A new apparatus for CT-guided stereotactic surgery

Combining whole-body CT scan with a stereotactic system, the authors have developed and applied clinically an apparatus which readily provides intraoperative CT images, making it possible to confirm the location of the target point and ascertain the intraoperative environment. It takes about 9 s to obtain a CT image. Our purpose is to make stereotactic surgery, a kind of blind surgery, as safe and reliable as a visualized procedure by intraoperative CT scanning. By the method, in which there is very little invasion under local anesthesia, evacuation of deep-seated intracerebral hematomas as well as brain abscesses and also biopsy or brachytherapy of brain tumors in the brain can be done with safety and reliability.     

Brown-Roberts-Wells stereotactic frame modifications to accomplish magnetic resonance imaging guidance in three planes

The Brown-Roberts-Wells (BRW) computer tomography (CT) stereotactic guidance system has been modified to accommodate magnetic resonance imaging (MRI). A smaller head ring, which fits in standard MRI head coils, is constructed of a non-ferromagnetic aluminum ring that is split to prevent eddy currents and anodized to prevent MRI image distortion and resolution degradation. A new localizing device has been designed in a box configuration, which allows BRW stereotactic coordinates to be calculated from coronal and sagittal MRI images, in addition to axial images. The system was tested utilizing a phantom and T1- and T2-weighted images. Using 5-mm MRI scan slices, targets were localized accurately to a 5-mm cube in three combined planes. Optimized calibration of both low field strength (0.3 T) and high field strength (1.5 T) MRI systems is necessary to obtain thin slice (5 mm) images with acceptable image resolution. To date, 10 patients have had MRI stereotactic localization of brain lesions that were better defined by MRI than CT.     

Stereotactic neurosurgery and computerized tomographic scanning

The marriage of computerized tomographic (CT) scanning and stereotactic surgery opens up new technical possibilities, as it becomes feasible to introduce a probe into any lesion which is identified on a CT scan. The various CT stereotactic techniques are reviewed, and generally involve four variations. The head holder of a standard stereotactic apparatus can be adapted to the CT scanner to interdigitate the coordinates of both devices in a known relationship. Second, some types of CT scanners allow the visualization of the vertical coordinate. Third, a stereotactic microdrive can be incorporated into the scanner. Finally, a simple aiming device can be attached to the patient's head and repeated scans taken as the probe is advanced to the target. Various authors have reported the use of techniques for biopsy, aspiration of cysts or hematomas, insertion of radioisotopes, or as an adjunct to open surgery.     

Magnetic resonance imaging in the assessment and surgical management of epilepsy and functional neurological disorders

Magnetic resonance imaging (MRI) offers significant advantages over computerized tomography (CT) and teleradiographic techniques when used for the evaluation and management of epilepsy and functional neurological disorders. Depth recording and radiofrequency electrodes can be more accurately positioned within structures such as the amygdala and hippocampus. The extent of corpus callosum section, lobectomy, topectomy, and radiofrequency stereotactic lesions can now be readily confirmed and related with seizure, neurological, and behavioral outcome. Occult, usually low grade, intraparenchymal neoplasms not visualized on CT scans can be located by MRI and biopsied or excised by MRI stereotactic techniques.     

An integrated method for reproducible and accurate image-guided stereotactic cranial irradiation of brain tumors using the small animal radiation research platform

Preclinical studies of cranial radiation therapy (RT) using animal brain tumor models have been hampered by technical limitations in the delivery of clinically relevant RT. We established a bioimageable mouse model of glioblastoma multiforme (GBM) and an image-guided radiation delivery system that facilitated precise tumor localization and treatment and which closely resembled clinical RT. Our novel radiation system makes use of magnetic resonance imaging (MRI) and bioluminescent imaging (BLI) to define tumor volumes, computed tomographic (CT) imaging for accurate treatment planning, a novel mouse immobilization system, and precise treatments delivered with the Small Animal Radiation Research Platform. We demonstrated that, in vivo, BLI correlated well with MRI for defining tumor volumes. Our novel restraint system enhanced setup reproducibility and precision, was atraumatic, and minimized artifacts on CT imaging used for treatment planning. We confirmed precise radiation delivery through immunofluorescent analysis of the phosphorylation of histone H2AX in irradiated brains and brain tumors. Assays with an intravenous near-infrared fluorescent probe confirmed that radiation of orthografts increased disruption of the tumor blood-brain barrier (BBB). This integrated model system, which facilitated delivery of precise, reproducible, stereotactic cranial RT in mice and confirmed RT's resultant histologic and BBB changes, may aid future brain tumor research.     

X-ray and magnetic resonance stereotaxy for functional and nonfunctional neurosurgery

By means of new plastic stereotactic ring and head fixers, stereotactic procedures can be combined with MRI, with stereotactic coordinates obtained from the MRI images. The method was rechecked against CT stereotaxy and shows a good correspondence of the target coordinates. With MRI stereotaxy, structures near bony regions will be more accessible than with CT stereotaxy. Moreover, the MRI procedure seems to have advantages for functional therapy without the necessity of contrast ventriculography.     

