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PubMed2003

Toward functional neuronavigation: implementation of functional magnetic resonance imaging data in a surgical guidance system for intraoperative identification of motor and language cortices. Technical note and illustrative case.

In recent years, surgical navigation systems have become equipped to allow incorporation of data such as functional neuronavigation data. Functional magnetic resonance (fMR) imaging is a noninvasive modality that demonstrates various brain functions. Although still in an experimental stage, fMR imaging is a promising tool for mapping of motor and language functions. One advantage is that it can be implemented in presurgical imaging protocols and is therefore potentially widely available in general neurosurgical practice. In this paper the integration of fMR imaging and surgical navigation is described, and the potential advantages and pitfalls of its application in clinical practice are discussed.

Adult↗
PubMedDate not supplied

[The results of applying the system of neuronavigation in the intracranial surgery].

Frameless stereotactic techniques combined with a high-resolution neuro-imaging made its possible for us to perform, with high reliability, interactive image-guided procedures. We used the Carl Zeiss Surgical Microscope Navigator System with Carl Zeiss OPMI NC-4 microscope. We reported our results on the first 82 patients during the 20-month period. 36 were males (44%), 46--females (56%) with the age range of 15 to 79 (mean 43.43). The predominant diagnosis was tumor (60 patients or 73.2%) with histological findings of astrocytoma and metastasis. The surgical procedure was open microneurosurgery. There were no significant technical problems. The clinical and surgical results were satisfying in all cases. 14 patients with secondary epilepsy, as the only symptom, were postoperatively seizure-free. Neuronavigation cuts the time of surgery and ensures a more radical resection of pathological tissue with lower mortality and morbidity thus improving the life quality of patients.

Adolescent↗
PubMed2001

Initial experience with an ultrasound-integrated single-RACK neuronavigation system.

A prototype ultrasound-integrated neuronavigation system was tested in 34 operations as regards image quality, stability, and handling during daily use in the operating theatre. The system consists of a high-end ultrasound scanner, a navigation computer, and an active optical positioning and digitiser system, all integrated in a single rack. An Ethernet interface between the two hardware devices enables digital data transfer between the ultrasound scanner and the navigation device without loss of image quality. The integration of an ultrasound scanner and a navigation device offers the opportunity of navigating directly to an intracranial or intraspinal lesion using intra-operative 3D ultrasound images. The brainshift problem is thus avoided. The ability to directly compare MR images and 3D ultrasound simplifies the interpretation of ultrasound images. The single-rack solution is an advantage in times of restricted space in the operating theatre caused by the increasing volume of technical equipment needed for a neurosurgical operation. In 30 cases the prototype system showed good reliability. In four cases the navigation system failed during the operation; however, the capacity of the ultrasound scanner was still available as a stand-alone function. With the single-rack concept, the flexibility of the system is high and the complete device can easily be moved from one operating theatre to another.

Equipment Design↗
PubMed2004

Identification and removal of an epileptogenic lesion using Ictal-EEG, functional-neuronavigation and electrocorticography.

PURPOSE: Cases with intractable epilepsy may present with multiple lesions in their brains. Ictal-EEG carries a great value in identification of the primary epileptogenic source. On the other hand, removal of low-grade tumors located around the eloquent cortex may be risky with conventional techniques. Functional-neuronavigation (f-NN) is the integration of functional magnetic resonance imaging and stereotactic technologies; and provides interactive data regarding localization of the motor cortex. This report presents a case with dysembryoplastic neuroepithelial tumor (DNET), which was removed using f-NN and electrocorticography (ECoG) techniques. METHODS: A 19-year-old patient with intractable complex partial and secondary generalized seizures is presented. MRI revealed a low-grade tumor located in right parietal region just behind the motor cortex, and a contralateral temporal arachnoid cyst. Ictal-EEG demonstrated the right parietal origin of the seizures. The patient underwent a right parietal craniotomy and tumor excision using f-NN and ECoG techniques intraoperatively. ECoG findings correlated with epileptogenicity of the parietal lesion. RESULTS: Postoperative course was uneventful. No postoperative deficit was observed. The patient was seizure free in eight months follow-up. Pathological examination reported the lesion as DNET. CONCLUSIONS: Ictal-EEG has a very important role in identification of the epileptogenic focus in cases with multiple brain lesions. Preservation of the functional cortex is the most prominent aim during lesional surgery of epilepsy. Intraoperative mapping using f-NN and ECoG supports the orientation of the neurosurgeon to the functional and epileptogenic cortical areas; and thus, increase the safety and efficacy of surgical procedures.

