Application, utility and safety of intraoperative 3T magnetic resonance imaging in pediatric epilepsy surgery: A 10-year retrospective single-center experience

Background: Intraoperative magnetic resonance imaging (ioMRI) is increasingly used in neurosurgery to enhance surgical precision and decision-making. However, its implementation remains limited due to high costs, infrastructure demands, and workflow considerations. While well studied in adult neurosurgery, the role of ioMRI in pediatric epilepsy surgery is less clear. Reported challenges include wound complications, infections, and positioning difficulties. This study evaluates the application, utility, and safety of intraoperative 3T MRI in pediatric epilepsy surgery over a ten-year period at a tertiary specialized referral center. Methods: This retrospective study analyzed data from all pediatric epilepsy surgeries performed between 2013 and 2022 in our unit. We reviewed patient demographics, the treated pathologies, the application of intraoperative 3T MRI (ioMRI), the extent of continued ioMRI-guided surgery, seizure outcomes at one year postoperatively, and the requirement for reoperation. Intraoperative MRI-related complications documented within 90 days of surgery were also assessed. Results: Altogether, 125 pediatric epilepsy patients underwent surgery. Resections were performed in 107 (85.6 %) and disconnection procedures in 18 (14.4 %) patients. Their overall median age was 10 years (range 0.5-19 years). In total, 108 (86.4 %) patients underwent surgery with ioMRI. Of these, 91 (84.3 %) had resection and 17 (15.7 %) had disconnection surgery. Of the 108 patients with ioMRI 56 (51.9 %) returned to theater, 45 (49.5 %) out of 91 for further resection, and 11 (64.7 %) out of 17 to complete disconnection. Thirteen (12 %) of the 108 patients were reoperated upon later in another session. In total, 17 (13.6 %) patients had surgery without ioMRI, 16 (94.1 %) of these for resection and 1 (5.9 %) for disconnection surgery; of these 3 (17.6 %) were reoperated upon later in another session. The complication rate for surgeries performed with ioMRI was 3.7 %. There were no wound healing disorders, position-related damages, or anesthesia-related complications. Conclusions: While the technology may present certain logistical and financial challenges, we observed a lower rate of reoperations and a low complication rate in ioMRI-guided resective epilepsy surgeries in children compared to surgeries without ioMRI. These findings require confirmation through larger, multi-center studies to better define the role of ioMRI in pediatric epilepsy surgery.