1. Surgical Planning Laboratory Brigham and Women’s Hospital Boston, Massachusetts USA a teaching affiliate of Harvard Medical School Neurosurgery Alexandra Golby, M.D.

2. ©2005 Surgical Planning Laboratory, ARR Slide 2 Functional imaging and electrocorticography- guided surgery in eloquent cortex Surgical resection is most effective initial therapy for a variety of brain tumors Maximal surgical excision relieves mass effect, decreases tumor burden, decreases incidence of seizures and may prolong time to recurrence and survival Defining limits of the resection difficult due to gross similarity of tumor and brain tissue Adjacency of essential cortex (e.g. motor, language) makes distinction critical

3. ©2005 Surgical Planning Laboratory, ARR Slide 3 Intra-operative MRI at BWH Craniotomy=699 Brain biopsy=180 LASER ablation=9 Transsphenoidal pituitary adenoma resection Total=918

4. ©2005 Surgical Planning Laboratory, ARR Slide 4 MRT allows surgeon to visualize resection progress and brain shift F. Talos

5. ©2005 Surgical Planning Laboratory, ARR Slide 5 Motor, visual cortex well demonstrated Language lateralization Increasingly, language localization and memory Functional MRI can provide a pre-operative map of critical brain areas

6. ©2005 Surgical Planning Laboratory, ARR Slide 6 Imaging white matter tracts MRI measures diffusion of water. Water proton diffusion facilitated parallel to fibers and restricted perpendicular anisotropic diffusion tensor imaging Trajectory and location of white matter tracts Three types of lesion/fiber tract interactions may occur: – fiber tract displacement – infiltration – destruction Higher diffusion along fiber Lower diffusion across fiber axons

7. ©2005 Surgical Planning Laboratory, ARR Slide 7 Stimulation mapping to locate essential cortical areas Fiber tracts

8. ©2005 Surgical Planning Laboratory, ARR Slide 8 Image coregistration and fusion

9. ©2005 Surgical Planning Laboratory, ARR Slide 9 Intraoperative image fusion and display: fMRI and Cortical Stimulation

10. ©2005 Surgical Planning Laboratory, ARR Slide 10 Conclusions and Future Directions Multi-modality image fusion Intra-operative functional testing annotation Develop paradigms which work well for patients with neurologic deficits Integrate fMRI with DTI and other imaging modalities Improve ability to predict post-operative outcomes and avoid neurologic injury Correlate fMRI signal with neuronal activity