Use of the Brown-Roberts-Wells stereotactic frame for functional neurosurgery

The Brown-Roberts-Wells (BRW) stereotactic unit has proven itself to be a highly accurate instrument for biopsying or locating pathologic intracranial lesions based on CT scan information. We utilized the BRW frame to select 18 target sites in 12 patients undergoing functional stereotactic procedures. Two patients had bilateral cingulumotomies, 5 had thalamotomies for movement disorders, and 5 underwent electrode implantations for the treatment of chronic pain. Stereotactic frame settings were determined using a positive contrast ventriculogram, orthogonal radiographs, and a computer program provided with the BRW system. In addition, attempts were made to select targets based on CT scan landmarks alone, and these were compared to those derived using ventriculography. We found the BRW frame to be a satisfactory device for performing functional neurosurgical procedures based on ventriculographic landmarks. Coordinates derived from CT scans were similar to those obtained with ventriculography, but were not accurate enough to permit the use of CT scanning as the sole means of target identification. Although future improvements in imaging techniques and computer software are likely to occur, our experience supports ventriculography as the current method of choice for the precise localization of functional targets with the BRW stereotactic system.     

Present and future developments of stereotactic technology

Incorporation of a surgical computer system into stereotactic methodology provides the facility for efficient utilization of the multiple data bases at the disposal of the modern stereotactician. Computed tomography, magnetic resonance imaging, and digital fluoroscopy data gathered in stereotactic conditions are digitized into a stereotactic surgical matrix for surgical planning and interactive surgical procedures. The advantages of this system are illustrated in stereotactic biopsy, interstitial irradiation, and laser resections of intracranial tumors.     

Computer graphics with computerized tomography for functional neurosurgery

A computer graphics technique for computer-assisted stereotactic surgery is presented. The program is designed to aid the surgeon by presenting an on-line graphics display of stereotactic probes and electrodes superimposed on cross sections of the human brain stem. This technique simulates an otherwise blind surgical procedure on a graphics screen for use during surgery. An earlier system based around the DEC MINC-11 BA computer system has been used by the authors for the performance of stereotactic surgery with conventional ventriculography. This system has been upgraded and is now configured about an even more compact microprocessor-based hardware system with expanded graphics capabilities, which also allows its use with computerized tomography.     

Stereotactic CT scanning for the biopsy of intracranial lesions and functional neurosurgery

This report describes a system for incorporation of stereotactic CT scanning data, stereotactic arteriographic data and a computer-generated stereotactic atlas into a three-dimensional matrix utilizing an operating room computer. 86 patients have undergone computer-assisted stereotactic biopsies of intracranial lesions without mortality or neurologic morbidity. Neuroablative and neuroaugmentative procedures have been performed on 5 patients using the CT stereotactic atlas with good correlation with target points determined by ventriculography and microelectrode recording.     

An applicability study on a CT-guided stereotactic technique for functional neurosurgery

When a CT-guided stereotactic technique for functional neurosurgery is adopted, extremely precise targeting is needed to obtain satisfactory surgical results. In this study the authors have investigated the accuracy of the target points determined by CT-guided techniques and compared with those of conventional roentgenographically controlled stereotactic procedures. Stereotactic surgery, employing the Brown-Roberts-Wells (BRW) system, was performed contemporarily 26 times in 23 patients, that is, 9 times in 8 patients for functional neurosurgery using with the roentgenographic method, and 17 times in 15 patients with the CT-guided method only for intracranial neoplasm biopsy. As a result, there were no problems of accuracy of determining the target points by CT-guided stereotactic surgery with the BRW system. When applying this technique for functional neurosurgery, it should be pointed out that there could be a discrepancy within 2 mm from the conventional target determination.     

Woroschiloff's locating device for interventions on the spinal cord and its influence on spinal stereotaxis

111 years ago the first locating device for the spinal cord was constructed, which became the basis for the contemporary spinal cord stereotaxy. Woroschiloff invented this device to operate stereotactically in different spinal cord segments. Nowadays only the fixation of the spinal cord stereotactic device to the wound retractor has changed from his concept, and control of the surgical instrument has been improved in three perpendicular planes corresponding to the special stereotactic maps of the human spinal cord.     

Single-scan stereotactic tumor biopsy and brachytherapy

Stereotactic tumor biopsy and brachytherapy catheter implantation can be accomplished with targets derived from computed axial tomography and magnetic resonance scans. Computer manipulation of image data allows both diagnostic and therapeutic procedures to be carried out from a single set of scan slices. This eliminates the need for repeat scanning as part of the surgical procedure. Microcomputer technology is sufficiently advanced to handle the images and graphics necessary for stereotactic neurosurgery. A system based on the IBM PC/AT designed for this purpose uses readily available graphics software and custom-designed imaging programs. Direct loading of computed axial or magnetic resonance scan images from magnetic tape can be accomplished. Determination of points, contours and volumes in three-dimensional space allows intraoperative alignment of image data and patient landmarks within the stereotactic head frame using pattern recognition overlays. Three-axis scaling for magnification correction along with rotational and linear data transformations provide the basis for single-scan stereotaxis. Interactive computer graphics integrate image, patient and frame coordinates for target determination. This method eliminates the need to design and fabricate nonmagnetic or radiolucent scanner-compatible devices.     

