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Real-Time Atlas-Based Stereotactic Neuronavigation

Vabulas, Mark BS*; Kumar, Vinodh A. MD; Hamilton, Jackson D. MD; Martinez, Juan J. MS§; Rao, Ganesh MD; Sawaya, Raymond MD; Prabhu, Sujit S. MD

doi: 10.1227/NEU.0000000000000199
Concepts, Innovations and Techniques
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BACKGROUND: Surgery for tumors in eloquent brain faces immense challenges when attempting to maximize resection and avoid neurological deficits.

OBJECTIVE: In order to give the surgeon real-time atlas-based anatomic information linked to the patient's anatomy, we developed a software-based interface between deformable anatomic templates (DATs) and an intraoperative navigation system.

METHODS: Magnetic resonance imaging (MRI), diffusion tensor imaging, and/or functional MRI were performed on 3 patients preoperatively for the purposes of tumor resection by the use of neuronavigation. The DAT was registered to the patients' navigation coordinate system and utilized coordinates from the navigation system during surgery. This provided the surgeon with a list of proximal anatomic and functional structures and a real-time image of the atlas at that location fused to the patient's MRI. The clinical feasibility of this approach was evaluated during the resection of 3 eloquent tumors (right postcentral gyrus, left inferior frontal gyrus, and left occipital cuneus gyrus).

RESULTS: Tumor resection was performed successfully in all 3 patients. With the use of the coordinates from the navigation system, anatomic and functional structures and their distances were visualized interactively during tumor resection by using the DAT.

CONCLUSION: This is a proof of concept that an interactive atlas-based navigation can provide detailed anatomic and functional information that supplements MRI, diffusion tensor imaging, and functional MRI. The atlas-based navigation generated distances to important anatomic structures from the navigation probe tip. It can be used to guide direct electrical stimulation and highlight areas to avoid during tumor resection.

ABBREVIATIONS: DAT, deformable anatomic template

DES, direct electrical stimulation

DTI, diffusion tensor imaging

fMRI, functional magnetic resonance imaging

*Anatom-e Information Systems, Ltd., Houston, Texas;

Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas;

§Brainlab Inc, Westchester, Illinois;

Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas

Correspondence: Sujit S. Prabhu, MD, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX 77030. E-mail:

Received June 19, 2013

Accepted September 25, 2013

Copyright © by the Congress of Neurological Surgeons