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Intra-operative MR enables superb resection in Hamburg

Best Practice
Kremer, Paul, M.D., Ph.D. Asklepios Clinic Hamburg, Neurosurgical Department, • Germany

When constructing a new neuro-OR building at Asklepios Clinic (Hamburg, Germany), the decision was made to include an intra-operative MR suite. To offset the potentially high costs of an MR system that might only be used a few times per week, a dual-use suite was designed for use both intraoperatively and by outpatients. So far, more than 1,000 patients have been scanned, about 30 of whom were examined intra-operatively.
 

 Paul Kremer, MD, PhD Asklepios Clinic, Hamburg
Paul Kremer, MD, PhD
Asklepios Clinic, Hamburg

Asklepios clinic takes full advantage of dual-use Achieva MR-OR scanner

Paul Kremer, MD, PhD, is head of the neurosurgical department at Asklepios Clinic, one of the first non-academic neurosurgery departments with intra-operative MRI. He helped to implement the intra-operative MRI suite in Heidelberg in 1995, then brought the concept to Asklepios, where the intra-operative MR suite was installed in July 2011.

“The difference between our center and others in the region is that we have a head and neck center, which includes ENT, facial maxillofacial surgery, neurosurgery, neurology, neuroradiology, neuropediatrics and neuropathology,” says Dr. Kremer. "We do intra-operative MRI on Tuesdays and Fridays so we can share the imaging time with the other departments.”

Dr. Kremer says the intra-operative MRI is usually used for patients who are having surgery for gliomas, both malignant and benign. “It’s very important to check the resection because it’s difficult during the microsurgery to determine the tumor margins. It’s very difficult. That is why we perform intra-operative MRI, including different image types – T1- or T2-weighted imaging – to check the resection. In Heidelberg several studies were  performed on the benefits for the patient, and these indeed showed a large benefit for the patient.”


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Special solutions for intra-operative MRI

There are several good reasons to have a dual-use MR scanner, from both a scheduling aspect and an economic one, but several challenges had to be overcome first.
 
“When using an MRI scanner only for intraoperative use, just one or two times a week, it’s too expensive,” says Dr. Kremer. “But the door between the OR room and the MR room allows us to directly go from the OR into the MR room for intra-operative MRI. And when the door is closed, the scanner can be used independently for regular MRI examinations. This is a very good approach.”

Special solutions were designed for intraoperative MR. “We use a trolley to transport the tabletop with the patient from the OR to the MRI system, and it works very smoothly,” Dr. Kremer explains. “Also very important is head fixation for neuro procedures. Fixation devices are usually made of metal, but we have found an MR-compatible solution.”

Dr. Kremer explains that at Asklepios, the MR room and the OR room share an airconditioning system, so the air in the magnet room is filtered by the same system as the OR. “First, the MR room is cleaned the day before a procedure,” says Dr. Kremer, “Then we clean the magnet gain one hour before the procedure. The room is closed for about half an hour, and all the air is treated again. The patient’s head and surgical wound still is open but covered, and the patient is transported into the magnet room.”

“It sounds like a difficult process, with the sterilization system, the trolley system, the head fixation system and the navigation system all working at the same time,” says Dr. Kremer. “But the results are very impressive.”

Resolution to see small remnants

“We have found the image quality is very good,” says Dr. Kremer. “In Heidelberg we used a 0.2T

magnet, and the imaging quality was quite nice. Now we have the Philips Achieva 1.5T magnet

and the image quality is outstanding. It helps that the head of the patient is fixed into the

head fixation system so the patient is lying motionless. We have the resolution to see small

tumor remnants – it’s really impressive.”

“The time it takes for intra-operative imaging is about half an hour,” explains Dr. Kremer.

“We bring the patient into the magnet, which is done quickly, then perform the imaging, and

then the patient comes back into the OR and we can start the surgery again. If there are

some tumor remnants we resect again; if not, we close the wound. We go back and forth as

much as we need to.”

Generally, the same sequences are used before and during the surgery. “If the tumor

has shown contrast enhancement before, we also scan sequences with gadolinium during

surgery; if there’s no enhancement we use T2-weighted or FLAIR sequences. We can also

do fiber tracking if we want.” In the near future, the clinic plans to begin using fMRI as well.

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Best Practice
Achieva 1.5T
Brain, Interventional, Intra-operative MR, MR-OR, Neuro, Oncology
 

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