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Deopujari C, Shroff K, Malineni S, Shaikh S, Mohanty C, Karmarkar V, Mittal A. Intraventricular Tumors: Surgical Considerations in Lateral and Third Ventricular Tumors. Adv Tech Stand Neurosurg 2024; 50:63-118. [PMID: 38592528 DOI: 10.1007/978-3-031-53578-9_3] [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] [Indexed: 04/10/2024]
Abstract
Management of lateral and third ventricular tumors has been a challenge for neurosurgeons. Advances in imaging and pathology have helped in a better understanding of the treatment options. Technical refinement of microsurgical technique and addition of endoscopy has enabled more radical excision of tumors, when indicated, and added more safety.A proper understanding of the pathology at various ages and treatment options is continuously evolving. Many pediatric tumors are amenable to conservative surgical methods with effective complementary treatments. However, radical surgery is required in many adults as the main treatment and for many benign tumors. Various intraventricular lesions encountered and their surgical management is reviewed here for their efficacy, safety, and outcome, encompassing changes in our practice over the last 20 years.
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Affiliation(s)
- Chandrashekhar Deopujari
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Krishna Shroff
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Suhas Malineni
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | | | - Chandan Mohanty
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Vikram Karmarkar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Amol Mittal
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
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Lim DH, Kim SY, Na YC, Cho JM. Navigation Guided Biopsy Is as Effective as Frame-Based Stereotactic Biopsy. J Pers Med 2023; 13:jpm13050708. [PMID: 37240878 DOI: 10.3390/jpm13050708] [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: 03/05/2023] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Stereotactic biopsy is a standard procedure for brain biopsy. However, with advances in technology, navigation-guided brain biopsy has become a well-established alternative. Previous studies have shown that frameless stereotactic brain biopsy is as effective and safe as frame-based stereotactic brain biopsy is. In this study, the authors evaluate the diagnostic yield and complication rate of frameless intracranial biopsy. MATERIALS AND METHODS We reviewed data from biopsy performed patients between March 2014 and April 2022. We retrospectively reviewed medical records, including imaging studies. Various intracerebral lesions were biopsied. Diagnostic yield and post-operative complications were compared with those of frame-based stereotactic biopsy. RESULTS Forty-two frameless navigation-guided biopsy were performed, and the most common pathology was primary central nervous system lymphoma (35.7%), followed by glioblastoma (33.3%), and anaplastic astrocytomas (16.7%), respectively. The diagnostic yield was 100%. Post-operative intracerebral hematoma occurred in 2.4% of cases, but it was not symptomatic. Thirty patients underwent frame-based stereotactic biopsy, and the diagnostic yield was 96.7%. There was no difference in diagnostic rates between two methods (Fisher's exact test, p = 0.916). CONCLUSIONS Frameless navigation-guided biopsy is as effective as frame-based stereotactic biopsy is, without causing further complications. We consider that frame-based stereotactic biopsy is no longer needed if frameless navigation-guided biopsy is used. A further study will be needed to generalize our results.
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Affiliation(s)
- Dae Hyun Lim
- Department of Neurosurgery, International St Mary's Hospital, Catholic Kwandong University, Incheon 22711, Republic of Korea
| | - So Yeon Kim
- Department of Neurosurgery, International St Mary's Hospital, Catholic Kwandong University, Incheon 22711, Republic of Korea
| | - Young Cheol Na
- Department of Neurosurgery, International St Mary's Hospital, Catholic Kwandong University, Incheon 22711, Republic of Korea
| | - Jin Mo Cho
- Department of Neurosurgery, International St Mary's Hospital, Catholic Kwandong University, Incheon 22711, Republic of Korea
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3
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Patient Safety Comparison of Frameless and Frame-Based Stereotactic Navigation for Brain Biopsy-A Single Center Cohort Study. Brain Sci 2022; 12:brainsci12091178. [PMID: 36138914 PMCID: PMC9497181 DOI: 10.3390/brainsci12091178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Leksell stereotactic system-based aspiration biopsy is a common procedure in the neurosurgical treatment of deep-seated or multiple brain lesions. This study aimed to evaluate the benefit of frameless biopsy using VarioGuide compared to frame-based biopsy using the Leksell stereotactic system (LSS). We analyzed all brain biopsies using VarioGuide or LSS at our neurooncological Department of Neurosurgery in the University Hospital of Bonn between January 2018 and August 2020. We analyzed demographic data, duration of surgery, size of lesion, localization, and early complications. Uni-variable analyses were carried out on data from both groups. In total, 109 biopsies were compared (40 VarioGuide vs. 69 LSS). Patients with VarioGuide were significant older (74 (62−80) years vs. 67 (57−76) years; p = 0.03) and had a shorter duration of general anesthesia (163 (138−194) min vs. 193 (167−215) min, p < 0.001). We found no significant differences in surgery duration (VarioGuide median 28 min (IQR 20−38); LSS: median 30 min (IQR 25−39); p = 0.1352) or in early complication rates (5% vs. 7%; p = 0.644). A slightly higher false negative biopsy rate was registered in the LSS group (3 vs. 1; p = 0.1347). The size of the lesions also did not differ significantly between the two groups (18.31 ± 26.35 cm3 vs. 12.63 ± 14.62; p = 0.15). Our data showed that biopsies performed using VarioGuide took significantly less time than LSS biopsies and did not differ in complication rates. Both systems offered a high degree of patient safety.
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Chavaz L, Davidovic A, Meling TR, Momjian S, Schaller K, Bijlenga P, Haemmerli J. Evaluation of the precision of navigation-assisted endoscopy according to the navigation tool setup and the type of endoscopes. Acta Neurochir (Wien) 2022; 164:2375-2383. [PMID: 35764694 PMCID: PMC9427865 DOI: 10.1007/s00701-022-05276-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/01/2022] [Indexed: 12/14/2022]
Abstract
OBJECT Preoperative image-based neuronavigation-assisted endoscopy during intracranial procedures is gaining great interest. This study aimed to analyze the precision of navigation-assisted endoscopy according to the navigation setup, the type of optic and its working angulation. METHODS A custom-made box with four screws was referenced. The navigation-assisted endoscope was aligned on the screws (targets). The precision on the navigation screen was defined as the virtual distance-to-target between the tip of the endoscope and the center of the screws. Three modifiers were assessed: (1) the distance D between the box and the reference array (CLOSE 13 cm - MIDDLE 30 cm - FAR 53 cm), (2) the distance between the tip of the endoscope and the navigation array on the endoscope (close 5 cm - middle 10 cm - far 20 cm), (3) the working angulation of the endoscope (0°-endoscope and 30°-endoscope angled at 90° and 45° with the box). RESULTS The median precision was 1.3 mm (Q1: 1.1; Q3: 1.7) with the best setting CLOSE/close. The best setting in surgical condition (CLOSE/far) showed a distance-to-target of 2.3 mm (Q1: 1.9; Q3: 2.5). The distance D was correlated to the precision (Spearman rho = 0.82), but not the distance d (Spearman rho = 0.04). The type of optic and its angulation with the box were also correlated to the precision (Spearman rho = - 0.37). The best setting was the use of a 30°-endoscope angled at 45° (1.4 mm (Q1: 1.0; Q3: 1.9)). CONCLUSION Navigated-assisted endoscopy is feasible and offers a good precision. The navigation setup should be optimized, reducing the risk of inadvertent perifocal damage.
