1
|
Micko A, Hosmann A, Marik W, Bartsch S, Weber M, Knosp E, Wolfsberger S. Optimizing MR imaging for intraoperative image guidance in sellar pathologies. Pituitary 2020; 23:266-272. [PMID: 32170516 PMCID: PMC7181417 DOI: 10.1007/s11102-020-01035-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE With the advancement of extended endonasal approaches, the ability to surgically reach parasellar tumor extensions increase. The aim of the study was to propose an optimized imaging protocol for surgical guidance in the cavernous sinus (CS) for proper visualization structures at risk. METHODS Prospective case control analysis of 20 consecutive pituitary adenoma patients scheduled for endoscopic transnasal surgery. Assessment of the capability of three different MRI sequences (MPRAGE, VIBE, CISS) by 4 investigators to correctly visualize sellar and parasellar structures. Invasiveness and position of the normal pituitary gland were compared with the intraoperative findings. RESULTS The consensus between the 4 examiners to achieve the same results for all modalities was 40% for MPRAGE, 70% for VIBE and 60% for CISS sequences (p = 0.155). A consensus of Knosp Grade per patient was 80% for MPRAGE, 100% for VIBE and 90% for CISS (overall kappa 0.60). A higher Knosp Grade was found in MPRAGE sequences compared to the other sequences. Intraoperative status of invasiveness was correctly identified in 12/20 (60%) with MPRAGE, 19/20 (95%) with VIBE and 11/20 (55%) with CISS sequences. The position of the normal pituitary gland was most frequent evaluable in 15/20 (75%) and correctly identified in 12/15 (80%) cases. CONCLUSION Our data showed that VIBE sequences obtain the highest degree of consensus with intraoperative findings of invasiveness and position of the normal pituitary gland. VIBE sequences, due to their high spatial resolution and at the same time fast image acquisition could provide improved imaging for neuronavigation.
Collapse
Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Wolfgang Marik
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sophie Bartsch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria.
| |
Collapse
|
2
|
Mert A, Micko A, Donat M, Maringer M, Buehler K, Sutherland GR, Knosp E, Wolfsberger S. An advanced navigation protocol for endoscopic transsphenoidal surgery. World Neurosurg 2015; 82:S95-105. [PMID: 25496642 DOI: 10.1016/j.wneu.2014.07.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 07/25/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report our clinical experience with an advanced navigation protocol that provides seamless integration into the operating workflow of endoscopic transsphenoidal surgery. PATIENTS AND METHODS From 32 consecutive cases of endoscopic transsphenoidal surgery, an optimal setup of continuous electromagnetic instrument navigation was created. Additionally, our standard multimodality image navigation of T1-weighted magnetic resonance (MR) images for soft tissue, MR angiogram for vascular structures, and computed tomography (CT) for solid bone was advanced by the addition of a CT surface rendering for fine paranasal sinus structures. The anatomic structures visualized and their clinical impacts were compared between standard and advanced visualization protocol. Bone-windowed CT images served as reference. The accuracy of the navigation setup was assessed by intraoperative landmark tests. Potential tissue shift was calculated by comparing pre- and postoperative MR angiograms of 20 macroadenomas. RESULTS After a learning curve of 2 cases (1 ferromagnetic interference and 1 dislocation of the patient reference tracker), the advanced navigation protocol was feasible in 30 cases. Advanced multimodality imaging was able to visualize significantly finer paranasal sinus structures than multimodality image navigation without CT surface rendering, equal to bone-windowed CT images (P < 0.001, McNemar test). This was found helpful for orientation in cases of complex sphenoid sinus anatomy. The accuracy of the advanced navigation setup corresponded to standard optic navigation with skull fixation. A tissue shift of median 2 mm (range 0-9 mm) was observed in the posterior genu of the internal carotid arteries after tumor resection. CONCLUSIONS The advanced navigation protocol permits continuous suction-tracked navigation guidance during endoscopic transsphenoidal surgery and optimal visualization of solid bone, fine paranasal sinus structures, soft-tissue and vascular structures. This may add to the safety of the procedure especially in cases of anatomical variations and in cases of recurrent adenomas with distorted anatomy.
