Abstract
BackgroundStereotactic neurosurgical procedures carry a risk of intracranial hemorrhage, which may result in significant morbidity and mortality. Vascular imaging is crucial for planning stereotactic procedures to prevent conflicts with intracranial vasculature. There is a wide range of vascular imaging methods used for stereoelectroencephalography (SEEG) trajectory planning. Computer-assisted planning (CAP) improves planning time and trajectory metrics. We aimed to quantify the effect of different vascular imaging protocols on CAP trajectories for SEEG.MethodsTen patients who had undergone SEEG (95 electrodes) following preoperative acquisition of gadolinium-enhanced magnetic resonance imaging (MR + Gad), magnetic resonance angiography and magnetic resonance angiography (MRV + MRA), and digital subtraction catheter angiography (DSA) were identified from a prospectively maintained database. SEEG implantations were planned using CAP using DSA segmentations as the gold standard. Strategies were then recreated using MRV + MRA and MR + Gad to define the “apparent” and “true” risk scores associated with each modality. Vessels of varying diameter were then iteratively removed from the DSA segmentation to identify the size at which all 3 vascular modalities returned the same safety metrics.ResultsCAP performed using DSA vessel segmentations resulted in significantly lower “true” risk scores and greater minimum distances from vasculature compared with the “true” risk associated with MR + Gad and MRV + MRA. MRV + MRA and MR + Gad returned similar risk scores to DSA when vessels <2 mm and <4 mm were not considered, respectively.ConclusionsSignificant variability in vascular imaging and trajectory planning practices exist for SEEG. CAP performed with MR + Gad or MRV + MRA alone returns “falsely” lower risk scores compared with DSA. It is unclear whether DSA is oversensitive and thus restricting potential trajectories.
Highlights
Stereoelectroencephalography (SEEG) is a procedure in which multiple electrodes are stereotactically inserted into predefined brain regions as part of the presurgical evaluation of patients with drug-resistant focal epilepsy.[1]
When evaluating the distribution of segmented digital subtraction catheter angiography (DSA) vessels according to brain anatomy (Figure 6), we found an equal chance of blood vessels being within sulci as within deep cortical tissue, i.e., at the target sites, which may explain why the inclusion of a sulcal model did not significantly change Computer-assisted planning (CAP) risk scores” (RS)
Accurate visualization of intracranial vasculature is key to safe trajectory planning
Summary
Stereoelectroencephalography (SEEG) is a procedure in which multiple electrodes (typically 8e14) are stereotactically inserted into predefined brain regions as part of the presurgical evaluation of patients with drug-resistant focal epilepsy.[1]. Key words - Computer-assisted planning - Epilepsy - EpiNav - Stereoelectroencephalography - Vascular segmentation. Abbreviations and Acronyms CAP: Computer-assisted planning DSA: Digital subtraction catheter angiography GIF: Geodesic information flows GM: Gray matter MD: Minimum distance MPRAGE: Magnetization prepared-rapid gradient echo MRA: Magnetic resonance angiography MR D Gad: Gadolinium-enhanced magnetic resonance imaging MRV: Magnetic resonance venography ROI: Region of interest RS: Risk score SEEG: Stereoelectroencephalography. Stereotactic neurosurgical procedures carry a risk of intracranial hemorrhage, which may result in significant morbidity and mortality. Vascular imaging is crucial for planning stereotactic procedures to prevent conflicts with intracranial vasculature. There is a wide range of vascular imaging methods used for stereoelectroencephalography (SEEG) trajectory planning. We aimed to quantify the effect of different vascular imaging protocols on CAP trajectories for SEEG
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