Assessment of a Patient-Specific, 3-Dimensionally Printed Endoscopic Sinus and Skull Base Surgical Model

OBJECTIVEDiffusion imaging tractography has allowed the in vivo description of brain white matter. One of its applications is preoperative planning for brain tumor resection. Due to a limited spatial and angular resolution, it is difficult for fiber tracking to delineate fiber crossing areas and small-scale structures, in particular brainstem tracts and cranial nerves. New methods are being developed but these involve extensive multistep tractography pipelines including the patient-specific design of multiple regions of interest (ROIs). The authors propose a new practical full tractography method that could be implemented in routine presurgical planning for skull base surgery.METHODSA Philips MRI machine provided diffusion-weighted and anatomical sequences for 2 healthy volunteers and 2 skull base tumor patients. Tractography of the full brainstem, the cerebellum, and cranial nerves was performed using the software DSI Studio, generalized-q-sampling reconstruction, orientation distribution function (ODF) of fibers, and a quantitative anisotropy–based generalized deterministic algorithm. No ROI or extensive manual filtering of spurious fibers was used. Tractography rendering was displayed in a tridimensional space with directional color code. This approach was also tested on diffusion data from the Human Connectome Project (HCP) database.RESULTSThe brainstem, the cerebellum, and the cisternal segments of most cranial nerves were depicted in all participants. In cases of skull base tumors, the tridimensional rendering permitted the visualization of the whole anatomical environment and cranial nerve displacement, thus helping the surgical strategy.CONCLUSIONSAs opposed to classical ROI-based methods, this novel full tractography approach could enable routine enhanced surgical planning or brain imaging for skull base tumors.

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Integrated multi-modality image-guided navigation for neurosurgery: open-source software platform using state-of-the-art clinical hardware

International Journal of Computer Assisted Radiology and Surgery ◽

10.1007/s11548-021-02374-5 ◽

2021 ◽

Author(s):

Jonathan Shapey ◽

Thomas Dowrick ◽

Rémi Delaunay ◽

Eleanor C. Mackle ◽

Stephen Thompson ◽

...

Keyword(s):

Skull Base ◽

Open Source ◽

Open Source Software ◽

Skull Base Surgery ◽

Patient Specific ◽

Software Platform ◽

Image Guided ◽

Phantom Model ◽

Technical Requirements ◽

Navigated Ultrasound

Abstract Purpose Image-guided surgery (IGS) is an integral part of modern neuro-oncology surgery. Navigated ultrasound provides the surgeon with reconstructed views of ultrasound data, but no commercial system presently permits its integration with other essential non-imaging-based intraoperative monitoring modalities such as intraoperative neuromonitoring. Such a system would be particularly useful in skull base neurosurgery. Methods We established functional and technical requirements of an integrated multi-modality IGS system tailored for skull base surgery with the ability to incorporate: (1) preoperative MRI data and associated 3D volume reconstructions, (2) real-time intraoperative neurophysiological data and (3) live reconstructed 3D ultrasound. We created an open-source software platform to integrate with readily available commercial hardware. We tested the accuracy of the system’s ultrasound navigation and reconstruction using a polyvinyl alcohol phantom model and simulated the use of the complete navigation system in a clinical operating room using a patient-specific phantom model. Results Experimental validation of the system’s navigated ultrasound component demonstrated accuracy of $$<4.5\,\hbox {mm}$$ < 4.5 mm and a frame rate of 25 frames per second. Clinical simulation confirmed that system assembly was straightforward, could be achieved in a clinically acceptable time of $$<15\,\hbox {min}$$ < 15 min and performed with a clinically acceptable level of accuracy. Conclusion We present an integrated open-source research platform for multi-modality IGS. The present prototype system was tailored for neurosurgery and met all minimum design requirements focused on skull base surgery. Future work aims to optimise the system further by addressing the remaining target requirements.