Collapse
Affiliation(s)
- Ayguel Mert
- Department of Neurosurgery, Medical University Vienna, Austria
| | - Alexander Micko
- Department of Neurosurgery, Medical University Vienna, Austria
| | - Markus Donat
- Department of Neurosurgery, Medical University Vienna, Austria
| | | | - Katja Buehler
- VRVis Research Centre for Virtual Reality and Visualization GmbH, Vienna, Austria
| | - Garnette R Sutherland
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Canada
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University Vienna, Austria; Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Canada.
| |
Collapse
|
3
|
Abstract
PURPOSE OF REVIEW Advances in the neurosurgical management of pituitary tumors have included the refinement of surgical access and significant progress in navigation technology to help further reduce morbidity and improve outcome. Similarly, stereotactic radiosurgery has evolved to become an integral part in pituitary tumors not amenable to medical or surgical treatment. RECENT FINDINGS The evolution of minimally invasive surgery has evolved toward endoscopic versus microscopic trans-sphenoidal approaches for pituitary tumors. Debate exists regarding each approach, with advocates for both championing their cause. Stereotactic and fractional radiosurgery have been shown to be a safe and effective means of controlling tumor growth and ensuring hormonal stabilization, with longer-term data available for GammaKnife compared with CyberKnife. SUMMARY The advances in trans-sphenoidal surgical approaches, navigation technological improvements and the current results of stereotactic radiosurgery are discussed.
Collapse
|
4
|
Patel SN, Youssef AS, Vale FL, Padhya TA. Re-evaluation of the role of image guidance in minimally invasive pituitary surgery: benefits and outcomes. ACTA ACUST UNITED AC 2011; 16:47-53. [DOI: 10.3109/10929088.2011.552954] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
5
|
Eboli P, Shafa B, Mayberg M. Intraoperative computed tomography registration and electromagnetic neuronavigation for transsphenoidal pituitary surgery: accuracy and time effectiveness. J Neurosurg 2011; 114:329-35. [DOI: 10.3171/2010.5.jns091821] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors assessed the feasibility, anatomical accuracy, and cost effectiveness of frameless electromagnetic (EM) neuronavigation in conjunction with portable intraoperative CT (iCT) registration for transsphenoidal adenomectomy (TSA).
Methods
A prospective database was established for data obtained in 208 consecutive patients who underwent TSA in which the iCT/EM navigation technique was used. Data were compared with those acquired in a retrospective cohort of 65 consecutive patients in whom fluoroscope-assisted TSA had been performed by the same surgeon. All patients in both groups underwent transnasal removal of pituitary adenomas or neuroepithelial cysts, using identical surgical techniques with an operating microscope. In the iCT/EM technique–treated cases, a portable iCT scan was obtained immediately prior to surgery for registration to the EM navigation system, which did not require rigid head fixation. Preexisting (nonnavigation protocol) MR imaging studies were fused with the iCT scans to enable 3D navigation based on MR imaging data. The accuracy of the navigation system was determined in the first 50 iCT/EM cases by visual concordance of the navigation probe location to 5 preselected bony landmarks. For all patients in both cohorts, total operating room time, incision-to-closure time, and relative costs of imaging and surgical procedures were determined from hospital records.
Results
In every case, iCT registration was successful and preoperative MR images were fused to iCT scans without affecting navigation accuracy. There was 100% concordance between probe tip location and predetermined bony loci in the first 50 cases involving the iCT/EM technique. Total operating room time was significantly less in the iCT/EM cases (mean 108.9 ± 24.3 minutes [208 patients]) compared with the fluoroscopy group (mean 121.1 ± 30.7 minutes [65 patients]; p < 0.001). Similarly, incision-to-closure time was significantly less for the iCT/EM cases (mean 61.3 ± 18.2 minutes) than for the fluoroscopy cases (mean 71.75 ± 19.0 minutes; p < 0.001). Relative overall costs for iCT/EM technique and intraoperative C-arm fluoroscopy were comparable; increased costs for navigation equipment were offset by savings in operating room costs for shorter procedures.
Conclusions
The use of iCT/MR imaging–guided neuronavigation for transsphenoidal surgery is a time-effective, cost-efficient, safe, and technically beneficial technique.
Collapse
Affiliation(s)
- Paula Eboli
- 1Swedish Neuroscience Institute, Seattle, Washington; and
| | - Bob Shafa
- 1Swedish Neuroscience Institute, Seattle, Washington; and
- 2Department of Neurosurgery, UCLA School of Medicine, University of California, Los Angeles, California
| | - Marc Mayberg
- 1Swedish Neuroscience Institute, Seattle, Washington; and
| |
Collapse
|
6
|
Wu JS, Shou XF, Yao CJ, Wang YF, Zhuang DX, Mao Y, Li SQ, Zhou LF. TRANSSPHENOIDAL PITUITARY MACROADENOMAS RESECTION GUIDED BY POLESTAR N20 LOW-FIELD INTRAOPERATIVE MAGNETIC RESONANCE IMAGING. Neurosurgery 2009; 65:63-70; discussion 70-1. [DOI: 10.1227/01.neu.0000348549.26832.51] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
ABSTRACT
OBJECTIVE
To evaluate the applicability of low-field intraoperative magnetic resonance imaging (iMRI) during transsphenoidal surgery of pituitary macroadenomas.
