MODERN STEREOTACTIC MODERN STEREOTACTIC NEUROSURGERY

Edited by L. Dade Lunsford, M.D.

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Martinus Nijhoff Publishing A member of the Kluwer" Academic Publishers Group BOSTON DORDRECHT LANCASTER DISTRIBUTORS

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Library of Congress Cataloging-in-Publication Data

Mo

(Topics in neurological ; 1) Includes index. 1. Nervous system-Surgery. 2. Stereoencephalotomy. I. Lunsford, L. Dade. II. Series. [DNLM: 1. Neuro• surgery-methods. 2. Stereotaxic Technics. WL 368 M689] RD593.M63 1987 617'.48 87-14058 ISBN-13:978-1-4612-8418-5 e-ISBN-13:978-1-4613-1081-5 001: 10.1007/978-1-4613-1081-5

COPYRIGHT

© 1988 by Martinus Nijhoff Publishing, Boston Sofcover reprint of the hardcover 1st edition 1988

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publishers, Martinus Nijhoff Publishing, 101 Philip Drive, Assinippi Park, Norwell, MA 02061, USA CONTENTS

Contributing Authors Vll 11. Diagnosis and Treatment of Mass Dedication xi Using the Leksell Stereotactic System 145 Acknowledgments XIV Preface xv L. Dade Lunsford

I. BASIC TECHNIQUES 1 12. Volumetric Stereotaxis and Computer• Assisted Stereotactic Resection of Sub- 1. General Concepts of cortical Lesions 169 3 Patrick j. Kelly Philip L. Gildenberg 13. Computerized Microstereotactic 2. The Imaging-Compatible Riechert- Neurosurgical Endoscopy under Direct Mundinger System 13 Three-Dimensional Vision 185 Fritz Mundinger and W. Birg Skip Jacques, C. Hunter Shelden, and Harold R. Lutes 3. The Leksell System 27 L. Dade Lunsford and Dan Leksell 14. Stereotactic Positron Emission Imaging for Tumor 4. The Hitchcock System 47 Diagnosis 195 Edward Hitchcock Hans Von Holst, Kaj Ericson, Mats Bergstrom and Georg Noren 5. The Brown-Roberts-Wells System 63 15. Stereotactic Treatment of Colloid Cysts of Michael L. j. Apuzzo and Craig A. Fredericks the Third Ventricle 207 L. Dade Lunsford and Walter A. Hall 6. Modification of Todd-Wells System for Imaging Data Acquisition 79 Patrick J. Kelly, Stephen J. Goerss and Bruce A. Kall 16. Stereotactic Evacuation of Intracerebral Hematoma 217 7. The Laitinen System 99 Alfred C. Higgins and Blaine S. Nashold Lauri V. Laitinen 17. Intracavitary Irradiation of Cystic 8. The Pati! System 117 229 Arun-Angelo Patil Volker Sturm, Bernd Wowra, John Clorius, Hansjorg Sinn, Andreas Gamroth, Ulrich Steude, Stephan Kunze and Walter j. Lorenz II. MORPHOLOGICAL SURGERY: DIAGNOSIS AND TREATMENT 127 18. Interstitial Brachytherapy for Malignant 9. Reliability of Stereotactic Tumor Brain Tumors: Technique and Results 129 235 Christoph B. Ostertag Nicholas M. Barbaro, Steven A. Leibel and Philip H. Gutin 10. Biopsy Techniques Using the Brown• Robert Wells (BR W) Stereotactic Guidance 19. Considerations in the Usage and Results of System 137 Curietherapy 245 M. Peter Heilbrun Fritz Mundinger and K. Weigel

v VI CONTENTS

20. A Robotic System for Stereotactic 30. Transplantation to the Brain 389 ~eurosurgery 259 Erik-Olof Backlund Ronald F. Young 31. for Chronic Pain: III. FUNCTIONAL NEUROSURGERY Long-Term Results and Complications 267 395 Robert M. Levy, Sharon Lamb, and John E. Adams 21. Mesencephalatomy and for Chronic Pain 269 32. Deep Brain Stimulation for the Treatment Lauri V. Laitinen of Motor Disorders 409 Jean Siegfried and G. L. Rea 22. Spinal and Pontine Tractotomies and ~ucleotomies 279 33. : Deep Brain Electrodes 413 Edward Hitchcock David W. Roberts

