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Tanrikulu L. Microscope-Based Augmented Reality: A New Approach in Intraoperative 3D Visualization in Microvascular Decompression? Cureus 2024; 16:e62417. [PMID: 39011207 PMCID: PMC11248489 DOI: 10.7759/cureus.62417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/17/2024] Open
Abstract
Neurovascular compression (NVC) syndromes such as trigeminal neuralgia (TN) are causally treated with microvascular decompression (MVD). Semiautomatic segmentation of high-resolution magnetic resonance imaging (MRI) data and constructive interference in steady state (CISS)/time-of-flight (TOF) sequences are utilized for the three-dimensional (3D) visualization of underlying causative vessels at the root entry zones of the relevant cranial nerves. Augmented reality (AR) of neurovascular structures was introduced especially in the resection of brain tumors or aneurysmatic operations. In this report, the potential feasibility of the implementation of microscope-based AR into the intraoperative microsurgical set-up of MVD was investigated. This article recommends the preoperative evaluation of 3D visualization besides the microscopical view of the surgeon. The implementation of multiple imaging data by AR into the operating microscope may afflict the experienced surgeon's view, which should be examined prospectively.
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Affiliation(s)
- Levent Tanrikulu
- Neurooncology, Klinik Sonnenblick, University of Marburg, Marburg, DEU
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Bsat S, Alshareef M, Pazniokas J, Handler MH. Technical evolution of pediatric neurosurgery: the evolution of intraoperative imaging. Childs Nerv Syst 2023; 39:2605-2611. [PMID: 37518061 DOI: 10.1007/s00381-023-06040-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/17/2023] [Indexed: 08/01/2023]
Abstract
Imaging has always been fundamental to neurosurgery, and its evolution over the last century has made a dramatic transformation in the ability of neurosurgeons to define pathology and preserve normal tissue during their operations. In the mid-70 s, the development of computerized cross-sectional imaging with CT scan and subsequently MRI have revolutionized the practice of neurosurgery. Later, further advances in computer technology and medical engineering have allowed the combination of many modalities to bring them into the operating theater. This evolution has allowed real-time intraoperative imaging, in the hope of helping neurosurgeons achieve accuracy, maximal safe resection, and the implementation of minimally invasive techniques in brain and spine pathologies. Augmented reality and robotic technologies are also being applied as useful intra-operative techniques that will improve surgical planning and outcomes in the future. In this article, we will review imaging modalities and provide our institutional perspective on how we have integrated them into our practice.
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Affiliation(s)
- Shadi Bsat
- Department of Neurological Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Mohammed Alshareef
- Department of Neurological Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Julia Pazniokas
- Department of Neurological Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael H Handler
- Department of Neurological Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
- Children's Hospital Colorado, Aurora, CO, USA.
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Mazzucchi E, Hiepe P, Langhof M, La Rocca G, Pignotti F, Rinaldi P, Sabatino G. Automatic rigid image Fusion of preoperative MR and intraoperative US acquired after craniotomy. Cancer Imaging 2023; 23:37. [PMID: 37055790 PMCID: PMC10099637 DOI: 10.1186/s40644-023-00554-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/05/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Neuronavigation of preoperative MRI is limited by several errors. Intraoperative ultrasound (iUS) with navigated probes that provide automatic superposition of pre-operative MRI and iUS and three-dimensional iUS reconstruction may overcome some of these limitations. Aim of the present study is to verify the accuracy of an automatic MRI - iUS fusion algorithm to improve MR-based neuronavigation accuracy. METHODS An algorithm using Linear Correlation of Linear Combination (LC2)-based similarity metric has been retrospectively evaluated for twelve datasets acquired in patients with brain tumor. A series of landmarks were defined both in MRI and iUS scans. The Target Registration Error (TRE) was determined for each pair of landmarks before and after the automatic Rigid Image Fusion (RIF). The algorithm has been tested on two conditions of the initial image alignment: registration-based fusion (RBF), as given by the navigated ultrasound probe, and different simulated course alignments during convergence test. RESULTS Except for one case RIF was successfully applied in all patients considering the RBF as initial alignment. Here, mean TRE after RBF was significantly reduced from 4.03 (± 1.40) mm to (2.08 ± 0.96 mm) (p = 0.002), after RIF. For convergence test, the mean TRE value after initial perturbations was 8.82 (± 0.23) mm which has been reduced to a mean TRE of 2.64 (± 1.20) mm after RIF (p < 0.001). CONCLUSIONS The integration of an automatic image fusion method for co-registration of pre-operative MRI and iUS data may improve the accuracy in MR-based neuronavigation.
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Affiliation(s)
- Edoardo Mazzucchi
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy.
- Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy.
| | | | | | - Giuseppe La Rocca
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
- Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Fabrizio Pignotti
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
- Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | | | - Giovanni Sabatino
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
- Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
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Costa M, Pierre C, Vivanco-Suarez J, Baldoncini M, Tymchak Z, Patel A, Monteith SJ. Head-Mounted Augmented Reality in the Planning of Cerebrovascular Neurosurgical Procedures: A Single-Center Initial Experience. World Neurosurg 2023; 171:e693-e706. [PMID: 36566980 DOI: 10.1016/j.wneu.2022.12.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Augmented reality (AR) technology has played an increasing role in cerebrovascular neurosurgery over the last 2 decades. Hence, we aim to evaluate the technical and educational value of head-mounted AR in cerebrovascular procedures. METHODS This is a single-center retrospective study of patients who underwent open surgery for cranial and spinal cerebrovascular lesions between April and August 2022. In all cases, the Medivis Surgical AR platform and HoloLens 2 were used for preoperative and intraoperative (preincision) planning. Surgical plan adjustment due to the use of head-mounted AR and subjective educational value of the tool were recorded. RESULTS A total of 33 patients and 35 cerebrovascular neurosurgical procedures were analyzed. Procedures included 12 intracranial aneurysm clippings, 6 brain and 1 spinal arteriovenous malformation resections, 2 cranial dural arteriovenous fistula obliterations, 3 carotid endarterectomies, two extracranial-intracranial direct bypasses, two encephaloduroangiosynostosis for Moyamoya disease, 1 biopsy of the superficial temporal artery, 2 microvascular decompressions, 2 cavernoma resections, 1 combined intracranial aneurysm clipping and encephaloduroangiosynostosis for Moyamoya disease, and 1 percutaneous feeder catheterization for arteriovenous malformation embolization. Minor changes in the surgical plan were recorded in 16 of 35 procedures (45.7%). Subjective educational value was scored as "very helpful" for cranial, spinal arteriovenous malformations, and carotid endarterectomies; "helpful" for intracranial aneurysm, dural arteriovenous fistulas, direct bypass, encephaloduroangiosynostosis, and superficial temporal artery-biopsy; and "not helpful" for cavernoma resection and microvascular decompression. CONCLUSIONS Head-mounted AR can be used in cerebrovascular neurosurgery as an adjunctive tool that might influence surgical strategy, enable 3-dimensional understanding of complex anatomy, and provide great educational value in selected cases.
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Affiliation(s)
- Matias Costa
- Cerebrovascular Neurosurgery, Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA.
| | - Clifford Pierre
- Cerebrovascular Neurosurgery, Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Juan Vivanco-Suarez
- Cerebrovascular Neurosurgery, Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Matias Baldoncini
- Department of Neurological Surgery, Hospital San Fernando, Argentina
| | - Zane Tymchak
- Cerebrovascular Neurosurgery, Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Akshal Patel
- Cerebrovascular Neurosurgery, Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Stephen J Monteith
- Cerebrovascular Neurosurgery, Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
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Bopp MHA, Saß B, Pojskić M, Corr F, Grimm D, Kemmling A, Nimsky C. Use of Neuronavigation and Augmented Reality in Transsphenoidal Pituitary Adenoma Surgery. J Clin Med 2022; 11:jcm11195590. [PMID: 36233457 PMCID: PMC9571217 DOI: 10.3390/jcm11195590] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/17/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to report on the clinical experience with microscope-based augmented reality (AR) in transsphenoidal surgery compared to the classical microscope-based approach. AR support was established using the head-up displays of the operating microscope, with navigation based on fiducial-/surface- or automatic intraoperative computed tomography (iCT)-based registration. In a consecutive single surgeon series of 165 transsphenoidal procedures, 81 patients underwent surgery without AR support and 84 patients underwent surgery with AR support. AR was integrated straightforwardly within the workflow. ICT-based registration increased AR accuracy significantly (target registration error, TRE, 0.76 ± 0.33 mm) compared to the landmark-based approach (TRE 1.85 ± 1.02 mm). The application of low-dose iCT protocols led to a significant reduction in applied effective dosage being comparable to a single chest radiograph. No major vascular or neurological complications occurred. No difference in surgical time was seen, time to set-up patient registration prolonged intraoperative preparation time on average by twelve minutes (32.33 ± 13.35 vs. 44.13 ± 13.67 min), but seems justifiable by the fact that AR greatly and reliably facilitated surgical orientation and increased surgeon comfort and patient safety, not only in patients who had previous transsphenoidal surgery but also in cases with anatomical variants. Automatic intraoperative imaging-based registration is recommended.
