Neuroendoscopy Based on Computer Assisted Adjustment of the Endoscope Holder in the Laboratory

Abstract

Objective: We present our initial clinical experience with a novel technique of frameless stereotactic neuroendoscopy using a neuronavigation system, a specially designed aiming device (endoscope holder/targeting device) combined with a vacuum-mouthpiece based head holder. Due to the reproducibility of patient immobilization in the fixation system, the endoscope holder can be adjusted in the laboratory in the absence of the patient.

Methods: An individual vacuum-mouthpiece was fabricated. The patients were scanned with an external reference frame attached to this mouthpiece and the images were transferred to the neuronavigation system. Determination of the path, mouthpiece-based registration and adjustment of the targeting device were performed the day before surgery in the absence of the patient. In the OR the patient was repositioned and the endoscope was introduced through the preadjusted aiming device to the precalculated depth.

Results: The novel technique was successfully used for frameless endoscopic navigation in five patients. Three endoscopic third ventriculostomies in adults, one endoscopic septostomy due to unilateral hydrocephalus in an adult female patient and one endoscopic ventriculo-cysto cisternostomy in a 20-month-old girl with a suprasellar arachnoid cyst, were performed with excellent clinical results and without technical complications.

Conclusion: Our initial experience indicates that frameless stereotaxy, in combination with a relocatable head holder and a special targeting device, allows for precise and preplanned advancement of the neuroendoscope, reducing or even eliminating intraoperative registration and endoscope trajectory adjustments, thus substantially reducing OR time. Due to the non-invasive but rigid immobilization method, neuronavigation can also be performed in children under 2 years of age.