Animal research stereotactic instrument modified for computed tomographic guidance

While target localization for human stereotactic surgery has been refined by computed tomographic (CT) and magnetic resonance imaging (MRI), stereotaxis in experimental animals has remained dependent upon external cranial landmarks and standardized atlas coordinates. To overcome the limitations and inaccuracies of animal devices using the original Horsley-Clarke method, we modified a standard animal stereotactic instrument in order to make target localization and coordinate determination possible with CT imaging. Although the device can be adapted to any medium-sized animal species, we demonstrate its use with dogs here.     

Optimizing MRI sequences and images for MRI-based stereotactic radiosurgery treatment planning

AimDevelopment of MRI sequences and processing methods for the production of images appropriate for direct use in stereotactic radiosurgery (SRS) treatment planning.BackgroundMRI is useful in SRS treatment planning, especially for patients with brain lesions or anatomical targets that are poorly distinguished by CT, but its use requires further refinement. This methodology seeks to optimize MRI sequences to generate distortion-free and clinically relevant MR images for MRI-only SRS treatment planning.Materials and methodsWe used commercially available SRS MRI-guided radiotherapy phantoms and eight patients to optimize sequences for patient imaging. Workflow involved the choice of correct MRI sequence(s), optimization of the sequence parameters, evaluation of image quality (artifact free and clinically relevant), measurement of geometrical distortion, and evaluation of the accuracy of our offline correction algorithm.ResultsCT images showed a maximum deviation of 1.3 mm and minimum deviation of 0.4 mm from true fiducial position for SRS coordinate definition. Interestingly, uncorrected MR images showed maximum deviation of 1.2 mm and minimum of 0.4 mm, comparable to CT images used for SRS coordinate definition. After geometrical correction, we observed a maximum deviation of 1.1 mm and minimum deviation of only 0.3 mm.ConclusionOur optimized MRI pulse sequences and image correction technique show promising results; MR images produced under these conditions are appropriate for direct use in SRS treatment planning.     

应用MRI预扫描定位提高大鼠脑立体定位术的准确性

目的评价MRI预扫描方法在鼠脑穿刺定位准确性上的作用与价值。材料与方法选取健康雄性SD大鼠18只,随机分为2组,分别为MRI预扫描定位组（9只）,在MR图像指导下进行穿刺注射;以及经典穿刺组（9只）,不采用MR影像学检测定位,严格按照脑立体定位图谱进行穿刺注射。穿刺以通过苍白球中心的鼠脑切面中尾状核区为靶目标,穿刺后采用MRI影像学方法确定穿刺点位置,比较MRI预扫描定位穿刺与经典立体定位穿刺的准确度。结果 MRI预扫描定位组穿刺准确率为88.89%,经典穿刺组穿刺准确率为66.67%;两种方法的穿刺定位差异有显著性（P〈0.05）,MRI预扫描组的穿刺定位准确度明显高于经典穿刺组。结论 MRI预扫描可显著提高鼠脑立体定位穿刺的准确度,是进行立体定位精细穿刺的必要操作。     

Stereotactic radiotherapy for brain oligometastases

Brain metastases, the most common metastases in adults, will develop in up to 40% of cancer patients, accounting for more than one-half of all intracranial tumors. They are most associated with breast and lung cancer, melanoma and, less frequently, colorectal and kidney carcinoma.Magnetic resonance imaging (MRI) is the gold standard for diagnosis. For the treatment plan, computed tomography (CT ) images are co-registered and fused with a gadolinium-enhanced T1-weighted MRI where tumor volume and organs at risk are contoured. Alternatively, plain and contrast-enhanced CT scans are co-registered. Single-fraction stereotactic radiotherapy (SRT ) is used to treat patients with good performance status and up to 4 lesions with a diameter of 30 mm or less that are distant from crucial brain function areas. Fractionated SRT (2–5 fractions) is used for larger lesions, in eloquent areas or in proximity to crucial or surgically inaccessible areas and to reduce treatment-related neurotoxicity. The single-fraction SRT dose, which depends on tumor diameter, impacts local control. Fractionated SRT may encompass different schedules. No randomized trial data compared the safety and efficacy of single and multiple fractions. Both single-fraction and fractionated SRT provide satisfactory local control rates, tolerance, a low risk of transient acute adverse events and of radiation necrosis the incidence of which correlated with the irradiated brain volume.     

Transposition of target information from the magnetic resonance and computed tomography scan images to conventional X-ray stereotactic space

A technique to apply reconstructed X-ray computed tomography (CT) and magnetic resonance imaging (MRI) for target determination in stereotactic Bragg peak proton beam therapy of intracranial lesions was developed. Twenty-one benign intracranial tumors and vascular abnormalities were managed using this technique. Clinical features of these lesions, as well as targeting problems associated with the MRI and CT image interpretation, are presented.     

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.     