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Patient-Specific Cranial Nerve Identification Using a Discrete Deformable Contour Model for Skull Base Neurosurgery Planning and Simulation

Clinical Image-Based Procedures. Translational Research in Medical Imaging - Lecture Notes in Computer Science ◽

10.1007/978-3-319-31808-0_5 ◽

2016 ◽

pp. 36-44 ◽

Cited By ~ 1

Author(s):

Sharmin Sultana ◽

Jason E. Blatt ◽

Yueh Lee ◽

Matthew Ewend ◽

Justin S Cetas ◽

...

Keyword(s):

Skull Base ◽

Cranial Nerve ◽

Patient Specific ◽

Deformable Contour ◽

Contour Model ◽

Nerve Identification ◽

Neurosurgery Planning

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Patient-Specific Three-Dimensionally Printed Models for Presurgical Planning, Training, and Patient Education in Skull Base Surgery

10.1055/s-0039-1679701 ◽

2019 ◽

Author(s):

Sandip Panesar ◽

Kumar Abhinav ◽

Michael Magnetta ◽

Debraj Mukherjee ◽

Paul Gardner ◽

...

Keyword(s):

Patient Education ◽

Skull Base ◽

Skull Base Surgery ◽

Patient Specific ◽

Presurgical Planning

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Extent of Surgery in Endoscopic Transsphenoidal Skull Base Approaches and the Effects on Sinonasal Morbidity

American Journal of Rhinology and Allergy ◽

10.2500/ajra.2018.32.4499 ◽

2018 ◽

Vol 32 (1) ◽

pp. 52-56 ◽

Cited By ~ 9

Author(s):

Vincent Wu ◽

Michael D. Cusimano ◽

John M. Lee

Keyword(s):

Quality Of Life ◽

Skull Base ◽

Cerebral Spinal Fluid ◽

Spinal Fluid ◽

Patient Specific ◽

Tumor Pathology ◽

Fluid Leak ◽

Snot 22

Background Endoscopic transsphenoidal skull base surgery (ETSS) is now considered the criterion standard approach for resection of pituitary adenomas and other midline anterior skull base lesions. Normal sinonasal structures are resected during ETSS, which raises concerns for nasal morbidity and patient-based outcome. Objective To perform a surgical outcome assessment by examining whether the extent of ETSS approaches affected patient-specific sinonasal quality of life as measured by the 22-item Sino-Nasal Outcome Test (SNOT-22). Methods A single-center prospective cohort study of patients operated on by the same skull base team between 2012 and 2016. Patients with completed pre- and postoperative SNOT-22 were included. The primary outcome was SNOT-22 scores at preoperative, 0–1 month, 2–4 months, >5 months follow-up. Age, sex, tumor pathology, surgical procedure, and intraoperative cerebral spinal fluid leak repair were also obtained. Results Of the 249 ETSS performed, 148 patients (59%) had at least one completed SNOT-22; 45 (18%) met the inclusion criteria. Sinonasal quality of life based on SNOT-22 at the 0–1-month follow-up was significantly worse than the presurgical levels (p < 0.05). However, there was a return of SNOT-22 scores to preoperative levels at 2–4 months (p > 0.05), which was sustained at >5 months (p > 0.05). Factors such as the extent of ETSS, a previous nasal surgery, repair of an intraoperative cerebral spinal fluid leak, and the tumor pathology did not affect SNOT-22 scores at any follow-up intervals (p > 0.05). Conclusion Sinonasal quality of life worsened after ETSS at 0–1 month follow-up but returned to preoperative levels at 2–4 months and remained at postoperative levels >5 months. Analysis of these data will allow us to educate our patients that the anticipated nasal morbidity after ETSS is usually only transient and should be expected to recover to preoperative levels.

