The 'Cambridge' stereotactic biopsy instrument

The recent expansion in CT guided stereotactic biopsy has revealed deficiencies in biopsy instrumentation. In view of this, the authors have developed a versatile side-cutting cannula which has been used successfully in over eighty stereotactic biopsies as well as for the drainage of deep seated abscesses.     

Image-directed functional neurosurgery with the Cosman-Roberts-Wells stereotactic instrument

Summary An isocentered system for functional stereotactic procedures with the Cosman-Roberts-Wells frame and a CT localizer that allows extrapolation of target data directly from the CT slice is presented. Based on anatomical landmarks and on the scaled corresponding transverse plates of the Schaltenbrand and Wahren atlas, we delineate the thalamic and cerebellar nuclei. Twenty three image-directed functional procedures were performed in one year on 18 patients (7 with Parkinson's disease, 4 with dystonia, 3 persons with essential tremor, 2 patients with choreo-athetosis and 2 with de-afferentiation pain). The 23 procedures included 19 thalamotomies, two dentatotomies and two stereotactic implantations of deep seated brain electrodes. Successful targeting was verified by intra-operative electrical stimulation and postoperative CT scan. Complete reduction of symptoms was observed in 4 persons with Parkinson's disease and in 2 patients with essential tremor with significant improvement observed in the rest of the patients with the exception of the individual with choreo-athetosis. There were no operation-related complications. The reported technique is safer and less distressing for patients than previous radiological procedures and it makes image-directed stereotactic functional neurosurgery available to many units with the CRW frame.     

History of Chinese stereotactic and functional neurosurgery

Chinese stereotactic and functional neurosurgery started in 1963. Dr. Jian-Ping Xu did stereotactic surgery for Parkinson's disease with a small Cartesian coordinate stereotactic device which he designed. In 1983, the first Chinese Institute of Stereotactic and Functional Neurosurgery was established by Dr. Jian-Ping Xu and Dr. Ye-Han Wang in the Anhui Provincial Hospital in the city of Hefei. Since then, the Institute has hosted an annual National Workshop on Stereotactic and Functional Neurosurgery, where more than 80% of the functional neurosurgeons now practicing in China have been trained. In 1986, the Chinese Society of Stereotactic and Functional Neurosurgery was established, and the first issue of the Chinese Journal of Stereotactic and Functional Neurosurgery was published. With more than 35 years of development, stereotactic and functional neurosurgery has become a very important branch of surgery in China. More than 5,000 functional neurosurgery procedures and more than 8,000 stereotactic radiosurgery procedures are now performed annually.     

History of Korean stereotactic and functional neurosurgery

ALTHOUGH FUNCTIONAL SURGERY for movement disorders did not begin in Korea until after the introduction of the stereotactic apparatus in 1958, some surgeons had already begun operating on epileptic patients, psychiatric patients, and patients with pain disorders even before the Korean War broke out in 1950. The Korean War itself was a good opportunity for the army surgeons to learn Western neurosurgery, and many operations for pain were performed during this period. Stereotactic thalamotomy and pallidotomy for parkinsonian tremor began in the late 1950s, but it was not until the 1970s that Sang-sup Chung and Chang-rak Choi devoted themselves fully to this field and actively performed these functional operations. They later established the Korean Functional and Stereotactic Society in 1990. Following the lead of these pioneers, many young neurosurgeons began to enter the field in the 1980s to become full-time functional surgeons. Currently, the society has approximately 150 registered members interested in movement disorders, pain, epilepsy, and radiosurgery and working full-time or part-time in this field.     

Initial experience related to the use of the Cosman-Roberts-Wells stereotactic instrument. Technical note

Initial experience with a new arc-radius design of stereotactic frame that interfaced with the existing components of the Brown-Roberts-Wells instrument is reported. Over a 6-month period, 32 procedures were performed on 23 males and nine female patients (mean age 32 years); these included 27 stereotactic biopsy procedures, two stereotactic implantations of cyst catheter reservoirs, two ventriculoscopic aspirations of third ventricular colloid cysts, and one stereotactic aspiration of a craniopharyngioma. In all cases successful targeting was achieved and verified by postoperative computerized tomography. There were no operation-related complications. This new frame offers rapid and accurate targeting and is a useful adjunct to the stereotactic armamentarium.     

Clinical evaluation of stereotactic brain biopsies with an MKM-mounted instrument holder

Summary ¶Object. The aim of this study was to assess the clinical usefulness and accuracy of robot-assisted frameless stereotactic brain biopsies with a recently introduced MKM-mounted instrument holder. Methods. Twenty-three patients with intracranial lesions participated in this study. Depending on the size of the intracranial lesion, fiducials for image-to-patient co-ordinate transformation consisted either of bone screws or adhesive markers. Shortly after surgery, postoperative MRI-imaging was performed to demonstrate the location of the biopsy site. These images were compared with the preoperative images to assess the biopsy localisation error. Results. Postoperative biopsy sites could be demonstrated in six patients with bone screws and in 14 with adhesive markers. These two subgroups yielded average biopsy localisation errors of 3.3mm (SD 1.7mm) and 4.5mm (SD 2.0mm) respectively. This difference was not statistically significant. One biopsy was located in a liquefied haematoma. All others yielded pathological tissue. There were two postoperative haemorrhages, of which only one was temporarily symptomatic. There was no mortality in the first 30 days after surgery. Conclusions. Robot-assisted frameless point-stereotactic techniques represent an alternative to frame-based techniques for the performance of stereotactic biopsies.Published online September 18, 2003     

Pioneers of stereotactic neurosurgery.

