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Roethe AL, Beer L, Schulz M, Schaumann A, Thomale UW. Tailored Concept for Accurate Neuroendoscopy: A Comparative Retrospective Single-Center Study on Image-Guided Neuroendoscopic Procedures. World Neurosurg 2024; 185:60-70. [PMID: 38325702 DOI: 10.1016/j.wneu.2024.01.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/30/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Precise planning and execution is key for neuroendoscopic interventions, which can be based on different available aiding technologies. The aim of this retrospective study is to report a case-based use of guided neuroendoscopy and to develop a stratification algorithm for the available technologies. METHODS We reviewed consecutive neuroendoscopic cases performed at our center from 2016 to 2018. We distinguished between patients receiving a new burr hole (group A) and those with a preexisting burr hole (group B). Case-specific technical requirements for procedure planning and execution, complication rate, surgical outcome, and possible subsequent surgery were evaluated. From this experience, a stratification system was developed to tailor the available guiding technologies. RESULTS A total of 309 neuroendoscopic interventions in 243 patients were included in the present study. The cases included hydrocephalic (81.6%) and nonhydrocephalic (18.4%) conditions. The interventions were supported by coordinate-based (group A, n = 49; group B, n = 67), guide-based (group A, n = 42; group B, n = 0), ultrasound-guided (group A, n = 50; group B, n = 7), or navigated augmented reality-guided (group A, n = 85; group B, n = 9) techniques. The overall complication rate was 4.5%. Stratified by the surgical indication, fontanel status, entry point localization, presence of a preexisting burr hole, ventricular size, and number of targets, an approach toward image-guided neuroendoscopy is suggested. CONCLUSIONS Planning and technical guidance is essential in neuroendoscopic procedures. The stratified decision-making algorithm for different available technologies aims to achieve lower cost and time consumption, which was found to be safe and efficient. Further investigations are warranted to deliver solid data on procedure efficiency.
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Affiliation(s)
- Anna L Roethe
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Lilian Beer
- Pediatric Neurosurgery, Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Schulz
- Pediatric Neurosurgery, Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Schaumann
- Pediatric Neurosurgery, Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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2
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El Ganainy SO, Cijsouw T, Ali MA, Schoch S, Hanafy AS. Stereotaxic-assisted gene therapy in Alzheimer's and Parkinson's diseases: therapeutic potentials and clinical frontiers. Expert Rev Neurother 2022; 22:319-335. [PMID: 35319338 DOI: 10.1080/14737175.2022.2056446] [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: 11/04/2022]
Abstract
INTRODUCTION Alzheimer's disease (AD) and Parkinson's disease (PD) are neurodegenerative disorders causing cognitive deficits and motor difficulties in the elderly. Conventional treatments are mainly symptomatic with little ability to halt disease progression. Gene therapies to correct or silence genetic mutations predisposing to AD or PD are currently being developed in preclinical studies and clinical trials, relying mostly on systemic delivery, which reduces their effectiveness. Imaging-guided stereotaxic procedures are used to locally deliver therapeutic cargos to well-defined brain sites, hence raising the question whether stereotaxic-assisted gene therapy has therapeutic potentials. AREAS COVERED The authors summarize the studies that investigated the use of gene therapy in PD and AD in animal and clinical studies over the past five years, with a special emphasis on the combinatorial potential with stereotaxic delivery. The advantages, limitations and futuristic challenges of this technique are discussed. EXPERT OPINION Robotic stereotaxis combined with intraoperative imaging has revolutionized brain surgeries. While gene therapies are bringing huge innovations to the medical field and new hope to AD and PD patients and medical professionals, the efficient and targeted delivery of such therapies is a bottleneck. We propose that careful application of stereotaxic delivery of gene therapies can improve PD and AD management. [Figure: see text].
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Affiliation(s)
- Samar O El Ganainy
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Pharos University in Alexandria, Alexandria, Egypt
| | - Tony Cijsouw
- Institute of Neuropathology, Section for Translational Epilepsy Research, Medical Faculty, University of Bonn, Bonn, Germany
| | - Mennatallah A Ali
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Pharos University in Alexandria, Alexandria, Egypt
| | - Susanne Schoch
- Institute of Neuropathology, Section for Translational Epilepsy Research, Medical Faculty, University of Bonn, Bonn, Germany
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3
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Bernard F, Haemmerli J, Zegarek G, Kiss-Bodolay D, Schaller K, Bijlenga P. Augmented reality-assisted roadmaps during periventricular brain surgery. Neurosurg Focus 2021; 51:E4. [PMID: 34333465 DOI: 10.3171/2021.5.focus21220] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/18/2021] [Indexed: 11/06/2022]
Abstract
Visualizing major periventricular anatomical landmarks intraoperatively during brain tumor removal is a decisive measure toward preserving such structures and thus the patient's postoperative quality of life. The aim of this study was to describe potential standardized preoperative planning using standard landmarks and procedures and to demonstrate the feasibility of using augmented reality (AR) to assist in performing surgery according to these "roadmaps." The authors have depicted stepwise AR surgical roadmaps applied to periventricular brain surgery with the aim of preserving major cognitive function. In addition to the technological aspects, this study highlights the importance of using emerging technologies as potential tools to integrate information and to identify and visualize landmarks to be used during tumor removal.