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Tissue Modeling in a Patient-Specific Skull Base Surgical Simulator

Otolaryngology ◽

10.1177/0194599811415823a312 ◽

2011 ◽

Vol 145 (2_suppl) ◽

pp. P230-P230

Author(s):

Erik Roberts ◽

Kenneth Salisbury ◽

Sonny Chan ◽

Nikolas H. Blevins

Keyword(s):

Skull Base ◽

Patient Specific ◽

Surgical Simulator ◽

Tissue Modeling

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Augmented Reality, Surgical Navigation, and 3D Printing for Transcanal Endoscopic Approach to the Petrous Apex

OTO Open ◽

10.1177/2473974x18804492 ◽

2018 ◽

Vol 2 (4) ◽

pp. 2473974X1880449 ◽

Cited By ~ 8

Author(s):

Samuel R. Barber ◽

Kevin Wong ◽

Vivek Kanumuri ◽

Ruwan Kiringoda ◽

Judith Kempfle ◽

...

Keyword(s):

Augmented Reality ◽

Skull Base ◽

Surgical Planning ◽

Preoperative Planning ◽

Endoscopic Approach ◽

Physical Models ◽

Petrous Apex ◽

Patient Specific ◽

Lateral Skull Base ◽

3D Printed

Otolaryngologists increasingly use patient-specific 3-dimensional (3D)–printed anatomic physical models for preoperative planning. However, few reports describe concomitant use with virtual models. Herein, we aim to (1) use a 3D-printed patient-specific physical model with lateral skull base navigation for preoperative planning, (2) review anatomy virtually via augmented reality (AR), and (3) compare physical and virtual models to intraoperative findings in a challenging case of a symptomatic petrous apex cyst. Computed tomography (CT) imaging was manually segmented to generate 3D models. AR facilitated virtual surgical planning. Navigation was then coupled to 3D-printed anatomy to simulate surgery using an endoscopic approach. Intraoperative findings were comparable to simulation. Virtual and physical models adequately addressed details of endoscopic surgery, including avoidance of critical structures. Complex lateral skull base cases may be optimized by surgical planning via 3D-printed simulation with navigation. Future studies will address whether simulation can improve patient outcomes.

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Infectious Complications of Expanded Endoscopic Transsphenoidal Surgery: A Retrospective Cohort Analysis of 100 Cases

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1696999 ◽

2019 ◽

Vol 81 (05) ◽

pp. 497-504

Author(s):

Seung J. Lee ◽

Justin Cohen ◽

Julie Chan ◽

Evan Walgama ◽

Arthur Wu ◽

...

Keyword(s):

Los Angeles ◽

Skull Base ◽

Transsphenoidal Surgery ◽

Medical Center ◽

Cohort Analysis ◽

Significant Risk ◽

Csf Leak ◽

Patient Specific ◽

Endoscopic Transsphenoidal Surgery ◽

Presumptive Diagnosis

Abstract Objective To identify perioperative factors that may predict postoperative cerebrospinal fluid (CSF) leak and meningitis following expanded endoscopic transsphenoidal surgery (EETS). Study Design This is a retrospective study. This study was set at the Cedars-Sinai Medical Center, Los Angeles. A total of 78 patients who underwent EETS between January 2007 and November 2018 were participated. The main outcome measures were CSF leak and meningitis. Results A total of 78 patients underwent a total of 100 EETS procedures; 17.9 and 10.3% of patients developed postoperative CSF leaks and meningitis, respectively. Out of eight, three patients with meningitis did not develop an observable CSF leak. The risk of developing meningitis in patients with a CSF leak was significantly higher than those without a leak, with an odds ratio (OR) of 11.48 (95% confidence interval, 2.33–56.47; p = 0.004). Pituicytomas were significantly associated with meningitis compared with other pathologies. No other patient-specific factors were identified as risks for leak or meningitis, including method of skull base repair, sex, tumor volume, or body mass index, although there was a strong trend toward reduced CSF leak rates in patient with nasoseptal flaps used for skull base repair, compared with those without (9.5 vs. 25%). CSF protein was consistently elevated on the first CSF values obtained when meningitis was suspected. Conclusion CSF leak and meningitis are common complications of expanded endonasal surgery No statistically significant risk factors for developing a postoperative leak other than the pathology of pituicytoma were identified, including method of skull base repair, although the use of a vascularized nasoseptal flap did trend toward a reduced CSF leak rate. CSF protein is the most sensitive marker for the presumptive diagnosis and timely treatment of meningitis.