The beginnings of stereotactic and functional neurosurgery can be traced as far back as 1873 when Dittmar reported the use of a guiding device for the placement of probes into the medulla oblongata in animals. Further pioneering work was done by Zernov and Altukhov in Russia (1889), Clarke and Horsley in England (1908), and Spiegel and Wycis in the United States (1947), as well as others. After a promising initiation, interest in stereotactic neurosurgery waned after the introduction of L-dopa in the 1960s. Later, the introduction and incorporation of new imaging technology into stereotactic techniques signaled the rebirth of stereotactic and functional neurosurgery as a versatile and exciting subspecialty not only in the resection of previously unresectable lesions but also in the functional restoration of central nervous system function. This brief paper will focus on the personalities that have pioneered stereotactic neurosurgery over the past century.     

Trigeminus stereoguide: an instrument for stereotactic approach through the foramen ovale and foramen jugulare

The author describes a new, fully stereotactic instrument for the percutaneous treatment of tic douloureux. The principle is to place the instrument in such a position around the patient's head that the foramen ovale lies at the midpoint for a spherical system consisting of a cylinder part and a 90 degrees arch with an electrode carrier. The foramen can then be reached from a suitable bone-free direction, either through the cheek or inframandibularly. The position of the foramen ovale is calculated from lateral and axial radiograms and defined with x, y, and z coordinates. The instrument can also be used for the percutaneous treatment of glossopharyngeal neuralgia.     

Current spectrum of stereotactic irradiation techniques.

Our 10-year experience with stereotactic irradiation techniques was evaluated in a series of 709 patients. Stereotactic intracavitary radiation of cystic neoplasms, brachytherapy of malignant glial neoplasms and radiosurgery represent effective and contemporary primary adjuvant or alternative methods to treat a wide variety of brain tumors and vascular malformations.     

Remotely-controlled approach for stereotactic neurobiopsy.

The objective of this study was to develop, demonstrate, and validate a remotely controlled operation scheme coupled with prospective magnetic resonance imaging (MRI)-based stereotaxy for in vivo neurosurgical applications. The novel concept of the prospective guidance scheme is to employ tomographical imaging feedback, such as MRI or CT, to facilitate prospectively the targeting process of a biopsy needle at near-real-time speed (1 image/s). Because the orientation of a biopsy needle pivoted at an entry point on the patient's skull has 2 degrees of freedom, the alignment of its trajectory to a target point can be guided by two-dimensional (2D) images whose plane is placed perpendicular to the desired trajectory. Using near-real-time 2D visual feedback during the adjustment of the alignment guide, the required trajectory alignment can be translated into a simple targeting task on a computer monitor employing a suitable graphic presentation. Also, both adjustments for the alignment and introduction of the biopsy needle were accomplished remotely with image-based feedback. The use of the method in actual MR-guided brain lesion biopsy procedures at 1.5 T showed an improved tissue yield due to the improved targeting accuracy even in the presence of brain shift. Furthermore, the postalignment trajectory can be validated immediately using near-real-time MRI scans in two orthogonal views before needle insertion. Because the final needle position is always visualized and confirmed, the consequent tissue sampling is performed with greater certainty, even in the case of a negative diagnosis. The actual targeting error was 1.53 +/- 0.17 mm from an intended target location, with the maximum distance error of 1.72 mm at a depth of 85 mm. This remotely controlled surgical approach with intraoperative MRI guidance is feasible at 1.5 T, and has allowed neurosurgeons to perform neurobiopsies comfortably and efficiently in a routine clinical MR scanner. This scheme provides a unique alternative stereotactic procedure that can take full advantage of the prospective guidance potential offered by various modern tomographic imaging systems.     

Positron emission tomography imaging-directed stereotactic neurosurgery.

The diagnostic yield of stereotactic biopsies depends upon safely sampling the most representative regions of masses. Potentially, localization information presently available from CT and MR scans might be improved by considering regional levels of cerebral metabolism by PET. In 10 selected stereotactic biopsies of intracranial mass lesions, PET scans were obtained using the Siemens CTI system; the Kelly-Goerss Compass system was used as the stereotactic development platform. PET-[18F]-fluorodeoxyglucose (FDG) images provided clinically significant information by appropriately directing biopsy efforts when CT and MRI was inconclusive or misleading. PET-FDG images can be successfully incorporated into routine image-directed stereotactic surgery.     

