An automatic technique for finding and localizing externally attached markers in CT and MR volume images of the head

Image-to-Patient Registration in Computer-Assisted Surgery of Head and Neck: State-of-the-Art, Perspectives, and Challenges

Today, image-guided systems play a significant role in improving the outcome of diagnostic and therapeutic interventions. They provide crucial anatomical information during the procedure to decrease the size and the extent of the approach, to reduce intraoperative complications, and to increase accuracy, repeatability, and safety. Image-to-patient registration is the first step in image-guided procedures. It establishes a correspondence between the patient's preoperative imaging and the intraoperative data. When it comes to the head-and-neck region, the presence of many sensitive structures such as the central nervous system or the neurosensory organs requires a millimetric precision. This review allows evaluating the characteristics and the performances of different registration methods in the head-and-neck region used in the operation room from the perspectives of accuracy, invasiveness, and processing times. Our work led to the conclusion that invasive marker-based methods are still considered as the gold standard of image-to-patient registration. The surface-based methods are recommended for faster procedures and applied on the surface tissues especially around the eyes. In the near future, computer vision technology is expected to enhance these systems by reducing human errors and cognitive load in the operating room.

Reattachable fiducial skin marker for automatic multimodality registration

Purpose

Fusing image information has become increasingly important for optimal diagnosis and treatment of the patient. Despite intensive research towards markerless registration approaches, fiducial marker-based methods remain the default choice for a wide range of applications in clinical practice. However, as especially non-invasive markers cannot be positioned reproducibly in the same pose on the patient, pre-interventional imaging has to be performed immediately before the intervention for fiducial marker-based registrations.

Methods

We propose a new non-invasive, reattachable fiducial skin marker concept for multi-modal registration approaches including the use of electromagnetic or optical tracking technologies. We furthermore describe a robust, automatic fiducial marker localization algorithm for computed tomography (CT) and magnetic resonance imaging (MRI) images. Localization of the new fiducial marker has been assessed for different marker configurations using both CT and MRI. Furthermore, we applied the marker in an abdominal phantom study. For this, we attached the marker at three poses to the phantom, registered ten segmented targets of the phantom’s CT image to live ultrasound images and determined the target registration error (TRE) for each target and each marker pose.

Results

Reattachment of the marker was possible with a mean precision of 0.02 mm ± 0.01 mm. Our algorithm successfully localized the marker automatically in all ($$n=201$$ n = 201 ) evaluated CT/MRI images. Depending on the marker pose, the mean ($$n=10$$ n = 10 ) TRE of the abdominal phantom study ranged from 1.51 ± 0.75 mm to 4.65 ± 1.22 mm.

Conclusions

The non-invasive, reattachable skin marker concept allows reproducible positioning of the marker and automatic localization in different imaging modalities. The low TREs indicate the potential applicability of the marker concept for clinical interventions, such as the puncture of abdominal lesions, where current image-based registration approaches still lack robustness and existing marker-based methods are often impractical.

A Comparative Study of Automatic Localization Algorithms for Spherical Markers within 3D MRI Data

Localization of features and structures in images is an important task in medical image-processing. Characteristic structures and features are used in diagnostics and surgery planning for spatial adjustments of the volumetric data, including image registration or localization of bone-anchors and fiducials. Since this task is highly recurrent, a fast, reliable and automated approach without human interaction and parameter adjustment is of high interest. In this paper we propose and compare four image processing pipelines, including algorithms for automatic detection and localization of spherical features within 3D MRI data. We developed a convolution based method as well as algorithms based on connected-components labeling and analysis and the circular Hough-transform. A blob detection related approach, analyzing the Hessian determinant, was examined. Furthermore, we introduce a novel spherical MRI-marker design. In combination with the proposed algorithms and pipelines, this allows the detection and spatial localization, including the direction, of fiducials and bone-anchors.

Automated fiducial marker detection and localization in volumetric computed tomography images: a three-step hybrid approach with deep learning

Purpose: Automating fiducial detection and localization in the patient’s pre-operative images can lead to better registration accuracy, reduced human errors, and shorter intervention time. Most current approaches are optimized for a single marker type, mainly spherical adhesive markers. A fully automated algorithm is proposed and evaluated for screw and spherical titanium fiducials, typically used in high-accurate frameless surgical navigation.

Approach: The algorithm builds on previous approaches with morphological functions and pose estimation algorithms. A 3D convolutional neural network (CNN) is proposed for the fiducial classification task and evaluated for both traditional closed-set and emerging open-set classifiers. A proposed digital ground-truth experiment, with cone-beam computed tomography (CBCT) imaging software, is performed to determine the localization accuracy of the algorithm. The localized fiducial positions in the CBCT images by the presented algorithm were compared to the actual known positions in the virtual phantom models. The difference represents the fiducial localization error (FLE).

Results: A total of 241 screws, 151 spherical fiducials, and 1550 other structures are identified with the best true positive rate 95.9% for screw and 99.3% for spherical fiducials at 8.7% and 3.4% false positive rate, respectively. The best achieved FLE mean and its standard deviation for a screw and spherical marker are 58 (14) and 14 (6)  μm, respectively.

Conclusions: Accurate marker detection and localization were achieved, with spherical fiducials being superior to screws. Large marker volume and smaller voxel size yield significantly smaller FLEs. Attenuating noise by mesh smoothing has a minor effect on FLE. Future work will focus on expanding the CNN for image segmentation.

Computer-Assisted Image-Guided Orbit Surgery

PURPOSE

Modern stereotaxy utilizes preoperative computed tomography (CT) and magnetic resonance imaging (MRI) to provide accurate localization information which can be very helpful in orbital surgery. The purpose of this report is to evaluate the usefulness of stereotactic surgery and application of this procedure in the orbit.