Electrodes, Implanted↗
PubMed2001

Transcranial magnetic stimulation in therapy studies: examination of the reliability of "standard" coil positioning by neuronavigation.

Transcranial magnetic stimulation is investigated as a new tool in the therapy of depression and other psychiatric disorders. In almost all studies, the dorsolateral prefrontal cortex (DLPFC) has been selected as the target site for stimulation. Usually this region was determined by identifying the patient's motor cortex, and from there the coil was placed 5 cm rostrally. The aim of our study was to test the reliability of this standard procedure. A neuronavigational system was used to relate the final coil position after applying the standard procedure to the individual cortical anatomy. In 7 of 22 subjects, the Brodman area 9 of the DLPFC was targeted correctly in this manner. In 15 subjects, the center of the coil was found to be located more dorsally (e.g., above the premotor cortex). The current method for locating the DLPFC is not precise anatomically and may be improved by navigating procedures taking individual anatomy into account.

Adult↗
PubMed2000

Accuracy and clinical applicability of a passive marker based frameless neuronavigation system.

A passive marker system permits the inclusion of an unlimited number of instruments and other devices during frameless stereotaxy. The aim of this study was to evaluate the accuracy and clinical applicability of a passive marker based frameless image guided system (VectorVision; BrainLab, Heimstetten, Germany) developed for surgical planning and intraoperative image guidance. The system was first applied to a plastic phantom to determine the accuracy of the system by measuring the difference between the actual probe position and its analogous position on the monitor screen. The navigational device was subsequently applied to 40 procedures for brain tumours and cavernomas. The mean error value between the image on the monitor screen and the real location in the phantom and the clinical study was 1.45 mm (+/-0.99) and 4.05 mm (+/-3.62), respectively. Many different instruments could be employed as pointing devices. It was helpful in minimising the size of the craniotomy. An average lengthening of the surgical procedure of 20 minutes was experienced. The neuronavigation system proved to be a useful surgical tool to approach and detect lesions larger than 5 mm in diameter. The passive marker technology is intuitive and enables the surgeon to use his or her own instruments at any time as a pointing device, thus avoiding further costs for specially designed surgical equipment.

Adult↗
PubMed2000

[Neuronavigation in the region of the skull base].

Neuronavigation (computer-aided surgery planning and performance) has proven to be helpful in performing neurosurgical operations. The experiences of our department gained on more than 500 patients operated upon will be presented, with special focus on more than 100 operations for lesions on the skull base. Navigation is one of several modern surgical tools, its value cannot be defined without observing other improvements e.g. in the area of preoperative diagnostics, intraoperative monitoring, microsurgical instruments and microsurgical approaches.

Adenoma↗
PubMed2001

The impact of an armless frameless neuronavigation system on routine brain tumour surgery: a prospective analysis of 51 cases.

A passive infrared armless and frameless neuronavigation system was introduced in routine intracranial and skull base surgery, and its impact on 51 cases in a one year period was assessed. No cases were rejected by the operating surgeon for lack of accuracy (> 3 mm). Operating time was not significantly lengthened, except in transphenoidal cases (255 +/- SD 168 min versus 185 +/- SD 119 min, p = 0.02). Length of stay was shorter in navigation cases in supratentorial glioma (12 +/- SD 7.3 days versus 15 +/- SD 7.9 days) and meningioma (11 +/- SD 5.3 days versus 16 +/- SD 6.7 days, p = 0.01). Outcome at 3 months was comparable in both the supratentorial glioma and meningioma group. Problems such as setup time and brain shift are addressed and discussed.

Adolescent↗
PubMed2000

Neuroendoscopy combined with frameless neuronavigation.

