Chapter 26 Book Biomedical Technology and Devices Handbook

26

Stereotactic Procedures

CONTENTS

26.1 Introduction

26.2 Methods

Frame or Frameless

26.3 Clinical Applications

Movement Disorders • Mass Lesions • Vascular Malformations • Palliation • Breast

26.4 Complications

26.5 New Directions

26.6 Discussion

References

26.1 Introduction

Stereotaxy employs minimally invasive techniques to precisely locate a target within the body. Thisrequires rendering the internal target and organs relative to an external reference in three-dimensionalspace. A system of coordinates links the defined exterior and the viewed internal anatomy. The imagingcan be performed with diagnostic x-rays, magnetic resonance imaging, or ultrasound. The externalreference can be a frame attached to the patient, or marked points on the patient’s surface anatomy.

Stereotactic systems can be used to diagnose or treat. Diagnostic procedures can be performed onsmall lesions with greater precision than conventional biopsy. Diagnostic accuracy is thereby improved.Therapy using stereotaxy can be done with surgery or radiation. The methods permit approach toinaccessible regions of the body with minimal disruption of the intervening tissues. As a result, there isless potential for morbidity and less discomfort for the patient.

Stereotactic procedures are employed in a wide range of applications, from basic scientific research tocommon clinical problems.

1

The research includes neurologic monitoring

2,3

and gene therapy. The clinicalspectrum of usage ranges from cancer diagnosis and treatment to the evaluation and treatment ofmovement disorders.

26.2 Methods

It is necessary to measure and define the three-dimensional volume around a target (Figure 26.1). Anexternal frame is attached to the patient or, alternatively, prominent surface anatomy is marked (“fra-meless”). The target and body are next imaged along with the external reference points. The importantstructures in the space are outlined. The distances of the anatomy relative to the reference frame canthen be measured (Figure 26.22). An orthogonal coordinate system (x-, y-, and z-axis) is delineatedaccording to these measurements. The points of interest, outside and inside the patient, are then knownby their position in the three-dimensional stereotactic space and given coordinates relative to the refer-

Michael D. Weil

Sirius Medicine, LLC

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© 2004 by CRC Press LLC

ence. Though the target is unseen by the clinician, it can be readily located and approached by startingat a known point on the patient’s surface and proceeding to the coordinates of the target (Figure 26.3).

26.2.1 Frame or Frameless

The methods require an image of the internal structures to be correlated to an accessible external reference.The orientation can be done within a frame to define the borders and coordinates of stereotactic space.Various commercial frames are on the market and most commonly used for neurosurgical procedures.The frame is secured to the patient, often by screws to the bony anatomy, which is then secured to theimmobilization mechanism. The images of the patient within the frame can next be scanned into varioussoftware.

4

The program can then be used to locate the anatomy based on the distance from the frame.

FIGURE 26.1

Stereotactic space is defined relative to a fixed, external reference plane. The coordinate system, x-,y-, and z-axis, is measured in millimeters from the reference plane to define a stereotactic volume (dotted lines). Thevolumes of the target and normal surrounding structures within the region are defined and localized to thesecoordinates by planning software.

FIGURE 26.2

The stereotactic volume characterizes the anatomy (cylinder) and the target (dark circle). Distancesfrom the reference markers are established by obtaining an image of the lesion within the frame or other orientationpoints. The coordinates of the lesion at depth can then be targeted from an access point on the surface.

Y-Axis

Z-Axis

X-Axis

X-Axis

Y-Axis

Z-Axis



Sophisticated planning systems can then design trajectories of approach for surgery or radiation. Thesame techniques can be performed by marking the surface anatomy with points (fiducials) that will bevisible to the clinician and on the image. Thus, stereotaxy can be performed without the frame as well.The surface is delineated with skin markers,

5

or natural anatomical projections. Various frameless systemsare commercially available and are very precise.

6

Whether the intent of the procedure is biopsy or ablation, the operator must have a mechanism toguide the instrument to the target. In the case of radiosurgery,

7

it is reasonably uncomplicated to aimthe beam at the coordinates of the target because the stereotactic frame is attached to the treatment table.The patient lying on the treatment table is aligned with lasers in the room via the frame’s coordinatesystem so that the isocenter of the beam intersects the location of the target. On the other hand, whenthe lesion is approached with an instrument in the surgeon’s hand, a navigation arrangement is neededto know where the needle or scalpel is relative to the target. So-called neuronavigation is accomplishedwith room sensors that track the instruments.

8

The registration process of the fiducials is critical to theaccuracy of these neuronavigation systems. The accuracy of the guidance system is similar whether aframeless or frame-based reference system is employed.

9

26.3 Clinical Applications

26.3.1 Movement Disorders

Tremor suppression can be accomplished with stimulation, which is as effective as coagulation butwith less adverse effects, and the possibility of bilateral operations. Thalamotomy may remain anoption in selected patients.