METHODS

Interventional case series of three patients with orbital tumors. All patients had tumor resection with the utilization of two frameless stereotactic systems: Cygnus and Stealth Station.

RESULTS

The applications of image-guided stereotactic surgery proved to be beneficial in three extensive orbital tumors, including optic nerve glioma, recurrent pleomorphic adenoma of lacrimal gland, and secondary orbital meningioma.

CONCLUSIONS

The interactive nature of image guidance can be useful in orbital surgery to orient the surgeon to the exact location within the surgical field and to determine the tumor margins.

Registration and fusion quantification of augmented reality based nasal endoscopic surgery

This paper quantifies the registration and fusion display errors of augmented reality-based nasal endoscopic surgery (ARNES). We comparatively investigated the spatial calibration process for front-end endoscopy and redefined the accuracy level of a calibrated endoscope by using a calibration tool with improved structural reliability. We also studied how registration accuracy was combined with the number and distribution of the deployed fiducial points (FPs) for positioning and the measured registration time. A physically integrated ARNES prototype was customarily configured for performance evaluation in skull base tumor resection surgery with an innovative approach of dynamic endoscopic vision expansion. As advised by surgical experts in otolaryngology, we proposed a hierarchical rendering scheme to properly adapt the fused images with the required visual sensation. By constraining the rendered sight in a known depth and radius, the visual focus of the surgeon can be induced only on the anticipated critical anatomies and vessel structures to avoid misguidance. Furthermore, error analysis was conducted to examine the feasibility of hybrid optical tracking based on point cloud, which was proposed in our previous work as an in-surgery registration solution. Measured results indicated that the error of target registration for ARNES can be reduced to 0.77 ± 0.07 mm. For initial registration, our results suggest that a trade-off for a new minimal time of registration can be reached when the distribution of five FPs is considered. For in-surgery registration, our findings reveal that the intrinsic registration error is a major cause of performance loss. Rigid model and cadaver experiments confirmed that the scenic integration and display fluency of ARNES are smooth, as demonstrated by three clinical trials that surpassed practicality.

Cadaveric Testing of Robot-Assisted Access to the Internal Auditory Canal for Vestibular Schwannoma Removal

HYPOTHESIS

An image-guided robotic system can safely perform the bulk removal of bone during the translabyrinthine approach to vestibular schwannoma (VS).

BACKGROUND

The translabyrinthine approach to VS removal involves extensive manual milling in the temporal bone to gain access to the internal auditory canal (IAC) for tumor resection. This bone removal is time consuming and challenging due to the presence of vital anatomy (e.g., facial nerve) embedded within the temporal bone. A robotic system can use preoperative imaging and segmentations to guide a surgical drill to remove a prescribed volume of bone, thereby preserving the surgeon for the more delicate work of opening the IAC and resecting the tumor.

METHODS

Fresh human cadaver heads were used in the experiments. For each trial, the desired bone resection volume was planned on a preoperative computed tomography (CT) image, the steps in the proposed clinical workflow were undertaken, and the robot was programmed to mill the specified volume. A postoperative CT scan was acquired for evaluation of the accuracy of the milled cavity and examination of vital anatomy.

RESULTS

In all experimental trials, the facial nerve and chorda tympani were preserved. The root mean squared surface accuracy of the milled cavities ranged from 0.23 to 0.65 mm and the milling time ranged from 32.7 to 57.0 minute.

CONCLUSION

This work shows feasibility of using a robot-assisted approach for VS removal surgery. Further testing and system improvements are necessary to enable clinical translation of this technology.

Strategy for accurate liver intervention by an optical tracking system

Image-guided navigation for radiofrequency ablation of liver tumors requires the accurate guidance of needle insertion into a tumor target. The main challenge of image-guided navigation for radiofrequency ablation of liver tumors is the occurrence of liver deformations caused by respiratory motion. This study reports a strategy of real-time automatic registration to track custom fiducial markers glued onto the surface of a patient's abdomen to find the respiratory phase, in which the static preoperative CT is performed. Custom fiducial markers are designed. Real-time automatic registration method consists of the automatic localization of custom fiducial markers in the patient and image spaces. The fiducial registration error is calculated in real time and indicates if the current respiratory phase corresponds to the phase of the static preoperative CT. To demonstrate the feasibility of the proposed strategy, a liver simulator is constructed and two volunteers are involved in the preliminary experiments. An ex-vivo porcine liver model is employed to further verify the strategy for liver intervention. Experimental results demonstrate that real-time automatic registration method is rapid, accurate, and feasible for capturing the respiratory phase from which the static preoperative CT anatomical model is generated by tracking the movement of the skin-adhered custom fiducial markers.

Validation of a magnetic resonance imaging guided stereotactic access to the ovine brainstem

Background

Anatomical differences between humans and domestic mammals preclude the use of reported stereotactic approaches to the brainstem in animals. In animals, brainstem biopsies are required both for histopathological diagnosis of neurological disorders and for research purposes. Sheep are used as a translational model for various types of brain disease and therefore a species-specific approach needs to be developed. The aim of the present study was to establish a minimally invasive, accurate and reproducible stereotactic approach to the brainstem of sheep, using the magnetic resonance imaging guided Brainsight^TM frameless stereotactic system.

Results

A transoccipital transcerebellar approach with an entry point in the occipital bone above the vermis between the transverse sinus and the external occipital protuberance was chosen. This approach provided access to the target site in all heads. The overall mean needle placement error was 1.85 ± 1.22 mm.