23. Thalamotomy for Parkinson's Disease: 34. Stereotactic CT Atlases 425 Microelectrode Technique 297 Tyrone L. Hardy Ronald R. Tasker, K. Yamashiro, F. Lenz, and J. O. Dostrovosky 35. Computerized Three-Dimensional Stereotactic Atlases 441 24. Selective Thalamotomy for Movement John K. Vries, Sean McLinden, Gorden Banks, and Disorders: Microrecording Stimulation Richard E. Latchaw Techniques and Results 315 Chihiro Ohye

25. Thalamotomy for Parkinson's Disease IV. STEREOTACTIC 333 461 Jean Siegfried and G. L. Rea 36. Stereotactic Bragg Peak Proton Beam 26. Post-traumatic Movement Disorders Therapy 463 341 Raymond N. Kjellberg and Masamitsu Abe Dennis E. Bullard and Blaine S. Nashold 37. Adaptation of Linear Accelerators to 27. The Role of Anterior Internal Stereotactic Systems 471 Capsulotomy in Psychiatric Surgery Arun-Angelo Patil 353 Bjorn A. Meyerson and Per Mindus 38. Stereotactic Radiosurgical Treatment of Acoustic ~eurinomas 481 28. Stereotactic Chemical Hypophysectomy Georg Noren, Jurgen Arndt, Tomas Hindmarsh, 365 Anita Hirsch Allan B. Levin 39. Stereotactic Radiosurgical Treatment of 29. Posteromedial Hypothalamotomy for Malformations of the Brain 491 Behavioral Disturbances and Intractable Christer Lindquist and Ladislau Steiner Pain 377 Yoshiaki Mayanagi and Keiji Sano Index 507 CONTRIBUTING AUTHORS

Masamitsu Abe, M.D. W. Birg Clinical and Research Fellow in Neurosurgery Department of Neurosurgery Massachusetts General Hospital N eurochirurgische U niversitatsklinik Boston, Massachusetts Abteilung Stereotaxie und Neuronklearmedizin Freiburg, West Germany John E. Adams, M.D. Professor of Neurological Surgery Dennis E. Bullard, M.D. University of California, San Francisco 3009 New Bern Avenue San Francisco, California P.O. Box 14027 Raleigh, North Carolina Michael L.J. Apuzzo, M.D. Professor John Clorius, M.D. Department of Neurological Surgery Department of Neurosurgery Tumor Center University of Southern California Heidelberg-Mannheim Institute of Nuclear Director of Neurological Surgery Medicine Kenneth R. Norris German Cancer Research Center Hospital and Research Institute University of Heidelberg Los Angeles, California Heidelberg, West Germany

Jurgen Arndt, B.S. Senior Staff J. O. Dostrovsky, M.D. Hospital Physics Associate Professor of Physiology University;of Toronto , Toronto, Canada

Erik-Olof Backlund, M.D., Ph.D Kaj Ericson, M.D., Ph.D. Professor and Chairman Associate Professor of Neuroradiology Department of Neurosurgery Karolinska Institute University of Bergen Stockholm, Sweden School of Medicine Bergen, Norway Craig A. Fredericks, M.D. Department of Neurological Surgery Gordon E. Banks, M.D. University

Vll Vlll CONTRIBUTING AUTHORS

Stephen]. Goerss, B.S. Bruce A. Kall, M.S. Research Technician Computer Scientist Department of Neurological Surgery Department of Information Processing and Mayo Clinic Systems Rochester, Minnesota Department of Neurosurgery Mayo Clinic Philip H. Gutin, M.D. Rochester, Minnesota Associate Professor of Neurological Surgery University of California, San Francisco Patrick]. Kelly, M.D. San Francisco, California Associate Professor Department of Neurological Surgery Walter Hall, M.D. Mayo Medical School, Department of Neurological Surgery Mayo Graduate School of Medicine University of Pittsburgh School of Medicine Rochester, Minnesota Pittsburgh, Pennsylvania Raymond N. Kjellberg, M.D. Tyrone L. Hardy, M.D. Associate Clinical Professor of Surgery Department of Neurosurgery Harvard Medical School Lovelace Medical Center Massachusetts General Hospital Albuquerque, New Mexico Boston, Massachusetts M. Peter Heilbrun, M.D. Stephan Kunze, M.D. Professor and Chairman Department of Neurosurger Tumor Center Division of Neurological Surgery Heidelberg-Mannheim Institute of Nuclear University of Utah School of Medicine Medicine Salt Lake City, Utah University of Heidelberg German Cancer Research Center Alfred C. Higgins, M.D. Heidelberg, West Germany Neurosurgery Hilton Head, South Carolina Lauri V. Laitinen, M.D., Ph.D. Associate Professor of Neurological Surgery Tomas Hindmarsh, M.D. Ph.D. and Chief of Stereotactic Surgery Associate Professor of Neuroradiology Umea Hospital Department of N euroradiology Umea, Sweden Karolinska Institute Sharon Lamb, R.N. Stockholm, Sweden Department of Neurological Surgery Anita Hirsch, M.D., Ph.D. University of California, San Francisco Senior Staff San Francisco, California Department of Audiology Richard E. Latchaw, M.D. Karolinska Institute Professor of Radiology and Chief, Division of Stockholm, Sweden N euroradiology University of Pittsburgh School of Medicine Edward R. Hitchcock, M.D. Pittsburgh, Pennsylvania Professor and Head Midland Center for Neurosurgery and Steven A. Leibel, M.D. Neurology Associate Professor of Radiation Oncology University of Birmingham University of California, San Francisco West Midlands San Francisco, California Birmingham, England Dan Leksell, M.D. Skip Jacques, M.D. Department of Head and Neck Surgery Advanced Neurosurgical Laboratory Karolinska Institute Huntington Medical Research Institutes Huddinge University Hospital Pasadena, California Huddinge, Sweden CONTRIBUTING AUTHORS IX

