Intraoperative Imaging in Neurosurgery Karanjit Singh Narang, Ajaya Nand Jha
INDEX
ABCDEFGHIJKLMNOPRSTUVW
Page numbers followed by f refer to figure and t refer to table
A
Adenoid cystic carcinoma 136f, 137f
Adenomatous tissue, removal of 117f
Adenosine triphosphate 89
American College of Radiology 34
Aminolevulinic acid 88, 89, 92
Aneurysm
clips 61
microsurgery 146
Angiography, intraoperative 14
Anisotropy, functional 43
Anterior cranial fossa skull base 133f
Arteriovenous fistula 151f
Arteriovenous malformation 13, 42, 80, 145
microsurgery 148
surgery 173
ruptured 150f
Astrocytoma, low-grade 105f
Automated endoscopic system 173
Axial computed tomography angiography 149f
B
Basal ganglia intracerebral hematoma, deep-seated 152f
Blood
brain barrier 163, 174
oxygen level 97
pressure 32
Bone scan, intraoperative 128
Brain
biopsy 40
deep-seated cavernous malformation of 153f
roentgenography of 3f
shift 40
surgery 70, 72, 158
tumor, primary 41
Brainstem 154
cavernous malformation 155f
Burr hole transducer 80f
C
Cannula placement 172
Capnography 33, 60
Cardiac arrest 61
Carotid artery 111
Catheter placement 72
Cavernous malformation 84t, 153f
microsurgery, deep-seated 154, 154f
Cavernous sinus invasion 111
Central nervous system 88
Cerebellopontine angle 134
Cerebral
artery 147f
atrophy 12
vessels, angiography of 2
Cerebrospinal fluid 12, 39, 53, 85f, 96, 112, 113, 139, 159, 168
Cerebrovascular surgeries 144
Chondrosarcoma 136
low-grade 138f
Chronic neurodegenerative diseases 96
Cochlear implants 61
Computed tomography 26, 57, 63, 169
angiography 144
Convection-enhanced delivery 163, 172
Coproporphyrinogen oxidase 89
Coronal magnetic resonance imaging 140
Corticospinal tracts 159f
Cranial nerve 134
Craniocervical junction 75
Craniomaxillofacial surgery 65
Craniotomy 64, 80f
Cyst, large 85f
D
Deep arteriovenous malformation 149f
Deep brain stimulation 41, 41f, 64, 98, 163, 169, 172
Deep vein thrombosis 123
Delta-aminolevulinic acid 88
Diffusion tensor imaging 4, 9, 12f, 26, 31, 39, 43, 82, 97, 112, 148, 159, 169
Digital subtraction angiography 3f, 63, 144, 170
Dural arteriovenous fistulas 145, 150
E
Electrical cortical stimulation 160
Electrocardiogram 32
monitoring 60
Electrocortical mapping 161
Electrocortical stimulation 161
Electrodes reconstruction image 41f
Electroencephalography 99, 159
Electromyography 129
Endoscopic surgery 114f
Endotracheal tubes 60
Endovascular embolization 132
Enzymes 89f
Epilepsy 96
extratemporal 97
lesional 99
surgery 96
temporal 97
Ethmoidal fistula 151f
External pallidum 41f
F
Facial nerve 134
Fast contrast enhancement 113
Fluid attenuation inversion recovery 37, 92, 19, 105
Fluorescence, principles of 88
Fluoroscopy 63
Focal cortical dysplasia 99
Functional magnetic resonance imaging 26, 39, 96, 112, 159, 169
Functional mapping, invasive methods of 160
G
Gadolinium-contrast agents 61
Ganglioglioma 99
Gauss plot 33f
Glioblastoma 103, 104f
multiforme 17
contrast enhancing 49f
Glioma surgery 47, 102
Glomerular filtration rate 33, 61
Gross total resection 13, 88, 102, 118, 121
H
Haem biosynthetic pathway 89f
Hardy's grade 122t
Hemangioblastomas 14
Hematoma 150f, 151f
High-definition fiber tractography 153
High-field intraoperative magnetic resonance imaging 18, 31
High-grade glioma 82, 83f, 84f, 88, 102, 104
left frontoparietal 43f
resection of 15, 18
photodynamic detection of 90
Huntington's disease 175
Hyperechoic tissue 85f
I
Indocyanine green 42
videoangiography 148
Intracarotid amytal test 160
Intracerebral hematoma, aspiration of 72
Intracerebral hemorrhage
evacuation 150
nontraumatic 150
Intracranial biopsy 7t
Intracranial dural arteriovenous fistulas 150
Intracranial structure 83t
Intracranial vessels, angiography of 2
Intradural neurofibroma 86f
Intraoperative