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Affiliation(s)
- Miriam H. A. Bopp
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (CMBB), 35032 Marburg, Germany
- Correspondence:
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
| | - Mirza Pojskić
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
| | - Felix Corr
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
- EDU Institute of Higher Education, Villa Bighi, Chaplain’s House, KKR 1320 Kalkara, Malta
| | - Dustin Grimm
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
- EDU Institute of Higher Education, Villa Bighi, Chaplain’s House, KKR 1320 Kalkara, Malta
| | - André Kemmling
- Department of Neuroradiology, University of Marburg, 35043 Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (CMBB), 35032 Marburg, Germany
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Aguilar-Salinas P, Gutierrez-Aguirre SF, Avila MJ, Nakaji P. Current status of augmented reality in cerebrovascular surgery: a systematic review. Neurosurg Rev 2022; 45:1951-1964. [PMID: 35149900 DOI: 10.1007/s10143-022-01733-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/01/2021] [Accepted: 01/05/2022] [Indexed: 12/29/2022]
Abstract
Augmented reality (AR) is an adjuvant tool in neuronavigation to improve spatial and anatomic understanding. The present review aims to describe the current status of intraoperative AR for the treatment of cerebrovascular pathology. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following databases were searched: PubMed, Science Direct, Web of Science, and EMBASE up to December, 2020. The search strategy consisted of "augmented reality," "AR," "cerebrovascular," "navigation," "neurovascular," "neurosurgery," and "endovascular" in both AND and OR combinations. Studies included were original research articles with intraoperative application. The manuscripts were thoroughly examined for study design, outcomes, and results. Sixteen studies were identified describing the use of intraoperative AR in the treatment of cerebrovascular pathology. A total of 172 patients were treated for 190 cerebrovascular lesions using intraoperative AR. The most common treated pathology was intracranial aneurysms. Most studies were cases and there was only a case-control study. A head-up display system in the microscope was the most common AR display. AR was found to be useful for tailoring the craniotomy, dura opening, and proper identification of donor and recipient vessels in vascular bypass. Most AR systems were unable to account for tissue deformation. This systematic review suggests that intraoperative AR is becoming a promising and feasible adjunct in the treatment of cerebrovascular pathology. It has been found to be a useful tool in the preoperative planning and intraoperative guidance. However, its clinical benefits remain to be seen.
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Affiliation(s)
- Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | | | - Mauricio J Avila
- Department of Neurosurgery, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Peter Nakaji
- Department of Neurosurgery, Banner University Medical Center, University of Arizona, 755 E. McDowell Rd, Phoenix, AZ, 85006, USA.
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Pojskić M, Bopp M, Saß B, Kirschbaum A, Nimsky C, Carl B. Intraoperative Computed Tomography-Based Navigation with Augmented Reality for Lateral Approaches to the Spine. Brain Sci 2021; 11:brainsci11050646. [PMID: 34063546 PMCID: PMC8156391 DOI: 10.3390/brainsci11050646] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background. Lateral approaches to the spine have gained increased popularity due to enabling minimally invasive access to the spine, less blood loss, decreased operative time, and less postoperative pain. The objective of the study was to analyze the use of intraoperative computed tomography with navigation and the implementation of augmented reality in facilitating a lateral approach to the spine. Methods. We prospectively analyzed all patients who underwent surgery with a lateral approach to the spine from September 2016 to January 2021 using intraoperative CT applying a 32-slice movable CT scanner, which was used for automatic navigation registration. Sixteen patients, with a median age of 64.3 years, were operated on using a lateral approach to the thoracic and lumbar spine and using intraoperative CT with navigation. Indications included a herniated disc (six patients), tumors (seven), instability following the fracture of the thoracic or lumbar vertebra (two), and spondylodiscitis (one). Results. Automatic registration, applying intraoperative CT, resulted in high accuracy (target registration error: 0.84 ± 0.10 mm). The effective radiation dose of the registration CT scans was 6.16 ± 3.91 mSv. In seven patients, a control iCT scan was performed for resection and implant control, with an ED of 4.51 ± 2.48 mSv. Augmented reality (AR) was used to support surgery in 11 cases, by visualizing the tumor outline, pedicle screws, herniated discs, and surrounding structures. Of the 16 patients, corpectomy was performed in six patients with the implantation of an expandable cage, and one patient underwent discectomy using the XLIF technique. One patient experienced perioperative complications. One patient died in the early postoperative course due to severe cardiorespiratory failure. Ten patients had improved and five had unchanged neurological status at the 3-month follow up. Conclusions. Intraoperative computed tomography with navigation facilitates the application of lateral approaches to the spine for a variety of indications, including fusion procedures, tumor resection, and herniated disc surgery.
