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Transcript
BrainLab has asked me to kick this off and give a talk on OR workflow with the Airo Intraoperative CT Scanner, and also to give some discussions about the Elements Software, a relatively new edition, and then I'll introduce my two distinguished colleagues, who will discuss their topics.
So...That wasn't supposed to be in there, anymore. Okay.
So, I was trained in the classical awake stereotactic technique for performing functional mood disorder surgery. Patient awake, or minimally sedated, frame application, stereotactic MRI for targeting, verbal micro recording, lead insertion, test stimulation and IPG implantation at a second time, at a later date. This, of course, this technique has worked extraordinarily well for the last quarter century, but I would say is under siege from various other technologies. And folks, I've made it over the years as comfortable as possible for the patients. That's Irene Osborn, master anesthesiologist, who I worked with for many years in New York, who is outstanding at performing total scalp blocks, which allows patients, for instance, the child with dystonia, to have the surgery with minimal sedation.
You also see a BIS monitor there, so we were able to titrate the level of consciousness for the patient, so that we can have them asleep just enough to be able to do recordings and keep them comfortable, and then allow them to be awakened by turning off the Propofol and waiting a minimal amount of time, before we can perform test stimulation. But of course, for the adult patients, wide awake and quite comfortable having the operation.
The downside was always having to transport the patient down to MRI, for patients that were sedated, but also time consuming for awake cases.
In the interest of both patient comfort and they believe better targeting, you now have the ClearPoint system, which allows you to perform the operation with the patient completely asleep in the MRI scanner. I have resisted obtaining this technology, because I don't want to give up test stimulation, and you cannot test stimulate, given the microelectric cord, you cannot test stimulate with the patient asleep and in the MRI scanner.
Robotics also is coming into fore. You see the Renishaw system here, the Mazor cranial-based robot for performing the surgery, and there are people who are doing these operations with patients asleep, using these technologies.
We have this paper that came out of Kim Burchiel's shop in Oregon, where he suggests that clinical outcomes of the sleep or awake deep brain stim are equivalent in terms of motor performance, and motor results, but might even be superior in terms of reduced cognitive side effects. It's one paper.
And also, the group in Queens Square, Ludvic, who have now gone to a purely asleep anatomically based implantation using immediate postoperative MRI verification, as he says of the DBS procedure.
And then finally also, for focused ultrasound, where patients aren't asleep, but they're not having an incision or a burr hole, and therefore is becoming a more acceptable procedure for patients to have.
For me, my response to all of this was to acquire the Airo Intraoperative CT when it became available a few years ago. And what I liked about it for my institution, having gone from Mount Sinai, which is a high resource environment, to one that's somewhat lower resourced, compared to my other competitors in Boston, what I liked about the Airo CT, it had greater flexibility when performing deep brain stimulation. I could still perform microelectric recording when I wanted to, with the patient awake, or even asleep. I can still perform test stimulation, and I can adapt or customize the procedure to the patient's particular needs.
I'm not tying up an MRI scanner for a number of hours. I don't need any special equipment to use this, and I can use it for other types of cases, which unfortunately, I don't have time to show, and also, of course, much, much, lower cost than installing an intraoperative MRI. And in fact, I'll tell you whereabout, we just started, broke ground on a new hospital building, at Beth Israel in Boston, and there were discussions about getting an intraoperative MRI, and in the end they went and looked at how often the Brigham was using their Amiga suite which they like to promote, and in fact, they're using it so infrequently, that the BI decided that it was not economically feasible to use it, to install a similar system.
So the way I do this operation now, we can do high resolution MRI. I can do my targeting, here's a GPI, and then plan the operation ahead of time. Now with the Elements Software, which has significant improvements, the Image Fusion Algorithm is significantly improved, which is great in terms of fusing the CT later. AC-PC virtual autodetection, very simple now compared to the older software, to set your AC-PC coordinates, which I still do. Even if I can see the target, I still like to see where I am relative to the offsets that I'm used to. You have the ability to adjust the target freehand, or using the AC-PC parameters, or using the frame based parameters, however you prefer.
I particularly like this trajectory view, which is something I've asked for and they adapted, where I can see in 3-D exactly where I'm going to be entering relative to the veins, see the trajectories, in both orthogonally in line, and in probe's eye view, this being a thalamic DBS case.
That way, we are quite efficient on the day of surgery. We can bring the patient directly into the operating room. We can apply the stereotactic head frame, put on the fiducial box, this is the older frame and box, and using my iPhone with a balancing tool, I can get the patient perfectly square to the CT scanner. It's very nice. We make sure that we're getting purely orthogonal cuts, which increases the number of slices that I have of usable fiducials, and the draping is nice and easy, and the setup is quite comfortable for everyone. You can see my anesthesiology resident quite comfortable here as we're doing micro recordings, Dr. Burstein, there.
