Visualization of anterior skull base defects with intraoperative cone-beam CT

Department of Otolaryngology-Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada.
Head & Neck (Impact Factor: 2.64). 01/2009; 32(4):504-12. DOI: 10.1002/hed.21219
Source: PubMed
The role of cone-beam CT (CBCT) in demonstrating anterior skull base defects (ASBDs), differing in size and location, was investigated. The study was designed to describe the potential advantage of CBCT in the setting of an intraoperative cerebrospinal fluid (CSF) leak.
In all, 120 ASBD were evaluated in 5 cadaver heads. Orthogonal and oblique slices were reconstructed. Observer studies assessed the visibility of ASBD in each location as a function of defect size.
For 1-, 2-, and 4-mm defects, the percentage that were undetectable ranged from 20% to 33%, 0% to 14%, and 0% to 5%, respectively. Confident breach detection increased with defect size and was most challenging in the lateral lamella and cribriform. CBCT permitted confident detection of ASBD as small as about 2 mm in the fovea ethmoidalis and planum. Oblique views were found to be superior to orthogonal planes.
The ability to identify ASBD depended on the size and location of defect. Oblique viewing planes were optimal for ASBD visualization.


Available from: Gil N Bachar
Gideon Bachar, MD,
* Emma Barker, MD,
* Harley Chan, PhD,
Michael J. Daly, MSc,
Sajendra Nithiananthan, BSc,
Al Vescan, MD,
Jonathan C. Irish, MD,
Jeffrey H. Siewerdsen, PhD
Department of Otolaryngology–Head and Neck Surgery, Department of Surgical Oncology,
Princess Margaret Hospital, Toronto, Ontario, Canada. E-mail:
Ontario Cancer Institute, Princess Margaret Hospital, University Health Network,
The Institute of Medical Science at the University of Toronto, Toronto, Ontario, Canada
Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
Department of Otolaryngology–Head and Neck Surgery, Mount Sinai Hospital, Toronto, Canada
Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
Accepted 17 June 2009
Published online 19 August 2009 in Wiley InterScience ( DOI: 10.1002/hed.21219
Abstract: Background. The role of cone-beam CT (CBCT)
in demonstrating anterior skull base defects (ASBDs), differing
in size and location, was investigated. The study was designed
to describe the potential advantage of CBCT in the setting of
an intraoperative cerebrospinal fluid (CSF) leak.
Methods. In all, 120 ASBD were evaluated in 5 cadaver
heads. Orthogonal and oblique slices were reconstructed. Ob-
server studies assessed the visibility of ASBD in each location
as a function of defect size.
Results. For 1-, 2-, and 4-mm defects, the percentage that
were undetectable ranged from 20% to 33%, 0% to 14%, and
0% to 5%, respectively. Confident breach detection increased
with defect size and was most challenging in the lateral
lamella and cribriform. CBCT permitted confident detection of
ASBD as small as about 2 mm in the fovea ethmoidalis and
planum. Oblique views were found to be superior to orthogo-
nal planes.
Conclusions. The ability to identify ASBD depended on the
size and location of defect. Oblique viewing planes were opti-
mal for ASBD visualization.
2009 Wiley Periodicals, Inc.
Head Neck 32: 504–512, 2010
Keywords: cone-beam CT; sinus; skull base; surgery;
intraoperative; imaging; cerebrospinal fluid (CSF)
Cerebrospinal fluid (CSF) rhinorrhea results
from a breach in the anterior skull base, leading
to a direct communication between the subarach-
noid space and either the sinus or nasal cavity.
Classified according to etiology,
mately 90% of cases are a result of trauma,
either an accide nt or a postsurgical (iatrogenic)
CSF rhinorrhea resulting fro m an iatrogenic
surgical complication is an increasing concern
as a result of the increasing popularity of endo-
scopic sinus surgery and closed neurosurgical
procedures. The size and anatomic location of
Correspondence to: G. Bachar
*The first 2 authors contributed equally to this work.
2009 Wiley Periodicals, Inc.
504 Intraoperative Cone-Beam CT HEAD & NECK—DOI 10.1002/hed April 2010
Page 1
an anterior skull base defect are multifactoral,
depending on the type of procedure, extent and
location of disease, surgical instruments used,
and surgical expertise.