Computer-assisted stereotactic biopsy of intracranial lesions

The use of a computer program that allows the integration of stereotactically gathered CT, MRI and digital angiographic data in the planning of a biopsy trajectory is described. This system has been used to perform 447 stereotactic biopsies in 439 patients. Intracranial hemorrhages occurred in three patients; combined morbidity and mortality was less than 1%. Incorporation of angiographic data and visualization of the surgical trajectory enhances the safety and accuracy of stereotactic biopsy of intracranial lesions.     

Angiographic localizer for the BRW stereotactic system

Preliminary experience with a newly constructed angiographic localizer system for use in stereotactic neurosurgery is reported. This localizer ring, mounted on the BRW head ring, allows for the transformation of target points with known stereotactic coordinates (e.g., visible on computerized tomography scans) onto angiograms, as well as the determination of stereotactic coordinates of a set of points (e.g., arteriovenous malformations) indicated on at least two angiograms.     

Stereotactic radiosurgery: comparing different technologies

Radiosurgery can be defined as 3-dimensional stereotactic irradiation of small intracranial targets by various radiation techniques. The goal is to deliver, with great accuracy, a large, single fraction dose to a small intracranial target, while minimizing the absorbed dose in the surrounding tissue. This article describes certain technical aspects of radiosurgery and compares the different methods of performing such treatment. The 2 most frequently used types of devices for radiosurgery are units with multiple cobalt sources (e.g., the Gamma Knife) and those based on a linear accelerator. In the former, highly collimated beams of radiation from the cobalt sources intersect at the target. In the latter, the source of a highly collimated beam of high-energy photons directed at the target turns through an arc or set of arcs. The accuracy of target localization, the steepness of fall-off of the radiation dose outside the target and the ability to irradiate an irregularly shaped target are all comparable for these 2 types of devices, despite claims to the contrary.     

The impact of computer and imaging technology on stereotactic surgery

Computers, particularly medical imaging techniques, have created a renaissance in stereotactic surgery. Human stereotaxis was primarily developed and performed beginning in the 1940s for functional disorders. Interest waned in the 1960s following the introduction of L-dopa until computer-based three-dimensionally precise tomographic modalities (specifically computed tomography) were introduced beginning in the mid-1970s as a routine diagnostic aid. New image-compatible hardware and instrumentation were introduced along with techniques and associated software for relating points and volumes appearing on these diagnostic images into stereotactic space. This paper reviews the computer and imaging technology that has led to this renaissance and discusses some of the important features of a computer-interactive stereotactic system.     

Transcranial Doppler ultrasonography: stereotactically guided examinations using magnetic resonance angiography]

The accurate localization of specific intracranial blood vessels is a major difficulty with transcranial Doppler sonography (TCD). It was the purpose of this study to develop a system enabling stereotactic navigation during a TCD examination on the basis of high-resolution three-dimensional magnetic resonance angiographic (MRA) data. During TCD, the examiner is provided--on a computer screen--with a projected view of the respective intracranial vessel anatomy. With the aid of an optoelectronic localization system, the spatial orientation and localization of the US probe is determined in real time, and correlated with the patient's MRA data using a dedicated stereotactic mask. Subsequently, the US beam and the points of insonation are displayed on the screen overlaid on the vessel anatomy. In this way the examiner gains real time control of the localization of the respective intracranial vessel insonated. Points of insonation can be stored and recalled for follow-up examinations. In addition to the successful verification of the system, it was shown that, in comparison with conventional TCD, stereotactic navigation distinctly improves the reproducibility of repeat TCD examinations.     

The position and organization of motor fibers in the internal capsule found during stereotactic surgery.

Data gathered from exploratory stimulation of the diencephalon in 130 stereotactic operative procedures have been studied, with the aid of a computer graphic technique, to show the position and topography of motor responses in the internal capsule. The results obtained indicate that pyramidal fibers are organized into a rostral-caudal face-arm-leg sequence and occupy a short compact band in the caudal third of the posterior limb of the internal capsule. This is in contrast to previous concepts of the position of these fibers in the capsule.     

Measurment of pedal loading in bicycling: I. Instrumentation

This paper presents a new instrumentation system to precisely measure pedal loads and pedal position. A pedal/dynamometer unit implementing four octagonal strain rings measures all six load components between the foot and pedal. To study the relationship between foot position and loading, the pedal/dynamometer offers three degree-of-freedom adjustability. Pedal position along the pedal arc is precisely described by measuring crank arm angle and relative angle between pedal and crank arm. Linear, continuous rotation potentiometers measure the two angles. Transducer signals are sampled by a digital computer which calculates resultant loads and pedal position as functions of crank arm angle. Transducers are designed to mount on most bicycles without modification. Test subjects ride their own bicycles unconstrained on rollers so that loading data is representative of actual cycling.     

