Image guidance in neurosurgery

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Image guidance in neurosurgery

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

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