title: Neurosurgical tools to extend tumor resection in pediatric hemispheric low-grade gliomas: iMRI.
abstract: BACKGROUND
  The treatment of low-grade gliomas (LGGs) in pediatric age is still controversial. However, most authors report longer life expectancy in case of completely removed cerebral gliomas. Intraoperative magnetic resonance imaging (iMRI) is increasingly utilized in the surgical management of intra-axial tumor in adults following the demonstration of its effectiveness. In this article, we analyze the management of LGG using iMRI focusing on its impact on resection rate and its limits in the pediatric population.
  
  
  METHODS
  We performed review of the literature regarding the treatment of LGG using iMRI focusing on its impact on resection rate and its limits in the pediatric population. Some exemplary cases are also described.
  
  
  RESULTS
  Intraoperative MRI allowed extension of tumor resection after the depiction of residual tumor at the intraoperative imaging control from 21 to 52 % of the cases in the published series. Moreover, the early reoperation rate was significantly lower when compared with the population treated without this tool (0 % vs 7-14 %). Some technical difficulties have been described in literature regarding the use of iMRI in the pediatric population especially for positioning due to the structure of the headrest coil designed for adult patients.
  
  
  CONCLUSIONS
  The analysis of the literature and our own experience with iMRI in children indicates significant advantages in the resection of LGG offered by the technique. All these advantages are obtained without elongation of the surgical times or increased risk for complications, namely infection. The main limit for a wider diffusion of iMRI for the pediatric neurosurgical center is the cost required, for acquisition of the system, especially for high-field magnet, and the environmental and organizational changes necessary for its use.
authors.affiliation: Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany. giordano.nch@gmail.com.
authors.forename: Mario
authors.identifier: http://orcid.org/0000-0001-8094-1297
authors.initials: M
authors.lastname: Giordano
authors.affiliation: Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany.
authors.forename: Cinta
authors.initials: C
authors.lastname: Arraez
authors.affiliation: Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany.
authors.forename: Amir
authors.initials: A
authors.lastname: Samii
authors.affiliation: Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany.
authors.forename: Madjid
authors.initials: M
authors.lastname: Samii
authors.affiliation: Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625, Hannover, Germany.
authors.forename: Concezio
authors.initials: C
authors.lastname: Di Rocco
mesh_terms: D001932:Brain Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D002648:Child; D005260:Female; D007839:Functional Laterality / Q000502:physiology*; D005910:Glioma / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D016343:Monitoring, Intraoperative; D019635:Neurosurgical Procedures / Q000379:methods*; D010372:Pediatrics
keywords: Children; Glioma; Intraoperative magnetic resonance imaging; Neuroimaging