Peter W. A. Willems

Brain shift estimation in image-guided neurosurgery using 3-D ultrasound

Intraoperative brain deformation is one of the most important causes affecting the overall accuracy of image-guided neurosurgical procedures. One option for correcting for this deformation is to acquire three-dimensional (3-D) ultrasound data during the operation and use this data to update the information provided by the preoperatively acquired MR data. For 12 patients 3-D ultrasound images have been reconstructed from freehand sweeps acquired during neurosurgical procedures. Ultrasound data acquired prior to and after opening the dura, but prior to surgery, have been quantitatively compared to the preoperatively acquired MR data to estimate the rigid component of brain shift at the first stages of surgery. Prior to opening the dura the average brain shift measured was 3.0 mm parallel to the direction of gravity, with a maximum of 7.5 mm, and 3.9 mm perpendicular to the direction of gravity, with a maximum of 8.2 mm. After opening the dura the shift increased on average 0.2 mm parallel to the direction of gravity and 1.4 mm perpendicular to the direction of gravity. Brain shift can be detected by acquiring 3-D ultrasound data during image-guided neurosurgery. Therefore, it can be used as a basis for correcting image data and preoperative planning for intraoperative deformations.

Neuronavigation and surgery of intracerebral tumours

Approximately four decades after the successful clinical introduction of framebased stereotactic neurosurgery by Spiegel and Wycis, frameless stereotaxy emerged to enable more elaborate image guidance in open neurosurgical procedures. Frameless stereotaxy, or neuronavigation, relies on one of several different localizing techniques to determine the position of an operative instrument relative to the surgical field, without the need for a coordinate frame rigidly fixed to the patients’ skull. Currently, most systems are based on the optical triangulation of infrared light sources fixed to the surgical instrument.In its essence, a navigation system is a three-dimensional digitiser that correlates its measurements to a reference data set, i.e. a preoperatively acquired CT or MRI image stack. This correlation is achieved through a patient-to-image registration procedure resulting in a mathematical transformation matrix mapping each position in ‘world space’ onto ‘image space’. Thus, throughout the remainder of the surgical procedure, the position of the surgical instrument can be demonstrated on a computer screen, relative to the CT or MRI images.Though neuronavigation has become a routinely used addition to the neurosurgical armamentarium, its impact on surgical results has not yet been examined sufficiently. Therefore, the surgeon is left to decide on a case-by-case basis whether to perform surgery with or without neuronavigation. Future challenges lie in improvement of the interface between the surgeon and the neuronavigator and in reducing the brainshift error, i.e. inaccuracy introduced by changes in tissue positions after image acquisition.

Non-rigid Registration of 3D Ultrasound Images of Brain Tumours Acquired during Neurosurgery

Intraoperative brain deformation is one of the most contributing factors to the inaccuracy of image-guided neurosurgery systems. One option for correcting for this deformation is to acquire 3D ultrasound images during surgery and use these to update the information provided by the preoperatively acquired MR. To compare ultrasound volumes at different stages of surgery, non-rigid registration techniques are necessary. We present the results of applying a non-rigid registration algorithm, based on free-form deformations using B-splines and using normalized mutual information as a similarity measure, to 3D ultrasound volumes of two patients with brain tumours. For these two patients we registered an ultrasound volume acquired prior to opening the dura with an ultrasound volume acquired after opening the dura, but prior to surgery. When comparing the segmented tumours after affine registration plus free-form registration with a control point spacing of 4 mm to the segmented tumour volumes after registration with the image-guided surgery system, the volume overlap increased from approximately 76% to 96% for both patients.

Auditory feedback during frameless image-guided surgery in a phantom model and initial clinical experience

In this study the authors measured the effect of auditory feedback during image-guided surgery (IGS) in a phantom model and in a clinical setting. In the phantom setup, advanced IGS with complementary auditory feedback was compared with results obtained with 2 routine forms of IGS, either with an on-screen image display or with image injection via a microscope. The effect was measured by means of volumetric resection assessments. The authors also present their first clinical data concerning the effects of complementary auditory feedback on instrument handling during image-guided neurosurgery. When using image-injection through the microscope for navigation, however, resection quality was significantly worse. In the clinical portion of the study, the authors performed resections of cerebral mass lesions in 6 patients with the aid of auditory feedback. Instrument tip speeds were slightly (although significantly) influenced by this feedback during resection. Overall, the participating neurosurgeons reported that the auditory feedback helped in decision-making during resection without negatively influencing instrument use. Postoperative volumetric imaging studies revealed resection rates of > or = 95% when IGS with auditory feedback was used. There was only a minor amount of brain shift, and postoperative resection volumes corresponded well with the preoperative intentions of the neurosurgeon. Although the results of phantom surgery with auditory feedback revealed no significant effect on resection quality or extent, auditory cues may help prevent damage to eloquent brain structures.