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Affiliation(s)
- Lara Chavaz
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Torstein R Meling
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Shahan Momjian
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Karl Schaller
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Philippe Bijlenga
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Julien Haemmerli
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
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Straehle J, Erny D, Neidert N, Heiland DH, El Rahal A, Sacalean V, Steybe D, Schmelzeisen R, Vlachos A, Mizaikoff B, Reinacher PC, Coenen VA, Prinz M, Beck J, Schnell O. Neuropathological interpretation of stimulated Raman histology images of brain and spine tumors: part B. Neurosurg Rev 2021; 45:1721-1729. [PMID: 34890000 PMCID: PMC8976804 DOI: 10.1007/s10143-021-01711-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/22/2021] [Accepted: 11/26/2021] [Indexed: 12/01/2022]
Abstract
Intraoperative histopathological examinations are routinely performed to provide neurosurgeons with information about the entity of tumor tissue. Here, we quantified the neuropathological interpretability of stimulated Raman histology (SRH) acquired using a Raman laser imaging system in a routine clinical setting without any specialized training or prior experience. Stimulated Raman scattering microscopy was performed on 117 samples of pathological tissue from 73 cases of brain and spine tumor surgeries. A board-certified neuropathologist — novice in the interpretation of SRH — assessed image quality by scoring subjective tumor infiltration and stated a diagnosis based on the SRH images. The diagnostic accuracy was determined by comparison to frozen hematoxylin–eosin (H&E)-stained sections and the ground truth defined as the definitive neuropathological diagnosis. The overall SRH imaging quality was rated high with the detection of tumor cells classified as inconclusive in only 4.2% of all images. The accuracy of neuropathological diagnosis based on SRH images was 87.7% and was non-inferior to the current standard of fast frozen H&E-stained sections (87.3 vs. 88.9%, p = 0.783). We found a substantial diagnostic correlation between SRH-based neuropathological diagnosis and H&E-stained frozen sections (κ = 0.8). The interpretability of intraoperative SRH imaging was demonstrated to be equivalent to the current standard method of H&E-stained frozen sections. Further research using this label-free innovative alternative vs. conventional staining is required to determine to which extent SRH-based intraoperative decision-making can be streamlined in order to facilitate the advancement of surgical neurooncology.
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Affiliation(s)
- Jakob Straehle
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Daniel Erny
- Institute of Neuropathology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nicolas Neidert
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany.,Microenvironment and Immunology Research Laboratory, Medical Center, University of Freiburg, Freiburg, Germany
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany.,Microenvironment and Immunology Research Laboratory, Medical Center, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), partner site Freiburg, Freiburg, Germany.,Medical Faculty of Freiburg University, Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Vlad Sacalean
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany.,Microenvironment and Immunology Research Laboratory, Medical Center, University of Freiburg, Freiburg, Germany
| | - David Steybe
- Department of Oral and Maxillofacial Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Rainer Schmelzeisen
- Medical Faculty of Freiburg University, Freiburg, Germany.,Department of Oral and Maxillofacial Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Andreas Vlachos
- Medical Faculty of Freiburg University, Freiburg, Germany.,Department of Neuroanatomy, Institute of Anatomy and Cell Biology, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center Brain Links Brain Tools, University of Freiburg, Freiburg, Germany
| | - Boris Mizaikoff
- Institute of Analytical and Bioanalytical Chemistry, Ulm University, Ulm, Germany.,Hahn-Schickard Institute for Microanalysis Systems, Ulm, Germany
| | - Peter Christoph Reinacher
- Medical Faculty of Freiburg University, Freiburg, Germany.,Department of Stereotactic and Functional Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany.,Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
| | - Volker Arnd Coenen
- Medical Faculty of Freiburg University, Freiburg, Germany.,Department of Stereotactic and Functional Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Marco Prinz
- Institute of Neuropathology, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Medical Faculty of Freiburg University, Freiburg, Germany.,Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.,Medical Faculty of Freiburg University, Freiburg, Germany.,Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany. .,Medical Faculty of Freiburg University, Freiburg, Germany.
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6
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Miyazaki T, Kambara M, Fujiwara Y, Nakagawa F, Yoshikane T, Akiyama Y. Frameless Free-Hand Navigation-Guided Biopsy for Brain Tumors: A Simpler Method with an Endoscope Holder. Asian J Neurosurg 2021; 16:258-263. [PMID: 34268148 PMCID: PMC8244691 DOI: 10.4103/ajns.ajns_25_21] [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: 01/19/2021] [Accepted: 03/02/2021] [Indexed: 11/21/2022] Open
Abstract
Context/Aims: Given the limitations of current navigation-guided brain biopsy methods, we aimed to introduce a novel method and validate its safety and accuracy. Setting and Design: This was a retrospective study of twenty consecutive patients who underwent brain biopsy at Shimane University Hospital, Japan. Subjects and Methods: Clinical records of 13 and 7 patients who underwent brain biopsy with the novel frameless free-hand navigation-guided biopsy (FFNB) method or a framed computed tomography-guided stereotactic biopsy (CTGB) method, respectively, were retrospectively reviewed. We compared age, sex, tumor location, histological diagnosis, maximum size of the tumor (target), depth from target to cortical surface on the same slice of CT or magnetic resonance imaging, operative position, anesthesia method, setup time for biopsy, incision-to-closure time, trial times for puncture, success rate, and complications in the two groups. Statistical Analysis: Fisher's exact test and the Wilcoxon rank-sum test were performed. Results: Clinical characteristics and lesion size did not differ significantly between the FFNB and CTGB groups. The depth of the target lesion was significantly greater in the CTGB group (P < 0.05). All FFNB and CTGB procedures reached and obtained the target tissue. The number of punctures and the average incision-to-closure time did not differ between the FFNB and CTGB groups. However, the preoperative setup time was significantly shorter using FFNB (P = 0.0003). No complications were observed in either group. Conclusions: FFNB was comparable with CTGB in terms of safety, accuracy, and operative duration. The preoperative setup time was shorter using FFNB. Therefore, FFNB is a feasible method for brain tumor biopsy.
