Yonsei Med J.  2015 Mar;56(2):388-396. 10.3349/ymj.2015.56.2.388.

Clinical Experience of Glioma Surgery Using "Tailed Bullet": Overcoming the Limitations of Conventional Neuro-Navigation Guided Surgery

• Cho JM
• Lim JJ
• Kim SH
• Cho KG

• KMID: 2070015
• DOI: http://doi.org/10.3349/ymj.2015.56.2.388

Abstract

PURPOSE
Although conventional neuro-navigation is a useful tool for image-guided glioma surgery, there are some limitations, such as brain shift. We introduced our methods using an identifiable marker, a "tailed bullet", to overcome the limitation of conventional neuro-navigation. A tailed bullet is an identifiable tumor location marker that determines the extent of a resection and we have introduced our technique and reviewed the clinical results.
MATERIALS AND METHODS
We have developed and used "tailed bullets" for brain tumor surgery. They were inserted into the brain parenchyma or the tumor itself to help identify the margin of tumor. We retrospectively reviewed surgically resected glioma cases using "tailed bullet". Total 110 gliomas included in this study and it contains WHO grade 2, 3, and 4 glioma was 14, 36, and 60 cases, respectively.
RESULTS
Gross total resection (GTR) was achieved in 71 patients (64.5%), subtotal resection in 36 patients (32.7%), and partial resection in 3 patients (2.7%). The overall survival (OS) duration of grade 3 and 4 gliomas were 20.9 (range, 1.2-82.4) and 13.6 months (range, 1.4-173.4), respectively. Extent of resection (GTR), younger age, and higher initial Karnofsky Performance Status (KPS) score were related to longer OS for grade-4 gliomas. There was no significant adverse event directly related to the use of tailed bullets.
CONCLUSION
Considering the limitations of conventional neuro-navigation methods, the tailed bullets could be helpful during glioma resection. We believe this simple method is an easily accessible technique and overcomes the limitation of the brain shift from the conventional neuro-navigation. Further studies are needed to verify the clinical benefits of using tailed bullets.

Keyword

Glioma; image-guided surgery; neuro-navigation; tailed bullet

MeSH Terms

Adult
Aged
Brain/pathology
Brain Neoplasms/pathology/*surgery
Female
Glioma/pathology/*surgery
Humans
Karnofsky Performance Status
Magnetic Resonance Imaging, Interventional
Male
Middle Aged
Neuronavigation/*methods
Retrospective Studies
Surgery, Computer-Assisted/*methods
Survival Rate
Time Factors
Treatment Outcome

Figure

• 

  Fig. 1 Photos of tailed bullet used in image-guided surgery. (A) A tailed bullet and probe for the insertion. Optical sensor for navigation is attached to the probe. (B) Enlarged view of the bullet. The bullet is in a cylindrical shape and is coated with silicon. The hollow space is fitted to the probe. A number is tagged to each bullet. (C) Navigation probe fitted with a bullet.

• 

  Fig. 2 Intraoperative photos of bullet insertion. (A) After craniotomy, a small dura incision was made for tailed bullet insertion under navigation guidance. (B) Buried bullet in brain parenchyma. When the bullet is encountered, the resection has carried out to the tumor margin or eloquent location.

• 

  Fig. 3 Illustrative case for high grade glioma. (A) A preoperative MRI reveals a 2 cm left thalamic enhancing mass. (B) After craniotomy, several bullets were inserted at tumor margins. (C) During resection, the bullets delineate tumor margin. (D) Postoperative MRI reveals no residual enhancing lesion.

• 

  Fig. 4 Illustrative case for low grade glioma. A preoperative MRI reveals non-enhancing mass on left inferior frontal gyrus on T1 weighted image (A). The mass was shown in high signal intensity on T2 weighted image (B) and FLAIR image (C). Postoperative MRI reveals no residual high signal intensity on FLAIR image (D). FLAIR, fluid-attenuated inversion recovery.

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