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Affiliation(s)
- Florian Bernard
- 1Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland.,2Division of Neurosurgery, Angers University Hospitals.,3Laboratory of Anatomy, University of Angers; and.,4CRCINA, UMR 1232 INSERM/CNRS and EA7315 team, Angers, France
| | - Julien Haemmerli
- 1Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Gregory Zegarek
- 1Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Daniel Kiss-Bodolay
- 1Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Karl Schaller
- 1Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Bijlenga
- 1Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
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4
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Kiesel B, Freund J, Reichert D, Wadiura L, Erkkilae MT, Woehrer A, Hervey-Jumper S, Berger MS, Widhalm G. 5-ALA in Suspected Low-Grade Gliomas: Current Role, Limitations, and New Approaches. Front Oncol 2021; 11:699301. [PMID: 34395266 PMCID: PMC8362830 DOI: 10.3389/fonc.2021.699301] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/19/2021] [Indexed: 11/13/2022] Open
Abstract
Radiologically suspected low-grade gliomas (LGG) represent a special challenge for the neurosurgeon during surgery due to their histopathological heterogeneity and indefinite tumor margin. Therefore, new techniques are required to overcome these current surgical drawbacks. Intraoperative visualization of brain tumors with assistance of 5-aminolevulinic acid (5-ALA) induced protoporphyrin IX (PpIX) fluorescence is one of the major advancements in the neurosurgical field in the last decades. Initially, this technique was exclusively applied for fluorescence-guided surgery of high-grade glioma (HGG). In the last years, the use of 5-ALA was also extended to other indications such as radiologically suspected LGG. Here, we discuss the current role of 5-ALA for intraoperative visualization of focal malignant transformation within suspected LGG. Furthermore, we discuss the current limitations of the 5-ALA technology in pure LGG which usually cannot be visualized by visible fluorescence. Finally, we introduce new approaches based on fluorescence technology for improved detection of pure LGG tissue such as spectroscopic PpIX quantification fluorescence lifetime imaging of PpIX and confocal microscopy to optimize surgery.
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Affiliation(s)
- Barbara Kiesel
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Julia Freund
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - David Reichert
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory OPTRAMED, Medical University of Vienna, Vienna, Austria
| | - Lisa Wadiura
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Mikael T Erkkilae
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Adelheid Woehrer
- Department of Neurology, Institute for Neuropathology and Neurochemistry, Medical University of Vienna, Vienna, Austria
| | - Shawn Hervey-Jumper
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California San Francisco (UCSF), San Francisco, CA, United States
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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5
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Wurzer A, Minchev G, Cervera-Martinez C, Micko A, Kronreif G, Wolfsberger S. The endonasal patient reference tracker: a novel solution for accurate noninvasive electromagnetic neuronavigation. J Neurosurg 2021; 134:1951-1958. [PMID: 32679564 DOI: 10.3171/2020.4.jns20394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Electromagnetic (EM) navigation provides the advantages of continuous guidance and tip-tracking of instruments. The current solutions for patient reference trackers are suboptimal, as they are either invasively screwed to the bone or less accurate if attached to the skin. The authors present a novel EM reference method with the tracker rigidly but not invasively positioned inside the nasal cavity. METHODS The nasal tracker (NT) consists of the EM coil array of the AxiEM tracker plugged into a nasal tamponade, which is then inserted into the inferior nasal meatus. Initially, a proof-of-concept study was performed on two cadaveric skull bases. The stability of the NT was assessed in simulated surgical situations, for example, prone, supine, and lateral patient positioning and skin traction. A deviation ≤ 2 mm was judged sufficiently accurate for clinical trial. Thus, a feasibility study was performed in the clinical setting. Positional changes of the NT and a standard skin-adhesive tracker (ST) relative to a ground-truth reference tracker were recorded throughout routine surgical procedures. The accuracy of the NT and ST was compared at different stages of surgery. RESULTS Ex vivo, the NT proved to be highly stable in all simulated surgical situations (median deviation 0.4 mm, range 0.0-2.0 mm). In 13 routine clinical cases, the NT was significantly more stable than the ST (median deviation at procedure end 1.3 mm, range 0.5-3.0 mm vs 4.0 mm, range 1.2-11.2 mm, p = 0.002). The loss of accuracy of the ST was highest during draping and flap fixation. CONCLUSIONS Application of the EM endonasal patient tracker was found to be feasible with high procedural stability ex vivo as well as in the clinical setting. This innovation combines the advantages of high precision and noninvasiveness and may, in the future, enhance EM navigation for neurosurgery.
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Affiliation(s)
- Ayguel Wurzer
- 1Department of Neurosurgery, Medical University Vienna; and
| | - Georgi Minchev
- 1Department of Neurosurgery, Medical University Vienna; and
| | | | | | - Gernot Kronreif
- 2Austrian Center of Medical Innovation and Technology, Wiener Neustadt, Austria
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Squires A, Hovet S, Li R, Oshinski J, Ho Tse ZT. A body-mounted device for MRI-guided spinal therapy. Int J Med Robot 2021; 17:e2235. [PMID: 33497520 DOI: 10.1002/rcs.2235] [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: 05/03/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with no cure and limited treatment options. Recent studies have shown that delivering cellular therapeutics to the ventral horn of the spinal cord can effectively halt neurodegeneration associated with ALS in small animal models. METHODS We developed a robotic system that assists with MRI-guided percutaneous injections to the spinal cord. The needle positioning robot consists of two linear axes with motorised translational sleds for two-degree-of-freedom (2-DOF) needle translation and a radial template for 2-DOF discrete rotation. RESULTS The robot's targeting capability, evaluated using phantom models and swine cadavers, showed mean targeting errors of 0.48 and 2.84 mm, respectively. The duration of the targeting procedure is approximately 60 min, with an extra 10 min for each additional injection. CONCLUSIONS The presented robot does not affect imaging quality during MRI-guided procedures, and it enables a simplified workflow for MRI-guided spinal therapy.
