- Email: [email protected]
Endovascular treatment of AVM
532
"As you like it"
was used as an inclusioncriterionfor either treatment. 78 patientswere treated with GDC: 22 have been operated upon. We observed an overall mortality of 6 patients(6%); a permanent morbiditywas presentin 8 patients(8%). In details, among the 78 GDC patients, 1 died due to rebleeding after an incomplete occlusion (around 50%); 3 died due to late ischemic deficits (grade IV-V). Four more patients with immediate and persistent ischemicdeficits after GDC procedure. In the group of 22 surgical patients, 2 died owing to late ischemic deficits (grade IV-V) and 4 presented with persistent neurological deficits to be ascribedto vasospasm. The incidenceof spasm was statisticallydifferentin the two groups, with a significantreduction in GDC patients(17.9%versus32%, x2 , P =0.05). The very low mortality and morbidity of these 100 patients suggest that the endovasculartreatmentwith GDC has indeedimproved the outcomeof patientspresenting with ruptured intracranial aneurysm.
I0-10-140 I Endovascular treatmentof AVM FA Serbinenko, A.G. Lysatchev. Burdenko Neurosurgical Institute, Moscow, Russia
AVM presents the most difficult problem for endovascular surgery. We treated 318ptswith inoperableAVMtaking intoconsideration theirsize,and localization. (I11-V Grades by Spetzlera. Martin, 1986). Two techniques were used: balloon occlusionof AVMafferentvessels-208 pts and superselective embolization with glue composition -110 pts in the period 1980-1990. Balloon occlusion of AVM afferent vessels decreases shuntingof the blood flow,but it's very difficultto occludethe AVMtotally. Superselective embolization ensurestotal separationof the AVMfrom the circulation. TotalAVMthrombosis was achieved in 12.7% (14/110) pts. It is possible in cases of terminal-formed AVMwhen some afferent vessel is terminated by AVM-net. Localization of such AVMswas motor area, corpus callosum, ganglia, speech area. Subtotal AVM occlusion was achieved in 35.4% (39/110) pts. The volumedecreased by 80% and reached 5 ccm (up to 2 cm in diameter).Such AVMsweretreatedby proton beam. Surgical mortality was 2.2% (7/318) pts, and morbidity-6.6% (21/318) pts. According to superselective embolization, these figures were 3.6% (4/110) pts and 9.1% (10/110) pts. It is very importantto evaluatethe results of endovascular treatmentof AVM in a follow-upstudy comparing them with a group of non-operated (180 pts) and after operation (217 pts). Period of follow-up study was 6-10 years. In the first group without operation, hemorrhages occurred approximately in each third pt with hemorrhage in history-36.1 % (48/133), mortality-21 % (28/133) pts, Balloon occlusion of afferent vessels and superselective embolization decreased the risk of recurrenthemorrhage to 24.4% (2t/86), mortality-10.4% (11/86) pts, and to 5.9% (4/67), mortality-2.2% (2167) pts. respectively. A positive effect of afferent vessels balloonocclusionon epilepticsyndrome was noted in 55.1 % (27/49) and in 68.6% (24/35) of pts after embolization. The developmentof more effective and safe methods of treatment of this cerebral abnormality is important but is associated with many problems.
I0-10-141 I Contourguided frameless stereotactic resection of intracranial lesions
K. Unqersbock, K. Rossler, M. Aichholzer, K. Hittrnalr'. T. Czech,W.T. Koos. Department of Neurosurgery, University of Vienna Medical School, Vienna, Austria, 1 Department of Neuroradiology, University of Vienna Medical School, Vienna, Austria
Purpose: Image guided surgery provides intraoperative navigation to points, lines or volumes of interest. The purpose of the study was to evaluate the availabilityof a frameless stereotacticmicroscopefor contourguided resection of intracranial lesions. Methods: BetweenMarch1995and October1996,51frameless stereotactic procedures of intracranial lesions were performed using the Zeiss stereotactic microscope MKM. These included 15 high grade gliomas, 8 low grade gliomas, 7 metastases, 12cavernomas, 3 meningeomas, 1 lymphoma, 1sarcoidosis and 4 functional interventions. The planning of the operativeprocedures was based on CT (43 cases) or MR-imaging (8 cases) using skin markers. In axial images the tumour contour was defined on the computerworkstation and transferred to a display in the microscopeocular. Results: Based on image guided mapping of lesion boundaries the MKMsystem provides a projectionof the defined contourto the operative field before starting the surgical procedure. This allows for optimal planning of the bone flap and approach. Intraoperatively it proved helpful in calculating a three dimensional transformation of tumour volumes especially in low grade gliomas. Additionally this technique demonstrates the tumour relationship to eloquent brain regions. However, in metastatictumoursand malignant gliomasthe intraoperativeshift due to evacuation of cystic or necroticareascan be important. Conclusion: The exact lesion localisation with image guide surgery optimizes craniotomy and approach. A significant benefit is the transfer of image defined lesion contours onto the surgeons microscopical view, this technique
Monday, 7 July 1997 allowsfor volumetricstereotactic resection as proposed by Kelly et ai, but in an interactive and frameless way.
