Neuronavigation in Skull Base Tumors

Abstract

Objective: Computer-assisted neuronavigation was used in 87 cases of skull base lesions (SBLs). Preoperative planning and intraoperative identification of anatomic landmarks is especially important in SBLs since it helps to avoid or minimize surgical morbidity and mortality. In this study, we assessed the accuracy and the clinical usefulness of a frameless system based on the optical digitizer in SBLs. Patients and Methods: Between April 2000 and March 2003, eighty-seven patients with SBLs were operated on in our department using cranial neuronavigation. A passive-marker-based neuronavigation system was used for intraoperative image guidance. There were 56 women and 31 men. The patient's ages ranged from 4 to 76 years (average: 45.7 year). The locations of the tumors reported in this series were as follows: frontobasal, 24 cases; sellar/parasellar, 32 cases; petroclival, 16 cases; tentorial/subtemporal, 15 cases. Results: The computer-calculated registration accuracy ranged between 0.3 and 1.7 mm (mean, 1.1 mm). Gross total removal of the SBLs was accomplished in 82 out of 87 patients as was confirmed on postoperative CT and MRI scans. The follow-up period ranged from 1 month to 48 months (average: 20.1 months). Overall mortality and severe morbidity (meningitis, permanent cranial nerve deficits, and cerebrospinal fluid fistulae) rates were 4.6 % and 33.3 %, respectively. Conclusion: The image-guided surgery is a valuable aid for safe, helpful and complete removal of SBLs of the brain where accurate localization of the lesion is critical. Although our preliminary series is not large, interactive image guidance provides a constant display of surgical instrument position during surgery and its relationship with the SBLs components, surrounding normal brain, and vascular structures, providing valuable guidance to the surgeon during an operation. Our experience with the neuronavigation suggests that image guidance is helpful in this type of lesions, providing better anatomic orientation during skull base surgery, delineating tumor margins and their relation to critical neurovascular structures.