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Affiliation(s)
- Mirza Pojskić
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
- Correspondence: ; Tel.: +49-64215869848
| | - Miriam Bopp
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 35043 Marburg, Germany
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
| | - Andreas Kirschbaum
- Department of Visceral, Thoracic and Vascular Surgery, University of Marburg, 35043 Marburg, Germany;
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 35043 Marburg, Germany
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
- Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, 65199 Wiesbaden, Germany
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Fick T, van Doormaal JAM, Hoving EW, Willems PWA, van Doormaal TPC. Current Accuracy of Augmented Reality Neuronavigation Systems: Systematic Review and Meta-Analysis. World Neurosurg 2020; 146:179-188. [PMID: 33197631 DOI: 10.1016/j.wneu.2020.11.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Augmented reality neuronavigation (ARN) systems can overlay three-dimensional anatomy and disease without the need for a two-dimensional external monitor. Accuracy is crucial for their clinical applicability. We performed a systematic review regarding the reported accuracy of ARN systems and compared them with the accuracy of conventional infrared neuronavigation (CIN). METHODS PubMed and Embase were searched for ARN and CIN systems. For ARN, type of system, method of patient-to-image registration, accuracy method, and accuracy of the system were noted. For CIN, navigation accuracy, expressed as target registration error (TRE), was noted. A meta-analysis was performed comparing the TRE of ARN and CIN systems. RESULTS Thirty-five studies were included, 12 for ARN and 23 for CIN. ARN systems could be divided into head-mounted display and heads-up display. In ARN, 4 methods were encountered for patient-to-image registration, of which point-pair matching was the one most frequently used. Five methods for assessing accuracy were described. Ninety-four TRE measurements of ARN systems were compared with 9058 TRE measurements of CIN systems. Mean TRE was 2.5 mm (95% confidence interval, 0.7-4.4) for ARN systems and 2.6 mm (95% confidence interval, 2.1-3.1) for CIN systems. CONCLUSIONS In ARN, there seems to be lack of agreement regarding the best method to assess accuracy. Nevertheless, ARN systems seem able to achieve an accuracy comparable to CIN systems. Future studies should be prospective and compare TREs, which should be measured in a standardized fashion.
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Affiliation(s)
- Tim Fick
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - Jesse A M van Doormaal
- Department of Oral and Maxillofacial Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Eelco W Hoving
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Peter W A Willems
- Department of Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Tristan P C van Doormaal
- Department of Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands; Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
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Sharma RK, Kumar A, Yamada Y, Tanaka R, Sharma S, Miyatani K, Higashiguchi S, Kawase T, Talluri S, Kato Y. Institutional Experience of Microsurgical Management in Posterior Circulation Aneurysm. Asian J Neurosurg 2020; 15:484-493. [PMID: 33145196 PMCID: PMC7591165 DOI: 10.4103/ajns.ajns_69_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/01/2020] [Accepted: 05/12/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction: Posterior circulation aneurysm constitutes 15%–20% of all intracerebral aneurysms. With the advancement of endovascular techniques, the microsurgery for posterior circulation aneurysms has been pushed back a little. Even the International Subarachnoid Aneurysmal Trial gave support to the concepts of endovascular procedures, but microsurgical modality should not be discouraged. We present our institutional experience of microsurgical techniques on posterior circulation aneurysms. Materials and Methods: We performed a retrospective analysis of 37 patients of posterior circulation aneurysm from 2015 to 2019, referred to Bantane Hospital, Japan. We included all posterior circulation aneurysms such as basilar tip, basilar trunk, and vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms, admitted and treated with clipping or bypass and trapping. We assessed the outcome as measured by modified Rankin Score (mRS), complications, and mortality. Results: Out of 37 patients, 10 cases were a basilar tip, one case was the basilar trunk, and 26 cases were VA-PICA aneurysm. Intraoperatively, neuromonitoring, indocyanine green dye, dual-image videoangiography (DIVA), and neuro endoscope were used. Two patients of basilar tip aneurysm developed third cranial nerve paresis and six patients of VA-PICA aneurysm developed lower cranial nerve paresis which resolved spontaneously. All the patients were discharged with mRS of 0 or 1. No mortality was recorded in our study. Conclusion: Microsurgical clipping of posterior circulation aneurysm is safe in unruptured aneurysm with a very low risk of mortality and morbidity under experienced hands. All postoperative complications in our study were transient and resolved with time with no residual deficits. Preoperative simulation, intraoperative neuromonitoring, DIVA, and neuro endoscope help achieve complete obliteration of aneurysmal sac and avoid complications.
