Stereo augmented reality in the surgical microscope

We present an augmented reality system that allows surgeons to view features from preoperative radiological images accurately overlaid in stereo in the optical path of a surgical microscope. The purpose of the system is to show the surgeon structures beneath the viewed surface in the correct 3-D position. The technical challenges are registration, tracking, calibration and visualisation. For patient registration, or alignment to preoperative images, we use bone-implanted markers and a dental splint is used for patient tracking. Both microscope and patient are tracked by an optical localiser. Calibration uses an accurately manufactured object with high contrast circular markers which are identified automatically. All ten camera parameters are modelled as a bivariate polynomial function of zoom and focus. The overall system has a theoretical overlay accuracy of better than 1 mm. Implementations of the system have been tested on seven patients. Recent measurements in the operating room conformed to our accuracy predictions. For visualisation the system has been implemented on a graphics workstation to enable high frame rates with a variety of rendering schemes. Several issues of 3-D depth perception remain unsolved, but early results suggest that perception of structures in the correct 3-D position beneath the viewed surface is possible.

Medical image registration

Radiological images are increasingly being used in healthcare and medical research. There is, consequently, widespread interest in accurately relating information in the different images for diagnosis, treatment and basic science. This article reviews registration techniques used to solve this problem, and describes the wide variety of applications to which these techniques are applied. Applications of image registration include combining images of the same subject from different modalities, aligning temporal sequences of images to compensate for motion of the subject between scans, image guidance during interventions and aligning images from multiple subjects in cohort studies. Current registration algorithms can, in many cases, automatically register images that are related by a rigid body transformation (i.e. where tissue deformation can be ignored). There has also been substantial progress in non-rigid registration algorithms that can compensate for tissue deformation, or align images from different subjects. Nevertheless many registration problems remain unsolved, and this is likely to continue to be an active field of research in the future.

Retinoic acid (RA) receptor transcriptional activation correlates with inhibition of 12-O-tetradecanoylphorbol-13-acetate-induced ornithine decarboxylase (ODC) activity by retinoids: a potential role for trans-RA-induced ZBP-89 in ODC inhibition

Evaluation of retinoic acid receptor (RAR) subtype-selective alpha and gamma agonists and antagonists and a retinoid X receptor (RXR) class-selective agonist for efficacy at inhibiting both induction of ornithine decarboxylase (ODC) by the tumor promoter 12-O-tetradecanoylphorbol-13-acetate (TPA) in mouse epidermis and rat tracheal epithelial cells and the appearance of papillomas in mouse epidermis treated in the 2-stage tumor initiation-promotion model indicated that (i) RXR class-selective transcriptional agonists, such as MM11246, were not involved in ODC inhibition; (ii) RAR-selective agonists that induce gene transcription from RA-responsive elements (RAREs) were active at low concentrations; (iii) RAR-selective antagonists that bind RARs and inhibit AP-1 activation on the collagenase promoter but do not activate RAREs to induce gene transcription were less effective inhibitors; and (iv) RARgamma-selective retinoid agonists were more effective inhibitors of TPA-induced ODC activity than RARalpha-selective agonists. These results suggest that RARE activation has a more important role in inhibition of ODC activity than RXR activation or AP-1 inhibition and that RARgamma-selective agonists would be the most useful inhibitors of epithelial cell proliferation induced by tumor promoters. The natural retinoid all-trans-RA induced expression of transcription factor ZBP-89, which represses activation of the GC box in the ODC promoter by the transcription factor Sp1.

Lack of functional and morphological susceptibility of the greater superficial petrosal nerve to developmental dietary sodium restriction

Restriction of dietary sodium during gestation has major effects on taste function and anatomy in the offspring. The chorda tympani nerve of offspring that are maintained on sodium-reduced chow throughout life (NaDep) has reduced neurophysiological responses to sodium and altered morphology of its terminal field in the nucleus of the solitary tract. There are many anatomical and physiological similarities between the chorda tympani nerve that innervates taste buds on the anterior tongue and the greater superficial petrosal nerve (GSP) that innervates taste buds on the palate. To determine if the GSP is similarly susceptible to the effects of dietary sodium restriction, the present study examined neurophysiological responses and the terminal field of the GSP in NaDep and control rats. Neurophysiological responses of the GSP to a variety of sodium and non-sodium stimuli did not differ between NaDep and control rats. Furthermore, the volume and shape of the GSP terminal field in the nucleus of the solitary tract did not differ between the groups. Therefore, despite the high degree of functional and anatomical correspondence between the chorda tympani nerve and the GSP, the GSP does not appear to be susceptible to the effects of lifelong dietary sodium restriction.