Conclusions

The developed transoccipital transcerebellar route is short, provides accurate access to the ovine caudal cranial fossa and is a promising approach to be further assessed in live animals.

Minimally invasive image-guided cochlear implantation for pediatric patients: clinical feasibility study

OBJECTIVE

Minimally invasive image-guided cochlear implantation (CI) involves accessing the cochlea via a linear path from the lateral skull to the cochlea avoiding vital structures including the facial nerve. Herein, we describe and demonstrate the feasibility of the technique for pediatric patients.

STUDY DESIGN

Prospective.

SETTING

Children's Hospital.

SUBJECTS AND METHODS

Thirteen pediatric patients (1.5 to 8 years) undergoing traditional CI participated in this Institutional Review Board-approved study. Three fiducial markers were bone-implanted surrounding the ear, and a CT scan was acquired. The CT scan was processed to identify the marker locations and critical structures of the temporal bone. A safe linear path was determined to target the cochlea avoiding damage to vital structures. A custom microstereotactic frame was fabricated that would mount on the fiducial markers and constrain a tool to the desired trajectory. After traditional mastoidectomy and prior to cochleostomy, the custom microstereotactic frame was mounted on the bone-implanted markers to confirm that the achieved trajectory was safe and accurately accessed the cochlea.

RESULTS

For all the 13 patients, it was possible to determine a safe trajectory to the cochlea. Custom microstereotactic frames were validated successfully on 9 patients. Two of these patients had inner ear malformations, and this technique helped the surgeon confirm ideal location for cochleostomy. For patients with normal anatomy, the mean and standard deviation of the closest distance of the trajectory to facial nerve and chorda tympani were 1.1 ± 0.3 mm and 1.2 ± 0.5 mm, respectively.

CONCLUSION

Minimally invasive image-guided CI is feasible for pediatric patients.

High-accuracy patient-to-image registration for the facilitation of image-guided robotic microsurgery on the head

Image-guided microsurgery requires accuracies an order of magnitude higher than today's navigation systems provide. A critical step toward the achievement of such low-error requirements is a highly accurate and verified patient-to-image registration. With the aim of reducing target registration error to a level that would facilitate the use of image-guided robotic microsurgery on the rigid anatomy of the head, we have developed a semiautomatic fiducial detection technique. Automatic force-controlled localization of fiducials on the patient is achieved through the implementation of a robotic-controlled tactile search within the head of a standard surgical screw. Precise detection of the corresponding fiducials in the image data is realized using an automated model-based matching algorithm on high-resolution, isometric cone beam CT images. Verification of the registration technique on phantoms demonstrated that through the elimination of user variability, clinically relevant target registration errors of approximately 0.1 mm could be achieved.

Local intensity feature tracking and motion modeling for respiratory signal extraction in cone beam CT projections

Accounting for respiration motion during imaging can help improve targeting precision in radiation therapy. We propose local intensity feature tracking (LIFT), a novel markerless breath phase sorting method in cone beam computed tomography (CBCT) scan images. The contributions of this study are twofold. First, LIFT extracts the respiratory signal from the CBCT projections of the thorax depending only on tissue feature points that exhibit respiration. Second, the extracted respiratory signal is shown to correlate with standard respiration signals. LIFT extracts feature points in the first CBCT projection of a sequence and tracks those points in consecutive projections forming trajectories. Clustering is applied to select trajectories showing an oscillating behavior similar to the breath motion. Those "breathing" trajectories are used in a 3-D reconstruction approach to recover the 3-D motion of the lung which represents the respiratory signal. Experiments were conducted on datasets exhibiting regular and irregular breathing patterns. Results showed that LIFT-based respiratory signal correlates with the diaphragm position-based signal with an average phase shift of 1.68 projections as well as with the internal marker-based signal with an average phase shift of 1.78 projections. LIFT was able to detect the respiratory signal in all projections of all datasets.

Automatic pre- to intra-operative CT registration for image-guided cochlear implant surgery

Percutaneous cochlear implantation (PCI) is a minimally-invasive image-guided cochlear implant approach, where access to the cochlea is achieved by drilling a linear channel from the skull surface to the cochlea. The PCI approach requires pre- and intra-operative planning. Computation of a safe linear drilling trajectory is performed in a preoperative CT. This trajectory is mapped to intraoperative space using the transformation matrix that registers the pre- and intra-operative CTs. However, the difference in orientation between the pre- and intra-operative CTs is too extreme to be recovered by standard, gradient descent-based registration methods. Thus far, the registration has been initialized manually by an expert. In this paper, we present a method that aligns the scans completely automatically. We compared the performance of the automatic approach to the registration approach when an expert does the manual initialization on 11 pairs of scans. There is a maximum difference of 0.18 mm between the entry and target points of the trajectory mapped with expert initialization and the automatic registration method. This suggests that the automatic registration method is accurate enough to be used in a PCI surgery.

Co-registration of glucose metabolism with positron emission tomography and vascularity with fluorescent diffuse optical tomography in mouse tumors

BACKGROUND

Bimodal molecular imaging with fluorescence diffuse optical tomography (fDOT) and positron emission tomography (PET) has the capacity to provide multiple molecular information of mouse tumors. The objective of the present study is to co-register fDOT and PET molecular images of tumors in mice automatically.

METHODS

The coordinates of bimodal fiducial markers (FM) in regions of detection were automatically detected in planar optical images (x, y positions) in laser pattern optical surface images (z position) and in 3-D PET images. A transformation matrix was calculated from the coordinates of the FM in fDOT and in PET and applied in order to co-register images of mice bearing neuroendocrine tumors.