Computer tomography-controlled stereotactic surgery

In computed tomography (CT)-controlled stereotactic surgery, the coordinate system of the CT scanner is applied to determine the target depth and direction as well as for readjustment of final probe direction. This method can be used for all types of stereotactic surgery for the brain.     

Do alignment thresholds define a critical boundary in long-range detection facilitation with co-linear lines?

Thresholds for line contrast detection (experiment 2) were measured with a two-alternative temporal forced-choice procedure as a function of the spatial position of a vertical target line with regard to two co-linear context lines. The different spatial positions of the target line corresponded to values near the position discrimination threshold (experiment 1) reflecting the just detectable lateral offset, or non-co-linearity, between the context lines which were vertically separated by about 100 minutes of visual arc. Target and context lines were vertically separated by about 30 minutes of arc, had equal contrast polarity in one case, and opposite contrast polarity in the other. Strong line contrast detection facilitation is found at perceptually co-linear target locations. This facilitation decreases noticeably at a horizontal target offset that corresponds to the alignment threshold measured with the context lines. The effects are independent of the relative contrast polarity of target and context and, as shown in a third experiment, also independent of both the relative length or number of lines, and the magnitude of their absolute co-axial separation. This independence seems to hold, provided individual line length and co-axial distance between lines are larger than what appears to be the lower limit of the long-range spatial domain for orientation or contour integration (i.e. 20 minutes of arc), as determined by previous studies. The findings reported here suggest that alignment thresholds are likely to define a critical lateral boundary in long-range detection facilitation with co-linear lines. They support models of contour integration based on interactions between neural mechanisms that integrate local signals of contrast, orientation, and relative position or end-to-end alignment. Such mechanisms may help to explain the formation of representations of virtual contours and object contours in human perception.     

Technique of stereotactic biopsy of two cranial target employing spherical coordinates to define a single trajectory

A 'spherical coordinate system' has been developed to allow either stereotactic biopsy of two intracranial lesions using a single predetermined trajectory or biopsy of a single lesion through an existing burr hole. By means of the Gildenberg technique, the CT coordinates of the targets (or target and burr hole) are obtained. These are employed in three simple trigonometric equations to give three coordinates-two angles for the probe carrier (theta and alpha) and the radius (T) of a sphere, defined by one target as the center and the other target on the surface. These can be utilized in the Todd-Wells stereotactic frame. This system was evaluated using hollow skulls and crossed 30-gauge wire for phantom targets. The system was tried on ten different target combinations, and eight successful trajectories were obtained to within 3 mm. Two target combinations were inaccessible because of technical limitations of the Todd-Wells frame. This 'spherical coordinate system' can decrease the time to localize multiple targets as well as minimize the number of passes.     

Contrast transfer function of the visual system]

Visually evoked potentials were used to determine the spatial contrast response function of the visual system and the visual acuity of the pigeon. The spatial contrast response describes the relationship between the contrast in a pattern of vertical stripes, whose luminance is a function of position, and the amplitude of the visually evoked response at various spatial frequencies for a given temporal frequency (pattern reversal frequency); it indicates how particular spatial frequencies are attenuated in the visual system. The visually evoked responses were recorded using monopolar stainless steel electrodes inserted into the stratum griseum superficiale of the optic tectum; the depth of penetration was determined on the basis of a stereotactic atlas. The stimulus patterns were generated on a video monitor placed 75 cm in front of the animal's eye perpendicular to the optic axis. The spatial contrast response function measured at 10% contrast and 0.5 Hz reversal frequency shows a peak at a spatial frequency of 0.5 c/deg, corresponding to 1 degree of visual angle, and decreases progressively at higher spatial frequencies. The high-frequency limit (cut-off frequency) for resolution of sinusoidal gratings, estimated from the contrast response function, is 15.5 c/deg, corresponding to a visual acuity of 1.9 min of arc.     

The role of computed tomographic and digital radiographic techniques in stereotactic procedures for electrode implantation and mapping, and lesion localization

This paper describes a computer-based system for analyzing stereotactic CT scans and angiograms. Simple Plexiglas frames containing metallic marker pellets and rods are affixed to the sides of the frame during CT scanning and angiography. The images of these markers are recognized by the computer program and used to compute the frame coordinate system. Coordinates of a lesion on CT and angiogram images may be readily computed and coordinate sets specified by the operator may be displayed on the imager, along with positions of implanted electrodes and a numerical indication of recorded activity for each site.     

A true 'advanced imaging assisted' skull-mounted stereotactic system

A stereotactic system has been designed based upon a series of interlocking discs secured to the skull with self-tapping screws. Unlike previous skull-mounted systems, this system is a true, advanced imaging based stereotactic device with the capabilities and accuracy of more traditional, frame based devices. It has been used in a range of applications, from simple biopsies to interstitial radiation implant procedures. Well tolerated by the patient, it allows reaccess to the intracranial target without rescanning. It is convenient for the physician to utilize, both mechanically and timewise, is adaptable to MRI, DSA, and conventional X-ray techniques without modification, and is affordable.