Stereotactic Neurosurgery Research Articles

Development of a miniaturized robotic guidance device for stereotactic neurosurgery.

Consistently high accuracy and a straightforward use of stereotactic guidance systems are crucial for precise stereotactic targeting and a short procedural duration. Although robotic guidance systems are widely used, currently available systems do not fully meet the requirements for a stereotactic guidance system that combines the advantages of frameless surgery and robotic technology. The authors developed and optimized a small-scale yet highly accurate guidance system that can be seamlessly integrated into an existing operating room (OR) setup due to its design. The aim of this clinical study is to outline the development of this miniature robotic guidance system and present the authors' clinical experience. After extensive preclinical testing of the robotic stereotactic guidance system, adaptations were implemented for robot fixation, software usability, navigation integration, and end-effector application. Development of the robotic system was then advanced in a clinical series of 150 patients between 2013 and 2019, including 111 needle biopsies, 13 catheter placements, and 26 stereoelectroencephalography (SEEG) electrode placements. During the clinical trial, constant modifications were implemented to meet the setup requirements, technical specifications, and workflow for each indication. For each application, specific setup, workflow, and median procedural accuracy were evaluated. Application of the miniature robotic system was feasible in 149 of 150 cases. The setup in each procedure was successfully implemented without adding significant OR time. The workflow was seamlessly integrated into the preexisting procedure. In the course of the study, procedural accuracy was improved. For the biopsy procedure, the real target error (RTE) was reduced from a mean of 1.8 ± 1.03 mm to 1.6 ± 0.82 mm at entry (p = 0.05), and from 1.7 ± 1.12 mm to 1.6 ± 0.72 mm at target (p = 0.04). For the SEEG procedures, the RTE was reduced from a mean of 1.43 ± 0.78 mm in the first half of the procedures to 1.12 ± 0.52 mm (p = 0.002) at entry in the second half, and from 1.82 ± 1.13 mm to 1.57 ± 0.98 mm (p = 0.069) at target, respectively. No healing complications or infections were observed in any case. The miniature robotic guidance device was able to prove its versatility and seamless integration into preexisting workflow by successful application in 149 stereotactic procedures. According to these data, the robot could significantly improve accuracy without adding time expenditure.

Pilot study of a new type of machine vision-assisted stereotactic neurosurgery for EVD placement.

The usage of machine vision technologies for image-based analysis and inspection is increasing. With the advent of the ability to process high-dimension data instantly, the possibilities of machine vision multiply exponentially. Robots now use this technology to assist in surgery. The aim of this study is to explore the efficacy of Surgical Navigation Robot NaoTrac (Brain Navi Biotechnology Co., Ltd.), which utilizes machine vision-inspired technology for patient registration and stereotactic external ventricular drainage (EVD) by the robotic arm. Preoperative and postoperative computed tomography (CT) scans were acquired for each case. The surgeons planned the targets and trajectories with the preoperative CT images. The postoperative CT images were utilized in the accuracy measurements. All 14 cases had cerebrospinal fluid drained through the catheter. The NaoTrac placed the catheter into the frontal horn in one attempt in 13 cases and was able to drain CSF in 12 cases. Not a single case had any bleeding or intraoperative complications. The average time spent on the patient registration was 142.8s. The mean target deviation was 1.68mm, and the mean angular deviation was 1.99°, all within the accepted tolerance for minimal tissue damage. The results of this report demonstrate that machine vision-inspired patient registration is feasible and fast. NaoTrac has demonstrated its accuracy and safety in performing frameless catheter placement in 13 clinical cases. Other stereotactic neurosurgical operations such as stereotactic biopsy, depth electrode placement, deep brain stimulation electrode positioning, and neuroendoscopy may also be benefited from the assistance of NaoTrac.

Characterization of neurosurgery fellowship directors: strengths and room for improvement.

