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VectorVision® - image-guided surgery

The history of brain surgery
Brain surgery is perhaps the oldest of all practiced medical arts. The remains of successful brain operations were found in France circa 7000 BC, and the success rate was remarkable even then. There is evidence of brain surgery as early as 3000 BC in Africa. Historical records show that surgery of the brain was practiced by Hippocrates in Greece, in the Roman times, and by Medieval surgeons in the Arab world, well until the 18th century. Hippocrates, the father of modern medical ethics, left many texts on brain surgery. Back in those times, surgeons didn't know about the function of the brain.

The road to scientific neurosurgery first began in the 19th century with the discovery that certain parts of the brain control temper, mood and intellect. One clinical case was fundamental in the discovery of the brain's functionality: a railroad construction supervisor received an extensive lesion of the frontal part of his brain when a steel rod traversed his skull. The injury then led to profound changes in his mood and character. This was the first time the connection between the brain and human behavior was recognized.

Since the first scientific operations, the medical devices and techniques used for neurosurgery have been continuously improving. Today, many different diseases can be treated by neurosurgical techniques.

When treating brain tumors, tumor resection (tumor removal by operation) is still a common treatment. Until recently, open neurosurgery meant a fairly high risk for patients in terms of damaging important structures of the brain. Today, computer-based neuronavigation or image-guided surgery assists the surgeon during all phases of the operation. This allows the surgeon to keep the operation minimally invasive and to avoid critical structures of the brain. Thus, the risks of paralysis or other impairments after surgery are minimized and recovery time is considerably reduced.

What is image-guided surgery?
Image-guided surgery has been employed in neurosurgery since the mid-1990s. This new technique relies on a powerful computer system, which assists the surgeon in precisely localizing a lesion, in planning each step of the procedure via a 3D model on the computer screen, and in calculating the ideal access to the tumor before the operation. The tumor and its surroundings can be viewed from different angles and in relation to landmark structures, such as the optic nerve or the brain stem. During the operating procedure, the movement of the instruments in use inside the brain can be tracked on the monitor with a precision of 1-2 millimeters, through which damage to healthy tissue and to critical areas can be avoided as much as possible.

What is VectorVision®?
VectorVision® is the state-of-the-art image-guided surgery system used for the resection of brain tumors, as well as for other neurosurgical applications. While conventional x-ray images depict tumors in two dimensions, VectorVision® provides the third dimension - depth - creating a three-dimensional image of the head and brain. This is particularly useful in reaching a tumor located deep within brain areas traditionally considered to be difficult to reach.


Vectorvision display


Thanks to pre-operative planning with VectorVision┬«, the procedure can be simulated on the computer: the surgeon can map out the surgical procedure ahead of time and can identify the best access to the tumor. The tumor's location and its position relative to the sensitive structures in the brain will be pinpointed so that sensitive structures can be avoided and the incision can be kept as small as possible. During the procedure, VectorVision® tracks instrument movement with an extremely high precision, providing the surgeon with total control inside the brain at all times using "real-time" imaging. The surgeon can also check if the tumor has been removed as planned. This improves the prognosis of the patient.

What types of surgery can be performed image-guided?

Stereotactic Biopsy
A stereotactic biopsy is performed in order to obtain an exact diagnosis of the tumor and to differentiate the tumor from healthy tissue or necrotic tissue. A small tissue sample is obtained from a defined region of the brain by using a long and very thin needle, which is passed through a skin puncture and tiny opening in the bone to the location of the tumor. The tissue sample is then examined by a pathologist and the nature of the lesion is determined. If the lesion proves to be a tumor, the type of tumor will be determined. The image-guided surgery system assures that the tissue sample is taken from the area of interest and not accidentally from the neighbouring region. It also helps in the pre-operative procedural planning, as well as in the avoidance of critical structures. A biopsy can be performed as part of the surgery to remove the tumor, or as a separate procedure. The risks of this procedure are low, including a less than 1% chance for significant hemmorrhage. Most patients are able to leave the hospital after a 24-hour stay.

The most commonly performed surgery for the removal of a brain tumor is called a craniotomy. A craniotomy is performed to rid the patient of the tumor or to halt its progress. The objective of the surgery is to excise as much of the tumor as possible. Even if only a portion of the tumor can be removed, this can still lead to an improvement of symptoms. In most cases, the remaining tumor has to be treated by other methods. For the surgery, a portion of the scalp is usually shaved, and an incision is made through the skin. A piece of bone is removed to expose the area of brain over the tumor, then the tumor is removed. After the tumor has been removed, the bone is generally replaced and the incision closed.