METHODS
Fifty-five transsphenoidal surgeries were performed for macroadenomas (modified Hardy's Grade II–IV) resections. All of the surgical processes were guided by real-time updated contrast T1-weighted coronal and sagittal images, which were acquired with 0.15 Tesla PoleStar N20 iMRI (Medtronic Navigation, Louisville, CO). The definitive benefits as well as major drawbacks of low-field iMRI in transsphenoidal surgery were assessed with respect to intraoperative imaging, tumor resection control, comparison with early postoperative high-field magnetic resonance imaging, and follow-up outcomes.
RESULTS
Intraoperative imaging revealed residual tumor and guided extended tumor resection in 17 of 55 cases. As a result, the percentage of gross total removal of macroadenomas increased from 58.2% to 83.6%. The accuracy of imaging evaluation of low-field iMRI was 81.8%, compared with early postoperative high-field MRI (Correlation coefficient, 0.677; P <0.001). A significantly lower accuracy was identified with low-field iMRI in 6 cases with cavernous sinus invasion (33.3%) in contrast to the 87.8% found with other sites (Fisher's exact test, P <0.001).
CONCLUSION
The PoleStar N20 low-field iMRI navigation system is a promising tool for safe, minimally invasive, endonasal, transsphenoidal pituitary macroadenomas resection. It enables neurosurgeons to control the extent of tumor resection, particularly for suprasellar tumors, ensuring surgical accuracy and safety, and leading to a decreased likelihood of repeat surgeries. However, this technology is still not satisfying in estimating the amount of the parasellar residual tumor invading into cavernous sinus, given the false or uncertain images generated by low-field iMRI in this region, which are difficult to discriminate between tumor remnant and blood within the venous sinus.
Collapse
Affiliation(s)
- Jin-Song Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xue-Fei Shou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Cheng-Jun Yao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yong-Fei Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Dong-Xiao Zhuang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shi-Qi Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Liang-Fu Zhou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| |
Collapse
|
7
|
Shamir RR, Joskowicz L, Spektor S, Shoshan Y. Localization and registration accuracy in image guided neurosurgery: a clinical study. Int J Comput Assist Radiol Surg 2008; 4:45-52. [PMID: 20033601 DOI: 10.1007/s11548-008-0268-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 09/23/2008] [Indexed: 11/29/2022]
Abstract
PURPOSE To measure and compare the clinical localization and registration errors in image-guided neurosurgery, with the purpose of revising current assumptions. MATERIALS AND METHODS Twelve patients who underwent brain surgeries with a navigation system were randomly selected. A neurosurgeon localized and correlated the landmarks on preoperative MRI images and on the intraoperative physical anatomy with a tracked pointer. In the laboratory, we generated 612 scenarios in which one landmark pair was defined as the target and the remaining ones were used to compute the registration transformation. Four errors were measured: (1) fiducial localization error (FLE); (2) target registration error (TRE); (3) fiducial registration error (FRE); (4) Fitzpatrick's target registration error estimation (F-TRE). We compared the different errors and computed their correlation. RESULTS The image and physical FLE ranges were 0.5-2.0 and 1.6-3.0 mm, respectively. The measured TRE, FRE and F-TRE were 4.1 +/- 1.6, 3.9 +/- 1.2, and 3.7 +/- 2.2 mm, respectively. Low correlations of 0.19 and 0.37 were observed between the FRE and TRE and between the F-TRE and the TRE, respectively. The differences of the FRE and F-TRE from the TRE were 1.3 +/- 1.0 mm (max = 5.5 mm) and 1.3 +/- 1.2 mm (max = 7.3 mm), respectively. CONCLUSION Contrary to common belief, the FLE presents significant variations. Moreover, both the FRE and the F-TRE are poor indicators of the TRE in image-to-patient registration.