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Affiliation(s)
- Takeshi Miyazaki
- Department of Neurosurgery, Shimane University School of Medicine, Izumo, Japan
| | - Mizuki Kambara
- Department of Neurosurgery, Shimane University School of Medicine, Izumo, Japan
| | - Yuta Fujiwara
- Department of Neurosurgery, Shimane University School of Medicine, Izumo, Japan
| | - Fumio Nakagawa
- Department of Neurosurgery, Shimane University School of Medicine, Izumo, Japan
| | - Tsutomu Yoshikane
- Department of Neurosurgery, Shimane University School of Medicine, Izumo, Japan
| | - Yasuhiko Akiyama
- Department of Neurosurgery, Shimane University School of Medicine, Izumo, Japan
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7
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Woodall RT, Hormuth Ii DA, Wu C, Abdelmalik MRA, Phillips WT, Bao A, Hughes TJR, Brenner AJ, Yankeelov TE. Patient specific, imaging-informed modeling of rhenium-186 nanoliposome delivery via convection-enhanced delivery in glioblastoma multiforme. Biomed Phys Eng Express 2021; 7. [PMID: 34050041 DOI: 10.1088/2057-1976/ac02a6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/18/2021] [Indexed: 12/25/2022]
Abstract
Convection-enhanced delivery of rhenium-186 (186Re)-nanoliposomes is a promising approach to provide precise delivery of large localized doses of radiation for patients with recurrent glioblastoma multiforme. Current approaches for treatment planning utilizing convection-enhanced delivery are designed for small molecule drugs and not for larger particles such as186Re-nanoliposomes. To enable the treatment planning for186Re-nanoliposomes delivery, we have developed a computational fluid dynamics approach to predict the distribution of nanoliposomes for individual patients. In this work, we construct, calibrate, and validate a family of computational fluid dynamics models to predict the spatio-temporal distribution of186Re-nanoliposomes within the brain, utilizing patient-specific pre-operative magnetic resonance imaging (MRI) to assign material properties for an advection-diffusion transport model. The model family is calibrated to single photon emission computed tomography (SPECT) images acquired during and after the infusion of186Re-nanoliposomes for five patients enrolled in a Phase I/II trial (NCT Number NCT01906385), and is validated using a leave-one-out bootstrapping methodology for predicting the final distribution of the particles. After calibration, our models are capable of predicting the mid-delivery and final spatial distribution of186Re-nanoliposomes with a Dice value of 0.69 ± 0.18 and a concordance correlation coefficient of 0.88 ± 0.12 (mean ± 95% confidence interval), using only the patient-specific, pre-operative MRI data, and calibrated model parameters from prior patients. These results demonstrate a proof-of-concept for a patient-specific modeling framework, which predicts the spatial distribution of nanoparticles. Further development of this approach could enable optimizing catheter placement for future studies employing convection-enhanced delivery.
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Affiliation(s)
- Ryan T Woodall
- Biomedical Engineering, The University of Texas at Austin, Austin, Texas, United States of America
| | - David A Hormuth Ii
- Oden Institute for Computational Engineering and Sciences,The University of Texas at Austin, Austin, Texas, United States of America.,Oncology, The University of Texas at Austin, Austin, Texas, United States of America
| | - Chengyue Wu
- Oden Institute for Computational Engineering and Sciences,The University of Texas at Austin, Austin, Texas, United States of America
| | - Michael R A Abdelmalik
- Oden Institute for Computational Engineering and Sciences,The University of Texas at Austin, Austin, Texas, United States of America.,Mechanical Engineering, Eindhoven University of Technology, The Netherlands
| | - William T Phillips
- Departments of Radiology at UT Health San Antonio, San Antonio, Texas, United States of America
| | - Ande Bao
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, Ohio, United States of America.,School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Thomas J R Hughes
- Oden Institute for Computational Engineering and Sciences,The University of Texas at Austin, Austin, Texas, United States of America.,Aerospace Engineering and Engineering Mechanics, The University of Texas at Austin, Austin, Texas, United States of America
| | - Andrew J Brenner
- Mays Cancer Center at UT Health San Antonio, San Antonio, Texas, United States of America
| | - Thomas E Yankeelov
- Biomedical Engineering, The University of Texas at Austin, Austin, Texas, United States of America.,Oden Institute for Computational Engineering and Sciences,The University of Texas at Austin, Austin, Texas, United States of America.,Diagnostic Medicine, The University of Texas at Austin, Austin, Texas, United States of America.,Oncology, The University of Texas at Austin, Austin, Texas, United States of America.,Livestrong Cancer Institutes, The University of Texas at Austin, Austin, Texas, United States of America.,Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
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8
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Ladisich B, Machegger L, Romagna A, Krainz H, Steinbacher J, Leitinger M, Kalss G, Thon N, Trinka E, Winkler PA, Schwartz C. VarioGuide® frameless neuronavigation-guided stereoelectroencephalography in adult epilepsy patients: technique, accuracy and clinical experience. Acta Neurochir (Wien) 2021; 163:1355-1364. [PMID: 33580853 PMCID: PMC8053662 DOI: 10.1007/s00701-021-04755-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022]
Abstract
Background Stereoelectroencephalography (SEEG) allows the identification of deep-seated seizure foci and determination of the epileptogenic zone (EZ) in drug-resistant epilepsy (DRE) patients. We evaluated the accuracy and treatment-associated morbidity of frameless VarioGuide® (VG) neuronavigation-guided depth electrode (DE) implantations. Methods We retrospectively identified all consecutive adult DRE patients, who underwent VG-neuronavigation DE implantations, between March 2013 and April 2019. Clinical data were extracted from the electronic patient charts. An interdisciplinary team agreed upon all treatment decisions. We performed trajectory planning with iPlan® Cranial software and DE implantations with the VG system. Each electrode’s accuracy was assessed at the entry (EP), the centre (CP) and the target point (TP). We conducted correlation analyses to identify factors associated with accuracy. Results The study population comprised 17 patients (10 women) with a median age of 32.0 years (range 21.0–54.0). In total, 220 DEs (median length 49.3 mm, range 25.1–93.8) were implanted in 21 SEEG procedures (range 3–16 DEs/surgery). Adequate signals for postoperative SEEG were detected for all but one implanted DEs (99.5%); in 15/17 (88.2%) patients, the EZ was identified and 8/17 (47.1%) eventually underwent focus resection. The mean deviations were 3.2 ± 2.4 mm for EP, 3.0 ± 2.2 mm for CP and 2.7 ± 2.0 mm for TP. One patient suffered from postoperative SEEG-associated morbidity (i.e. conservatively treated delayed bacterial meningitis). No mortality or new neurological deficits were recorded. Conclusions The accuracy of VG-SEEG proved sufficient to identify EZ in DRE patients and associated with a good risk-profile. It is a viable and safe alternative to frame-based or robotic systems. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-04755-w.
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Affiliation(s)
- Barbara Ladisich
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
| | - Lukas Machegger
- University Institute of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Alexander Romagna
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
- Department of Neurosurgery, München Klinik Bogenhausen, Englschalkingerstr. 77, 81925, Munich, Germany
| | - Herbert Krainz
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
| | - Jürgen Steinbacher
- University Institute of Neuroradiology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Niklas Thon
- Department of Neurosurgery, University Hospital Munich, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Eugen Trinka
- Department of Neurology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria
| | - Peter A Winkler
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria
| | - Christoph Schwartz
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University Salzburg, Ignaz-Harrer-Str. 79, A-5020, Salzburg, Austria.
