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Schwandt E, Kockro R, Kramer A, Glaser M, Ringel F. Presurgical selection of the ideal aneurysm clip by the use of a three-dimensional planning system. Neurosurg Rev 2022; 45:2887-2894. [PMID: 35546216 PMCID: PMC9349090 DOI: 10.1007/s10143-022-01794-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/19/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
Abstract
Aneurysm occlusion rate after clipping is higher than after endovascular treatment. However, a certain percentage of incompletely clipped aneurysms remains. Presurgical selection of the proper aneurysm clips could potentially reduce the rate of incomplete clippings caused by inadequate clip geometry. The aim of the present study was to assess whether preoperative 3D image-based simulation allows for preoperative selection of a proper aneurysm clip for complete occlusion in individual cases. Patients harboring ruptured or unruptured cerebral aneurysms prior to surgical clipping were analyzed. CT angiography images were transferred to a 3D surgical-planning station (Dextroscope®) with imported models of 58 aneurysm clips. Intracranial vessels and aneurysms were segmented and the virtual aneurysm clips were placed at the aneurysm neck. Operating surgeons had information about the selected aneurysm clip, and patients underwent clipping. Intraoperative clip selection was documented and aneurysm occlusion rate was assessed by postoperative digital subtraction angiography. Nineteen patients were available for final analysis. In all patients, the most proximal clip at the aneurysm neck was the preselected clip. All aneurysms except one were fully occluded, as assessed by catheter angiography. One aneurysm had a small neck remnant that did not require secondary surgery and was occluded 15 months after surgery. 3D image-based preselection of a proper aneurysm clip can be translated to the operating room and avoids intraoperative clip selection. The associated occlusion rate of aneurysms is high.
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Affiliation(s)
- Eike Schwandt
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Ralf Kockro
- Department of Neurosurgery, Klinik Hirslanden, Zurich, Switzerland
| | - Andreas Kramer
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Martin Glaser
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
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Linsenmann T, Cattaneo A, März A, Weiland J, Stetter C, Nickl R, Westermaier T. Combined frameless stereotactical biopsy and intraoperative cerebral angiography by 3D-rotational fluoroscopy with intravenous contrast administration: a feasibility study. BMC Med Imaging 2021; 21:94. [PMID: 34082701 PMCID: PMC8173902 DOI: 10.1186/s12880-021-00622-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/19/2021] [Indexed: 11/27/2022] Open
Abstract
Background Mobile 3-dimensional fluoroscopes are an integral part of modern neurosurgical operating theatres and can also be used in combination with free available image post processing to depict cerebral vessels. In preparation of stereotactic surgery, preoperative Computed Tomography (CT) may be required for image fusion. Contrast CT may be of further advantage for image fusion as it regards the vessel anatomy in trajectory planning. Time-consuming in-hospital transports are necessary for this purpose. Mobile 3D-fluoroscopes may be used to generate a CT equal preoperative data set without an in-hospital transport. This study was performed to determine the feasibility and image quality of intraoperative 3-dimensional fluoroscopy with intravenous contrast administration in combination with stereotactical procedures. Methods 6 patients were included in this feasibility study. After fixation in a radiolucent Mayfield clamp a rotational fluoroscopy scan was performed with 50 mL iodine contrast agent. The image data sets were merged with the existing MRI images at a planning station and visually evaluated by two observer. The operation times were compared between the frame-based and frameless systems (“skin-to-skin” and “OR entry to exit”). Results The procedure proves to be safe. The entire procedure from fluoroscope positioning to the transfer to the planning station took 5–6 min with an image acquisition time of 24 s. In 5 of 6 cases, the fused imaging was able to reproduce the vascular anatomy accurately and in good quality. Both time end-points were significantly shorter compared to frame-based interventions. Conclusion The images could easily be transferred to the planning and navigation system and were successfully merged with the MRI data set. The procedure can be completely integrated into the surgical workflow. Preoperative CT imaging or transport under anaesthesia may even be replaced by this technique in the future. Furthermore, hemorrhages can be successfully visualized intraoperatively and might prevent time delays in emergencies.