Skull base anatomy presents a complicated
architecture predisposed to iatrogenic CSF leaks
that can be difficult to detect intraoperatively.
CSF rhinorrhea may be associated with both sig-
nificant morbidity and mortality. Meningitis is
the most common complication, with a reported
incidence of 19% in patients with persistent CSF
Other complications include ortho-
static (upright) headache, intracranial infections,
pneumocephalus, and bleeding.
CSF leaks that are diagnosed intraoperatively
are treated immediately. In cases in which the
leak is diagnosed a few days after surgery, a con-
servative approach is generally adopted.
with CSF leaks present a diagnostic challenge to
the surgeon. Various preoperative imaging modal-
ities are available for the diagnosis and identifica-
tion of a CSF leak. High-resolution CT scans, T2-
weighted MRI, MR cisternography, and intrathe-
cal fluorescein have all been described.
ever, both radionuclide cisterno graphy and
contrast-enhanced CT cisternography have been
the mainstay of evaluation of a skull base defect.
The clear disadvantage of the cystenography
studies is the need for intrathecal injection. These
are invasive, time consuming, and include poten-
tial side effects of headache, nausea, vomiting,
seizures, and intracerebral hemorrhage.
ability to identify a CSF leak during the surgical
procedure has a significant advantage. It enables
the surgeon to immediately seal the skull base
defect and to minimize the risk of further trauma
and postoperative complications.
To overcome the limitations associated with
guidance based on preoperative image data, we
described a technology for 3-dimensional (3D)
cone-beam CT (CBCT) imaging using a mobile C-
arm modified to include a high-performance flat-
panel x-ray detector.
The method operates
similar to CT, exce pt CBCT captures an entire
volume image in a single half-rotation (180
about the patient at lower radiation dose. Its
application in head and neck surgery has been
reported in a variety of studies,
and a system
for CBCT-guided head and neck surgery has
entered research trials at our institution. In the
present study, we investig ated the role of CBCT
in demonstrating anterior sku ll base defects
(ASBDs) varying in size and anatomic location.
The study was designed to evaluate the perform-
ance of CBCT for intra operative detection of an-
terior skull base CSF leak.
C-Arm for Cone-Beam CT Imaging.
A prototype
mobile isocentric C-arm (Siemens PowerMobil)
was developed in collaboration with Siemens
Healthcare (Special Products Division, Erlangen,
Germany) for intraoperative CBCT. As illustrated
in Figure 1A, the C-arm was modified to include
FIGURE 1.(A) Experimental setup showing the C-arm and cadaveric head. (B) Endoscopic photograph illustrating skull base defects
after total ethmoidectomy, medial maxillectomy, sphenoidotomy, and excision of the pituitary gland. Eight locations were systematically
breached: (1 and 2) left and right cribriform plate; (3 and 4) left and right lateral lamella; (5 and 6) left and right fovea ethmoidalis; and
(7 and 8) left and right planum, respectively. The figure shows a specimen with 2-mm-diameter defects introduced at each location.
[Color figure can be viewed in the online issue, which is available at]
Intraoperative Cone-Beam CT HEAD & NECK—DOI 10.1002/hed April 2010 505
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a flat-panel detector (FPD; PaxScan 4030CB,
Varian, Palo Alto, CA), a motorized orbital drive,
geometric calibration, and a computer control sys-
tem for 3D reconstruction. CBCT acquisition
involved collection of projections across a rota-
tional arc of about 178
, nominally 200 projections
acquired in about 60 s (3.3 fps). The 3D field of
view (FOV, 20 cm 20 cm 15 cm) is sufficient
to encompass the skull base.
ated with CBCT imaging on the C-arm has been
previously described
: approximately 2.9 mGy
sufficient for visualization of bone and soft tis-
sues, respectively. Such dose levels represent a
fraction (1/10–1/3) that of diagnostic CT.
Specimen Preparation and CBCT Imaging. Five
cadaver heads were acquired from the Division of
Anatomy, University of Toronto, in accord with
the Anatomy Act of Ontario. All heads were ini-
tially scanned on a 16-slice diagnostic CT scanner
(Discovery PET-CT; General Electric, Milwaukee,
WI) to review any anatomic variations and
excluded any anatomic abnormality or disease.