Design and evaluation of a system for microscope-assisted guided interventions (MAGI)

The problem of providing surgical navigation using image overlays on the operative scene can be split into four main tasks--calibration of the optical system; registration of preoperative images to the patient; system and patient tracking, and display using a suitable visualization scheme. To achieve a convincing result in the magnified microscope view a very high alignment accuracy is required. We have simulated an entire image overlay system to establish the most significant sources of error and improved each of the stages involved. The microscope calibration process has been automated. We have introduced bone-implanted markers for registration and incorporated a locking acrylic dental stent (LADS) for patient tracking. The LADS can also provide a less-invasive registration device with mean target error of 0.7 mm in volunteer experiments. These improvements have significantly increased the alignment accuracy of our overlays. Phantom accuracy is 0.3-0.5 mm and clinical overlay errors were 0.5-1.0 mm on the bone fiducials and 0.5-4 mm on target structures. We have improved the graphical representation of the stereo overlays. The resulting system provides three-dimensional surgical navigation for microscope-assisted guided interventions (MAGI).

Celecoxib inhibits N-butyl-N-(4-hydroxybutyl)-nitrosamine-induced urinary bladder cancers in male B6D2F1 mice and female Fischer-344 rats

Epidemiological studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) may have a role in the prevention of human cancers. A number of preclinical studies have also suggested that inhibition of cyclooxygenase (COX) with NSAIDs has an anticancer effect in animal models of colon, urinary bladder, skin, and breast. In these studies, we evaluated the COX-2 inhibitor celecoxib in two rodent models of urinary bladder cancer. Male B6D2F1 mice treated with N-butyl-N-(4-hydroxybutyl)-nitrosamine (OH-BBN) developed transitional and squamous cell urinary bladder cancers, many of which grew rapidly and caused substantial morbidity that required sacrifice of the mice. Groups of mice received various daily doses of celecoxib in the diet (1250, 500, or 200 mg/kg of diet) beginning 7 days before the initiation of 12 weekly doses of OH-BBN. Mice were checked weekly for the presence of palpable urinary bladder masses. The study was terminated at 8 months following the initial treatment with OH-BBN. The percentage of mice with large palpable bladder lesions, which necessitated sacrifice of the mice, was 40% in the OH-BBN control group. In contrast, only 10% of all celecoxib-treated mice required sacrifice before the scheduled termination of the experiment, implying that all three doses of celecoxib inhibited the formation of large palpable lesions. Celecoxib did not significantly alter the incidence of preneoplastic bladder lesions, but did dose-dependently decrease the total number of urinary bladder cancers/mouse, palpable plus microscopic, by 77, 57, and 43% at dosages of 1250, 500, and 200 mg of celecoxib/kg of diet, respectively. In the second model, female Fischer-344 rats were administered OH-BBN twice/week for a period of 8 weeks. After 8 months, all rats developed preneoplastic lesions, whereas roughly 60% of the rats developed relatively small urinary bladder cancers. Rats were treated continually with celecoxib in the diet (500 or 1000 mg/kg of diet) beginning either 1 week prior to the initial OH-BBN treatment or beginning 1 week following the last OH-BBN treatment. Neither celecoxib treatment regimen significantly altered the number of preneoplastic lesions. Whereas celecoxib treatment initiated prior to OH-BBN administration decreased cancer incidence roughly 65%, celecoxib treatment initiated beginning 1 week after the last dose of OH-BBN profoundly decreased cancer incidence (>95%). Celecoxib did not alter the body weights of the mice or rats, or cause other signs of toxicity at any of the doses studied. Taken together these results demonstrate that: (a) celecoxib effectively inhibits tumor growth and enhances survival in the mouse model of urinary bladder cancer; and (b) celecoxib profoundly inhibits development of urinary bladder cancers in the rat model even when administered following the last dose of OH-BBN. Clinical trials will be necessary to determine whether COX-2 inhibitors will provide a clinical benefit in human bladder cancer.

