The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
© 2001 The American Laryngological,
Rhinological and Otological Society, Inc.
Intraoperative Magnetic Resonance Imaging
for Skull Base Surgery
Joseph C. Dort, MD; Garnette R. Sutherland, MD
Objectives/Hypothesis: Skull base surgery has
evolved over the past several decades. Major improve-
ments in the imaging of skull base pathology led to
better target localization and better surgical plan-
ning. The objectives of this study were to assess the
use of intraoperative magnetic resonance (MR) imag-
ing in the management of a series of patients with
skull base pathology. We hypothesized that high-
quality intraoperative MR imaging would have an
impact on surgery in this patient group. Study Design:
Prospective, non-randomized, cohort study. Methods:
Thirty-one patients with skull base lesions under-
went surgery in a 1.5-Tesla intraoperative MR suite.
The concepts of a moving magnet, high magnetic field
strength, and radiofrequency coil design are pre-
sented. Results: Eleven of 31 patients had the course
of surgery significantly altered by the information
acquired from the images obtained during surgery.
Conclusions: Intraoperative MR imaging is a valuable
adjunct to skull base surgery. One third of patients
had altered surgery as a result of this adjunct. Intra-
operative MR imaging is of particular value in the
treatment of pituitary adenomas and benign skull
base tumors. Key Words: Skull base surgery, MRI,
intraoperative magnetic resonance imaging, intraop-
erative imaging.
Laryngoscope, 111:1570 –1575, 2001
INTRODUCTION
Over the past two decades, considerable advances
have been made in the anatomical understanding and
surgical treatment of lesions involving the skull base.1–5
To a large extent, these advances reflect enhanced preop-
erative lesion localization with computerized tomographic
(CT) and magnetic resonance (MR) imaging together with
the evolution of endovascular techniques.6 –9 The develop-
ment of multidisciplinary approaches combining the skills
of neurosurgeons, neuroradiologists, otolaryngologists,
and reconstructive surgeons have had a major impact on
From the Departments of Surgery (J.C.D.) (Division of Otolaryngol-
ogy) and Clinical Neurosciences (J.C.D., G.R.S.) (Division of Neurosurgery),
The University of Calgary, Calgary, Alberta, Canada.
Editor’s Note: This Manuscript was accepted for publication May 30,
2001.
Send Correspondence to Joseph C. Dort, MD, Seaman Family MR
Research Center, 1403–29 Street NW Calgary, Alberta, Canada T2N 2T9.
E-mail: jdort@ucalgary.ca
Laryngoscope 111: September 2001
1570
patient morbidity and mortality.10,11 Advances in technol-
ogy, such as intraoperative physiological monitoring, ul-
trasonic homogenization, and refined instrumentation,
have allowed surgeons to safely and effectively remove
even the most complex lesions involving the cranial base.
The surgical treatment of skull base lesions would be
particularly benefited by intraoperative imaging because
many of these lesions are large, and the three-dimensional
relationship of the lesion to surrounding structures is
often lost during dissection. To enhance surgical naviga-
tion, a number of systems based on preoperatively ac-
quired images have been developed.12–15 However, the act
of surgical exposure or the resection of the lesion often
negates the accuracy of such systems.16 –19 It is with these
concerns in mind that intraoperative imaging based on a
moveable 1.5-Tesla magnet was developed.20
The ability to move the magnet out of the operating
room between imaging studies minimizes the impact of
the magnetic field on surgical, anesthetic, and monitoring
techniques. The system developed at the University of
Calgary in collaboration with the National Research
Council, Institute for Biodiagnostics and Innovative Mag-
netic Resonance Systems Incorporated (IMRIS) has been
used during the surgical management of 154 patients with
a variety of skull base and intracranial pathologies.20 –22
This report illustrates the experience using the intraoper-
ative MR system during the surgical management of 31
patients with various skull base lesions.