While many current and aspiring neurosurgeons are looking to supplement their clinical practices with leadership positions, there has not been research characterizing current leadership positions such as fellowship directors (FDs) in neurosurgery to provide insight into objective qualities that distinguish these individuals from the rest of the workforce. This study aims to outline the current characterization of spine, endovascular, pediatric, and stereotactic and functional neurosurgery fellowship directors. A list of accredited neurosurgical fellowship programs located within the US and their respective directors was acquired through the AANS Neurosurgical Fellowship Training Program Directory. This study obtained educational, demographic, institutional, research, and professional background variables through curriculum vitae, institutional profiles, personal websites, emails, and the Scopus database. Of the 152 FDs analyzed, 143 (94%) were male, 9 (6%) were female, and the mean age was 52.2±8.5 years. The mean Scopus H-index and mean total citations for all FDs was 27±15.7 and 3782.1±4526.7, respectively. Furthermore, the majority of FDs were Caucasian (69.1%), followed by Asian (20.4%), Black or African American (5.3%), and Hispanic or Latino (5.3%). The mean number of years as FD was 8.9±7.2. This analysis showed neurosurgery fellowship directors are primarily Caucasian males. Neurosurgery training pedigree seems to play a role in FD attainment. In addition, these directors are largely distinguished by their research productivity. This analysis serves as an insight into the current climate for students aspiring to serve as academic leaders in the field of neurosurgery.

Lessons from the life of Asia's first female neurosurgeon for modern neurosurgical trainees and educators worldwide.

Surgical specialties, and particularly neurosurgery, have historically had and continue to have poor representation of female trainees. This is especially true of South Asia, considering the added social and cultural expectations for women in this region. Yet it was in India, with its difficult history of gender relations, that Asia's first fully qualified female neurosurgeon, Dr. T. S. Kanaka (1932-2018), took root, flourished, and thereafter played an integral role in helping develop stereotactic and functional neurosurgery in the country. While a few biographical accounts of her exist, highlighted here are the lessons from her illustrious life for neurosurgical trainees and educators worldwide, along with the instances that exemplify those lessons, drawn from several hitherto unutilized primary sources. These lessons are consistent with the factors identified in previous systematic reviews to be contributing to gender disparities in neurosurgery. Many of the virtues that ensured her success are attributes that continue to be critical for a neurosurgical career. Additionally, the circumstances that helped Kanaka succeed have been recounted as considerations for those working to promote diversity and inclusion. Finally, her life choices and sacrifices are described, which are underexplored but relevant concerns for women in neurosurgery.

The History of Stereotactic and Functional Neurosurgery in Zurich

Zurich's stereotactic and functional neurosurgery (SFN) has a rich legacy beginning with the studies of the physiologist and Nobel prize winner Walter Rudolf Hess over the efforts of the neurosurgeons Hugo Krayenbühl and Mahmut Gazi Yaşargil up to the work of the functional surgeon Jean Siegfried and the modern era of SFN and neuromodulation. A comprehensive review and synthesis of data acquired from institutional archives and personal interviews as well as from journal articles, included references, proceedings of scientific meetings, staff biographies, and book publications were performed to gain insight into Zurich's long journey toward contemporary SFN and to highlight its stereotactic and functional history with special reference to the development of deep brain stimulation. Zurich's history of medicine includes decisive moments for the fundamentals and development of SFN. After an early period of innovation and research later followed by a long time of clinical application during the 20th century, it became quieter at the turn of the century. Since the end of the 2000s, an impressive renaissance occurred in Zurich that revived its rich SFN tradition.