Development of rat chorda tympani sodium responses: evidence for age-dependent changes in global amiloride-sensitive Na(+) channel kinetics

In rat, chorda tympani nerve taste responses to Na(+) salts increase between roughly 10 and 45 days of age to reach stable, mature magnitudes. Previous evidence from in vitro preparations and from taste nerve responses using Na(+) channel blockers suggests that the physiological basis for this developmental increase in gustatory Na(+) sensitivity is the progressive addition of functional, Na(+) transduction elements (i.e., amiloride-sensitive Na(+) channels) to the apical membranes of fungiform papilla taste receptor cells. To avoid potential confounding effects of pharmacological interventions and to permit quantification of aggregate Na(+) channel behavior using a kinetic model, we obtained chorda tympani nerve responses to NaCl and sodium gluconate (NaGlu) during receptive field voltage clamp in rats aged from 12-14 to 60 days and older (60+ days). Significant, age-dependent increases in chorda tympani responses to these stimuli occurred as expected. Importantly, apical Na(+) channel density, estimated from an apical Na(+) channel kinetic model, increased monotonically with age. The maximum rate of Na(+) response increase occurred between postnatal days 12-14 and 29-31. In addition, estimated Na(+) channel affinity increased between 12-14 and 19-23 days of age, i.e., on a time course distinct from that of the maximum rate of Na(+) response increase. Finally, estimates of the fraction of clamp voltage dropped across taste receptor apical membranes decreased between 19-23 and 29-31 days of age for NaCl but remained stable for NaGlu. The stimulus dependence of this change is consistent with a developmental increase in taste bud tight junctional Cl(-) ion permeability that lags behind the developmental increase in apical Na(+) channel density. A significant, indirect anion influence on apical Na(+) channel properties was present at all ages tested. This influence was evident in the higher apparent apical Na(+) channel affinities obtained for NaCl relative to NaGlu. This stimulus-dependent modulation of apical Na(+) channel apparent affinity relies on differences in the transepithelial potentials between NaCl and NaGlu. These originate from differences in paracellular anion permeability but act also on the driving force for Na(+) through apical Na(+) channels. Detection of such an influence on taste depends fundamentally on the preservation of taste bud polarity and on a direct measure of sensory function, such as the response of primary afferents.

A system for microscope-assisted guided interventions

We present a system for surgical navigation using stereo overlays in the operating microscope aligned to the operative scene. This augmented reality system provides 3D information about nearby structures and offers a significant advancement over pointer-based guidance, which provides only the location of one point and requires the surgeon to look away from the operative scene. With a previous version of this system, we demonstrated feasibility, but it became clear that to achieve convincing guidance through the magnified microscope view, a very high alignment accuracy was required. We have made progress with several aspects of the system, including automated calibration, error simulation, bone-implanted fiducials and a dental attachment for tracking. We have performed experiments to establish the visual display parameters required to perceive overlaid structures beneath the operative surface. Easy perception of real and virtual structures with the correct transparency has been demonstrated in a laboratory and through the microscope. The result is a system with a predicted accuracy of 0.9 mm and phantom errors of 0.5 mm. In clinical practice errors are 0.5-1.5 mm, rising to 2-4 mm when brain deformation occurs.

Sources of error in comparing functional magnetic resonance imaging and invasive electrophysiological recordings

OBJECT

Several authors have recently reported studies in which they aim to validate functional magnetic resonance (fMR) imaging against the accepted gold standard of invasive electrophysiological monitoring. The authors have conducted a similar study, and in this paper they identify and quantify two characteristics of these data that can make such a comparison problematic.

METHODS

Eight patients in whom surgery for epilepsy was performed and five healthy volunteers underwent fMR imaging to localize the part of the sensorimotor cortex responsible for hand movement. In the patient group subdural electrode mats were subsequently implanted to identify eloquent regions of the brain and the epileptogenic zone. The fMR imaging data were processed to correct for motion during the study and then registered with a postimplantation computerized tomography (CT) scan on which the electrodes were visible. The motion during imaging in the two groups studied, and the deformation of the brain between the preoperative images and postoperative scans were measured. The patients who underwent epilepsy surgery moved significantly more during fMR imaging experiments than healthy volunteers performing the same motor task. This motion had a particularly increased out-of-plane component and was significantly more correlated with the stimulus than in the volunteers. This motion was especially increased when the patients were performing a task on the side affected by the lesion. The additional motion is hard to correct and substantially degrades the quality of the resulting fMR images, making it a much less reliable technique for use in these patients than in others. Also, the authors found that after electrode implantation, the brain surface can shift more than 10 mm relative to the skull compared with its preoperative location, substantially degrading the accuracy of the comparison of electrophysiological measurements made in the deformed brain and fMR studies obtained preoperatively.