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Affiliation(s)
- Alexander Squires
- School of Electrical and Computer Engineering, University of Georgia, Athens, Georgia, USA
| | - Sierra Hovet
- School of Electrical and Computer Engineering, University of Georgia, Athens, Georgia, USA
| | - Rui Li
- Tandon School of Engineering, New York University, Brooklyn, New York, USA
| | - John Oshinski
- Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA.,Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, Georgia, USA
| | - Zion Tsz Ho Tse
- Department of Electronic Engineering, University of York, York, Heslington, UK
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Wang J, Liu H, Ke J, Hu L, Zhang S, Yang B, Sun S, Guo N, Ma F. Image-guided cochlear access by non-invasive registration: a cadaveric feasibility study. Sci Rep 2020; 10:18318. [PMID: 33110188 PMCID: PMC7591497 DOI: 10.1038/s41598-020-75530-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/15/2020] [Indexed: 11/09/2022] Open
Abstract
Image-guided cochlear implant surgery is expected to reduce volume of mastoidectomy, accelerate recovery, and improve safety. The purpose of this study was to investigate the safety and effectiveness of image-guided cochlear implant surgery by a non-invasive registration method, in a cadaveric study. We developed a visual positioning frame that can utilize the maxillary dentition as a registration tool and completed the tunnels experiment on 5 cadaver specimens (8 cases in total). The accuracy of the entry point and the target point were 0.471 ± 0.276 mm and 0.671 ± 0.268 mm, respectively. The shortest distance from the margin of the tunnel to the facial nerve and the ossicular chain were 0.790 ± 0.709 mm and 1.960 ± 0.630 mm, respectively. All facial nerves, tympanic membranes, and ossicular chains were completely preserved. Using this approach, high accuracy was achieved in this preliminary study, suggesting that the non-invasive registration method can meet the accuracy requirements for cochlear implant surgery. Based on the above accuracy, we speculate that our method can also be applied to neurosurgery, orbitofacial surgery, lateral skull base surgery, and anterior skull base surgery with satisfactory accuracy.
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Affiliation(s)
- Jiang Wang
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Hongsheng Liu
- The Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Jia Ke
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Lei Hu
- The Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Shaoxing Zhang
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Biao Yang
- The Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Shilong Sun
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Na Guo
- The Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing, China
| | - Furong Ma
- Department of Otorhinolaryngology - Head and Neck Surgery, Peking University Third Hospital, Peking University, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.
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Manini I, Caponnetto F, Dalla E, Ius T, Pepa GMD, Pegolo E, Bartolini A, Rocca GL, Menna G, Loreto CD, Olivi A, Skrap M, Sabatino G, Cesselli D. Heterogeneity Matters: Different Regions of Glioblastoma Are Characterized by Distinctive Tumor-Supporting Pathways. Cancers (Basel) 2020; 12:cancers12102960. [PMID: 33066172 PMCID: PMC7601979 DOI: 10.3390/cancers12102960] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 12/22/2022] Open
Abstract
Simple Summary 5-ALA Fluorescence Guided Surgery aims at extending the boundaries of glioblastoma (GBM) resection. It is based on the use of a fluorescent dye, 5-aminolevulinic acid (5-ALA). Depending on the fluorescence levels, it is possible to distinguish the core of the tumor, the infiltrating borders and the healthy tissue. Since GBM progression is supported by tumor cells and their interaction with the surrounding microenvironment, we hypothesized that 5-ALA intensity could identify microenvironments with different tumor supporting properties. Taking advantage of glioma-associated stem cells; a human in vitro model of the glioma microenvironment, we demonstrate that all regions of the tumor support the tumor growth, but through different pathways. This study highlights the importance of understanding the TME to obtain key information on GBM biology and develop new therapeutic approaches. Abstract The glioblastoma microenvironment plays a substantial role in glioma biology. However, few studies have investigated its spatial heterogeneity. Exploiting 5-ALA Fluorescence Guided Surgery (FGS), we were able to distinguish between the tumor core (ALA+), infiltrating area (ALA-PALE) and healthy tissue (ALA−) of the glioblastoma, based on the level of accumulated fluorescence. The aim of this study was to investigate the properties of the microenvironments associated with these regions. For this purpose, we isolated glioma-associated stem cells (GASC), resident in the glioma microenvironment, from ALA+, ALA-PALE and ALA− samples and compared them in terms of growth kinetic, phenotype and for the expression of 84 genes associated with cancer inflammation and immunity. Differentially expressed genes were correlated with transcriptomic datasets from TCGA/GTEX. Our results show that GASC derived from the three distinct regions, despite a similar phenotype, were characterized by different transcriptomic profiles. Moreover, we identified a GASC-based genetic signature predictive of overall survival and disease-free survival. This signature, highly expressed in ALA+ GASC, was also well represented in ALA PALE GASC. 5-ALA FGS allowed to underline the heterogeneity of the glioma microenvironments. Deepening knowledge of these differences can contribute to develop new adjuvant therapies targeting the crosstalk between tumor and its supporting microenvironment.
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Affiliation(s)
- Ivana Manini
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
- Correspondence:
| | - Federica Caponnetto
- Department of Medicine, University of Udine, 33100 Udine, Italy; (F.C.); (E.D.)
| | - Emiliano Dalla
- Department of Medicine, University of Udine, 33100 Udine, Italy; (F.C.); (E.D.)
| | - Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, University Hospital of Udine, 33100 Udine, Italy; (T.I.); (M.S.)
| | - Giuseppe Maria Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
| | - Enrico Pegolo
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
| | - Anna Bartolini
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
| | - Giuseppe La Rocca
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
- Department of Neurosurgery, Mater Olbia Hospital, 07026 Olbia, Italy
| | - Grazia Menna
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
| | - Carla Di Loreto
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
- Department of Medicine, University of Udine, 33100 Udine, Italy; (F.C.); (E.D.)
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
| | - Miran Skrap
- Neurosurgery Unit, Department of Neurosciences, University Hospital of Udine, 33100 Udine, Italy; (T.I.); (M.S.)
| | - Giovanni Sabatino
- Institute of Neurosurgery, Fondazione Policlinico Gemelli, Catholic University, 00168 Rome, Italy; (G.M.D.P.); (G.L.R.); (G.M.); (A.O.); (G.S.)