RESULTS

The method yielded accurate non-supervised co-registration of fDOT and PET images. The mean fiducial registration error was smaller than the respective voxel sizes for both modalities, allowing comparison of the distribution of contrast agents from both modalities in mice. Combined imaging depicting tumor metabolism with PET-[18 F]2-deoxy-2-fluoro-d-glucose and blood pool with fDOT demonstrated partial overlap of the two signals.

CONCLUSIONS

This automatic method for co-registration of fDOT with PET and other modalities is efficient, simple and rapid, opening up multiplexing capacities for experimental in vivo molecular imaging.

Marker-free registration for the accurate integration of CT images and the subject's anatomy during navigation surgery of the maxillary sinus

OBJECTIVE

This study compared three marker-free registration methods that are applicable to a navigation system that can be used for maxillary sinus surgery, and evaluated the associated errors, with the aim of determining which registration method is the most applicable for operations that require accurate navigation.

METHODS

The CT digital imaging and communications in medicine (DICOM) data of ten maxillary models in DICOM files were converted into stereolithography file format. All of the ten maxillofacial models were scanned three dimensionally using a light-based three-dimensional scanner. The methods applied for registration of the maxillofacial models utilized the tooth cusp, bony landmarks and maxillary sinus anterior wall area. The errors during registration were compared between the groups.

RESULTS

There were differences between the three registration methods in the zygoma, sinus posterior wall, molar alveolar, premolar alveolar, lateral nasal aperture and the infraorbital areas. The error was smallest using the overlay method for the anterior wall of the maxillary sinus, and the difference was statistically significant.

CONCLUSION

The navigation error can be minimized by conducting registration using the anterior wall of the maxillary sinus during image-guided surgery of the maxillary sinus.

Automatic segmentation of the facial nerve and chorda tympani in pediatric CT scans

PURPOSE

Cochlear implant surgery is used to implant an electrode array in the cochlea to treat hearing loss. The authors recently introduced a minimally invasive image-guided technique termed percutaneous cochlear implantation. This approach achieves access to the cochlea by drilling a single linear channel from the outer skull into the cochlea via the facial recess, a region bounded by the facial nerve and chorda tympani. To exploit existing methods for computing automatically safe drilling trajectories, the facial nerve and chorda tympani need to be segmented. The goal of this work is to automatically segment the facial nerve and chorda tympani in pediatric CT scans.

METHODS

The authors have proposed an automatic technique to achieve the segmentation task in adult patients that relies on statistical models of the structures. These models contain intensity and shape information along the central axes of both structures. In this work, the authors attempted to use the same method to segment the structures in pediatric scans. However, the authors learned that substantial differences exist between the anatomy of children and that of adults, which led to poor segmentation results when an adult model is used to segment a pediatric volume. Therefore, the authors built a new model for pediatric cases and used it to segment pediatric scans. Once this new model was built, the authors employed the same segmentation method used for adults with algorithm parameters that were optimized for pediatric anatomy.

RESULTS

A validation experiment was conducted on 10 CT scans in which manually segmented structures were compared to automatically segmented structures. The mean, standard deviation, median, and maximum segmentation errors were 0.23, 0.17, 0.18, and 1.27 mm, respectively.

CONCLUSIONS

The results indicate that accurate segmentation of the facial nerve and chorda tympani in pediatric scans is achievable, thus suggesting that safe drilling trajectories can also be computed automatically.

A frameless stereotaxic MRI technique for macaque neuroscience studies

MRI has achieved widespread use for preplanning neuroscience procedures for non-human primate studies. However, orienting imaging studies in stereotaxic space has relied primarily on using a stereotaxic frame or co-registering fiducial markers with the neuroimaging. In this study, we present a simple approach in which the MRI dataset is aligned to the bony landmarks that define the Frankfurt stereotaxic baseline plane, without the need for a stereotaxic frame or additional external fiducials. To facilitate localizing the bony landmarks (infraorbital margin, external bony auditory meatus) on the MRI scans additional imaging landmarks (mid ocular plane, temporomandibular joint) are discussed that provide supplementary and readily visible points of reference.

The frameless MRI stereotaxic technique was evaluated in 8 rhesus macaque monkeys using 3D fast gradient echo MRI images with 0.7mm isotropic resolution. 1) Difference in stereotaxic coordinates of fiducial markers was compared between a traditional stereotaxic frame and the frameless MRI technique (n=2). 2) Differences in stereotaxic coordinates for cerebral regions were compared between the frameless MRI technique and MRI obtained with the animal positioned in a MRI-compatible stereotaxic frame (n=4). 3) The frameless MRI technique was further refined to prescribe electrode penetrations within a dural recording chamber in stereotaxic coordinates relative to the electrode microdrive. Differences in MRI coordinates were compared with the electrode microdrive (n=3).

Mean localization of fiducial markers differed by 1.6 +/- 0.6 mm between the frameless MRI technique and a traditional stereotaxic frame. Between the frameless technique and an MRI-compatible stereotaxic frame, localization of cerebral anatomy differed by 2.8 +/- 2.2 mm with the primary source of error being a pitch-up rotation in the sagittal plane. This localization difference was reduced to 0.5 +/- 0.6 mm when this rotation was removed. Frameless MRI coordinates for electrode tracts within the dural recording chamber were within 0.5mm +/- 0.2 mm of the electrode microdrive readings.

This simple technique provides the ability to accurately plan surgery and neurophysiological recordings in an individual animal, and to define the location of cerebral anatomy and electrode or injection tracts using publically available software, and without the need for dedicated MRI-compatible localization hardware. The reduced need for deep anesthesia (a necessity with traditional stereotaxic frames) makes the technique more amenable for functional MRI studies. Since each animal provides the bony landmarks to define their own stereotaxic space, this technique is readily applicable to other species.