F. Lenz, M.D. Bjorn A. Meyerson, M.D., Ph.D. Research Fellow Associate Professor of Neurosurgery Division of Neurosurgery Karolinska Institute Toronto General Hospital Stockholm, Sweden Instructor of Medical Science University of Toronto Per Mindus, M.D. Toronto, Canada Associate Professor of Psychiatry Allan B. Levin, M.D. Karolinska Institute Associate Professor of Neurological Surgery Stockholm, Sweden Division of Neurological Surgery University of Wisconsin Fritz Mundinger, M.D. Madison, Wisconsin Professor and Director Abteilung fur Stereotaxis und Robert Levy, M.D., Ph.D. Neuronuklearmedizin and Director in Assistant Professor charge of the Neurochirurgische Division of Neurological Surgery U niversitatsklinik, Northwestern University Klinikum der Albert Ludwigs-Universitat Chicago, Illinois Freiburg, West Germany Christer Lindquist, M.D. Associate Professor of Neurological Surgery Blaine S. Nashold, Jr., M.D. Department of Neurosurgery Professor of Surgery (Neurological Surgery) Karolinska Institute Duke University School of Medicine Stockholm, Sweden Durham, North Carolina

Walter J. Lorenz, Ph.D. Georg Noren, M.D. Department of Neurosurgery Turmor Center Senior Staff Heidelberg-Mannheim Institute of Nuclear Department of Neurosurgery Medicine Karolinska Institute University of Heidelberg Stockholm, Sweden German Cancer Research Center Heidelberg, West Germany Christoph B. Ostertag, M.D. L. Dade Lunsford, M.D. Professor and Direktor Associate Professor of Neurological Surgery Abteilung fur Stereotaktische Neurochirurgie and Radiology Neurochirugische Universitatsklinik University of Pittsburgh School of Medicine Homburg, West Germany Chief, Stereotactic and Functional Surgery Presbyterian-University Hospital Pittsburgh, Pennsylvania Chihiro Ohye, M.D. Professor and Chairman Harold P. Lutes, O.D. Department of Neurosurgery Advanced Neuorsurgical Laboratory Gunma University School of Medicine Huntington Medical Research Institutes Gunma-Ken, Japan Pasadena, California Yoshiaki Mayanagi, M.D., D.M.Sc. Arun-Angelo Patil, M.D. Chief Neurosurgeon Associate Professor Tokyo Metropolitan Police Hospital Division of Neurological Surgery, Lecturer, University of Tokyo University of Nebraska Medical Center Tokyo, Japan Omaha, Nebraska Sean McLinden, M.D. G. L. Rea Department of Neurology Neurosurgical Department University of Pittsburgh School of Medicine University Hospital Pittsburgh, Pennsylvania Zurich, x CONTRIBUTING AUTHORS