I have, apparently was the first person to use, the Leksell Vantage frame. Unfortunately, to date, we do not have the CT localizer, but with the new CT localizer, once it becomes available, which is imminent, we will be able to adapt this technique to using the Vantage frame, and the Elements Software is specifically designed to work with the Vantage frame as well.
The other nice thing is immediate post-op confirmation of the lead, at least relative to my planned trajectory. So I can shoot a CT scan immediately, and confirm that the lead went where I intended it to go. And now, this is a video which we've added. We have the protection...Oh, there's the software. So this shows the new feature which allows you, this is a case I implanted with a Boston Scientific directional lead, and the software will find the orientation of the lead as it's actually implanted, which will facilitate matters for the programmers.
And you can see the rotation there, and it shows you orientation.
This is from the first six months that I had the scanner. Number of patients, 24 and number of leads implanted, 43. Male/female breakdown, age. Diagnoses, 20 Parkinson's, three ET and one dystonia patient, in that period of time. This was the target breakdowns. Number of MER trajectories to localize the target for those, very similar to what I have experienced without the intraoperative CT, and my median 3D targeting adjustment was less than a mm on average, 0-3.5 mm. Most importantly, DBS procedure time over the course of a number of cases came down substantially, so that we were now doing bilateral implants in under 2.5 hours, going into the room to out of the room. I have used this for complex ventricular catheterization, so a woman came in with a glioma and was able to do the stereotactic biopsy, implant both ventricular catheters, confirm proper placement, and then place a shunt at the end.
And then finally, I was also able to use this for draining this brainstem abscess. I was able to position the patient inside the Airo scanner, get the registration from the skull to the MRI with the Reference Star, do a small sub-occipital approach, a small burr hole. Then using the Varian guide, was able to drain this abscess via the superior cerebellar peduncle. And then you see the patient two months post op. She did beautifully.
So, I conclude by saying the Airo iCT is a versatile operative took that provides probably 90% of the functionality of an intraoperative MRI, and at a fraction of the cost. Improved soft tissue resolution and the ability to perform contrast enhanced scans, will be significant advances, and combined with Elements Software, DBS procedures can be performed efficiently, enhancing patient comfort, and integration with robotics will likely continue to improve accuracy and workflow.
With that, we'll move onto the next speaker, Volker Coenen, from Freiburg, who will be talking about advanced imaging technologies and workflows for DBS surgery.
So...That wasn't supposed to be in there, anymore. Okay.
So, I was trained in the classical awake stereotactic technique for performing functional mood disorder surgery. Patient awake, or minimally sedated, frame application, stereotactic MRI for targeting, verbal micro recording, lead insertion, test stimulation and IPG implantation at a second time, at a later date. This, of course, this technique has worked extraordinarily well for the last quarter century, but I would say is under siege from various other technologies. And folks, I've made it over the years as comfortable as possible for the patients. That's Irene Osborn, master anesthesiologist, who I worked with for many years in New York, who is outstanding at performing total scalp blocks, which allows patients, for instance, the child with dystonia, to have the surgery with minimal sedation.
You also see a BIS monitor there, so we were able to titrate the level of consciousness for the patient, so that we can have them asleep just enough to be able to do recordings and keep them comfortable, and then allow them to be awakened by turning off the Propofol and waiting a minimal amount of time, before we can perform test stimulation. But of course, for the adult patients, wide awake and quite comfortable having the operation.
The downside was always having to transport the patient down to MRI, for patients that were sedated, but also time consuming for awake cases.
In the interest of both patient comfort and they believe better targeting, you now have the ClearPoint system, which allows you to perform the operation with the patient completely asleep in the MRI scanner. I have resisted obtaining this technology, because I don't want to give up test stimulation, and you cannot test stimulate, given the microelectric cord, you cannot test stimulate with the patient asleep and in the MRI scanner.
Robotics also is coming into fore. You see the Renishaw system here, the Mazor cranial-based robot for performing the surgery, and there are people who are doing these operations with patients asleep, using these technologies.
We have this paper that came out of Kim Burchiel's shop in Oregon, where he suggests that clinical outcomes of the sleep or awake deep brain stim are equivalent in terms of motor performance, and motor results, but might even be superior in terms of reduced cognitive side effects. It's one paper.
And also, the group in Queens Square, Ludvic, who have now gone to a purely asleep anatomically based implantation using immediate postoperative MRI verification, as he says of the DBS procedure.
And then finally also, for focused ultrasound, where patients aren't asleep, but they're not having an incision or a burr hole, and therefore is becoming a more acceptable procedure for patients to have.