During the head preparation, each head under-
went a complete surgical clearance of the eth-
moid, maxillary, and sphenoidal sinuses. Air
space along the skull base (attributed to postfixa-
tion brain shrinkage) was filled with water-equiv-
alent gel via craniotomy. Subsequently, the
cranial bone flap was reopposed and secured.
After preparation, a baseline CBCT scan was
taken. Each head was immobilized in a carbon-
fiber frame using 6 to 8 cranial pins, and was
supported at the C-arm isocenter for each scan.
Eight locations on the anterior skull base were
selected for introduction of skull base breach as
illustrated in Figure 1B: the (left and right) cri-
briform plate, fovea ethmoidalis, lateral lamella,
and planum. After the baseline scan, an experi-
enced skull base surgeon used a 1-mm-diameter
drill to introduce skull base defects into each
site, and a second CBCT scan was acquired.
Then each of the 1-mm defects was widened
using a 2-mm drill (2-mm defects are shown in
Figure 2), followed by a third CBCT scan.
Finally, all sites were drilled to a 4-mm diame-
ter, and a final CBCT scan was acquired.
Visualization of Skull Base Defects: Observer Study
and Data Analysis.
The images were viewed in 3D
visualization software (3D Slicer v3.2; Brigham &
Women’s Hospital, Boston, MA, and Massachu-
setts Institute of Technology, Cambridge, MA).
The 3D coordinates of each defect were iden-
tified by an independent observer. For smaller
defects that were difficult to identify (eg, 1 mm),
the coordinates of the large defects (4 mm) were
translated to the earlier scans, using anatomic
landmarks to account for possible displacement
of the specimen between scans. In all, 120
defects (5 heads 8 locations 3 diameters)
were thus localized.
For the observer studies described in the fol-
lowing text, image slices through each defect
were extracted from CBCT volume reconstruc-
tions using the ‘‘3D Slicer’’ software. These
included ‘‘orthogonal’’ slices that correspond to
conventional triplanar views (coronal, sagittal,
and axial) as well as ‘‘oblique’’ slices. The
oblique slices included both a coronal and a lon-
gitudinal slice (ie, a quasi-sagittal slice in the
plane of the drill) and a tangential slice (ie, a
quasi-axial slice in the plane of the defect).
For each defect, an area of interest was
cropped from t he image such that the defect
was presented in the center of the image. Slice
triples (either orthogonal or oblique) were dis-
played in comparison with the corresponding
‘‘baseline’’ area of interest (ie, the identical area
of skull base before introduction of a defect).
Example images are shown in Figures 2 and 3
for each anatomic location.
Observer studies were conducted to assess
visibility of skull base defects in each location as
a function of defect size. Five expert observers
participated, including 1 radiologist, 2 skull
base surgeons, and 2 head and neck surgeons.
The study was conducted under controlled view-
ing conditions: a darkened reading room on a
diagnostic workstation (Dell Precision 380, 3-
GHz Pentium 4 with dual-head Barco displays,
1536 2048 resolution, 8-bit grayscale; Dell
Inc., Round Rock, TX). A fixed viewing distance
of 50 cm was recommended but not enforc ed.
Observers received identical instructions and
training. Reading order across 120 cases was in-
dependently randomized for each observer. For
each case, observers were shown (1) the full
FOV (nominal resolution) coronal and sagittal
images for purposes of orientation; (2) the base-
line images (orthogonal or oblique slices with no
defect); and (3) the defect images (orthogonal or
oblique slices with a defect). Observers were
then asked to rate their satisfaction in detect-
ing, localizing, and characterizing the defect on
a scale of 1 to 5 (1 ¼ Unable to identify any
breach, 2 ¼ The breach could be overlooked, 3 ¼
506 Intraoperative Cone-Beam CT HEAD & NECK—DOI 10.1002/hed April 2010
Page 3
The breach is visible, but detection and charac-
terization of subtle features are a bit challeng-
ing, 4 ¼ The Breach is visible, 5 ¼ The breach
is perfectly obvious).
The results were analyzed using both a
mixed-regression model and trend testing. Mean
values (and SD) in observer scores were ana-
lyzed as a function of anatomic location (4 sites)
and defect size (3 diameters). Results were also
analyzed for orthogonal views compared with
oblique views to see whether the latter more
clearly demonstrated defects. A paired t test
(Wilcoxon) was used to test statistical signifi-
cance in observer scores between orthogonal and
oblique views.