MATERIALS AND METHODS
MR System
The system is based on a movable, ceiling-mounted, 1.5-
Tesla magnet that has a free bore diameter of 92 cm and working
bore diameter of 72 cm after placement of gradients that generate
23 mT/M @ 450 A with a 400 ␮sec rise time (Fig. 1). The magnet
is moved into and out of the operating room using a small electric
motor. The radiofrequency (RF) coil, the bottom half of which is
attached to the OR table, is able to be disassembled so that
between imaging studies the surgeon is provided free access to
the surgical field. A non-ferromagnetic three-pin head holder that
is fixed to the bottom half of the RF coil provides head fixation. To
limit RF noise, local shielding has been used. The system includes
a hydraulically controlled, stainless steel OR table that can be
moved into all positions currently available in a standard OR
table. Because the OR table remains stationary for imaging,
Dort and Sutherland: MR Imaging for Skull Base Surgery
Fig. 1. Ceiling-mounted, 1.5-T magnet
being moved toward the OR table. Be-
tween imaging sessions, the magnet is
located in an alcove adjacent to the OR.
Also shown are the stainless steel hy-
draulically controlled OR table, local RF
shielding, and RF coil.

anesthetic monitoring and safety have not been compromised. sequences. In all studies, the signal-to-noise ratio was
Further improvements in image quality and acquisition time sufficient to provide high-quality images that enhanced
have been realized as a result of new electronics provided through the surgical procedure.
IMRIS by Marconi Medical Systems.
Pituitary Adenoma Group (n ⴝ 15)
Imaging Parameters In all patients surgical planning MR imaging studies
Surgical planning MR studies were performed following the
showed well the tumor together with its suprasellar ex-
administration of anesthesia and patient positioning, interdissec-
tion MR studies were acquired at various stages of the surgical
tension (Fig. 2A). In nine patients interdissection imaging
dissection, and quality assurance MR studies were acquired after showed unexpected residual tumor that in 8 was removed
wound closure but before emergence from anesthesia. before wound closure (Fig. 2B). In 2 patients surgical
The time required for imaging is dependent on the specific dissection was augmented with three interdissection im-
MR sequences used. A scout image (field of view [FOV] 35 cm, aging studies and 2 patients had two interdissection MR
TR/TE 97/11 msec, matrix size 256 ⫻ 256, slice thickness 10 mm, studies.
1 average) is obtained in 25 seconds. Multi-slice spin-echo (FOV
25 cm, matrix size 256 ⫻ 256, slice thickness 5 mm, 2 averages) Meningioma Group (n ⴝ 7)
axial, coronal, or sagittal T1-weighted (TR/TE ⫽ 500/13 ms) im- Intraoperative MR imaging provided quality assur-
ages were acquired in 4.5 minutes. T2-weighted images (FOV 25
ance in all 7 patients. In one patient residual tumor in-
cm, matrix size 256 ⫻ 256, slice thickness 5 mm, 1 average)
obtained with spin-echo sequences (TR/TE ⫽ 2000/15 ms) require
8.5 minutes. Preparation for interdissection imaging, including
positioning of the magnet, requires approximately 5 minutes.
Moving the magnet out of the surgical field and re-exposing the TABLE I.
surgical site required an additional 3 minutes. Thus, to acquire a Patient Characteristics Grouped by Pathologic Finding (n ⫽ 31).
set of T1-weighted images, with and without gadolinium contrast, No. and Gender
in both axial and coronal planes (four image sets) would interrupt Patient Group of Patients Age (range)*
OR time by approximately 25 minutes.
Pituitary adenoma 7F, 8M 50 ⫾ 20 (15–80)
Meningioma 5F, 2M 54 ⫾ 21 (26–84)
RESULTS
Schwannoma 2F, 2M 30 ⫾ 20 (14–59)
Patient Characteristics Miscellaneous lesions
Table I presents the 31 patients by pathological di- Angiofibroma 1M 15
agnosis, gender, and age. The majority of patients har- Craniopharyngioma 1F 51
bored pituitary adenoma, meningioma, or schwannoma in Dermoid 1F 36
that order. The remaining five patients had various skull
Sarcoma 1M 67
base pathologies. In total, 75 MR imaging studies were
Glomus jugulare 1M 60
performed in the 31 patients (Table II). The studies in-
cluded 61 T1, 49 T1 with gadolinium, and 6 T2-weighted *Values are expressed as mean ⫾ standard deviation.