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Open Anterior Skull Base Reconstruction: A Contemporary Review

Seminars in Plastic Surgery ◽

10.1055/s-0037-1607273 ◽

2017 ◽

Vol 31 (04) ◽

pp. 189-196 ◽

Cited By ~ 10

Author(s):

Alfred Iloreta ◽

Brett Miles ◽

Jared Inman ◽

Daniel Kwon

Keyword(s):

Skull Base ◽

Tumor Biology ◽

Free Tissue Transfer ◽

Patient Specific ◽

Surgical Approaches ◽

Skull Base Reconstruction ◽

Invasive Approach ◽

Endoscopic Techniques ◽

Interdisciplinary Field ◽

Reconstructive Techniques

AbstractSkull base extirpative and reconstructive surgery has undergone significant changes due to technological and operative advances. While endoscopic resection and reconstruction will continue to advance skull base surgery for the foreseeable future, traditional open surgical approaches and reconstructive techniques are still contemporarily employed as best practices in certain tumors or patient-specific anatomical cases. Skull base surgeons should strive to maintain a working knowledge and technical skill set to manage these challenging cases where endoscopic techniques have previously failed, are insufficient from anatomical constraints, or tumor biology with margin control supersedes the more minimally invasive approach. This review focuses on the reconstructive techniques available to the open skull base surgeon as an adjunct to the endoscopic reconstructive options. Anatomic considerations, factors relating to the defect or patient, reconstructive options of nonvascular grafts, local and regional flaps, and free tissue transfer are outlined using the literature and author's experience. Future directions in virtual surgical planning and emerging technologies will continue to enhance open and endoscopic skull base surgeon's preparation, performance, and outcomes in this continually developing interdisciplinary field.

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Automated Surgical Approach Planning for Complex Skull Base Targets: Development and Validation of a Cost Function and Semantic At-las

Surgical Innovation ◽

10.1177/1553350618782287 ◽

2018 ◽

Vol 25 (5) ◽

pp. 476-484 ◽

Cited By ~ 4

Author(s):

Nava Aghdasi ◽

Mark Whipple ◽

Ian M. Humphreys ◽

Kris S. Moe ◽

Blake Hannaford ◽

...

Keyword(s):

Cost Function ◽

Skull Base ◽

Surgical Approach ◽

Preoperative Planning ◽

Anatomical Variation ◽

Multidisciplinary Treatment ◽

Patient Specific ◽

Pareto Optimal Set ◽

Preoperative Ct ◽

Surgical Pathway

Successful multidisciplinary treatment of skull base pathology requires precise preoperative planning. Current surgical approach (pathway) selection for these complex procedures depends on an individual surgeon’s experiences and background training. Because of anatomical variation in both normal tissue and pathology (eg, tumor), a successful surgical pathway used on one patient is not necessarily the best approach on another patient. The question is how to define and obtain optimized patient-specific surgical approach pathways? In this article, we demonstrate that the surgeon’s knowledge and decision making in preoperative planning can be modeled by a multiobjective cost function in a retrospective analysis of actual complex skull base cases. Two different approaches— weighted-sum approach and Pareto optimality—were used with a defined cost function to derive optimized surgical pathways based on preoperative computed tomography (CT) scans and manually designated pathology. With the first method, surgeon’s preferences were input as a set of weights for each objective before the search. In the second approach, the surgeon’s preferences were used to select a surgical pathway from the computed Pareto optimal set. Using preoperative CT and magnetic resonance imaging, the patient-specific surgical pathways derived by these methods were similar (85% agreement) to the actual approaches performed on patients. In one case where the actual surgical approach was different, revision surgery was required and was performed utilizing the computationally derived approach pathway.

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