Key words

Skull base tumors - frameless stereotaxy - neuronavigation

References

• 1 Barnett G H. Surgical management of convexity and falcine meningiomas using interactive image-guided surgery systems.  Neurosurg Clin North Am. 1996;  7 279-284
• 2 Eisenberg M B. The application of modern skull base techniques to routine neurosurgical problems.  Contemp Neurosurg. 2000;  22 1-7
• 3 Elias W J, Chadduck J B, Alden T D, Laws E D. Frameless stereotaxy for transsphenoidal surgery.  Neurosurgery. 1999;  45 271-277
• 4 Germano I M, Villalobos H, Silvers A. Postclinical use of the optical digitizer for intracranial neuronavigation.  Neurosurgery. 1999;  45 261-270
• 5 Gumprecht H K, Widenka D C, Lumenta C B. BrainLab VectorVision neuronavigation system: technology and clinical experience in 131 cases.  Neurosurgery. 1999;  44 97-105
• 6 Muacevic A, Steiger H J. Computer-assisted resection of cerebral arteriovenous malformations.  Neurosurgery. 1999;  45 1161-1171
• 7 Schul C, Wassmann H, Skopp G B, Marinov M, Wolfer J, Schuierer G, Joos U, Willich N. Surgical management of intraosseous skull base tumors with aid of Operating Arm System.  Comput Aided Surg. 1998;  3 312-319
• 8 Wagner W, Gaab M R, Schroeder H WS, Tschiltschke W. Cranial neuronavigation in neurosurgery: Assessment of usefulness in relation to type and site of pathology.  Minim Invas Neurosurg. 2000;  43 124-131
• 9 Ostertag C B, Warnke P C. Neuronavigation. Computer-assisted neurosurgery.  Nervenarzt. 1999;  70 517-521
• 10 Wadley J, Dorward N, Kitchen N, Thomas D. Pre-operative planning and intra-operative guidance in modern neurosurgery: a review of 300 cases.  Ann R Coll Surg Engl. 1999;  81 217-225
• 11 Watanabe E, Watanabe T, Manaka S, Mayanagi Y, Takakura K. Three-dimensional digitizer (neuronavigator): new equipment for computed tomography-guided stereotaxic surgery.  Surg Neurol. 1987;  27 543-547
• 12 Nimsky C, Ganslandt O, Kober H, Möller M, Ulmer S, Tomandl B, Fahlbusch R. Integration of functional magnetic resonance imaging supported by magnetoencephalography in functional neuronavigation.  Neurosurgery. 1999;  44 1249-1256
• 13 Klimek L, Mösges R, Laborde G, Korves B. Computer-assisted image-guided surgery in pediatric skull-base procedures.  J Pediatric Surg. 1995;  30 1673-1676
• 14 Mehdorn H M, Schrader B, Nabavi A, Hempelmann R. Neuronavigation in the region of the skull base.  Laryngorhinootologie. 2000;  79 404-411
• 15 Sure U, Alberti O, Petermeyer M, Becker R, Bertalanffy H. Advanced image-guided skull base surgery.  Surg Neurol. 2000;  53 563-572
• 16 Hill D LG, Hawkes D J, Crossman J E, Gleeson M J, Cox T CS, Bracey E EC, Strong A J, Graves P. Registration of MR and CT images for skull base surgery using point-like anatomical features.  Br J Radiol. 1991;  64 1030-1035
• 17 Al-Mefty O, Ayoubi S, Smith R R. The petrosal approach: indication, technique, and results.  Acta Neurochir. 1991 (suppl);  53 166-170
• 18 Al-Mefty O, Fox J L, Smith R R. Petrosal approach for petroclival meningiomas.  Neurosurgery. 1988;  22 510-517
• 19 Al-Mefty O. Supraorbital-pterional approach to skull base lesions.  Neurosurgery. 1987;  21 474-477
• 20 Al-Mefty O. The cranio-orbital zygomatic approach for intracranial lesions.  Contemp Neurosurg. 1992;  14 1-8
• 21 Cass S P, Sekhar L N, Pomeranz S, Hirsch B E, Synderman C H. Excision of petroclival tumors by a total petrosectomy approach.  Am J Otology. 1994;  15 474-484
• 22 Delashaw Jr J B, Tedeschi H, Rhoton A L. Modified supraorbital craniotomy: Technical note.  Neurosurgery. 1992;  30 954-956
• 23 Lang D A, Honeybul S, Neil-Dwyer N, Evans B T, Weller R O, Gill J. The extended transbasal approach: Clinical application and complication.  Acta Neurochir. 1999;  141 579-585
• 24 Raveh J, Laedrach K, Speiser M, Chen J, Vuillemin T, Seiler R, Ebeling U, Leibinger K. The subcranial approach for fronto-orbital and anteroposterior skull-base tumors.  Arch Otolaryngol Head Neck Surg. 1992;  119 385-393
• 25 Roux F X, Moussa R, Devaux B, Nataf F, Page P, Laccourreye O, Schwaab G, Brasnu D, Lacau Saint-Guily J. Subcranial fronto-orbito-nasal approach for ethmoidal cancers: Surgical techniques and results.  Surg Neurol. 1999;  52 501-510
• 26 Sanna M, Mazzoni A, Saleh E A, Taibah A K, Russo A. Lateral approaches to the median skull base through the petrous bone: The system of the modified transcochlear approach.  J Laryngol Otol. 1994;  108 1036-1044
• 27 Sekhar L N, Janecka I P, Jones N F. Subtemporal-infratemporal and basal subfrontal approach to the extensive cranial base tumor.  Acta Neurochir. 1998;  92 83-92
• 28 Sekhar L N, Schessel D A, Bucur S D, Raso J L, Wright D C. Partial labyrinthectomy petrous apicectomy approach to neoplastic and vascular lesions of the petroclival area.  Neurosurgery. 1999;  44 537-552
• 29 Shah J P, Kraus D H, Arbit E, Galicich J H. Craniofacial resection for tumors involving the anterior skull base.  Otolaryngol Head Neck Surg. 1992;  106 387-393
• 30 Dijk J MC Van, Thomeer R TWM. Control of complication in the midfrontobasal approach.  Acta Neurochir. 1997;  139 355-358
• 31 Zabramski J M, Talat K, Sankhia S K, Cabiol J, Spetzler R F. Orbitozygomatic craniotomy.  J Neurosurg. 1998;  89 336-341
• 32 Deschler D G, Gutin P H, Mamelak A N, McDermott M W, Kaplan M J. Complication of anterior skull base surgery.  Skull Base Surgery. 1996;  6 113-118
• 33 Dorward N L, Alberti O, Velani B, Gerritsen F A, Harkness W F, Kitchen N D, Thomas D G. Postimaging brain distortion: magnitude, correlates, and impact on neuronavigation.  J Neurosurg. 1998;  88 656-662
• 34 Catalano P J, Hecht C S, Biller H F, Lawson W, Post K D, Sachdev V, Sen C, Urken M L. Craniofacial resection: An analysis of 73 cases.  Arch Otolaryngol Head Neck Surg. 1994;  120 1203-1208