Original Report
Intraoperative 3tesla magnetic resonance imaging: Our experience in tumors
Resonancia magnética intraoperatoria de 3 teslas: Nuestra experiencia en patología tumoral
A. García-Baizán
, A. Tomás-Biosca, P. Bartolomé Leal, P.D. Domínguez, R. García de Eulate Ruiz, S. Tejada, J.L. Zubieta
Corresponding author
Departamento de Radiología, Departamento de Neurocirugía, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
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García-Baizán, A. Tomás-Biosca, P. Bartolomé Leal, P.D. Domínguez, R. García de Eulate Ruiz, S. Tejada, J.L. Zubieta" "autores" => array:7 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "García-Baizán" "email" => array:1 [ 0 => "agarcia.13@unav.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Tomás-Biosca" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Bartolomé Leal" ] 3 => array:2 [ "nombre" => "P.D." "apellidos" => "Domínguez" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "García de Eulate Ruiz" ] 5 => array:2 [ "nombre" => "S." "apellidos" => "Tejada" ] 6 => array:2 [ "nombre" => "J.L." "apellidos" => "Zubieta" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Radiología, Departamento de Neurocirugía, Clínica Universidad de Navarra, Pamplona, Navarra, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resonancia magnética intraoperatoria de 3 teslas: Nuestra experiencia en patología tumoral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2007 "Ancho" => 2501 "Tamanyo" => 329758 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Transfer of the patient from the operating room to the intraoperative magnetic resonance imaging room (A and B). Schematic drawing showing the location of the MRI and other rooms (C).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The main goal of neurosurgery is the surgical resection of intracranial lesions without damage to the normo-functioning parenchyma while preserving essential neurologic functions.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> The MRI has proven the ideal imaging modality to establish what the situation of the tumor really is and analyze the best way to approach it. During the last few years, systems of intraoperative MRI (iMRI) have been developed in order to assess the resection of intracranial lesions during the surgical act. Although initially the iMRI has been used in the resection of glial tumors, today, it is also used in other procedures.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">2–14</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The development of 3<span class="elsevierStyleHsp" style=""></span>T MRIs allows us to acquire images with shorter can times, higher resolution, and better performance than other studies conducted using lower field MRI machines.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">15–19</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the usual protocols, one postoperative control MRI is conducted to assess whether the resection of the target lesion has been complete. This postoperative MRI is conducted during the first 24–36<span class="elsevierStyleHsp" style=""></span>h. Although these postoperative studies are accurate, the problem is that if the tumor resection has not been satisfactory, a second intervention is required in order to complete it, with the corresponding risks and associated costs.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Ever since it was first introduced to the surgical practice, the iMRI systems have become important tools for the surgery of brain tumors in many centers. Several studies have confirmed that by using iMRIs we can achieve wider and more accurate tumor resections, which, in turn, associates higher survival rates.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">8,11,16,18</span></a> Also, the existence of immediate complications (hemorrhages, infarctions, …) can be assessed too. All this allows us to analyze whether the goal of the surgery has been achieved in order to make the decision of ending or continuing the surgery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The main advantages of the iMRI are: get to know the degree of “real time” resection, the preservation of healthy structures, and brain-shift compensation. Brain-shift is defined as a distortion of intracranial structures as a consequence of one craniectomy procedure; this displacement involves a lack of correlation with preoperative studies, in which intracranial pressures have not been modified.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In Spain, several centers already have iMRI machines, although most of them are low-field MRI machines. The goal of this paper is to describe our own experience with the implementation of 3<span class="elsevierStyleHsp" style=""></span>T iMRI machines in neurosurgical procedures for the management of tumor pathology and establish the criteria conditioning margin-widening surgeries.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Retrospective study conducted between January 2016 and March 2017 where all the iMRIs conducted and evaluated at our center by neuro-oncological pathology were recorded.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Ninety-three (93) patients were included, whose age, sex, and imaging diagnosis were recorded in preoperative studies.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We did not feel it was necessary to ask for the approval from the hospital ethics committee given the descriptive retrospective nature of the study and use of anonymized data.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In all cases, and with the presence of an experienced neuro-radiologist, the operative results were evaluated and briefed personally to the neurosurgical team. The following topics were discussed: all possible immediate complications, the presence of tumor remnants, and whether the iMRI results modified the surgical management. In cases with positive tumor remnants it was discussed whether this finding led to continuing or ending the surgery, or whether the resection was interrupted in the presence of inoperable tumor remnants located in eloquent areas. Studies with altered signal foci on the T1, T2-weighted and diffusion-tensor images (DTI), and high signal intensities after the administration of paramagnetic contrast were considered tumor remnants; particularly, these areas were distinguished from the enhancement areas inherent to the surgical act and the presence of intraoperative hemostasic material. Also, the surgeon determined whether the tumor remnant was located in an eloquent area through navigation, tractography, and neurological monitoring. The surgical time was measured in all the cases.</p><p id="par0055" class="elsevierStylePara elsevierViewall">All the iMRI studies were conducted using one 3T MRI machine (Magnetom Skyra, Siemens Medical Systems, Erlangen, Germany) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). At our center, the MRI machine is located close to the neurosurgery operating room (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B and <span class="elsevierStyleSmallCaps">C</span>). In this OR, the lower part of the operating table hosts the surface coils that are used for brain imaging acquisition. When appropriate, the patient is transferred from the OR to the MRI machine on a surgical table compatible with the MRI. The patient is monitored at all time by a team of anesthesiologists and neurosurgeons, and the medical staff sees that the maximum conditions of asepsis are observed. Once within the magnet, the surface coil is complemented with its upper half and we proceed with the analysis. Since both spaces are separate, no ferromagnetic material is allowed inside the MRI room, which is why the acquisition of compatible surgical material is not required. Obviously, one 3<span class="elsevierStyleHsp" style=""></span>T-compatible respiratory ventilator system and, of course, one flexible surface coil are required.