Of the 120 defects (5 heads 8 locations 3
diameters), 102 were deemed successful ([5 2
3] ¼ 30 in the planum, 30 in the fovea eth-
moidalis, 29 in the lateral lamella, and 13 in the
cribriform). The shortfall of cases in the cribri-
form was attributed to difficulty in drilling large
(4-mm) defects, which was technically challeng-
ing because of the thickness of the skull base at
this point, resulting in a much bigger defect
being created than desired and thus leading to
rejection of nearly 17 cases from the analysis.
The percentage of defects that were judged
undetectable (a score of 1) depended on the loca-
tion and size of the defect. For the 1-mm defects,
the percentage judged undetectable ranged
from 20% to 33% (specifically, 30% [cribriform],
33% [lateral lamella], 20% [fovea ethmoidalis],
and 21% [planum]). For the 2-mm defects, the
percentage judged undetectable was consider-
ably lower, 0% to 14% (12% [cribriform], 14% [lat-
eral lamella], 0% [fovea ethmoidalis], and 1%
FIGURE 2. Illustration of variable defect size (baseline, 1-, 2-, and 4-mm-diameter breach). Examples correspond to defects in the pla-
num demonstrated in orthogonal (coronal, sagittal, and axial) views. Cone-beam computed tomographic (CBCT) images. Throughout
the following figures, the full field-of-view (FOV) images (left) at ‘nominal’ resolution (0.8-mm voxels) illustrate the surrounding ana-
tomic context. The zoomed images (right) at ‘high’ resolution (0.4-mm voxels) illustrate the region of the breach. In each case, the
breach is near the center of the image, and its location is demarked by gray triangles at the image boundaries.
Intraoperative Cone-Beam CT HEAD & NECK—DOI 10.1002/hed April 2010 507
Page 4
[planum]). The 4-mm defects were almost always
detectable, with 0% to 5% rated undetectable (5%
[cribriform], 2% [lateral lamella], 1% [fovea eth-
moidalis], and 0% [planum]). Besides demon-
strating more confident detection for larger
defects, these results indicate that breach
FIGURE 3. Illustration of skull base breach in regions of the cribriform plate (A), fovea ethmoidalis (B), lateral lamella (C), and planum
(D). Each example shows baseline images in comparison to images of a 2-mm defect in oblique views.
508 Intraoperative Cone-Beam CT HEAD & NECK—DOI 10.1002/hed April 2010
Page 5
detection was most challenging in the lateral
lamella and cribriform and most conspicuous in
the fovea ethmoidalis and planum.
Similarly, the results indicate the degree to
which CBCT enables confident detection of skull
base breach (score of 4 in observer rating). For
the 1-mm defects, confident detection was
achieved in 3% to 14% of cases (specifically, 3%
[cribriform], 7% [lateral lamella], 7% [fovea eth-
moidalis], and 14% [planum]). For the 2-mm
defects, confident detection was achieved in 44%
to 69% of cases (specifically, 45% [cribriform],
44% [lateral lamella], 69% [fovea ethmoidalis],
and 67% [planum]). Finally, for the 4-mm
defects, confident detection was achieved in 47%
to 91% of cases (specifically, 47% [cribriform],
71% [lateral lamella], 87% [fovea ethmoidalis],
and 91% [planum]).
A mixed-regression model allowed analysis of
statistical significance in the differences arising
from defect size, in a manner that adjusts for
the dependence on anatomic site, showing the
observer scores for the 3 defect sizes (1, 2, and
4 mm) to be significantly different (p < .0001).
As shown in Figure 4, the average score
increased with defect size: average score ¼ 2.51
for 1 mm, 3.82 for 2 mm, and 4.45 for 4 mm.
The regression model also tested the linear de-
pendence in scores from 1 mm to 4 mm, suggest-
ing a trend that is significantly greater than 0.
Specifically, observer score increased by 0.60 for
every 1-mm increase in defect size (p < .0001).
After considering various anatomic sites, the
slopes of regression were found to be 0.68 (pla-
num), 0.64 (lateral lamella), 0.65 (fovea ethmoi-
dalis), and 0.30 (cribriform). The last is
consistent with the prev iously noted point that
breaches were more difficult to detect in the cri-
briform. Interestingly, the intercept points for
the 4 sites plotted in Figure 4 were not signifi-
cantly different (p ¼ .14).