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9
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Švaco M, Stiperski I, Dlaka D, Šuligoj F, Jerbić B, Chudy D, Raguž M. Stereotactic Neuro-Navigation Phantom Designs: A Systematic Review. Front Neurorobot 2020; 14:549603. [PMID: 33192433 PMCID: PMC7644893 DOI: 10.3389/fnbot.2020.549603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/16/2020] [Indexed: 11/28/2022] Open
Abstract
Diverse stereotactic neuro-navigation systems are used daily in neurosurgery and novel systems are continuously being developed. Prior to clinical implementation of new surgical tools, methods or instruments, in vitro experiments on phantoms should be conducted. A stereotactic neuro-navigation phantom denotes a rigid or deformable structure resembling the cranium with the intracranial area. The use of phantoms is essential for the testing of complete procedures and their workflows, as well as for the final validation of the application accuracy. The aim of this study is to provide a systematic review of stereotactic neuro-navigation phantom designs, to identify their most relevant features, and to identify methodologies for measuring the target point error, the entry point error, and the angular error (α). The literature on phantom designs used for evaluating the accuracy of stereotactic neuro-navigation systems, i.e., robotic navigation systems, stereotactic frames, frameless navigation systems, and aiming devices, was searched. Eligible articles among the articles written in English in the period 2000–2020 were identified through the electronic databases PubMed, IEEE, Web of Science, and Scopus. The majority of phantom designs presented in those articles provide a suitable methodology for measuring the target point error, while there is a lack of objective measurements of the entry point error and angular error. We identified the need for a universal phantom design, which would be compatible with most common imaging techniques (e.g., computed tomography and magnetic resonance imaging) and suitable for simultaneous measurement of the target point, entry point, and angular errors.
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Affiliation(s)
- Marko Švaco
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Ivan Stiperski
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - Domagoj Dlaka
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Filip Šuligoj
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Bojan Jerbić
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Darko Chudy
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Croatian Institute for Brain Research, School of Medicine University of Zagreb, Zagreb, Croatia.,Department of Surgery, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Marina Raguž
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Croatian Institute for Brain Research, School of Medicine University of Zagreb, Zagreb, Croatia.,Department of Anatomy and Clinical Anatomy, School of Medicine University of Zagreb, Zagreb, Croatia
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10
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Gates EDH, Lin JS, Weinberg JS, Prabhu SS, Hamilton J, Hazle JD, Fuller GN, Baladandayuthapani V, Fuentes DT, Schellingerhout D. Imaging-Based Algorithm for the Local Grading of Glioma. AJNR Am J Neuroradiol 2020; 41:400-407. [PMID: 32029466 DOI: 10.3174/ajnr.a6405] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Gliomas are highly heterogeneous tumors, and optimal treatment depends on identifying and locating the highest grade disease present. Imaging techniques for doing so are generally not validated against the histopathologic criterion standard. The purpose of this work was to estimate the local glioma grade using a machine learning model trained on preoperative image data and spatially specific tumor samples. The value of imaging in patients with brain tumor can be enhanced if pathologic data can be estimated from imaging input using predictive models. MATERIALS AND METHODS Patients with gliomas were enrolled in a prospective clinical imaging trial between 2013 and 2016. MR imaging was performed with anatomic, diffusion, permeability, and perfusion sequences, followed by image-guided stereotactic biopsy before resection. An imaging description was developed for each biopsy, and multiclass machine learning models were built to predict the World Health Organization grade. Models were assessed on classification accuracy, Cohen κ, precision, and recall. RESULTS Twenty-three patients (with 7/9/7 grade II/III/IV gliomas) had analyzable imaging-pathologic pairs, yielding 52 biopsy sites. The random forest method was the best algorithm tested. Tumor grade was predicted at 96% accuracy (κ = 0.93) using 4 inputs (T2, ADC, CBV, and transfer constant from dynamic contrast-enhanced imaging). By means of the conventional imaging only, the overall accuracy decreased (89% overall, κ = 0.79) and 43% of high-grade samples were misclassified as lower-grade disease. CONCLUSIONS We found that local pathologic grade can be predicted with a high accuracy using clinical imaging data. Advanced imaging data improved this accuracy, adding value to conventional imaging. Confirmatory imaging trials are justified.
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Affiliation(s)
- E D H Gates
- From the Departments of Imaging Physics (E.D.H.G., J.S.L., J.D.H., D.T.F.), Neurosurgery (J.S.W., S.S.P.), Pathology (G.N.F.), Neuroradiology (D.S.), and Cancer Systems Imaging (D.S.), University of Texas MD Anderson Cancer Center, Houston, Texas.,University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences (E.D.H.G.), Houston, Texas
| | - J S Lin
- From the Departments of Imaging Physics (E.D.H.G., J.S.L., J.D.H., D.T.F.), Neurosurgery (J.S.W., S.S.P.), Pathology (G.N.F.), Neuroradiology (D.S.), and Cancer Systems Imaging (D.S.), University of Texas MD Anderson Cancer Center, Houston, Texas.,Baylor College of Medicine (J.S.L.), Houston, Texas.,Department of Bioengineering (J.S.L.), Rice University, Houston, Texas
| | - J S Weinberg
- From the Departments of Imaging Physics (E.D.H.G., J.S.L., J.D.H., D.T.F.), Neurosurgery (J.S.W., S.S.P.), Pathology (G.N.F.), Neuroradiology (D.S.), and Cancer Systems Imaging (D.S.), University of Texas MD Anderson Cancer Center, Houston, Texas
| | - S S Prabhu
- From the Departments of Imaging Physics (E.D.H.G., J.S.L., J.D.H., D.T.F.), Neurosurgery (J.S.W., S.S.P.), Pathology (G.N.F.), Neuroradiology (D.S.), and Cancer Systems Imaging (D.S.), University of Texas MD Anderson Cancer Center, Houston, Texas
| | - J Hamilton
- Radiology Partners (J.H.), Houston, Texas
| | - J D Hazle
- From the Departments of Imaging Physics (E.D.H.G., J.S.L., J.D.H., D.T.F.), Neurosurgery (J.S.W., S.S.P.), Pathology (G.N.F.), Neuroradiology (D.S.), and Cancer Systems Imaging (D.S.), University of Texas MD Anderson Cancer Center, Houston, Texas
| | - G N Fuller
- From the Departments of Imaging Physics (E.D.H.G., J.S.L., J.D.H., D.T.F.), Neurosurgery (J.S.W., S.S.P.), Pathology (G.N.F.), Neuroradiology (D.S.), and Cancer Systems Imaging (D.S.), University of Texas MD Anderson Cancer Center, Houston, Texas
| | - V Baladandayuthapani
- Department of Computational Medicine and Bioinformatics (V.B.), University of Michigan School of Public Health, Ann Arbor, Michigan
| | - D T Fuentes
- From the Departments of Imaging Physics (E.D.H.G., J.S.L., J.D.H., D.T.F.), Neurosurgery (J.S.W., S.S.P.), Pathology (G.N.F.), Neuroradiology (D.S.), and Cancer Systems Imaging (D.S.), University of Texas MD Anderson Cancer Center, Houston, Texas
| | - D Schellingerhout
- From the Departments of Imaging Physics (E.D.H.G., J.S.L., J.D.H., D.T.F.), Neurosurgery (J.S.W., S.S.P.), Pathology (G.N.F.), Neuroradiology (D.S.), and Cancer Systems Imaging (D.S.), University of Texas MD Anderson Cancer Center, Houston, Texas
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11
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Taweesomboonyat C, Tunthanathip T, Sae-Heng S, Oearsakul T. Diagnostic Yield and Complication of Frameless Stereotactic Brain Biopsy. J Neurosci Rural Pract 2019; 10:78-84. [PMID: 30765975 PMCID: PMC6337997 DOI: 10.4103/jnrp.jnrp_166_18] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: With the advancement of neuronavigation technologies, frameless stereotactic brain biopsy has been developed. Previous studies proved that frameless stereotactic brain biopsy was as effective and safe as frame-based stereotactic brain biopsy. The authors aimed to find the factors associated with diagnostic yield and complication rate of frameless intracranial biopsy. Materials and Methods: Frameless stereotactic brain biopsy procedures, between March 2009 and April 2017, were retrospectively reviewed from medical records including imaging studies. Using logistic regression analysis, various factors were analyzed for association with diagnostic yield and postoperative complications. Results: Eighty-nine frameless stereotactic brain biopsy procedures were performed on 85 patients. The most common pathology was primary central nervous system lymphoma (43.8%), followed by low-grade glioma (15.7%), and high-grade glioma (15%), respectively. The diagnostic yield was 87.6%. Postoperative intracerebral hematoma occurred in 19% of cases; however, it was symptomatic in only one case. The size of the lesion was associated with both diagnostic yield and postoperative intracerebral hematoma complication. Lesions, larger than 3 cm in diameter, were associated with a higher rate of positive biopsy result (P = 0.01). Lesion 3 cm or smaller than 3 cm in diameter, and intraoperative bleeding associated with a higher percentage of postoperative intracerebral hematoma complications (P = 0.01). Conclusions: For frameless stereotactic brain biopsy, the size of the lesion is the essential factor determining diagnostic yield and postoperative intracerebral hematoma complication.