Minimal invasive neurosurgery is becoming more and more standard in neurosurgical procedures. Several types of lesions are now approached endoscopically. The surgical planning and intraoperative orientation during endoscopic surgical procedures are sometimes difficult. To solve this problem, a combination of the endoscopic procedure with a frameless, armless neuronavigation system is used in our service. The combination of the endoscope and the frameless navigation system was used in tumour surgery, ventriculostomies and arachnoid cyst operations. All procedures were performed successfully. The combination of both systems has proved to be advantageous because of safe surgical planning using the frameless stereotactic technique and the possibility of real time orientation of the endoscope. This technique is very useful in removing intraventricular and large brain mass lesions.

Arachnoid Cysts↗
PubMed2001

Ultrasound-guided neuronavigation of deep-seated cavernous haemangiomas: clinical results and navigation techniques.

The aim of this study was to evaluate guidance techniques and patient outcomes of ultrasound-guided neuronavigation of deep-seated intracerebral cavernous hemangiomas (CAs). Thirty-five patients with deep-seated intracerebral CAs with sizes ranging between 7 and 45 mm were operated upon only with ultrasound-guidance. Twenty-seven were located in or near eloquent regions. In 30 patients dissection to the lesion was performed through sulci and fissures. The best approach to a lesion based on surface anatomy and depth was determined using sonographic information. Navigation was done sonographically. In five patients the shortest approach via a corticotomy was determined sonographically. Twenty-six patients had no neurological deficit postoperatively. Preoperative deficits improved in seven of nine patients. Fifteen of 19 patients suffering epileptic seizures had no seizures postoperatively. Intraoperative sonography revealed residual CA tissue after microsurgical extirpation in two cases. This report shows that intraoperative sonographic navigation provides safe guidance to deep-seated CAs with good clinical outcome independent of size.

Adolescent↗
PubMed1997

Development of a frameless and armless stereotactic neuronavigation system with ultrasonographic registration.

OBJECTIVE: We have developed a frameless stereotactic neuronavigation system that allows navigation during neurosurgical procedures through an image formed from integrating ultrasonography and preoperative magnetic resonance (MR) imaging and/or x-ray computed tomography. METHODS: The system consists of a ultrasound imaging scanner, a workstation with an image capture board, and an ultrasonic tracking sensor with a 5-MHz ultrasonographic transducer. The ultrasonic tracking sensor measures the position and orientation of the ultrasonographic transducer. The oblique plane of the MR/computed tomographic image corresponding to the ultrasound image is then displayed on the workstation monitor. A three-dimensional computer graphic representation of the integrated image is also reported as a preliminary test. For the patient-image registration, the coordinates of digitized and imaged markers on a specifically developed reference frame are used. The reference frame is noninvasive because it is not bolted but only fastened to the patient's head with silicon. RESULTS: Based on the findings from the clinical application of the system in three cases, the system was advantageous because of the surgical procedures could be controlled by intraoperative ultrasonography as well as by preoperative MR/computed tomographic images. Missing parts in the ultrasonogram were supplemented with preoperative MR/computed tomographic images. At other times, spatial positioning and visualization by ultrasonography were useful for identifying anatomical objects in the image. CONCLUSION: This preliminary study of the frameless integration of ultrasonography into stereotactic space demonstrated its clinical usefulness. We believe that the concept of pre- and intraoperative image-guided surgery presented here will find increasing use in the future.

Adolescent↗
PubMed2000

Advanced surgical approach for selective amygdalohippocampectomy through neuronavigation.

OBJECTIVE: Selective removal of the mesiobasal temporal structures through the transsylvian approach was introduced by Yasargil and Wieser in 1982. This alternative to standard temporal lobectomy provides excellent outcomes for seizure control. Basic actions in the transsylvian fissure exposure mainly serve to orient the surgeon, and they carry the risk of vasospasm and vessel damage. The aim of our study was to reduce landmark-guided surgery steps through neuronavigation. METHODS: During a 14-month period, 16 selective amygdalohippocampectomies were performed with the aid of the SMN (Carl Zeiss, Inc., Thornwood, NY) or StealthStation (Sofamor Danek, Memphis, TN) optically guided systems. We added safety procedures to the operation (including intraoperative rereferencing, obtaining additional bony reference points before craniotomy, performing a small craniotomy and making an accurate dural incision, and using contrast medium for vessel visualization) to develop a method that relies on navigational systems without further orientation by anatomic landmarks. RESULTS: Originally, performing an amygdalohippocampectomy required exposing the sylvian fissure from the carotid bifurcation to 2 cm beyond the middle cerebral artery bifurcation, which exposed one-third of the insula. By determining the entry point at the limen insulae and the target at the tip of the temporal horn, the mandatory extent of the opening to the sylvian fissure can be projected. Therefore, the exposure of the fissure can be limited to exactly the extent required for the transventricular approach through the uncinate fasciculus. CONCLUSION: Computer-assisted surgery is an effective tool in eliminating the exposure of anatomic landmarks in selective amygdalohippocampectomy. This modification combines the precision of targeting with minimal cortical and vessel traumatization.