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Affiliation(s)
- Thomas Linsenmann
- Department of Neurosurgery, Julius Maximilians University, Josef-Schneider Str. 11, 97080, Würzburg, Germany.
| | - Andrea Cattaneo
- Department of Neurosurgery, Julius Maximilians University, Josef-Schneider Str. 11, 97080, Würzburg, Germany
| | - Alexander März
- Department of Neuroradiology, Julius Maximilians University, Josef-Schneider Str. 11, 97080, Würzburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, Julius Maximilians University, Josef-Schneider Str. 11, 97080, Würzburg, Germany
| | - Christian Stetter
- Department of Neurosurgery, Julius Maximilians University, Josef-Schneider Str. 11, 97080, Würzburg, Germany
| | - Robert Nickl
- Department of Neurosurgery, Julius Maximilians University, Josef-Schneider Str. 11, 97080, Würzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Julius Maximilians University, Josef-Schneider Str. 11, 97080, Würzburg, Germany
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Linsenmann T, März A, Duffner V, Stetter C, Weiland J, Westermaier T. Optimization of radiation settings for angiography using 3D fluoroscopy for imaging of intracranial aneurysms. Comput Assist Surg (Abingdon) 2021; 26:22-30. [PMID: 33689512 DOI: 10.1080/24699322.2021.1894240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Mobile 3D fluoroscopes have become increasingly available in neurosurgical operating rooms. We recently reported its use for imaging cerebral vascular malformations and aneurysms. This study was conducted to evaluate various radiation settings for the imaging of cerebral aneurysms before and after surgical occlusion. Eighteen patients with cerebral aneurysms with the indication for surgical clipping were included in this prospective analysis. Before surgery the patients were randomized into one of three different scan protocols according (default settings of the 3D fluoroscope): Group 1: 110 kV, 80 mA (enhanced cranial mode), group 2: 120 kV, 64 mA (lumbar spine mode), group 3: 120 kV, 25 mA (head/neck settings). Prior to surgery, a rotational fluoroscopy scan (duration 24 s) was performed without contrast agent followed by another scan with 50 ml of intravenous iodine contrast agent. The image files of both scans were transferred to an Apple PowerMac® workstation, subtracted and reconstructed using OsiriX® MD 10.0 software. The procedure was repeated after clip placement. The image quality regarding preoperative aneurysm configuration and postoperative assessment of aneurysm occlusion and vessel patency was analyzed by 2 independent reviewers using a 6-grade scale. This technique quickly supplies images of adequate quality to depict intracranial aneurysms and distal vessel patency after aneurysm clipping. Regarding these features, a further optimization to our previous protocol seems possible lowering the voltage and increasing tube current. For quick intraoperative assessment, image subtraction seems not necessary. Thus, a native scan without a contrast agent is not necessary. Further optimization may be possible using a different contrast injection protocol.