Fractionated stereotactic radiotherapy for intracranial neoplasms.

Fractionated stereotactic radiotherapy is a method which attempts to combine the radiobiological advantages offered by dose fractionation with a technique for focal delivery of radiation. At McGill University, fractionated stereotactic radiotherapy is given with a linear accelerator-based dynamic stereotactic radiosurgery unit. The first treatment is given using the stereotactic frame for target localization and head immobilization. Subsequent treatments are given using skin tattoos and laser alignment for target placement within the isocenter of the linear accelerator, and a modified portable halo-ring device is used for skull immobilization. Typically, a marginal dose of 42 Gy was prescribed at the margins of the lesion, divided in 6 fractions and given over a 2-week period. We report the pathological profile and treatment results in a series of 21 patients with a variety of intracranial tumors, treated in this manner between May 1987 and April 1990. Fractionated stereotactic radiotherapy appears to be a worthwhile procedure for the treatment of well-selected patients with intracranial neoplasms.     

Positron emission tomography-guided stereotactic brain biopsy.

We describe a technique that allows target definition for stereotactic brain biopsy using coordinates calculated on stereotactic positron emission tomographic (PET) images. In this study, PET images were obtained using [18F]-labeled fluorodeoxyglucose, a marker for glucose metabolism. The difference between PET-calculated and actual stereotactic coordinates of simulated targets is within PET spatial resolution. Combined computed tomography- and PET-guided stereotactic biopsies were performed in 11 patients with brain tumors. In this report, we describe two representative patients who underwent stereotactic brain biopsy using the present technique. Because of the complementary role of PET and computed tomography, their integration in multimodality planning might optimize the target selection for stereotactic brain biopsies.     

Image-guided stereotactic management of non-AIDS-related cerebral infection.

Every neurosurgeon can appreciate Dandy's recognition that the drainage of brain abscesses causes trauma to the delicate parenchyma. Over the years, brain surgery has evolved toward management of problems by using less and less invasive techniques and thus gaining ever lower morbidity. Clearly, the advent of better imaging techniques has improved the outcome in patients afflicted with intracerebral infections. The combination of stereotaxy with these imaging techniques is contributing a "zero mortality" in the treatment of these infections. In our series of 29 consecutive patients with non-AIDS-related infections, no patient died as a direct result of a stereotactic surgical procedure. Two patients (7%) had new neurologic deficits after surgery. The only patient left with a permanent disability had a kidney allograft and subacute bacterial endocarditis. His condition deteriorated 6 hours after aspiration of a sterile abscess, when an intra-abscess hematoma was diagnosed and evacuated. In retrospect, this complication may have been avoided by less vigorous aspiration. Three of the four patients with nonviral infections who died were iatrogenically immunosuppressed for their organ transplants. These patients are difficult to treat, and given the current popularity of transplantation procedures, neurosurgeons will face more and more opportunistic infections. In general, the patients with abscesses did well. On the other hand, nonoperative mortality was extremely high for patients with viral encephalitides. This high mortality may have resulted from a delay in diagnosis and treatment or from the unavailability of highly effective antiviral agents at the time the biopsies were performed. The importance of early diagnosis and treatment of infection cannot be overemphasized. T.H. Flewett's warning about the management of HSE applies to the management of all cerebral infections: "It seems clear from everybody's published results [in the papers already given] if we wait to do biopsy until the clinical indications are unmistakable, we have waited so long that the patient, if he survives, will be left a severe neurological cripple." Because it is relatively noninvasive, stereotactic neurosurgery has been used increasingly to diagnose brain masses in patients with AIDS. We recommend its use for establishing diagnoses in all suspected cases of cerebral infection. We agree with Rosenblum et al: Empiric treatment of brain infections should be regarded as "radical." Such treatment should be reserved for patients who have an identifiable source of infection and causative organism or for patients who are clinically too unstable to undergo surgery.(ABSTRACT TRUNCATED AT 400 WORDS)     

New model of stereotactic system. Preliminary experience

A new localizer system and a stereotactic frame based on cylindrical coordinates are described and discussed. Preliminary neurosurgical experience.     

Infratentorial stereotactic biopsy. A review of 11 cases.

A review of the stereotactic cases performed at the University of Iowa between February, 1985, and December, 1990, yielded 12 infratentorial stereotactic biopsies in 11 patients. A definitive diagnosis was obtained in 9 of 11 patients. One patient required a second biopsy to obtain a diagnosis and 1 yielded cystic fluid only. The pathological diagnosis obtained included 4 high-grade gliomas, 2 undifferentiated adenocarcinomas, 2 low-grade astrocytomas, 1 malignant ependymoma, 1 pontine hematoma and 1 cyst. None of the patients experienced increased neurological deficit following biopsy and there was no mortality. One patient developed postoperative meningitis. We conclude that stereotactic biopsy of infratentorial lesions can be performed safely with a high probability of obtaining a diagnosis. Adequate tissue diagnosis is necessary to direct further therapy.