Florian Kral

Registration and fusion of CT and MRI of the temporal bone.

Objective: To present and evaluate a registration method to fuse complementary information of CT and MRI of the temporal bone. Methods: CT and MRI of the temporal bone of 26 patients were independently registered 4 times. A manual, iterative, intrinsic, rigid, and retrospective registration method was used. Mean CREm (consistency registration error) was calculated as a reproducibility measurement. Results: CREm was 0.6 mm (95% CI = 0.52-0.68 mm). T-test revealed no difference between pathologic and normal cases (t[102] = −1.71; P = 0.09). Time needed: 13 minutes. In the registered and fused datasets, important bony surgical landmarks (eg, facial nerve canal, inner ear) could be assessed in 3 dimensions relatively to tumor tissue (eg, acoustic schwannoma). Fluid distribution within partially obliterated cochleae could be assigned to either scalae. Conclusion: An accurate, reproducible registration and fusion method that improves tumor surgery and cochlea implantation planning with only minor changes to the clinical workflow was presented and described. We suggest this method in selected cases.

Navigated Surgery at the Lateral Skull Base and Registration and Preoperative Imagery: Experimental Results

OBJECTIVES To assess factors that affect the accuracy of navigated surgery at the human lateral skull base, including the choice of registration procedures and preoperative computed tomography (CT) section thickness, and to compare target registration error, a measure of clinical application accuracy, with root mean square, an accuracy variable provided by several surgical navigation systems. DESIGN Experimental cadaver study. SETTING Medical university. PARTICIPANTS Anatomic specimen. MAIN OUTCOME MEASURES Target registration error. RESULTS A combination of high-resolution CT images, 0.5-mm section thickness, with pair-point matching of a combination of markers on the anatomical specimen, and the registration element was found to be superior (mean [SD], 0.72 [0.28] mm). No correlation was found between target registration error and root mean square. A statistical analysis that considers image registration and acquisition method did not show any correlation between target registration error and root mean square error (r = -0.175, P = .15). CONCLUSIONS High-resolution CT images, 0.5 mm, of the petrous bone and a pair-point registration using loci on the patient and registration superstructures worked best under experimental conditions. Only target registration error was found to provide reliable information on accuracy intraoperatively. In line with the literature, these data prove that root mean square bears little relevance for clinical application accuracy.

Quantitative error analysis for computer assisted navigation: a feasibility study

PURPOSE The benefit of computer-assisted navigation depends on the registration process, at which patient features are correlated to some preoperative imagery. The operator-induced uncertainty in localizing patient features-the user localization error (ULE)-is unknown and most likely dominating the application accuracy. This initial feasibility study aims at providing first data for ULE with a research navigation system. METHODS Active optical navigation was done in CT-images of a plastic skull, an anatomic specimen (both with implanted fiducials), and a volunteer with anatomical landmarks exclusively. Each object was registered ten times with 3, 5, 7, and 9 registration points. Measurements were taken at 10 (anatomic specimen and volunteer) and 11 targets (plastic skull). The active NDI Polaris system was used under ideal working conditions (tracking accuracy 0.23 mm root-mean-square, RMS; probe tip calibration was 0.18 mm RMS). Variances of tracking along the principal directions were measured as 0.18 mm(2), 0.32 mm(2), and 0.42 mm(2). ULE was calculated from predicted application accuracy with isotropic and anisotropic models and from experimental variances, respectively. RESULTS The ULE was determined from the variances as 0.45 mm (plastic skull), 0.60 mm (anatomic specimen), and 4.96 mm (volunteer). The predicted application accuracy did not yield consistent values for the ULE. CONCLUSIONS Quantitative data of application accuracy could be tested against prediction models with iso- and anisotropic noise models and revealed some discrepancies. This could potentially be due to the facts that navigation and one prediction model wrongly assume isotropic noise (tracking is anisotropic), while the anisotropic noise prediction model assumes an anisotropic registration strategy (registration is isotropic in typical navigation systems). The ULE data are presumably the first quantitative values for the precision of localizing anatomical landmarks and implanted fiducials. Submillimetric localization is possible for implanted screws; anatomic landmarks are not suitable for high-precision clinical navigation.

