Download PDF
J Neurol Surg B Skull Base 2021; 82(S 03): e306-e314
DOI: 10.1055/s-0040-1701211
Original Article

Evaluating an Image-Guided Operating Room with Cone Beam CT for Skull Base Surgery

Nidal Muhanna
1   Department of Otolaryngology, Head and Neck Surgery, University of Toronto, Toronto, Canada
2   Department of Surgical Oncology, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
3   Department of Otolaryngology, Head and Neck and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center—Tel Aviv University, Tel Aviv-Yafo, Israel
,
Catriona M. Douglas 
1   Department of Otolaryngology, Head and Neck Surgery, University of Toronto, Toronto, Canada
2   Department of Surgical Oncology, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
,
Michael J. Daly
4   TECHNA Institute, University Health Network, Toronto, Ontario, Canada
,
Harley H.L. Chan
4   TECHNA Institute, University Health Network, Toronto, Ontario, Canada
,
Robert Weersink
4   TECHNA Institute, University Health Network, Toronto, Ontario, Canada
5   Department of Medical Physics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
,
Jason Townson
4   TECHNA Institute, University Health Network, Toronto, Ontario, Canada
,
Eric Monteiro
1   Department of Otolaryngology, Head and Neck Surgery, University of Toronto, Toronto, Canada
,
Eugene Yu
6   Joint Department of Medical Imaging, University Health Network/Mt. Sinai Hospital, Toronto, Ontario, Canada
,
Emilie Weimer
6   Joint Department of Medical Imaging, University Health Network/Mt. Sinai Hospital, Toronto, Ontario, Canada
,
Walter Kucharczyk
6   Joint Department of Medical Imaging, University Health Network/Mt. Sinai Hospital, Toronto, Ontario, Canada
,
David A. Jaffray
5   Department of Medical Physics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
6   Joint Department of Medical Imaging, University Health Network/Mt. Sinai Hospital, Toronto, Ontario, Canada
,
Jonathan C. Irish
1   Department of Otolaryngology, Head and Neck Surgery, University of Toronto, Toronto, Canada
2   Department of Surgical Oncology, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
4   TECHNA Institute, University Health Network, Toronto, Ontario, Canada
,
John R. de Almeida
1   Department of Otolaryngology, Head and Neck Surgery, University of Toronto, Toronto, Canada
2   Department of Surgical Oncology, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
› Author Affiliations Funding This work was supported by research funding from Siemens Healthcare, the AHSC AFP Innovation Fund (Ontario Ministry of Health and Long Term Care), and the Princess Margaret Cancer Foundation.
› Further Information
    Permissions and Reprints

Abstract

Importance Skull base surgery requires precise preoperative assessment and intraoperative management of the patient. Surgical navigation is routinely used for complex skull base cases; however, the image guidance is commonly based on preoperative scans alone.

Objective The primary objective of this study was to assess the image quality of intraoperative cone-beam computed tomography (CBCT) within anatomical landmarks used in sinus and skull base surgery. The secondary objective was to assess the registration error of a surgical navigation system based on intraoperative CBCT.

Design Present study is a retrospective case series of image quality after intraoperative cone beam CT.

Setting The study was conducted at Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto.

Participants A total of 46 intraoperative scans (34 patients, 21 skull base, 13 head and neck) were studied.

Main Outcome and Measures Thirty anatomical landmarks (vascular, soft tissue, and bony) within the sinuses and anterior skull base were evaluated for general image quality characteristics: (1) bony detail visualization; (2) soft-tissue visualization; (3) vascular visualization; and (4) freedom from artifacts (e.g., metal). Levels of intravenous (IV) contrast enhancement were quantified in Hounsfield's units (HU). Standard paired-point registration between imaging and tracker coordinates was performed using 6 to 8 skin fiducial markers and the corresponding fiducial registration error (FRE) was measured.