Collapse
Affiliation(s)
- Reuben R Shamir
- School of Engineering and Computer Science, The Hebrew University of Jerusalem, Givat Ram Campus, 91904 Jerusalem, Israel.
| | | | | | | |
Collapse
|
8
|
Abstract
Trans-sphenoidal surgery, which is the most widely used technique for the treatment of pituitary tumors, has continued to evolve by introducing new approaches and technologies, such as the direct endonasal route and the endoscope. The endonasal approach is a minimally invasive route to the sella turcica with the advantages of using a simpler and more rapid nasal dissection and eliminating the nasal and lip complications. Restricted exposure provided by the endonasal approach is overcome by combined use of an endoscope that provides a more panoramic view of the surgical field beyond the area covered by the operating microscope. An operating microscope permits binocular vision and bimanual technique, which are familiar to neurosurgeons. Neurosurgeons should exploit the advantages of both modalities for the benefit of patients. This review describes the advances in trans-sphenoidal surgery focusing on the endoscopic approach.
Collapse
Affiliation(s)
- Takakazu Kawamata
- a Department of Neurosurgery Tokyo Women's Medical University Yachiyo Medical Center, 477-96 Owada-Shinden, Yachiyo-shi, Chiba 276-8524, Japan.
| | - Tomokatsu Hori
- b Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| |
Collapse
|
9
|
Rosen MR, Saigal K, Evans J, Keane WM. A review of the endoscopic approach to the pituitary through the sphenoid sinus. Curr Opin Otolaryngol Head Neck Surg 2006; 14:6-13. [PMID: 16467631 DOI: 10.1097/01.moo.0000193168.46827.43] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The refinement of minimally invasive endoscopic techniques has resulted in 'pure' endoscopic endonasal trans-sphenoidal surgery, which is a new approach for the removal of pituitary tumors. RECENT DEVELOPMENTS This procedure is performed via a wide anterior sphenoidotomy with detachment of the septum from the sphenoid face, and avoids the use of a trans-sphenoidal retractor and any intraoral or nasal incisions. Straight and angled endoscopes are used throughout the procedure to provide a wide view of the sella and are manipulated by a co-surgeon. This technique represents an improvement over pituitary microsurgery, with decreased post-operative morbidities and a shortened postoperative stay, and it eliminates the need for packing while providing an opportunity to monitor the sella after surgery. The technique has been established as being efficacious and safe. It incorporates image-guided surgery, with the fusion of computer tomography and magnetic resonance imaging, and employs new and dedicated instrumentation. Training in endoscopic techniques is required. SUMMARY Future advancements in intraoperative imaging, cranial base reconstruction, and robotics will make this technique even more successful.
Collapse
Affiliation(s)
- Marc R Rosen
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut St, 6th Floor, Philadelphia, PA 19107, USA.
| | | | | | | |
Collapse
|
10
|
Hejazi N. Frameless image-guided neuronavigation in orbital surgery: practical applications. Neurosurg Rev 2005; 29:118-22. [PMID: 16374647 DOI: 10.1007/s10143-005-0007-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2005] [Revised: 08/29/2005] [Accepted: 09/26/2005] [Indexed: 11/28/2022]
Abstract
Frameless neuronavigation has been increasingly used in intracranial and spinal neurosurgery. However, the application of neuronavigation in orbital surgery has not yet been reported. The purpose of this study was to evaluate whether frameless navigation in the orbit provides sufficient clinical application accuracy and thus a useful tool in orbital surgery. A frameless infrared-based neuronavigation system (VectorVision, BrainLAB, Heimstetten, Germany) was used in the microsurgical removal of 11 orbital tumors (five cavernomas, three lymphomas, two dermoid tumors, and one rhabdomyosarcoma). The transconjunctival approach was performed in seven cases, lateral orbitotomy in three cases, and the extradural pterional approach was performed in one case. The surgery was successful and without any complications in all cases. The registration accuracy of the neuronavigation was between 1.8 and 2.2 mm, with a mean of 1.9 mm. Subtotal tumor debulking was performed in one case with lymphoma. One patient was only biopsied due to suspected systemic lymphoma disease. Total removal of the tumor could be accomplished in the other nine patients. Image guidance during orbital surgery offered excellent three-dimensional guidance on the surface of the intraorbital lesions, allowing a safer, more controlled surgery. The surgical targets in the orbit are fixed structures, thus no shifting occurs and continuous high intraoperative navigation accuracy can be achieved. The use of the navigation clearly reduces the operative risk and increases the effectiveness of microsurgical orbital procedures.
Collapse
Affiliation(s)
- Nedal Hejazi
- Department of Neurosurgery, Landeskrankenhaus Feldkirch, Academic Hospital of the University of Innsbruck, Feldkirch, Austria.
| |
Collapse
|
11
|
Surgical techniques in transsphenoidal surgery: what is the standard of care in pituitary adenoma surgery? ACTA ACUST UNITED AC 2004. [DOI: 10.1097/01.med.0000140007.57133.4b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|