Evaluation of Neuronavigation in Glioma Surgery

Background: Glioma is one of the most common intracranial tumors, the treatment for which is surgical resection. Cerebral gliomas in eloquent brain areas are closely associated with important structures. The deep location of such gliomas renders complete resection difficult overlaying structures can be injured, causing hemiplegia, aphasia, coma, and other severe complications. The degree of resection directly influences the prognosis of patients. The application of neuronavigation enables the accurate localization of lesions during surgery, significantly improving microneurosurgery. The accuracy of navigation, however, has typically been compromised by several factors, including operation error, shifting of registration system, and intraoperative brain tissue deformation (brain shift). Aim of Study: The aim of the study is to evaluate and demonstrate the efficacy of neuronavigation in the management of brain gliomas. Patients and Methods: This is a prospective randomized clinical trial study included 35 patients with brain glioma were operated for excision or biopsy taken. Results: Localization of burr hole and craniotomy flap was excellent in 33 patients (94.2%) and fault in 2 cases (5.7%), 29 patients (82.8%) had near total excision of the lesions, and 6 patients (17.1%) had burr hole biopsy, intra operative course was smooth in 33 patients (94.2%) with no intra operative complications, 2 cases (5.7%) developed intra operative bleeding that was due to liver problems. Reading the post operative imaging shows that 27 patients (77.1%) had mild to moderate post operative edema around the site of the lesion, the other eight cases were free of hemorrhage, infarction or edema. Conclusion: We found that neuronavigation is very helpful in our cases in localization of the lesions, decreasing time of surgery, reducing morbidity and mortality and decreasing hospital stay. There are concerns about navigation systems including time consuming, calculation and registration, restriction of space and view inside the operating field, and so on, we didn’t find these issues as obstacles in our work, but we found that there are many advantages that can be helpful in the process of operation.

Neuronavigation and epilepsy surgery

Resective epilepsy surgery is an elective therapy indicated in focal epilepsy patients who are resistant to pharmacotherapy. Every effort should be undertaken to perform the procedures as safe and less traumatic as possible. Neuronavigation could represent a suitable tool to reduce surgical morbidity and increase surgical radicality. Here, we present a series of 41 patients who were operated on for medically intractable epilepsy using neuronavigation. Overall, complication rate was 17% with a favourable seizure outcome of 88% (Engel’s class I/II). Our data suggest that neuronavigation is a valuable surgical technique to accomplish a favourable outcome in epilepsy surgery.

Usage of neuronavigation system to treat a case of traumatic acute subdural hematoma after two-side ventriculoperitoneal shunt

Traumatic acute subdural hematoma is one of the most lethal causes of head injuries,which leads to high mortality.While combined diseases always make it more intractable for the treatment.We present a case of a 68-year-old female patient with traumatic acute subdural hematoma combined with hydrocephalus after ventriculoperitoneal shunt assisted by the neuronavigation system in January 12,2017.She was undergone ventriculoperitoneal shunt 6 years and 5 months ago on two sides respectively because of hydrocephalus,with the ventriculoperitoneal shunt device on the right side out of work.The initial neurological examination showed a Glasgow Coma Scale of E2V1M5 with no papillary defect.A CT scan of the head revealed a left homogeneously hyperdense and subdural hematoma,with compression of the lateral ventricle(2.6 cm thick)and a 0.5 cm midline shift.To protect the ventriculoperitoneal shunt device,we used neuronavigation system to precisely mark the relative location of the device and“invisible”subdural hematoma,thus to design a perfect incision preoperatively.Subsequently,evacuation of the subdural hematoma was performed via craniotomy without damaging the ventriculoperitoneal shunt device.Postoperative CT of the head showed totally removing of the subdural hematoma.The patient recovered three months later.With the assistant of neuronavigation system,it is much easier for the preoperative planning and to reduce the surgical risk.Our case gives a clue that more approaches can be considered when encountering acute head trauma with the complicated combined diseases.