Microdebrider-assisted intracapsular Tonsillectomy in adults with chronic or recurrent tonsillitis

We compared the effectiveness and morbidity of microdebrider‐assisted total intracapsular tonsillectomy (ICTE) with conventional extracapsular tonsillectomy (ECTE) in adults with chronic or recurrent tonsillitis.

Anatomy of the murine and human cochlea visualized at the cellular level by synchrotron-radiation-based micro-computed tomography

Diseases of the hearing organ and impairment affect a significant fraction of population. Therefore, the hearing organ embedded as a helical structure in the cochlea within the hardest human osseous structure inside the petrous bone is intensively investigated. Currently, studies of the cochlea with true micrometer resolution or better are destructive. Membranes and three-dimensional vessel structures of post-mortem explanted human cochlea were only visualized with limited spatial resolution or deformed anatomical features resulting from preparation artifacts. We have applied a preparation and staining protocol developed for electron microscopy, which allows the visualization and quantification of a great variety of soft-tissue structures including the Reissners membrane, the tectorial membrane, basilar membrane, modiolus, lamina radialis, and Nuels space by the use of synchrotron-radiation-based micro computed tomography at the beamline BW 2 (HASYLAB at DESY). The level of detail can be even improved by the application of sophisticated computer vision tools, which enables the extraction of the vascular tree down to the capillaries and of the course of nerve fibers as well as the topology of the osseous lamina radialis, which assembles the nerve fibers from the hair-cells to the ganglia in the center of the cochlea, the modiolus. These non-destructively obtained three-dimensional data are principal for the refined understanding of the hearing process by membranes morphologies and further anatomical features at the cellular level and for teaching purposes in medical curricula.

Chondrosarcoma of the nasal cavity in a patient with Maffucci syndrome: case report and review of the literature

IntroductionMaffucci syndrome is a rare, congenital, non-hereditary mesodermal dysplasia, manifested by multiple enchondromas and hemangiomas. Malignant transformation of these lesions is seen in up to 40% of the cases.Case reportWe present a case of a patient with Maffucci syndrome and an associated chondrosarcoma of the nose. Treatment consisted of surgical resection. Because of the low grade of the tumor, additional treatment, such as radiotherapy, was not necessary.ConclusionMaffucci syndrome is an exceedingly rare mesodermal dysplasia. Its manifestation in the head and neck region is even less common. Malignant transformation of the associated enchondromas is common, and should be considered whenever a change of the clinical course occurs. Random, periodically performed X-ray examinations give little additional information on malignant transformation and are considered useless.

Exploring the clinical validity of predicted TRE in navigation

In a detailed laboratory investigation we performed a series of experiments in order to assess the validity of the widely used TRE concept to predict the application accuracy. On base of 1mm CT scan a plastic skull, a cadaver head and a volunteer were registered to an in house navigation system. We stored the position data of an optical camera (NDI Polaris) for registration with pre-defined CT coordinates. For every specimen we choose 3, 5, 7 and 9 registration and 10 evaluation points, respectively, performing 10 registrations. The data were evaluated both with the Arun and the Horn approaches. The vectorial difference between actual and predefined position in the CT data set was stored and evaluated for FRE and TRE. Evaluation and visualization was implemented in Matlab. The data were analyzed, specifically for normal distribution, with MS Excel and SPSS Version 15.0. For the plastic skull and the anatomic specimen submillimetric application accuracy was found experimentally and confirmed by the calculated TRE. Since for the volunteer no Titanium screws were implanted anatomic landmarks had to be used for registration and evaluation; an application accuracy in the low millimeter regime was found in all approaches. However, the detailed statistical analysis of the data revealed that the model predictions and the actual measurements do not exhibit a strong statistical correlation (p < 0.05). These data suggest that the TRE predictions are too optimistic and should be used with caution intraoperatively.

