Surgical planning for retrosigmoid craniotomies improved by 3D computed tomography venography.

OBJECTIVE: It is impossible to precisely anticipate the crooked course of the transverse and sigmoid sinuses and their individual relationship to superficial landmarks such as the asterion during retrosigmoid approaches. This study was designed to evaluate this anatomical relationship with the help of a surgical planning system and to analyze the impact of these in vivo findings on trepanation placement in retrosigmoid craniotomies. METHODS: In a consecutive series of 123 patients with pathologies located in the cerebellopontine angle, 72 patients underwent surgical planning for retrosigmoid craniotomies based on 3D volumetric renderings of computed tomography venography. By opacity modulation of surfaces in 3D images the position of the asterion was assessed in relationship to the transverse-sigmoid sinus transition (TST) and compared to its intraoperative localization. We evaluated the impact of this additional information on trepanation placement. RESULTS: The spatial relationship of the asterion and the underlying TST complex could be identified and recorded in 66 out of 72 cases. In the remaining 6 cases the sutures were ossified and not visible in the 3D CT reconstructions. The asterion was located on top of the TST in 51 cases, above the TST in 4 cases, and below the TST in 11 cases. The location of the trepanation was modified in 27 cases due to the preoperative imaging findings with major and minor modifications in 10 and 17 cases, respectively. CONCLUSION: Volume-rendered images provide reliable 3D visualization of complex and hidden anatomical structures in the posterior fossa and thereby increase the precision in retrosigmoid approaches.

Evaluation of a new electromagnetic tracking system using a standardized assessment protocol.

This note uses a published protocol to evaluate a newly released 6 degrees of freedom electromagnetic tracking system (Aurora, Northern Digital Inc.). A practice for performance monitoring over time is also proposed. The protocol uses a machined base plate to measure relative error in position and orientation as well as the influence of metallic objects in the operating volume. Positional jitter (E(RMS)) was found to be 0.17 mm +/- 0.19 mm. A relative positional error of 0.25 mm +/- 0.22 mm at 50 mm offsets and 0.97 mm +/- 1.01 mm at 300 mm offsets was found. The mean of the relative rotation error was found to be 0.20 degrees +/- 0.14 degrees with respect to the axial and 0.91 degrees +/- 0.68 degrees for the longitudinal rotation. The most significant distortion caused by metallic objects is caused by 400-series stainless steel. A 9.4 mm maximum error occurred when the rod was closest to the emitter, 10 mm away. The improvement compared to older generations of the Aurora with respect to accuracy is substantial.

Clinical fluoroscopic fiducial-based registration of the vertebral body in spinal neuronavigation.

We present a system involving a computer-instrumented fluoroscope for the purpose of 3D navigation and guidance using pre-operative diagnostic scans as a reference. The goal of the project is to devise a computer-assisted tool that will improve the accuracy, reduce risk, minimize the invasiveness, and shorten the time it takes to perform a variety of neurosurgical and orthopedic procedures of the spine. For this purpose we propose an apparatus that will track surgical tools and localize them with respect to the patient's 3D anatomy and pre-operative 3D diagnostic scans using intraoperative fluoroscopy for in situ registration and embedded fiducials. Preliminary studies have found a fiducial registration error (FRE) of 1.41 mm and a Target Localization Error (TLE) of 0.48 mm. The resulting system leverages equipment already commonly available in the operating room (OR), providing an important new functionality that is free of many current limitations, while keeping costs contained.

A comparative statistical analysis of neuronavigation systems in a clinical setting.

The use of neuronavigation (NN) in neurosurgery has become ubiquitous. A growing number of neurosurgeons are utilizing NN for a wide variety of purposes, including optimizing the surgical approach (macrosurgery) and locating small areas of interest (microsurgery). The goal of our team is to apply rapid advances in hardware and software technology to the field of NN, challenging and ultimately updating current NN assumptions. To identify possible areas in which new technology may improve the surgical applications of NN, we have assessed the accuracy of neuronavigational measurements in the Radionics and BrainLab systems. Using a phantom skull, we measured how accurate the visualization of a navigational probe's tip was in these systems, taking a total of 2180 measurements. We found that, despite current NN tenets, error is maximal at the six marker count and minimal in the spreaded marker setting; that is, placing less markers around the area of interest maximizes accuracy and active tracking does not necessarily increase accuracy. Comparing the two systems, we also found that accuracy of NN machines differs both overall and in different axes. As researchers continue to apply technological advances to the NN field, an increasing number of currently held tenets will be revised, making NN an even more useful tool in neurosurgery.

Quantification of the gravity-dependent change in the C-arm image center for image compensation in fluoroscopic spinal neuronavigation.

In the quest to develop a viable, frameless spinal navigation system, many researchers are utilizing the C-arm fluoroscope. However, there is a significant problem with the C-arm that must be quantified: the gravity-dependent sag effect resulting from the geometry of the C-arm and aggravated by the inequity of weight at each end of the C-arm. This study quantified the C-arm sag effect, giving researchers the protocol and data needed to develop a program that accounts for this distortion. The development of spinal navigation algorithms that account for the C-arm sag effect should produce a more accurate spinal navigation system.

Comparative tracking error analysis of five different optical tracking systems.