10

By using stereotaxy with MRI and electrophysiology, it is possible torecord

11

and stimulate single neuron activity deep within the brain. Electrodes placed at suitablelocations can be stimulated with high frequency to treat tremor of different origins.

12

Targets includethe ventral intermediate (VIM) region of the thalamus, the subthalamic nucleus (STN), and the medialpallidum (Gpi). Improvement of tremor, rigidity, and akinesia translates into less medication and itsassociated dyskinesia. In Parkinson’s disease,

13

the STN has become the preferred site of stimulationin carefully selected patients, often with the use of ventriculography to improve the accuracy of thestereotactic coordinates.

FIGURE 26.3

Trajectory of an instrument or beam is designed through an accessible point on the patient’s surfaceto the coordinates of the target. The coordinates of the surface, interior anatomy, and the target are relative to theframe, or skin markers. Planning software navigates the path (double-lined arrow) and can guide the procedure.

X-Axis

Y-Axis

Z-Axis



Stereotactic intracerebral EEG stimulations and recordings can be used to study epilepsy along withother modalities.

14

By mapping somatosensory-evoked potentials via stereotactically placed intracorticalelectrodes it is possible to study complex projections.

15

The use of standard stereotactic atlases can beexpanded with software adapted to compare individuals to averaged anatomy.

16

Stereotactic surgical techniques can safely reach and ablate deep structures in the brain such as thethalamus. Ventral intermediate (VIM) thalamotomies have been used to treat medically intractableessential tremor,

17

with a 60% success rate and low morbidity. Tremor in multiple sclerosis has beenreported to respond to stereotactic surgery of the thalamus, zona incerta and subthalamic nuclei.

18

Stereotactic surgery has been performed with reasonable outcomes in some Parkinson’s patients as well.Ventrolateral (VL) thalamotomies and posteroventral (PV) pallidotomies can improve dyskinesias,though without a significant decrease in the levodopa dose.

19

Following stereotactic pallidotomy, patientswith Parkinson’s disease have been noted to have improvement in perception.

20

Involuntary, abnormal head movements and pain characterize cervical dystonia. The mechanisms arepoorly understood but complex forms of the condition have been reported to respond to stereotacticsurgery with bilateral pallidotomy or globus pallidus deep brain stimulation.

21

Unresponsive Tourette’ssyndrome has been treated with stereotactic surgical zona incerta (ZI) and VL thalamotomy.

22

There isa significant risk of complications with bilateral surgery.

26.3.2 Mass Lesions

Orientation in an operative field in the brain ordinarily requires adequate exposure so the surgeon canidentify familiar structures. Image-guided and computer-assisted navigation systems can display accuratespatial information directly from patient images.

23

This data permits delineation of normal anatomy andpathologic lesions with much less manipulation. Therefore, the technique readily lends itself to brainbiopsy

24

and drainage of abscesses.

25

Alternatively, the technique can be used with endoscopy. Neuronav-igation has been successfully incorporated into surgery for brain and spine masses with improvement inthe postoperative course.

8

Computer-assisted guidance has been reported to be of use in transsphenoidalparasellar surgery.

27

Radiosurgery offers great promise and many advantages over conventional techniques.

28

However, todate there have been no randomized clinical trials to confirm the early hopeful data.

29

Radiosurgicalbeams, i.e., radiation that is highly conformal to the target, can be delivered to a selected point in astereotactic volume by several methods. Specially outfitted linear accelerators and the Gamma Knife(multiple cobalt sources) deliver photons. While several specialty centers can treat with protons, there isa huge disadvantage in cost of the protons. Modern accelerators rigged with micro-, multileaf collimationcan deliver conformal radiation that is comparable to protons.

30

In rare situations, when a lesion is toointimately involved with a critical structure protons may give a better dose distribution. Intensity mod-ulation along with these dynamic micro-, multileaf collimators can significantly decrease the impact ofx-ray beams overshooting the target with unintended consequences.

31

Delivery of fractionated radiation with stereotactic setups, i.e., fractionated stereotactic radiotherapy,improves reproducibility of multiple treatments,

32

and may be appropriate in selected circumstances.

33,34

Radiosurgery is playing an increasingly important role in the management of brain metastases whenthe primary disease is controlled.

35

The role of whole brain radiotherapy with its significant morbidityis challenged by radiosurgery.

36,37

26.3.3 Vascular Malformations

Endovascular embolization, stereotactic radiosurgery, and microsurgery can be used alone or in com-bination to effectively treat arteriovenous malformations (AVM) of the brain.