There was a significant difference in the
scores associated with orthogonal versus oblique
views, as shown in Figure 5. The intercept
implied by the mixed regression analysis was
significantly different (p ¼ .02) for the 2 types of
views, with a lower intercept for orthogonal
views (1.75) than that for oblique views (2.06).
Interestingly, the slopes in the observer scores
(ie, the change in score per unit size of the
breach) of the 2 types of views were not signifi-
cantly different (p ¼ .26). A paired t test
between scores in orthogonal and oblique views
suggests a significant difference in the planum,
combining defect sizes ( p < .001) and also
when all 4 sites were combined (p < .001) (see
FIGURE 4. Plots summarizing the visibility of skull base breach (observer score 1–5) as a function of the defect size (1–4 mm). Mixed
linear regression is consistent with the finding that visibility of breach in the cribriform was significantly more challenging than that in
the fovea ethmoidalis, lateral lamella, and planum.
Intraoperative Cone-Beam CT HEAD & NECK—DOI 10.1002/hed April 2010 509
Page 6
Figure 5). However, the cribriform plate, lateral
lamella, and fovea ethmoidalis, individu ally, did
not show a significant difference between or-
thogonal and oblique views. In comparing differ-
ent anatomic sites, there was a significant
difference for 1-mm defects (p < .001) and 2-mm
defects (p < .002), but not 4-mm defects (p ¼ .4).
This study is the first to investigate the role of
CBCT imaging for visualization of ASBD. The
cadaver model provided a somewhat idealized,
but reasonably robust, tool to evaluate CBCT in
the detection of known breaches of variable size
and within distinct anatomic locations of the
anterior skull base. The advantage of the cur-
rent study is that cadaveric specimens allowed a
strict protocol, enabling the creation of bony
defects of specific size in predetermined loca-
tions. We were therefore able to evaluate the
identification rate/sensitivity of each site sepa-
rately and assess how easily individual defects
could be detected.
To date, there is no universally accepted mo-
dality or algorithm to evaluate anterior skull
base defects. Various authors suggest different
imaging modalities to evaluate iatrogenic ante-
rior skull base defects,
but t he reported
sensitivity and specificity of such tests are
inconsistent, probably the result of different
imaging modalities and small numbers of cases.
In addition, the visibility of a defect depends on
its location and size, an uncontrolled variable in
previous studies. The results in this report con-
firm this point: a 2-mm breach in the cribriform
plate was significantly more challenging to iden-
tify than was a breach of identical size in the
planum. Shetty et al
found that high-resolution
CT was accurate in 93% of patients, whereas
MR cisternography was accurate in 89% of
patients with clinically suspected CSF rhinor-
rhea. The combination of high-resolution CT
and MR cisternography was accurate in 96% of
patients. In contrast, Eljamel et al
strated the use of high-resolution CT with an
identification rate of only 47%.
For small (1-mm) skull base defects, 20% to
33% of cases did not demonstrate visualization
of the defect in CBCT, despite observers know-
ing of its existence in the image. This is in con-
trast to just 2% of cases for which a 4-mm
defect could not be identified. Of the 4 anatomic
FIGURE 5. Plots summarizing the visibility of skull base breach (observer score 1–5) for or thogonal views (light gray bars) and oblique
views (black bars). For individual anatomic sites, only the planum (D) illustrated a statistically significant difference between orthogonal
and oblique views, whereas pooling over all sites and defect sizes demonstrated an overall improvement (p < .001) for oblique views.
510 Intraoperative Cone-Beam CT HEAD & NECK—DOI 10.1002/hed April 2010
Page 7
sites, the planum and fovea ethmoidalis demon-
strated clearer visibility of defects of any size.
These and the lateral lamella exhibited similar
‘‘slopes’’ in detectability versus size of breach
(from 1 mm to 4 mm), suggesting an improve-
ment at larger defect identification (2 mm then
4 mm). The detection rate within the cribriform
plate was significantly lower, suggesting that
even larger defects (eg, 2 and 4 mm) in the cri-
briform we re not as easy to identify as in other
anatomic sites. Interestingly, the ‘‘y-intercept’’
on plots of detectability versus size of breach
were not significantly different among the 4
anatomic sites, implying that a small breach
(<1 mm) would become unidentifiable irrespec-
tive of anatomic site.
