35 Image-Guided Surgical Techniques for Meningiomas


35 Image-Guided Surgical Techniques for Meningiomas

Elliott Robert E., Golfinos John G.

The skin opening must be bigger than the bone opening. The bone opening must be bigger than the dural opening. The dural opening must be bigger than the tumor.

—Patrick J. Kelly, MD


Meningiomas are one of the more common brain tumors. Given their typically benign histopathology, optimal treatment remains complete resection when it can be accomplished with no or minimal morbidity. For difficult tumors with higher-risk profiles, other treatment options include radiosurgery and radiation therapy—with or without surgical debulking.15 Nevertheless, even completely resected benign meningiomas can recur in nearly 10 to 30% of cases with long-term follow-up, and progression of incompletely resected tumors is quite high610 ( Table 35.1 ). Incomplete resections predispose patients not only to a high probability of recurrence but also to a decreased chance of successful resection at subsequent operations7 and worse overall survival.11 These findings underscore the need for attempted complete removal at the initial operation—including removal of the bulky tumor in addition to the dural tail, sinus invasion, and bony involvement when possible. To better achieve this end safely and in a manner as minimally invasive as possible, image guidance surgery (IGS) systems have become an increasingly important and utilized tool.

Stereotactic neurosurgery was originally conceived for the treatment of intraparenchymal lesions and utilized a headframe-based platform. With engineering advances in imaging, optical, and infrared technologies, “frameless” stereotaxy systems (neuronavigation) were developed12 and, given their ease of application, have grown in prominence for the treatment of all types of intracranial lesions—including meningiomas.13 Many centers now routinely use IGS for resection of meningiomas to minimize skin incision and craniotomy size,8 but few centers have reported on their experience.1419 This chapter discusses the techniques of IGS for intracranial meningiomas and their utility beyond minimally invasive neurosurgery.

Rationale for Use of Image Guidance Surgery Systems in Meningioma Resection

IGS systems use the information obtained in a two-dimensional (2-D) plane to re-create and display the patient’s anatomy in a three-dimensional (3-D) space. This reconstructed 3-D volume can then be analyzed and manipulated, allowing visualization of the target lesion in multiple planes, planning of the optimal surgical trajectory, and accurate localization of critical nearby structures. All of this can be accomplished before the patient enters the operative suite and can be updated with real-time positional feedback with tracked instruments as the surgery progresses.

To date, however, no prospective, randomized studies have demonstrated improved outcomes using IGS for meningioma resection. Paleologos et al17 retrospectively reported on 270 patients who underwent meningioma re-section (100 with IGS, 170 with standard surgery). Matching 100 patients with similar baseline characteristics (50 in each group), they noted shorter operative times, fewer major complications, shorter hospital stays, and lower costs in the patients in whom IGS was used. In agreement with other centers,13,15,17,2023 we believe neuronavigation not only enhances surgeon confidence but can result in improved patient outcomes and satisfaction, with smaller scalp flaps and craniotomy sizes, shorter operative times, more complete resections, less trauma to the surrounding structures, lower surgical morbidity, and shorter hospital stays.

Types and Overview of Image Guidance Surgery Systems

Table 35.2 summarizes the major IGS platforms and the commercially available products. No objective, prospective studies have determined the benefits of using IGS systems compared with not using neuronavigation for meningioma resection nor the superiority of one system over another. Ultimately, the choice of IGS device depends on surgeon preference and institutional availability.

Table 35.1 Simpson Grading Scale for Removal of Meningiomas and Risk of Recurrence or Progression

Rates of Recurrence or Progression


Degree of Removal a


Miraminoff et alc

Adegbite et ald


Macroscopically complete tumor removal with excision of dural attachment and abnormal bone; including sinus resection when involved





Macroscopically complete tumor removal with coagulation (Bovie electrocautery or laser) of dural attachment





Macroscopically complete tumor removal without resection or coagulation of dural attachment or of its extradural extensions (e.g., hyperostotic bone)





Partial tumor removal





Simple decompression (with or without biopsy)




Abbreviation: NA, not available.

a Grading scale and definitions adapted from Simpson D. The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 1957;20(1):22–39.14

b Median survival times are not reported.

c Outcome data from 225 patients derived from reported actuarial 15-year progression-free survival values.

d Outcome data from 114 patients with rates derived from reported 5-year progression-free survival values. The 100% recurrence rate for grade III resection is based on n = 3.

