May 25, 2000 -- Every day for eight months Gisela Roubeck lived with pounding pain behind her temples. Every day she reached for the bottle of ibuprofen and hoped for some relief. Relief came on Jan. 25, 2000, when neurosurgeon Ezriel F. Kornel, MD, guided by special 3-D images of her brain carefully removed a benign tumor through an incision about the width of a half-dollar.
"I went home the next day. No headaches. Dr. Kornel is my miracle," says Roubeck, 32. "The surgery was on a Tuesday, I was back at work the following Monday."
Not science fiction and certainly not a miracle. What Roubeck describes was the first image-guided brain surgery using on the spot CAT scan images. Kornel, director of the Institute for Neurosciences at Northern Westchester Hospital Center, says the new approach adds a precision that was previously unknown in brain surgery. The center, in Mt. Kisco, New York, is developing an image-guided program in conjunction with Yale-New Haven Hospital and Yale Medical School.
This latest high-tech improvement requires specially constructed operating rooms as well as a combination of several high-tech approaches, says Kornel. A portable CAT scan is placed at the end of a specially designed operating table.
Because operating tables are steel, they won?t allow the CAT scan beams to penetrate the table, Kornel says. So researchers had to design an operating table that would let the beams through, he tells WebMD. The patient is scanned before surgery and the images are fed into a computerized navigational system that then displays 3-D images of the area scanned.
The navigational system, called a Stealth System, "plots" the area for the special microscope used by brain surgeons. The scope then "actually becomes a pointer, precisely directing the instruments," he says. "During surgery we can repeat the scan by simply rolling the patient into the scanner and then feeding the images into the navigational system," he says.
At University Hospitals of Cleveland, neurosurgeons are using a different system, one that uses MRI pictures, to guide their surgeries, but they have not yet integrated these images with the navigational system, Robert Ratcheson, MD, chief of neurosurgery at University Hospitals tells WebMD.
Kornel tells WebMD that he has done about 20 operations using the system. In addition to brain surgery he is using it for spine surgery such as herniated disc repair.
In brain surgery, Kornel is concentrating on gliomas, brain tumors that start in the brain and have not spread from somewhere else. "Gliomas ... are difficult to see at the time of surgery." Using this system, he is able to more fully take out the tumor with more confidence, he says.
Ratcheson says he thinks the MRI approach used for the past year at University Hospitals may be superior to the CAT system used by Kornel. "We take a different approach to this ... intraoperative CAT is somewhat limited as far as what it can tell you about the brain at the time of surgery." It is probably better for spine surgery because CAT scan is better for looking at bones, but for brain surgery MRI is better, says Ratcheson.
Kornel agrees that MRI probably does give better images of the brain. He says, however, that he decided to proceed with CAT instead because "the [MRI] system is very cumbersome to work with and it?s very expensive. [CAT] is much more user friendly at the beginning," he says.
Neither approach, however, is cheap. At Northern Westchester hospital, the Center for Minimally Invasive Neurosurgery spent $1 million to purchase the system and build a special operating room for its use. Ratcheson says University hospital "spent probably twice that much" for the MRI system.
Both centers, however, say the benefits of the systems far outweigh the costs. For example, Kornel says, "there is less brain trauma, people feel better sooner and go home earlier." In the case of a brain biopsy, Kornel says that with the image-guided approach the "patient can go home the same day instead of 24-hour hospitalization that is the usual approach."
Ratcheson agrees that the imaging systems are probably responsible for fewer complications after surgery and less brain trauma at time of surgery.
Another advantage to this "miniaturization" is purely cosmetic, Roubeck explains. "I was so worried about my hair, that my head would be shaved. But they only took away a little hair just in front of my ear, it wasn?t even noticeable. Not even I noticed," she says.
- Surgeons are developing new techniques that involve using on the spot 3-D images of the brain to guide them during surgery.
- A special operating room must be constructed to do the image-guided surgery, and construction can cost at least $1 million.
- During this type of brain surgery, the surgeon can be more precise, so there is less trauma to the brain during surgery, fewer complications after surgery, and the patients go home much sooner.