Overall, CBCT provided confident detection
(score of 4) in 44% to 69% of 2-mm defects and
47% to 91% of 4-mm defects, across all anatomic
sites tested. We acknowledge that the identifica-
tion rate may be falsely elevated by the prede-
fect skull preparation (including ethmoidectomy
and mucosa stripping). However, to create a
comparable model, between individual skulls,
this preparation was necessary.
In a comparison of conventional orthogonal
triplanar views (coronal, axial, and sagittal
planes) with oblique views (coronal, longitudi-
nal, and tangential planes through the defect),
the results confirm that breaches were better
demonstrated in the latter. Therefore, if 3D vis-
ualization software permits convenient selection
of oblique planes to more accurately contain the
true plane of the breach, the identification rate
is improved.
CSF leaks are typically intermittent, and
some imaging (cisternography) requires active
leakage during the examination to improve sen-
sitivity. Moreover, cisternography also requires
an intrathecal injection and a transfer to the CT
scanner, before the operating room. The use of
CBCT overcomes these obstacles and would be
ideal in sinus/skull base surgery if there were a
risk of skull base breach. It has the potential to
demonstrate skull base defects intraoperatively,
and does not depend on the presence of CSF
flow during the examination. It can be com-
pleted in the operating theater without the need
of injection or patient transfer. Moreover, the
CBCT provides a noninvasive, near real-time
images at 1/10 of the time and radiation dose
delivered by conventional CT. Therefore, in
cases in which suspicion of a skull base breach
exists, the defect can potentially be localized
and treated during the primary procedure using
CBCT. This would minimize the need for a sec-
ond procedure, reduce patient stress and dis-
comfort, and decrease both operating room costs
and time. In addition, practice that aims to
repair a CSF leak as a second procedure con-
tends with a previously operated field with asso-
ciated scar tissue and fibrosis. The ability to
identify and repair a CSF leak durin g the pri-
mary surgery can eliminate such problems. In
any case, we are not suggesting that CBCT will
replace the need for good preoperative imaging.
This study has a variety of limitations. First,
the study was performed on cadaver heads and
not on living patients with an actual CSF leak.
Second, the observers were asked to identify the
skull base breach while reviewing a narrow part
of the image, unable to scroll through adjacent
slices, and the observers were informed that the
breach did, in fact, exist in the image. This is
in contrast to the clinical setting in which the
surgeon or radiologist is required to search an
entire volume to locate the bony defect from
multiple images collected during the CT scan. In
addition, the test (satisfaction rating scale) does
not allow quantitation of sensitivity or specific-
ity of breach detection.
In summary, a cadaver model was used to
test intraoperative CBCT detection of ASBD,
investigating detectability thresholds as a func-
tion of defect size and location, each found to
affect detectability. In addition, optimal viewing
planes (oblique) were identified. The utility of
this experimental model was demonstrated, and
implementation of the system in a clinical intra-
operative environment is under way.
Acknowledgments. The authors extend their
thanks to the Guided Therapeutics Program
(GTx) at the University Health Network (Toronto,
ON) and to Dr. Eugene Yu (University Health
Network, Toronto, ON) for expert assistance with
the observer studies. The work was supported by
the Princess Margaret Hospital Foundation and a
grant from the National Institutes of Health
(NIH R01-CA-127444).
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512 Intraoperative Cone-Beam CT HEAD & NECK—DOI 10.1002/hed April 2010
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    [Show abstract] [Hide abstract] ABSTRACT: A system for intraoperative cone-beam CT (CBCT) surgical guidance is under development and translation to trials in head and neck surgery. The system provides 3D image updates on demand with sub-millimeter spatial resolution and soft-tissue visibility at low radiation dose, thus overcoming conventional limitations associated with preoperative imaging alone. A prototype mobile C-arm provides the imaging platform, which has been integrated with several novel subsystems for streamlined implementation in the OR, including: real-time tracking of surgical instruments and endoscopy (with automatic registration of image and world reference frames); fast 3D deformable image registration (a newly developed multi-scale Demons algorithm); 3D planning and definition of target and normal structures; and registration / visualization of intraoperative CBCT with the surgical plan, preoperative images, and endoscopic video. Quantitative evaluation of surgical performance demonstrates a significant advantage in achieving complete tumor excision in challenging sinus and skull base ablation tasks. The ability to visualize the surgical plan in the context of intraoperative image data delineating residual tumor and neighboring critical structures presents a significant advantage to surgical performance and evaluation of the surgical product. The system has been translated to a prospective trial involving 12 patients undergoing head and neck surgery - the first implementation of the research prototype in the clinical setting. The trial demonstrates the value of high-performance intraoperative D imaging and provides a valuable basis for human factors analysis and workflow studies that will greatly augment streamlined implementation of such systems in complex OR environments.
