Efficacy study of neuronavigation-assisted stereotactic drilling of urokinase drainage versus craniotomy in the treatment of massive intracerebral haemorrhage in elderly patientsa.

To evaluate the efficacy of neuronavigation-assisted stereotactic drilling drainage compared with that of craniotomy in the treatment of massive intracerebral haemorrhage (ICH) in elderly patients. This was a randomized, controlled, blind endpoint clinical study. Elderly patients with massive ICH treated at our neurosurgery department, without the formation of brain herniation preoperatively, all underwent neurosurgical intervention. Patients were randomly assigned to two groups: the minimally invasive surgery (MIS) group, which received neuronavigation-assisted stereotactic drilling drainage, and the craniotomy haematoma removal surgery (CHRS) group. Patient characteristics, surgical anaesthesia methods, surgery duration, intraoperative bleeding volume, duration of ICU stay duration of hospital stay, complications, and modified Rankin scale (mRS) scores at 90 days posttreatment were compared between the two groups. Statistical analysis was performed on the collected data. A total of 67 patients were randomly assigned, with 33 (49.25%) in the MIS group and 34 (50.75%) in the CHRS group. Compared with the CHRS group, the MIS group had advantages, including the use of local anaesthesia, shorter surgery duration, less intraoperative bleeding, shorter ICU stay, and fewer complications (P < 0.05). The MIS group had a significantly improved patient prognosis at 90 days (mRS 0-3). However, there were no significant differences in hospital stay or 90-day survival rate between the two groups (P > 0.05). For elderly patients with massive ICH without brain herniation, stereotactic drilling drainage is a simple surgical procedure that can be performed under local anaesthesia. Patients treated with this approach seem to have better outcomes than those treated with craniotomy. In clinical practice, neuronavigation-assisted stereotactic drilling drainage is recommended for surgical treatment in elderly patients with massive ICH without brain herniation.Clinical trial registration number: NCT04686877.

Operative Adjuncts in Pediatric Brain Tumor Surgery with a Focus on Suprasellar Tumors.

The primary objective of surgery for brain tumor resection has always been maximizing safe resection while minimizing the risk to normal brain tissue. Technological advances applied in the operating room help surgeons to achieve this objective. This chapter discusses specific tools and approaches in the operating environment that target safe surgery for brain tumors in children, with a focus on pathologies in the sellar/suprasellar region. Particular focus is given to tools that help with safe patient positioning; intraoperative imaging modalities; and chemical visualization adjuncts. Both static (preoperative images used for neuronavigation) and dynamic (images updated during the procedure) intraoperative imaging modalities are discussed. There is further overview of operative rehearsal and preparation strategies, which are rapidly evolving as virtual reality systems become more commonplace. While the rapid evolution of intraoperative adjuncts in neurosurgery means the status of a given technology as novel is quite transient, this chapter offers a snapshot of the current state of advanced intraoperative tools for pediatric brain tumor surgery.

A comprehensive approach to lateral ventricular tumor resection: techniques, technologies, and outcomes.

This study reviews lateral ventricular tumors (LVTs), which are rare brain lesions accounting for 0.64-3.5% of brain tumors, and the unique challenges they present due to their location and growth patterns. Once deemed inoperable, advancements in microneurosurgery, imaging, and tumor pathobiology have significantly improved treatment outcomes. This letter summarizes recent studies and key findings in the management of LVTs. Research by S.A. Maryashev et al. identified risk factors for early hemorrhagic complications following the surgical resection of lateral ventricular neoplasms, highlighting the significance of patient characteristics, tumor location, and surgical approach. The study found that factors such as gender, hydrocephalus, tumor blood flow, and Evans index correlate with a higher risk of hemorrhage, with the transcallosal approach having a greater risk compared to the transcortical approach. The utilization of navigation technologies, including fMRI, neuronavigation, and intraoperative brain mapping, has been shown to reduce surgical complications and enhance patient outcomes in the treatment of lateral ventricular meningiomas. Moreover, endoscopic and endoport-assisted endoscopic techniques have proven to be valuable in intraventricular tumor surgery, enabling minimally invasive procedures with better visualization and fewer complications. The integration of advanced surgical techniques, neuroimaging, and neurophysiological monitoring emphasizes the necessity of a multidisciplinary approach to optimize patient outcomes. To improve the study's validity and applicability, further research with larger sample sizes and advanced statistical analyses is needed. This letter advocates for the continued exploration of innovative surgical techniques and technologies to enhance the management of lateral ventricular tumors.