David W. Roberts, M.D. Ronald R. Tasker, M.D. Assistant Professor of Clinical Surgery Head, Division of Neurosurgery (N eurosurgery) Toronto General Hospital Dartmouth-Hitchcock Medical Center Professor of Surgery Hanover, New Hampshire University of Toronto Toronto, Canada Keiji Sano, M.D., D.M.Sc. Emeritus Professor University of Tokyo Hans von Holst, M.D., Ph.D. Director and Professor Associate Professor Department of Neurosurgery Department of Neurological Surgery T eikyo University Karolinska Institute Tokyo, Japan Stockholm, Sweden C. Hunter Sheldon, M.D. Director of Huntington Medical Research Institutes John Vries, M.D. Pasadena, California Associate Professor of Neurological Surgery Director, Epilepsy Center Jean Siegfried, M.D. University of Pittsburgh School of Medicine Professor of Neurological Surgery Pittsbugh, Pennsylvania University Hospital Zurich, Switzerland K. Weigel Hansjorg Sinn, Ph.D. N eurochirurgische U niversitatsklinik, Department of Neurosurgery Tumor Center Klinikum der Albert-Ludwigs-Universitat Heidelberg-Mannheim Institute of Nuclear Freiburg, West Germany Medicine University of Heidelberg Heidelberg, West Germany Bernd Wowra, M.D. Ladislau Steiner, M.D. Department of Neurosurgery Tumor Center Professor of Neurosurgery Heidelberg-Mannheim Institute of Nuclear Karolinska Institute Medicine Stockholm, Sweden German Cancer Research Center University of Heidelberg Ulrich Steude, M.D. Heidelberg, West Germany Department of Neurosurgery Tumor Center Heidelberg-Mannheim Institute of Nuclear Medicine K. Yamashiro, M.D. University of Heidelberg Research Fellow Heidelberg, West Germany Division of Neurosurgery Toronto General Hospital Volker Sturm, M.D. Toronto, Canada Professor Department of Neurological Surgery Tumor Center Ronald F. Young, M.D. Heidelberg-Mannheim Institute of Nuclear Professor and Chief Medicine Division of Neurological Surgery German Cancer Research Center California College of Medicine University of Heidelberg University of California, Irvine, Heidelberg, West Germany Orange, California Dedication

Modern Stereotactic Neuro• visits and monitoring all types of surgery is dedicated stereotactic surgery performed posthumously to , one there. of the great innovators and His accomplishments include the investigators in modern combination of multiple imaging neurological surgery. Professor modalities with guided brain Leksell died suddenly on January surgery: encephalography in 12, 1986, at the age of 78, after 1949, in completing a morning walk in the 1955, computed tomography in Swiss Alps. Characteristically, 1976, and magnetic resonance earlier that day he had imaging in 1983. He was telephoned his son and proposed convinced that all forms of another clinical study designed to energy could be devoted to the further expand the usage of of tumors or the creation stereotactic surgery. He was of therapeutic brain lesions. buried in Rome next to his Perhaps the most creative beloved wife, Ludmila, and is invention of this brilliant mind survived by five children and was the development of stereot• many grandchildren, all actic radiosurgery (the gamma successful in their own right. knife), a technique in which Lars Leksell was born in multiple cobalt sources are Fassberg, Sweden, on November focused stereotactically in the 23,1907. He completed his brain to ablate brain tumors medical studies at the Karolinska without the. ne.e~ for a surgical Institute. In 1935, he began his mczszon. neurosurgical training with Honored internationally by many Professor at surgical and neurological societies the Serafimer lasarettet, a nesting and decorated by many place for many other governments, Lars Leksell neurosurgical pioneers. His 1945 remained a man always available Ph.D. dissertation, under the to his peers, his patients, his direction of 1967 Nobel Laureate family, and even to the unknown , described the visitors who streamed to his side. gamma motor system. Forty years He left a legacy offriends and later (1985), Professor Granit de• trainees throughout the world. livered the first "Lars Leksell Foremost a scientist, he was a Lecture" at the Karolinska linguist (Swedish, English, Institute. Lars Leksell was German, French, Italian), an Professor of Neurological Surgery adventurer (he often traveled to at between 1958 and 1960 the Karolinska by motorcycle or and then Professor of boat), and a gregarious Neurosurgery at the Karolinska raconteur. In his later years, Institute from 1960 until his those who had the opportunity to "retirement" in 1974. For the spend many hours in conversation next 12 years, Lars remained with him at the Diplomat Tea actively involved in the research House can testify to his wide• and clinical activities of the ranging interests. He was a Karolinska, continuing daily perfectionist: Each of his scientific.

Xl xu DEDICATION DEDICATION X11l

papers was remarkable for its involved in the Swedish succinct presentation, clarity, and controversy over the definition of literacy; regardless of the brain death, which culminated language in which he wrote, each with his coauthorship (with punctuation mark was important. Gerda Antti) of Hjarn dod?, The stereotactic instrument over published in 1985. which he labored remained in Lars Leksell trained in the evolution, as Lars continued to infancy of neurological surgery, a make even seemingly minor time when families lined up changes designed to perfect the outside the operating-room door device. He vociferously to donate blood, lest exsanguina• campaigned against the tion terminate the removal of a aggrandizement of bibliographies relative's . He was by the inclusion of inconsequen• convinced that all areas of the tial papers; his concern was brain could be explored safely if quality, not quantity. His only the proper tools were avail- sparkling humor was manifest in able. He lived to see one of his his personal writings: fondest dreams realized: the full Hjarnfragment (a play on the integration of safe and effective Swedish double entendre Hjarn stereotactic instrumentation into meaning both "brain" and its rightful place in the field of "iron") is an autobiographical neurological surgery. sketch ostensibly intended as a L. Dade Lunsford family memoir. He was a passionate humanist, intimately ACKNOWLEDGMENTS