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Affiliation(s)
| | - Ambuj Kumar
- Department of Neurosurgery, N.S.C.B. Medical College, Jabalpur, Madhya Pradesh, India
| | - Yasuhiro Yamada
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Riki Tanaka
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Saurabh Sharma
- Department of Neurosurgery, Max Hospital, New Delhi, India
| | - Kyosuke Miyatani
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Saeko Higashiguchi
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Srikanth Talluri
- Department of Neurosurgery, SVIMS, Tirupati, Andhra Pradesh, India
| | - Yoko Kato
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
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10
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Carl B, Bopp M, Benescu A, Saß B, Nimsky C. Indocyanine Green Angiography Visualized by Augmented Reality in Aneurysm Surgery. World Neurosurg 2020; 142:e307-e315. [PMID: 32640326 DOI: 10.1016/j.wneu.2020.06.219] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/25/2020] [Accepted: 06/28/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We prospectively investigated how to integrate indocyanine green (ICG) angiography in an augmented reality (AR) setting for aneurysm surgery. METHODS In 20 patients with a total of 22 aneurysms, the head-up display of the operating microscope (Kinevo900) was used for AR. ICG-AR was established directly by the head-up display superimposing the ICG angiography as green live video overlay. In addition, the reconstructed outline of the three-dimensional (3D) vessel architecture was visualized by AR applying intraoperative low-dose computed tomography (vessel-AR). RESULTS In all patients, ICG-AR and vessel-AR were successfully implemented. The flow in the vessels could be observed directly in the white light view of the microscope oculars without being distracted from the surgical site by looking on separate screens. This factor enabled also surgical manipulation during ICG angiography. In parallel, AR additionally visualized the 3D vessel architecture, enhancing the understanding of the 3D anatomy (target registration error, 0.71 ± 0.21 mm; intraoperative low-dose computed tomography effective dose, 42.7 μSv). Linear (n = 28; range, 1-8.5 mm) and rotational (n = 3; range, 2.9°-14.4°) navigation adjustments performed in 18 of 20 patients resulted in a close matching of the vessel-AR outline with the real vessel situation after preparation, compensating for shifting. CONCLUSIONS ICG-AR could be successfully implemented. It facilitated surgical manipulation and flow interpretation during ICG angiography because it could be observed directly while looking through the microscope oculars in white light instead of being distracted from the surgical site while looking on separate screens. Additional AR visualizing the vessel architecture improved understanding of 3D anatomy for preparation and clipping.
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Affiliation(s)
- Barbara Carl
- Department of Neurosurgery, University Marburg, Marburg, Germany; Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Miriam Bopp
- Department of Neurosurgery, University Marburg, Marburg, Germany; Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| | - Andreea Benescu
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | - Benjamin Saß
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University Marburg, Marburg, Germany; Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany.
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Abstract
STUDY DESIGN A prospective, case-based, observational study. OBJECTIVES To investigate how microscope-based augmented reality (AR) support can be utilized in various types of spine surgery. METHODS In 42 spinal procedures (12 intra- and 8 extradural tumors, 7 other intradural lesions, 11 degenerative cases, 2 infections, and 2 deformities) AR was implemented using operating microscope head-up displays (HUDs). Intraoperative low-dose computed tomography was used for automatic registration. Nonlinear image registration was applied to integrate multimodality preoperative images. Target and risk structures displayed by AR were defined in preoperative images by automatic anatomical mapping and additional manual segmentation. RESULTS AR could be successfully applied in all 42 cases. Low-dose protocols ensured a low radiation exposure for registration scanning (effective dose cervical 0.29 ± 0.17 mSv, thoracic 3.40 ± 2.38 mSv, lumbar 3.05 ± 0.89 mSv). A low registration error (0.87 ± 0.28 mm) resulted in a reliable AR representation with a close matching of visualized objects and reality, distinctly supporting anatomical orientation in the surgical field. Flexible AR visualization applying either the microscope HUD or video superimposition, including the ability to selectively activate objects of interest, as well as different display modes allowed a smooth integration in the surgical workflow, without disturbing the actual procedure. On average, 7.1 ± 4.6 objects were displayed visualizing target and risk structures reliably. CONCLUSIONS Microscope-based AR can be applied successfully to various kinds of spinal procedures. AR improves anatomical orientation in the surgical field supporting the surgeon, as well as it offers a potential tool for education.