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Affiliation(s)
- Chin Taweesomboonyat
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Thara Tunthanathip
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Sakchai Sae-Heng
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Thakul Oearsakul
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
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12
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Sciortino T, Fernandes B, Conti Nibali M, Gay LG, Rossi M, Lopci E, Colombo AE, Elefante MG, Pessina F, Bello L, Riva M. Frameless stereotactic biopsy for precision neurosurgery: diagnostic value, safety, and accuracy. Acta Neurochir (Wien) 2019; 161:967-974. [PMID: 30895395 DOI: 10.1007/s00701-019-03873-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/06/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Stereotactic biopsy is consistently employed to characterize cerebral lesions in patients who are not suitable for microsurgical resection. In the past years, technical improvement and neuroimaging advancements contributed to increase the diagnostic yield, the safety, and the application of this procedure. Currently, in addition to histological diagnosis, the molecular analysis is considered essential in the diagnostic process to properly select therapeutic and prognostic algorithms in a personalized approach. The present study reports our experience with frameless stereotactic brain biopsy in this molecular era. METHODS One hundred forty consecutive patients treated from January 2013 to September 2018 were analyzed. Biopsies were performed using the Brainlab Varioguide® frameless stereotactic system. Patients' clinical and demographic data, the time of occupation of the operating room, the surgical time, the morbidity, and the diagnostic yield in providing a histological and molecular diagnosis were recorded and evaluated. RESULTS The overall diagnostic yield was 93.6% with nine procedures resulting non-diagnostic. Among 110 patients with glioma, the IDH-1 mutational status was characterized in 108 cases (98.2%), resulting wild-type in all subjects but 3; MGMT methylation was characterized in 96 cases (87.3%), resulting present in 60 patients, and 1p/19q codeletion was founded in 6 of the 20 cases of grade II-III gliomas analyzed. All the specimens were apt for molecular analysis when performed. Bleeding requiring surgical drainage occurred in 2.1% of the cases; 8 (5.7%) asymptomatic hemorrhages requiring no treatment were observed. No biopsy-related mortality was recorded. Median length of hospital stay was 5 days (IQR 4-8) with mean surgical time of 60.77 min (± 23.12) and 137.44 ± 24.1 min of total occupation time of the operative room. CONCLUSIONS Stereotactic frameless biopsy is a safe, feasible, and fast procedure to obtain a histological and molecular diagnosis.
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Affiliation(s)
- Tommaso Sciortino
- Università degli Studi di Milano, Milan, Italy
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
| | - Bethania Fernandes
- Unit of Pathology, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
| | - Marco Conti Nibali
- Università degli Studi di Milano, Milan, Italy
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
| | - Lorenzo G Gay
- Università degli Studi di Milano, Milan, Italy
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
| | - Marco Rossi
- Università degli Studi di Milano, Milan, Italy
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
| | - Egesta Lopci
- Unit of Nuclear Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
| | - Anna E Colombo
- Unit of Pathology, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
| | - Maria G Elefante
- Unit of Pathology, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
| | - Federico Pessina
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
- Department of Biomedical Sciences, Humanitas University, Rozzano (MI), Italy
| | - Lorenzo Bello
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Marco Riva
- Unit of Oncological Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy.
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy.
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13
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Bernstock JD, Wright Z, Bag AK, Gessler F, Gillespie GY, Markert JM, Friedman GK, Johnston JM. Stereotactic Placement of Intratumoral Catheters for Continuous Infusion Delivery of Herpes Simplex Virus -1 G207 in Pediatric Malignant Supratentorial Brain Tumors. World Neurosurg 2018; 122:e1592-e1598. [PMID: 30481622 DOI: 10.1016/j.wneu.2018.11.122] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The engineered herpes simplex virus-1 G207, is a promising therapeutic option for central nervous system tumors. The first-ever pediatric phase 1 trial of continuous-infusion delivery of G207 via intratumoral catheters for recurrent or progressive malignant brain tumors is ongoing. In this article, we describe surgical techniques for the accurate placement of catheters in multiple supratentorial locations and perioperative complications associated with such procedures. METHODS A prospective study of G207 in children with recurrent malignant supratentorial tumors is ongoing. Preoperative stereotactic protocol magnetic resonance imaging was performed, and catheter trajectories planned using StealthStation planning software. Children underwent placement of 3-4 silastic catheters using a small incision burr hole and the Vertek system. Patients had a preinfusion computed tomography scan to confirm correct placement of catheters. RESULTS Six children underwent implantation of 3-4 catheters. Locations of catheter placement included frontal, temporal, parietal, and occipital lobes, and the insula and thalamus. There were no clinically significant perioperative complications. Postoperative computed tomography scans coupled with preoperative MRI scans demonstrated accurate placement of 21 of 22 catheters, with 1 misplaced catheter pulled back to an optimal location at the bedside. One patient had hemorrhage along the catheter tract that was clinically asymptomatic. Another patient had cerebrospinal fluid leak from a biopsy incision 9 days after surgery that was oversewn without complication. CONCLUSIONS The placement of multiple intratumoral catheters in pediatric patients with supratentorial tumors via frameless stereotactic techniques is feasible and safe. Intratumoral catheters provide a potentially effective route for the delivery of G207 and may be employed in other trials utilizing oncolytic virotherapy for brain tumors.
