Melanie Cole (Host): In a first for Alabama, UAB Hospital has opened a new surgical suite with the ability to take MRI images while the surgery is underway. This allows surgeons to see images in real time as an operation is progressing. Welcome to UAB Med Cast. I'm Melanie Cole and joining me today is Dr. James Markert. He's the James Garber Galbreath Endowed Chair of Neurosurgery at UAB Medicine. Dr. Markert it's always a pleasure to have you join us. Today, I'd like you to get right into this. Tell us about the new surgical suite with the ability to take intra-operative MRI images while surgery is underway.

James Markert, MD, MPH (Guest): Hey Melanie. Well, it's great to talk to you again and thank you for having us. We are very pleased to have the ability to have this intra-operative MRI suite in Alabama, because it will allow us to take even better care of our patients with brain tumors, as well as some other conditions like epilepsy and movement disorders. And it's really an extraordinary feat to be able to do this. If you can imagine we can actually stop an operation or at least pause it and then take the patient into an MRI scanner. In our case, the MRI unit comes to the patient, get new images, find out updated data about where we are, what needs to be done, what the result has been so far, before we even complete the operation. So on the fly adjustments can be made and the operation perfected before the patient even wakes up from his or her anesthesia.

Host: How cool is that? So why the need? What had been some of the challenges that you identified prior to the new suite that may have frustrated you over time?

Dr. Markert: Sure. Well, I think that it depends of course upon the indication that we're using it for, but let's start with brain tumors because that's my own personal area of specialization. Brain tumors are different from other cancers because they occur in the eloquence of the human brain. And obviously we can't take a margin of tissue around the tumor to optimize our postoperative result, because if we did so, we could end up impacting the patient's function afterwards. We simply can't take out normal brain tissue from certain parts of the brain without having a profound effect on the patient post-operatively. So instead we're left with trying to take out every little bit of tumor that we can without impeding on the normal surrounding brain. Some brain tumors can be very obvious where they start and stop. Meningiomas are a good example of this kind of tumor, but other tumors, particularly primary brain tumors, such as gliomas, really fade off into normal brain.

They're more invasive. They have a center, a nucleus, if you will, that is compact and consists entirely of tumor cells. But as you get to the edge of the tumor, it starts to intermix with normal brain tissue and you have tumor cells associated with brain cells. In some cases, we can take a small margin of these brain cells, in others we can't simply because of where the tumor's located. So what we do is as we get close to that margin, we can go ahead and get an MRI scan during the operation, update our information. We'll use special neuro navigation during our operation, which is kind of like GPS for your brain. And this really helps us be extremely precise as we operate on each individual. And it lets us get a result that really is optimal for that particular patient. That's brain tumors.

The other indications that we use it for include things like deep brain stimulator placement. So there's different ways to place stimulators for people who have tremors and Parkinson's disease. But this is a remarkable technology. And perhaps you've seen a patient who has a terrible tremor in his or her hand, and then has their stimulator turned on and it completely disappears with the stimulation. These stimulators are implanted into a specific portion of the brain, depending upon the source of the tremors. And by actually getting an MRI scan in the middle of the operation, we can make sure that the stimulator is optimally placed to get the best possible result for the patient.

And then a third indication is for epilepsy. We have a new technology at UAB called LIT, which is laser interstitial thermal therapy, a big title, but basically it means we can actually implant a laser into portions of the brain that are not functional for normal brain function, but in certain patients are producing seizures. We can then get an MRI scan with the stimulator in place in the brain. And actually heat the brain tissue by the use of the MRI scan and destroy the source of the epilepsy. It's a fantastic procedure. And we can do that all in our intra-operative MRI scanner as well. So you can see, depending upon the condition, there are different reasons for wanting this, but in each case, it ends up with a much better treatment for our patient.

Host: No kidding. So tell us about your first procedure in the new suite. What procedure did you perform Dr. Markert and tell us a little bit about that.

Dr. Markert: Yeah, it was a very exciting procedure. It was a patient with a brain tumor in their frontal lobe. And this was a particular kind of brain tumor that actually gradually faded out into normal tissue. So we wanted to make sure that we took as much of the tumor out as was safe for the patient. We wanted to take as much of the tumor out as we could that was safe for the patient and remove these so-called tentacles of tumor that were invading to normal brain. We were limited though, by the fact that the tumor was relatively close to the speech center of the brain. And so we wanted to make sure that we didn't take out too much tissue because that could have left the patient with a post-operative deficit in their ability to communicate.