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Affiliation(s)
- Barbara Carl
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | - Miriam Bopp
- Department of Neurosurgery, University Marburg, Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| | - Benjamin Saß
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | - Mirza Pojskic
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | | | - Christopher Nimsky
- Department of Neurosurgery, University Marburg, Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
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Carl B, Bopp M, Saß B, Pojskic M, Gjorgjevski M, Voellger B, Nimsky C. Reliable navigation registration in cranial and spine surgery based on intraoperative computed tomography. Neurosurg Focus 2019; 47:E11. [DOI: 10.3171/2019.8.focus19621] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/26/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVELow registration errors are an important prerequisite for reliable navigation, independent of its use in cranial or spinal surgery. Regardless of whether navigation is used for trajectory alignment in biopsy or implant procedures, or for sophisticated augmented reality applications, all depend on a correct registration of patient space and image space. In contrast to fiducial, landmark, or surface matching–based registration, the application of intraoperative imaging allows user-independent automatic patient registration, which is less error prone. The authors’ aim in this paper was to give an overview of their experience using intraoperative CT (iCT) scanning for automatic registration with a focus on registration accuracy and radiation exposure.METHODSA total of 645 patients underwent iCT scanning with a 32-slice movable CT scanner in combination with navigation for trajectory alignment in biopsy and implantation procedures (n = 222) and for augmented reality (n = 437) in cranial and spine procedures (347 craniotomies and 42 transsphenoidal, 56 frameless stereotactic, 59 frame-based stereotactic, and 141 spinal procedures). The target registration error was measured using skin fiducials that were not part of the registration procedure. The effective dose was calculated by multiplying the dose length product with conversion factors.RESULTSAmong all 1281 iCT scans obtained, 1172 were used for automatic patient registration (645 initial registration scans and 527 repeat iCT scans). The overall mean target registration error was 0.86 ± 0.38 mm (± SD) (craniotomy, 0.88 ± 0.39 mm; transsphenoidal, 0.92 ± 0.39 mm; frameless, 0.74 ± 0.39 mm; frame-based, 0.84 ± 0.34 mm; and spinal, 0.80 ± 0.28 mm). Compared with standard diagnostic scans, a distinct reduction of the effective dose could be achieved using low-dose protocols for the initial registration scan with mean effective doses of 0.06 ± 0.04 mSv for cranial, 0.50 ± 0.09 mSv for cervical, 4.12 ± 2.13 mSv for thoracic, and 3.37 ± 0.93 mSv for lumbar scans without impeding registration accuracy.CONCLUSIONSReliable automatic patient registration can be achieved using iCT scanning. Low-dose protocols ensured a low radiation exposure for the patient. Low-dose scanning had no negative effect on navigation accuracy.
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Affiliation(s)
- Barbara Carl
- 1Department of Neurosurgery, University of Marburg; and
| | - Miriam Bopp
- 1Department of Neurosurgery, University of Marburg; and
- 2Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| | - Benjamin Saß
- 1Department of Neurosurgery, University of Marburg; and
| | - Mirza Pojskic
- 1Department of Neurosurgery, University of Marburg; and
| | | | | | - Christopher Nimsky
- 1Department of Neurosurgery, University of Marburg; and
- 2Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
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Carl B, Bopp M, Saß B, Pojskic M, Nimsky C. Augmented reality in intradural spinal tumor surgery. Acta Neurochir (Wien) 2019; 161:2181-2193. [PMID: 31300886 DOI: 10.1007/s00701-019-04005-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/05/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Microscope-based augmented reality (AR) is commonly used in cranial surgery; however, until recently, this technique was not implemented for spinal surgery. We prospectively investigated, how AR can be applied for intradural spinal tumor surgery. METHODS For ten patients with intradural spinal tumors (ependymoma, glioma, hemangioblastoma, meningioma, and metastasis), AR was provided by head-up displays (HUDs) of operating microscopes. User-independent automatic AR registration was established by low-dose intraoperative computed tomography. The objects visualized by AR were segmented in preoperative imaging data; non-linear image registration was applied to consider spine flexibility. RESULTS In all cases, AR supported surgery by visualizing the tumor outline and other relevant surrounding structures. The overall AR registration error was 0.72 ± 0.24 mm (mean ± standard deviation), a close matching of visible tumor outline and AR visualization was observed for all cases. Registration scanning resulted in a low effective dose of 0.22 ± 0.16 mSv for cervical and 1.68 ± 0.61 mSv for thoracic lesions. The mean HUD AR usage in relation to microscope time was 51.6 ± 36.7%. The HUD was switched off and turned on again in a range of 2 to 17 times (5.7 ± 4.4 times). Independent of the status of the HUD, the AR visualization was displayed on monitors throughout surgery. CONCLUSIONS Microscope-based AR can be reliably applied to intradural spinal tumor surgery. Automatic AR registration ensures high precision and provides an intuitive visualization of the extent of the tumor and surrounding structures. Given this setting, all advanced multi-modality options of cranial AR can also be applied to spinal surgery.
