February 2006
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MR-OR in action
Liliana Goumnerova, MD, and Nichole Paone When 13-year-old Nichole Paone awoke one chilly morning in November, something just wasn't right. She'd been lethargic for several days prior, experiencing a tingling sensation in her head and some mild vomiting. But that particular Tuesday, she was looking almost yellow.
Nichole had been in and out of her pediatrician's office all month, undergoing several tests to determine what was causing her symptoms. When the tests provided no answers, she was eventually referred to a neurologist, but the appointment wasn't for another few days.
But that wasn't soon enough for her mother, Michelle, who had been watching her little girl's symptoms change and get worse over the weeks. So, she brought Nichole to Children's Hospital Boston's emergency room later that day.
A CT scan revealed that Nichole had a tumor the size of a baseball lodged in the back of her brain. "The tumor was a juvenile pilocytic astrocytoma (JPA)," says neurosurgeon Liliana Goumnerova, MD. "This is probably the most common tumor in that location in children. There are no known causes of JPA; it is believed to occur sporadically."
Nichole, who wants to be a veterinarian, took her diagnosis in stride. When told she had a brain tumor, she described, in great detail, a brain operation she had seen performed on a dog on one of her favorite TV shows, "Emergency Vets." Once the doctor confirmed that she would be undergoing a similar procedure, she didn't need any further explanation.
But what made Nichole's operation much different than her four-legged friend's was the use of Children's new MR-OR—the world's first-of-its-kind Intraoperative Magnetic Resonance Imaging (MRI) system in a pediatric hospital. Suspended from ceiling tracks, the 15,000-pound magnet travels from behind doors in the operating room's wall to take images before, during and after an operation. With this technology, surgeons can determine the extent of a tumor while the patient is undergoing surgery and ensure its accurate removal.
Surrounded by a team of neurosurgeons, anesthesiologists, radiologists, radiology technicians and nurses, Nichole became the second patient at Children's to undergo an operation in the MR-OR the very next morning.
While anesthesiologist Craig McClain, MD, managed Nichole's anesthesia, Goumnerova removed Nichole's tumor using her usual metal surgical tools instead of the non-metallic instruments that must be used in other MR operating rooms. And before Goumnerova closed the wound, radiologist Caroline Robson, MB, ChB, deployed the MRI from its dock to scan Nichole's brain to determine if the entire tumor had been resected. And in fact, it had.
"Nichole's case is a perfect example of how the new MR-OR can be used to benefit our patients," says Goumnerova, citing that 12 patients have now undergone procedures in the new unit. "The quality of the images we obtained during her surgery was very good, so we were able to interpret them accurately to see if the tumor has been completely removed, therefore avoiding additional procedures."
By 11 a.m., Nichole was out of surgery and recovering in the MSICU, and by 2 p.m. that afternoon, she was already up and walking to the restroom with the help of her mother and her nurse. She spent just three additional days in the hospital before returning home.
"She was out of school for about a month, but that mostly has to do with the holidays," says Michelle. "And she's already caught up on all of her school work. You look at her, and you'd never even know she'd just had brain surgery. It's truly amazing."
Nichole returned to Children's in January for a follow-up visit with Goumnerova and was given a clean bill of health. "Nichole has recovered wonderfully from the surgery," says Goumnerova. "Her examination was normal, and she can return to her usual activities without any restrictions. Generally, these tumors have about a 96 percent cure rate if completely removed, so Nichole's long-term outcome is expected to be excellent."
