College of Physicians and Surgeons

Advanced Intraoperative Imaging for Parasagittal Meningioma SurgeryAndrew K. Chan, B.S.M.D. CandidateSub-InternNeurological Surgery ServiceMassachusetts General Hospital

1Case PresentationHPI48 year old womanIntermittent, dull, bilateral frontal headache x 5 weeksWorsened the past 4 days, now persistent, n/v, difficulty focusingExamLeft Pronator Drift, 4+/5 Left Upper Extremity Strength

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5Right Parietal Craniotomy for ResectionLeft-lateral position, with head down 60 degreesMonitoring / Imaging:Central Venous CatheterPre-Cordial DopplerIntraoperative CT scan for BrainLab frameless stereotaxyMicroscopeRemoved tumor near sinus, and removed medial portion of tumor above a draining vein, that was preservedFrozen Pathology: Meningioma w/o atypical features

6Convexity Meningiomas391 convexity meningiomas60.1 years (19 92 years)WHO I, II, III (90.3, 5.6, 4.1%)Median Follow-up: 7.1 years (0.0 20.9 years)1-, 5-, 10-year survival 96%, 89%, 78%Overall survival associated with age, sex, WHO grade, Simpson grade1-, 5-, 10-year retreatment-free survival 99%, 94%, 90%Retreatment-free survival associated with WHO grade, Simpson gradeHasseleild et al. 2012, J Neurosurg 7

Hasseleild et al. 2012, J Neurosurg Convexity Meningiomas4.9x13.2x8Indocyanine Green Videography

9Nussbaum et al. 2012, Neurosurgery

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Ueba et al. 2013, J Neurosurg

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Ueba et al. 2013, J Neurosurg

Diminishment of Eclipse SignEclipse Sign12Intraoperative Guidance: Extent of Resection

Kim et al. 2011, Acta Neurochir13Intraoperative Guidance: Extent of Resection

dAvella et al. 2013, Acta Neurochir

14ConclusionsAids in the real time, in situ visualization ofDural venous sinusesCortical arteries and veinsDural attachmentSelect surgical scenariosClose to major vesselsApproaching highly vascularized tumorsSafe, non-invasive, inexpensiveFuture, large series to assess clinical impact

U/S Pros: Noninvasive, SimpleCons: Evaluation of Veins, or small perforating artery less than 1 mm

DSA Pros: Gold standardCons: Invasive, Requires additional personnel and equipment, long set up time, DSA results need to be interpreted as the images are not integrated into the operative view, small perforator visualization is nearly impossible 15Thank You AttendingsResidentsStaffCo-Sub Is

Guy M. McKhann II, MDSameer A. Sheth, MD, PhD

16Cost Comparison: Transsphenoidal SurgeryFactorC-Arm Fluoroscopic GuidanceiCT/EM NavigationNo. of patients65208Mean OR time (mins)121.1 30.7108.9 24.3

Mean Incision-to-Closure Time (mins)71.75 19.061.3 18.2Cost/Charges---Imaging1.0001.053---Disposable Navigation Products00.307---OR4.9715.519---Total6.5196.331Eboli et al. 2011, J Neurosurg

17BrainlabCost$ 225,000 Watkins et al. 2010 Open Orthop J

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