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Affiliation(s)
- Thomas Linsenmann
- Department of Neurosurgery, University of Wuerzburg, Wuerzburg, Germany
| | - Alexander März
- Department of Neuroradiology, University of Wuerzburg, Wuerzburg, Germany
| | - Vera Duffner
- Department of Neurosurgery, University of Wuerzburg, Wuerzburg, Germany
| | - Christian Stetter
- Department of Neurosurgery, University of Wuerzburg, Wuerzburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University of Wuerzburg, Wuerzburg, Germany
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Torné R, García S, Sanroman L, Rodríguez-Hernández A, Reyes L, Tercero J, Enseñat J. Safety and Feasibility Assessment of the O-Arm as an Intraoperative Angiography Device in Aneurysm Surgery. World Neurosurg 2019; 127:e1159-e1165. [PMID: 30995551 DOI: 10.1016/j.wneu.2019.04.076] [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: 01/08/2019] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe the technique and initial experience of using a rotational 3-dimensional (3D) fluoroscopy system (O-arm; Medtronic) as intraoperative angiography (IA) in the surgery of cerebral aneurysms. METHODS The 3D IA with O-arm (IAWOA) was performed in a consecutive cohort of patients with unruptured intracranial aneurysms. Conventional microsurgical clipping was performed with the assistance of indocyanine green videoangiography. Then the O-arm chassis was brought in, the ipsilateral internal carotid artery was catheterized, and contrasted images were acquired. Resulting datasets were exported in Digital Imaging and Communications in Medicine and processed using the Osirix software in an accessory computer. The 3D image reconstruction was evaluated intraoperatively to confirm aneurysm occlusion and parent vessel patency. Afterward, agreement among IAWOA, indocyanine green videoangiography, and standard postoperative angiography was analyzed. RESULTS The initial pilot study was performed in 6 patients with 7 unruptured aneurysms. The aneurysm occlusion rate was 100%. The concordance of the IAWOA and the standard postoperative angiography was complete, both in terms of occlusion and parent vessel patency. No complications derived from the IAWOA were observed except in 1 patient, who presented a retroperitoneal hematoma without clinical consequences. CONCLUSIONS The 3D rotational fluoroscopy (O-arm) device could be safely and effectively used as an IA system in selected patients. To the best of our knowledge, this is the first study reporting its use as an IA device. This technique seems to offer excellent image quality that could be compared with that of the gold standard 3D digital subtraction angiography but with a lower cost and versatility of use for other subspecialties.
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Affiliation(s)
- Ramón Torné
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain.
| | - Sergio García
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Luís Sanroman
- Department of Radiology, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Ana Rodríguez-Hernández
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Luís Reyes
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Javier Tercero
- Department of Anestiology, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
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Fong YW, Hsu SK, Huang CT, Hsieh CT, Chen MH, Huang JS, Chang CJ, Su IC. Impact of Intraoperative 3-Dimensional Volume-Rendering Rotational Angiography on Clip Repositioning Rates in Aneurysmal Surgery. World Neurosurg 2018; 114:e573-e580. [DOI: 10.1016/j.wneu.2018.03.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 12/20/2022]
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Spiriev T, Nakov V, Laleva L, Tzekov C. OsiriX software as a preoperative planning tool in cranial neurosurgery: A step-by-step guide for neurosurgical residents. Surg Neurol Int 2017; 8:241. [PMID: 29119039 PMCID: PMC5655755 DOI: 10.4103/sni.sni_419_16] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 06/06/2017] [Indexed: 01/18/2023] Open
Abstract
Background: OsiriX (Pixmeo, Switzerland) is an open-source Digital Imaging and Communications in Medicine (DICOM) viewer that is gaining more and more attention in the neurosurgical community because of its user-friendly interface, powerful three-dimensional (3D) volumetric rendering capabilities, and various options for data integration. This paper presents in detail the use of OsiriX software as a preoperative planning tool in cranial neurosurgery. Methods: In January 2013, OsiriX software was introduced into our clinical practice as a preoperative planning tool. Its capabilities are being evaluated on an ongoing basis in routine elective cranial cases. Results: The program has proven to be highly effective at volumetrically representing data from radiological examinations in 3D. Among its benefits in preoperative planning are simulating the position and exact location of the lesion in 3D, tailoring the skin incision and craniotomy bone flap, enhancing the representation of normal and pathological anatomy, and aiding in planning the reconstruction of the affected area. Conclusion: OsiriX is a useful tool for preoperative planning and visualization in neurosurgery. The software greatly facilitates the surgeon's understanding of the relationship between normal and pathological anatomy and can be used as a teaching tool.
