Combined and Three-dimensional Rendered Multimodal Data for Planning Cranial Base Surgery: A Prospective Evaluation

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Abstract
MAGNETIC RESONANCE (MR), X-RAY computed tomography (CT), and angiographic images best depict soft tissue, bone, and blood vessels respectively. No one on its own is sufficient in the preoperative assessment of cranial base lesions. We have developed and evaluated a computational technique for the three-dimensional (3D) combination and display of multimodality images for planning cranial base surgery. This evaluation was prospective and performed in such a way that the results could be quantified. Eight patients (three acoustic neuromas, four subfrontal and suprasellar meningiomas, and one petrous apex meningioma) underwent MR, CT, and MR angiographic investigations. These images were registered with anatomical landmarks rather than an external frame. Two techniques were used to display the resulting combined images: multiple slices in which bone from CT was overlaid on soft tissue from registered MR and pseudo-3D-rendered movie sequences showing bone from CT, lesions and optic nerves from MR, and blood vessels from MR angiography. The advantages of the combined displays compared with those of conventional methods of viewing were assessed prospectively by the operating surgeon and by an independent surgeon, and the results were compared with operative findings. The preoperative assessment showed a significant improvement (P < 0.05, sign test) in the depiction of both individual structures (lesion and bone from overlaid slices and lesion and vasculature from 3D-rendered displays) and structural relationships (tumor-bone relationships from overlaid slices and of tumor-vasculature relationships from 3D-rendered displays). The operative findings indicated that a more accurate interpretation of this information was possible from the combined images.