computed tomography 14, 63, 64, 70, 71, 97, 127, 128
cone-beam computed tomography 8f
diffusion tensor imaging 26
functional magnetic resonance imaging 28
imaging techniques 128
magnetic resonance
imaging 8, 9f, 15, 18, 19, 26, 31, 33–35, 41, 49, 49f, 53, 58, 96, 97f, 102, 103, 104f, 105, 105f, 107, 111–113, 117, 118, 121, 127, 128, 130f, 162f
spectroscopy 28
neuromonitoring 128
neuronavigation 10, 146, 148
limitations of 12
ultrasound 13, 79, 96, 128
video monitoring 134
Intravenous gadolinium 37
Invasive blood pressure transducers 60
J
Jablonski diagram 88
Juvenile nasopharyngeal angiofibroma 135
K
Kaplan-Meier plot 130f
L
Laryngeal masks 60
Laryngoscopes 60
Laser interstitial thermal ablation therapy 161f
Low-field intraoperative magnetic resonance imaging 15, 31, 47
Low-grade glioma 13, 84, 103, 105
resection of 18
Lumbar discography 2
Lung cancer metastasis 85f
M
Magnetic resonance
angiography 42, 144
imaging 3, 26, 31, 35, 42f, 47, 58, 61, 63, 84t, 118, 138f, 144, 158, 168
scanning 79, 98
spectroscopy 32, 38, 41, 50
therapy 162
venography 42
Magnetic source imaging 20
Magnetoencephalography 35, 99, 159, 169
Matrix-assisted laser desorption ionization 163
Meningioma 82, 85f, 131, 133f
Mesial temporal sclerosis 97f
Metastasis 82
Methyl-l-tryptophan 169
Meyer's loop 98
Minimally invasive
brain surgery 73
spinal instrumentation 75
Mobile computed tomography scanner 71
Modern portable intraoperative ultrasound system 81f
Multicompartment disease 111
Multimodality image-guided neurosurgery 158
Myelography 1
N
Nasal stage 116
National Institutes of Health Stroke Scale Score 152
Near-field techniques 135
Nephrogenic systemic fibrosis 33
Neurosurgery 7, 31
Noninvasive blood pressure cuffs 60
Non-lesional epilepsy 99
Non-radiographic intraoperative imaging techniques 132
O
Obsessive compulsive disorder 169
Oligodendroglioma grade 84
Open neurosurgery 37
Orthopedic prostheses 61
P
Parkinson's disease 172
Pedicle screw 66, 74
Peritumoral edema 160f
Photodynamic therapy 92
Pituitary adenoma 111, 129
transsphenoidal resection of 112
Pituitary surgeries 111
Pneumoencephalography 1
Positron emission tomography 20, 26, 57, 99, 158, 169
Preoperative magnetic resonance imaging 10f, 12f, 97f, 133f, 136f–138f, 140f, 162f
Prosthetic heart valves 61
Pulse oximeters 33, 60
R
Radiographic intraoperative imaging techniques 132
Renal failure, chronic severe 33
Rotational three-dimensional angiography 144
S
Sclerosis, hippocampal 98
Sella, reconstruction of 117
Sellar stage 116
Single tensor streamline tractography 160f
Single voxel spectroscopy 38
Sinonasal mass, large 136f, 137f
Skull base 73
surgeries 65, 127
tumors 129
Skull, X-ray 2f
Somatosensory evoked potentials 129
Sphenoid sinus ostium 116
Sphenoidal stage 116
Spinal trauma 66
Spinal vessels, angiography of 2
Spine 66
surgery 42, 69, 74
Stereoelectroencephalography 174
Stereotactic procedures 64
Stimulated Raman spectroscopy 163
Substantia nigra 41f
Subtemporal craniotomy 138f
Subthalamic nucleus 41, 41f
Supratentorial cavernous malformation microsurgery 153
Syringe pumps 60
T
Target resection volume 107
Thalamus, anterior nucleus of 42f
Tractography 169
Transcranial magnetic stimulation 160, 170
Transsphenoidal
resection 140f
surgery 19, 41
Transverse magnetization 36
formation of 36f
Transverse relaxation time 36
Trauma 74
Tumor
benign 111
dimension 107
resection 65, 66, 74, 160
margins 37f
residual 105f
skull base 135
volume resection 122t
Turbo-spectroscopic imaging 38
U
Ultrasonography 63
V
Vascular neurosurgery 42
Vascular surgery 65
Ventricular cannulation 82
Ventriculography 1
Ventriculoperitoneal shunt placement 65
Vertebroplasty 66, 75
Vestibular schwannoma 127, 134
Vestibulocochlear nerve 134
Vomer stage 116
W
Wada testing 160
World Health Organization 18
×
Chapter Notes