Frameless stereotactic cerebral biopsy: our experience in 296 cases

AIMS

To evaluate the reliability, safety and accuracy of a the frameless stereotactic system in our clinical series and the differences between head fixation by means of a standard Mayfield head holder and the pinless FESS frame, and to evaluate the usefulness of biopsy targeting on the basis of magnetic resonance spectroscopy (MRS) data.

METHODS

The spectroscopic analysis was used to facilitate the targeting of the lesion. The fusion image function embedded in the Neuronavigation Unit was used postoperatively to assess the level of accuracy of the biopsy. The grading of the glioma specimens was correlated to the spectroscopic data.

RESULTS

296 patients underwent cerebral biopsy in 8 years. The diagnostic yield was 99.7%. The spectroscopic choline/N-acetyl aspartate ratio in different areas of the same tumor correlated well with the histological grading of the lesion.

CONCLUSION

The frameless stereotactic systems guarantee excellent biopsy results. Advanced imaging, in particular MRS, facilitates the correct targeting of nonenhancing lesions.

Evaluation of portable CT scanners for otologic image-guided surgery

PURPOSE

Portable CT scanners are beneficial for diagnosis in the intensive care unit, emergency room, and operating room. Portable fixed-base versus translating-base CT systems were evaluated for otologic image-guided surgical (IGS) applications based on geometric accuracy and utility for percutaneous cochlear implantation.

METHODS

Five cadaveric skulls were fitted with fiducial markers and scanned using both a translating-base, 8-slice CT scanner (CereTom(®)) and a fixed-base, flat-panel, volume CT (fpVCT) scanner (Xoran xCAT(®)). Images were analyzed for: (a) subjective quality (i.e., noise), (b) consistency of attenuation measurements (Hounsfield units) across similar tissue, and (c) geometric accuracy of fiducial marker positions. The utility of these scanners in clinical IGS cases was tested.

RESULTS

Five cadaveric specimens were scanned using each of the scanners. The translating-base, 8-slice CT scanner had spatially consistent Hounsfield units, and the image quality was subjectively good. However, because of movement variations during scanning, the geometric accuracy of fiducial marker positions was low. The fixed-base, fpVCT system had high spatial resolution, but the images were noisy and had spatially inconsistent attenuation measurements, while the geometric representation of the fiducial markers was highly accurate.

CONCLUSION

Two types of portable CT scanners were evaluated for otologic IGS. The translating-base, 8-slice CT scanner provided better image quality than a fixed-base, fpVCT scanner. However, the inherent error in three-dimensional spatial relationships by the translating-based system makes it suboptimal for otologic IGS use.

General bounds for electrode mislocation on the EEG inverse problem

We analyze the effect of electrode mislocation on the electroencephalography (EEG) inverse problem using the Cramér-Rao bound (CRB) for single dipolar source parameters. We adopt a realistic head shape model, and solve the forward problem using the Boundary Element Method; the use of the CRB allows us to obtain general results which do not depend on the algorithm used for solving the inverse problem. We consider two possible causes for the electrode mislocation, errors in the measurement of the electrode positions and an imperfect registration between the electrodes and the scalp surfaces. For 120 electrodes placed in the scalp according to the 10-20 standard, and errors on the electrode location with a standard deviation of 5mm, the lower bound on the standard deviation in the source depth estimation is approximately 1mm in the worst case. Therefore, we conclude that errors in the electrode location may be tolerated since their effect on the EEG inverse problem are negligible from a practical point of view.

Validation for 2D/3D registration. I: A new gold standard data set

PURPOSE

In this article, the authors propose a new gold standard data set for the validation of two-dimensional/three-dimensional (2D/3D) and 3D/3D image registration algorithms.

METHODS

A gold standard data set was produced using a fresh cadaver pig head with attached fiducial markers. The authors used several imaging modalities common in diagnostic imaging or radiotherapy, which include 64-slice computed tomography (CT), magnetic resonance imaging using T1, T2, and proton density sequences, and cone beam CT imaging data. Radiographic data were acquired using kilovoltage and megavoltage imaging techniques. The image information reflects both anatomy and reliable fiducial marker information and improves over existing data sets by the level of anatomical detail, image data quality, and soft-tissue content. The markers on the 3D and 2D image data were segmented using ANALYZE 10.0 (AnalyzeDirect, Inc., Kansas City, KN) and an in-house software.

RESULTS

The projection distance errors and the expected target registration errors over all the image data sets were found to be less than 2.71 and 1.88 mm, respectively.

CONCLUSIONS

The gold standard data set, obtained with state-of-the-art imaging technology, has the potential to improve the validation of 2D/3D and 3D/3D registration algorithms for image guided therapy.

Integration and evaluation of a needle-positioning robot with volumetric microcomputed tomography image guidance for small animal stereotactic interventions

PURPOSE

Preclinical research protocols often require insertion of needles to specific targets within small animal brains. To target biologically relevant locations in rodent brains more effectively, a robotic device has been developed that is capable of positioning a needle along oblique trajectories through a single burr hole in the skull under volumetric microcomputed tomography (micro-CT) guidance.

METHODS

An x-ray compatible stereotactic frame secures the head throughout the procedure using a bite bar, nose clamp, and ear bars. CT-to-robot registration enables structures identified in the image to be mapped to physical coordinates in the brain. Registration is accomplished by injecting a barium sulfate contrast agent as the robot withdraws the needle from predefined points in a phantom. Registration accuracy is affected by the robot-positioning error and is assessed by measuring the surface registration error for the fiducial and target needle tracks (FRE and TRE). This system was demonstrated in situ by injecting 200 microm tungsten beads into rat brains along oblique trajectories through a single burr hole on the top of the skull under micro-CT image guidance. Postintervention micro-CT images of each skull were registered with preintervention high-field magnetic resonance images of the brain to infer the anatomical locations of the beads.