[lJ Kelly PJ: Stereotactic imaging, surgical planning and computer assisted volumetric resection of intracranial lesions: methodsand results. Advances and Technical Standards in Neurosurgery 17: 77-118, 1990
1
0-10-1421 Neuronavigation in surgery for intracranial tumors
M. Hardenack, K, Schmieder, M. Scholz, U. Wildforster, A. Hentsch 1 , A.G, Harders. Department of Neurosurgery, Ruhr-University, Bochum, Germany, 1 Institute tor Radiology and Nuclear Medicine, Ruhr-University, Bochum, Germany
Introduction: Neuronavigation as an image-guided interactive surgical tool is increasingly usedin neurosurgical procedures. Experiencewiththese systemsis stilllimited.We reporton the use of a navigational deviceused in our department and describeindications, advantages, and possible pitfalls. Methods: In an on-going trial study we employed the EasyGuide system, a computerized image-guided navigational device in patients with intracranial tumors. The system consists of a freely movable pointer emitting LED signals to a block with three sensors, which is securedto the operating table. This data is transferred to a computerworkstation, where the current surgical position is displayed. In four cases preoperative data was acquired using CT scans of 1 mm slice thickness, in 18 patients we used MR images of 1.3 to 1.5 mm slice thickness. Results: So far we haveemployed the systemin 22 patientswith intracranial tumors(9 men, 13 women, between 14 and 74 years of age). There were three meningiomas, one chordoma, five metastaticlesions and 13 astrocytic tumors. In two cases the tumor was located infratentorially. The accuracy of the system was arithmetically determined to be between 1 and 4 mm; however, during surgical procedures this theoretical error could not be noticed. Two instances with dysfunction of the camera system occurred, in which the neuronavigational information becameuseless, but this had no influenceon the surgicalprocedures. Conclusions: The navigational device used in our department allows for exact planning and guidance in surgical procedures for intracranial tumors. It aids in determining the craniotomy site and provides reliable information on the shortest and safest approach to the lesion. Indications for its use include deep-seated tumors, lesions in or around eloquent areas or where localization of vital structures is required.
1
0-10-1431 An internet-connected, patient-specific, deformable brain atlas integrated into a surgical navigation system
Richard D. Bucholz1 , Armond L. Levy 1 , Gary E. Christensen 2, Kevin J. Frank3, Abed Hammoud", Jaimie M. Henderson 1, Sarang Joshi 4, Leslie L. McDurmont 1, Kevin E. Mark3, Michael I. Miller4, TimothyJ. Schaewe, Kurt R. Smith3, Christopher D. Sturm'. 'St. Louis University Medical Center, Div. Neurosurgery, St. Louis, MO, USA, 2 Washington University School of Medicine, Dept. Radiology, St. Louis, MO, USA, 3 Surgical Navigation Techn%gies, Boulder, CO, USA, 4 Washington University, Dept. Electrical Engineering, St. Louis, MO. USA
Introduction: Surgeonscurrently do not have ready access to crucial medical information when they need it most - during a surgical procedure. Atlases have been used intraoperatively to gUide procedures; however such sources are based upon individual specimens, and thus do not reflect the anatomic variabilitybetween patients. We presenta deformableatlas whereinsegmented cranialimagesare "deformed" to matchcorresponding patient images,and then linkedto the World Wide Web (WWW). Methods: Brainstructureswere segmented within a three-dimensional photographictemplate dataset, which was registered to corresponding MR images (The Visible Human Proieot", National Library of Medicine, Bethesda, MD), A hierarchical algorithm, unifying landmark and volume-based transformations, was then utilized to deform the template MRI and photographic data to match patient scans for use by our frameless surgical navigational system. The navigational system has an integrated WWW browserso that the patient'sanatomy can be used as a 3-dimensional lookup table to Web sites containing pertinent neuroanatomicallneurosurgical information. Results: To verify the accuracy of this technique, and as an example of its clinical utility, the process was applied to target-selection for stereotactic RF-ablation pallidotomies for Parkinson's disease. An ideal target consistingof the postero-ventral globus palliduswas selected on the photographictemplate, and deformed as aboveto match patients'preoperative MRI scans. The spatial difference betweenthe predicted target and the true pallidotomy site, which is visible on a postoperative MRI scan, was measured. As such, the availabilityof highly-detailed anatomical data for surgicalplanningand navigationmayobviate the need for expensive and time-consuming intraoperative location procedures such as X-ray ventriculography.