Table 35.2 Types of Image Guidance Surgery Systems and Commercially Available Products

Type of Image Guidance Surgery



Articulated arms

Consist of movable arm with multiple position sensors that provide correlation of pointer location with imaging

Require movement into and out of operative field for use

ISG Wand (ISG Technologies, Inc., Mississauga, Ontario, Canada/Elekta, Atlanta, GA)

Radionics Operating Arm (Radionics, Burlington, MA)

Light-emitting diode systems

Pointing probe and array attached to skull or head holder have light-emitting diodes that emit pulses of infrared light

Cameras receive the infrared light and determine the location of the pointer relative to the head array

Allow stereotactic microscope integration

iNtellect Cranial Navigation System (Stryker, Kalamazoo, MI)

EasyGuide Neuro (Phillips, Shelton, CT)

SMN-Zeiss (Carl Zeiss, Inc., Thornwood, NY)

Passive infrared systems

Consist of cameras that emit pulses of infrared light that are returned by reflective spheres attached to the pointer probe, head array, and surgical instruments

Allow stereotactic microscope integration

Brainlab VectorVision (Brainlab USA, Redwood City, CA)

StealthStation TREON (Medtronic Navigation, Louisville, CO)

Electromagnetic systems

Create a small magnetic field that tracks a magnetically active pointer

Cygnus Stereotactic System (Compass International, Inc., Rochester, MN)

StealthStation AxiEM (Medtronic Navigation, Louisville, CO)

Articulated Arms

Original frameless IGS devices involved articulated arms with multiple electropotentiometer position-sensors within the joints that allowed simple patient-to-image registration. They can be cumbersome to move into and out of the operative field—especially during use of the microscope for skull base tumors. Their bulk and frequent collisions with the microscope led to their demise. Nevertheless, accuracy on the order of 2 mm had been reported by multiple authors using these systems—adequate for most meningioma surgeries20 and rivaling the accuracy of later systems.

Light-Emitting Diode Systems

Light-emitting diode (LED) neuronavigation systems are optically based systems that use an infrared camera array to monitor instrument and head position. The camera tracks the location of LEDs mounted to surgical instruments and to the reference array attached to the head holder or directly onto the skull. Rigid fixation is required with LED systems to maintain the 3-D coordinate space created during registration. These systems require maintenance of line of sight between the camera, head holder array, and probe but allow stereotactic integration with the operating microscope (using the focal point as the “pointer position”).

Passive Infrared Sensors

Systems utilizing passive infrared sensors use cameras that flash pulses of infrared light reflected from specially coated spheres attached to a pointing probe or from an array of spheres attached to surgical instruments. Surgical instruments (e.g., endoscopes, ventricular catheters, biopsy probes, etc.) can be registered and calibrated using both device length and diameter to be used during surgery. Importantly, these systems allow a wide array of instruments to be registered and require no cable attachments for ease of use. Similar to LED systems, however, rigid fixation is required, line of sight must be maintained, and the spheres must be cleaned periodically to maintain their reflective properties. Infrared systems also allow stereotactic integration with the operating microscope (using the focal point as the “pointer position”).

Electromagnetic Neuronavigation

Electromagnetic IGS systems involve the creation of a small magnetic field enveloping the cranial space and allow tracking of a magnetically active pointing device in the registered field. Magnetic systems avoid line-of-site issues but are prone to magnetic field distortion and disruption of navigation if instruments composed of ferromagnetic materials are brought into the field. Both the Cygnus Stereotactic System (Compass International, Inc., Rochester, MN) used at our center for years and the StealthStation AxiEM (Medtronic Navigation, Louisville, CO) can be used with or without a head holder attachment. The latter has been used successfully in small children where pinning is not advisable.

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Jul 14, 2020 | Posted by in NEUROLOGY | Comments Off on 35 Image-Guided Surgical Techniques for Meningiomas
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