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History of Neuroimaging1

Karanjit Singh Narang,
Rishabh Kedia,
Ajaya Nand Jha
 
INTRODUCTION
Advances in the field of radiology and in turn modern neurosurgery have been so rapid that, it is almost impossible to recall the older techniques and still be abreast with the latest modalities at the same time. The obsolete modalities have become a part of theoretical textbooks only. The neurosurgical residents of this generation might not even know about the older techniques such as pneumoencephalography. These advances are not just useful in making the work of a neurosurgeon easier, but at the same time, it helps in reducing the mortality and morbidity in patients or aid in better outcomes.1
 
GENEALOGY OF NEUROIMAGING
 
X-ray
Sir Victor Horsley was the first neurosurgeon to use X-rays in neurosurgery way back in the late 19th century after their discovery.2 Soon after the discovery of plain radiograph and its utility in clinical medicine, some specialists tried to X-ray of skull of patients in order to diagnose suspected lesions in the brain.3–6 One of the most famous publications of its time was “Röntgen-diagnostik der Erkrankungen des Kopfes” by Arthur Schüller.7 The same was later translated into English under the name “Radiology of Diseases of the Head”. “Neuroradiology” was first used by Schüller describing pathologies of the brain using skull radiographs.8 The modality gained such popularity in those times that Walter Dandy and George Heuer published a paper proving changes seen in 45 patients with brain tumors out of their enlisted 100 patients (Figure 1.1).9
However, this modality had its own limitations namely long period of immobility to acquire image, soft tissue pathologies could not be detected, neoplasms without bony involvement or calcification were literally invisible. In reality, by the time actual pathologies were identified on skull radiographs, clinically, it was too late for the patient to undergo any intervention.10 Despite of the advances over the centuries, spine radiograph is still an essential part of orthopedics and neurosurgery.
 
Ventriculography and Pneumoencephalography
Walter Dandy came up with an idea of somehow analyzing the changes in the morphology of the ventricles by injecting some contrast material, in order to localize lesions in the brain and diagnosing pathologies in a timely manner.10 He failed with his experiments using different radiopaque contrast materials, until he accidentally noticed that air in the ventricles in head injury patients made the ventricles partially radiopaque.10,11 This discovery resulted in further increase in detection capacity of brain tumors in his patients (Figure 1.2).12
Pneumoencephalography was also discovered by him, when he further noticed that the air from the ventricles escaped into the subarachnoid space.13 The procedure was then popularized in the form of drawing small amount of CSF during lumbar puncture and injecting air instead. This discovery paved the path for contrast studies of the brain.
However, these techniques proved to be associated with significant morbidity and mortality, especially with neurosurgeons other than Dandy.8 Through the following years of discovery, refinement of the procedure led to the discovery of a skull table by Lysholm which helped with the movement of patient in some positions to enable the air to move to different parts of the brain as needed.14
 
Myelography with Contrast
Myelography was first done using air as contrast medium as was the case with ventriculography in the early 20th century.15,16 By the same time, iodine was discovered to be a safe radiopaque contrast.2
zoom view
Figure 1.1: X-ray skullSource: Adapted from www.archive.org.
Although initially iodine was used with an oily medium, which led to cases of arachnoiditis and was later replaced by water soluble material over the next 50 years.17 Lumbar discography came to be popular in the mid-20th century where injection of radiopaque material was done directly into the intervertebral disks.18,19
 