Adult↗
PubMed1999

The relationship of magnetic source imaging to ictal electrocorticography in a neuronavigational workspace.

Magnetic source imaging (MSI) registers magnetoencephalographic (MEG) activity to a three-dimensional MRI volume. State-of-the-art MSI allows concurrent whole head coverage, but is practically restricted to interictal recording. However, the purpose of the presurgical evaluation of epileptic patients, in which MSI is playing an increasing role, is the elucidation of the ictal epileptogenic focus. The manner in which interictal MSI activity relates to the ictal focus has not yet been adequately examined. To facilitate this analysis, we are developing techniques to precisely coregister MSI to the ictal onset zone as defined by extraoperative intracranial grid/strip monitoring. The neuronavigational workspace is a convenient area in which to precisely coregister these (and other) imaging and physiological data sets.

Cerebral Cortex↗
PubMed1996

Intraoperative computer-assisted neuronavigation in functional neurosurgery.

The clinical experience with a frameless computer-assisted neuronavigational system (ISG. Canada) used in functional neurosurgery is described. The advantage of image-guided surgery is stressed for functional procedures of the cortex with delineation of the gyral pattern, e.g. motor cortex stimulation and procedures at the base of the skull with triplanar and three-dimensional reconstruction of the bony landmarks. A general use of the device for aiming at subcortical targets cannot be recommended. Limitations are the accuracy (< or = 2.2 mm) and software deficiencies and the lack of a reliable fixation of the position sensing arm (wand).

Cerebral Cortex↗
PubMed1997

Neuronavigation--impact on operating time.

It is uncertain whether the use of image-guided surgery has an influence on operating time. We prospectively studied the time requirements which have to be invested for using image-guided surgery and performed a comparison of operating room times from 125 matched pairs of image-guided and conventional operations. Our study revealed that neuronavigation has to be regarded as time neutral in general neurosurgery, whereas in stereotactic surgery, namely biopsy retrival, a significant reduction of anaesthetic time can be achieved through the complete separation of imaging and operation in the frameless approach.

Anesthesia↗
PubMed2002

Iterative neuronavigation using 3D ultrasound. A feasibility study.

Intra-operative ultrasound (iUS) can generate 2D images in real-time as well as near real-time 3D datasets of the current situation during an intervention. Tracked ultrasound can locate the images in 3D space and relate them to patient, devices, andpre-operative planning data. Therefore, tracked US is an efficient means for controlling the validity of pre-operative planning, recognition of changes (brain shift) during the intervention, replanning of the operational path due to situational changes (iterative navigation), and finally, controlling the results (residual tumor). This paper describes a neuronavigation system exploiting this potential of interventional tracked US for permanent control of intervention progress and iterative adaptation of the planned procedure to the current situation.

Brain Mapping↗
PubMed2000

[Sulcal identification and neuronavigation in supratentorial cavernoma surgery].

We present the use of cortical sulci, segmented from magnetic resonance imaging, in image guided neurosurgery. Sulcal information was transferred to a surgical microscope with enhanced reality features. This assistance was used for the resection of supratentorial cavernomas (7 patients). Sulci were semi-automatically segmented from 3D MRI data sets. Sulci close to the cavernoma were selected and transferred to the neuronavigation system which allows the superimposition of graphics into the right ocular of the microscope. Selected sulci were displayed on the workstation and superimposed into the ocular of the microscope. Cortical sulci proved to be useful for the recognition of the anatomical environment. The superimposed sulci helped to optimize location and size of the skin incision as well as to guide the access to the cavernoma by using the course of a sulcus as indirect trajectory.

Adult↗