    Preview · Article · Feb 2009 · Proceedings of SPIE - The International Society for Optical Engineering
  • [Show abstract] [Hide abstract] ABSTRACT: A prototype mobile C-arm for cone-beam CT (CBCT) has been translated to a prospective clinical trial in head and neck surgery. The flat-panel CBCT C-arm was developed in collaboration with Siemens Healthcare, and demonstrates both sub-mm spatial resolution and soft-tissue visibility at low radiation dose (e. g., < 1/5(th) of a typical diagnostic head CT). CBCT images are available similar to 15 seconds after scan completion (similar to 1 min acquisition) and reviewed at bedside using custom 3D visualization software based on the open-source Image-Guided Surgery Toolkit (IGSTK). The CBCT C-arm has been successfully deployed in 15 head and neck cases and streamlined into the surgical environment using human factors engineering methods and expert feedback from surgeons, nurses, and anesthetists. Intraoperative imaging is implemented in a manner that maintains operating field sterility, reduces image artifacts (e. g., carbon fiber OR table) and minimizes radiation exposure. Image reviews conducted with surgical staff indicate bony detail and soft-tissue visualization sufficient for intraoperative guidance, with additional artifact management (e. g., metal, scatter) promising further improvements. Clinical trial deployment suggests a role for intraoperative CBCT in guiding complex head and neck surgical tasks, including planning mandible and maxilla resection margins, guiding subcranial and endonasal approaches to skull base tumours, and verifying maxillofacial reconstruction alignment. Ongoing translational research into complimentary image-guidance subsystems include novel methods for real-time tool tracking, fusion of endoscopic video and CBCT, and deformable registration of preoperative volumes and planning contours with intraoperative CBCT.
    No preview · Article · Mar 2011 · Proceedings of SPIE - The International Society for Optical Engineering
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    [Show abstract] [Hide abstract] ABSTRACT: Conventional surgical tracking configurations carry a variety of limitations in line-of-sight, geometric accuracy, and mismatch with the surgeon's perspective (for video augmentation). With increasing utilization of mobile C-arms, particularly those allowing cone-beam CT (CBCT), there is opportunity to better integrate surgical trackers at bedside to address such limitations. This paper describes a tracker configuration in which the tracker is mounted directly on the Carm. To maintain registration within a dynamic coordinate system, a reference marker visible across the full C-arm rotation is implemented, and the "Tracker-on-C" configuration is shown to provide improved target registration error (TRE) over a conventional in-room setup - (0.9+/-0.4) mm vs (1.9+/-0.7) mm, respectively. The system also can generate digitally reconstructed radiographs (DRRs) from the perspective of a tracked tool ("x-ray flashlight"), the tracker, or the C-arm ("virtual fluoroscopy"), with geometric accuracy in virtual fluoroscopy of (0.4+/-0.2) mm. Using a video-based tracker, planning data and DRRs can be superimposed on the video scene from a natural perspective over the surgical field, with geometric accuracy (0.8+/-0.3) pixels for planning data overlay and (0.6+/-0.4) pixels for DRR overlay across all C-arm angles. The field-of-view of fluoroscopy or CBCT can also be overlaid on real-time video ("Virtual Field Light") to assist C-arm positioning. The fixed transformation between the x-ray image and tracker facilitated quick, accurate intraoperative registration. The workflow and precision associated with a variety of realistic surgical tasks were significantly improved using the Tracker-on-C - for example, nearly a factor of 2 reduction in time required for C-arm positioning, reduction or elimination of dose in "hunting" for a specific fluoroscopic view, and confident placement of the x-ray FOV on the surgical target. The proposed configuration streamlines the integration of C-arm CBCT with realtime tracking and demonstrated utility in a spectrum of image-guided interventions (e.g., spine surgery) benefiting from improved accuracy, enhanced visualization, and reduced radiation exposure.
    Full-text · Conference Paper · Feb 2012
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