OBJECTIVE: Effective utilization of an optical tracking system for image-based surgical guidance requires optimal placement of the dynamic reference frame (DRF) with respect to the tracking camera. Unlike other studies that measure the overall accuracy of a particular navigation system, this study investigates the precision of one component of the navigation system: the optical tracking system (OTS). The precision of OTS measurements is quantified as jitter. By measuring jitter, one can better understand how system inaccuracies depend on the position of the DRF with respect to the camera. MATERIALS AND METHODS: Both FlashPointtrade mark (Image Guided Technologies, Inc., Boulder, Colorado) and Polaristrade mark (Northern Digital Inc., Ontario, Canada) optical tracking systems were tested in five different camera and DRF configurations. A linear testing apparatus with a software interface was designed to facilitate data collection. Jitter measurements were collected over a single quadrant within the camera viewing volume, as symmetry was assumed about the horizontal and vertical axes. RESULTS: Excluding the highest 5% of jitter, the FlashPoint cameras had an RMS jitter range of 0.028 +/- 0.012 mm for the 300 mm model, 0.051 +/- 0.038 mm for the 580 mm model, and 0.059 +/- 0.047 mm for the 1 m model. The Polaris camera had an RMS jitter range of 0.058 +/- 0.037 mm with an active DRF and 0.115 +/- 0.075 mm with a passive DRF. CONCLUSION: Both FlashPoint and Polaris have jitter less than 0.11 mm, although the error distributions differ significantly. Total jitter for all systems is dominated by the component measured in the axis directed away from the camera.

A1 functions at the mitochondria to delay endothelial apoptosis in response to tumor necrosis factor.

Tumor necrosis factor (TNF) does not cause endothelial apoptosis unless the expression of cytoprotective genes is blocked. We have previously demonstrated that one of the TNF-inducible cytoprotective genes is the Bcl-2 family member, A1. A1 is induced by the action of the transcription factor, NFkappaB, in response to inflammatory mediators. In this report we demonstrate that, as with other cell types, inhibition of NFkappaB initiates microvascular endothelial apoptosis in response to TNF. A1 is able to inhibit this apoptosis over 24 h. We demonstrate that A1 is localized to and functions at the mitochondria. Whereas A1 is able to inhibit mitochondrial depolarization, loss of cytochrome c, cleavage of caspase 9, BID, and poly(ADP-ribose) polymerase, it does not block caspase 8 or caspase 3 cleavage. In contrast, A1 is not able to prevent endothelial apoptosis by TNF over 72 h, when NFkappaB signaling is blocked. On the other hand, the caspase inhibitor, benzyloxycarbonyl-VAD-formylmethyl ketone, completely blocks TNF-induced endothelial apoptosis over 72 h. Our findings indicate that A1 is able to maintain temporary survival of endothelial cells in response to TNF by maintaining mitochondrial viability and function. However, a mitochondria-independent caspase pathway eventually results in endothelial death despite mitochondrial protection by A1.

Remote-rendered 3D CT angiography (3DCTA) as an intraoperative aid in cerebrovascular neurosurgery.

OBJECTIVE: To assess the viability and utility of network-based rendering in the treatment of patients with cerebral aneurysms, we implemented an intraoperative rendering system and protocol using both three-dimensional CT angiography (3DCTA) and perspective volume rendering (PVR). MATERIALS AND METHODS: A Silicon Graphics InfiniteReality engine was connected via a Fast Ethernet network to a workstation in the neurosurgical operating room. A protocol was developed to isolate bone and vessels using an appropriate transfer function. Three-dimensional CT angiogram images were volume rendered and transmitted to the workstation using a bandwidth-conserving remote rendering system, and were rotated, cut using clipping planes, and viewed using normal and perspective views. Twelve patients with intracranial aneurysms were examined at surgery using this system. RESULTS: Rendering performance at optimal operating bandwidths (50-60 Mb/s) was excellent, with regeneration of a high-resolution image in less than 1 s. Network performance varied in two cases, slowing image regeneration. Surgeons found the images to be useful as an adjunct to conventional imaging in understanding the morphology of complex aneurysms and their relationship to the skull base. CONCLUSIONS: Intraoperative volume rendering using 3DCTA is achievable over a network, can reduce hardware costs by amortizing hardware among multiple users, and provides useful imaging information during the surgical treatment of cerebral aneurysms. Future operating suites may incorporate network-transmitted three-dimensional images as additional sources of imaging information.

Proposed simulation of volumetric image navigation using a surgical microscope.

This paper describes a simulated surgical setup based on modern, frameless stereotactic techniques that enable surgeons to visualize the field of view of the surgical microscope, overlaid with the segmented volumetric medical images, of a localized area of the patient's head. Using this "true three-dimensional" navigation system, the surgeon visualizes the surgical site while exploring the inner layers of the patient's anatomy via the surgical microscope. It also allows the surgeon to "fly through," and around, the site of the surgery to visualize several alternatives and qualitatively choose what he or she believes is the best surgical approach. Moving surgical devices are tracked with stereo vision cameras, allowing determination of their spatial relationship to the target lesion.

Coronary artery disease: metabolic risk factors and latent disease in individuals with paraplegia.

Individuals with spinal cord injury (SCI) currently have a longer life span as a result of recent improvements in medical care. As in the able-bodied population, cardiovascular disease is the leading cause of death in persons with SCI, but it appears to occur at younger ages in those with SCI than in the able-bodied population. The reduction in level of activity and adverse changes in body composition caused by SCI have profound metabolic consequences that may influence the progression and severity of coronary artery disease. Metabolic sequelae of SCI include disorders of carbohydrate and lipid metabolism. Almost half of the 45 active, healthy subjects with paraplegia we studied have a disorder of carbohydrate tolerance, 1 in 5 subjects having a diabetic oral glucose tolerance test. Hyperinsulinemia is found in those with abnormal glucose tolerance. Subjects with paraplegia having impaired glucose tolerance or diabetes mellitus are significantly older than those with normal glucose tolerance. High-density lipoprotein cholesterol is markedly depressed, and low density lipoprotein is relatively elevated. Radionuclide myocardial perfusion imaging after upper body ergometry exercise reveals latent coronary artery disease in 12 of 19 subjects with paraplegia.