Mixed Reality Assisted Navigation Guided Microsurgical Removal of Cranial Lesions.

AIM: To demonstrate the possible use of mixed reality (MR) technology in neurosurgery for multiple purposes, including preoperative planning, training, and three-dimensional (3D) navigation. MATERIAL AND METHODS: Using magnetic resonance imaging (MRI) and computed tomography (CT), 3D holographic images of three patients were created and inspected using a remote control. Preoperative planning was performed in a conference room using holographic images. Intraoperatively, the 3D images were matched and the adjacent structures were examined. RESULTS: The MR System (MRS) was a useful tool for preoperative planning and intraoperative navigation during the cranial intervention. It reduces operative time, decreases complication rates, increases surgical success, and enhances surgical outcomes. Eventually, MRS may be more economical. CONCLUSION: The MRS can be used for intraoperative navigation by displaying a 3D hologram at the surgeon's fingertips and for preoperative 3D examination of the lesions and its surrounding structures. The MRS enhances surgical efficacy, reduces healthcare costs, and has a shorter learning curve than the conventional methods. It also enables customized patient-specific surgery.

How I do it. Posterolateral lumbar spine fixation and decompression with navigation interfaced with a robotic exoscope with head mounted display.

INTRODUCTION: Lumbar spine fixation and fusion is currently performed with intraoperative tools such as intraoperative CT scan integrated to navigation system to provide accurate and safe positioning of the screws. The use of microscopic visualization systems enhances visualization and accuracy during decompression of the spinal canal as well. METHODS: We introduce a novel setting in microsurgical decompression and fusion of lumbar spine using an exoscope with robotized arm (RoboticScope) interfaced with navigation and head mounted displays. CONCLUSION: Spinal canal decompression and fusion can effectively be performed with RoboticScope, with significant advantages especially regarding ergonomics.

Intraoperative ultrasound and magnetic resonance comparative analysis in brain tumor surgery: a valuable tool to flatten ultrasound's learning curve.

BACKGROUND: Intraoperative ultrasound (IOUS) is a profitable tool for neurosurgical procedures' assistance, especially in neuro-oncology. It is a rapid, ergonomic and reproducible technique. However, its known handicap is a steep learning curve for neurosurgeons. Here, we describe an interesting postoperative analysis that provides extra feedback after surgery, accelerating the learning process. METHOD: We conducted a descriptive retrospective unicenter study including patients operated from intra-axial brain tumors using neuronavigation (Curve, Brainlab) and IOUS (BK-5000, BK medical) guidance. All patients had preoperative Magnetic Resonance Imaging (MRI) prior to tumor resection. During surgery, 3D neuronavigated IOUS studies (n3DUS) were obtained through craniotomy N13C5 transducer's integration to the neuronavigation system. At least two n3DUS studies were obtained: prior to tumor resection and at the resection conclusion. A postoperative MRI was performed within 48 h. MRI and n3DUS studies were posteriorly fused and analyzed with Elements (Brainlab) planning software, permitting two comparative analyses: preoperative MRI compared to pre-resection n3DUS and postoperative MRI to post-resection n3DUS. Cases with incomplete MRI or n3DUS studies were withdrawn from the study. RESULTS: From April 2022 to March 2024, 73 patients were operated assisted by IOUS. From them, 39 were included in the study. Analyses comparing preoperative MRI and pre-resection n3DUS showed great concordance of tumor volume (p < 0,001) between both modalities. Analysis comparing postoperative MRI and post-resection n3DUS also showed good concordance in residual tumor volume (RTV) in cases where gross total resection (GTR) was not achieved (p < 0,001). In two cases, RTV detected on MRI that was not detected intra-operatively with IOUS could be reviewed in detail to recheck its appearance. CONCLUSIONS: Post-operative comparative analyses between IOUS and MRI is a valuable tool for novel ultrasound users, as it enhances the amount of feedback provided by cases and could accelerate the learning process, flattening this technique's learning curve.