"As you like it"
was used as an inclusioncriterionfor either treatment. 78 patientswere treated with GDC: 22 have been operated upon. We observed an overall mortality of 6 patients(6%); a permanent morbiditywas presentin 8 patients(8%). In details, among the 78 GDC patients, 1 died due to rebleeding after an incomplete occlusion (around 50%); 3 died due to late ischemic deficits (grade IV-V). Four more patients with immediate and persistent ischemicdeficits after GDC procedure. In the group of 22 surgical patients, 2 died owing to late ischemic deficits (grade IV-V) and 4 presented with persistent neurological deficits to be ascribedto vasospasm. The incidenceof spasm was statisticallydifferentin the two groups, with a significantreduction in GDC patients(17.9%versus32%, x2 , P =0.05). The very low mortality and morbidity of these 100 patients suggest that the endovasculartreatmentwith GDC has indeedimproved the outcomeof patientspresenting with ruptured intracranial aneurysm.
I0-10-140 I Endovascular treatmentof AVM FA Serbinenko, A.G. Lysatchev. Burdenko Neurosurgical Institute, Moscow, Russia
AVM presents the most difficult problem for endovascular surgery. We treated 318ptswith inoperableAVMtaking intoconsideration theirsize,and localization. (I11-V Grades by Spetzlera. Martin, 1986). Two techniques were used: balloon occlusionof AVMafferentvessels-208 pts and superselective embolization with glue composition -110 pts in the period 1980-1990. Balloon occlusion of AVM afferent vessels decreases shuntingof the blood flow,but it's very difficultto occludethe AVMtotally. Superselective embolization ensurestotal separationof the AVMfrom the circulation. TotalAVMthrombosis was achieved in 12.7% (14/110) pts. It is possible in cases of terminal-formed AVMwhen some afferent vessel is terminated by AVM-net. Localization of such AVMswas motor area, corpus callosum, ganglia, speech area. Subtotal AVM occlusion was achieved in 35.4% (39/110) pts. The volumedecreased by 80% and reached 5 ccm (up to 2 cm in diameter).Such AVMsweretreatedby proton beam. Surgical mortality was 2.2% (7/318) pts, and morbidity-6.6% (21/318) pts. According to superselective embolization, these figures were 3.6% (4/110) pts and 9.1% (10/110) pts. It is very importantto evaluatethe results of endovascular treatmentof AVM in a follow-upstudy comparing them with a group of non-operated (180 pts) and after operation (217 pts). Period of follow-up study was 6-10 years. In the first group without operation, hemorrhages occurred approximately in each third pt with hemorrhage in history-36.1 % (48/133), mortality-21 % (28/133) pts, Balloon occlusion of afferent vessels and superselective embolization decreased the risk of recurrenthemorrhage to 24.4% (2t/86), mortality-10.4% (11/86) pts, and to 5.9% (4/67), mortality-2.2% (2167) pts. respectively. A positive effect of afferent vessels balloonocclusionon epilepticsyndrome was noted in 55.1 % (27/49) and in 68.6% (24/35) of pts after embolization. The developmentof more effective and safe methods of treatment of this cerebral abnormality is important but is associated with many problems.
I0-10-141 I Contourguided frameless stereotactic resection of intracranial lesions
K. Unqersbock, K. Rossler, M. Aichholzer, K. Hittrnalr'. T. Czech,W.T. Koos. Department of Neurosurgery, University of Vienna Medical School, Vienna, Austria, 1 Department of Neuroradiology, University of Vienna Medical School, Vienna, Austria
Purpose: Image guided surgery provides intraoperative navigation to points, lines or volumes of interest. The purpose of the study was to evaluate the availabilityof a frameless stereotacticmicroscopefor contourguided resection of intracranial lesions. Methods: BetweenMarch1995and October1996,51frameless stereotactic procedures of intracranial lesions were performed using the Zeiss stereotactic microscope MKM. These included 15 high grade gliomas, 8 low grade gliomas, 7 metastases, 12cavernomas, 3 meningeomas, 1 lymphoma, 1sarcoidosis and 4 functional interventions. The planning of the operativeprocedures was based on CT (43 cases) or MR-imaging (8 cases) using skin markers. In axial images the tumour contour was defined on the computerworkstation and transferred to a display in the microscopeocular. Results: Based on image guided mapping of lesion boundaries the MKMsystem provides a projectionof the defined contourto the operative field before starting the surgical procedure. This allows for optimal planning of the bone flap and approach. Intraoperatively it proved helpful in calculating a three dimensional transformation of tumour volumes especially in low grade gliomas. Additionally this technique demonstrates the tumour relationship to eloquent brain regions. However, in metastatictumoursand malignant gliomasthe intraoperativeshift due to evacuation of cystic or necroticareascan be important. Conclusion: The exact lesion localisation with image guide surgery optimizes craniotomy and approach. A significant benefit is the transfer of image defined lesion contours onto the surgeons microscopical view, this technique
Monday, 7 July 1997 allowsfor volumetricstereotactic resection as proposed by Kelly et ai, but in an interactive and frameless way.