- Department of Neurosurgery, Mater Olbia Hospital, 07026 Olbia, Italy
| | - Daniela Cesselli
- Institute of Pathology, University Hospital of Udine, 33100 Udine, Italy; (E.P.); (A.B.); (C.D.L.); (D.C.)
- Department of Medicine, University of Udine, 33100 Udine, Italy; (F.C.); (E.D.)
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Santistevan L, Easley J, Ruple A, Monck S, Randall E, Wininger F, Packer RA. A pilot study of optical neuronavigation-guided brain biopsy in the horse using anatomic landmarks and fiducial arrays for patient registration. J Vet Intern Med 2020; 34:1642-1649. [PMID: 32469442 PMCID: PMC7379038 DOI: 10.1111/jvim.15813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 01/24/2023] Open
Abstract
Background Optical neuronavigation‐guided intracranial surgery has become increasingly common in veterinary medicine, but its use has not yet been described in horses. Objectives To determine the feasibility of optical neuronavigation‐guided intracranial biopsy procedures in the horse, compare the use of the standard fiducial array and anatomic landmarks for patient registration, and evaluate surgeon experience. Animals Six equine cadaver heads. Methods Computed tomography images of each specimen were acquired, with the fiducial array rigidly secured to the frontal bone. Six targets were selected in each specimen. Patient registration was performed separately for 3 targets using the fiducial array, and for 3 targets using anatomic landmarks. In lieu of biopsy, 1 mm diameter wire seeds were placed at each target. Postoperative images were coregistered with the planning scan to calculate Euclidian distance from the tip of the seed to the target. Results No statistical difference between registration techniques was identified. The impact of surgeon experience was examined for each technique using a Mann‐Whitney U test. The experienced surgeon was significantly closer to the intended target (median = 2.52 mm) than were the novice surgeons (median = 6.55 mm) using the fiducial array (P = .001). Although not statistically significant (P = .31), for the experienced surgeon the median distance to target was similar when registering with the fiducial array (2.47 mm) and anatomic landmarks (2.58 mm). Conclusions and Clinical Importance Registration using both fiducial arrays and anatomic landmarks for brain biopsy using optical neuronavigation in horses is feasible.
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Affiliation(s)
- Lawrence Santistevan
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Jeremiah Easley
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Audrey Ruple
- Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, Indiana, USA
| | - Sam Monck
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Elissa Randall
- Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Fred Wininger
- Charlotte Animal Referral and Emergency, Charlotte, North Carolina, USA
| | - Rebecca A Packer
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
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10
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Maschke S, Martínez-Moreno M, Micko A, Millesi M, Minchev G, Mallouhi A, Knosp E, Wolfsberger S. Challenging the osseous component of sphenoorbital meningiomas. Acta Neurochir (Wien) 2019; 161:2241-2251. [PMID: 31368053 PMCID: PMC6820812 DOI: 10.1007/s00701-019-04015-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 07/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraosseous growth is a unique feature of sphenoorbital meningiomas (SOM). Its close relation to neurovascular structures limits complete surgical resection and possibly contributes to the high recurrence rate. OBJECTIVE To evaluate the growth behavior of intraosseous remnants and develop a protocol for precise intraoperative visualization of intraosseous SOM. METHODS We included 31 patients operated for SOM from 2004 to 2017. The growth velocity of the intraosseous tumor component was volumetrically calculated in 20 cases. To improve accuracy of image guidance, we implemented a specialized bone surface-based registration algorithm. For intraoperative bone visualization, we included CT in multimodality continuous image guidance in 23 patients. The extent of resection (EOR) was compared with a standard MR-only navigation group (n = 8). RESULTS In 11/20 cases (55%), a progressive regrowth of the intraosseous SOM remnant was noted during a mean follow-up of 52 months (range 20-132 months). We observed a mean increase of 6.2 cm3 (range 0.2-23.7 cm3) per patient and side during the follow-up period. Bone surface-based registration was significantly more accurate than skin surface-based registration (mean 0.7 ± 0.4 mm and 1.9 ± 0.7 mm, p < 0.001). The EOR of the intraosseous component was significantly higher using CT + MRI navigation compared with controls (96% vs. 81%, p = 0.044). CONCLUSION Quantitative assessment of the biological behavior of intraosseous remnants revealed a continuous slow growth rate independent of the soft tumor component of more than half of SOM. According to our data, application of a multimodal image guidance provided high accuracy and significantly increased the resection rate of the intraosseous component of SOM.
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Affiliation(s)
- Svenja Maschke
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1080, Vienna, Austria
| | - Mauricio Martínez-Moreno
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1080, Vienna, Austria
| | - Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1080, Vienna, Austria
| | - Matthias Millesi
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1080, Vienna, Austria
| | - Georgi Minchev
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1080, Vienna, Austria
| | - Ammar Mallouhi
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1080, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1080, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1080, Vienna, Austria.
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11
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Mongen MA, Willems PWA. Current accuracy of surface matching compared to adhesive markers in patient-to-image registration. Acta Neurochir (Wien) 2019; 161:865-870. [PMID: 30879130 PMCID: PMC6483968 DOI: 10.1007/s00701-019-03867-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/03/2019] [Indexed: 11/28/2022]
Abstract
Object In the past, the accuracy of surface matching has been shown to be disappointing. We aimed to determine whether this had improved over the years by assessing application accuracy of current navigation systems, using either surface matching or point-pair matching. Methods Eleven patients, scheduled for intracranial surgery, were included in this study after a power analysis had shown this small number to be sufficient. Prior to surgery, one additional fiducial marker was placed on the scalp, the “target marker,” where the entry point of surgery was to be expected. Using one of three different navigation systems, two patient-to-image registration procedures were performed: one based on surface matching and one based on point-pair matching. Each registration procedure was followed by the digitization of the target marker’s location, allowing calculation of the target registration error. If the system offered surface matching improvement, this was always used; and for the two systems that routinely offer an estimate of neuronavigation accuracy, this was also recorded. Results The error in localizing the target marker using point-pair matching or surface matching was respectively 2.49 mm and 5.35 mm, on average (p < 0.001). In those four cases where an attempt was made to improve the surface matching, the error increased to 6.35 mm, on average. For the seven cases where the system estimated accuracy, this estimate did not correlate with target registration error (R2 = 0.04, p = 0.67). Conclusion The accuracy of navigation systems has not improved over the last decade, with surface matching consistently yielding errors that are twice as large as when point-pair matching with adhesive markers is used. These errors are not reliably reflected by the systems own prediction, when offered. These results are important to make an informed choice between image-to-patient registration strategies, depending on the type of surgery at hand.