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In each procedure we used a specific protocol based on the surgical indication (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). For the contrast-enhanced sequences, gadobutrol at 0.1<span class="elsevierStyleHsp" style=""></span>ml/kg was used (Gadovist<span class="elsevierStyleSup">®</span>, Bayer Schering Pharma AG, Berlin-Wedding, Germany).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The data obtained was recorded in a database (Excel; Microsoft, Redmond, WA, USA) and the results were analyzed statistically (SPSS Statistics Base 20.0; Armonk, NY, United States). Both the continuous and categorical variables were expressed as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>typical deviation, and percentage, respectively.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Ninety-three (93) patients were included (49 males and 44 women), with ages from 4 to 82 years old (average: 51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17 years).</p><p id="par0075" class="elsevierStylePara elsevierViewall">No immediate postoperative complications were confirmed in any of the cases.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The surgical indications and the percentage of cases with tumor remnants are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. The complete resection was a reality for 26 patients (28%), while 67 patients still showed tumor remnants (72%).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">In 57 patients (85%) with tumor remnants, surgeons decided to extend the surgery because of this finding, but in 10 patients (15%) they decided to end it (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The average surgical time was 390<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>122<span class="elsevierStyleHsp" style=""></span>min, and no incidences were reported following any effects derived from the high magnetic field due to the presence of non-compatible material.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">During the first 13 months after the implementation of the iMRI we analyzed 93 studies in tumor pathology with different surgical indications–being the most common of all the primary glioblastoma multiforme, the recurrent glioblastoma multiforme, and metastasis. In 72% (67/93) of the iMRIs, tumor remnants were found. The iMRI improved the neurosurgeons margin-widening surgery for resection purposes in 85% of the cases (57/67).</p><p id="par0100" class="elsevierStylePara elsevierViewall">In our work we have found a high percentage of tumor remnants in the iMRIs conducted (72%); in the primary glioblastoma multiforme (86.6%), the recurrent glioblastoma multiforme (77%), and metastasis (66.6%). We also saw that in up to 85% of all interventions, it was decided to proceed with margin-widening surgery for resection purposes with different percentages (80% of primary glioblastomas multiformes, and 100% of metastases). In some of the cases where it was decided to end the intervention after the iMRI findings, it was because of total resection, or after finding remnants in eloquent areas. In a study conducted by Pamir et al.,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> tumor remnants were found in 44.6% of all iMRIs in surgeries conducted to remove gliomatous lesions, continuing with margin-widening surgeries in 37.5% of the cases. These results support the idea that if, while conducting one iMRI we see remnants of the target lesion, then it is necessary to continue with the surgery and the procedure. All this suggests that, with the iMRI, surgeons have a second chance to continue with the procedure and perform wider and more accurate resections, which is why they are more cautious when it comes to removing the lesion at first. However, by being less aggressive during resection, the number of incomplete resections is higher. In our series we did not achieve any complete resections of World Health Organization low-grade tumors in a first surgical time, although this may have been favored by the fact that in these tumors, neurosurgeons do not use 5-aminolevulinic acid that distinguishes the tone of the tumor from a healthy parenchyma and is used in high-grade tumors.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The study conducted by Senft et al.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> showed that the iMRI leads to complete resections in 96% of the cases, compared to 68% of the cases in the group that was operated using conventional microsurgery. In our series, out of 15 primary glioblastomas multiformes, 13 of them (86%) showed tumor remnants on the iMRI. However, with the iMRI findings, the surgeons changed surgical management in 84% (11/13) of the cases. The findings from our own early experience show that this type of studies allow us to make accurate assessments of tumor resection whether to continue or not with resection without damaging the eloquent areas.</p><p id="par0110" class="elsevierStylePara elsevierViewall">One of the consequences of the iMRI described in the medical literature is longer surgical times – already reported in a study conducted by Chicoine et al.,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> being the average time of surgeries with gliomas around 446<span class="elsevierStyleHsp" style=""></span>min. In our database of more than 400 patients operated between 2008 and 2011 at our center (before the implementation of the iMRI), the average surgical times were 340<span class="elsevierStyleHsp" style=""></span>min, and in our work, it was 390<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>122<span class="elsevierStyleHsp" style=""></span>min, meaning that the iMRIs make surgical times longer in about 50<span class="elsevierStyleHsp" style=""></span>min. The duration of the iMRI sequences is 15.45<span class="elsevierStyleHsp" style=""></span>min (in low-grade tumors, since no paramagnetic contrast is required), and 17.08<span class="elsevierStyleHsp" style=""></span>min (in high-grade tumors), and the tasks of preparing, moving, setting up the patient, and returning him safely to the operating room take around 30<span class="elsevierStyleHsp" style=""></span>min. This is something that should be taken into consideration when implementing the iMRI, although there is a certain learning curve, yet we hope that in future studies, times will be shorter.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Our work has several limitations. It is a retrospective study with a small number of examinations. We only tried to describe our own early experience with the implementation of 3<span class="elsevierStyleHsp" style=""></span>T iMRIs for the management of neurosurgical procedures. More statistical studies are needed before we can analyze the impact that this imaging modality has on surgical success.