Accuracy of Robotic and Frame-Based Stereotactic Neurosurgery in a Phantom Model

BackgroundThe development of robotic systems has provided an alternative to frame-based stereotactic procedures. The aim of this experimental phantom study was to compare the mechanical accuracy of the Robotic Surgery Assistant (ROSA) and the Leksell stereotactic frame by reducing clinical and procedural factors to a minimum.MethodsTo precisely compare mechanical accuracy, a stereotactic system was chosen as reference for both methods. A thin layer CT scan with an acrylic phantom fixed to the frame and a localizer enabling the software to recognize the coordinate system was performed. For each of the five phantom targets, two different trajectories were planned, resulting in 10 trajectories. A series of five repetitions was performed, each time based on a new CT scan. Hence, 50 trajectories were analyzed for each method. X-rays of the final cannula position were fused with the planning data. The coordinates of the target point and the endpoint of the robot- or frame-guided probe were visually determined using the robotic software. The target point error (TPE) was calculated applying the Euclidian distance. The depth deviation along the trajectory and the lateral deviation were separately calculated.ResultsRobotics was significantly more accurate, with an arithmetic TPE mean of 0.53 mm (95% CI 0.41–0.55 mm) compared to 0.72 mm (95% CI 0.63–0.8 mm) in stereotaxy (p < 0.05). In robotics, the mean depth deviation along the trajectory was −0.22 mm (95% CI −0.25 to −0.14 mm). The mean lateral deviation was 0.43 mm (95% CI 0.32–0.49 mm). In frame-based stereotaxy, the mean depth deviation amounted to −0.20 mm (95% CI −0.26 to −0.14 mm), the mean lateral deviation to 0.65 mm (95% CI 0.55–0.74 mm).ConclusionBoth the robotic and frame-based approach proved accurate. The robotic procedure showed significantly higher accuracy. For both methods, procedural factors occurring during surgery might have a more relevant impact on overall accuracy.

Gamma Knife® stereotactic radiosurgery as a treatment for essential and parkinsonian tremor: long-term experience

IntroductionUnilateral Gamma Knife™ stereotactic radiosurgery on the ventral-intermediate nucleus of the thalamus is a minimally invasive neurosurgical option for refractory tremor. We describe the experience of Gamma Knife™ thalamotomy (GKT) in patients with essential tremor (ET) and tremor-dominant Parkinson's disease (PD) at our specialised stereotactic neurosurgery unit. MethodsWe reviewed the cases of patients treated with GKT between January 2014 and February 2018 with a minimum of 12 months’ follow-up. We analysed clinical and demographic variables, indication, radiation dose, effectiveness (based on subscales of the Fahn-Tolosa-Marin [FTM] scale and the Movement Disorders Society-Unified Parkinson's Disease Rating Scale [MDS-UPDRS] motor score), and adverse events. ResultsThirteen patients were registered, 6 with a diagnosis of tremor-dominant PD, four with refractory ET, and three with ET and PD. Median age was 78 years (range, 62-83), with seven patients aged over 75 years. Four patients were receiving anticoagulants and two had history of stroke. The maximum radiation dose administered was 130 Gy. Mean (standard deviation) follow-up duration was 30.0 (14.5) months. Significant tremor improvement was observed on the FTM subscales: 63.6% at 12 months and 63.5% at the end of follow-up; MDS-UPDRS tremor items showed improvements of 71.3% at 12 months and 60.3% at the end of follow up. Eleven patients reported significant improvements in quality of life, and 3 reported mild and transient adverse effects. ConclusionsThis is the largest series of patients with essential and parkinsonian tremor treated with GKT and followed up in the long term in Spain. GKT can be safe and effective in the long term in patients with refractory tremor, including in elderly patients and those receiving anticoagulants.

Jean Talairach (1911–2007). An untold story of the pioneer of stereotactic and functional neurosurgery