Results Median score for bony detail on CBCT was 5, remaining at 5 after administration of IV contrast. Median soft-tissue score was 2 for both pre- and postcontrast. Median vascular score was 1 precontrast and 3 postcontrast. Median score for artifacts on CBCT were 2 for both pre-and postcontrast, and metal objects were noted to be the most significant source of artifact. Intraoperative CBCT allowed preresection images and immediate postresection images to be available to the skull base surgeon. There was a significant improvement in mean (standard deviation [SD]) CT intensity in the left carotid artery postcontrast 334 HU (67 HU) (p < 10−10). The mean FRE was 1.8 mm (0.45 mm).

Conclusion Intraoperative CBCT in complex skull base procedures provides high-resolution bony detail allowing immediate assessment of complex resections. The use of IV contrast with CBCT improves the visualization of vasculature. Image-guidance based on CBCT yields registration errors consistent with standard techniques.

Keywords

cone-beam CT - image-guided surgery - intraoperative imaging - head and neck cancer

Key Points

Question: Is intraoperative CBCT image quality adequate for skull base surgery?


Finding: Intraoperative CBCT can provide good quality images, particularly for bony and vascular anatomy.


Meaning: Intraoperative images can be used to update the navigation system. The combined image quality and intraoperative update allow the surgeon to assess surgical resections in real time.


Meeting Presentations: A preliminary summary of this work was presented at the 5th World Congress of International Federation of Head & Neck Oncologic Societies, New York, NY, July 26–30, 2014.