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Affiliation(s)
- Mireli A Mongen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter W A Willems
- Departmesnt of Neurosurgery, University Medical Center Utrecht, Internal Postage G03.124, PO-box 85500, 3584 CX, Utrecht, The Netherlands.
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12
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Guo Z, Leong MCW, Su H, Kwok KW, Chan DTM, Poon WS. Techniques for Stereotactic Neurosurgery: Beyond the Frame, Toward the Intraoperative Magnetic Resonance Imaging–Guided and Robot-Assisted Approaches. World Neurosurg 2018; 116:77-87. [DOI: 10.1016/j.wneu.2018.04.155] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 04/20/2018] [Accepted: 04/21/2018] [Indexed: 11/16/2022]
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13
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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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14
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Kiesel B, Mischkulnig M, Woehrer A, Martinez-Moreno M, Millesi M, Mallouhi A, Czech T, Preusser M, Hainfellner JA, Wolfsberger S, Knosp E, Widhalm G. Systematic histopathological analysis of different 5-aminolevulinic acid-induced fluorescence levels in newly diagnosed glioblastomas. J Neurosurg 2017; 129:341-353. [PMID: 29076783 DOI: 10.3171/2017.4.jns162991] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Glioblastoma (GBM) is characterized by distinct intratumoral histopathological heterogeneity with regard to variable tumor morphology, cell proliferation, and microvascularity. Maximum resection of a GBM results in an improved prognosis and thus represents the aim of surgery in the majority of cases. Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) is currently widely applied for improved intraoperative tumor visualization in patients with a GBM. Three intratumoral fluorescence levels (i.e., strong, vague, or no fluorescence) can usually be distinguished during surgery. So far, however, their exact histopathological correlates and their surgical relevance have not been clarified sufficiently. Thus, the aim of this study was to systematically analyze tissue samples from newly diagnosed GBMs with different fluorescence levels according to relevant histopathological parameters. METHODS This prospective study recruited patients who underwent 5-ALA fluorescence-guided resection of a newly diagnosed radiologically suspected GBM. Each patient received 5-ALA approximately 3 hours before surgery, and a modified neurosurgical microscope was applied for intraoperative visualization of 5-ALA-induced fluorescence. During surgery, tissue samples with strong, vague, or no fluorescence were collected. For each sample, the presence of tumor tissue, quality of tissue (compact, infiltrative, or no tumor), histopathological criteria of malignancy (cell density, nuclear pleomorphism, mitotic activity, and presence of microvascular proliferation/necrosis), proliferation rate (MIB-1 labeling index [LI]), and microvessel density (using CD34 staining) were investigated. RESULTS Altogether, 77 patients with a newly diagnosed, histopathologically confirmed GBM were included, and 131 samples with strong fluorescence, 69 samples with vague fluorescence, and 67 samples with no fluorescence were collected. Tumor tissue was detected in all 131 (100%) of the samples with strong fluorescence and in 65 (94%) of the 69 samples with vague fluorescence. However, mostly infiltrative tumor tissue was still found in 33 (49%) of 67 samples despite their lack of fluorescence. Strong fluorescence corresponded to compact tumors in 109 (83%) of 131 samples, whereas vague fluorescence was consistent with infiltrative tumors in 44 (64%) of 69 samples. In terms of the histopathological criteria of malignancy, a significant positive correlation of all analyzed parameters comprising cell density, nuclear pleomorphism, mitotic activity, microvascular proliferation, and necrosis with the 3 fluorescence levels was observed (p < 0.001). Furthermore, the proliferation rate significantly and positively correlated with strong (MIB-1 LI 28.3%), vague (MIB-1 LI 16.7%), and no (MIB-1 LI 8.8%) fluorescence (p < 0.001). Last, a significantly higher microvessel density was detected in samples with strong fluorescence (CD34 125.5 vessels/0.25 mm2) than in those with vague (CD34 82.8 vessels/0.25 mm2) or no (CD34 68.6 vessels/0.25 mm2) fluorescence (p < 0.001). CONCLUSIONS Strong and vague 5-ALA-induced fluorescence enables visualization of intratumoral areas with specific histopathological features and thus supports neurosurgeons in improving the extent of resection in patients with a newly diagnosed GBM. Despite the lack of fluorescence, tumor tissue was still observed in approximately half of the cases. To overcome this current limitation, the promising approach of complementary spectroscopic measurement of fluorescence should be investigated further.