The impact of auditory feedback on neuronavigation

Summary.Object. We aimed to develop an auditory feedback system to be used in addition to regular neuronavigation, in an attempt to improve the usefulness of the information offered by neuronavigation systems.Instrumentation. Using a serial connection, instrument co-ordinates determined by a commercially available neuronavigation system were transferred to a laptop computer. Based on preoperative segmentation of the images, the software on the laptop computer produced an audible signal whenever the instrument moved into an area the surgeon wanted to avoid.Methods. To evaluate the impact of our setup on volumetric resections, phantom experiments were conducted. CT scans were acquired from eight blocks of floral foam. In each of these scans, a target-volume was segmented. This target-volume was subsequently resected using either regular neuronavigation or neuronavigation extended with auditory feedback. A ‘postoperative’ CT scan was used to compare the resection cavity to the preoperatively planned target-volume.Findings. The resemblance between the resection cavity and the target-volume was greater each time auditory feedback had been used. This corresponded with more complete removal of the target-volume. However, it also corresponded with the removal of more non-target ‘tissue’ in two out of four cases.Conclusions. The usefulness of auditory feedback was made plausible and the use of a new type of navigation phantom was illustrated. Based on these results, we recommend incorporation of auditory feedback in commercially available neuronavigation systems, especially since this is relatively inexpensive.

Volume rendering for neurosurgical planning

A volume rendering library is presented to interactively analyze volume data from modalities like CT, MR, PET, SPECT< and fMRI for the planning of nuerosurgical procedures. Current applications are logging of Penfield procedures, fMRI visualization, blood vessel visualization and interactive localization of EEG electrodes implanted in the subdural space of a patient with epilepsy.

Sound and volumetric workflow feedback during image guided neurosurgery

To improve the efficacy of tumor resection in image guided neurosurgery, two new types of feedback were investigated. Firstly, sound feedback to give the surgeons a warning signal when the instrument tip approaches normal/non-planned brain tissue. Secondly, workflow feedback by logging and tagging all instrument positions in image space. Results from laboratory and clinic suggest that sound feedback seems to be useful but needs more fine tuning before it will be practical for clinical use. Workflow feedback, on the other hand, appears to be a simple, cheap and efficient method to give the surgeon insight in the progress of resection, to log locations of interest, and to give insight in brain deformations occurring during surgery.

Investigation of MR scanning, image registration, and image processing techniques to visualize cortical veins for neurosurgery

The visualization of brain vessels on the cortex helps the neurosurgeon in two ways: To avoid blood vessels when specifying the trepanation entry, and to overcome errors in the surgical navigation system due to brain shift. We compared 3D T1 MR, 3D T1 MR with gadolinium contrast, MR venography and MR phase contrast angiography as scanning techniques, mutual information as registration technique, and thresholding and multi-vessel enhancement as image processing techniques. We evaluated the volume rendered results based on their quality and correspondence with photos took during surgery. It appears that with 3D T1 MR scans, gadolinium is required to show cortical veins. The visibility of small cortical veins is strongly enhanced by subtracting a 3D T1 MR baseline scan, which should be registered to the scan with gadolinium contrast, even when the scans are made during the same session. Multi-vessel enhancement helps to clarify the view on small vessels by reducing the noise level, but strikingly does not reveal more. MR venography does show intracerebral veins with high detail, but is, as is, unsuited to show cortical veins due to the low contrast with CSF. MR phase contrast angiography can perform equally well as the subtraction technique, but its quality seems to show more inter-patient variability.

Evaluation of MR scanning, image registration, and image processing methods to visualize cortical veins for neurosurgery

The visualization of brain vessels on the cortex helps the neurosurgeon in two ways: to avoid blood vessels when specifying the trepanation entry, and to overcome errors in the surgical navigation system due to brain shift. We compared 3D T1, MR, 3D T1 MR with gadolinium contrast, MR venography as scanning techniques, mutual information as registration technique, and thresholding and multi-vessel enhancement as image processing techniques. We evaluated the volume rendered results based on their quality and correspondence with photos took during surgery. It appears that with 3D T1 MR scans, gadolinium is required to show cortical veins. The visibility of small cortical veins is strongly enhanced by subtracting a 3D T1 MR baseline scan, which should be registered to the scan with gadolinium contrast, even when the scans are made during the same session. Multi-vessel enhancement helps to clarify the view on small vessels by reducing noise level, but strikingly does not reveal more. MR venography does show intracerebral veins with high detail, but is, as is, unsuited to show cortical veins due to the low contrast with CSF.