Pediatric Central Nervous System Tumors: State-of-the-Art and Debated Aspects

Abstract

Pediatric neuro-oncology surgery continues to progress in sophistication, largely driven by advances in technology used to aid the following aspects of surgery: operative planning (advanced MRI techniques including fMRI and DTI), intraoperative navigation [preoperative MRI, intra-operative MRI (ioMRI) and intra-operative ultrasound (ioUS)], tumor visualization (microscopy, endoscopy, fluorescence), tumor resection techniques (ultrasonic aspirator, micro-instruments, micro-endoscopic instruments), delineation of the resection extent (ioMRI, ioUS, and fluorescence), and intraoperative safety (neurophysiological monitoring, ioMRI). This article discusses the aforementioned technological advances, and their multimodal use to optimize safe pediatric neuro-oncology surgery.

Keywords: intraoperative magnetic resonance imaging; neurooncology; pediatric brain tumors; pediatric neuroimaging; technology in surgery.

Figure 1

Neuro-navigation guided surgical approach: Top left: microscope view with navigation overlaid. Top right (axial), Bottom left (sagittal), and bottom right (coronal): Views of target lesion with planned trajectory (green) and microscope line of sight (blue).

Figure 2

Preoperative imaging for planning surgical approach and resection extent: Top Left: Axial post gadolinium T1 MRI. Top Right: DTI derived tractography to map white matter bundles in vicinity of tumor. Bottom: Multi-voxel MR Spectroscopy to define resection target.

Figure 3

Multimodal use of technology: The use of intraoperative endoscopy for an extended endo-nasal approach, in tandem with neuro-navigation and intraoperative MRI was vital in maximizing resection of this complex recurrent atypical meningioma.