The Use of Neuronavigation with Vasular Microdoppler in Transsphenoidal Pituitary Surgery

Object: To evaluate the use of neuronavigation with vascular micro-doppler in transsphenoidal pituitary surgery. Methods: 141 cases having done transsphenoidal pituitary surgery are evaluated from 2005 to 2014. Fluoroscopy was used in 69 cases and vascular micro-doppler with neuronavigation were used in 72 cases. Results: Transsphenoidal surgery has a lot of risks due to sella’s deep location, and position of the carotid artery and the optic nerve. Clasically the fluoroscopy and microscopic anatomical markers were used in order to minimize the risk of carotid artery and optic nerve damage. Additional devices such as neuronavigation and vascular micro-doppler are needed to decrease the morbidity and mortality arising from these injuries. Conclusion: Neurovascular complications such as carotid artery and optic nerve injuries owing to disorientation in transsphenoidal surgery will reduce the use of neuronavigation with vascular micro-doppler.

Neuronavigation surgery in China： reality and prospects

Objective To review the history, development, and reality of neuronavigation surgery in China and to discuss the future of neuronavigation surgery. Data sources PubMed, the China Knowledge Resource Integrated Database, and the VIP Database for Chinese Technical Periodicals were searched for papers published from 1995 to the present with the key words ＂neuronavigation,＂ ＂functional navigation,＂ ＂image-guided,＂ and ＂stereotaxy.＂ Articles were reviewed for additional citations, and some information was gathered from Web searches. Study selection Articles related to neuronavigation surgery in China were selected, with special attention to application to brain tumors. Results Since the introduction of neurosurgical navigation to China in 1997, this core technique in minimally invasive neurosurgery has seen rapid development. This development has ranged from brain structural localization to functional brain mapping, from static digital models of the brain to dynamic brain-shift compensation models, and from preoperative image-guided surgery to intraoperative real-time image-guided surgery, and from application of imported equipment and technology to use of equipment and technology that possess Chinese independent intellectual property rights. Conclusions The development and application of neuronavigation techniques have made neurological surgeries in China more safe, precise and effective, and less invasive, and promoted the quality of Chinese neurosurgical practice to the rank of the most advance and excellence in the world.

Anatomical study of endoscope-assisted far lateral keyhole approach to the ventral craniocervical region with neuronavigational guidance

Background Image-guided neurosurgery, endoscopic-assisted neurosurgery and the keyhole approach are three important parts of minimally invasive neurosurgery and have played a significant role in treating skull base lesions. This study aimed to investigate the potential usefulness of coupling of the endoscope with the far lateral keyhole approach and image guidance at the ventral craniocervical junction in a cadaver model. Methods We simulated far lateral keyhole approach bilaterally in five cadaveric head specimens （10 cranial hemispheres）. Computed tomography-based image guidance was used for intraoperative navigation and for quantitative measurements. Skull base structures were observed using both an operating microscope and a rigid endoscope. The jugular tubercle and one-third of the occipital condyle were then drilled, and all specimens were observed under the microscope again. We measured and compared the exposure of the petroclivus area provided by the endoscope and by the operating microscope. Statistical analysis was performed by analysis of variance followed by the Student-Newman-Keuls test. Results With endoscope assistance and image guidance, it was possible to observe the deep ventral craniocervical junction structures through three nerve gaps （among facial-acoustical nerves and the lower cranial nerves） and structures normally obstructed by the jugular tubercle and occipital condyle in the far lateral keyhole approach. The surgical area exposed in the petroclival region was significantly improved using the 0° endoscope （1147.80 mm2） compared with the operating microscope （（756.28±50.73） mm2）. The far lateral retrocondylar keyhole approach, using both 0° and 30° endoscopes, provided an exposure area （（1147.80±159.57） mm2 and （1409.94±155.18） mm2, respectively） greater than that of the far lateral transcondylar transtubercular keyhole approach （（1066.26±165.06） mm2） （P 〈0.05）. Conclusions With the aid of the endoscope and image guidance, it is possible to approach the ventral craniocervical junction with the far lateral keyhole approach. The use of an angled-lens endoscope can significantly improve the exposure of the petroclival region without drilling the jugular tubercle and occipital condyle.