"Words are but empty thanks."-Colley Pittsburgh. Phyllis Shoemaker and Mary Ann Cibber, Woman's Wit, Act 1, 1697 Vincenzini were the superb transcribers and organizers who laboriously prepared each To the authors of this first edition of Modern manuscript for publication. Stereotactic Nevro Surgery I offer my gratitude To my wife, Julie, and my children, Stepha• and admiration. For some, it probably has nie and Andrew, I convey my appreciation for proved difficult to transcribe into a few words support and time to complete the task. what may be the result of much of a lifetime's The Department of Neurological Surgery, efforts. For others, stereotactic technique rep• University of Pittsburgh, provided personnel resents only a small part of their contributions and economic resources. Lastly, to Jeffrey Stier within the field of brain surgery. and the staff of Martinus Nijhoff Publishing, Completion of this volume was impossible Boston, I give accolades for their efforts in without the special help of three talented, pa• presenting an attractive and, I hope, instruc• tient, and tireless individuals. Helene Hochman tional survey of the contemporary field of hu• reviewed, edited, and when necessary, revised man stereotactic surgery of the brain. each chapter. She brought great skill, humor, and expertise to the job of Editor, Department L. Dade Lunsford, M.D. of Neurological Surgery, at the University of Pittsburgh, Pennsylvania

XIV PREFACE

When I was first approached by the publisher As in any multiauthored textbook penned by of this volume, Martinus Nijhoff, Boston, I writers of diverse backgrounds and interests, explored the possibility of writing a personal Modern Stereotactic Neurosurgery to some monograph on contemporary stereotactic extent suffers from incompleteness. Future surgery. After a review of available literature, volumes no doubt will include many additions several aspects became apparent. First, no cur• from other authors who also are important rent, readily accessible, multiauthored text de• specialists in the field. Because not all authors signed to survey the field was available. Those write in the same style (or even language), we books that were available tended to heavily have attempted to achieve a more cohesive text emphasize theory, physiology, and anatomy. in the editorial process. Each chapter has been Second, stereotactic were considered subdivided into pertinent headings for easier abstruse and for too long were relegated to a reference. Because of my own background, status outside of the mainstream of neuro• some readers will note an Americanization (as surgery. This attitude probably reflected the opposed to anglicization) of the chapters. insufficient explanation of the practical uses While many chapters comprise primarily sum• and advantages of stereotactic technique. maries of the authors' work within the field, Third, in recent years, the field has expanded each author was encouraged to review the liter• so rapidly that it has become a major compo• ature in that discipline if appropriate. In most nent of any active neurosurgical teaching prog• chapters, the bibliography purposely was kept ram. For example, at some centers, stereotactic small so that interested readers might know technique may be used in 25%-30% of all precisely those references regarded as impor• neurosurgical procedures. My goal, therefore, tant by recognized authorities in the field. changed to one of editing a general textbook The practice of stereotactic surgery prog• designed to emphasize the practical role of resses-new indications, new devices, and stereotactic technique in the daily routine. new techniques. Few specialities more suc• Modern Stereotactic Neurosurgery is di• cessfully have combined the advantages of vided into four sections. Section I, Basic Tech• tremendously advanced imaging tools, compu• niques, identifies and explains many, but cer• ter technology, and therapeutic devices. In the tainly not all, of the currently commercially process, the goal of reduced patient morbidity available stereotactic instruments. Section II, has been maintained in an era in which the Morphological Surgery, discusses the use of preservation or improvement of neurological these devices in the diagnosis and treatment of function after surgery has become a major structural mass lesions of the brain. Section III, achievement. Stereotactic surgery is firmly in• Functional Surgery, describes the role of tegrated within the neurosurgical armamentar• stereotactic technique in the treatment of phys• ium and, no doubt, future investigators will iologic disorders of the brain. Section IV, further expand its uses. Stereotactic Radiosurgery, introduces a quickly growing field that combines stereotactic preci• L. Dade Lunsford, M.D. sion with powerful radiotherapeutic treatment Pittsburgh, Pennsylvania modalities.

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