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Image guidance in neurosurgery
 

Image guidance in neurosurgery

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    Image guidance in neurosurgery Image guidance in neurosurgery Presentation Transcript

    • Image guidance in Neurosurgery Towards improved quality and consistency in patient care Deepak Agrawal Assist Prof, Department of Neurosurgery All India Institute of Medical Sciences, New Delhi
    • NEURONAVIGATION (IG SURGERY)
      • A step towards consistency in surgical results
      • Improves the quality of neurosurgical output in a centre
      • Increases accuracy of the procedure
    • OBSTACLES
      • High initial purchase cost
      • Learning curve
      • Cost of disposables (fiducials)
    • INITIAL PURCHASE COSTS
      • Initial systems cost upto US$ 500000
      • AIIMS was the first centre in India to have IG system (Stealthstation) in India in 1998
    • MANTAINANCE COSTS
      • Can be nearly 10% of capital cost every yr
      • Nowadays maintenance contracts 5-10 yrs built into the initial purchase cost
    • LEARNING CURVE
      • Initially added 2-3hrs to the operating time
      • Systems are getting more user friendly
      • With experience, only 15-20 minutes are needed to set up the system
    • COST OF DISPOSABLES
      • Propriety item.
      • Set of 10 fiducials costs $100
    • AIMS & OBJECTIVES
      • To assess Vitamin E capsules as fiducials for IG neurosurgery
      • Compare the accuracy of registration of Vitamin E capsules and proprietary fiducials
    • Materials & Methods
      • INTERNAL VALIDATION
      • Overall accuracy of registration (OAR) in mm (automatically calculated by stealthstation)
      • OAR compared for Vitamin E & proprietary fiducials
    • Materials & Methods
      • External Validation
      • Accuracy physically checked by touching known bony points
    •  
    • VITAMIN E CAPSULES
      • Easily available
      • Extremely cheap
      • Easy to apply
          • Dab area with Tinc Benzoin
          • Tape the capsule with leukoplast/ dynapore
      • Easy to register
    •  
    • VITAMIN E CAPSULES
    • MPRAGE
    •  
    • FLAIR T2 FATSAT
    • OBSERVATIONS
      • Vitamin E group -23 pts over 6 months
      • Regular fiducials group- 22 historical controls over 6 months prior to introduction of vitamin E
    • RESULTS (Overall Accuracy of registration {OAR})
      • Vitamin E- 23 pts
      • Mean OAR- 1.84 mm (1.2- 2.8 mm)
      • Regular Fiducials- 22 pts
      • Mean OAR- 2.41 mm (2.1-2.9 mm).
      • In spite of availability of image guidance (neuronavigation) at major centers around the world, most trans-sphenoidal surgeries for pituitary adenomas continue to be done under fluoroscopic control.
    • FLOUROSCOPY (Image intensifier)
      • Limitations
      • Radiation exposure
      • Only 2D images available
      • Inability to confirm midline access to sella
      • Relationship of critical structures like carotid artery is not known
      • Lead aprons- surgeon fatigue
      Image Guidance in Trans-sphenoidal surgery
    • IMAGE GUIDANCE
      • ADVANTAGES
      • Exquisite 3D visualization of midline & carotid arteries
      • Not affected by brain shift
      • Almost real time guidance
      • None of the disadv of fluoroscopy
      • Frees up X-ray machine
      Image Guidance in Trans-sphenoidal surgery
    •  
    • AIMS & OBJECTIVES
      • To study the utility of image guidance in trans-sphenoidal surgeries for pituitary adenomas in a tertiary care teaching hospital
      Image Guidance in Trans-sphenoidal surgery
    • MATERIALS & METHODS
      • Prospective study carried out over a 5 month period
      • All surgeries were done under image-guidance only & no fluoroscopy was employed.
      Image Guidance in Trans-sphenoidal surgery
    • MATERIALS & METHODS
      • Parameters Assessed
      • Time to set up IG in OR
      • Overall accuracy of registration (OAR)
      • Midline access
      • Visualization of carotid arteries
      • intra-operative complications
      Image Guidance in Trans-sphenoidal surgery
    • MATERIALS & METHODS
      • All patients had a contrast CT of the head done within 48 hours of surgery to see for residual tumor.
      Image Guidance in Trans-sphenoidal surgery
    • TECHNIQUE Image Guidance in Trans-sphenoidal surgery
    • TECHNIQUE
    • TECHNIQUE Image Guidance in Trans-sphenoidal surgery
    • TECHNIQUE Image Guidance in Trans-sphenoidal surgery
    • TECHNIQUE Image Guidance in Trans-sphenoidal surgery
    • TECHNIQUE
    • TECHNIQUE Image Guidance in Trans-sphenoidal surgery
    • OBSERVATIONS
      • Seven pts underwent IG pit ad surgery
      • Three patients had giant Pit ad
      • Two had recurrent/residual disease
      Image Guidance in Trans-sphenoidal surgery
    • OBSERVATIONS
      • 3 patients (all giant tumors) non-contrast MR images were used in for image guidance and contrast CT images were used in the rest
      Image Guidance in Trans-sphenoidal surgery
    • RESULTS
      • mean set up time for image-guidance was 12 minutes (range 7-17 minutes)
      • mean ‘overall accuracy of registration’ was 1.6 mm (range 1.4-2.1 mm)
      • mean operating time was 68 minutes (range 47-84 minutes)
      Image Guidance in Trans-sphenoidal surgery
    • RESULTS
      • In all cases the midline and the relation of the carotid artery to the sella could be confirmed using IG
      • IG greatly helped in increasing the bony opening laterally
      Image Guidance in Trans-sphenoidal surgery
    • RESULTS
      • No intra-operative or post-operative complications in any of the patients.
      Image Guidance in Trans-sphenoidal surgery
    • RESULTS
      • Postoperative scans
      • Complete (grade 1) removal -3 pts.
      • Residual tumor -4 pts.
      Image Guidance in Trans-sphenoidal surgery
    •  
    • SPECIAL ADVANTAGES
      • Recurrent/Residual tumors
      • Fibrous Tumors
      • All trans-sphenoidal procedures
      • Residency Programs
    • CONCLUSIONS
      • Image guidance markedly improves the visualization of sellar floor and its relation to the carotid arteries
      • Improves the safety and quality of the surgical procedure
      • Free of limitations of fluoroscopy
      Image Guidance in Trans-sphenoidal surgery
    • CONCLUSIONS
      • Vitamin E capsules serve as excellent fiducials for image guided neurosurgery
      • Save more than 99% costs on the disposables
      • Improve accuracy of the procedure as scalp movement is diminished
    • THANK YOU
      • For want of a nail the shoe was lost, For want of a shoe the horse was lost, For want of a horse the rider was lost, For want of a rider the battle was lost, For want of a battle the Kingdom was lost, And all for the want of a horseshoe nail.