Assessment of necessity of neuronavigation in localization of calvarial extra-axial lesions in the setting of limited resources

Background:Neuronavigation is a very beneficial tool in modern neurosurgical practice.However,the neuronavigation is not available in most of the hospitals in our country raising the question about its importance in localizing the calvarial extra-axial lesions and to what extent it is safe to operate without it.Methods:We studied twenty patients with calvarial extra-axial lesions who underwent surgical interventions.All lesions were preoperatively located with both neuronavigation and the usual linear measurements.Both methods were compared regarding the time consumed to localize the tumor and the accuracy of each method to anticipate the actual center of the tumor.Results:The mean error of distance between the planned center of the tumor and the actual was 6.50±1.762 mm in conventional method,whereas the error was 3.85±1.309 mm in IGS method.Much more time was consumed during the neuronavigation method including booting,registration,and positioning.A statistically significant difference was found between the mean time passed in the conventional method and IGS method(2.05±0.826,24.90±1.334,respectively),P-value<0.001.Conclusion:In the setting of limited resources,the linear measurement localization method seems to have an accepted accuracy in the localization of calvarial extra-axial lesions and it saves more time than neuronavigation method.

Neuronavigation for the resection of cavernous angiomas

Objective To introduce the use of the StealthStation neuronavigator combined with preoperative computerized tomography (CT) in resection of intracranial cavernous angiomas (CAs) Methods The StealthStation neuronavigator was used to provide a realtime correlation of the operating field and the computerized images in 6 patients with CAs All patients suffered from epileptic seizures Four patients underwent keyhole surgery and 2 underwent small skin flap craniotomy The mean follow up was 4 5 months Results With the guidance of neuronavigator, lesionectomy associated with removal of hemosiderin deposition, gliosis and calcification was performed precisely The mean fiducial error was from 1 65?mm to 4 53?mm, the predicted accuracy at 10?cm was between 1 82?mm and 3 28?mm, and the sustained accuracy ranged from 0 50?mm to 3 45?mm Conclusion The StealthStation neuronavigator is reliable and accurate in the resection of CAs

Neuronavigation combined with nerve electrophysiology in excision of brain abscess: A case report and literature review

A brain abscess is a parenchymal infection,which is a severe intracranial infectious disease. Although the incidence is low,it causes serious inflammation and neurological deficits. The current treatments for brain abscesses are primarily surgical,including abscess resection or puncture and drainage. In recent years,extensive application of neuronavigation and electrophysiological monitoring technology have improved the safety and reliability of neurosurgery. To explore the application and curative effect of neuronavigation combined with neurophysiological techniques in the treatment of brain abscesses,we retrospectively analyzed a female patient who had undergone neurological monitoring and neuronavigation-assisted surgery to remove an abscess in 2015. Diagnosis and treatment are reported.

Task-related functional magnetic resonance imaging-based neuronavigation for the treatment of depression by individualized repetitive transcranial magnetic stimulation of the visual cortex

To determine whether repetitive transcranial magnetic stimulation(rTMS)of the visual cortex(VC)provides effective and welltolerated treatment and whether magnetic resonance imaging(MRI)measures functional change of the VC as a biomarker of therapeutic effect in major depressive disorder(MDD),we performed a sham-controlled,double-blind,randomized,three-arm VC rTMS treatment study in 74 MDD patients.Neuronavigated rTMS(10 Hz,90%of resting motor threshold,1,600 pulses over20 min twice per day)was performed over the VC for five days.Clinical outcome was measured by Hamilton Depression Rating Scale(HAMD-24)at days 0,1,3,5 and after terminating rTMS,with follow-up at four weeks.MRI was measured at days 0 and5.The individualized group exhibited the greatest change in HAMD-24 scores after VC rTMS for 5 days(F=5.53,P=0.005),which were maintained during follow-up period(F=4.22,P=0.016).All patients reported good tolerance.Changes in VC taskrelated functional MRI correlated with symptomatic reduction in the individualized group.Treatment reduced the initially abnormal increase in resting state functional connectivity from the VC to the pre/subgenual anterior cingulate cortex at day 5,especially in the individualized group.We demonstrated therapeutic potential and good tolerance of VC rTMS in MDD patients,indicated by biomarkers of f MRI measurement.