Angiography of the Intracranial and Spinal Vessels
Egas Moniz dreamt of making either the brain or the cerebral vessels opaque on imaging. His efforts led to the discovery of angiography of cerebral vessels.20 In the early 20th century, he performed multiple experiments on animals and cadavers. Once confident of his method, he performed a “cutdown” to reach the carotid artery and injected contrast material directly into it making angiography possible. Loman and Myerson further refined the technique by allowing percutaneous access to the carotid artery and injecting contrast material without “‘cutdown” procedure.21 Angiography of the vertebral arteries was discovered approaching it through the brachial, subclavian, and vertebral arteries over the next few years.22 The most famous Seldinger technique, using a catheter instead of a needle, was devised in 1953, but it took almost 10 years to be used in cerebral angiography.23,243
zoom view
Figure 1.2: Roentgenography of the brain after the injection of air into the spinal canalSource: Adapted from Dandy WE. Röntgenography of brain after the injection of air into the spinal canal. Ann Surg. 1919;70:397-403.
The transfemoral approach was also developed along the same time and was accepted quite late. The technique kept improving with the help of technological advances such as digital subtraction, safer contrast agents, magnification technology, and multiple planes of imaging. Glue, particles, coils, and Onyx were discovered for intravascular procedures (Figure 1.3).
The procedure has withstood the early complications25 and the modern day cerebral angiography does not require any general anesthesia and takes much shorter time, thus reducing the incidence of the known complications.
Spinal angiography was developed almost four decades after cerebral angiography.26,27 It is still considered the gold standard for diagnosing spinal vascular lesions.28
 
Computed Tomography
The development of computed tomography (CT) started with the ideas of William Oldendorf29,30 and mathematically developed by physicist Allan Cormack.31,32 A few years later, Geoffrey Hounsfield developed a cross-sectional scanner based on the same concept. The first patient to be scanned using CT was a woman with a suspected tumor in her brain in 1972.33 This was followed by multiple patients and the first paper on CT imaging of the head was published in 1973.34 This proved to be a ground-breaking discovery of its time. Hounsfield and Cormack were the most famous names in the medical community worldwide and even received the Nobel prize for their contribution in 1979. The initial versions of a CT scanner allowed only imaging of the head. Multiple improvements and advancements of the initial idea of CT scanner led to bigger and better machines which could scan the entire human body. Eventually, advancements were made in decreasing the total radiation dosage, time taken for scans and quality of images. Earlier scans used 8–13 mm slice thickness, thus their quality was poor based on current scans. It took a few hours for the first machines to process each scan. The market politics estimated that not many CT scanners would be sold worldwide at the time of its inception due to its high cost and fewer advantages.35,36 This modality changed neurosurgery as we speak. It was beyond anyone's imagination that without cutting into the brain we would be able to see the contents of the brain. The initial advantages of a CT scan of brain helped in identifying bleeds, calcification, edema, and necrosis. With the introduction of intravenous contrast, CT angiography of cerebral vessels was also made possible. Once all this became a part of the routine practice, the age-old procedure of pneumoencephalography became obsolete (Figure 1.4).37,38
zoom view
Figure 1.3: Digital subtraction angiography of intracranial vessel
The biggest advantage of CT scan in diagnosing many intracranial pathologies with one single scan turned down all concerns regarding scanners using high doses of ionizing radiation, high costs, etc. It started being called a “doctor's toy” and was leading to less skilled doctors.39 All such skepticism has been proven wrong even decades after its discovery when it continues to be an indispensable tool even today.
 