CONCLUSIONS

These two findings indicate that studies of this sort are currently of limited use for validating fMR imaging and should be interpreted with care. Additional image analysis research is necessary to solve the problems caused by patients' motion and brain deformation.

Sampling and reconstruction effects due to motion in diffusion-weighted interleaved echo planar imaging

Subject motion during diffusion-weighted interleaved echo-planar imaging causes k-space offsets which lead to irregular sampling in the phase-encode direction. For each image, the k-space shifts are monitored using 2D navigator echoes, and are shown to lead to a frequent violation of the Nyquist condition when an ungated sequence is used on seven subjects. Combining data from four repeat acquisitions allows the Nyquist condition to be satisfied in all but 1% of images. Reconstruction of the irregularly-sampled data can be performed using a matrix inversion technique. The repeated acquisitions make the inversion more stable and additionally improve the signal-to-noise ratio. The resultant isotropic diffusion-weighted images and average apparent diffusion coefficient (ADC) maps show high resolution and enable clear localization of a stroke lesion. Residual ADC artifacts with a slow spatial variation are observed and assumed to originate from non-rigid pulsatile brain motion. Magn Reson Med 44:101-109, 2000.

Feasibility study of magnetic resonance imaging-guided intranasal flexible microendoscopy

Interventional magnetic resonance imaging (MRI) offers potential advantages over conventional interventional modalities such as X-ray fluoroscopy, ultrasonography, and computed tomography (CT). In particular, it does not use ionizing radiation, can provide high-quality images, and allows acquisition of oblique sections. We have carried out a feasibility study on the use of interventional MRI to track a flexible microendoscope in the paranasal sinuses. In this cadaver study, high-speed MRI was used to track a passive marker attached to the end of the endoscope. Automatic image registration algorithms were used to transfer the coordinates of the endoscope tip into the preoperative MRI and CT images, enabling us to display the position of the endoscope in reformatted orthogonal views or in a rendered view of the preoperative images. The endoscope video images were digitized and could be displayed alongside an approximately aligned, rendered preoperative image. Intraoperative display was provided in the scanner room by means of an liquid crystal display (LCD) projector. We estimate the accuracy of the endoscope tracking to be approximately 2 mm.

Neuron/target matching between chorda tympani neurons and taste buds during postnatal rat development

During postnatal development, a relationship is established between the size of individual taste buds and number of innervating neurons. To determine whether rearrangement of neurons that innervate taste buds establishes this relationship, we labeled single taste buds at postnatal day 10 (P10) and again at either P15, P20, or P40 with retrograde fluorescent neuronal tracers. The number of single- and double-labeled geniculate ganglion cells was counted, and the respective taste bud volumes were measured for the three groups of rats. The current study replicates findings from an earlier report demonstrating that the larger the taste bud, the more geniculate ganglion cells that innervate it. This relationship between taste bud size and number of innervating neurons is not apparent until P40, when taste bud size reaches maturity. These findings are extended here by demonstrating that the number of neurons that innervate taste buds at P10, when taste bud size is small and relatively homogeneous, predicts the size that the respective taste bud will become at maturity. Moreover, while there is some neural rearrangement of taste bud innervation from P10 to P40, rearrangement does not impact the relationship between taste bud size and innervating neurons. That is, the neurons that maintain contact with taste buds from P10 through P40 accurately predict the mature taste bud size. Therefore, the size of the mature taste bud is determined by P10 and relates to the number of sensory neurons that innervate it at that age and the number of neurons that maintain contact with it throughout the first 40 days of postnatal development.

Behavioral taste responses of developmentally NaCl-restricted rats to various concentrations of NaCl

The behavioral taste responses of developmentally NaCl-restricted rats were examined with a brief-exposure taste test. Neurophysiological and morphological alterations have been reported in rats whose dietary sodium is restricted during pre- and postnatal development, yet there exists little data discerning their behavioral response to tastants. Control and developmentally NaCl-restricted rats were maintained on a low-NaCl diet and trained to lick from individually presented sipper tubes. Each subject received 4 days of testing on various NaCl concentrations. Results indicate that developmentally NaCl-restricted rats have dramatically increased lick rates to NaCl solutions. These responses are likely due to some combination of factors including (a) numbers and type of active chorda tympani fibers, (b) compensatory responses to NaCl-solutions from other nerves of the oral cavity, and (c) increased sensitivity of central taste systems to NaCl.

