Frameless neuronavigation based only on 3D digital subtraction angiography using surface-based facial registration

Abstract

Paralleling the rapid development of neuroimaging technology, the introduction of neuronavigation in the 1980s has revolutionized the surgery of intracranial diseases.2,11 Neuronavigation based on CT or MRI studies has tailored surgical interventions to individual anatomy and pathology, with minimal disruption to the physical and functional architecture of the brain. Vascular anatomy is best appreciated with digital subtraction angiography (DSA), which remains the gold standard for imaging of cerebrovascular pathology. Both CT angiography (CTA) and MR angiography (MRA) have lower detection sensitivity and inferior spatial resolution relative to DSA for aneurysms smaller than 3 mm. 1,19,20 The use of DS angiograms as source images for neuronavigation, however, has been limited because DSA studies typically lack the soft-tissue information necessary to register the radiographic image space to the head in the physical space. Images from DSA typically require fusion with CT or MR images for coregistration.Frameless neuronavigation based only on 3D digital subtraction angiography using surface-based facial registration Object. Cerebrovascular lesions can have complicated abnormal anatomy that is not completely characterized by CT or MR angiography. Although 3D rotational angiography provides superior spatial and temporal resolution, catheter angiograms are not easily registered to the patient, limiting the use of these images as a source for neuronavigation. However, 3D digital subtraction angiography (DSA) contains not only vascular anatomy but also facial surface anatomy data. The authors report a novel technique to register 3D DSA images by using only the surface anatomy contained within the data set without having to fuse the DSA image set to other imaging modalities or use fiducial markers.Methods. A cadaver model was first created to assess the accuracy of neuronavigation based on 3D DSA images registered by facial surface anatomy. A 3D DSA scan was obtained of a formalin-fixed cadaver head, with acquisitions of mask and contrast runs. The right common carotid artery was injected prior to the contrast run with a 45% contrast solution diluted with water-soluble red liquid latex. One week later, the head was registered to a neuronavigation system loaded with the 3D DSA images acquired earlier using facial surface anatomy. A right pterional craniotomy was performed and 10 different vascular landmarks were identified and measured for accuracy using the neuronavigation system. Neuronavigation based only on 3D DSA was then used to guide an open clipping procedure for a patient who presented with a ruptured distal lenticulostriate aneurysm.Results. The accuracy of the measurements for the cadaver model was 0.71 ± 0.25 mm (mean ± SE), which is superior to the 1.8-5 mm reported for neuronavigation. The 3D DSA-based navigation-assisted surgery for the distal lenticulostriate aneurysm aided in localization, resulting in a small craniotomy and minimal brain dissection.Conclusions. This is the first example of frameless neu...

Surgery of brain aneurysm in a BrainSuite® theater: A review of 105 cases

“…As every surgeon familiar with navigation knows, it is very easy to match the patient's head with the radiological model, by using the Z touch technique or surface registration (which involves using an emitting infrared tool to point at several cutaneous markers on the forehead as well as on both the orbital regions and the nose). This technique has been used recently also for neuronavigation based only on 3D digital subtraction angiography registered by only the surface anatomy data contained in the 3D-DSA image set [5]. This registration process is particularly easy in the case of patients placed in supine position and provides the best accuracy when the preoperative radiological model is a CT scan, as in our series.…”

“…The choice of the best preoperative, intraoperative, and postoperative radiological imaging for brain aneurysms is a very popular and controversial topic in recent literature [1,[3][4][5][6][7][8], with many authors proposing that CTA replace DSA as the state of the art means of investigating and evaluating brain aneurysms [7,8]. CTA is not invasive, is easy and fast to perform, is cheap to run and presents almost no risks and provides high diagnostic accuracy [7,8].…”

“…The development of advanced neuroimaging makes techniques, such as CT angiography (CTA), high resolution contrastenhanced MR angiography (with the MIP sequences), perfusion and diffusion MRI (DWI) as well as angiography (DSA), potentially usable by the Navigator workstation (which is almost completely identical to a radiological workstation), although the potential advantages of this technological theater in cerebrovascular surgery are still a matter of debate [1][2][3][4][5][6][7][8].…”

Cone-beam CT angiography (Dyna CT) for intraoperative localization of cerebral arteriovenous malformations

“…Previous authors have described and compared the effectiveness of CBCT-A against DSA in assessing AVM dimension, arterial feeders, venous drainage, nidal density, and shunting;14 all of this information is further provided in three dimensions instead of two 15. Furthermore, CBCT-A overcomes the limitations of DSA with use in neuronavigation systems by acquisition of skin line tracings, allowing it to be used as a stand-alone reference image 1. CBCT-A has also been shown to be useful in the assessment of AVMs following hemorrhage, especially when DSA does not sufficiently show the lesion 12.…”

“…In this study we review a series of cases in which CBCT-A was performed preoperatively, either with or without an endovascular intervention, to assist in the image-guided surgical resection of cerebral AVMs. The use of CBCT-A has been tested in laboratory/cadaveric studies by other groups;1 we report its use in a series of patients at two different institutions.…”