遥操作脑立体定向手术的临床初步应用

目的 评价应用CAS-R-5远程立体定向机器人系统,实施遥操作脑立体定向手术的临床实用性、操作精确性和手术安全性.方法 回顾性分析2005年9月至2006年9月,我们应用CASR-5型机器人系统实施遥操作无框架脑立体定向手术32例.遥操作是专家在北京通过数字专线,控制位于远在1300千米以外的延安机器人,对患者实行手术.术后随访3～14个月(平均12个月),观察定位精度及症状改善情况.结果 临床成功完成无框架定向脑手术32例,定位操作均一次性完成,远程定位精度是(1.50±0.32)mm,无手术相关并发症.结论 本结果提示无框架立体定向遥操作治疗和诊断颅内病变是安全可行的.     

无框架脑立体定向手术

目的:在脑立体定向手术中,研究采用无框架定位方法,取代传统的定向仪框架的效果。方法:CT扫描确定脑内病变及头部标志点,计算机建立与靶点对应的三维坐标体系和手术规划,智能机械臂为术者提供准确导航和操作平台。结果:临床成功完成无框架定位脑手术42例,手术种类包括脑肿瘤内放疗28例、脑内病变活检6例、小型脑瘤切除2例、脑脓肿抽吸2例、脑内血肿排空2例、金属异物取出2例。结论:采用无框架定位脑手术,具有减少病人痛苦、方便术者操作、扩大手术范围、提高手术安全性等优点。     

脑内小病灶立体定向显微开颅切除术

目的总结立体定向指导下小骨瓣开颅脑内小病灶切除术的经验。方法全部病例均采用驹井式CT脑立体定向仪引导对30例脑内小病灶进行切除。结果30例脑内小病灶立体定向导引切除均得到满意的临床效果,无任何重大并发症,无死亡病例。结论立体定向显微神经外科手术切除颅内病变具有定位精确、损伤小,临床效果明显优于传统开颅,是一种安全和有效的微创手术方法。     

立体定向手术治疗桥脑出血10例

目的探讨立体定向手术治疗桥脑出血的手术方法及治疗效果.方法采用国产FY-98Ⅱ型立体定向仪,通过CT定位,计算以桥脑血肿最大横截面的中心为靶点的三维坐标,在定位系统引导下向靶点置管抽吸尿激酶灌洗引流治疗桥脑出血10例.结果10例均获成功,无手术死亡.手术时间50～80 min,平均60 min.术中出血量25～40 ml,平均30 ml.术后因脑干功能衰竭、消化道出血死亡3例.术后住院时间16～30 d,平均21 d.术后存活7例随访3个月～1年,平均8个月,ADL评定Ⅱ级3例,Ⅲ级2例,Ⅳ级1例,V级1例.结论立体定向手术治疗桥脑出血定位准确,安全可靠,疗效满意.     

脑血管造影立体定向术的研究

目的研究脑血管造影（ＤＳＡ）与脑立体定向术相结合治疗颅内病变。方法研制成脑血管立体定向仪１台，并设计出纠正近距离Ｘ线摄片中的图像移位、放大的方法和计算机专用软件，成对实验１７次。结果定位、导向精确率＜０．５ｍｍ。结论所研制的脑血管立体定向仪经过应用达到设计要求。     

立体定向辅助显微手术切除脑功能区病灶

随着立体定向技术的进展．尤其是神经导航技术出现．立体定向切除术已成为神经外科手术的主流．尤其当病灶位于重要功能区或脑深部时．常规方法手术容易造成医源性损伤。采用立体定向和显微外科技术．经脑沟或非功能区切除肿瘤损伤最小．手术效果好旧。本院自2004年9月以来．采用ASA602S立体定向仪与ASA620手术计划系统辅助．利用双靶点法优化手术路径．对9例额顶颢叶功能区病灶施行显微切除．取得满意效果．现报告如下。     

脑转移瘤的立体定向显微切除手术18例临床分析

目的 探讨立体定向显微切除手术治疗脑转移瘤的可行性和临床疗效。方法 局麻下安装立体定向仪头架，行CT扫描，计算出肿瘤中心、肿瘤距离皮层最近点及其连线的延长线与颅骨外板交点(作为骨窗中点)的三维坐标，然后用环钻钻一骨窗，根据已计算出的三维坐标用探针指出肿瘤位置，在手术显微镜下手术切除肿瘤。结果 临床应用18例，全部病例均达到肿瘤全切除，无手术死亡及严重并发症发生，结论 立体定向显微手术治疗脑转移瘤有显著疗效，这一术式特别适用于功能区或深部脑转移瘤手术。     