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Also, we need to gain more experience before knowing whether, in undifferentiated tumors, the iMRI avoids control MRIs in periods of less than 48<span class="elsevierStyleHsp" style=""></span>h. While, in pediatric patients, it is widely accepted to avoid the use of general anesthesia, in adults its use is still controversial. At our center, the findings from both studies are being correlated in an attempt to establish what the definitive protocol may look like.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In sum, the iMRI using high-field machines is a valid new imaging modality to accurately study tumor resection and assess whether margin-widening surgery without damage to eloquent areas is feasible. Although the use of iMRIs gives way to longer surgical times, the time required is shorter as the team becomes more and more familiar using this imaging modality.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Authors’ contribution</span><p id="par0130" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0135" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study: JZZ, AGB, ATB, PBL, PD, RGE and ST.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0140" class="elsevierStylePara elsevierViewall">Study Idea: JZZ, AGB, ATB, PBL, PD, RGE and ST.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0145" class="elsevierStylePara elsevierViewall">Study Design: JZZ and AGB.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0150" class="elsevierStylePara elsevierViewall">Data Mining: JZZ, AGB, ATB and PBL.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0155" class="elsevierStylePara elsevierViewall">Data Analysis and Interpretation: JZZ, AGB and ATB.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0160" class="elsevierStylePara elsevierViewall">Statistical Analysis: JZZ, AGB and ATB.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0165" class="elsevierStylePara elsevierViewall">Reference: JZZ and AGB.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0170" class="elsevierStylePara elsevierViewall">Writing: JZZ, AGB and ATB.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0175" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks: JZZ, AGB, ATB, PBL, PD, RGE and ST.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0180" class="elsevierStylePara elsevierViewall">Approval of final version: JZZ, AGB, ATB, PBL, PD, RGE and ST.</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests associated with this article whatsoever.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1006453" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec966164" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1006454" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec966163" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors’ contribution" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-04-07" "fechaAceptado" => "2017-12-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec966164" "palabras" => array:3 [ 0 => "Magnetic resonance" 1 => "Brain tumors" 2 => "Intraoperative complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec966163" "palabras" => array:3 [ 0 => "Resonancia magnética" 1 => "Neoplasias cerebrales" 2 => "Complicaciones intraoperatorias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To report our experience in the use of 3<span class="elsevierStyleHsp" style=""></span>T intraoperative magnetic resonance imaging (MRI) in neurosurgical procedures for tumors, and to evaluate the criteria for increasing the extension of resection.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This retrospective study included all consecutive intraoperative MRI studies done for neuro-oncologic disease in the first 13 months after the implementation of the technique. We registered possible immediate complications, the presence of tumor remnants, and whether the results of the intraoperative MRI study changed the surgical management. We recorded the duration of surgery in all cases.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The most common tumor was recurrent glioblastoma, followed by primary glioblastoma and metastases. Complete resection was achieved in 28%, and tumor remnants remained in 72%. Intraoperative MRI enabled neurosurgeons to improve the extent of the resection in 85% of cases. The mean duration of surgery was 390<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>122<span class="elsevierStyleHsp" style=""></span>min.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Intraoperative MRI using a strong magnetic field (3<span class="elsevierStyleHsp" style=""></span>T) is a valid new technique that enables precise study of the tumor resection to determine whether the resection can be extended without damaging eloquent zones. Although the use of MRI increases the duration of surgery, the time required decreases as the team becomes more familiar with the technique.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir nuestra experiencia con la resonancia magnética intraoperatoria (RMio) de 3 teslas en procedimientos neuroquirúrgicos en patología tumoral y evaluar los criterios que condicionaron la ampliación quirúrgica.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo en el que se incluyeron todas las RMio consecutivas realizadas por patología neurooncológica en los primeros 13 meses tras su instalación. Se registraron las posibles complicaciones inmediatas, la presencia de restos tumorales y la modificación de la actitud quirúrgica por los resultados de la RMio. Se midió el tiempo quirúrgico en todos los casos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El mayor porcentaje de lesiones resecadas correspondió a glioblastomas recidivados, seguido de glioblastomas primarios y metástasis. Se evidenció una resección completa en un 28% y restos tumorales en un 72%. La RMio permitió a los neurocirujanos mejorar la extensión de la resección en un 85%. La media del tiempo quirúrgico fue de 390<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>122 minutos.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La RMio con equipos de alto campo (3 teslas) es una técnica novedosa y válida, que permite estudiar la resección tumoral de forma precisa y evaluar si se puede continuar la resección sin dañar zonas elocuentes. Aunque su empleo conlleva una prolongación del tiempo quirúrgico, este mejora con la curva de aprendizaje del personal.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as: García-Baizán A, Tomás-Biosca A, Bartolomé Leal P, Domínguez PD, García de Eulate Ruiz R, Tejada S, et al. Resonancia magnética intraoperatoria de 3 teslas: Nuestra experiencia en patología tumoral. Radiología. 2018;60:136–142.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1262 "Ancho" => 1800 "Tamanyo" => 270886 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Subependymoma: preoperative (A), intraoperative (B) and postoperative (C) studies. Glioblastoma multiforme: preoperative (D), intraoperative (E) and postoperative (F) studies.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2007 "Ancho" => 2501 "Tamanyo" => 329758 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Transfer of the patient from the operating room to the intraoperative magnetic resonance imaging room (A and B). Schematic drawing showing the location of the MRI and other rooms (C).