[Automatic registration of patients with A-mode ultrasound for computer-assisted surgery. Laboratory proof of concept].

BACKGROUND The main source of error in 3D navigation is the patient-to-image registration process. Anatomical landmarks or adhesive markers perform sub-optimally. Bone-anchored invasive markers significantly change the clinical workflow of navigated ENT surgery, are invasive and cause patient discomfort. In order to minimize registration errors and to further streamline the clinical use of intraoperative 3D navigation we demonstrate that A-mode ultrasound allows an accurate 3D surface profile of the os occipitale to be created which can be reliably registered on preoperative patient CT data. METHODS The transducer is mechanically positioned with sub-millimeter accuracy on the patients occiput. From the sound echos a 3D surface is generated and registered to the preoperative CT images with the iterative closest point (ICP) algorithm. The evaluation of our setup was performed on three anatomic specimens and one bony skull. RESULTS The ultrasound echoes from the occiput allowed the creation of an adequate 3D surface which could be registered to a segmentation of the CT image with an accuracy greater than 1.5 mm. The experiments were evaluated by an intuitive representation of the spatial deviation between CT and ultrasound data as a color-coded map. CONCLUSION The approach to scan the posterior skull with A-mode ultrasound enables automatic intraoperative registration and can be integrated into the intraoperative setup.

A New Nasopharyngeal Dynamic Reference Frame Improves Accuracy in Navigated Skull Base Targets

Objective. We questioned whether the position of the dynamic reference frame (DRF) influences the application accuracy in electromagnetically navigated cranial procedures. A carrier for an electromagnetic DRF was developed, which could be fixed at the posterior edge of the vomer near the center of the head. This nasopharyngeal DRF was compared with a standard DRF fixed to the surface of the forehead. Methods. Image coordinates and real-world coordinates were co-registered and the total target error (TTE) was measured in the frontal and the lateral skull base of formalin fixed human head. At each anatomical site, 10 targets served for TTE determinations and 5 different fiducial combinations were used for registration. Results. With the nasopharyngeal DRF, lower TTE values (2.8 ± 1.4 mm; mean ± SD) were observed when compared with the forehead DRF (3.7 ± 2.8 mm; P = .004). TTEs of both anatomical sites investigated were significantly lower when using the nasopharyngeal DRF (frontal skull base 3.4 vs 2.1 mm, P = .005 and lateral skull base 3.9 vs 3.5 mm, P = .013) than with the standard forehead mounted one. Conclusion. Positioning the DRF in the center of the head significantly improved the application accuracy of targets in the skull base with electromagnetic navigation by 25%.

Automatische Registration des Patienten mit A-Mode-Ultraschall für computerunterstützte Chirurgie

BACKGROUND The main source of error in 3D navigation is the patient-to-image registration process. Anatomical landmarks or adhesive markers perform sub-optimally. Bone-anchored invasive markers significantly change the clinical workflow of navigated ENT surgery, are invasive and cause patient discomfort. In order to minimize registration errors and to further streamline the clinical use of intraoperative 3D navigation we demonstrate that A-mode ultrasound allows an accurate 3D surface profile of the os occipitale to be created which can be reliably registered on preoperative patient CT data. METHODS The transducer is mechanically positioned with sub-millimeter accuracy on the patients occiput. From the sound echos a 3D surface is generated and registered to the preoperative CT images with the iterative closest point (ICP) algorithm. The evaluation of our setup was performed on three anatomic specimens and one bony skull. RESULTS The ultrasound echoes from the occiput allowed the creation of an adequate 3D surface which could be registered to a segmentation of the CT image with an accuracy greater than 1.5 mm. The experiments were evaluated by an intuitive representation of the spatial deviation between CT and ultrasound data as a color-coded map. CONCLUSION The approach to scan the posterior skull with A-mode ultrasound enables automatic intraoperative registration and can be integrated into the intraoperative setup.