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Augmented Reality in Transsphenoidal Surgery. World Neurosurg 2019; 125:e873-e883. [DOI: 10.1016/j.wneu.2019.01.202] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/27/2019] [Accepted: 01/30/2019] [Indexed: 11/23/2022]
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Carl B, Bopp M, Saß B, Voellger B, Nimsky C. Implementation of augmented reality support in spine surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1697-1711. [DOI: 10.1007/s00586-019-05969-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/02/2018] [Accepted: 04/02/2019] [Indexed: 01/07/2023]
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Dasenbrock HH, See AP, Smalley RJ, Bi WL, Dolati P, Frerichs KU, Golby AJ, Chiocca EA, Aziz-Sultan MA. Frameless Stereotactic Navigation during Insular Glioma Resection using Fusion of Three-Dimensional Rotational Angiography and Magnetic Resonance Imaging. World Neurosurg 2019; 126:322-330. [PMID: 30898738 DOI: 10.1016/j.wneu.2019.03.096] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Perioperative cerebral infarction is a potential complication of glioma resection, of which insular tumors are at higher risk because of the proximity of middle cerebral artery branches, including the lateral lenticulostriates and long insular arteries. In this study, 3 patients received three-dimensional rotational angiography, which was fused with magnetic resonance imaging (MRI) for frameless stereotactic navigation during dominant-hemisphere insular glioma resection. METHODS All patients obtained a preoperative catheter angiogram with a three-dimensional rotational acquisition of the ipsilateral internal carotid artery. The pixel-based axial three-dimensional angiography data, thin-cut structural MRI, tractography from diffusion tensor imaging, and expressive language activation from functional MRI were uploaded into the iPlan software (Brainlab, Heimstetten, Germany) and fused. The target tumor, regional blood vessels, adjacent functional areas, and their associated fiber tracts were segmented and overlaid on the appropriate MRI sequence. This image fusion was used preoperatively to visualize the relationship of the mass with the adjacent vasculature and intraoperatively for frameless stereotactic navigation to optimize preservation of arterial structures. RESULTS Three patients aged 27-60 years with excellent baseline functional status presented with seizures and were found to have a large dominant-hemisphere T2 hyperintense nonenhancing insular mass. Surgical resection was performed using multimodality neuronavigation. None sustained a postoperative arterial infarction or a perioperative neurologic deficit. CONCLUSIONS Neuronavigation using a fusion of three-dimensional rotational angiography with MRI is a technique that can be used for preoperative planning and during resection of insular gliomas to optimize preservation of adjacent arteries.
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Affiliation(s)
- Hormuzdiyar H Dasenbrock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Alfred P See
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Smalley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parviz Dolati
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kai U Frerichs
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - E Antonio Chiocca
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - M Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Carl B, Bopp M, Gjorgjevski M, Oehrn C, Timmermann L, Nimsky C. Implementation of Intraoperative Computed Tomography for Deep Brain Stimulation: Pitfalls and Optimization of Workflow, Accuracy, and Radiation Exposure. World Neurosurg 2018; 124:S1878-8750(18)32902-4. [PMID: 30593970 DOI: 10.1016/j.wneu.2018.12.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is an effective treatment for movement disorders. Stereotactic electrode placement can be guided by intraoperative imaging, which also allows for immediate intraoperative quality control. This article is about implementation and refining a workflow applying intraoperative computed tomography (iCT) for DBS. METHODS Eighteen patients underwent DBS with bilateral implantation of directional electrodes applying a 32-slice movable computed tomography scanner in combination with microelectrode recording. RESULTS iCT led to a significant decrease in overall procedural time, despite performing multiple scans. In 3 of the initial 5 cases, iCT caused an adjustment of the final electrodes demonstrating the learning curve and the necessity to integrate road mapping for the exchange of microelectrode to final electrode. Implementation of low-dose computed tomography protocols added microelectrode iCT to the refined workflow, resulting in an intraoperative adjustment of a trajectory in 1 patient. Low-dose protocols lowered the total effective dose to 1.15 mSv, that is, a reduction by a factor of 3.5 compared to a standard non-iCT DBS procedure, despite repeated iCTs. Intraoperative lead detection based on final iCT revealed a radial error of 1.04 ± 0.58 mm and a vector error of 2.28 ± 0.97 mm compared to the preoperative planning, adjusted by the findings of microelectrode recording. CONCLUSIONS iCT can be easily integrated into the surgical workflow resulting in an overall efficient time-saving procedure. Repeated intraoperative scanning ensures reliable electrode placement, although low-dose scanning protocols prevent extensive radiation exposure. iCT of microelectrodes is feasible and led to the adjustment of 1 electrode.