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Affiliation(s)
- Joshua D Bernstock
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Zachary Wright
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Asim K Bag
- Department of Radiology, Neuroradiology Section, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Florian Gessler
- Department of Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gregory K Friedman
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - James M Johnston
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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14
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The role of frameless stereotactic biopsy in contemporary neuro-oncology: molecular specifications and diagnostic yield in biopsied glioma patients. J Neurooncol 2018; 141:183-194. [DOI: 10.1007/s11060-018-03024-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/03/2018] [Indexed: 12/31/2022]
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15
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Squires A, Oshinski JN, Boulis NM, Tse ZTH. SpinoBot: An MRI-Guided Needle Positioning System for Spinal Cellular Therapeutics. Ann Biomed Eng 2018; 46:475-487. [PMID: 29150766 PMCID: PMC7215142 DOI: 10.1007/s10439-017-1960-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 11/10/2017] [Indexed: 12/14/2022]
Abstract
The neurodegenerative disease amyotrophic lateral sclerosis (ALS) results in the death of motor neurons in voluntary muscles. There are no cures for ALS and few available treatments. In studies with small animal models, injection of cellular therapeutics into the anterior horn of the spinal cord has been shown to inhibit the progression of ALS. It was hypothesized that spinal injection could be made faster and less invasive with the aid of a robot. The robotic system presented-SpinoBot-uses MRI guidance to position a needle for percutaneous injection into the spinal cord. With four degrees of freedom (DOF) provided by two translation stages and two rotational axes, SpinoBot proved capable of advanced targeting with a mean error of 1.12 mm and standard deviation of 0.97 mm in bench tests, and a mean error of 2.2 mm and standard deviation of 0.85 mm in swine cadaver tests. SpinoBot has shown less than 3% signal-to-noise ratio reduction in 3T MR imaging quality, demonstrating its compliance to the MRI environment. With the aid of SpinoBot, the length of the percutaneous injection procedure is reduced to less than 60 min with 10 min for each additional insertion. Although SpinoBot is designed for ALS treatment, it could potentially be used for other procedures that require precise access to the spine.
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Affiliation(s)
| | - John N Oshinski
- Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
- Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, GA, USA
| | - Nicholas M Boulis
- Neurosurgery, Emory University Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Zion Tsz Ho Tse
- Engineering, The University of Georgia, Athens, GA, USA.
- Driftmier Engineering Center, 597 D.W. Brooks Dr, Annex Room 111, Athens, GA, 30602, USA.
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16
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Avecillas-Chasin JM, Budke M, Villarejo F. Neuroendoscopic Intraventricular Biopsy in Children with Small Ventricles Using Frameless VarioGuide System. World Neurosurg 2016; 87:136-42. [PMID: 26723291 DOI: 10.1016/j.wneu.2015.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 11/15/2022]
Abstract
Endoscopic biopsy for intraventricular tumors in pediatric patients with small ventricles is a challenging procedure because of the risk of morbidity during the intraventricular approach. We describe the use of the VarioGuide system for intraventricular endoscopic biopsy in 9 consecutive pediatric patients with intraventricular lesions and small ventricular size. All patients had lesions in the anterior part of the third ventricle with a median frontal and occipital horn ratio of 0.33. Patients presented with growth failure (n = 4), visual disturbances (n = 4), and seizures (n = 1). The VarioGuide system consists of an ergonomic arm with 3 joints for gross adjustment. The 3 rotational joints on the distal side of the system are adjusted according to the angles of the planned trajectory. The endoscope is adjusted to the distal side of the VarioGuide and inserted through the ring, previously set for the diameter of the endoscope and for the planned trajectory. The accuracy of the trajectory and correct ventricular cannulation are confirmed under endoscopic guidance. The biopsy is carried out according to the standard technique. In all cases, the biopsy sample provided the definitive diagnosis. Diagnoses included germinomas in 4 patients, hamartoma in 1 patient, hypothalamic astrocytoma in 2 patients, and craniopharyngioma in 2 patients. The use of the VarioGuide system for intraventricular endoscopic biopsy is highly recommended for pediatric patients with small ventricle size. This technique may help minimize the risk of unnecessary brain damage during the entrance to small ventricles.
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Affiliation(s)
| | - Marcelo Budke
- Department of Neurosurgery, Hospital Infantil Universitario Niño Jesus, Madrid, Spain.
| | - Francisco Villarejo
- Department of Neurosurgery, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
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17
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Verburg N, Baayen JC, Idema S, Klitsie MAJ, Claus S, de Jonge CS, Vandertop WP, de Witt Hamer PC. In Vivo Accuracy of a Frameless Stereotactic Drilling Technique for Diagnostic Biopsies and Stereoelectroencephalography Depth Electrodes. World Neurosurg 2015; 87:392-8. [PMID: 26700749 DOI: 10.1016/j.wneu.2015.11.041] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 11/29/2015] [Accepted: 11/30/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Accurate frameless neuronavigation is highly important in cranial neurosurgery. The accuracy demonstrated in phantom models might not be representative for results in patients. Few studies describe the in vivo quantitative accuracy of neuronavigation in patients. The use of a frameless stereotactic drilling technique for stereoelectroencephalography depth electrode implantation in epilepsy patients, as well as diagnostic biopsies, provides a unique opportunity to assess the accuracy with postoperative imaging of preoperatively planned trajectories. METHODS In 7 patients with refractory epilepsy, 89 depth electrodes were implanted using a frameless stereotactic drilling technique. Each electrode was planned on a preoperative magnetic resonance and computed tomographic scan, and verified on postoperative computed tomographic scan. After fusion of preoperative and postoperative imaging, the accuracy for each electrode was calculated as the Euclidean distance between the planned and observed position of the electrode tip. RESULTS The median Euclidean distance between planned and observed electrode implantations was 3.5 mm (95% confidence interval, 2.9-3.9 mm) with a range of 1.2-13.7 mm. CONCLUSIONS In this study, we showed that the in vivo accuracy of our frameless stereotactic drilling technique, suitable for stereoelectroencephalography depth electrode placement and diagnostic brain biopsies, was 3.5 mm.