In a conventional craniotomy, surgeons guide themselves by what they can see, their knowledge of anatomy and their interpretation of the pre-operative scans. The greatest application of the image- guided surgery system is in anatomic navigation around tumor margins and determining regional anatomy. With the use of VectorVision®, the tumor, as well as different brain structures, can be well identified and viewed on the computer screen. The surgeon can navigate precisely to the tumor while avoiding sensible structures. The depth of the tumor can be mapped, as well as critical structures that might lie on the other side of the resection plane. Such navigation increases the precision of the procedure, and can increase the speed at which surgery can be performed.

Occasionally, patients with brain tumors develop increased intracranial pressure. To relieve the pressure, a shunt procedure to drain excess or blocked fluid might be necessary. When compared to other brain tumor surgery, the surgery to implant a shunt is relatively minor: a small hole is drilled in the skull through which a catheter - a narrow piece of flexible tubing - is inserted into a ventricle of the brain. The other end of the tubing is threaded to another body cavity where the fluid is drained and absorbed. A small incision is necessary at the body cavity to which the catheter is threaded (abdomen or chest). Shunts might be temporarily left in a position until the brain tumor has been surgically removed; yet in some cases, they may be permanent.

Image-guided surgery assures that the shunt can be accurately placed in the ventricle to reduce the intracranial pressure. Even with patients, in whom the build-up of fluid has lead to anatomical changes inside the brain, the procedure can still be safely performed. In most patients, the symptoms of increased intracranial pressure cease a couple of days after the operation, in other patients it may take up to a couple of weeks. If the symptoms reappear, a doctor should be consulted, as the catheter may be blocked or dislocated. Under certain circumstances, a second surgery may become necessary. Other complications, such as bacterial infections may also occur.

In many cases, patients with brain tumors are treated by the insertion of radioactive material (brachytherapy) or genetic material into the cavity left by the tumor's removal. VectorVision® is able to ensure the accurate placement of an implant into the defined area.

Functional Neurosurgery
The scans taken before surgery yield a great deal of information; however, they don't always provide the precision needed to avoid critical areas of the brain during surgery. Mapping tools can improve the safety and effectiveness of surgery by locating the exact areas of the brain responsible for speech, comprehension, sensation or movement. Specific areas of the brain are stimulated by a tiny electrical current, through which their functionality can be determined. This allows these areas to be avoided during surgery.

What are the side effects and complications of brain surgery?
The risk of side effects largely depends on the type of neurosurgical procedure performed. Some operations have higher risks than others, and for some the risk is lower. Please talk to your physician or neurosurgeon to find out what kind of side effects might occur in your individual case. An example of a difficult operation is that of the large acoustic neuroma. There is a serious risk of hearing loss and/or facial function on one side of the face. A shunt operation also carries the risk that the shunt may not be working properly following the operation. This means that an additional surgery may be necessary.

What can you expect as a patient?

 Marker Attachment Step 1 - Marker Attachment and Diagnostic Imaging
On the day of surgery or the day before the surgery, special adhesive markers will be attached to certain areas of your head. These markers are visible in the CT or MRI scan and will stay placed while the diagnostic images are taken. Later, when you are in the operating room, these markers are seen by the cameras of the VectorVision® navigation system and are used to pinpoint your exact position in the operating room. This procedure is not painful. The attachment of the markers, along with the diagnostic imaging, only take about 45 minutes.
 Treatment planning Step 2 - Treatment Planning
Following imaging, the data obtained from the CT/MRI is transferred to the VectorVision® planning station. The computer calculates a 3-D image of your head, based on the CT/MRI scan. A strategic plan for the optimal surgical approach can then be developed by your surgeon. Based on the information provided by the computer, your surgeon will plan the surgery in such a way as to avoid vital structures within the brain, and keep the surgical interference as small as possible. While you are being prepared for the operation and the general anesthesia is being applied, the plan is transferred to the neuronavigation system in the operating room.
 Surgery Step 3 - Surgery
After you have received general anesthesia, your head will be securely fixed to the operating table in order to avoid a shifting of your head. The cameras of the VectorVision® system track the exact position of your head as well as that of the surgeon's instruments. The monitor allows the surgeon to survey the entire procedure in real-time, and to view the brain and the tumor, as well as the instruments from different angles and viewpoints. The surgeon can then safely navigate towards the tumor.
  Step 4 - Post-operative
After the tumor resection is complete, the bone and skin flap are closed and you will be brought to the recovery room. In most cases, the surgical procedure will take about 4-5 hours. Treatment time may vary considerably depending on the type of surgical procedure.

For more information, contact:

Fred J. Epstein, MD
Director of the Institute for Neurology and Neurosurgery (INN)
Beth Israel North Medical Center
170 East End Avenue
New York 10128
(212) 870-9600

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