Charting the success of neuronavigation in brain tumor surgery: from inception to adoption and evolution.

PURPOSE: Neuronavigation, explored as an intra-operative adjunct for brain tumor surgery three decades ago, has become globally utilized with a promising upward trajectory. This study aims to chart its success from idea to adoption and evolution within the US and globally. METHODS: A three-pronged methodology included a systematic literature search, impact analysis using NIH relative citation ratio (RCR) and Altmetric scores, and assessment of patent holdings. Data was dichotomized for US and international contexts. RESULTS: The first neuronavigation publication stemmed from Finland in 1993, marking its inception. Over three decades, the cumulative number of 323 studies, along with the significantly increasing publication trend (r = 0.74, p < 0.05) and distribution across 34 countries, underscored its progressive and global adoption. Neuronavigation, mostly optical systems (58%), was utilized in over 19,000 cases, predominantly for brain tumor surgery (84%). Literature impact showed a robust cumulative median RCR score surpassing that for NIH-funded studies (1.37 vs. 1.0), with US studies having a significantly higher median RCR than international (1.71 vs. 1.21, p < 0.05). Technological evolution was characterized by adjuncts, including micro/exo/endoscope (21%), MRI (17%), ultrasound (10%), and CT (7%). Patent analysis demonstrated academic and industrial representation with an interdisciplinary convergence of medical and computational sciences. CONCLUSION: Since its inception thirty years ago, neuronavigation has been adopted worldwide, and it has evolved with adjunct technology integration to enhance its meaningful use. The current neuronavigation innovation pipeline is progressing, with academic and industry partnering to advance its further application in treating brain tumor patients.

Resection of meningiomas located in motor eloquent areas - comparative analysis of navigated transcranial magnetic stimulation and conventional neuronavigation.

BACKGROUND: Navigated transcranial magnetic stimulation (nTMS) has been established as a preoperative diagnostic procedure in glioma surgery, increasing the extent of resection and preserving functional outcome. nTMS motor mapping for the resection of motor eloquent meningiomas has not been evaluated in a comparative analysis, yet. METHODS: We conducted a retrospective matched-pair analysis for tumor location and size in meningioma patients with tumors located over or close to the primary motor cortex. Half of the study population received nTMS motor mapping preoperatively (nTMS-group). The primary endpoint were permanent surgery-related motor deficits. Additional factors associated with new motor deficits were evaluated apart from nTMS. RESULTS: 62 patients (mean age 62 ± 15.8 years) were evaluated. 31 patients received preoperative nTMS motor mapping. In this group, motor thresholds (rMT) corresponded with tumor location and preoperative motor status, but could not predict motor outcome. No patient with preoperative intact motor function had a surgery-related permanent deficit in the nTMS group whereas four patients in the non-TMS group with preoperative intact motor status harbored from permanent deficits. 13 patients (21.3%) had a permanent motor deficit postoperatively with no difference between the nTMS and the non-TMS-group. Worsening in motor function was associated with higher patient age (p = 0.01) and contact to the superior sagittal sinus (p = 0.027). CONCLUSION: nTMSmotor mapping did not lead to postoperative preservation in motorfunction. nTMS data corresponded well with the preoperative motorstatus and were associated with postoperative permanent deficits if tumors were located over the motor hotspot according to nTMS.

Neuronavigation assisted percutaneous balloon compression of the gasserian ganglion for trigeminal neuralgia. How I do it.

BACKGROUND: Surgical treatment for trigeminal neuralgia includes percutaneous techniques, including balloon compression, first described in 1983 by Mullan and Lichtor (J Neurosurg 59(6):1007-1012, 6). METHOD: Here we present a safe and simple navigation-assisted percutaneous technique for balloon compression, which can also be used for glycerol injection. CONCLUSION: The navigation-assisted percutaneous technique for balloon compression for trigeminal neuralgia is a quick and safe treatment for patients not candidates for microvascular decompression.