ContextThe Department of neurosurgery of the Sainte-Anne Hospital hosted Jean Talairach who created and developed stereotactic neurosurgery in France. Despite numerous neurosurgical and neuroscientific achievements, little is known about the life of Jean Talairach. MethodsSystematic screening of Sainte-Anne Hospital Museum, Henry Ey Library, and Bibliothèque Inter-Universitaire de Santé funds, and medical databases using the term “Jean Talairach”. ResultsJean Talairach started his medical career at the Sainte-Anne Hospital in 1942 as a psychiatrist and became a neurosurgeon due to his interest in stereotactic neurosurgery. During World War II, Jean Talairach joined the French Resistance in Paris, then the French First Army. Jean Talairach created an original and specific stereotactic methodology with appropriate stereotactic frame and tools and performed one of the first human stereotactic surgeries in 1948. He described the reference lines passing by the anterior and posterior commissures in 1952 and developed a tridimensional co-planar stereotactic atlas of the human brain. With the collaboration of Jean Bancaud, he created stereo-electroencephalography to investigate patients suffering from drug-resistant epilepsy. The “Sainte-Anne school” trained French and foreign stereotactic and functional neurosurgeons ensuring the spread of Jean Talairach's innovative ideas. Jean Talairach retired in 1980. ConclusionJean Talairach's achievements encapsulate the evolution of neurosurgery in France during the 20th century. He developed an original stereotactic methodology including a tridimensional stereotactic atlas of the human brain and a stereotactic frame. He created stereo-electroencephalography, which remains the gold-standard to investigate patients suffering from drug-resistant epilepsy.

Anaesthetic management in a patient with cervical dystonia undergoing pallidotomy

Stereotactic neurosurgery poses number of anaesthetic challenges. Awake craniotomy involves proper patient selection and co-ordination by the multi-disciplinary team. We report a case with isolated cervical dystonia posted for pallidotomy performed under Monitored Anaesthesia Care.: Awake craniotomy poses a unique challenge by itself. We had to face an additional challenge of difficult airway.

Thermocoagulation Treatment of a Patient with Obsessive Compulsive Disorder and Substance Use Disorder: Case Report

AbstractObsessive compulsive disorder (OCD) is a possible cause associated with substance use disorder (SUD), a set of physical, psychological, behavioral, and cognitive phenomena related to the use of one or more chemical substances as a priority in a person's life that compromises quality of life. Since they can share the same neuronal network, this serves as a basis for neurosurgical procedures in cases refractory to conventional therapies. A 31-year-old male patient with a history of OCD and SUD refractory to conventional therapies underwent bilateral ablative stereotactic neurosurgery of the anterior limb of the internal capsule, the subgenual cingulate region, the nucleus accumbens, and the cingulate gyrus. Up to 33 months after the the procedure, the patient showed an absolute improvement in OCD and SUD and reported lack of withdrawal signs or symptoms and/or need to use drugs. In recent years, ablative neurosurgery has proven to be an alternative to OCD refractoriness, with long-term benefits. In the case analyzed, ablative stereotactic neurosurgery was effective in controlling both the signs and symptoms triggered by OCD, as well as those of anxiety and stress.

Women in Neuromodulation: Innovative Contributions to Stereotactic and Functional Neurosurgery.

Stereotactic neurosurgery emerged in the mid-20th century following the development of a stereotactic frame by Spiegel and Wycis. Historically women were underrepresented in clinical and academic neurosurgery. There is still a significant deficit of female scientists in this field. This article aims to demonstrate the career and scientific work of some of the most important women who contributed to the development of stereotactic and functional neurosurgery. Exceptional women from all over the world, represented in this review, assisted the evolution of modern stereotactic and functional neurosurgery as neurosurgeons, neuropathologists, neurologists, neurophysiologists and occupational therapists. Fortunately, we could conclude that in the last two decades the number of female researchers has increased significantly.

A Brief Insight on Magnetic Resonance Conditional Neurosurgery Robots.

