Computer-assisted stereotaxic laser resection of intra-axial brain neoplasms

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✓ Computer interpolation of stereotaxic computerized tomography (CT) scanning data allows the transposition of a tumor volume in stereotaxic space. A stereotaxically directed and computer-monitored CO2 laser is then utilized to vaporize that volume as the surgeon monitors the position of a cursor representing the laser beam against planar contours of the tumor displayed on an operating room computer monitor. Computer-assisted stereotaxic laser microsurgery provides precise three-dimensional control for aggressive resection of deep-seated tumors from neurologically important areas with acceptable postoperative results. Thus, a significant cytoreduction can be achieved in addition to providing a tissue diagnosis and internal decompression.

The authors report 83 computer-assisted stereotaxic laser procedures for tumor excision in 78 patients. The tumors were located in the thalamus/basal ganglia in 15 patients, ventricular system in five, corpus callosum in four, brain stem in three, and deep and centrally in the hemispheres in 51. Histologically, there were 26 glioblastomas, seven grade III astrocytomas, 14 grade II astrocytomas, 14 metastatic tumors, nine vascular lesions, and eight miscellaneous lesions. Resection of these subcortical lesions was confirmed by postoperative contrast-enhanced CT scanning. Neurological examinations performed 1 week after the 83 procedures revealed that 48 patients had improved from their preoperative level and 23 were unchanged (12 were neurologically normal preoperatively). Twelve patients had an increase in a preoperative neurological deficit, three of whom died in the postoperative period: one from infection, one from pulmonary emboli, and one from brain-stem edema.

The average survival period (37.6 weeks) of patients having glioblastomas treated by this technique and irradiation was no different from that of patients having glioblastomas in more favorable locations treated by conventional surgery and irradiation. Patients with circumscribed lower-grade astrocytomas did better in terms of morbidity and completeness of resection than those with infiltrative neoplasms. Other circumscribed lesions, such as metastatic tumors, vascular lesions, and intraventricular tumors, were easily resected by the technique described.

Article Information

Address reprint requests to: Patrick J. Kelly, M.D., Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905.

© AANS, except where prohibited by US copyright law.

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Figures

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    Left: Computerized tomography (CT)-compatible stereotaxic headholder with localization system which consists of nine rods arranged in the shape of the letter “N” located bilaterally and anteriorly. This produces nine reference marks on each CT slice from which the position and orientation of the slice in stereotaxic space may be determined. Right: Computer-interactive stereotaxic 400-mm arc-quadrant which directs the operating microscope and laser beam to the target point. A small internal arc-quadrant holds a stereotaxic retractor (inset).

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    Stereotaxic computerized tomography slice showing the nine reference marks produced by the localization system. The surgeon digitizes the outlines of the tumor using the cursor and trackball subsystems of the display console.

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    Interactive display of a slice of tumor volume reconstructed from digitized computerized tomography-defined boundaries and reformatted orthogonal to the surgical approach at the level at which the microscope and laser are focused. The position of the surgical retractor (circle) and CO2 laser beam (cursor) are also shown in relation to the tumor size.

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    Lateral teleradiograph demonstrating the stainless steel reference balls which have been inserted along the stereotaxic surgical viewline prior to open craniotomy.

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    Left: Lateral teleradiograph showing a Hypaque-soaked cotton ball in a cavity produced by stereotaxic laser vaporization of a tumor. Right: Sagittal reconstruction of the computerized tomography data through the tumor volume is shown for comparison.

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    Diagram showing the location of tumors in 78 patients. R = right, L = left.

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    Pre- (left) and postoperative (right) contrast-enhanced computerized tomography scans in three patients with glioblastoma in the left thalamus (upper), in the medial right parietal lobe (center), and in the corpus callosum (lower).

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    Pre- (left) and postoperative (right) computerized tomography scans in two patients with grade III astrocytomas: Case 28 (upper) and Case 27 (lower).

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    Case 72. Computerized tomography scans showing a large ganglioglioma in the third ventricle that was resected in two stages.

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