Impact of BrainLab VectorVision Infrared-Based Neuronavigation on Surgical Outcomes in Intracranial Meningioma Patients: A Retrospective Study.

BACKGROUND The BrainLab VectorVision neuronavigation system is an image-guided, frameless localization system used intraoperatively, which includes a computer workstation for viewing and analyzing operative microscopic images. This retrospective study aimed to evaluate the use of the BrainLab VectorVision infrared-based neuronavigation imaging system in 80 patients with intracranial meningioma removed surgically between 2013 and 2023. MATERIAL AND METHODS Data were retrospectively collected from 36 patients with convexity meningioma and 44 patients with parasagittal meningioma between 2013 and 2023. The surgical operation of 40 of these patients was performed with the help of neuronavigation, while the other 40 were performed without neuronavigation. Demographic data, preoperative and postoperative radiologic images, craniotomy measurements, surgical complications, and operative times of patients with and without neuronavigation were analyzed. RESULTS Using neuronavigation significantly increased surgery duration (P=0.023). In 6 patients without the use of neuronavigation, the craniotomy had to be enlarged and this resulted in superior sagittal sinus (SSS) damage (P=0.77, P=0.107). Patients for whom neuronavigation was used did not experience any sinus damage and did not require craniotomy enlargement. Postoperative epidural hematoma (EH) developed in 9 patients without navigation, whereas it developed in only 1 patient with navigation (P=0.104). Residual tumors were less common in patients using navigation (P=0.237). CONCLUSIONS The use of neuronavigation allows the incision and craniotomy to be reduced in size. Intraoperatively, it allows the surgeon to master the boundaries of the tumor and surrounding vascular structures, reducing the risk of complications. These results suggest that neuronavigation systems are an effective ancillary in meningioma surgery.

Clinical evaluation of resection of functional area gliomas guided by intraoperative 3.0 T MRI combined with functional MRI navigation.

BACKGROUND: In assessing the clinical utility and safety of 3.0 T intraoperative magnetic resonance imaging (iMRI) combined with multimodality functional MRI (fMRI) guidance in the resection of functional area gliomas, we conducted a study. METHOD: Among 120 patients with newly diagnosed functional area gliomas who underwent surgical treatment, 60 were included in each group: the integrated group with iMRI and fMRI and the conventional navigation group. Between-group comparisons were made for the extent of resection (EOR), preoperative and postoperative activities of daily living based on the Karnofsky performance status, surgery duration, and postoperative intracranial infection rate. RESULTS: Compared to the conventional navigation group, the integrated navigation group with iMRI and fMRI exhibited significant improvements in tumor resection (complete resection rate: 85.0% vs. 60.0%, P = 0.006) and postoperative life self-care ability scores (Karnofsky score) (median ± interquartile range: 90 ± 25 vs. 80 ± 30, P = 0.013). Additionally, although the integrated navigation group with iMRI and fMRI required significantly longer surgeries than the conventional navigation group (mean ± standard deviation: 411.42 ± 126.4 min vs. 295.97 ± 96.48 min, P<0.0001), there was no significant between-group difference in the overall incidence of postoperative intracranial infection (16.7% vs. 18.3%, P = 0.624). CONCLUSION: The combination of 3.0 T iMRI with multimodal fMRI guidance enables effective tumor resection with minimal neurological damage.

Navigated Exoscopic Transtubular Approach for Lumbar Decompression: Surgical Video.

