Functional brain MR battles technological, economic barriers

No better way exists than functional MRI to plot the intricate neural pathways of the brain. Neurosurgeons regularly call on this technique to plan surgical routes around eloquent brain areas, yet fMRI's potential has remained untapped, largely due to benign neglect on the part of developers and third-party payers. The recent formation of a society dedicated to fMRI might change that situation.

The American Society of Functional Neuroradiology (ASFNR), formed in 2004, plans to help convince vendors to standardize capabilities and make them more accessible, according to group president Dr. Andrei Holodny, a neuroradiologist at Memorial Sloan-Kettering Cancer Center. The society is also focusing on the development of practice standards and training guidelines in the hope of more quickly bringing research advances into clinical practice.

Turf is not an issue. Preoperative functional brain mapping is primarily performed and interpreted by radiologists, Holodny said in a session dedicated to fMRI at the 2005 RSNA meeting. The problem is unlocking the capabilities of this technology. Radiologists typically need a physicist to help analyze the data. An informal query of panel attendees revealed that most use a physicist and perform 50 or fewer fMR scans per month.

"The impediment right now to moving fMRI to the clinical arena is the lack of user-friendly software," he said. "There is little doubt that fMRI is a good tool to the surgeon. But physicians in private practice don't have the ability or the time to install the right software."

Software programs that come with certain MR packages generally are not as sensitive as dedicated programs, but they do enable radiologists to view in real-time preliminary online fMRI data, according to Arthur Wunderlich, Ph.D., a physicist at University Hospital Ulm in Germany. These programs can help determine whether the patient understands and executes the tasks correctly.

Panel member Dr. John Ulmer, a neuroradiologist at the Medical College of Wisconsin and vice president of the ASFNR, encouraged neuroradiologists to use diffusion tensor imaging as a complement to fMRI.

"DTI is so easy to perform," he said. "All neuroradiologists who serve neurosurgeons will be required to do DTI, and fMRI powers that."

Regardless of developments in technique, however, the adoption of fMRI will be restrained until reimbursement issues are adequately addressed. The ASFNR is spearheading efforts to get CPT codes issued for fMR brain scans, a first step toward widespread reimbursement. The next step is to produce enough data to convince the Centers for Medicare and Medicaid Services to reimburse for the procedure, Holodny said.

Ulmer predicted that the availability of CPT codes for fMRI will produce an explosion in demand for the procedure from neurosurgeons.

ASFNR officials have recruited about 150 members - three times the number they had expected to enroll by this time. The specialized society met during the annual American Society of Neuroradiology meeting, but the group expects to have its own meeting in 2007.