• Atsushi Tsugu, Hideo Ishizaka, Yoshihito Mizokami, Takahiro Osada, Tanefumi Baba, Michitsura Yoshiyama, Jun Nishiyama, and Mitsunori Matsumae.
• Department of Neurosurgery, Tokai University School of Medicine, Kanagawa, Japan. tsugu@is.icc.u-tokai.ac.jp
• World Neurosurg. 2011 Jul 1;76(1-2):120-7.

ObjectiveTo compare intraoperative magnetic resonance imaging (MRI)-guided resection with resection guided by 5-aminolevulinic acid (5-ALA)-induced fluorescence in patients with gliomas and to evaluate the impact of intraoperative MRI in glioma surgery.MethodsFrom January 2005 to February 2009, 33 patients with gliomas (6 with World Health Organization [WHO] grade II, 7 with WHO grade III, 20 with WHO grade IV) who underwent craniotomy with neuronavigation and received 5-ALA by the same neurosurgeon were investigated retrospectively. In 19 patients, operations were performed using a combination of 5-ALA with intraoperative 1.5-T MRI. All patients were subjected to postoperative 1.5-T MRI to confirm the extent of resection.ResultsOf 33 patients with gliomas, 21 (4 with WHO grade III and 17 with WHO grade IV) were 5-ALA-induced fluorescence-positive (5-ALA (+)). Surgery with intraoperative MRI was performed in 10 of the 21 patients, and the average resection rate was 92.6%. The average resection rate of patients who underwent surgery without intraoperative MRI was 91.8%. 5-ALA-induced fluorescence was not detected in 12 patients (6 with WHO grade II, 3 with WHO grade III, and 3 with WHO grade IV) with gliomas. Surgery with intraoperative MRI was performed in 9 of 12 patients, and the average resection rate was 89.2%. The average resection rate of patients who underwent surgery without intraoperative MRI was 68.7%. Intraoperative MRI-guided tumor resection resulted in a better resection rate in patients with 5-ALA-induced fluorescence-negative (5-ALA (-)) gliomas than in patients with 5-ALA (+) gliomas (20.5% vs 0.8%).ConclusionsIntraoperative MRI-guided resection is a powerful tool to treat 5-ALA (-) gliomas (mostly low grade), and 5-ALA is useful for high-grade gliomas. The combination of intraoperative MRI and 5-ALA has a synergistic effect in glioma surgery. Additionally, precise tumor grading in preoperative imaging studies can be difficult. Surgery for gliomas should be performed using both 5-ALA-induced fluorescence and intraoperative MRI-guided resection.Copyright © 2011 Elsevier Inc. All rights reserved.

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