Publication History

Received: 21 May 2019

Accepted: 29 August 2019

Article published online:
03 February 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Jackman AH, Palmer JN, Chiu AG, Kennedy DW. Use of intraoperative CT scanning in endoscopic sinus surgery: a preliminary report. Am J Rhinol 2008; 22 (02) 170-174
    CrossrefPubMedGoogle Scholar
  • 2 American Academy of Otolaryngology—Head and Neck Surgery. Accessed September 16, 2019 at: https://www.entnet.org/content/intra-operative-use-computer-aided-surgery
  • 3 Kalender WA, Kyriakou Y. Flat-detector computed tomography (FD-CT). Eur Radiol 2007; 17 (11) 2767-2779
    CrossrefPubMedGoogle Scholar
  • 4 Siewerdsen JH. Cone-beam CT with a flat-panel detector: from image science to image-guided surgery. Nucl Instrum Methods Phys Res A 2011; 648 (S1): S241-S250
    CrossrefPubMedGoogle Scholar
  • 5 Murayama Y, Irie K, Saguchi T. et al. Robotic digital subtraction angiography systems within the hybrid operating room. Neurosurgery 2011; 68 (05) 1427-1432
    CrossrefPubMedGoogle Scholar
  • 6 Tjardes T, Shafizadeh S, Rixen D. et al. Image-guided spine surgery: state of the art and future directions. Eur Spine J 2010; 19 (01) 25-45
    CrossrefPubMedGoogle Scholar
  • 7 Ujiie H, Effat A, Yasufuku K. Image-guided thoracic surgery in the hybrid operation room. J Vis Surg 2017; 3: 148-148
    CrossrefPubMedGoogle Scholar
  • 8 Fujiwara T, Kunisada T, Takeda K. et al. Intraoperative O-arm-navigated resection in musculoskeletal tumors. J Orthop Sci 2018; 23 (06) 1045-1050
    CrossrefPubMedGoogle Scholar
  • 9 King E, Daly MJ, Chan H. et al. Intraoperative cone-beam CT for head and neck surgery: feasibility of clinical implementation using a prototype mobile C-arm. Head Neck 2013; 35 (07) 959-967
    CrossrefPubMedGoogle Scholar
  • 10 Batra PS, Kanowitz SJ, Citardi MJ. Clinical utility of intraoperative volume computed tomography scanner for endoscopic sinonasal and skull base procedures. Am J Rhinol 2008; 22 (05) 511-515
    CrossrefPubMedGoogle Scholar
  • 11 Bai M, Liu B, Mu H, Liu X, Jiang Y. The comparison of radiation dose between C-arm flat-detector CT (DynaCT) and multi-slice CT (MSCT): a phantom study. Eur J Radiol 2012; 81 (11) 3577-3580
    CrossrefPubMedGoogle Scholar
  • 12 Yushkevich PA, Piven J, Hazlett HC. et al. User-guided 3D active contour segmentation of anatomical structures: significantly improved efficiency and reliability. Neuroimage 2006; 31 (03) 1116-1128
    CrossrefPubMedGoogle Scholar
  • 13 Daly MJ, Chan H, Nithiananthan S. et al. Clinical implementation of intraoperative cone-beam CT in head and neck surgery. Progress in Biomedical Optics and Imaging—Proceedings of SPIE 2011;7964. Doi: https://doi.org/10.1117/12.878976
    Google Scholar
  • 14 Enquobahrie A, Gobbi D, Turek M. et al. Designing tracking software for image-guided surgery applications: IGSTK experience. Int J CARS 2008; 3 (05) 395-403
    CrossrefPubMedGoogle Scholar
  • 15 Fitzpatrick JM, West JB. The distribution of target registration error in rigid-body point-based registration. IEEE Trans Med Imaging 2001; 20 (09) 917-927
    CrossrefPubMedGoogle Scholar
  • 16 Engelhorn T, Struffert T, Richter G. et al. Flat panel detector angiographic CT in the management of aneurysmal rupture during coil embolization. AJNR Am J Neuroradiol 2008; 29 (08) 1581-1584
    CrossrefPubMedGoogle Scholar
  • 17 Meyer BC, Frericks BB, Albrecht T, Wolf KJ, Wacker FK. Contrast-enhanced abdominal angiographic CT for intra-abdominal tumor embolization: a new tool for vessel and soft tissue visualization. Cardiovasc Intervent Radiol 2007; 30 (04) 743-749
    CrossrefPubMedGoogle Scholar
  • 18 Watanabe H, Honda E, Tetsumura A, Kurabayashi T. A comparative study for spatial resolution and subjective image characteristics of a multi-slice CT and a cone-beam CT for dental use. Eur J Radiol 2011; 77 (03) 397-402
    CrossrefPubMedGoogle Scholar
  • 19 Naitoh M, Nakahara K, Suenaga Y, Gotoh K, Kondo S, Ariji E. Comparison between cone-beam and multislice computed tomography depicting mandibular neurovascular canal structures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109 (01) e25-e31
    CrossrefPubMedGoogle Scholar
  • 20 Doelken M, Struffert T, Richter G. et al. Flat-panel detector volumetric CT for visualization of subarachnoid hemorrhage and ventricles: preliminary results compared to conventional CT. Neuroradiology 2008; 50 (06) 517-523
    CrossrefPubMedGoogle Scholar
  • 21 Kim MS, Kim BY, Choi HY. et al. Intravenous contrast media application using cone-beam computed tomography in a rabbit model. Imaging Sci Dent 2015; 45 (01) 31-39
    CrossrefPubMedGoogle Scholar
  • 22 Groell R, Willfurth P, Schaffler GJ. et al. Contrast-enhanced spiral CT of the head and neck: comparison of contrast material injection rates. AJNR Am J Neuroradiol 1999; 20 (09) 1732-1736
    PubMedGoogle Scholar
  • 23 Citardi MJ, Batra PS. Intraoperative surgical navigation for endoscopic sinus surgery: rationale and indications. Curr Opin Otolaryngol Head Neck Surg 2007; 15 (01) 23-27
    CrossrefPubMedGoogle Scholar
  • 24 Otake Y, Leonard S, Reiter A. et al. Rendering-based video-CT registration with physical constraints for image-guided endoscopic sinus surgery. Proc SPIE Int Soc Opt Eng 2015; 9415 DOI: 10.1117/12.2081732.
    CrossrefPubMedGoogle Scholar
  • 25 Daly MJ, Siewerdsen JH, Moseley DJ, Jaffray DA, Irish JC. Intraoperative cone-beam CT for guidance of head and neck surgery: Assessment of dose and image quality using a C-arm prototype. Med Phys 2006; 33 (10) 3767-3780
    CrossrefPubMedGoogle Scholar
  • 26 McCollough CH, Bushberg JT, Fletcher JG, Eckel LJ. Answers to common questions about the use and safety of CT scans. Mayo Clin Proc 2015; 90 (10) 1380-1392
    CrossrefPubMedGoogle Scholar