Operation of Arteriovenous Malformations Assisted by Stereoscopic Navigation-controlled Display of Preoperative Magnetic Resonance Angiography and Intraoperative Ultrasound Angiography

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Abstract
To study the application of navigated stereoscopic display of preoperative three-dimensional (3-D) magnetic resonance angiography and intraoperative 3-D ultrasound angiography in a clinical setting. Preoperative magnetic resonance angiography and intraoperative ultrasound angiography are presented as stereoscopic images on the monitor during the operation by a simple red/blue technique. Two projections are generated, one for each eye, according to a simple ray casting method. Because of integration with a navigation system, it is possible to identify vessels with a pointer. The system has been applied during operations on nine patients with arteriovenous malformations (AVMs). Seven of the patients had AVMs in an eloquent area. The technology makes it easier to understand the vascular architecture during the operation, and it offers a possibility to identify and clip AVM feeders both on the surface and deep in the tissue at the beginning of the operation. All 28 feeders identified on the preoperative angiograms were identified by intraoperative navigated stereoscopy. Twenty-five were clipped at the beginning of the operation. The other three were clipped at a later phase of the operation. 3-D ultrasound angiography was useful to map the size of the nidus, to detect the degree of brain shift, and to identify residual AVM. Stereoscopic visualization enhances the surgeon's perception of the vascular architecture, and integrated with navigation technology, this offers a reliable system for identification and clipping of AVM feeders in the initial phase of the operation.
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