Stereotactic interstitial brachytherapy--current concepts and concerns in twenty patients

Recent advances in imaging and stereotactic techniques have resulted in wider application of interstitial brachytherapy (IBT) for brain tumors. The advantages of brachytherapy alone or in combination with teletherapy have been detailed, and may be responsible for increasing survival time. We report the preliminary results of 20 patients who underwent CT stereotactic IBT for malignant brain tumors. Despite both old and recent evidence about the efficacy of IBT, concerns remain about the proper grade neoplasm, the target, the dose, and the timing for treatment. Current usage of IBT should be limited to centers with both stereotactic and radiotherapeutic expertise, and where the risks and benefits are being investigated.     

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.     

MRI contribution to the stereotactic management of cerebral tumours

Of 67 patients with cerebral tumours studied by MRI, 60 underwent stereotactic biopsy for histological diagnosis. The data from MRI were compared with those obtained from the CT scan with regard to the pathological diagnosis. The tumoural nature and extent of a lesion were better revealed by MRI. The single or multiple localization of the process was also seen better by MRI. Moreover, the sagittal-plane views shown by MRI provide much more accurate target placement and probe guiding for an orthogonal stereotactic approach. Finally, a post-biopsy MRI can show the biopsy site in relation to the tumour better.     

Experience using two CT-guided stereotactic biopsy methods

15 patients had intracranial CT-guided stereotactic biopsies. Biopsies were performed either with a Riechert-Mundinger stereotactic frame modified for use in the CT or by using the CT scan to establish the relationship of the intracranial lesion to identifiable bony landmarks, and subsequently performing the biopsy in a standard stereotactic frame. Both systems provided safe and accurate methods for obtaining intracranial tissue.     

Feasibility of using ultra-high field (7 T) MRI for clinical surgical targeting

The advantages of ultra-high magnetic field (7 Tesla) MRI for basic science research and neuroscience applications have proven invaluable. Structural and functional MR images of the human brain acquired at 7 T exhibit rich information content with potential utility for clinical applications. However, (1) substantial increases in susceptibility artifacts, and (2) geometrical distortions at 7 T would be detrimental for stereotactic surgeries such as deep brain stimulation (DBS), which typically use 1.5 T images for surgical planning. Here, we explore whether these issues can be addressed, making feasible the use of 7 T MRI to guide surgical planning. Twelve patients with Parkinson's disease, candidates for DBS, were scanned on a standard clinical 1.5 T MRI and a 7 T MRI scanner. Qualitative and quantitative assessments of global and regional distortion were evaluated based on anatomical landmarks and transformation matrix values. Our analyses show that distances between identical landmarks on 1.5 T vs. 7 T, in the mid-brain region, were less than one voxel, indicating a successful co-registration between the 1.5 T and 7 T images under these specific imaging parameter sets. On regional analysis, the central part of the brain showed minimal distortion, while inferior and frontal areas exhibited larger distortion due to proximity to air-filled cavities. We conclude that 7 T MR images of the central brain regions have comparable distortions to that observed on a 1.5 T MRI, and that clinical applications targeting structures such as the STN, are feasible with information-rich 7 T imaging.     

Combined use of digital subtraction angiography and MRI for radiosurgery and stereoencephalography

The authors report their experience with the combined use of digital subtraction angiography (DSA) and magnetic resonance imaging (MRI) for the stereotactic placement of intracerebral electrodes in epilepsy and for the radiosurgical treatment of otherwise inoperable arteriovenous malformations of the brain. Both imaging techniques, when used in conjunction, have been found most useful and complementary. For deep electrode placement, they permit optimal visualization of the cerebral structures to be reached by the electrode array while allowing the avoidance of vessels in the vicinity. For radiosurgery of arteriovenous malformations, DSA provides optimal visualization of the feeders and of the malformation itself, while the MRI reveals the cerebral structures to be spared by the photon beam of the linear accelerator. A discussion of their respective roles is presented, with the specific question as to whether MRI alone could be used for both procedures.     

C T、常规MRI 序列和SWI 诊断弥漫性轴索脑损伤比较

目的:探讨弥漫性轴索损伤(DAI)的CT、常规MRI序列和磁敏感加权成像(SWI)表现与诊断价值。方法:回顾分析42例DAI患者的影像资料,分析、比较CT、MRI和SWI的信号特征及脑内病灶显示率。结果:SWI显示病灶最多、最敏感;脑CT扫描次之;常规MRI序列敏感性差,只有部分病灶显示。结论:CT、MRI和SWI对DAI早期诊断、治疗及评价预后具有重要参考价值,SWI是诊断DAI最有效的首选影像学检查方法。     

Accuracy of CT scans in identifying tumor tissue

The authors present their experience with stereotactic biopsy of brain tumors. Biopsies were obtained sequentially at different depths from the center of the tumor according to coordinates derived from computerized tomography (CT). Biopsies were obtained from 23 brain tumors: 17 gliomas, 5 metastases, and 1 lymphoma. In all a total of 137 biopsies were studied from both enhancing and nonenhancing areas. The tumor yield from these biopsies was 68 and 73%, respectively. It appears that tumor tissue may be obtained from both the enhancing periphery as well as the nonenhancing center of tumors.