-year-old woman. Transverse functional MR images derived from series of T2*-weighted echo-planar MR images (2000/40, 24 x 24-cm field of view, 64 x 64 matrix, 5-mm section thickness, no intersection gap) are displayed as thresholded activation maps overlaid in red and yellow on a set of coplanar transverse T2-weighted fast spin-echo MR images (3000/84, 24 x 24-cm field of view, 256 x 192 matrix, 5-mm section thickness, no intersection gap, echo train length of eight). Biopsy was planned because of lesion proximity to presumed receptive speech area. Left inferior frontal gyral activation (yellow arrows) is consistent with expressive speech area. Left superior temporal gyrus activation (white arrows) is consistent with dominant receptive speech area and is anterior and superior to left temporooccipital resection cavity, with small component (green arrow) within 1 cm anterior to T2 signal intensity abnormality at superior aspect of resection cavity. Imaging results helped plan surgical approach, and craniotomy with mapping and resection were performed. No postoperative neurologic deficits were documented.

View larger version (106K): [in a new window]   Figure 6: Right parietal lobe anaplastic oligodendroglioma in 23-year-old woman. Transverse functional MR images derived from series of T2*-weighted echo-planar MR images (2000/40, 24 x 24-cm field of view, 64 x 64 matrix, 5-mm section thickness, no intersection gap) are displayed as thresholded activation maps overlaid in red and yellow on a set of coplanar transverse T2-weighted fast spin-echo MR images (3000/84, 24 x 24-cm field of view, 256 x 192 matrix, 5-mm section thickness, no intersection gap, echo train length of eight). Resection and craniotomy with mapping were initially planned. Left-hand sensory motor area (yellow-red regions) is adjacent to anterior margin of superior portion of lesion in right parietal lobe. Bilateral sensory motor areas (white arrows) are shown, and activation is seen in supplementary motor cortex (yellow arrows). Because patient experienced left hemiplegia and because functional motor area was intimately involved with lesion, treatment plan was changed to biopsy. No postoperative neurologic deficits were documented.

View larger version (28K): [in a new window]   Figure 7: Bar graph illustrates trend for reduced surgical time (in minutes) over course of study between May 2004 and January 2005, presumably because of increased confidence in functional MR imaging. Patients who underwent surgery are indicated for each time period. Note that the study was terminated in February 2005, during which one additional patient (not shown) was included. This patient had an estimated reduction in surgical time of 0–15 minutes.