RESULTS

Registration using four fiducial needle tracks and one target track produced a FRE and a TRE of 96 and 210 microm, respectively. Evaluation with tissue-mimicking gelatin phantoms showed that locations could be targeted with a mean error of 154 +/- 113 microm.

CONCLUSIONS

The integration of a robotic needle-positioning device with volumetric micro-CT image guidance should increase the accuracy and reduce the invasiveness of stereotactic needle interventions in small animals.

Submillimetric target-registration error using a novel, non-invasive fiducial system for image-guided otologic surgery

OBJECTIVE

Otologic surgery is undertaken to treat ailments of the ear, including persistent infections, hearing loss, vertigo, and cancer. Typically performed on otherwise-healthy patients in outpatient facilities, the application of image-guided surgery (IGS) has been limited because accurate (<1 mm), non-invasive fiducial systems for otologic surgery have not been available. We now present such a fiducial system.

METHODS

A dental bite-block was fitted with a custom-designed rigid frame with 7 fiducial markers surrounding each external ear. The bones containing the ear (i.e., the temporal bones) of 3 cadaveric skulls were removed and replaced with discs containing 13 surgical targets arranged in a cross-hair pattern about the centroid of each ear. The surgical targets (26/skull) and fiducial markers (14/skull) were identified both within CT scans using a published algorithm and in physical space using an infrared optical tracking system. Fiducial registration error (FRE), fiducial localization error (FLE), and target registration error (TRE) were calculated.

RESULTS

For all trials, root mean square FRE = 0.66, FLE = 0.72, and TRE = 0.77 mm. The mean TRE for n = 234 independent targets was 0.73 with a standard deviation of 0.25 mm.

CONCLUSIONS

Using a novel, non-invasive fiducial system (the EarMark), submillimetric accuracy was repeatably achieved. This system will facilitate image-guided otologic surgery.

Initial investigation of an automatic registration algorithm for surgical navigation

The procedure required for registering a surgical navigation system prior to use in a surgical procedure is conventionally a time-consuming manual process that is prone to human errors and must be repeated as necessary through the course of a procedure. The conventional procedure becomes even more time consuming when intra-operative 3D imaging such as the C-arm cone-beam CT (CBCT) is introduced, as each updated volume set requires a new registration. To improve the speed and accuracy of registering image and world reference frames in image-guided surgery, a novel automatic registration algorithm was developed and investigated. The surgical navigation system consists of either Polaris (Northern Digital Inc., Waterloo, ON) or MicronTracker (Claron Technology Inc., Toronto, ON) tracking camera(s), custom software (Cogito running on a PC), and a prototype CBCT imaging system based on a mobile isocentric C-arm (Siemens, Erlangen, Germany). Experiments were conducted to test the accuracy of automatic registration methods for both the MicronTracker and Polaris tracking cameras. Results indicate the automated registration performs as well as the manual registration procedure using either the Claron or Polaris camera. The average root-mean-squared (rms) observed target registration error (TRE) for the manual procedure was 2.58 +/- 0.42 mm and 1.76 +/- 0.49 mm for the Polaris and MicronTracker, respectively. The mean observed TRE for the automatic algorithm was 2.11 +/- 0.13 and 2.03 +/- 0.3 mm for the Polaris and MicronTracker, respectively. Implementation and optimization of the automatic registration technique in Carm CBCT guidance of surgical procedures is underway.

New technique for real-time interface pressure analysis: getting more out of large image data sets

Recent technological improvements have led to increasing clinical use of interface pressure mapping for seating pressure evaluation, which often requires repeated assessments. However, clinical conditions cannot be controlled as closely as research settings, thereby creating challenges to statistical analysis of data. A multistage longitudinal analysis and self-registration (LASR) technique is introduced that emphasizes real-time interface pressure image analysis in three dimensions. Suitable for use in clinical settings, LASR is composed of several modern statistical components, including a segmentation method. The robustness of our segmentation method is also shown. Application of LASR to analysis of data from neuromuscular electrical stimulation (NMES) experiments confirms that NMES improves static seating pressure distributions in the sacral-ischial region over time. Dynamic NMES also improves weight-shifting over time. These changes may reduce the risk of pressure ulcer development.

Image guided oral implantology and its application in the placement of zygoma implants

The application of zygoma implants proposes a successful treatment for functional reconstruction of maxillary defects. However, the placement of zygoma implants is not without risk due to anatomically complex operation sites. Aiming at minimizing the risks and improving the precision of the surgery, an image guided oral implantology system (IGOIS) is presented in this study to transfer the preoperative plan accurately to the operating theatre. The principle of IGOIS is introduced in detail, including the framework, 3D-reconstruction, preoperative planning, registration, and the motion tracking algorithm. The phantom experiment shows that fiducial registration error (FRE) and TRE (target registration error) of IGOIS are, respectively, 1.12mm and 1.35mm. With respect to the overall accuracy, the average distance deviations at the coronal and apical point of the implant are, respectively, 1.36+/-0.59mm and 1.57+/-0.59mm, while average angle deviation between the axes of the planned and the actual implant is 4.1 degrees +/-0.9 degrees . A clinical report for a patient with a severely atrophic maxilla demonstrates that the major advantage of this computer-aided navigation technology lies in its accuracy, reliability, and flexibility.