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Affiliation(s)
- Niels Verburg
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands.
| | - Johannes C Baayen
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands
| | - Sander Idema
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands
| | - Michiel A J Klitsie
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands
| | - Steven Claus
- Department of Clinical Neurophysiology, Stichting Epilepsy Instellingen Nederland, Epilepsy Institutes in The Netherlands, SEIN, Heemstede, The Netherlands
| | | | - W Peter Vandertop
- Neurosurgical Center Amsterdam, VU Medical Centre, Amsterdam, The Netherlands
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18
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Contemporary frameless intracranial biopsy techniques: Might variation in safety and efficacy be expected? Acta Neurochir (Wien) 2015; 157:2011-6; discussion 2016. [PMID: 26315461 PMCID: PMC4604498 DOI: 10.1007/s00701-015-2543-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 08/07/2015] [Indexed: 11/10/2022]
Abstract
Background Frameless stereotactic neuronavigation has proven to be a feasible technology to acquire brain biopsies with good accuracy and little morbidity and mortality. New systems are constantly introduced into the neurosurgical armamentarium, although few studies have actually evaluated and compared the diagnostic yield, morbidity, and mortality of various manufacturer’s frameless neuronavigation systems. The present study reports our experience with brain biopsy procedures performed using both the Medtronic Stealth TreonTM Vertek® and BrainLAB® Varioguide frameless stereotactic brain biopsy systems. Patients and methods All 247 consecutive biopsies from January 2008 until May 2013 were evaluated retrospectively. One hundred two biopsies each were performed using the Medtronic (2008–2009) and BrainLAB® system (2011–2013), respectively. The year 2010 was considered a transition year, in which 43 biopsies were performed with either system. Patient demographics, perioperative characteristics, and histological diagnosis were reviewed, and a comparison was made between the two brain biopsy systems. Results The overall diagnostic yield was 94.6 %, i.e., 11 biopsies were nondiagnostic, 5 (4.9 %) with the Medtronic and 6 (5.9 %) with the BrainLAB® system. No differences besides the operating time (108 vs 120 min) were found between the two biopsy methods. On average, 6.6 tissue samples were taken with either technique. Peri- and postoperative complications were seen in 5.3 % and 12.9 %, consisting of three symptomatic hemorrhages (1.2 %). Biopsy-related mortality occurred in 0.8 % of all biopsies. Conclusions Regarding diagnostic yield, complication rate, and biopsy-related mortality, there seems to be no difference between the frameless biopsy technique from Medtronic and BrainLAB®. In contemporary time, the neurosurgeon has many tools to choose from, all with a relatively fast learning curve and ever improving feasibility. Thus, the issue of choice involves not the results, but the familiarity, end-user friendliness, and overall comfort when operating the system.
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19
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Cooke DL, Levitt MR, Kim LJ, Hallam DK, Sekhar LN, Ghodke BV. Laser-assisted flat-detector CT-guided intracranial access. Int J Comput Assist Radiol Surg 2015; 11:467-72. [PMID: 26239371 DOI: 10.1007/s11548-015-1271-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Flat-detector CT can be integrated with C-arm fluoroscopy for CT-guided neurosurgical and endovascular procedures. We studied the accuracy of this technique with laser assistance in targeting intracranial lesions in a cranial model. METHODS An acrylic scale-model skull containing foam parenchyma was embedded with 2.16-mm-diameter targets. A flat-detector CT was acquired and registered to the skull's position. Ten targets were accessed with biopsy needles under fluoroscopic guidance, flat-detector CT overlay, and laser assistance. Accuracy was measured from the needle tip to the target center using flat-detector CT. RESULTS Ten targets were accessed successfully using XperGuide software. Needles were placed within 1.30 [Formula: see text] 0.63 mm of target isocenter. Accuracy did not vary by entry site, operator, location, or lesion depth. CONCLUSIONS Laser-assisted flat-detector CT-guided targeting of all intracranial targets was successful with excellent accuracy. This technique can be applied to other minimally invasive neurosurgical procedures.
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Affiliation(s)
- Daniel L Cooke
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Michael R Levitt
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359924, Seattle, WA, 98104-2499, USA. .,Department of Radiology, University of Washington, Seattle, WA, USA.
| | - Louis J Kim
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359924, Seattle, WA, 98104-2499, USA.,Department of Radiology, University of Washington, Seattle, WA, USA
| | - Danial K Hallam
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359924, Seattle, WA, 98104-2499, USA.,Department of Radiology, University of Washington, Seattle, WA, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359924, Seattle, WA, 98104-2499, USA
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359924, Seattle, WA, 98104-2499, USA.,Department of Radiology, University of Washington, Seattle, WA, USA
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20
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Mabray MC, Datta S, Lillaney PV, Moore T, Gehrisch S, Talbott JF, Levitt MR, Ghodke BV, Larson PS, Cooke DL. Accuracy of flat panel detector CT with integrated navigational software with and without MR fusion for single-pass needle placement. J Neurointerv Surg 2015; 8:731-5. [PMID: 26047903 DOI: 10.1136/neurintsurg-2015-011799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 05/21/2015] [Indexed: 11/04/2022]
Abstract
PURPOSE Fluoroscopic systems in modern interventional suites have the ability to perform flat panel detector CT (FDCT) with navigational guidance. Fusion with MR allows navigational guidance towards FDCT occult targets. We aim to evaluate the accuracy of this system using single-pass needle placement in a deep brain stimulation (DBS) phantom. MATERIALS AND METHODS MR was performed on a head phantom with DBS lead targets. The head phantom was placed into fixation and FDCT was performed. FDCT and MR datasets were automatically fused using the integrated guidance system (iGuide, Siemens). A DBS target was selected on the MR dataset. A 10 cm, 19 G needle was advanced by hand in a single pass using laser crosshair guidance. Radial error was visually assessed against measurement markers on the target and by a second FDCT. Ten needles were placed using CT-MR fusion and 10 needles were placed without MR fusion, with targeting based solely on FDCT and fusion steps repeated for every pass. RESULTS Mean radial error was 2.75±1.39 mm as defined by visual assessment to the centre of the DBS target and 2.80±1.43 mm as defined by FDCT to the centre of the selected target point. There were no statistically significant differences in error between MR fusion and non-MR guided series. CONCLUSIONS Single pass needle placement in a DBS phantom using FDCT guidance is associated with a radial error of approximately 2.5-3.0 mm at a depth of approximately 80 mm. This system could accurately target sub-centimetre intracranial lesions defined on MR.
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Affiliation(s)
- Marc C Mabray
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | | | - Prasheel V Lillaney
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Teri Moore
- Siemens Healthcare AG, Forchheim, Germany
| | | | - Jason F Talbott
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Paul S Larson
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
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Ling JM, Dinesh SK, Pang BC, Chen MW, Lim HL, Louange DT, Yu CS, Wang CME. Routine spinal navigation for thoraco-lumbar pedicle screw insertion using the O-arm three-dimensional imaging system improves placement accuracy. J Clin Neurosci 2013; 21:493-8. [PMID: 24090516 DOI: 10.1016/j.jocn.2013.02.034] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 02/16/2013] [Accepted: 02/20/2013] [Indexed: 01/15/2023]
Abstract
Modern image-guided spinal navigation employs high-quality intra-operative three dimensional (3D) images to improve the accuracy of spinal surgery. This study aimed to assess the accuracy of thoraco-lumbar pedicle screw insertion using the O-arm (Breakaway Imaging, LLC, Littleton, MA, USA) 3D imaging system. Ninety-two patients underwent insertion of thoraco-lumbar pedicle screws guided by O-arm navigation over a 27 month period. Intra-operative scans were retrospectively reviewed for pedicle breach. The operative time of patients where O-arm navigation was used was compared to a matched control group where fluoroscopy was used. A total of 467 pedicle screws were inserted. Four hundred and forty-five screws (95.3%) were placed within the pedicle without any breach (Gertzbein classification grade 0). Sixteen screws (3.4%) had a pedicle breach of less than 2mm (Gertzbein classification grade 1), and six screws (1.3%) had a pedicle breach between 2mm and 4mm (Gertzbein classification grade 2). The grade 2 screws were revised intra-operatively. There was no incidence of neurovascular injury in this series of patients. The mean operative time for O-arm patients was 5.25 hours. In a matched control group of fluoroscopy patients, the mean operative time was 4.75 hours. The difference in the mean operative time between the two groups was not statistically significant (p=0.15, paired t-test). Stereotactic navigation based on intra-operative O-arm 3D imaging resulted in high accuracy in thoraco-lumbar pedicle screw insertion.
