Terry M. Peters

Transcranial Magnetic Stimulation during Positron Emission Tomography: A New Method for Studying Connectivity of the Human Cerebral Cortex

We describe a new technique permitting the mapping of neural connections in the living human brain. The method combines two well established tools of brain research: transcranial magnetic stimulation (TMS) and positron emission tomography (PET). We use TMS to stimulate directly a selected cortical area while simultaneously measuring changes in brain activity, indexed by cerebral blood flow (CBF), with PET. The exact location of the stimulation site is achieved by means of frameless stereotaxy. In the first study using this technique, we found significant positive correlations between CBF and the number of TMS pulse trains at the stimulation site, namely the left frontal eye field (FEF) and, most importantly, in the visual cortex of the superior parietal and medial parieto-occipital regions. The pattern of these distal effects was consistent with the known anatomic connectivity of the monkey FEF. We suggest that the combined TMS/PET technique offers an objective tool for assessing the state of functional connectivity without requiring the subject to engage in any specific behavior.

Rapid combined T1 and T2 mapping using gradient recalled acquisition in the steady state.

A novel, fully 3D, high‐resolution T1 and T2 relaxation time mapping method is presented. The method is based on steady‐state imaging with T1 and T2 information derived from either spoiling or fully refocusing the transverse magnetization following each excitation pulse. T1 is extracted from a pair of spoiled gradient recalled echo (SPGR) images acquired at optimized flip angles. This T1 information is combined with two refocused steady‐state free precession (SSFP) images to determine T2. T1 and T2 accuracy was evaluated against inversion recovery (IR) and spin‐echo (SE) results, respectively. Error within the T1 and T2 maps, determined from both phantom and in vivo measurements, is approximately 7% for T1 between 300 and 2000 ms and 7% for T2 between 30 and 150 ms. The efficiency of the method, defined as the signal‐to‐noise ratio (SNR) of the final map per voxel volume per square root scan time, was evaluated against alternative mapping methods. With an efficiency of three times that of multipoint IR and three times that of multiecho SE, our combined approach represents the most efficient of those examined. Acquisition time for a whole brain T1 map (25 × 25 × 10 cm) is less than 8 min with 1 mm3 isotropic voxels. An additional 7 min is required for an identically sized T2 map and postprocessing time is less than 1 min on a 1 GHz PIII PC. The method therefore permits real‐time clinical acquisition and display of whole brain T1 and T2 maps for the first time. Magn Reson Med 49:515–526, 2003.

Medical Image Computing and Computer-Assisted Intervention - MICCAI 2003

Although there have been significant advances in the development of virtual reality based surgical simulations, there still remain fundamental questions concerning the fidelity required for effective surgical training. A dual station experimental platform was built for the purpose of investigating these fidelity requirements. Analogous laparoscopic surgical tasks were implemented in a virtual and a real station, with the virtual station modeling the real environment to various degrees of fidelity. After measuring subjects’ initial performance in the real station, different groups of subjects were trained on the virtual station under a variety of conditions and tested finally at the real station. Experiments involved bimanual pushing and cutting tasks on a nonlinear elastic object. The results showed that force feedback results in a significantly improved training transfer compared to training without force feedback. The training effectiveness of a linear approximation model was comparable to the effectiveness of a more accurate nonlinear model.

Poly(vinyl alcohol) cryogel phantoms for use in ultrasound and MR imaging.

Poly(vinyl alcohol) cryogel, PVA-C, is presented as a tissue-mimicking material, suitable for application in magnetic resonance (MR) imaging and ultrasound imaging. A 10% by weight poly(vinyl alcohol) in water solution was used to form PVA-C, which is solidified through a freeze-thaw process. The number of freeze-thaw cycles affects the properties of the material. The ultrasound and MR imaging characteristics were investigated using cylindrical samples of PVA-C. The speed of sound was found to range from 1520 to 1540 m s(-1), and the attenuation coefficients were in the range of 0.075-0.28 dB (cm MHz)(-1). T1 and T2 relaxation values were found to be 718-1034 ms and 108-175 ms, respectively. We also present applications of this material in an anthropomorphic brain phantom, a multi-volume stenosed vessel phantom and breast biopsy phantoms. Some suggestions are made for how best to handle this material in the phantom design and development process.

High-resolution T1 and T2 mapping of the brain in a clinically acceptable time with DESPOT1 and DESPOT2.

Variations in the intrinsic T1 and T2 relaxation times have been implicated in numerous neurologic conditions. Unfortunately, the low resolution and long imaging time associated with conventional methods have prevented T1 and T2 mapping from becoming part of routine clinical evaluation. In this study, the clinical applicability of the DESPOT1 and DESPOT2 imaging methods for high‐resolution, whole‐brain, T1 and T2 mapping was investigated. In vivo, 1‐mm3 isotropic whole‐brain T1 and T2 maps of six healthy volunteers were acquired at 1.5 T with an imaging time of <17 min each. Isotropic maps (0.34 mm3) of one volunteer were also acquired (time <21 min). Average signal‐to‐noise within the 1‐mm3 T1 and T2 maps was ∼20 and ∼14, respectively, with average repeatability standard deviations of 46.7 ms and 6.7 ms. These results demonstrate the clinical feasibility of the methods in the study of neurologic disease. Magn Reson Med 53:237–241, 2005.