</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sequences</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Acquisition \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fat saturation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RT/ET \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FoV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Matrix \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Thickness (mm) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"># slices per block \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"># of blocks \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Acceleration \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Flip angle (°) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time (min) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Flip angle (°) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3D axial T1-weighted gradient-echo sequences \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Without contrast<br><br>Post-contrast<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Righ-left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2200/2.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">250<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>250 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">256<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>256 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">192 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 GRAPPA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5:38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5:38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">20 direction diffusion tension (DTI) sequences<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td><td class="td" title="table-entry " align="left" valign="top">Anterior–posterior \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3700/92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">220<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>220 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">128<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>128 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 GRAPPA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4:39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4:39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">T2-weighted sagittal variable flip-angle turbo spin echo sequences<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a></td><td class="td" title="table-entry " align="left" valign="top">Anterior–posterior \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3200/408 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">250<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>250 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">256<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>256 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">208 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 GRAPPA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6:51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6:51 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1704379.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">In high-grade tumors, and metastasis.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">In low and high-grade tumors, and metastasis.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">In low-grade, or hypophyseal tumors.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Sequences used while conducting iMRIs.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">WHO, World Health Organization.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complete resection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tumor remnants \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO IV recurrent glioblastoma multiforme \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (23%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (77%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO IV primary glioblastoma multiforme \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (13.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (86.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metastasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (33.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (66.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO I oligodendroglioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO I meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (50%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO I hypophyseal adenoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (83.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (16.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO grade II astrocytoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO grade III astrocytoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO grade I astrocytoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rest<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (44.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (55.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (28%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 (72%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1704381.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Hemangioblastoma (1), subependymoma (1), neurocytoma (1), ganglioglioma (1), supratentorial primitive neuroectodermal tumor (1), epidermoid cyst (2), neurinoma (2).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Total number of cases and percentage of complete resections <span class="elsevierStyleItalic">vs</span> tumor remnants.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">WHO, World Health Organization.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Continue surgery \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Stop surgery \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO IV recurrent glioblastoma multiforme \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (80%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (20%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO IV primary glioblastoma multiforme primario \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (84.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (15.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metastasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO I oligodendroglioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO I meningioma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO I hypophyseal adenoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO grade II astrocytoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO grade III astrocytoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">WHO grade I astrocytoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rest<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (40%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (60%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 (85%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (15%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1704380.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Subependymoma (1), neurocytoma (1), epidermoid cyst (1), neurinoma (2).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Therapeutic decision in cases where tumor remnants were found.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative magnetic resonance imaging and magnetic resonance imaging-guided therapy for brain tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.A. 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