Timisoara MRI Spectroscopy Investigation
Dr. Stanca Mihaela Ples is primary neurosurgeon in the Department of Neurosurgery of the Clinical Emergency Hospital in Timisoara and physician in the Neuromed Medical Diagnostic Imaging Center. The specialist from Timisoara speaks for opiniatimisoarei.ro about a pack of investigations that is being offered only in Timisoara and the importance of spectroscopy, at Neuromed Medical Diagnostic Imaging Center.
Timisoara is the only center in the country where spectroscopy is performed, a type of investigation that can eventually help patients get rid of surgeries? Was it also the first one?
We are the first center in Romania, we started in 2008. It all started with the desire to know more, so that the image that we get, what you can see, is a physical image. It is the conversion of the organs' characteristics that can be seen in physical images. Simple information about the component of these images does not exist. Spectroscopy was a method that chemists have developed so that what is seen can be also quantified.
MRI spectroscopy is a chemical measurement, the transformation of the physical picture into a chemical picture. Just like in forensic laboratories, where samples are taken from tissues, samples are taken from fragments that are discovered when an incident happens. Yet, spectroscopy is done in two ways: in vivo spectroscopy when the patient does only am MRI and an evaluation is done with the patient in MRI and in vitro spectroscopy, when laboratory samples are taken (tissue or fluid). The tissue sample is simply taken and put in the MRI device and analyzed.
What does the patient that needs this investigation go through? He simply does an MRI?
The patient enters an MRI just like in a conventional investigation. The spectroscopy is never made without a prior conventional investigation. Any investigation begins with the classical part, the end of the investigation means adding the spectroscopic sequences to the conventional ones. Basically, the main region of interest is centered, different types of spectroscopic evaluations are performed, certain metabolites resonate at a particular spectrum and the second spectrum resonates other metabolites.
At the end of the investigation we have two kinds of spectroscopy. Together they give a graph in which there are some peaks of some metabolites with integral values. With regards to the patient's evaluation, the evaluation through reports of metabolites is very important. Often, the lesions are identical to on the conventional MRI and then the difference is huge. When you have an infection, a tumor or injury of any kind and it is identical on the conventional image, the only possibility is the chemical analysis. The chemical differences are so big that it is almost impossible to make a mistake. This means a sensitivity of 95%, which is a lot.
This type of investigation excludes biopsy? Can the patient get rid of the surgery?
Yes, it excludes it in certain situations. Biopsy started to be performed again after spectroscopy, but there is nothing safer than biopsy. If in certain regions of the tumor there are different types of tumors, the spectroscopy shows which is the area that we need to target in the biopsy. If a doctor takes samples from an area which is external to the tumor and the malignancy is in another area, then the diagnosis is lost. Spectroscopy provides orientation. During the first cases that we have had, the doctors have called me and thanked me especially because they knew exactly where to take samples from, because otherwise the real diagnosis would have been lost.
Since 2008 and up to now you had over 1,000 ... you are working with a pretty strong team here. How much do the specialists matter compared to the software?
The team begins from the doctor who prepares the patient and who keeps him absolutely motionless during spectroscopy ... because the chemically evaluated area must remain the same from the beginning to the end; any movement involves an alteration of the diagnosis. And then, the first physician in contact with the patient is the anesthesiologist who must ensure that during this investigation the patient is absolutely motionless. Then there is the physicist, conducting the practical investigation, then the radiologist who always monitors it and finally the team that interprets the result.
Neuromed offers a complete package of a neuro-diagnostic. How important is spectroscopy in this package and what does it involve more exactly?
This package begins with spectroscopy. In time, the results of some analyzes can also be wrong. Other methods are starting to be necessary to be added to the spectroscopy. This means that in case of identical spectra with injuries which are absolutely different, something else was needed. Something else in this case means the method of the infusion type. That means that each lesion, when it is made for example in a certain area of the brain, it is infused in a certain way. The way it receives blood and the amount of blood circulating is very specific to different tumor types. In this way we are approaching even more of the final diagnosis.
Where else is exactly this package of neuro-diagnostic offered?
Spectroscopy is also performed in Budapest, but I do not think that there they offer this entire package. There is also a very good center in Vienna where spectroscopy is performed, but even there, I do not think that the neuro-diagnostic package is defined.