Research progress of localization technique assisted neuroendoscopy for cerebral hemorrhage

Neurosurgeons who perform intracere-bral hemorrhage(ICH)evacuation procedures have lim-ited options for monitoring hematoma evacuation and intraoperatively assessing residual-hematoma burden.In recent years,neuroendoscope-assisted,minimally inva-sive surgery for spontaneous ICH is simple and effective and becoming increasingly common.Many methods are applied in neuronavigation-assisted surgery for ICH evac-uation,such as neuroendoscopy,three-dimensional(3D)reconstruction,intraoperative ultrasound,and stereotac-tic craniotomy.Compared with a traditional craniotomy operation,hematoma removal(using methods of accurate localization)can reduce iatrogenic damage,protect white matter,and shorten patients’recovery time.This paper mainly outlines the treatment of basal ganglia-cerebral hemorrhage with neuroendoscopy assistance using local-ization techniques.

Navigation-assisted transcortical transventricular approach for paraventricular cavernoma:A technical note and review of the literature

The surgery of paraventricular cavernoma remains a challenge for the neurosurgeon.Few approaches have been specially described for paraventricular cavernoma in literature.We present a patient with a symptomatic paraventricular cavernoma in the dorsal portion of the right lateral ventricles roof causing ventricular hemorrhage,and review his surgical approaches.This patient underwent a navigationassisted transcortical transventricular approach resulting in a complete resection without any neurologic deficits.The approach allows a safe and effective resection of paraventricular cavernomas.

Minimally Invasive Neuronavigator-guided Microsurgery and Photodynamic Therapy for Gliomas

In order to evaluate the effectiveness ofneuronavigator-guided microsurgery and keyhole technique for the resection of gliomas, a total of 60 patients with gliomas were exactly located by using neuronavigator during microsurgery. Forty deep-seated gliomas were resected through a keyhole operative approach. Thirty out of the 60 cases were subjected to photodynamic therapy （PDT） after tumor resection. The therapeutic effectiveness of all the cases was recorded and analyzed. The resuits showed that glioma was totally resected in 52 cases （86.7%）, subtotally in 5 （8.3%）, and most partially in 3 （5%）. Neurological deficits occurred postoperatively in 4 cases. One patient died of multiple system organ failure 4 days after operation. It was concluded that the application of minimally invasive technique could dramatically decrease surgical complications following resection of glioma, and its combination with PDT could obviously improve the quality of life of patients and prolong the survival time.

神经导航系统辅助神经外科临床教学的实践

神经导航系统将神经影像资料与真实解剖结构直观地结合起来,是现代神经外科手术必不可少的辅助设备。本文通过一定的实践,充分利用导航系统虚拟实时、三维图象的强大功能,将其用于初级神经外科医师的培训,提出一套有效的教学方法。它有利于年轻医师形成立体的解剖概念,训练其对手术入路及病变位置的预见性思维,对于初级神经外科医师的临床手术技能培训大有益处,值得有条件的医学教学单位推广普及。

Neuronavigator-guided percutaneous radiofrequency thermocoagulation in the treatment of intractable trigeminal neuralgia