Frameless stereotaxis - neuroendoscopy - stereotaxy - VBH head holder

References

• 1 Apuzzo M L, Chandrasoma P T, Cohen D, Zee C S, Zelman V. Computed imaging stereotaxy: experience and perspective related to 500 procedures applied to brain masses.  Neurosurgery. 1987;  20 930-937
• 2 Goodman R R. Magnetic resonance imaging-directed stereotactic endoscopic third ventriculostomy.  Neurosurgery. 1993;  32 1043-1047
• 3 Grunert P, Perneczky A, Resch K. Endoscopic procedures through the foramen interventriculare of Monro under stereotactical conditions.  Minim lnvasive Neurosurg. 1994;  37 2-8
• 4 Rhoten R L, Luciano M G, Barnett G H. Computer-assisted endoscopy for neurosurgical procedures: technical note.  Neurosurgery. 1997;  40 632-637
• 5 Benabid A L, Lavallee S, Hoffmann D, Cinquin P, Demongeot J, Danel F. Potential use of robots in endoscopic neurosurgery.  Acta Neurochir SuppI (Wien). 1992;  54 93-97
• 6 Caemaert J, Abdullah J, Calliauw L. A multipurpose cerebral endoscope and reflections on technique and instrumentation in endoscopic neurosurgery.  Acta Neurochir SuppI (Wien). 1994;  61 49-53
• 7 Fukushima T. Flexible endoneurosurgical therapy for aqueductal stenosis.  Neurosurgery. 1994;  34 379
• 8 Haines S, Camarata P, Finn M, Poss T. Prototype instruments for endoscopic microsurgery: technical note.  Minim lnvasive Neurosurg. 1995;  38 167-169
• 9 Heilman C B, Cohen A R. Endoscopic ventricular fenestration using a “saline torch”.  J Neurosurg. 1991;  74 224-229
• 10 Hellwig D, Bauer B L. Minimally invasive neurosurgery by means of ultrathin endoscopes.  Acta Neurochir SuppI (Wien). 1992;  54 63-68
• 11 McCallum J. Combined frameless stereotaxy and neuroendoscopy in placement of intracranial shunt catheters.  Pediatr Neurosurg. 1997;  26 127-129
• 12 Auer L M, Holzer P, Ascher P W, Heppner F. Endoscopic neurosurgery.  Acta Neurochir (Wien). 1988;  90 1-14
• 13 Caemaert J, Abdullah J. Diagnostic and therapeutic stereotactic cerebral endoscopy.  Acta Neurochir (Wien). 1993;  124 11-13
• 14 Caemaert J, Abdullah J, Calliauw L. Endoscopic diagnosis and treatment of para- and intraventricular cystic lesions.  Acta Neurochir Suppl (Wien). 1994;  61 69-75
• 15 Caemaert J, Abdullah J, Calliauw L, Carton D, Dhooge C, Coster R van. Endoscopic treatment of suprasellar arachnoid cysts.  Acta Neurochir (Wien). 1992;  119 68-73
• 16 Cohen A R. Ventriculoscopic surgery.  Clin Neurosurg. 1994;  41 546-562
• 17 Cohen A R. Endoscopic ventricular surgery.  Pediatr Neurosurg. 1993;  19 127-134
• 18 Decq P, Yepes C, Anno Y, Djindjian M, Nguyen J P, Keravel Y. Neurosurgical endoscopy. Diagnostic and therapeutic indications.  Neurochirurgie. 1994;  40 313-321
• 19 Sweeney R, Bale R, Vogele M, Nevinny-Stickel M, Bluhm A, Auer T, Hessenberger G, Lukas P. Repositioning accuracy: comparison of a noninvasive head holder with thermoplastic mask for fractionated radiotherapy and a case report.  Int J Radiat Oncol Biol Phys. 1998;  41 475-483
• 20 Bale R J, Sweeney R A, Burtscher J, Eisner W, Vogele M, Donnemiller E, Stockhammer G, Felber S, Lukas P, Jaschke W. A new concept of a unified approach in the treatment of brain tumors. HU Lemke, MW Vannier, K lnamura, AG Farman, and K Doi. (14), 679 - 683. 2000. ISRS, 2000 Elsevier Science B.C. Proceedings of the 14th International Congress and Exhibition CARS 2000, San Francisco
• 21 Bale R J, Burtscher J, Eisner W, Obwegeser A A, Rieger M, Sweeney R A, Dessl A, Giacomuzzi S M, Twerdy K, Jaschke W. Computer-assisted neurosurgery by using a noninvasive vacuum-affixed dental cast that acts as a reference base: another step toward a unified approach in the treatment of brain tumors.  J Neurosurg. 2000;  93 208-213
• 22 Bale R J, Vogele M, Freysinger W, Gunkel A R, Martin A, Bumm K, Thumfart W F. Minimally invasive head holder to improve the performance of frameless stereotactic surgery.  Laryngoscope. 1997;  107 373-377
• 23 Bale R J, Freysinger W, Gunkel A R, Vogele M, Sztankay A, Auer T, Eichberger P, Martin A, Auberger T, Scholtz A W, Jaschke W, Thumfart W F, Lukas P. Head and neck tumors: fractionated frameless stereotactic interstitial brachytherapy-initial experience.  Radiology. 2000;  214 591-595
• 24 Sweeney R A, Bale R, Auberger T, Vogele M, Foerster S, Nevinny-Stickel M, Lukas P. A simple and non-invasive vacuum mouthpiece-based head fixation system for high precision radiotherapy.  Strahlenther Onkol. 2001;  177 43-47
• 25 Adams L W, Burg W P van der, Vogele M, Bale R. Image Guided Surgery System. (96 202 690.2[PHN 16.013]). 1999 European Patent Office
• 26 Dorward N L, Alberti O, Dijkstra A, Buurman J, Kitchen N D, Thomas D G. Clinical introduction of an adjustable rigid instrument holder for frameless stereotactic interventions.  Comput Aided Surg. 1997;  2 180-185
• 27 Hellwig D, Benes L, Bertalanffy H, Bauer B L. Endoscopic stereotaxy - an eight year's experience.  Stereotact Funct Neurosurg. 1997;  68 90-97
• 28 Gumprecht H, Trost H A, Lumenta C B. Neuroendoscopy combined with frameless neuronavigation.  Br J Neurosurg. 2000;  14 129-131
• 29 Oka K, Yamamoto M, Ikeda K, Tomonaga M. Flexible endoneurosurgical therapy for aqueductal stenosis.  Neurosurgery. 1993;  33 236-242
• 30 Zamorano L, Chavantes C, Moure F. Endoscopic stereotactic interventions in the treatment of brain lesions.  Acta Neurochir SuppI (Wien). 1994;  61 92-97
• 31 Schroeder H W, Gaab M R, Niendorf W R. Neuroendoscopic approach to arachnoid cysts.  J Neurosurg. 1996;  85 293-298
• 32 Martin A, Bale R J, Vogele M, Gunkel A R, Thumfart W F, Freysinger W. Vogele-Bale-Hohner mouthpiece: registration device for frameless stereotactic surgery.  Radiology. 1998;  208 261-265