Voxel similarity measures for 3-D serial MR brain image registration

We have evaluated eight different similarity measures used for rigid body registration of serial magnetic resonance (MR) brain scans. To assess their accuracy we used 33 clinical three-dimensional (3-D) serial MR images, with deformable extradural tissue excluded by manual segmentation and simulated 3-D MR images with added intensity distortion. For each measure we determined the consistency of registration transformations for both sets of segmented and unsegmented data. We have shown that of the eight measures tested, the ones based on joint entropy produced the best consistency. In particular, these measures seemed to be least sensitive to the presence of extradural tissue. For these data the difference in accuracy of these joint entropy measures, with or without brain segmentation, was within the threshold of visually detectable change in the difference images.

The identification of cerebral volume changes in treated growth hormone-deficient adults using serial 3D MR image processing

PURPOSE

A pilot study to detect volume changes of cerebral structures in growth hormone (GH)-deficient adults treated with GH using serial 3D MR image processing and to assess need for segmentation prior to registration was conducted.

METHOD

Volume MR scans of the brain were obtained in five patients and six control subjects. Patients were scanned before and after 3 and 6 months of therapy. Control subjects were scanned at the same intervals. A phantom was used to quantify scaling errors. Second and third volumes were aligned with the baseline by maximizing normalized mutual information and transformed using sinc interpolation. Registration was performed with and without brain segmentation and correction of scaling errors. Each registered, transformed image had the original subtracted, generating a difference image. Structural change and effects of segmentation and scaling error correction were assessed on original and difference images. The radiologists' ability to detect volume change was also assessed.

RESULTS

Compared with control subjects, GH-treated subjects had an increase in cerebral volume and reduction in ventricular volume (p = 0.91 x 10(-3)). Scale correction and segmentation made no difference (p = 1 and p = 0.873). Structural changes were identified in the difference images but not in the original (p = 0.136). The radiologists detected changes >200 microm.

CONCLUSION

GH treatment in deficient patients results in cerebral volume changes detectable by registration and subtraction of serial MR studies but not by standard assessment of images. This registration method did not require prior segmentation.

Comparison and evaluation of rigid, affine, and nonrigid registration of breast MR images

PURPOSE

A new nonrigid registration method, designed to reduce the effect of movement artifact in subtraction images from breast MR, is compared with existing rigid and affine registration methods.

METHOD

Nonrigid registration was compared with rigid and affine registration methods and unregistered images using 54 gadolinium-enhanced 3D breast MR data sets. Twenty-seven data sets had been previously reported normal, and 27 contained a histologically proven carcinoma. The comparison was based on visual assessment and ranking by two radiologists.

RESULTS

When analyzed by two radiologists independently, all three registration methods gave better-quality subtraction images than unregistered images (p < 0.01), but nonrigid registration gave significantly better results than the rigid and affine registration methods (p < 0.01). There was no significant difference between rigid and affine registration methods.

CONCLUSION

Nonrigid registration significantly reduces the effects of movement artifact in subtracted contrast-enhanced breast MRI. This may enable better visualization of small tumors and those within a glandular breast.

Nonrigid registration using free-form deformations: application to breast MR images

In this paper we present a new approach for the nonrigid registration of contrast-enhanced breast MRI. A hierarchical transformation model of the motion of the breast has been developed. The global motion of the breast is modeled by an affine transformation while the local breast motion is described by a free-form deformation (FFD) based on B-splines. Normalized mutual information is used as a voxel-based similarity measure which is insensitive to intensity changes as a result of the contrast enhancement. Registration is achieved by minimizing a cost function, which represents a combination of the cost associated with the smoothness of the transformation and the cost associated with the image similarity. The algorithm has been applied to the fully automated registration of three-dimensional (3-D) breast MRI in volunteers and patients. In particular, we have compared the results of the proposed nonrigid registration algorithm to those obtained using rigid and affine registration techniques. The results clearly indicate that the nonrigid registration algorithm is much better able to recover the motion and deformation of the breast than rigid or affine registration algorithms.