Accuracy and reproducibility of tumor positioning during prolonged and multi-modality animal imaging studies

Dedicated small-animal imaging devices, e.g. positron emission tomography (PET), computed tomography (CT) and magnetic resonance imaging (MRI) scanners, are being increasingly used for translational molecular imaging studies. The objective of this work was to determine the positional accuracy and precision with which tumors in situ can be reliably and reproducibly imaged on dedicated small-animal imaging equipment. We designed, fabricated and tested a custom rodent cradle with a stereotactic template to facilitate registration among image sets. To quantify tumor motion during our small-animal imaging protocols, 'gold standard' multi-modality point markers were inserted into tumor masses on the hind limbs of rats. Three types of imaging examination were then performed with the animals continuously anesthetized and immobilized: (i) consecutive microPET and MR images of tumor xenografts in which the animals remained in the same scanner for 2 h duration, (ii) multi-modality imaging studies in which the animals were transported between distant imaging devices and (iii) serial microPET scans in which the animals were repositioned in the same scanner for subsequent images. Our results showed that the animal tumor moved by less than 0.2-0.3 mm over a continuous 2 h microPET or MR imaging session. The process of transporting the animal between instruments introduced additional errors of approximately 0.2 mm. In serial animal imaging studies, the positioning reproducibility within approximately 0.8 mm could be obtained.

Intraoperative laparoscope augmentation for port placement and resection planning in minimally invasive liver resection

In recent years, an increasing number of liver tumor indications were treated by minimally invasive laparoscopic resection. Besides the restricted view, two major intraoperative issues in laparoscopic liver resection are the optimal planning of ports as well as the enhanced visualization of (hidden) vessels, which supply the tumorous liver segment and thus need to be divided (e.g., clipped) prior to the resection. We propose an intuitive and precise method to plan the placement of ports. Preoperatively, self-adhesive fiducials are affixed to the patient's skin and a computed tomography (CT) data set is acquired while contrasting the liver vessels. Immediately prior to the intervention, the laparoscope is moved around these fiducials, which are automatically reconstructed to register the patient to its preoperative imaging data set. This enables the simulation of a camera flight through the patient's interior along the laparoscope's or instruments' axes to easily validate potential ports. Intraoperatively, surgeons need to update their surgical planning based on actual patient data after organ deformations mainly caused by application of carbon dioxide pneumoperitoneum. Therefore, preoperative imaging data can hardly be used. Instead, we propose to use an optically tracked mobile C-arm providing cone-beam CT imaging capability intraoperatively. After patient positioning, port placement, and carbon dioxide insufflation, the liver vessels are contrasted and a 3-D volume is reconstructed during patient exhalation. Without any further need for patient registration, the reconstructed volume can be directly augmented on the live laparoscope video, since prior calibration enables both the volume and the laparoscope to be positioned and oriented in the tracking coordinate frame. The augmentation provides the surgeon with advanced visual aid for the localization of veins, arteries, and bile ducts to be divided or sealed.

Development of prototype for navigated real-time sonography for the head and neck region

BACKGROUND

To date, few imaging methods have been established for the head and neck region, in particular for soft tissues, that allow adequate visualization and simultaneously adequate real-time orientation.

METHODS

We report a new method using a navigated ultrasound device and a navigated surgical instrument that allows--even in the absence of bony landmarks--appropriate visualization and reliable orientation in real time.

RESULTS

The practical applicability of the system was tested. Good handling and acceptance of the system could be shown. The "3-dimensional error" derived from the deviations in all 3 dimensions lies at 0.64 mm.

CONCLUSIONS

With this ultrasound-guided navigated procedure, an accurate approach of soft tissue structures with a surgical instrument is possible. Changes of the situs are represented in real time.

Merging molecular and anatomical information: A feasibility study on rodents using microPET and MRI

OBJECTIVE

The use of the micro positron emission tomography (microPET) technique provides a powerful means for molecular imaging on small animals, while its inferior spatial resolution offers insufficient anatomical information which impedes the interpretations of the scans. To improve this limitation, it often relies on a clinical magnetic resonance imaging (MRI) for providing anatomical details. In this study, we designed and developed a new image co-registration platform which contains a stereotactic frame and external fiducial markers for microPET and MRI studies. The image co-registration accuracies were also validated by this new platform using various imaging protocols for microPET and MRI.

METHODS

The microPET images were reconstructed by filtered back-projection (FBP) and ordered subset expectation maximization (OSEM) methods. Two MRI pulse sequences, two-dimensional T1-weighted fast spin-echo (FSE) and three-dimensional spoiled gradient recalled (SPGR), were employed in the studies. Two MRI scanning protocols were proposed for small animal imaging: the whole-body high-speed mode and the partial high-resolution mode.

RESULTS

Reconstructed images from two different modalities were integrated by point-to-point registration via the external fiducials. Four inter-modality matched co-registration pairs (FBP-FSE, FBP-SPGR, OSEM-FSE, OSEM-SPGR) were obtained for both the high speed and high resolution modes. Co-registration accuracy was given as the average fiducial registration error (FRE) between the centroids of six markers from the registered images. The overall systemic FREs were about 0.50 mm.

CONCLUSIONS

From the inter-modality FRE comparison, MRI imaging with FSE performed better than that with SPGR sequence, due to its higher signal-to-noise ratio and less magnetic susceptibility effects. In the microPET perspective, the OSEM was superior to the FBP, as a result of fewer image artifacts.