The brain is a delicate organ in the human body that requires extreme care. Brain-related diseases are unavoidable. Perse, neurosurgery is a complicated procedure that demands high precision and accuracy. Developing a surgical robot is a complex task. To date, there are only a handful of neurosurgery robots in the market that distinctly undergo clinical procedures. These robots have exorbitant cost that hinders the utmost care progress in the area as they are unaffordable. This paper looked at the historical perspective and presented insight literature of the magnetic resonance conditional stereotactic neurosurgery robots that find their ways in clinics, abandoning research projects and promising research yet to undergo clinical use. In addition, the study also gives a thorough insight into the advantage of magnetic resonance imaging modalities and magnetic resonance conditional robots and the future challenges in automation use. Image compatibility test data and accuracy results are also examined because they guarantee that these systems work correctly in particular imaging settings. The primary differences between these systems include actuation and control technologies, construction materials, and the degree of freedom. Thus, one system has an advantage over the other.

19th Biennial Meeting of the World Society for Stereotactic and Functional Neurosurgery 2022: Abstracts

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American Society for Stereotactic and Functional Neurosurgery 2022 Biennial Meeting Atlanta Georgia, June 4-7, 2022: Abstracts

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Contribution of Japan to Stereotactic and Functional Neurosurgery

Contribution of Japan to Stereotactic and Functional Neurosurgery

Optimal Path Planning for Stereotactic Neurosurgery based on an Elastostatic Cannula Model

In this paper, we propose a path-planning problem for stereotactic neurosurgery using concentric tube robots. The main goal is to reach a given region of interest inside the brain, e.g. a tumor, starting from a feasible point on the skull with an ideally short path avoiding certain sensitive brain areas. To describe the shape of the entire cannula from an entry point to the point of interest we use an existing mechanical model for continuum robots. We show numerically that our approach enables the surgeon to reach areas within the brain that would be impossible with a straight cannula as it is currently state of the art.

The American Society for Stereotactic and Functional Neurosurgery Position Statement on Laser Interstitial Thermal Therapy for the Treatment of Drug-Resistant Epilepsy.

Magnetic resonance image-guided laser interstitial thermal therapy (MRgLITT) is a novel tool in the neurosurgical armamentarium for the management of drug-resistant epilepsy. Given the recent introduction of this technology, the American Society for Stereotactic and Functional Neurosurgery (ASSFN), which acts as the joint section representing the field of stereotactic and functional neurosurgery on behalf of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, provides here the expert consensus opinion on evidence-based best practices for the use and implementation of this treatment modality. Indications for treatment are outlined, consisting of failure to respond to, or intolerance of, at least 2 appropriately chosen medications at appropriate doses for disabling, localization-related epilepsy in the setting of well-defined epileptogenic foci, or critical pathways of seizure propagation accessible by MRgLITT. Applications of MRgLITT in mesial temporal lobe epilepsy and hypothalamic hamartoma, along with its contraindications in the treatment of epilepsy, are discussed based on current evidence. To put this position statement in perspective, we detail the evidence and authority on which this ASSFN position statement is based.

Survey of practice preferences in deep brain stimulation surgery in the United States

ObjectiveDeep Brain Stimulation (DBS) is an established treatment modality for various movement disorders. There is sparse data reporting long-term efficacy and cost-effectiveness in DBS. The rapidly evolving techniques, devices and technology leads to highly variable practice patterns within the specialty. The purpose of this study is to survey the current variability in national practice patterns in DBS. MethodsWe conducted an online survey to investigate various practice preferences related to the perioperative management of DBS. Variables included practice types, hardware used, timing of surgery, and postoperative management. The survey was distributed electronically to all American Association of Neurological Surgeons (AANS)-registered board-certified neurosurgeons in North America with sub-specialty training in functional and stereotactic neurosurgery. ResultsWe received 40 responses from 114 surveys sent via email (35.1% response rate). There was notable heterogeneity in practice preferences specific to type of anesthesia utilized with the majority of respondents using conscious sedation (62.6%) or local anesthesia (22.5%). Less than half of respondents (47.5%) used intra-operative O-arm or computed tomography (CT) to confirm electrode positioning with fewer using intra-operative magnetic resonance imaging (15%). The greatest concordance amongst respondents pertained to placement of bilateral electrodes during the same case (72.5%), performing internal pulse generator placement on a later date (80%) and obtaining a post-operative CT (77.5%). There were additional practice differences in microelectrode recording, device specific characteristics and post-operative care. ConclusionPractice patterns in DBS vary widely and will grow more varied as new technology and devices become available. This may lead to overall increased cost and difficulty incorporating individualized technologies for patients, especially in light of hospitals’ financial structures. This study identified significant variability in anesthesia techniques, intraoperative imaging, microelectode recording, device selection and post-operative care. Understanding sources of variability in DBS may enable implementation of cost-efficient measures without compromising patient safety and outcomes.