38

Results with stereotacticradiosurgery for the treatment of benign intracranial mass lesions such as AVM

39

have been very goodin terms of toxicity and local control. Only 5% of the patients have been reported to suffer adversesymptoms, with a 71% obliteration rate at 2 years. AVMs can reappear after total occlusion with



radiosurgery on occasion, particularly in pediatric patients.

40

After being declared cured, 10 of 48patients had clinical symptoms from AVMs. Radiosurgical procedures for AVMs can be repeated withacceptable risk.

41

Control decreases for bigger lesions. In the case of large AVMs (>3 cm diameter),there was a greater complication rate and significantly less chance of obliteration.

42

The majority oflong-term complications after radiosurgery for AVM

43

were associated with radiation injury to thebrain. Minimal sequelae after radiosurgery and no history of bleeding resulted in significantly lesssymptoms. Other vascular pathology, such as cerebral cavernous malformations are presently treatedwith microsurgical techniques rather than radiosurgery.

44

26.3.4 Palliation

Posteromedial thalamotomy with stereotactic navigation under MR guidance has been used to suc-cessfully relieve intractable pain.

45

Radiosurgery is more effective for idiopathic trigeminal neuralgia

46

than for tumor-related facial pain. Radiosurgery produced control in

≥

70% of patients treated fortrigeminal neuralgia.

47

Insertion of Ommaya reservoirs for intrathecal chemotherapy in difficult technical scenarios is facil-itated by stereotactic techniques.

48

26.3.5 Breast

Mammography and biopsy of suspicious lesions can be readily performed with stereotactic methods,

49

where the breast and lesion can be viewed in three-dimensional. Surgical excisional biopsy of nonpalpablesuspicious breast lesions are more invasive, and likely more costly than stereotactic large-core needlebiopsy.

50

Stereotaxy can be employed for breast biopsy in place of wire localization for nonpalpableabnormalities on mammogram.

51

The procedure is accurate

52

with less surgical trauma. Stereotacticbiopsy avoided a surgical procedure in nearly half of the patients in this study. Amorphous calcificationson mammogram remain a diagnostic dilemma. Additionally, there is still risk of false-negative exams,

53

which might be lessened with improved procedures.

54-56

It is expected to be the biopsy technique of choicein the near future for lesions discovered by mammogram.

26.4 Complications

The use of stereotactic navigation is not totally without risk. Seizures can be induced by brain proce-dures.

24

Bleeding can occur at a biopsy site requiring craniotomy.

57

Tumor seeding along a stereotacticbiopsy tract, though rare, has been reported.

58,59

In addition, there have been reports of surgical instru-ments transferring the infectious agents of variant Creuztfeldt-Jakob disease, though blood-borne agentsportend the greatest risk of clinically significant contamination.

60

It is less difficult to radiate after surgery than vice versa. In a survey of a small group of acousticneuroma patients retreated with microsurgery after radiosurgery the results were not good.

61

This is likelythe result of the technical hurdles from scarring following high dose delivered to a small region.

26.5 New Directions

It may be possible in the near future to perform real-time tissue identification during stereotactic brainbiopsies and functional neurosurgery.

62

Cannulas containing microsensors can discriminate cancer frombenign tissue via optical scattering spectroscopy

in vivo

. Stereotactic biopsy of parasitic brain lesions;e.g., neurocysticercosis, has been considered the standard of care. However, serodiagnosis might becomea reasonable alternative as access to the biopsy techniques is not available in many areas.

63

Stereotactic methods are commonly employed for brain research, such as electrode placement,

64

orcreating precise lesions.

65

Models for tissue transplant into the brain with stereotactic guidance havealso been reported,

66

along with early clinical data.

67

Characterization of neuroanatomy is possible by



delivering neurotropic viruses into specific regions of the brain with stereotactic guidance.

68

Directinjection of gene therapy into gliomas may be performed routinely with stereotaxy as the efficiency ofthe vectors is improved.

69

The impact of precision treatment is often difficult to document initially. Mapping of complex three-dimensional dose distributions of stereotactic radiation treatment can be achieved with polymer geldosimetry,

70,71

or with radiochromic film.

72

26.6 Discussion

Stereotactic neurosurgery has been practiced for the past half century.

73

Since its inception, the field hasexpanded to epilepsy, movement disorders, radiosurgery, frameless techniques, and applied to other sitessuch as spine and breast. The treatment of Parkinson’s disease, for instance, has progressed from opensurgical techniques in the 1950s to recording and stimulation with deeply implanted electrodes.

74

Theseadvances were possible with the accuracy of locating the lesions under stereotactic guidance.

The methodology of stereotaxis and image guidance dramatically reduce the potential for harmingthe patient with invasive procedures in critical areas. However, improved therapeutic modalities willdramatically enhance the impact of these less-invasive delivery systems. Progress in viral vectors for genetherapy,

75

or combinations of treatments could offer the next opportunity for growth of the field ofstereotaxy and image-guided navigation.

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