Tubular retractors in minimally invasive lumbar stenosis permit surgeons to achieve satisfactory neural decompression while minimizing the morbidity of the surgical access.1-3 Transtubular lumbar decompression requires intraoperative image guidance and microscopic magnification to achieve precise and reproductible surgical results. Use of 2-dimensional image guidance in transtubular lumbar decompression has a major limitation due to the lack of multiplanar orientation. Consequently, there is a risk of incomplete decompression and excessive bone removal resulting in iatrogenic instability. Furthermore, available microscopes have limited optics (short focal lengths) and unsatisfactory surgeon ergonomics. To overcome these limitations, the authors present a step-by-step video of the navigated exoscopic transtubular approach (NETA) for spinal canal decompression (Video 1). The patient suffers from bilateral L5 radiculopathy due to L4-L5 bilateral synovial cysts responsible for severe L4-L5 canal stenosis. During the entire surgical procedure, NETA implements the use of navigation based on intraoperative 3-dimensional (3D) fluoroscopic images for retractor placement, bone mapping, and neural decompression.4 NETA represents a modification of the "standard" MIS transtubular technique for bilateral lumbar decompression. NETA is based on the use of neuronavigation during each surgical step to guide the placement of tubular retractor. This tailors the bone resection to achieve adequate neural decompression while minimizing the risks of potential spine instability. After precise placement of the tubular retractor, bone removal and neural decompression are accomplished under robotic exoscope magnification with 4k 3D images. Using a 3D robotic exoscope (Modus V, Synaptive, Toronto, Canada) allows better tissue magnification and improves surgeon ergonomics during lumbar decompression through tubular retractors.5,6.

Navigated intraoperative ultrasound in pediatric brain tumors.

PURPOSE: The aim of this study was to evaluate the diagnostic value and accuracy of navigated intraoperative ultrasound (iUS) in pediatric oncological neurosurgery as compared to intraoperative magnetic resonance imaging (iMRI). METHODS: A total of 24 pediatric patients undergoing tumor debulking surgery with iUS, iMRI, and neuronavigation were included in this study. Prospective acquisition of iUS images was done at two time points during the surgical procedure: (1) before resection for tumor visualization and (2) after resection for residual tumor assessment. Dice similarity coefficients (DSC), Hausdorff distances 95th percentiles (HD95) and volume differences, sensitivity, and specificity were calculated for iUS segmentations as compared to iMRI. RESULTS: A high correlation (R = 0.99) was found for volume estimation as measured on iUS and iMRI before resection. A good spatial accuracy was demonstrated with a median DSC of 0.72 (IQR 0.14) and a median HD95 percentile of 4.98 mm (IQR 2.22 mm). The assessment after resection demonstrated a sensitivity of 100% and a specificity of 84.6% for residual tumor detection with navigated iUS. A moderate accuracy was observed with a median DSC of 0.58 (IQR 0.27) and a median HD95 of 5.84 mm (IQR 4.04 mm) for residual tumor volumes. CONCLUSION: We found that iUS measurements of tumor volume before resection correlate well with those obtained from preoperative MRI. The accuracy of residual tumor detection was reliable as compared to iMRI, indicating the suitability of iUS for directing the surgeon's attention to areas suspect for residual tumor. Therefore, iUS is considered as a valuable addition to the neurosurgical armamentarium. TRIAL REGISTRATION NUMBER AND DATE: PMCLAB2023.476, February 12th 2024.

Phantom and in vivo accuracy of frameless optical navigation in stereotactic laser interstitial thermal therapy.

OBJECTIVE: Targeting accuracy presents a key factor in achieving maximal safe ablation in laser interstitial thermal therapy (LITT). The VarioGuide system has proven precise for brain biopsies, but data showing its accuracy in combination with LITT are limited. The aim of this study was to determine the phantom and in vivo accuracy of LITT probe placement using the VarioGuide system and to evaluate the effect of targeting error on maximum possible ablation volume. METHODS: Stereotactic LITT probe placement was performed using the VarioGuide system in 3 phantom skulls. The same system was used in 10 patients treated with LITT, for which data were retrospectively analyzed. Target point error (TPE), target depth deviation (TDD), target lateral deviation (TLD), and angular deviation (AD) were derived from intraprocedural MRI scans of both the phantom and in vivo trajectories. In vivo, the effect of targeting error on the maximum reachable ablation was calculated as the difference between the planned maximal achievable tumor ablation (PTA) and the actual maximal achievable tumor ablation (ATA). RESULTS: In total, 24 phantom and 16 in vivo trajectories were analyzed. In the phantom setting, the median TPE was 3.3 mm and median AD was 1.9°. Targeting accuracy significantly decreased for longer trajectories and those less perpendicular to the skull. In patients, the authors observed a comparable median TPE of 4.0 mm but significantly higher AD of 3.2°. In vivo, targeting inaccuracy resulted in a median decrease in maximum achievable ablation volume of 6% as compared to the planned trajectory. CONCLUSIONS: The authors' study indicates that utilizing the VarioGuide system in combination with LITT yields an average targeting error as large as 4 mm, which was smaller for shorter and straighter trajectories. In patients, targeting inaccuracy resulted in a median 6% decrease of the planned tumor ablation volume. These are important factors that should be considered in optimal case planning and patient selection in LITT.