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Affiliation(s)
- Barbara Carl
- Department of Neurosurgery, University Marburg, Marburg, Germany.
| | - Miriam Bopp
- Department of Neurosurgery, University Marburg, Marburg, Germany; Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| | | | - Carina Oehrn
- Department of Neurology, University Marburg, Marburg, Germany
| | - Lars Timmermann
- Department of Neurology, University Marburg, Marburg, Germany; Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University Marburg, Marburg, Germany; Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
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Seng LB, Yamada Y, Rajagopal N, Mohammad AA, Teranishi T, Miyatani K, Kawase T, Kato Y. Multimodality Techniques in Microsurgical Clipping as the Gold Standard Treatment in the Management of Basilar Tip Aneurysm: A Case Series. Asian J Neurosurg 2018; 13:1148-1157. [PMID: 30459884 PMCID: PMC6208256 DOI: 10.4103/ajns.ajns_159_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: Basilar aneurysms represent 5%–7% of all intracranial aneurysms. The main goal of open surgery is to achieve complete obliteration of the aneurysmal sac using minimal invasive technique while emphasizing on avoidance of complication. Materials and Methods: We performed a retrospective cohort study of nine cases of unruptured basilar tip aneurysm referred to the Fujita Health University Banbuntane-Hotokukai Hospital, Japan. The objective of the study was to analyze the surgical outcomes of unruptured basilar tip aneurysm. Results: Nine patients with unruptured basilar tip aneurysm were referred to our hospital between 2015 and 2017. The median size of the aneurysm and age were 4.00 mm (interquartile range [IQR] = 3.25–6.75 mm) and 58 years (IQR = 54–70 years), respectively. Five patients (55.6%) were presented with multiple intracranial aneurysms. Surgical adjuncts such as intraoperative neuromonitoring, intraoperative indocyanine green (ICG) angiography with dual-image videoangiography (DIVA), and neuroendoscope were used. Two patients developed transient postoperative oculomotor nerve palsy which resolved spontaneously. The median duration of surgery and days of hospitalization were 292 min (IQR = 237.5–350.5 min) and 12 days (IQR = 12–25 days), respectively. There was no mortality recorded in this case series. Conclusion: Microsurgical clipping of basilar tip aneurysm is safe in unruptured basilar tip aneurysm with a low risk of postoperative mortality or morbidity. All complications reported in this case series were transient with no long-term sequalae. The improved safety profile of microsurgical technique is due to the availability of intraoperative neuromonitoring, neuroendoscope, ICG, and DIVA. The application of multimodality technique in neurovascular surgery has also helped to achieve complication avoidance. The obliteration of the aneurysmal sac helps to restore the laminar blood flow in the bifurcation and distal blood vessels and improves the brain perfusion.
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Affiliation(s)
- Liew Boon Seng
- Department of Neurosurgery, Hospital Sungai Buloh, Selangor, Malaysia
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Niranjana Rajagopal
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | | | - Takao Teranishi
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Kyosuke Miyatani
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
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Navigation-Supported Stereotaxy by Applying Intraoperative Computed Tomography. World Neurosurg 2018; 118:e584-e592. [DOI: 10.1016/j.wneu.2018.06.246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 06/28/2018] [Accepted: 06/29/2018] [Indexed: 12/22/2022]
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Intraoperative computed tomography as reliable navigation registration device in 200 cranial procedures. Acta Neurochir (Wien) 2018; 160:1681-1689. [PMID: 30051160 DOI: 10.1007/s00701-018-3641-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Registration accuracy is a main factor influencing overall navigation accuracy. Standard fiducial- or landmark-based patient registration is user dependent and error-prone. Intraoperative imaging offers the possibility for user-independent patient registration. The aim of this paper is to evaluate our initial experience applying intraoperative computed tomography (CT) for navigation registration in cranial neurosurgery, with a special focus on registration accuracy and effective radiation dose. METHODS A total of 200 patients (141 craniotomy, 19 transsphenoidal, and 40 stereotactic burr hole procedures) were investigated by intraoperative CT applying a 32-slice movable CT scanner, which was used for automatic navigation registration. Registration accuracy was measured by at least three skin fiducials that were not part of the registration process. RESULTS Automatic registration resulted in high registration accuracy (mean registration error: 0.93 ± 0.41 mm). Implementation of low-dose scanning protocols did not impede registration accuracy (registration error applying the full dose head protocol: 0.87 ± 0.36 mm vs. the low dose sinus protocol 0.72 ± 0.43 mm) while a reduction of the effective radiation dose by a factor of 8 could be achieved (mean effective radiation dose head protocol: 2.73 mSv vs. sinus protocol: 0.34 mSv). CONCLUSION Intraoperative CT allows highly reliable navigation registration with low radiation exposure.
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