For me, my response to all of this was to acquire the Airo Intraoperative CT when it became available a few years ago. And what I liked about it for my institution, having gone from Mount Sinai, which is a high resource environment, to one that's somewhat lower resourced, compared to my other competitors in Boston, what I liked about the Airo CT, it had greater flexibility when performing deep brain stimulation. I could still perform microelectric recording when I wanted to, with the patient awake, or even asleep. I can still perform test stimulation, and I can adapt or customize the procedure to the patient's particular needs.
I'm not tying up an MRI scanner for a number of hours. I don't need any special equipment to use this, and I can use it for other types of cases, which unfortunately, I don't have time to show, and also, of course, much, much, lower cost than installing an intraoperative MRI. And in fact, I'll tell you whereabout, we just started, broke ground on a new hospital building, at Beth Israel in Boston, and there were discussions about getting an intraoperative MRI, and in the end they went and looked at how often the Brigham was using their Amiga suite which they like to promote, and in fact, they're using it so infrequently, that the BI decided that it was not economically feasible to use it, to install a similar system.
So the way I do this operation now, we can do high resolution MRI. I can do my targeting, here's a GPI, and then plan the operation ahead of time. Now with the Elements Software, which has significant improvements, the Image Fusion Algorithm is significantly improved, which is great in terms of fusing the CT later. AC-PC virtual autodetection, very simple now compared to the older software, to set your AC-PC coordinates, which I still do. Even if I can see the target, I still like to see where I am relative to the offsets that I'm used to. You have the ability to adjust the target freehand, or using the AC-PC parameters, or using the frame based parameters, however you prefer.
I particularly like this trajectory view, which is something I've asked for and they adapted, where I can see in 3-D exactly where I'm going to be entering relative to the veins, see the trajectories, in both orthogonally in line, and in probe's eye view, this being a thalamic DBS case.
That way, we are quite efficient on the day of surgery. We can bring the patient directly into the operating room. We can apply the stereotactic head frame, put on the fiducial box, this is the older frame and box, and using my iPhone with a balancing tool, I can get the patient perfectly square to the CT scanner. It's very nice. We make sure that we're getting purely orthogonal cuts, which increases the number of slices that I have of usable fiducials, and the draping is nice and easy, and the setup is quite comfortable for everyone. You can see my anesthesiology resident quite comfortable here as we're doing micro recordings, Dr. Burstein, there.
I have, apparently was the first person to use, the Leksell Vantage frame. Unfortunately, to date, we do not have the CT localizer, but with the new CT localizer, once it becomes available, which is imminent, we will be able to adapt this technique to using the Vantage frame, and the Elements Software is specifically designed to work with the Vantage frame as well.
The other nice thing is immediate post-op confirmation of the lead, at least relative to my planned trajectory. So I can shoot a CT scan immediately, and confirm that the lead went where I intended it to go. And now, this is a video which we've added. We have the protection...Oh, there's the software. So this shows the new feature which allows you, this is a case I implanted with a Boston Scientific directional lead, and the software will find the orientation of the lead as it's actually implanted, which will facilitate matters for the programmers.
And you can see the rotation there, and it shows you orientation.
This is from the first six months that I had the scanner. Number of patients, 24 and number of leads implanted, 43. Male/female breakdown, age. Diagnoses, 20 Parkinson's, three ET and one dystonia patient, in that period of time. This was the target breakdowns. Number of MER trajectories to localize the target for those, very similar to what I have experienced without the intraoperative CT, and my median 3D targeting adjustment was less than a mm on average, 0-3.5 mm. Most importantly, DBS procedure time over the course of a number of cases came down substantially, so that we were now doing bilateral implants in under 2.5 hours, going into the room to out of the room. I have used this for complex ventricular catheterization, so a woman came in with a glioma and was able to do the stereotactic biopsy, implant both ventricular catheters, confirm proper placement, and then place a shunt at the end.
And then finally, I was also able to use this for draining this brainstem abscess. I was able to position the patient inside the Airo scanner, get the registration from the skull to the MRI with the Reference Star, do a small sub-occipital approach, a small burr hole. Then using the Varian guide, was able to drain this abscess via the superior cerebellar peduncle. And then you see the patient two months post op. She did beautifully.
So, I conclude by saying the Airo iCT is a versatile operative took that provides probably 90% of the functionality of an intraoperative MRI, and at a fraction of the cost. Improved soft tissue resolution and the ability to perform contrast enhanced scans, will be significant advances, and combined with Elements Software, DBS procedures can be performed efficiently, enhancing patient comfort, and integration with robotics will likely continue to improve accuracy and workflow.
With that, we'll move onto the next speaker, Volker Coenen, from Freiburg, who will be talking about advanced imaging technologies and workflows for DBS surgery.