So this was a fantastic opportunity for this patient and the use of the intraoperative MRI scan allowed us to stop when we were getting near the end of the tumor resection, recheck the current status of the tumor in the brain by MRI scan, and then come back and take out some additional tumor and end up with really an outstanding result for this patient. So, fantastic opportunity. Great example of how useful this is for improving patient outcome.

Host: Dr. Markert, what happens to the staff when the MRI is in use?

Dr. Markert: Yeah. So, it's important. We have a very defined protocol for what happens during the actual MRI scanner. There is a broad blue line painted on the floor of the operating room. That is the reminder of the potential danger of a magnet this powerful. And we have to make sure that everything that is metallic is outside of this line.

So staff that are in during the MRI scanner include the anesthesiologist and a safety nurse officer who maintains the safety and is really responsible for making sure that the patient remains safe during this whole procedure. Obviously that's critical to our success. The rest of the staff then goes into the console room, which is outside of the operating room. And that's where I sit. And I'm able to look at a console and see the images as they come up in real time, which helps me make decisions quickly about what we will do when we go back in to the operating room. Do we need to take out additional tumor? Have we accomplished everything we need to, or in the case of some of our other specialties, do we like where the stimulator ended up?

Or does an adjustment needs to be made? Then MRI scan is completed. The MRI unit is removed from the room and we immediately go back in. Obviously, everybody repreps, gowns and gloves, and we complete the operation at that time.

Host: Tell us a little bit about the design, Dr. Markert. You mentioned that the MRI comes to the patient in your suite. Tell us a little bit about how this was designed. Is this going on around the country? Obviously it's a first for Alabama, but what's happening around the country as far as this design?

Dr. Markert: Yeah. So that's a great question. So there are actually different approaches to this issue. So for some MRI scanners that are in the operating room, we actually need to move the patient to the MRI scanner. The MRI scanner for these particular designs is located in the central area and the patient's MRI and operating table, which are one in the same is on a track. And you simply roll the patient from the operating room into the adjacent room where the MRI scanner is. I looked at some of these and I wasn't convinced that they were quite as safe for our patient population. So we chose a different type where the MRI scanner's actually on an overhead track in the ceiling. It does sit in a central room. And then when we're ready for the patient to undergo the MRI scan, we actually stop the operation. We close the scalp so that things are kept sterile. We have to count all the metal instruments, because we want to make sure that there's nothing in the room that could get sucked into the MRI scanner by its very strong magnet.

And then the MRI unit actually comes into the operating room along its overhead track and envelops the patient. And we get the scan that way. And then at the end of the scan, it then returns back to its central room. The double door closes and we take the drapes off the patient and we can resume our surgery immediately. It's fantastic.

Host: It is fantastic. Where do you see this going in the future as far as additions and updates? Will other service lines be using it? Tell us about what you see happening.

Dr. Markert: Yes. I think that as it becomes familiar, it's like so many other introductions of technology into medicine in the operating room. Once we try it in one indication, we find out, well, gosh, maybe we can use it for this indication as well and improve things. So I think that there's going to be other opportunities, to use LIT perhaps in the context of tumor destruction, that's already been done at some centers, but to be able to use it with the intraoperative MRI unit that we have, will really be step up from current technology. I envisioned that we will also be able to use this for other conditions. We hope, for example, that patients with spinal cord tumors might benefit from this kind of technology, I assume that our deep brain stimulator surgeons will find other approaches to using this, to help patients get the best outcomes from their surgery without having to stop at the end of surgery, go get an MRI scan and see if things ended up the way you wanted them to end up.

I think there's a whole host of things that we could use this for in neurosurgery and they remain to be delineated. I know that we have other service lines here that have already expressed interest in it. For example, our gynecologic oncologic radiation oncologists are interested in using this to confirm their placement of tiny particles or seeds of radioactivity called brachy therapy, in their patient population so that they can end up placing these radiation seeds exactly where they need to be, first time, every time.

I think that other service lines will say, gosh, this is something that we can use in our setting as well, and it'll be exciting to see how these unfold as we go forward.

Host: I imagine they will, so many uses and what a cool advancement. Thank you so much, Dr. Markert for joining us and telling us about the surgical suite with the built-in MRI at UAB Medicine. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST, or you can always visit our website at UABmedicine.org/physician.

That concludes this episode of UAB Med Cast. I'm Melanie Cole.