Laryngoscope 111: September 2001 Dort and Sutherland: MR Imaging for Skull Base Surgery
1571
 TABLE II. DISCUSSION
Number of Intraoperative Imaging Studies in 31 Patients. Technology
MR Technique The moveable high-field MR system used in the
present series has several advantages over other intraop-
Imaging Sequence MR Studies T1 T1-Gd T2
erative MR or CT systems.23–25 Magnetic field strength
Surgical planning 29 24 21 4 directly correlates with signal to noise and hence image
Interdissection 26 21 16 1 acquisition time and, to a large extent, image quality. The
Quality assurance 20 16 12 1 1.5-T magnetic field not only permits high-quality ana-
Total 75 61 49 6 tomical images, but also the ability to use the full spec-
trum of MR capability, including angiography, spectros-
MR ⫽ magnetic resonance; Gd ⫽ gadolinium.
copy, functional imaging, and diffusion/perfusion imaging.
While intraoperative CT has been introduced,23 imaging
the hindbrain or skull base by such technology is compli-
volving the orbital roof and cavernous sinus was evident
cated by artifact. Because CT is based on ionizing radia-
at wound closure. One patient, who was postpartum, with
tion, the technology is also not without risk to patients
a tuberculum sella meningioma showed considerable tu-
and operating room personnel. MR, on the other hand,
mor size reduction on surgical planning MR studies com-
produces excellent soft-tissue resolution and is ideally
pared with the preoperative diagnostic MR images ob-
tained during pregnancy. suited to the study of skull base pathology.
The RF coil design with rings placed above and below
Schwannoma Group (n ⴝ 4) the head results in uniform images, in contrast with those
The translabyrinthine dissection for the subsequent acquired with surface coils or with images acquired by CT.
removal of acoustic schwannoma was performed in two This is particularly important when evaluating complex
patients. Surgical planning MR imaging studies showed lesions involving the cranial base because signal in the
well the tumors and their effect on adjacent neural struc- region of interest is decreased when a surface coil is used
tures. Quality assurance MR imaging showed anticipated as the RF transmitter and receiver.
residual tumor lying on the facial nerve in one patient and Moving the magnet outside the surgical field and
complete resection in the other. In both patients with operating room between imaging studies allows estab-
olfactory and trigeminal nerve schwannomas, interdissec- lished surgical, anesthetic, and nursing techniques to be
tion MR imaging revealed unsuspected residual tumor unaltered. The use of surgical adjuncts, including a stan-
that was removed (Fig. 3A, B). dard Midas-Rex威 air drill, standard instruments, illumi-
nation, and magnification using a counterbalanced, mul-
Miscellaneous Lesions (n ⴝ 5) tihead, microscope with a video display and tumor
Five patients with various other pathologies had debulking with an ultrasonic aspirator, was possible. Fur-
their surgical procedure monitored using intraoperative thermore, physiological monitoring of cranial nerves was
MR imaging. Quality assurance MR imaging studies dem- not impeded. During imaging, the non-MR-compatible in-
onstrated complete resection in all cases (Fig. 4). struments and equipment remained in the OR, beyond the

Fig. 2. T1-weighted sagittal surgical plan-

ning images (A) showing a large pituitary
adenoma with suprasellar extension. T1-
weighted, gadolinium-enhanced sagittal in-
terdissection images (B) show unsuspected
residual tumor that was removed before
wound closure.

Laryngoscope 111: September 2001 Dort and Sutherland: MR Imaging for Skull Base Surgery
1572
Fig. 3. T1-weighted, gadolinium-
enhanced coronal (A) and axial (B) sur-
gical planning (left) and interdissection
(right) MR images. The surgical planning
study shows the large dumbbell-shaped
trigeminal schwannoma, whereas the in-
terdissection study shows the unre-
sected extracranial component and un-
suspected tumor within Meckel’s Cave
(arrow).