Effects of the Use of Neuronavigation in Patients with Supratentorial Brain Gliomas: A Cohort Study.

OBJECTIVE: Despite the growing acceptance of neuronavigation in the field of neurosurgery, there is limited comparative research with contradictory results. This study aimed to compare the effectiveness (tumor resection rate and survival) and safety (frequency of neurological complications) of surgery for brain gliomas with or without neuronavigation. METHODS: This retrospective cohort study evaluated data obtained from electronic records of patients who underwent surgery for gliomas at Dr. Alejandro Dávila Bolaños Military Hospital and the Clinic Hospital of Barcelona between July 2016 and September 2022. The preoperative and postoperative clinical and radiologic characteristics were analyzed and compared according to the use of neuronavigation. RESULTS: This study included 110 patients, of whom 79 underwent surgery with neuronavigation. Neuronavigation increased gross total resection by 57% in patients in whom it was used; gross total resection was performed in 56% of patients who underwent surgery with neuronavigation as compared with 35.5% in those who underwent surgery without neuronavigation (risk ratio [RR], 1.57; P=0.056). The incidence of postoperative neurologic deficits (transient and permanent) decreased by 79% with the use of neuronavigation, (12% vs. 33.3%; RR, 0.21; P=0.0003). Neuronavigation improved survival in patients with grade IV gliomas (15 months vs. 13.8 months), but it was not statistically significant (odds ratio (OR), 0.19; P=0.13). CONCLUSIONS: Neuronavigation improved the effectiveness (greater gross total resection of tumors) and safety (fewer neurological deficits) of brain glioma surgery. However, neuronavigation does not significantly influence the survival of patients with grade IV gliomas.

Bony Surface-Matching Registration of Neuronavigation with Sectioned 3-Dimensional Skull in Prone Position.

BACKGROUND: Neuronavigation has become an essential system for brain tumor resections. It is sometimes difficult to obtain accurate registration of the neuronavigation with the patient in the prone position. Bony surface-matching registration should be more precise than skin surface-matching registration; however, it is difficult to establish bony registration with limited exposed bone. We created a new bony surface-matching method to a sectioned 3-dimensional (3D) virtual skull in a neuronavigation system and registered with a sectioned 3D skull. In this study, the bony surface-matching with sectioned 3D registration is applied to provide precise registration for brain tumor resection in the prone position. METHODS: From May 2023 to April 2024, 17 patients who underwent brain tumor resection in the prone position were enrolled. The navigation system StealthStation S8 (Medtronic, Dublin, Ireland) was used. Bony surface-matching registration with a whole 3D skull in a neuronavigation system was performed. Next, a sectioned 3D skull was made according to the surgical location to compare with the whole 3D skull registration. A phantom model was also used to validate the whole and sectioned 3D skull registration. RESULTS: Whole 3D skull registration was successful for only 2 patients (11.8%). However, sectioned 3D skull registration was successful for 16 patients (94.1%). The examinations with a phantom skull model also showed superiority of sectioned 3D skull registration to whole 3D skull registration. CONCLUSIONS: Sectioned 3D skull registration was superior to whole 3D skull registration. The sectioned 3D skull method could provide accurate registration with limited exposed bone.