Spectroscopy is a type of investigation that can be done in many areas, not just in neurology?
We also have many patients from Oncology. We perform preoperative evaluation, if necessary, but the postoperative assessment is very important. I mean the lesion is removed and the patient is monitored through spectroscopy if this lesion is recurrent or not. The pathology is very very different, we are not talking only about tumors. We had a case treated abroad, it went all wrong, the patient came to Timisoara, became drowsy, felt into a coma, the patient received the treatment for parasite from Vienna ... we performed a spectroscopy and I called the doctor to ask him to change the treatment because it was not an infection, but a pathology that required a completely different treatment.
Out of over 1,000 cases, how many were problems?
We had many identical cases that have posed problems. We had a situation with three identical images, one was abscess and during night time I remembered that I can go and ask for another investigation, because otherwise the operation would have turned into a tragedy.
There is one thing to remove an abscess and something different to remove a tumor, surgeries themselves are completely different. We've had also cases with diagnoses that implied a survival between six months and one year, as average survival depending on the tumor type ... I recently had a consultation, the patient is still alive for about 7 years ... we are monitoring him through spectroscopy and each time the area tends to recur, the patient receives therapy again.
Where do most patients who use this method come from? Because they are not only from Timisoara. Do you also have patients from abroad?
The neurosurgical centers from the country send a lot. Many patients came from Cluj, Bucharest, Iasi, Targu Mures ... from abroad we have even patients from Vienna, they are not necessarily Romanians, they are also foreigners. We have presented the method at hospitals in Amsterdam, Rotterdam, Paris, Bonn, Berlin, Vienna, where it was understood, known, but the specialists from there did not know that it is so easily approachable at a distance not so far from them.
Do you have many children patients?
Yes, unfortunately ... about 20% of those who come are children who come for epileptic pathology. The epileptogenesis areas are easier to be searched during spectroscopy. Most of the times we find exactly the lesion and the cause for which these children have epilepsy. From my point of view, they have a maximum benefit, because they basically find the area that cause epilepsy and the doctor knows exactly what to treat.
Does spectroscopy save lives so easily?
Yes! That is why I insisted so much in bringing it to Timisoara. I am glad that in the end people have become accustomed and have a comfort knowing that when the lesion is inoperable there is a way to put a diagnose and the chance after all to receive treatment without surgery.
Besides that, you also hold courses on this subject. With what frequency do they occur and who participates exactly?
Unfortunately, I cannot hold them that often, I am pretty busy. But I held at least 33 presentations last year. I had lectures for physicians, I presented strictly the pathology with which they are dealing, I also had students. This year, unfortunately, I have not had so many courses, although they are very much required. I hope to do a class every two weeks starting from autumn.
How did you ultimately manage to bring this method to Timisoara? You started in 1999, at Neuromed, with a single MRI ...
The first MRI that I bought started from the desire to have an investigation of the MRI type in this area of the country, to make it available to the patients 24 hours from 24. We were eight people and we ensured non-stop guard. A third MRI was brought in Romania and the first one that was given up in Romania - has been replaced with a new MRI. It was a desire to get more, I was not at all satisfied with what I saw ...
Spectroscopy was the method that I saw in Marrakech in 2005 ... at the beginning the doctors did not trust the method. I found it very interesting, I started reading about the method and said that it was very useful. I worked for two years to set the device so that it can support the spectroscopy and since 2008 we simply do the investigation, with a team of 12 specialists.
We perform only one spectroscopy per day, because the workload is very high, the image processing takes hours and there are over 8,000 images. At Neuromed, a conventional MRI has between 500 and 800 images. If at the beginning I had two spectroscopy per week, now we do at maximum two per day, because they cannot be processed at the rate at which it takes to obtain the result.
Does Timisoara remain the only center in Romania where such investigations are made?
Yes! It was tried in Bucharest as well. I was asked to take a look over spectroscopic investigations from other centers, but my demands are slightly higher regarding the quality of the images and what is obtained during spectroscopy. For the neuro-diagnostic package (spectroscopy, perfusion, diffusion, magnetic susceptibility), the reference remains Timisoara. It is very important that from a nonsurgical point of view and with a sensitivity of 95% to get a result about the lesion. There are strange situations when I did spectroscopy after the injury had a pathological anatomy. We had situations in which the biopsy was uncertain and we decided to do spectroscopy.
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