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Affiliation(s)
- Barbara Kiesel
- 1Department of Neurosurgery.,2Institute of Neurology.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
| | | | - Adelheid Woehrer
- 2Institute of Neurology.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
| | | | - Matthias Millesi
- 1Department of Neurosurgery.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
| | - Ammar Mallouhi
- Departments of3Radiology and.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
| | - Thomas Czech
- 1Department of Neurosurgery.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
| | - Matthias Preusser
- 4Medicine I, and.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
| | - Johannes A Hainfellner
- 2Institute of Neurology.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
| | - Stefan Wolfsberger
- 1Department of Neurosurgery.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
| | - Engelbert Knosp
- 1Department of Neurosurgery.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
| | - Georg Widhalm
- 1Department of Neurosurgery.,5Comprehensive Cancer Center-Central Nervous System Tumours Unit (CCC-CNS), Medical University Vienna, Austria
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Sefcik RK, Rasouli J, Bederson JB, Shrivastava RK. Three-Dimensional, computer simulated navigation in endoscopic neurosurgery. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2017; 8:17-22. [PMID: 28451520 DOI: 10.1016/j.inat.2017.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In order to address the pre- and perioperative need for visualization and prediction of patient-specific anatomy for surgical planning, endoscopic neurosurgeons have increasingly relied on computerized navigation devices to guide their surgical approaches. OBJECTIVE This manuscript aims to review: 1) the use of neuronavigation in endoscopic neurosurgery for pre-operative planning, 2) the intraoperative advantages of neuronavigation in endoscopic neurosurgery, and 3) the effects of navigation guidance on operative time, registration accuracy, brain shift, and avoidance of complications. Limitations of the current neuroendoscopic navigation literature will be discussed. METHODS We conducted a search using PubMed-MEDLINE; the keywords "stereotactic navigation AND endoscopic surgery" and "simulation AND endoscopic neurosurgery". 36 studies were identified that addressed the use of neuronavigation in endoscopic neurosurgery. These studies were then further analyzed for topics relevant to computerized neuroendoscopy and reviewed for the purposes of this article. CONCLUSION Three-dimensional, frameless neuronavigation systems are useful in endoscopic neurosurgery to assist in the pre-operative planning of potential trajectories and to help localize the pathology of interest. Neuronavigation appears to be accurate to < 1-2 mm without issues related to brain shift. Further work is necessary in the investigation of the effect of neuronavigation on operative time, cost, and patient-centered outcomes.
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Affiliation(s)
- Roberta K Sefcik
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 7th Floor, 5 E 98th St New York, New York 10029, United States
| | - Jonathan Rasouli
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 7th Floor, 5 E 98th St New York, New York 10029, United States
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 7th Floor, 5 E 98th St New York, New York 10029, United States
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 7th Floor, 5 E 98th St New York, New York 10029, United States
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16
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Hermann EJ, Polemikos M, Heissler HE, Krauss JK. Shunt Surgery in Idiopathic Intracranial Hypertension Aided by Electromagnetic Navigation. Stereotact Funct Neurosurg 2017; 95:26-33. [PMID: 28088808 DOI: 10.1159/000453277] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 11/07/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is characterized by increased cerebrospinal fluid (CSF) pressure and normal or slit ventricles. Lumboperitoneal shunting had been favored by many investigators for CSF diversion in IIH for decades; however, it has been associated with various side effects. Because of the small ventricular size adequate positioning of a ventricular catheter is challenging. OBJECTIVES Here, we investigated the usefulness of electromagnetic (EM)-guided ventricular catheter placement for ventriculoperitoneal shunting in IIH. METHODS Eighteen patients with IIH were included in this study. The age of patients ranged from 5 to 58 years at the time of surgery (mean age: 31.8 years; median: 29 years). There were 2 children (5 and 11 years old) and 16 adults. Inclusion criteria for the study were an established clinical diagnosis of IIH, lack of improvement with medication, and the presence of small ventricles. In all patients EM-navigated placement of the ventricular catheter was performed using real-time tracking of the catheter tip for exact positioning close to the foramen of Monro. Postoperative CT scans were correlated with intraoperative screen shots to validate the position of the catheter. RESULTS In all patients EM-navigated ventricular catheter placement was achieved with a single pass. There were no intraoperative or postoperative complications. Postoperative imaging confirmed satisfactory positioning of the ventricular catheter. No proximal shunt failure was observed during the follow-up at a mean of 41.5 months (range: 7-90 months, median: 40.5 months). CONCLUSIONS EM-navigated ventricular catheter placement in shunting for IIH is a safe and straightforward technique. It obviates the need for sharp head fixation, the head of the patient can be moved during surgery, and it may reduce the revision rate during follow-up.
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Affiliation(s)
- Elvis J Hermann
- Department of Neurosurgery, Medical School Hannover, Hannover, Germany
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Soteriou E, Grauvogel J, Laszig R, Grauvogel TD. Prospects and limitations of different registration modalities in electromagnetic ENT navigation. Eur Arch Otorhinolaryngol 2016; 273:3979-3986. [PMID: 27149874 DOI: 10.1007/s00405-016-4063-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 04/19/2016] [Indexed: 01/03/2023]
Abstract
The present study examined electromagnetic tracking technology for ENT navigation. Five different registration modalities were compared and navigation accuracy was assessed. Four skull models were individually fabricated with a three-dimensional printer, based on patients' computer tomography datasets. Individual silicone masks were fitted for skin and soft tissue simulation. Five registration modalities were examined: (1) invasive marker, (2) automatic, (3) surface matching (AccuMatch), (4) anatomic landmarks, and (5) oral splint registration. Overall navigation accuracy and accuracy on selected anatomic locations were assessed by targeting 26 titanium screws previously placed over the skull. Overall navigation accuracy differed significantly between all registration modalities. The target registration error was 0.94 ± 0.06 mm (quadratic mean ± standard deviation) for the invasive marker registration, 1.41 ± 0.04 mm for the automatic registration, 1.59 ± 0.14 mm for the surface matching registration, and 5.15 ± 0.66 mm (four landmarks) and 4.37 ± 0.73 mm (five landmarks) for the anatomic landmark registration. Oral splint registration proved itself to be inapplicable to this navigation system. Invasive marker registration was superior on most selected anatomic locations. However, on the ethmoid and sphenoid sinus the automatic registration process revealed significantly lower target registration error values. Only automatic and surface registration met the accuracy requirements for noninvasive registration. Particularly, the automatic image-to-world registration reaches target registration error values on the anterior skull base which are comparable with the gold standard of invasive screw registration.
