Surgical navigation in the open MRI.

The introduction of MRI into neurosurgery has opened multiple avenues, but also introduced new challenges. The open-configuration intraoperative MRI installed at the Brigham and Women's Hospital in 1996 has been used for more than 500 open craniotomies and beyond 100 biopsies. Furthermore the versatile applicability, employing the same principles, is evident by its frequent use in other areas of the body. However, while intraoperative scanning in the SignaSP yielded unprecedented imaging during neurosurgical procedures their usage for navigation proved bulky and unhandy. To be fully integrated into the procedure, acquisition and display of intraoperative data have to be dynamic and primarily driven by the surgeon performing the procedure. To use the benefits of computer-assisted navigation systems together with immediate availability of intraoperative imaging we developed a software package. This "3D Slicer" has been used routinely for biopsies and open craniotomies. The system is stable and reliable. Pre- and intraoperative data can be visualized to plan and perform surgery, as well as to accommodate for intraoperative deformations, "brain shift", by providing online data acquisition.

An integrated visualization system for surgical planning and guidance using image fusion and an open MR.

A surgical guidance and visualization system is presented, which uniquely integrates capabilities for data analysis and on-line interventional guidance into the setting of interventional MRI. Various pre-operative scans (T1- and T2-weighted MRI, MR angiography, and functional MRI (fMRI)) are fused and automatically aligned with the operating field of the interventional MR system. Both pre-surgical and intra-operative data may be segmented to generate three-dimensional surface models of key anatomical and functional structures. Models are combined in a three-dimensional scene along with reformatted slices that are driven by a tracked surgical device. Thus, pre-operative data augments interventional imaging to expedite tissue characterization and precise localization and targeting. As the surgery progresses, and anatomical changes subsequently reduce the relevance of pre-operative data, interventional data is refreshed for software navigation in true real time. The system has been applied in 45 neurosurgical cases and found to have beneficial utility for planning and guidance. J. Magn. Reson. Imaging 2001;13:967-975.

Serial intraoperative magnetic resonance imaging of brain shift.

OBJECTIVE: A major shortcoming of image-guided navigational systems is the use of preoperatively acquired image data, which does not account for intraoperative changes in brain morphology. The occurrence of these surgically induced volumetric deformations ("brain shift") has been well established. Maximal measurements for surface and midline shifts have been reported. There has been no detailed analysis, however, of the changes that occur during surgery. The use of intraoperative magnetic resonance imaging provides a unique opportunity to obtain serial image data and characterize the time course of brain deformations during surgery. METHODS: The vertically open intraoperative magnetic resonance imaging system (SignaSP, 0.5 T; GE Medical Systems, Milwaukee, WI) permits access to the surgical field and allows multiple intraoperative image updates without the need to move the patient. We developed volumetric display software (the 3D Slicer) that allows quantitative analysis of the degree and direction of brain shift. For 25 patients, four or more intraoperative volumetric image acquisitions were extensively evaluated. RESULTS: Serial acquisitions allow comprehensive sequential descriptions of the direction and magnitude of intraoperative deformations. Brain shift occurs at various surgical stages and in different regions. Surface shift occurs throughout surgery and is mainly attributable to gravity. Subsurface shift occurs during resection and involves collapse of the resection cavity and intraparenchymal changes that are difficult to model. CONCLUSION: Brain shift is a continuous dynamic process that evolves differently in distinct brain regions. Therefore, only serial imaging or continuous data acquisition can provide consistently accurate image guidance. Furthermore, only serial intraoperative magnetic resonance imaging provides an accurate basis for the computational analysis of brain deformations, which might lead to an understanding and eventual simulation of brain shift for intraoperative guidance.

Volume assessment of the normal female cervix with MR imaging: comparison of the segmentation technique and two geometric formula.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine the volume of the normal female cervix and to determine the geometric formula that yields the best estimate. MATERIALS AND METHODS: Magnetic resonance images of the pelvis in 30 young women were reviewed retrospectively. The volume of the cervix was estimated by using the formulas for an ellipse and a cylinder. Manual labeling and segmentation of the cervix were also performed, and the volume was calculated on the basis of the number and size of the voxels. Comparison of these methods was then performed by using a two-tailed Student t test. RESULTS: No statistically significant difference was found (P = .7) between the volume calculated with the segmentation technique (25.3 mL) and that estimated with the formula for a cylinder (24.8 mL). A statistically significant difference (P < .05) was found between the volume calculated with the segmentation technique and that estimated with the formula for an ellipse (16.4 mL). CONCLUSION: The normal volume of the cervix in this population of young women was approximately 25 mL. The volume of the cervix should be estimated with the formula for a cylinder.

MR-based three-dimensional modeling of the normal pelvic floor in women: quantification of muscle mass.

OBJECTIVE: Our objective was to use a combination of axial MR source images and three-dimensional (3D) models to describe the anatomy of the normal pelvic floor in young nulliparous women and to measure the volume of the levator ani. SUBJECTS AND METHODS: Ten healthy nulliparous female volunteers (average age, 27 years) underwent T2-weighted MR imaging of the pelvis. Three-dimensional color-coded models of the pelvic bones and organs and the three major components of the levator ani--puborectalis, iliococcygeus, and coccygeus--were created. Source images were used to measure muscle width and signal intensity and to identify ligamentous structures. Using 3D models, we measured the volume of the levator ani, the angle of the levator plate, the posterior urethrovesical angle, and the distance of the bladder neck from the symphysis pubis and the pubococcygeal line. RESULTS: In all volunteers, the signal intensity of the puborectalis exceeded that of the obturator externus. The average volume of the levator ani was 46.6 ml, the average width of the levator hiatus was 41.7 mm, and the average posterior urethrovesical angle was 143.5 degrees. Vaginal shape in the volunteers followed no recognizable pattern. CONCLUSION: Muscle morphology, signal intensity, and volume is relatively uniform among healthy young women.

Image-guided therapy and intraoperative MRI in neurosurgery.

Computer-assisted 3D planning, navigation and the possibilities offered by intra-operative imaging updates have made a large impact on neurological surgery. Three-dimensional rendering of complex medical image information, as well as co-registration of multimodal sources has reached a highly sophisticated level. When introduced into surgical navigation however, this pre-operative data is unable to account for intra-operative changes, ('brain-shift'). To update structural information during surgery, an open-configured, intra-operative MRI (Signa SP, 0.5 T) was realised at our institution in 1995. The design, advantages, limitations and current applications of this system are discussed, with emphasis on the integration of imaging into procedures. We also introduce our integrated platform for intra-operative visualisation and navigation, the 3D Slicer.

Intraoperative, real-time, functional MRI.

Functional MRI (fMRI) methods have been demonstrated to noninvasively identify motor-sensory, visual, and other areas of eloquent cortex for guiding surgical intervention. Typically, fMRI data are acquired preoperatively during a conventional surgical planning MRI examination. Unlike direct cortical stimulation at the time of surgery, however, preoperative fMRI methods do not account for the potential movement of tissues (relative to the time of functional imaging) that may occur in the surgical suite as a direct result of the intervention. Recently, an MRI device has been demonstrated for use in the surgical suite that has the potential to reduce the extent of cortical exposure required for the intervention. However, the invasive requirements of cortical mapping may supersede the invasive requirements of the surgical intervention itself. Consequently, we demonstrate here a modification to the intraoperative MRI device that facilitates a noninvasive, real-time, functional MR examination in the surgical suite.