5 Gauss line. Moving the magnet from the operating room
also enhances the versatility of the system; while not
being used for surgery, the magnet could be used for
diagnostic MR studies.
Impact on Skull Base Surgery
Surgical planning imaging. Surgical planning
studies showed changes in lesion size compared with pre-
operative diagnostic studies and also demonstrated the
relationship of the lesion to the planned surgical corridor.
This is particularly important for skull base pathology
because such lesions may involve important vascular or
neural structures. For example, surgical planning images
may lead the surgical team to perform an incomplete
Laryngoscope 111: September 2001
versus a complete resection. Alternatively, total lesion
removal may be chosen with the knowledge that key sur-
rounding structures could be left unharmed.
Interdissection imaging. Among this patient
group, interdissection studies have proved most benefi-
cial. Eleven patients had intraoperatively defined unsus-
pected residual tumor. The present study, like others,
found the data particularly relevant to pituitary adenoma.
Patients with pituitary adenomas often undergo incom-
plete resection.26 –28 As many as 50% of patients with
pituitary adenoma have incomplete tumor resec-
tion.27,29 –31 The availability of interdissection imaging
will likely decrease the incidence of incomplete resection
and improve surgical outcome. Interdissection images also
Dort and Sutherland: MR Imaging for Skull Base Surgery
1573

proved valuable in updating surgical navigation. Surgical
navigation based on preoperatively acquired images has
been shown to become inaccurate once cerebral or lesion
shift has occurred.16,18
Complete resection of a benign cranial base tumor
with a single operation should be the goal of surgery. In
the case of angiofibroma, recurrence rates are directly
related to completeness of resection,32–34 and this also
holds true for other benign tumors. The ability to know
that a benign tumor has been completely removed is a
useful prognostic tool, and significantly reduces postoper-
ative anxiety and concern for patients and their families.
Although many skull base tumors are benign, some
patients have malignant disease affecting the cranial
base. Intraoperative MR imaging will be especially useful
for patients with chondrosarcomas, chordomas, and other
tumors in which extensive infiltration occurs.
Quality assurance imaging. Quality assurance im-
ages showed the completeness of resection and also dem-
onstrated that there were no acute intracranial complica-
tions such as stroke or hemorrhage. The images have
eliminated the need for early postoperative MR studies.
CONCLUSION
This article describes the application of a mobile
high-field MR system for the treatment of lesions involv-
ing the skull base. A significant number of patients
treated using intraoperative MR imaging have had their
surgical procedure altered. The future development of
novel imaging techniques together with MR spectroscopy
will further enhance the value of this technology for the
management of patients with these complex lesions. This
technology and its future application will have a signifi-
cant impact on the treatment of patients with disorders of
the cranial base.
Laryngoscope 111: September 2001
1574
Fig. 4. Surgical planning (A) and quality
assurance (B) T1-weighted gadolinium-
enhanced MR images obtained from a
31-year-old man with a well-
circumscribed lesion involving the left
frontal ethmoidal region. The quality as-
surance study shows complete removal
of the lesion.
Acknowledgments
This work was supported by a grant from the Canada
Foundation for Innovation. The authors thank the Insti-
tute for Biodiagnostics of the National Research Council of
Canada (Winnipeg, Manitoba, Canada), Innovative Mag-
netic Resonance Imaging Systems, and Magnex Scientific
(Abingdon, Oxon, England) for their help in developing
the described MR systems. The MR system described
in this report is presently being marketed by BrainLAB
(Heimstetten, Germany) under the brand name “iMotion.”
Dr. Dort further acknowledges the support of the Camp-
bell McLaurin Foundation. Finally, the authors thank
Drs. Phillip Park and Elizabeth MacRae of the Foothills
Medical Center, University of Calgary, for their support
by entering their patients into this study.
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