PreSurgical and Surgical Planning in Neurosurgical Oncology - A Case-Based Approach to Maximal Safe Surgical Resection in Neurosurgery

Use of functional neuroimaging capabilities such as fMRI, DTI, MRP, MRS, AS-PET-CT, SPECT, and TMS as noninvasive tools to visualize intrinsic brain and spine morphology in relation to function have developed over the past 30 years. Amongst these imaging modalities, functional magnetic resonance imaging (fMRI) is of particular interest since it follows the physiological coupling between neuronal electrical activity and metabolic structural (cellular) activity as it relates to tissue vascularity and perfusion states. This structure–function synesis (from the Greek noun, σύνεσις = being together), leads to three effects that contribute to the fMRI signal: an increase in the blood flow velocity, a change in the mean blood volume, and most importantly, alterations in the blood oxygenation level. The latter effect has lent to the development of blood-oxygenation-level-dependent or BOLD fMRI, which has been used in establishing the topographic relationship between eloquent cortex and neurosurgical planning. As an adjunct to this modality, MRI-based diffusion tensor imaging (DTI) allows further detailed radiographic assessment of fiber tracts in the brain in relationship to the surgical lesion of interest. Herein we review the roles of fMRI and DTI for presurgical mapping to allow for maximal safe resection procedures in neurosurgery with case-based illustrations.