Background Percutaneous radiofrequency thermocoagulation of the trigeminal ganglion （PRTTG） is regarded as the first choice for most patients with trigeminal neuralgia （TN） because of its safety and feasibility. However, neuronavigator-guided PRTTG has been seldom reported. The purpose of this study was to assess the safety and efficacy of neuronavigator-guided PRTTG for the treatment of intractable TN. Methods Between January 2000 and December 2004, 54 patients with intractable TN were enrolled into this study and were randomly divided into two groups. The patients in navigation group （n=26） underwent PRTTG with frameless neuronavigation, and those in control group （n=28） received PRTTG without neuronavigation. Three months after the operation, the efficacy, side effects, and complications of the surgery were recorded. The patients in the control group were followed up for 10 to 54 months （mean, 34±5）, and those in the navigation group were followed up for 13 to 58 months （mean, 36±7）. Kaplan-Meier analyses of the pain-free survival curves were used for the censored survival data, and the log-rank test was used to compare survival curves of the two groups. Results The immediate complete pain-relief rate of the navigation group was 100%, whereas it was 95% in the control. The proportion of sustained pain-relief rates at 12, 24 and 36 months after the procedure were 85%, 77%, and 62% in the navigation group, and 54%, 40%, and 35% in the control. Recurrences in the control group were more common than that in the navigation group. Annual recurrence rate in the first and second years were 15% and 23% in the navigation group, and 46%, 60% in the control group. No side-effect and complication was noted in the navigation group except minimal facial hypesthesia. Conclusion Neuronavigator-guided PRTTG is a safe and promising method for treatment of intractable TN with better short- and long-term outcomes and lower complication rate than PRTI＇G without neuronavigation.

Neuronavigator-guided glioma surgery

Objective To evaluate the effectiveness of neuronavigator-guided surgery for the resection of gliomas. Methods A total of 80 patients with gliomas underwent surgical treatment under the StealthStation neuronavigator to estimate the extent of the tumors. In 27 cases,the measurements of brain shifts at the dura,cortical surface and lesion margin were recorded during the operations. A technique termed “micro-catheter fence post” was used in superficial gliomas to compensate for brain shift.Results Mean fiducial error and predicted accuracy in the 80 cases were 2.03 mm±0.89 mm and 2.43 mm±0.99 mm,respectively. The shifts at the dura,cortical surface and lesion margin were 3.44 mm±2.39 mm,7.58 mm±3.75 mm,and 6.55 mm±3.19 mm,respectively. Although neuronavigation revealed residual tumors,operations were discontinued in 5 cases of deep-seated gliomas. In the other 75 cases,total tumor removals were achieved in 62 (82.7%),and subtotal removals were achieved in 13 (17.3%). Post-operation,neurological symptoms were improved or unchanged in 68 cases (85.0%),and worsened in 12 (15.0%). No deaths occurred during the operations and post-operations. Conclusions Intraoperative brain shifts mainly contribute to the fail of spatial accuracy during neuronavigator-guided glioma surgery. The “micro-catheter fence post” technique used for glioma surgery is shown to be useful for compensating for intraoperative brain shifts. This technique,thus,contributes to an increase in total tumor removal and a decrease in surgical complications.

Quantification of the presigmoid transpetrosal keyhole approach to petroclival region

Background Despite the presigmoid transpetrosal approach has been used by different researchers in various ways, the surgical injury rate remains high. Applying a minimally invasive keyhole idea, we devised a presigmoid transpetrosal keyhole approach （PTKA）, classified and quantitatively assessed their approach to the petroclival area on a cadaver model by using a neuronavigation system. Methods The presigmoid transpetrosal keyhole approach was divided into four increasingly morbidity-producing steps： retrolabyrinthine, partial labyrinthectomy with petrous apicectomy, translabyrinthine and transcochlear keyhole approaches. Six latex-injected cadaveric heads （twelve sides） underwent dissection in which a neuronavigation system was used. An area of exposure 10 cm superficial to a central target （working area） was calculated. The area of clival exposure with each subsequent dissection was also calculated. Results The retrolabyrinthine keyhole approach （RLK） spares hearing and facial function in theory but provides for only a small window of upper clival exposure. The view afforded by partial labyrinthectomy with petrous apicectomy keyhole approach （PLPAK） provides for up to four times this exposure. The translabyrinthine keyhole approach （TLK） and transcochlear keyhole approach （TCK）, although producing more morbidity, add little in terms of a larger petroclival window. However, with each step, the surgical freedom for manipulation of instruments increases. Conclusions The presigmoid transpetrosal keyhole approach to the petroclival area is feasible and useful. The RLK has relatively limited utility. For lesions without bone invasion, the PLPAK provides a much more versatile exposure with an excellent chance of hearing and facial nerve preservation. The TLK provides for greater versatility in treating lesions but clival exposure is not greatly enhanced. The TCK adds little in terms of intradural exposure but should be reserved for cases in which access to the petrous carotid artery is necessary.