[lJ Kelly PJ: Stereotactic imaging, surgical planning and computer assisted volumetric resection of intracranial lesions: methodsand results. Advances and Technical Standards in Neurosurgery 17: 77-118, 1990
1
0-10-1421 Neuronavigation in surgery for intracranial tumors
M. Hardenack, K, Schmieder, M. Scholz, U. Wildforster, A. Hentsch 1 , A.G, Harders. Department of Neurosurgery, Ruhr-University, Bochum, Germany, 1 Institute tor Radiology and Nuclear Medicine, Ruhr-University, Bochum, Germany
Introduction: Neuronavigation as an image-guided interactive surgical tool is increasingly usedin neurosurgical procedures. Experiencewiththese systemsis stilllimited.We reporton the use of a navigational deviceused in our department and describeindications, advantages, and possible pitfalls. Methods: In an on-going trial study we employed the EasyGuide system, a computerized image-guided navigational device in patients with intracranial tumors. The system consists of a freely movable pointer emitting LED signals to a block with three sensors, which is securedto the operating table. This data is transferred to a computerworkstation, where the current surgical position is displayed. In four cases preoperative data was acquired using CT scans of 1 mm slice thickness, in 18 patients we used MR images of 1.3 to 1.5 mm slice thickness. Results: So far we haveemployed the systemin 22 patientswith intracranial tumors(9 men, 13 women, between 14 and 74 years of age). There were three meningiomas, one chordoma, five metastaticlesions and 13 astrocytic tumors. In two cases the tumor was located infratentorially. The accuracy of the system was arithmetically determined to be between 1 and 4 mm; however, during surgical procedures this theoretical error could not be noticed. Two instances with dysfunction of the camera system occurred, in which the neuronavigational information becameuseless, but this had no influenceon the surgicalprocedures. Conclusions: The navigational device used in our department allows for exact planning and guidance in surgical procedures for intracranial tumors. It aids in determining the craniotomy site and provides reliable information on the shortest and safest approach to the lesion. Indications for its use include deep-seated tumors, lesions in or around eloquent areas or where localization of vital structures is required.
1
0-10-1431 An internet-connected, patient-specific, deformable brain atlas integrated into a surgical navigation system
Richard D. Bucholz1 , Armond L. Levy 1 , Gary E. Christensen 2, Kevin J. Frank3, Abed Hammoud", Jaimie M. Henderson 1, Sarang Joshi 4, Leslie L. McDurmont 1, Kevin E. Mark3, Michael I. Miller4, TimothyJ. Schaewe, Kurt R. Smith3, Christopher D. Sturm'. 'St. Louis University Medical Center, Div. Neurosurgery, St. Louis, MO, USA, 2 Washington University School of Medicine, Dept. Radiology, St. Louis, MO, USA, 3 Surgical Navigation Techn%gies, Boulder, CO, USA, 4 Washington University, Dept. Electrical Engineering, St. Louis, MO. USA
Introduction: Surgeonscurrently do not have ready access to crucial medical information when they need it most - during a surgical procedure. Atlases have been used intraoperatively to gUide procedures; however such sources are based upon individual specimens, and thus do not reflect the anatomic variabilitybetween patients. We presenta deformableatlas whereinsegmented cranialimagesare "deformed" to matchcorresponding patient images,and then linkedto the World Wide Web (WWW). Methods: Brainstructureswere segmented within a three-dimensional photographictemplate dataset, which was registered to corresponding MR images (The Visible Human Proieot", National Library of Medicine, Bethesda, MD), A hierarchical algorithm, unifying landmark and volume-based transformations, was then utilized to deform the template MRI and photographic data to match patient scans for use by our frameless surgical navigational system. The navigational system has an integrated WWW browserso that the patient'sanatomy can be used as a 3-dimensional lookup table to Web sites containing pertinent neuroanatomicallneurosurgical information. Results: To verify the accuracy of this technique, and as an example of its clinical utility, the process was applied to target-selection for stereotactic RF-ablation pallidotomies for Parkinson's disease. An ideal target consistingof the postero-ventral globus palliduswas selected on the photographictemplate, and deformed as aboveto match patients'preoperative MRI scans. The spatial difference betweenthe predicted target and the true pallidotomy site, which is visible on a postoperative MRI scan, was measured. As such, the availabilityof highly-detailed anatomical data for surgicalplanningand navigationmayobviate the need for expensive and time-consuming intraoperative location procedures such as X-ray ventriculography.