Application of the anatomical fiducials framework to a clinical dataset of patients with Parkinson\u2019s disease

Establishing spatial correspondence between subject and template images is necessary in neuroimaging research and clinical applications such as brain mapping and stereotactic neurosurgery. Our anatomical fiducial (AFID) framework has recently been validated to serve as a quantitative measure of image registration based on salient anatomical features. In this study, we sought to apply the AFIDs protocol to the clinic, focusing on structural magnetic resonance images obtained from patients with Parkinson’s disease (PD). We confirmed AFIDs could be placed to millimetric accuracy in the PD dataset with results comparable to those in normal control subjects. We evaluated subject-to-template registration using this framework by aligning the clinical scans to standard template space using a robust open preprocessing workflow. We found that registration errors measured using AFIDs were higher than previously reported, suggesting the need for optimization of image processing pipelines for clinical grade datasets. Finally, we examined the utility of using point-to-point distances between AFIDs as a morphometric biomarker of PD, finding evidence of reduced distances between AFIDs that circumscribe regions known to be affected in PD including the substantia nigra. Overall, we provide evidence that AFIDs can be successfully applied in a clinical setting and utilized to provide localized and quantitative measures of registration error. AFIDs provide clinicians and researchers with a common, open framework for quality control and validation of spatial correspondence and the location of anatomical structures, facilitating aggregation of imaging datasets and comparisons between various neurological conditions.

Deep brain stimulation in patients on chronic antiplatelet or anticoagulation treatment

BackgroundIn the aging society, many patients with movement disorders, pain syndromes, or psychiatric disorders who are candidates for deep brain stimulation (DBS) surgery suffer also from cardiovascular co-morbidities that require chronic antiplatelet or anticoagulation treatment. Because of a presumed increased risk of intracranial hemorrhage during or after surgery and limited knowledge about perioperative management, chronic antiplatelet or anticoagulation treatment often has been considered a relative contraindication for DBS. Here, we evaluate whether or not there is an increased risk for intracranial hemorrhage or thromboembolic complications in patients on chronic treatment (paused for surgery or bridged with subcutaneous heparin) as compared to those without.MethodsOut of a series of 465 patients undergoing functional stereotactic neurosurgery, 34 patients were identified who were on chronic treatment before and after receiving DBS. In patients with antiplatelet treatment, medication was stopped in the perioperative period. In patients with vitamin K antagonists or novel oral anticoagulants (NOACs), heparin was used for bridging. All patients had postoperative stereotactic CT scans, and were followed up for 1 year after surgery.ResultsIn patients on chronic antiplatelet or anticoagulation treatment, intracranial hemorrhage occurred in 2/34 (5.9%) DBS surgeries, whereas the rate of intracranial hemorrhage was 15/431 (3.5%) in those without, which was statistically not significant. Implantable pulse generator pocket hematomas were seen in 2/34 (5.9%) surgeries in patients on chronic treatment and in 4/426 (0.9%) without. There were only 2 instances of thromboembolic complications which both occurred in patients without chronic treatment. There were no hemorrhagic complications during follow-up for 1 year.ConclusionsDBS surgery in patients on chronic antiplatelet or anticoagulation treatment is feasible. Also, there was no increased risk of hemorrhage in the first year of follow-up after DBS surgery. Appropriate patient selection and standardized perioperative management are necessary to reduce the risk of intracranial hemorrhage and thromboembolic complications.