PET/CT image registration: Preliminary tests for its application to clinical dosimetry in radiotherapy

The quality of dosimetry in radiotherapy treatment requires the accurate delimitation of the gross tumor volume. This can be achieved by complementing the anatomical detail provided by CT images through fusion with other imaging modalities that provide additional metabolic and physiological information. Therefore, use of multiple imaging modalities for radiotherapy treatment planning requires an accurate image registration method. This work describes tests carried out on a Discovery LS positron emission/computed tomography (PET/CT) system by General Electric Medical Systems (GEMS), for its later use to obtain images to delimit the target in radiotherapy treatment. Several phantoms have been used to verify image correlation, in combination with fiducial markers, which were used as a system of external landmarks. We analyzed the geometrical accuracy of two different fusion methods with the images obtained with these phantoms. We first studied the fusion method used by the PET/CT system by GEMS (hardware fusion) on the basis that there is satisfactory coincidence between the reconstruction centers in CT and PET systems; and secondly the fiducial fusion, a registration method, by means of least-squares fitting algorithm of a landmark points system. The study concluded with the verification of the centroid position of some phantom components in both imaging modalities. Centroids were estimated through a calculation similar to center-of-mass, weighted by the value of the CT number and the uptake intensity in PET. The mean deviations found for the hardware fusion method were: deltax/ +/-sigma = 3.3 mm +/- 1.0 mm and /deltax/ +/-sigma = 3.6 mm +/- 1.0 mm. These values were substantially improved upon applying fiducial fusion based on external landmark points: /deltax/ +/-sigma = 0.7 mm +/- 0.8 mm and /deltax/ +/-sigma = 0.3 mm 1.7 mm. We also noted that differences found for each of the fusion methods were similar for both the axial and helical CT image acquisition protocols.

Spatial localization of EEG electrodes

AIM OF THE STUDY

An important goal for EEG-based functional brain studies is to estimate the location of brain sources that produce the scalp-recorded signals. Such source localization requires locating precisely the position of the EEG sensors. This review describes and compares different methods that are used for localizing EEG sensors.

RESULTS

Five different methods have been described in literature. Manual methods consist in manual measurements to calculate the 3D coordinates of the sensors. Electromagnetic and ultrasound digitization permit localization by using trade devices. The photogrammetry system consists in taking pictures of the patient's head with the sensors. The last method consists in directly localizing the EEG sensors in the MRI volume.

DISCUSSION AND CONCLUSIONS

The spatial localization of EEG sensors is an important step in performing source localization. This method should be accurate, fast, reproducible, and cheap. Currently, electromagnetic digitization is the most currently used method but MRI localization could be an interesting way because no additional method or device needs to be used to locate the EEG sensors.

COMBINED X-RAY AND MAGNETIC RESONANCE IMAGING FACILITY

OBJECTIVE

To assess the feasibility of a hybrid imaging setup combining x-ray and magnetic resonance imaging (MRI) in the setting of both stereotactic and functional neurosurgery.

METHODS

A combined x-ray and MRI scanning facility with a trolley system for a fast patient transfer between both modalities was installed in a neurosurgical setting. A registration algorithm for fusion of MRI scans and x-ray images was derived for augmentation of fluoroscopic x-ray projection images with MRI scan data, such as anatomic structures and planned probe trajectories. Phantom measurements were obtained between both modalities for estimation of registration accuracy. Practical application of our system in stereotactic and functional neurosurgery was tested in brachytherapy, deep brain stimulation, and motor cortex stimulation.

RESULTS

Phantom measurements yielded a mean spatial deviation of 0.7 +/- 0.3 mm with a maximum deviation of 1.1 mm for MRI scans versus x-rays. Augmentation of x-ray images with MRI scan data allowed intraoperative verification of the planned trajectory and target in three types of neurosurgical procedures: positioning iodine seeds in brachytherapy in one case with cerebellar metastasis, placement of electrodes for deep brain stimulation in two cases of advanced Parkinson's disease, and placement of an epidural grid for motor cortex stimulation in two cases of intractable pain.

CONCLUSION

Combined x-ray and MRI-guided stereotactic and functional neurosurgery is feasible. Augmentation of x-ray projection images with MRI scan data, such as planned probe trajectories and MRI scan segmented anatomic structures may be beneficial for probe guidance in stereotactic and functional neurosurgery.

IMAGE FUSION OF COMPUTED TOMOGRAPHIC AND MAGNETIC RESONANCE IMAGES FOR THE DEVELOPMENT OF A THREE-DIMENSIONAL MUSCULOSKELETAL MODEL OF THE EQUINE FORELIMB

Biomechanical models that compute the lengths and forces of muscle-tendon units are broadly applicable to the study of factors that promote injury and the planning and effects of orthopedic surgical procedures in equine athletes. A three-dimensional (3D) generic musculoskeletal model of the equine forelimb comprised of bony segment, muscle-tendon, and ligament information, was developed based on high-resolution computed tomographic (CT) and T1-weighted magnetic resonance (MR) images from an isolated forelimb of a Thoroughbred racehorse. Image fusion was achieved through coregistration of CT and MR images with an image analysis program (Analyze) by adjustment of the relative position and orientation of fiducial markers visible in both modalities until the mutual information between the images was maximized. 3D surfaces of the bones and origin/insertion sites, centroid paths and volumes of the muscle-tendon and ligamentous structures were obtained from the multimodal (CT/MR) images using semiautomated and manual segmentation combined with sagittal and transverse color-cryosection anatomic images obtained from three other cadaveric equine forelimbs. Once bony and soft-tissue structures were reconstructed in the same coordinate system, data were imported to a software package for interactive musculoskeletal modeling (SIMM). The combination of integrated CT and MR acquisitions and anatomical images provided an accurate and efficient means of generating a 3D model of the musculoskeletal structures of an average-sized equine adult horse.