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Cerebrovascular Neuronavigation: A Process in Evolution
Perspectives Commentary on: Fusion of Intraoperative Three-Dimensional Rotational Angiography and Flat-Panel Detector Computed Tomography for Cerebrovascular Neuronavigation by Leng et al. pp. 504-509.
Felipe C. Albuquerque, M.D. Assistant Director of Endovascular Neurosurgery Division of Neurological Surgery Barrow Neurological Institute St. Joseph’s Hospital and Medical Center
Cerebrovascular Neuronavigation: A Process in Evolution Felipe C. Albuquerque
I
n this issue of WORLD NEUROSURGERY, Leng et al. describe a novel technique in which they fuse intraoperative threedimensional angiography (3DA) with flat-panel computed tomographic images to facilitate surgical navigation during the treatment of two cerebral aneurysms in a single patient. Prior reports have documented the fusion of preoperatively obtained 3DA with neuronavigation systems. While useful, fusion of preoperatively obtained 3DA images has the disadvantage of failing to account for subtle intraoperative changes such as brain shift and adequacy of surgical clip ligation or resection. In the current report, the authors have overcome this disadvantage by performing intraoperative 3DA immediately after aneurysm treatment. Doing so allowed accurate neuronavigation for the subsequent clip ligation of two relatively small aneurysmal neck remnants. By employing the 3DA images, the authors have also overcome the issue of artifact generated by surgical clips and embolic agents such as coils. Despite the accuracy of this technique, it has several potential drawbacks that the authors themselves describe. Paramount in today’s hostile economic environment is the issue of cost effectiveness. One could argue that it is almost impossible to establish the cost effectiveness of this particular technique. Detecting small neck remnants after aneurysm clip ligation or residual arteriovenous malformation after resection potentially reduces the subsequent risk of postoperative subarachnoid or parenchymal hemorrhage. The theoretical cost– benefit of these “life-saving” events cannot be quantified even though they may be substantial. Standard intraoperative angiography and indocyanine green angiography are already well-established modalities that are both
Key words 䡲 Aneurysm 䡲 Angiography 䡲 Arteriovenous fistulas 䡲 Arteriovenous malformations 䡲 Digital subtraction angiography 䡲 Image-guided surgery 䡲 Neuronavigation 䡲 Three-dimensional angiography
Abbreviations and Acronyms 3DA: Three-dimensional angiography
accurate and less costly than the technique described by the authors. Furthermore, numerous reports have documented their utility in detecting residual aneurysms and arteriovenous malformations. Although the technique described by the current authors has the additional advantage of allowing neuronavigation, the benefits compared to these more commonly used modalities would be difficult to establish. Time and space are additional considerations. The authors report that they typically performed intraoperative angiography within 15 minutes. An additional 15 minutes were required to complete the image fusion. This length of time certainly represents a best-case scenario as well as one that potentially exposes the patient to the additional risk of relatively uncontrolled angiography and prolonged anesthesia times. Although repetition of this technique will undoubtedly improve procedural times, it will also increase costs dramatically. Finally, adequate space is necessary to move the essential equipment and to ensure the facile operation of the surgical and anesthesia teams. Such operative environments are not commonplace and tend to be relegated to higher volume surgical centers. Furthermore, the use of these neuronavigational techniques requires the expertise of many technicians, nurses, and physicians, another factor that increases their cost. Despite these drawbacks, advances in neuronavigation and intraoperative imaging are essential to the overall well-being of neurosurgical patients. In particular, cerebrovascular patients are often critically ill and harbor surgically challenging and dangerous lesions. The management of these lesions through accurate and safe neuronavigational techniques will assuredly improve outcomes. The authors have advanced this process and are to be commended.
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA To whom correspondence should be addressed: Felipe C. Albuquerque, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2013) 79, 3/4:430. DOI: 10.1016/j.wneu.2011.10.050 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2013 Elsevier Inc. All rights reserved.
430
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.10.050
Felipe C. Albuquerque, M.D. Assistant Director of Endovascular Neurosurgery Division of Neurological Surgery Barrow Neurological Institute St. Joseph’s Hospital and Medical Center
Cerebrovascular Neuronavigation: A Process in Evolution Felipe C. Albuquerque
I
n this issue of WORLD NEUROSURGERY, Leng et al. describe a novel technique in which they fuse intraoperative threedimensional angiography (3DA) with flat-panel computed tomographic images to facilitate surgical navigation during the treatment of two cerebral aneurysms in a single patient. Prior reports have documented the fusion of preoperatively obtained 3DA with neuronavigation systems. While useful, fusion of preoperatively obtained 3DA images has the disadvantage of failing to account for subtle intraoperative changes such as brain shift and adequacy of surgical clip ligation or resection. In the current report, the authors have overcome this disadvantage by performing intraoperative 3DA immediately after aneurysm treatment. Doing so allowed accurate neuronavigation for the subsequent clip ligation of two relatively small aneurysmal neck remnants. By employing the 3DA images, the authors have also overcome the issue of artifact generated by surgical clips and embolic agents such as coils. Despite the accuracy of this technique, it has several potential drawbacks that the authors themselves describe. Paramount in today’s hostile economic environment is the issue of cost effectiveness. One could argue that it is almost impossible to establish the cost effectiveness of this particular technique. Detecting small neck remnants after aneurysm clip ligation or residual arteriovenous malformation after resection potentially reduces the subsequent risk of postoperative subarachnoid or parenchymal hemorrhage. The theoretical cost– benefit of these “life-saving” events cannot be quantified even though they may be substantial. Standard intraoperative angiography and indocyanine green angiography are already well-established modalities that are both
Key words 䡲 Aneurysm 䡲 Angiography 䡲 Arteriovenous fistulas 䡲 Arteriovenous malformations 䡲 Digital subtraction angiography 䡲 Image-guided surgery 䡲 Neuronavigation 䡲 Three-dimensional angiography
Abbreviations and Acronyms 3DA: Three-dimensional angiography
accurate and less costly than the technique described by the authors. Furthermore, numerous reports have documented their utility in detecting residual aneurysms and arteriovenous malformations. Although the technique described by the current authors has the additional advantage of allowing neuronavigation, the benefits compared to these more commonly used modalities would be difficult to establish. Time and space are additional considerations. The authors report that they typically performed intraoperative angiography within 15 minutes. An additional 15 minutes were required to complete the image fusion. This length of time certainly represents a best-case scenario as well as one that potentially exposes the patient to the additional risk of relatively uncontrolled angiography and prolonged anesthesia times. Although repetition of this technique will undoubtedly improve procedural times, it will also increase costs dramatically. Finally, adequate space is necessary to move the essential equipment and to ensure the facile operation of the surgical and anesthesia teams. Such operative environments are not commonplace and tend to be relegated to higher volume surgical centers. Furthermore, the use of these neuronavigational techniques requires the expertise of many technicians, nurses, and physicians, another factor that increases their cost. Despite these drawbacks, advances in neuronavigation and intraoperative imaging are essential to the overall well-being of neurosurgical patients. In particular, cerebrovascular patients are often critically ill and harbor surgically challenging and dangerous lesions. The management of these lesions through accurate and safe neuronavigational techniques will assuredly improve outcomes. The authors have advanced this process and are to be commended.
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA To whom correspondence should be addressed: Felipe C. Albuquerque, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2013) 79, 3/4:430. DOI: 10.1016/j.wneu.2011.10.050 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2013 Elsevier Inc. All rights reserved.
430
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.10.050