立体定向和皮层脑电精确定位切除颅内癫痫灶的手术配合

利用立体定向和皮层脑电精确定位切除颅内癫痫灶是癫痫外科的重要治疗手段 ,手术方法简便可靠 ,手术创伤小 ,但手术能否顺利进行并取得满意的效果 ,手术中护理配合发挥了重要的作用。我科自 1998起利用ASA— 60 2型定向仪对 2 0例颅内单发病灶进行螺旋CT引导下立体定向和皮层脑电精确指导手术进程 ,取得了满意的效果 ,现将手术配合经验报道如下。1　临床资料1.1　一般资料 :本组 2 0例 ,男性 11例 ,女性 9例 ,年龄 9～48岁 ,平均 2 8岁。其中癫痫灶位于顶叶 5例 ,颞叶 5例 ,额叶 6例 ,枕叶 4例 ,病理报告脑囊虫 8例 ,钙化灶 6例 ,脑脓肿 4…     

比较开颅脑胶质瘤切除术与立体定向微创手术治疗脑胶质瘤的近期效果

目的比较开颅手术与立体定向微创脑胶质瘤切除术治疗脑胶质瘤的近期效果。方法选取2014-04—2018-04间信阳市中心医院收治的60例脑胶质瘤患者,将行开颅脑胶质瘤切除术的患者作为对照组,将行立体定向微创手术的患者作为观察组,各30例。回顾性分析患者的临床资料。结果观察组的总有效率、神经功能缺失程度评分量表(CCS)评分及术后随访1 a期间的复发率均优于对照组,差异有统计学意义(P<0.05)。结论立体定向微创手术治疗脑胶质瘤,可改善患者的CCS评分,近期总有效率高和复发率低,是安全有效的微创手术。     

CT引导下立体定向显微外科手术清除浅表脑实质内血肿

目的 介绍采用立体定向技术与显微外科技术相结合以清除浅表脑实质内血肿的手术方式和疗效.方法 对36例高血压性浅表脑实质内出血患者,头部安装Leksell立体定向框架,行头颅CT扫描定位,设计手术通路.采用局部麻醉下皮肤直切口,开颅骨小骨窗,在手术显微镜下切开脑皮层,逐步清除血肿,深部残余血肿者术后注入尿激酶溶解引流. 结果 术后复查CT,36例患者脑实质内血肿均得到有效清除.随访12 ～ 36个月,除2例失访外,其余患者按ADL分级评价:Ⅰ级(痊愈)9例占26.5％,Ⅱ级(轻残)16例占47.1％,Ⅲ级(中残)7例占20.6％,Ⅳ级(重残)2例占5.9％. 结论 应用CT引导下立体定向显微外科手术可以快速有效地清除血肿,获得良好的临床疗效.     

Application of a robotic telemanipulation system in stereotactic surgery

To assess the clinical usefulness, accuracy, and safety of telemanipulation for frameless stereotactic surgery using the CAS-BH5 robot system, we prospectively evaluated 10 patients (age: 5-79 years; mean: 44 years) who underwent telemanipulation frameless stereotactic operations from September to December 2005. The CAS-BH5 robot system consists of three main parts: a planning subsystem, a surgical localization subsystem, and a telemanipulation subsystem. Specifically, CAS-BH5 is capable of network communication, video transmission, graphic simulation and human-machine interaction, and thus facilitates remote planning and transmission of neuronavigation data, monitoring and manipulating. Telemanipulation was performed via a digital data network with a speed of 2,000 kilobytes per second by a neurosurgeon in Beijing while the patients were located in Yan'an, 1,300 km away. Remote fiducial registration was performed with a mean accuracy of 1.05 mm and the standard difference between the planned and actual trajectory was 0.13 mm. The mean time from fiducial registration to closure was 30.2 +/- 1.66 min. At 12-month follow-up, 90% of patients had improved neurologically. There were no complications. This preliminary data indicates that telemanipulation in frameless stereotactic surgeries is feasible, reliable and safe. In the future, we believe that telemanipulation will facilitate collaboration between surgeons, enhance training, allow for sharing of resources, and have wide applications in the field of neurosurgery.     

Accuracy of true frameless stereotaxy: in vivo measurement and laboratory phantom studies. Technical note.

