Ultrasound-controlled neuronavigator-guided brain surgery

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✓ The development of a unique neurosurgical navigator is described and a preliminary series of seven cases of intracerebral lesions approached with the assistance of this neuronavigation system under ultrasound control is presented. The clinical series included five low-grade astrocytomas, one chronic intracerebral hematoma, and one porencephalic cyst. Management procedures included biopsy in all cases, drainage of the hematoma, and endoscopy and fenestration for the cyst. The features of the neuronavigation system are interactive reconstructions of preoperative computerized tomography and magnetic resonance imaging data, corresponding intraoperative ultrasound images, versatility of the interchangeable end-effector instruments, graphic presentation of instruments on the reconstructed images, and voice control of the system. The principle of a common axis in the reconstructed images served to align the navigational pointer, biopsy guide, endoscope guide, ultrasound transducer, and surgical microscope to the brain anatomy. Intraoperative ultrasound imaging helped to verify the accuracy of the neuronavigator and check the results of the procedures. The arm of the neuronavigation system served as a holder for instruments, such as the biopsy guide, endoscope guide, and ultrasound transducer, in addition to functioning as a navigational pointer. Also, the surgical microscope was aligned with the neuronavigator for inspection and biopsy of the hematoma capsule to rule out tumor etiology. Voice control freed the neurosurgeon from manual exercises during start-up and calibration of the system.

Article Information

Address reprint requests to: John Koivukangas, M.D.. Ph.D., Department of Neurosurgery, Box 96 UMHC, B590 Mayo Memorial Building, 420 Delaware Street SE, Minneapolis, Minnesota 55455.

© AANS, except where prohibited by US copyright law.

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Figures

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    During surgery, the workstation monitor, shown at left, and the ultrasound scanner are situated adjacently. The neuronavigator is connected to the surgical table or Mayfield head holder. The ultrasound transducer is shown rigidly connected to the neuronavigator in such a way that the ultrasound image corresponds to the computerized tomography and/or magnetic resonance imaging reconstructions, each seen on respective monitors.

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    Left: Close-up photograph of the neuronavigator with a special collar adapting for different interchangeable instruments. The ultrasound transducer is being used transdurally. Right: Schematic drawing demonstrating the principle of the common central axis used in the construction of the end pieces to align various instruments interchangeably.

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    The UNIX workstation color monitor displaying the windows for pertinent preoperative computerized tomography or magnetic resonance imaging slices and the interactive two-dimensional reconstructions showing the graduated axis of the pointer or biopsy forceps passing to the tumor through a sulcus (lower center) and the perpendicular reconstruction at the desired depth (lower left). A triplanar representation of the approach axis passing into the tumor is also displayed (lower right).

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    Photograph showing calibration of the neuronavigator using encircled minute tattooed ink points.

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    Case 2. Left: Intraoperative ultrasound image of a deep low-grade astrocytoma. The tumor appears as a large echogenic region deep to the sylvian fissure, A biopsy was obtained at a depth of 46 mm (cross) with no complications. Center and Right: Neuronavigator-guided magnetic resonance (MR) imaging reconstructions showing a region of gadolinium enhancement beside lateral ventricle. One MR image (right) was obtained simultaneously with and corresponds to the ultrasound image (left); the graduated axis of this reconstruction thus corresponds to the central axis of the ultrasound image. Note that the echogenic region is fairly large in the ultrasound image, while the MR imaging reconstruction shows the contrast-enhanced part of the tumor. The other MR image (center) represents the reconstruction perpendicular to the axis of approach, at the depth indicated by the longer crossline of the axial reconstruction.

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    The biopsy guide aligned with the neuronavigator (which also serves as a holder) and the biopsy forceps have been passed to the appropriate depth for biopsy.

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    A neuroendoscope aligned in a porencephalic cyst with the neuronavigator to check for signs of tumor.

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    The surgical microscope aligned for examination of a chronic intracerebral hematoma. The central optical axis of the microscope corresponds to the axis in the image reconstructions, such as that in Fig. 5 right.

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