Magnetic Resonance Imaging
Felix Bloch and Edward Purcell were the ones who developed the magnetic resonance imaging (MRI) based on nuclear magnetic resonance.40,41 It was the first time that an imaging modality did not involve any nuclear radiation.42 Raymond Damadian, a physician from the US, came up with the idea almost 25 years later that this modality could differentiate diseased tissue, especially tumors from normal tissue.434
zoom view
Figure 1.4: The first full body CT scannerSource: Adapted from The Washington Post.
Herman Carr published his thesis based on MRI at Harvard University in the same year as Bloch and Purcell.44 Paul Lauterbur was inspired by Carr's thesis and used it to devise a way of generating two-dimensional and three-dimensional MR images. The credit for constructing the first MRI machine goes to Damadian (1972). Lauterbur took out the first scan using MRI of a mouse a year later.45,46 Peter Mansfield developed a new algorithm for MRI machines which greatly reduced the time required to acquire images and improve their quality too. In 1977, Damadian, Minkoff and Goldsmith were able to acquire the first human MRI scan.47
Publications started coming in during the 1980s using MRI for neuroimaging, especially in comparison to CT images.48,49 The first MRI machine to be used in hospital set-ups commercially and contrast for MRI based on Gadolinium were also developed during the same time.16,50 MRI ever since its inception has revolutionized neuroimaging.51 It was earlier considered to be “extremely difficult, time-consuming, and often disappointing”.52 Its challenges still remain, especially in unstable patients and the ones who have a fear of closed spaces.53
 
Image-guided Neurosurgery and Stereotaxy
The ever-improving radiological modalities and technologies over the past few decades have led to improved diagnosis of neurosurgical diseases and also better treatment outcomes. All machines developed with the intention of accurately localizing intracranial structures based on landmarks on the surface were first devised using Broca's craniograph54 and Kocher's craniometer.55 They proved to be less than optimal and were not of much use clinically. Then came the “encephalometer” developed by Russian anatomist Zernov. He developed a device which was based on an arc-shaped instrument attached to the skull.56 Three-dimensional Cartesian coordinate system was used in experimental monkeys through orthogonal stereotactic frame by Victor Horsley and Robert Henry Clarke.57
In the early 20th century, Kirschner first used frame-based stereotaxy while injecting into the foramen ovale to treat trigeminal neuralgia.58 Ernest Spiegel and Henry Wycis developed the “stereoencephalotome”,59 and Lars Leksell was the legendary neurosurgeon who first developed the most popular stereotactic device to be used in humans. Spiegel and Wycis were the first surgeons to perform stereotactic thalamotomy in humans using radiography in stereotaxy based on landmarks inside the brain such as calcified pineal gland and ventricles. Leksell based his system on the radius of the arc which was later used by the popular frame developed by Edwin Todd and Trent Wells. This led to the eventual development of Brown-Robert-Wells frame which used data from the computed tomographic scans into the surgical setting.60 Jean Talairach devised a special frame used in epilepsy surgery for temporal lobe lesions and used the anterior and posterior commissure as basis of intracranial landmarks.61
Stereotactic neurosurgery for psychiatric and functional disorders lost their popularity soon after levodopa started being used as a treatment for Parkinson's disease.62 Over the years, CT and MRI scans got integrated with stereotaxy and more accurate targeting of regions and lesions in the brain were made possible. This revived stereotactic neurosurgery as developed by Leksell in the form of deep brain stimulation, vascular neurosurgery, epilepsy, neuro-oncology, and radiation therapy.63
Rapid advances in technology have facilitated the development of frameless neuronavigation systems, which began with Roberts and colleagues in 1986.64 Stealth Station and Vector Vision navigation systems have introduced technology and instruments that allow frameless stereotaxy, and have become popular with many neurosurgeons.65 Intraoperative MRI (iMRI) has been proven to be more effective in achieving better resections and in turn better survival in patients with gliomas. Multiple papers have been published in international journals acknowledging the fact as at least a level 2 evidence of the same.66 A recent study showed the use of iMRI for placement of ventricular catheters to prevent complications.67
During endovascular surgery, angiography can be used to provide regular updates. Plain X-ray image intensifiers are widely used in spinal surgery, for example, to ensure correct level localization and confirm screw position. Intraoperative ultrasound is also used in some centers, and may be particularly useful in the emergency setting to exclude hematoma collection.1 The acquisition of more than just standard MRI intraoperatively, particularly, functional MRI (fMRI) and diffusion tensor imaging (DTI), may offer 5additional safety for complex tumor resections68 and management of vascular lesions69 but robust evidence in this regard is awaited. However, the equipment used to obtain this data is expensive and thus not widely available, and there are some important considerations, including that iMRI prolongs surgery and requires reconfiguration of the operating room. Certainly, wherever available, preoperative functional imaging and particularly fMRI can assist neurosurgical operation planning.70
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