Brain tumor surgery:supplemental intra-operative imaging techniques and future challenges

Modern brain tumor surgery stands in the pillar of maximum safe resection.Tumor borders are always challenging,especially infiltration zones in malignant brain tumors.Novel technologies are designed for a better delineation and to increase the extent of resection(EOR)in brain tumor surgery,such as:cortical and sub-cortical mapping strategies with somatosensory-evoked potentials,awake stimulation mapping and cortical/sub-cortical stimulation for motor pathways,important for resection in eloquent areas;intra-operative imaging as functional and intra-operative magnetic resonance imaging,diffusion tensor imaging and intra-operative ultrasound are important for the tumor borders and to achieve the gross total resection;neurochemical navigation methods as 5-aminolevulinic and sodium fluorescein are important for the non-contrast-enhanced tumor border;future methods can be achieved with augmented reality surgery,new intra-operative chemical markers,and visualization methods.Nevertheless all these techniques seem to be promising,the real challenge in the future will be held in how to apply them and how they really affect the prognosis of the patients.Also,new concepts in tumor genetics will provide knowledge for the tumor behavior and will guide resection.Despite all limitations,the increasing importance of safe EOR shows the possible benefits of the novel technologies and surgical advances in brain tumor surgery,taking it to a new step of the neuronavigation era.

Intraoperative MRI-assisted neuro-port surgery for the resection of cerebral intraparenchymal cavernous malformation

Background:Intraparenchymal cerebral cavernous malformation is difficult to localize intraoperatively with conventional frameless navigation due to the"brain shift"effect.We conducted this study to evaluate the efficacy and safety of intraoperative magnetic resonance image(iMRl)-assisted neuro-port surgery for the resection of cerebral intraparenchymal cavernous malformation.Methods:Between April 2016 and December 2017,54 consecutive patients with intraparenchymal cerebral cavernous malformation who get surgical treatment in our hospital were enrolled into this study.Twenty-one patients were treated using iMRI-assisted neuro-port surgery(experiment group),and 33 patients underwent treatment by conventional microsurgery(control group).The iMRI was used in all cases for the compensation of the"brain shift"effect and keeping the navigation system up-to-date.The surgical resection rate,the total operation time,and the preoperative and postoperative Karnofsky Performance Status(KPS)scores were determined to evaluate the operative procedures.Results:There were no significant differences between the two groups in mean age,gender ratio,and volume of lesions(P>0.05).For the experiment group,the average duration of the procedure was 188.8 min with total resection of the lesions achieved in all 21 cases.For the control group,the average duration of the procedure was 238.2 min with total resection of the lesions achieved in 25 of 33 cases.The differences in the average duration of the procedure and the number of totally resected lesions between the two groups were statistically significant(P<0.05).Regarding postoperative neurological function,postoperative KPS scores for the experiment group were significantly higher than those of the control group(P=0.018).Conclusion:Our results show that iMRl-assisted neuro-port surgery is helpful for intraparenchymal cerebral cavernous malformation surgery.The method provides high accuracy and efficiency for lesion targeting and permits excellent anatomic orientation.With the assistance of iMRI technology,we achieved a higher resection rate and a lower incidence of postoperative neurological deficits.Additionally,iMRI is helpful for the compensation of the"brain shift"effect,and it can update the navigation system.