Integrated Intraoperative Flat-Panel CT, Vascular Imaging, and Navigation in Skull Base Surgery: An Initial Experience in the Geneva Hybrid Operating Suite

Abstract

Introduction: Although the advantages of intraoperative imaging in intra-axial tumors are well documented, their role in skull base surgery is not clarified yet. Here, we used an integrated hybrid operating room equipped with a flat panel arm for intraoperative angiography, interventional procedures, and CT acquisition for skull base tumor procedures and describe our initial experience with 19 procedures. Methods: A flat panel system, integrating a pivoting C-arc intraoperative CT (Philips Allura FD20), a surgical microscope (Zeiss Pentero), and infrared-based neuronavigation (Brainlab VectorVision II) was used. Intraoperative 3D angiography and same-session interventional procedures were also possible. Acquisition of images was performed pre-, peri-, or postoperatively. Results: Nineteen surgeries were performed on 15 patients from February 2008 to September 2012: 7 meningiomas (2 foramen magnum, 1 pontocerebellar, 1 sellar, 1 petrosigmoid, 1 jugular foramen, 1 petroclival), 9 chordomas and chondrosarcomas (6 of the clivus, 2 petrous, 1 petroclival), 1 foramen jugular schwannoma, 1 suprasellar teratoma, and 1 petrous breast cancer metastasis. Neuronavigation was used in 12 surgeries. An intraoperative CT was done and correlated to navigation in 5 patients (1 meningioma and 4 chordomas/chondrosarcomas) for resection control in 7 cases, and anatomical orientation in 2 cases. Intraoperative CT imaging was categorized as useful in all patients who had intraoperative CT (9/19, 47%) by helping surgical decisions (change or confirmation of surgical plan). Associated interventional procedures (one immediate preoperative tumor embolization and one endovascular obliteration of an associated dural arteriovenous fistula) were done in two patients. Conclusion: Perioperative CT imaging and navigation can be successfully integrated in skull base procedures without significantly disrupting the surgical workflow. The main advantages of this setting are real-time anatomic orientation and resection control when needed. Moreover, the possibility of one-session pre- or postoperative CT imaging, vascular imaging, or associated interventional procedures can further optimize surgical workflow. Overall, we judge that an integrated interventional suite and perioperative CT imaging increase the comfort of the surgeon in many procedures, although intraoperative CT was not always judged necessary. Whether integrated perioperative imaging increases resection rates or avoids complications needs to be assessed in further studies with more patients.