The authors present the results of accuracy measurements, obtained in both laboratory phantom studies and an in vivo assessment, for a technique of frameless stereotaxy. An instrument holder was developed to facilitate stereotactic guidance and enable introduction of frameless methods to traditional frame-based procedures. The accuracy of frameless stereotaxy was assessed for images acquired using 0.5-tesla or 1.5-tesla magnetic resonance (MR) imaging or 2-mm axial, 3-mm axial, or 3-mm helical computerized tomography (CT) scanning. A clinical series is reported in which biopsy samples were obtained using a frameless stereotactic procedure, and the accuracy of these procedures was assessed using postoperative MR images and image fusion. The overall mean error of phantom frameless stereotaxy was found to be 1.3 mm (standard deviation [SD] 0.6 mm). The mean error for CT-directed frameless stereotaxy was 1.1 mm (SD 0.5 mm) and that for MR image-directed procedures was 1.4 mm (SD 0.7 mm). The CT-guided frameless stereotaxy was significantly more accurate than MR image-directed stereotaxy (p = 0.0001). In addition, 2-mm axial CT-guided stereotaxy was significantly more accurate than 3-mm axial CT-guided stereotaxy (p = 0.025). In the clinical series of 21 frameless stereotactically obtained biopsies, all specimens yielded the appropriate diagnosis and no complications ensued. Early postoperative MR images were obtained in 16 of these cases and displacement of the biopsy site from the intraoperative target was determined by fusion of pre- and postoperative image data sets. The mean in vivo linear error of frameless stereotactic biopsy sampling was 2.3 mm (SD 1.9 mm). The mean in vivo Euclidean error was 4.8 mm (SD 2 mm). The implications of these accuracy measurements and of error in stereotaxy are discussed.     

A New Procedure for Frameless Computer Navigated Stereotaxy

Summary ? Objective. Stereotactic procedures using frame-based systems have become well established in neurosurgery. Later, stereotactic computers have provided the neurosurgeon with a broader range of applications. A new, frameless stereotactic guide which utilizes the navigational abilities of a computer has been developed. This clinical study evaluates the accuracy and safety of the system when applied for puncture of tumours and abscesses in the cerebrum.  Methods. Using a frameless setup 36 patients were operated on for a total of 39 intracranial processes over a period of two years. Three patients were operated on twice. Computer data, time of surgery, anesthesia, complications, tumour localization and tissue examinations were recorded.  Results. Biopsies were obtained from all lobes of the cerebrum and a diagnosis established in all cases except two. Mean age and total range was 52 years and 15–82 years, respectively. Median time of surgery was approximately 60 minutes including positioning of the patient and the registration process on the stereotactic computer. Local anesthesia was used for 25 operations and general anesthesia for 14 operations. There was one postoperative abscess formation in a previously immunosupressed patient and a per-operative epileptic seizure caused by electrocoagulation of the dura in a second patient.  Conclusions. Based on this clinical study a new procedure for obtaining stereotactic biopsies of intracranial processes is introduced. All tumours were successfully reached with two cases of complications.     

An MKM-mounted instrument holder for frameless point-stereotactic procedures: a phantom-based accuracy evaluation.

To enable the use of the Mehrkoordinaten Manipulator (MKM) robotic navigation system for frameless point stereotactic procedures, a new instrument holder is presented. A phantom-based accuracy study was performed in which this new method was compared with frame-based procedures performed using the Brown-Roberts-Wells (BRW) stereotactic frame. The authors acquired computerized tomography scans of a test phantom, consisting of 19 acrylic plastic target rods on a circular base. These images were used in frame-based (BRW) and frameless (MKM) localization experiments. In both cases the authors calculated the distances between the actual target positions and the positions reached stereotactically. The mean application accuracy (target registration error) was 0.68 mm when the BRW frame was used and 0.96 mm when the MKM system was used after manual repositioning of the microscope (p < 0.001). Positioning accomplished using robotics only demonstrated a slightly larger inaccuracy: 1.47 mm (p < 0.005). Because the surgeon is concerned with the largest error in an individual case rather than the mean error in a large number of cases, the mean + three standard deviations was also compared. This value differed very little between the manually positioned MKM system and the BRW frame (2.04 mm and 1.84 mm, respectively). Although repeatability per target appeared to be slightly better when the BRW frame was used, accuracy was more homogeneous over the phantom volume when the MKM system was used (both differences were not significant). In conclusion, the accuracy of point stereotactic procedures performed using an instrument holder attached to the system is comparable with the accuracy of procedures involving a stereotactic frame. Moreover, the frameless techniques and robotic features of the MKM enable a more surgeon- and patient-friendly stereotactic procedure.     