Early dietary sodium restriction disrupts the peripheral anatomical development of the gustatory system

Dietary sodium restriction has profound effects on the development of peripheral taste function and central taste system anatomy. This study examined whether early dietary sodium restriction also affects innervation of taste buds. The number of geniculate ganglion cells that innervate single fungiform taste buds were quantified for the midregion of the tongue in two groups of rats: those fed either a low-sodium diet and those fed a sodium replete diet (control rats) from early prenatal development through adulthood. The same mean number of ganglion cells in developmentally sodium-restricted and control adult rats innervated taste buds on the midregion of the tongue. However, the characteristic relationship of the larger the taste bud, the more neurons that innervate it did not develop in sodium-restricted rats. The failure to form such a relationship in experimental rats was likely due to a substantially smaller mean taste bud volume than controls and probably not to changes in innervation. Further experiments demonstrated that the altered association between number of innervating neurons and taste bud size in restricted rats was reversible. Feeding developmentally sodium-restricted rats a sodium replete diet at adulthood resulted in an increase in taste bud size. Accordingly, the high correlation between taste bud volume and innervation was established in sodium-replete rats. Findings from the current study reveal that early dietary manipulations influence neuron-target interactions; however, the effects of dietary sodium restriction on peripheral gustatory anatomy can be completely restored, even in adult animals.

Taste responses in the greater superficial petrosal nerve: substantial sodium salt and amiloride sensitivities demonstrated in two rat strains

A great quantity of research has focused on neural responses of the chorda tympani nerve (CT) to taste stimuli. This report examined salt and sugar sensitivity of the greater superficial petrosal nerve (GSP) and the effect of amiloride on these neural responses. In addition to Sprague-Dawley (SD) rats that have CT responses typical of most rat strains, we included Fischer 344 (F344) rats whose CT responses to sodium chloride (NaCl) are higher than those of other strains. After a stimulation series in which water served as the rinse, a series of stimuli was presented in 100 microM amiloride. The GSP was highly responsive to NaCl, sodium acetate (NaAc), ammonium chloride, and sucrose; NaCl and NaAc responses were strongly suppressed by amiloride. Relative responses to NaCl were significantly higher in F344 than in SD rats. In summary, the GSP is highly sensitive to salt and sugar stimulation, and palatal taste receptors have a considerable degree of amiloride sensitivity.

Screening of potential cancer preventing chemicals as aromatase inhibitors in an in vitro assay

The inhibition of human placental aromatase was used to rank a series of compounds, with the objective of selecting compounds for further evaluation as chemopreventive agents. (+/-)-p-Aminoglutethimide, introduced over two decades ago as a treatment for breast cancer, had an IC50 of 6.5 microM. Five compounds were more potent than aminoglutethimide in this assay: (+)- vorozole, 4-hydroxyandrostenedione, miconazole nitrate, plomestane, and 4-methoxy-androst-4-ene-3,17-dione. Other compounds with known chemoprevention activity, such as curcumin and genistein, were inactive. This assay for aromatase inhibitors is a rapid, economical way of ranking compounds for further development as chemoprevention agents.

Automatic compensation of motion artifacts in MRI

Patient motion during the acquisition of a magnetic resonance image can cause blurring and ghosting artifacts in the image. This paper presents a new post-processing strategy that can reduce artifacts due to in-plane, rigid-body motion in times comparable to that required to re-scan a patient. The algorithm iteratively determines unknown patient motion such that corrections for this motion provide the best image quality, as measured by an entropy-related focus criterion. The new optimization strategy features a multi-resolution approach in the phase-encode direction, separate successive one-dimensional searches for rotations and translations, and a novel method requiring only one re-gridding calculation for each rotation angle considered. Applicability to general rigid-body in-plane rotational and translational motion and to a range of differently weighted images and k-space trajectories is demonstrated. Motion artifact reduction is observed for data from a phantom, volunteers, and patients.

A three-component deformation model for image-guided surgery

In image-guided surgery it is necessary to align preoperative image data with the patient. The rigid-body approximation is usually applied, but is often not valid due to tissue deformation. Non-rigid deformation algorithms have been applied to related, but not identical problems, such as atlas matching and surgery simulation. In image-guided surgery we have the additional information that the deformation is constrained by the physical properties of the different tissues. The most important properties that must be incorporated are the rigidity of bone, the unconstrained nature of fluid regions and the relatively smooth deformation of soft tissue. Hence, we have developed a simplified model of tissue deformation based on a three-component system. Rigid regions are constrained by the rigid-body transformation and fluid regions are unconstrained. A number of energy models for deformable tissues have been compared. The model can be deformed using intraoperative data, in this case landmarks, using a technique similar to active contours. A novel strategy to avoid folding in the transformation is described. Our method was applied to MRI and CT data from a neurosurgery patient with epilepsy. Although the current implementation is only two dimensional, the initial results are promising. As the algorithm must ultimately run in or near 'real-time' an improved implementation of the energy minimization is underway. This paper presents the problem of tissue deformation, which has received little attention in the literature and outlines the framework we have developed for tackling this difficult subject.