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Affiliation(s)
- Eric Soteriou
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert-Ludwigs-University Medical School Freiburg, Killianstr. 5, 79106, Freiburg, Germany
| | - Juergen Grauvogel
- Department of Neurosurgery, Albert-Ludwigs-University Medical School Freiburg, Freiburg, Germany
| | - Roland Laszig
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert-Ludwigs-University Medical School Freiburg, Killianstr. 5, 79106, Freiburg, Germany
| | - Tanja Daniela Grauvogel
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert-Ludwigs-University Medical School Freiburg, Killianstr. 5, 79106, Freiburg, Germany.
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Mert A, Kiesel B, Wöhrer A, Martínez-Moreno M, Minchev G, Furtner J, Knosp E, Wolfsberger S, Widhalm G. Introduction of a standardized multimodality image protocol for navigation-guided surgery of suspected low-grade gliomas. Neurosurg Focus 2015; 38:E4. [PMID: 25552284 DOI: 10.3171/2014.10.focus14597] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Surgery of suspected low-grade gliomas (LGGs) poses a special challenge for neurosurgeons due to their diffusely infiltrative growth and histopathological heterogeneity. Consequently, neuronavigation with multimodality imaging data, such as structural and metabolic data, fiber tracking, and 3D brain visualization, has been proposed to optimize surgery. However, currently no standardized protocol has been established for multimodality imaging data in modern glioma surgery. The aim of this study was therefore to define a specific protocol for multimodality imaging and navigation for suspected LGG. METHODS Fifty-one patients who underwent surgery for a diffusely infiltrating glioma with nonsignificant contrast enhancement on MRI and available multimodality imaging data were included. In the first 40 patients with glioma, the authors retrospectively reviewed the imaging data, including structural MRI (contrast-enhanced T1-weighted, T2-weighted, and FLAIR sequences), metabolic images derived from PET, or MR spectroscopy chemical shift imaging, fiber tracking, and 3D brain surface/vessel visualization, to define standardized image settings and specific indications for each imaging modality. The feasibility and surgical relevance of this new protocol was subsequently prospectively investigated during surgery with the assistance of an advanced electromagnetic navigation system in the remaining 11 patients. Furthermore, specific surgical outcome parameters, including the extent of resection, histological analysis of the metabolic hotspot, presence of a new postoperative neurological deficit, and intraoperative accuracy of 3D brain visualization models, were assessed in each of these patients. RESULTS After reviewing these first 40 cases of glioma, the authors defined a specific protocol with standardized image settings and specific indications that allows for optimal and simultaneous visualization of structural and metabolic data, fiber tracking, and 3D brain visualization. This new protocol was feasible and was estimated to be surgically relevant during navigation-guided surgery in all 11 patients. According to the authors' predefined surgical outcome parameters, they observed a complete resection in all resectable gliomas (n = 5) by using contour visualization with T2-weighted or FLAIR images. Additionally, tumor tissue derived from the metabolic hotspot showed the presence of malignant tissue in all WHO Grade III or IV gliomas (n = 5). Moreover, no permanent postoperative neurological deficits occurred in any of these patients, and fiber tracking and/or intraoperative monitoring were applied during surgery in the vast majority of cases (n = 10). Furthermore, the authors found a significant intraoperative topographical correlation of 3D brain surface and vessel models with gyral anatomy and superficial vessels. Finally, real-time navigation with multimodality imaging data using the advanced electromagnetic navigation system was found to be useful for precise guidance to surgical targets, such as the tumor margin or the metabolic hotspot. CONCLUSIONS In this study, the authors defined a specific protocol for multimodality imaging data in suspected LGGs, and they propose the application of this new protocol for advanced navigation-guided procedures optimally in conjunction with continuous electromagnetic instrument tracking to optimize glioma surgery.
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Berger M, Kallus S, Nova I, Ristow O, Eisenmann U, Dickhaus H, Kuhle R, Hoffmann J, Seeberger R. Approach to intraoperative electromagnetic navigation in orthognathic surgery: A phantom skull based trial. J Craniomaxillofac Surg 2015; 43:1731-6. [PMID: 26421472 DOI: 10.1016/j.jcms.2015.08.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/18/2015] [Accepted: 08/26/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Intraoperative guidance using electromagnetic navigation is an upcoming method in maxillofacial surgery. However, due to their unwieldy structures, especially the line-of-sight problem, optical navigation devices are not used for daily orthognathic surgery. Therefore, orthognathic surgery was simulated on study phantom skulls, evaluating the accuracy and handling of a new electromagnetic tracking system. MATERIAL AND METHODS Le-Fort I osteotomies were performed on 10 plastic skulls. Orthognathic surgical planning was done in the conventional way using plaster models. Accuracy of the gold standard, splint-based model surgery versus an electromagnetic tracking system was evaluated by measuring the actual maxillary deviation using bimaxillary splints and preoperative and postoperative cone beam computer tomography imaging. The distance of five anatomical marker points were compared pre- and postoperatively. RESULTS The electromagnetic tracking system was significantly more accurate in all measured parameters compared with the gold standard using bimaxillary splints (p < 0.01). The data shows a discrepancy between the model surgical plans and the actual correction of the upper jaw of 0.8 mm. Using the electromagnetic tracking, we could reduce the discrepancy of the maxillary transposition between the planned and actual orthognathic surgery to 0.3 mm on average. DISCUSSION The data of this preliminary study shows a high level of accuracy in surgical orthognathic performance using electromagnetic navigation, and may offer greater precision than the conventional plaster model surgery with bimaxillary splints. CONCLUSION This preliminary work shows great potential for the establishment of an intraoperative electromagnetic navigation system for maxillofacial surgery.