Intraoperative ultrasound for guidance and tissue shift correction in image-guided neurosurgery

We present a surgical guidance system that incorporates pre-operative image information (e.g., MRI) with intraoperative ultrasound (US) imaging to detect and correct for brain tissue deformation during image-guided neurosurgery (IGNS). Many interactive IGNS implementations employ pre-operative images as a guide to the surgeons throughout the procedure. However, when a craniotomy is involved, tissue movement during a procedure can be a significant source of error in these systems. By incorporating intraoperative US imaging, the target volume can be scanned at any time, and two-dimensional US images may be compared directly to the corresponding slice from the pre-operative image. Homologous points may be mapped from the intraoperative to the pre-operative image space with an accuracy of better than 2 mm, enabling the surgeon to use this information to assess the accuracy of the guidance system along with the progress of the procedure (e.g., extent of lesion removal) at any time during the operation. Anatomical features may be identified on both the pre-operative and intraoperative images and used to generate a deformation map, which can be used to warp the pre-operative image to match the intraoperative US image. System validation is achieved using a deformable multi-modality imaging phantom, and preliminary clinical results are presented.

Image-Guided Interventions: Technology Review and Clinical Applications

Image-guided interventions are medical procedures that use computer-based systems to provide virtual image overlays to help the physician precisely visualize and target the surgical site. This field has been greatly expanded by the advances in medical imaging and computing power over the past 20 years. This review begins with a historical overview and then describes the component technologies of tracking, registration, visualization, and software. Clinical applications in neurosurgery, orthopedics, and the cardiac and thoracoabdominal areas are discussed, together with a description of an evolving technology named Natural Orifice Transluminal Endoscopic Surgery (NOTES). As the trend toward minimally invasive procedures continues, image-guided interventions will play an important role in enabling new procedures, while improving the accuracy and success of existing approaches. Despite this promise, the role of image-guided systems must be validated by clinical trials facilitated by partnerships between scientists and physicians if this field is to reach its full potential.

Image-guidance for surgical procedures

Contemporary imaging modalities can now provide the surgeon with high quality three- and four-dimensional images depicting not only normal anatomy and pathology, but also vascularity and function. A key component of image-guided surgery (IGS) is the ability to register multi-modal pre-operative images to each other and to the patient. The other important component of IGS is the ability to track instruments in real time during the procedure and to display them as part of a realistic model of the operative volume. Stereoscopic, virtual- and augmented-reality techniques have been implemented to enhance the visualization and guidance process. For the most part, IGS relies on the assumption that the pre-operatively acquired images used to guide the surgery accurately represent the morphology of the tissue during the procedure. This assumption may not necessarily be valid, and so intra-operative real-time imaging using interventional MRI, ultrasound, video and electrophysiological recordings are often employed to ameliorate this situation. Although IGS is now in extensive routine clinical use in neurosurgery and is gaining ground in other surgical disciplines, there remain many drawbacks that must be overcome before it can be employed in more general minimally-invasive procedures. This review overviews the roots of IGS in neurosurgery, provides examples of its use outside the brain, discusses the infrastructure required for successful implementation of IGS approaches and outlines the challenges that must be overcome for IGS to advance further.

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Mri of Amygdala and Hippocampus in Temporal Lobe Epilepsy

In this study we compared the results of qualitative visual analysis of MRI with volumetric studies of the amygdala (AM) and hippocampal formation (HF) in a group of 31 patients. Twenty-six patients with temporal lobe epilepsy (TLE) and six with non-TLE had MRI studies using a 1.5 T Gyroscan following a specific protocol for scan acquisition. The MR images were interpreted by two blinded radiologists and by a third if discrepancy arose. Volumetric studies were carried out by one or two raters. The volumetric measurements of AM and HF were accurate in lateralizing the epileptogenic area in patients with TLE, concordant with the EEG in 92%; there was no false lateralization. In those patients who underwent surgery, there was a correlation between the degree of mesial temporal sclerosis demonstrated by histopathology, the amount of volume reduction, and the asymmetry. In patients with non-TLE, there was no volume asymmetry of AM or HF. The MR qualitative assessment yielded positive lateralization in patients with TLE in 56%, conflicting lateralization in 20%, and lateralization contralateral to the focus in 12%. A hyperintense signal in mesial structures was found ipsilateral to the focus in 40% and contralateral in 12% of patients with TLE. Volumetric study improves the diagnostic yield of MRI evaluation in patients with TLE not related to gross structural lesions. The interrater variability is low and the data are accurate and reproducible. Because they are quantitative, volumetric studies permit better comparison of results in different subgroups of patients with TLE.