Interventional MRI-guided frameless stereotaxy in pediatric patients

INTRODUCTION: We prospectively reviewed our experience with intraoperative MRI (iMRI)-guided stereotactic procedures in pediatric patients. METHODS: All procedures were performed within the magnet bore of the General Electric Signa SP MRI system, which allows for either continuous real-time or periodic imaging. The internal optical tracking system was used to plan and monitor target localization and instrument trajectory. RESULTS: Fifteen patients underwent 16 frameless stereotactic procedures, consisting of 4 tumor biopsies and 12 cyst aspirations and stereotactic catheter placements (average age 6 years, range 6 weeks to 18 years). There were no hemorrhagic, neurologic or infectious complications. CONCLUSION: iMRI is an important component in expanding the horizon of minimally invasive neurosurgery for pediatric patients. Thus far, we have found this technology to be safe, reliable and extremely useful for frameless stereotactic procedures.     

Clinical validation of true frameless stereotactic biopsy: analysis of the first 125 consecutive cases

OBJECTIVE: A lockable guide device, adjustable for positioning, was used to obtain samples for tissue analysis during brain biopsy procedures performed using an interactive image guidance system. Clinical validation of this technique, which was developed for true frameless stereotactic biopsies, and analyses of the histological yield, complication rate, and patient demographic characteristics for a large series of frameless stereotactic biopsies were the purposes of this study. METHODS: Demographic, radiological, surgical, and clinical data were prospectively collected for a series of 125 frameless stereotactic biopsies performed using the technique described in detail previously. RESULTS: Eighty-six procedures were magnetic resonance imaging-directed and 39 were computed tomography-directed. The mean diameter of the biopsied lesions was 36 mm, and the mean distance from the skin was 35.8 mm. Sixteen percent of the patients harbored multiple lesions, and 5.6% of the biopsied lesions were infratentorial. The mean operative time (including the entire anesthetic time) was 1.5 hours. The smear examination findings were corroborated by conclusive histological results in 96% of the cases, and definitive positive diagnoses were obtained in 122 cases (97.6%). Ten patients experienced surgical complications, but the sustained morbidity rate was 2.4% (including the death of a patient who was in critical clinical condition preoperatively and who died 2 mo later as a result of a chest infection; mortality rate, 0.8%). CONCLUSION: This true frameless stereotactic biopsy technique was associated with low morbidity and mortality rates and an excellent diagnostic yield, with overall results at least as good as those observed for frame-based stereotaxy. The excellent accuracy results demonstrated previously and statistically significant reductions in operative time, as well as improved image presentation, target selection, and simplicity, support the use of this frameless stereotactic technique in preference to frame-based biopsy techniques.     

The advantages of frameless stereotactic biopsy over frame-based biopsy

A comparison study is presented, which examines the outcome, complications and cost of stereotactic brain biopsy performed with a frameless versus a frame-based method. The technique of frameless stereotactic biopsy has been shown previously, in both laboratory and in vivo studies, to achieve a level of accuracy at least equal to frame-based biopsy. The investigators have validated the technique in a large clinical series. The frameless and frame-based series were concurrent, comprising 76 and 79 cases, respectively. The frameless stereotactic technique involved standard needle biopsy, targeted by an image-guidance system and directed by a novel rigid adjustable instrument-holder. Frame-based biopsies were performed with the CRW and Leksell systems. There were no significant differences in the demographics, lesion site, size and pathologies between the groups. Operating theatre occupancy and anaesthetic time were both significantly shorter for the frameless series than the frame-based series (p < 0.0001). In addition, the complication rate in the frameless biopsy series was significantly lower than in the frame-based series (p = 0.018). This resulted in lower ITU bed occupancy (p = 0.02), shorter mean hospital stay (p = 0.0013) and significant cost savings (p = 0.0022) for the frameless stereotactic biopsy group, despite the greater use of more expensive MRI in these cases. This comparison study demonstrates that the superior imaging, target visualization and flexibility of the technique of frameless stereotactic biopsy translates into tangible advantages for safety, time and cost when compared with the current gold-standard of frame-based biopsy. The principles are discussed and the authors propose a definition for the term 'frameless stereotaxy'.     

Frameless stereotactic placement of ventriculoperitoneal shunts in undersized ventricles: a simple modification to free-hand procedures

The aim of this report is to introduce a simple modification to the free-hand frameless stereotactic placement of ventriculoperitoneal shunts in undersized ventricles. In this technical note, we describe our experience with ventricular catheter placement in two children suffering from shunt dependent idiopathic intracranial hypertension using an image-guided instrument holder with a catheter guide. In both patients, the surgical procedure proved to be easy and accurate, with good initial clinical results. The use of an image-guided instrument holder is a modification to the free-hand frameless stereotactic placement of ventriculoperitoneal shunts in undersized ventricles.