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Affiliation(s)
- Ji Min Ling
- Department of Neurosurgery, National Neuroscience Institute, Singapore 11 Jalan Tan Tock Seng, Sinagpore 308433, Singapore
| | - Shree Kumar Dinesh
- Department of Neurosurgery, National Neuroscience Institute, Singapore 11 Jalan Tan Tock Seng, Sinagpore 308433, Singapore
| | - Boon Chuan Pang
- Department of Neurosurgery, National Neuroscience Institute, Singapore 11 Jalan Tan Tock Seng, Sinagpore 308433, Singapore
| | - Min Wei Chen
- Department of Neurosurgery, National Neuroscience Institute, Singapore 11 Jalan Tan Tock Seng, Sinagpore 308433, Singapore
| | - Heng Lip Lim
- Department of Neurosurgery, National Neuroscience Institute, Singapore 11 Jalan Tan Tock Seng, Sinagpore 308433, Singapore
| | - Danny T Louange
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chun Sing Yu
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chee Meng Ernest Wang
- Department of Neurosurgery, National Neuroscience Institute, Singapore 11 Jalan Tan Tock Seng, Sinagpore 308433, Singapore.
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Koivukangas T, Katisko JP, Koivukangas JP. Technical accuracy of optical and the electromagnetic tracking systems. SPRINGERPLUS 2013; 2:90. [PMID: 23586003 PMCID: PMC3622743 DOI: 10.1186/2193-1801-2-90] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/25/2013] [Indexed: 11/10/2022]
Abstract
Thousands of operations are annually guided with computer assisted surgery (CAS) technologies. As the use of these devices is rapidly increasing, the reliability of the devices becomes ever more critical. The problem of accuracy assessment of the devices has thus become relevant. During the past five years, over 200 hazardous situations have been documented in the MAUDE database during operations using these devices in the field of neurosurgery alone. Had the accuracy of these devices been periodically assessed pre-operatively, many of them might have been prevented. The technical accuracy of a commercial navigator enabling the use of both optical (OTS) and electromagnetic (EMTS) tracking systems was assessed in the hospital setting using accuracy assessment tools and methods developed by the authors of this paper. The technical accuracy was obtained by comparing the positions of the navigated tool tip with the phantom accuracy assessment points. Each assessment contained a total of 51 points and a region of surgical interest (ROSI) volume of 120x120x100 mm roughly mimicking the size of the human head. The error analysis provided a comprehensive understanding of the trend of accuracy of the surgical navigator modalities. This study showed that the technical accuracies of OTS and EMTS over the pre-determined ROSI were nearly equal. However, the placement of the particular modality hardware needs to be optimized for the surgical procedure. New applications of EMTS, which does not require rigid immobilization of the surgical area, are suggested.
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Affiliation(s)
- Tapani Koivukangas
- Department of Mechanical Engineering, University of Oulu, PL 4200, Oulu, 90014 Finland
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Gempt J, Buchmann N, Ryang YM, Krieg S, Kreutzer J, Meyer B, Ringel F. Frameless image-guided stereotaxy with real-time visual feedback for brain biopsy. Acta Neurochir (Wien) 2012; 154:1663-7. [PMID: 22847726 DOI: 10.1007/s00701-012-1425-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 06/08/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Frame-based stereotaxy remains the "gold standard" for cerebral biopsies and functional neurosurgery though new frameless stereotactic systems are evolving continually. As the technique of frameless stereotaxy gains increasing acceptance among neurosurgeons, this study assesses the feasibility of a system for frameless image-guided stereotaxy. METHODS All patients biopsied for intracranial lesions between February 2007 and August 2010 using the BrainLAB VarioGuide frameless stereotactic system were evaluated prospectively. Prior to surgery, patients underwent magnetic resonance (MR) imaging; additionally, fluoroethyl-tyrosine (FET)-positron emission tomography (PET) images were acquired and fused to MR images in selected cases. Biopsy trajectory length, lesion volume, procedure duration, and diagnostic yield were assessed. RESULTS Ninety-six diagnostic biopsies in 91 patients were evaluated. Lesion volume ranged from 0.17 to 121.8 cm(3); trajectory length from 25.3 to 101.9 mm. Diagnostic yield was 93.8%. Mean operation time from skin incision to wound closure was 42 min; in the operating room, it was 99 min. CONCLUSIONS Clinical experience indicates VarioGuide to be safe and accurate. Reachable range of lesion localisation appears to be comparable to a frame-based stereotaxy system. Operation times are brief. The unique design of this frameless stereotactic system allows real-time visual feedback of needle positioning.
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Affiliation(s)
- Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, München, Germany
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Patil AA. A modified stereotactic frame as an instrument holder for frameless stereotaxis: Technical note. Surg Neurol Int 2010; 1:62. [PMID: 20975978 PMCID: PMC2958333 DOI: 10.4103/2152-7806.70957] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 09/03/2010] [Indexed: 11/16/2022] Open
Abstract
Background: In order to improve the targeting capability and trajectory planning and provide a more secure probe-holding system, a simple method to use a stereotactic frame as an instrument holder for the frameless stereotactic system was devised. Methods: A modified stereotactic frame and BrainLab vector vision neuronavigation sys¬tem were used together. The patient was placed in the stereotactic head-holder to which a reference array of the neuronavigation system was attached. The pointer of the frameless system was placed in the probe-holder of the frame. An offset in distances was kept between the radius of the arch of the frame and the tip of the pointer so that the pointer was always outside the head during navigation. The offset correction was made on the BrainLab monitor so that the center of the arc of the frame was at the tip of the probe line on the monitor. Then, using the frame’s coordinate adjuster system, the center of the arc was positioned on the target. This method was used to insert depth electrodes (seven procedures) and gain access to the temporal horn (three procedures). Results: Post-operative scans showed that the accuracy was within 2.5 mm in all three planes for depth electrode placement, and easy access to the temporal horn was obtained in two other patients. Conclusion: This is a simple method to use a stereotactic frame to improve coordinate and trajectory adjustments and provides a better method to stabilize the pointer and the probe-holder during frameless stereotactic procedures.
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Affiliation(s)
- Arun Angelo Patil
- Division of Neurosurgery, University of Nebraska Medical Center, 982035 Nebraska Medical Center, Omaha, NE 68198-2035, USA
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