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Affiliation(s)
- Moritz Berger
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Germany.
| | - Sebastian Kallus
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Germany
| | - Igor Nova
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Germany
| | - Oliver Ristow
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Germany
| | - Urs Eisenmann
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Germany
| | - Hartmut Dickhaus
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Germany
| | - Reinald Kuhle
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Germany
| | - Jürgen Hoffmann
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Germany
| | - Robin Seeberger
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Germany
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Cabrilo I, Bijlenga P, Schaller K. Augmented reality in the surgery of cerebral aneurysms: a technical report. Neurosurgery 2015; 10 Suppl 2:252-60; discussion 260-1. [PMID: 24594927 DOI: 10.1227/neu.0000000000000328] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Augmented reality is the overlay of computer-generated images on real-world structures. It has previously been used for image guidance during surgical procedures, but it has never been used in the surgery of cerebral aneurysms. OBJECTIVE To report our experience of cerebral aneurysm surgery aided by augmented reality. METHODS Twenty-eight patients with 39 unruptured aneurysms were operated on in a prospective manner with augmented reality. Preoperative 3-dimensional image data sets (angio-magnetic resonance imaging, angio-computed tomography, and 3-dimensional digital subtraction angiography) were used to create virtual segmentations of patients' vessels, aneurysms, aneurysm necks, skulls, and heads. These images were injected intraoperatively into the eyepiece of the operating microscope. An example case of an unruptured posterior communicating artery aneurysm clipping is illustrated in a video. RESULTS The described operating procedure allowed continuous monitoring of the accuracy of patient registration with neuronavigation data and assisted in the performance of tailored surgical approaches and optimal clipping with minimized exposition. CONCLUSION Augmented reality may add to the performance of a minimally invasive approach, although further studies need to be performed to evaluate whether certain groups of aneurysms are more likely to benefit from it. Further technological development is required to improve its user friendliness.
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Affiliation(s)
- Ivan Cabrilo
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Medical Center, Geneva, Switzerland
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Cabrilo I, Sarrafzadeh A, Bijlenga P, Landis B, Schaller K. Augmented reality-assisted skull base surgery. Neurochirurgie 2014; 60:304-6. [DOI: 10.1016/j.neuchi.2014.07.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/29/2014] [Accepted: 07/19/2014] [Indexed: 12/01/2022]
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Cabrilo I, Bijlenga P, Schaller K. Augmented reality in the surgery of cerebral arteriovenous malformations: technique assessment and considerations. Acta Neurochir (Wien) 2014; 156:1769-74. [PMID: 25037466 DOI: 10.1007/s00701-014-2183-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 07/10/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Augmented reality technology has been used for intraoperative image guidance through the overlay of virtual images, from preoperative imaging studies, onto the real-world surgical field. Although setups based on augmented reality have been used for various neurosurgical pathologies, very few cases have been reported for the surgery of arteriovenous malformations (AVM). We present our experience with AVM surgery using a system designed for image injection of virtual images into the operating microscope's eyepiece, and discuss why augmented reality may be less appealing in this form of surgery. METHODS N = 5 patients underwent AVM resection assisted by augmented reality. Virtual three-dimensional models of patients' heads, skulls, AVM nidi, and feeder and drainage vessels were selectively segmented and injected into the microscope's eyepiece for intraoperative image guidance, and their usefulness was assessed in each case. RESULTS Although the setup helped in performing tailored craniotomies, in guiding dissection and in localizing drainage veins, it did not provide the surgeon with useful information concerning feeder arteries, due to the complexity of AVM angioarchitecture. CONCLUSION The difficulty in intraoperatively conveying useful information on feeder vessels may make augmented reality a less engaging tool in this form of surgery, and might explain its underrepresentation in the literature. Integrating an AVM's hemodynamic characteristics into the augmented rendering could make it more suited to AVM surgery.
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Affiliation(s)
- Ivan Cabrilo
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Medical Center, Rue Gabrielle-Perret-Gentil 4, 1211, Genève 14, Switzerland,
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Martínez-Moreno M, Widhalm G, Mert A, Kiesel B, Bukaty A, Furtner J, Reinprecht A, Knosp E, Wolfsberger S. A Novel Protocol of Continuous Navigation Guidance for Endoscopic Third Ventriculostomy. Oper Neurosurg (Hagerstown) 2014; 10 Suppl 4:514-23; discussion 523-4. [DOI: 10.1227/neu.0000000000000518] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Although considered a standard neurosurgical procedure, endoscopic third ventriculostomy (ETV) is associated with a relatively high complication rate that is predominantly related to malpositioning of the trajectory.
OBJECTIVE:
To develop an advanced navigation protocol for ETV, assess its possible benefits over commonly used ETV trajectories, and apply this protocol during surgery.
METHODS:
After development of our advanced protocol, the imaging data of 59 patients who underwent ETV without navigation guidance was transferred to our navigation software. An individualized endoscope trajectory was created according to our protocol in all cases. This trajectory was compared with 2 standard trajectories, especially with regard to the distance to relevant neuronal structures: a trajectory manually measured on preoperative radiological images, as performed in all 59 cases, and a trajectory resulting from a commonly used fixed coronal burr hole. Subsequently, we applied the protocol in 15 ETVs to assess the feasibility and procedural complications.
RESULTS:
Our individualized trajectory resulted in a significantly greater distance to the margins of the foramen of Monro, and the burr hole was located more posteriorly from the coronal suture in comparison with the standard trajectories. The advanced ETV technique was feasible in all 15 procedures, and no major complications occurred in any procedure. In 1 patient, a fornix contusion without clinical correlation was observed.
CONCLUSION:
Our data indicate that the proposed navigation protocol for ETV optimizes the distance of the endoscope to important neuronal structures. Continuous endoscope and puncture device guidance may further add to the safety of this procedure.
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Affiliation(s)
| | | | | | | | - Adam Bukaty
- Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - Julia Furtner
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
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