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Affiliation(s)
- Toma Spiriev
- Department of Neurosurgery, Tokuda Hospital, Sofia, Bulgaria
| | - Vladimir Nakov
- Department of Neurosurgery, Tokuda Hospital, Sofia, Bulgaria
| | - Lili Laleva
- Department of Neurosurgery, Tokuda Hospital, Sofia, Bulgaria
| | - Christo Tzekov
- Department of Neurosurgery, Tokuda Hospital, Sofia, Bulgaria
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周 路, 娄 明, 陈 国, 纠 智, 申 云, 鲁 琳. [Value of 640-slice 3D CT angiography plus 3D printing for improving surgeries for intracranial aneurysms]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:1222-1227. [PMID: 28951366 PMCID: PMC6765488 DOI: 10.3969/j.issn.1673-4254.2017.09.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate the value of 640-slice 3D CT angiography (3D-CTA) plus 3D printing for improving the outcomes of surgeries for intracranial aneurysms. METHODS Sixty patients with intracranial aneurysm were randomly divided into trial group (n=30) and control group (n=30). The control group received routine surgery, and the simulation models of the intracranial aneurysm in trial group was printed using a 3D printer using the imaging data from 3D-CTA. Using the simulation model, the surgery was designed and planned before operation (including surgical approaches and placement of clips) and simulation surgery was also conducted. The coincidence rates between preoperative and intraoperative findings of the intracranial aneurysms on 3D-CTA were compared. CT scan was performed at 1 and 3 days after the operation to detect potential cerebral infarction or bleeding associated with the operation; CTA was performed both at the same time and at 3-6 months after the operation to detect stenosis, occlusion and aneurysm clipping. The patients were followed up for 3-6 months to assess the outcomes using Glasgow Outcome Scale (GOS). RESULTS The preoperative 3D-CTA findings were basically consistent with the intraoperative findings in all the 60 patients. Nine patients in the control group and 2 patients in the trial group had short-term adverse operation events; 11 patients in control group and 4 patients in trial group had long-term adverse events; 18 patients in control group and 25 patients in trial group had good neurologic function. The incidences of short-term and long-term adverse events associated with the operation was significantly lower in the trial group than in the control group (χ2=5.364, P=0.021; χ2=4.841, P=0.028), and the outcomes were significantly better in the trial group than in the control group (χ2=4.633, P=0.031). CONCLUSION The simulation model of intracranial aneurysm is helpful to improve the quality of surgery and patients outcomes.
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Affiliation(s)
- 路球 周
- 广州中医药大学博士后工作站,广东 广州 510006Postdoctoral Research Station, Guangzhou University of Chinese Medicine, Guangzhou 510006, China
- 深圳市龙岗中心医院神经外科//影像科,广东 深圳 518116Department of Radiology, Department of Neurosurgery, Shenzhen Longgang Central Hospital, Shenzhen 518116, China
| | - 明武 娄
- 广州中医药大学博士后工作站,广东 广州 510006Postdoctoral Research Station, Guangzhou University of Chinese Medicine, Guangzhou 510006, China
- 深圳市龙岗中心医院神经外科//影像科,广东 深圳 518116Department of Radiology, Department of Neurosurgery, Shenzhen Longgang Central Hospital, Shenzhen 518116, China
| | - 国昌 陈
- 深圳市龙岗中心医院神经外科//影像科,广东 深圳 518116Department of Radiology, Department of Neurosurgery, Shenzhen Longgang Central Hospital, Shenzhen 518116, China
| | - 智松 纠
- 深圳市龙岗中心医院神经外科//影像科,广东 深圳 518116Department of Radiology, Department of Neurosurgery, Shenzhen Longgang Central Hospital, Shenzhen 518116, China
| | - 云霞 申
- 深圳市龙岗中心医院神经外科//影像科,广东 深圳 518116Department of Radiology, Department of Neurosurgery, Shenzhen Longgang Central Hospital, Shenzhen 518116, China
| | - 琳 鲁
- 深圳市龙岗中心医院神经外科//影像科,广东 深圳 518116Department of Radiology, Department of Neurosurgery, Shenzhen Longgang Central Hospital, Shenzhen 518116, China
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Huang CT, Hsu SK, Su IC. Accurate Localization of Aneurysm Neck Margins in Clipping of a Carotid Cave Aneurysm Using Intraoperative Dual-Volume 3-Dimensional Volume-Rendering Rotational Angiography. World Neurosurg 2017; 101:812.e11-812.e14. [DOI: 10.1016/j.wneu.2017.03.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 03/16/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
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