这个方案已经由卫生署和威康信托基金会健康创新挑战基金（HICF-T4-275，计划资助97914）的支持。我们感谢沃尔夫森基金会和癫痫协会支持癫痫协会MRI扫描仪。这项工作是由美国国家卫生研究院（NIHR）支持伦敦大学学院医院的生物医学研究中心（BRC）

注:此处提供的软件命令，具体到该软件的最新版本（2015年1月19日），并在随后的软件版本可能会改变。各个版本的手册可应要求提供。 1.执行图像集成和可视化<ol><li>获取影像。 <ol><li>收购神经导航T1加权MRI钆扫描enhancement-这将是参考图像。 （注:图像采集的要求可从神经导航商业供应商11,12 见表1）。 </li><li>收集在DICOM或Nifti格式的术前评估过程中进行的所有其他影像学（包括功能性磁共振成像（fMRI）技术，弥散张量成像（DTI）示踪，氟脱氧葡萄糖正电子发射断层扫描（FDG-PET），发作，发作间期单光子发射CT（ SPECT），脑磁图（MEG）偶极子，3D相衬MRI，CT血管造影）， 见表1。 </li></ol></li><li>外面跑前处理内部软件。 <ol><li>流程等长T1加权像开源软件Freesurfer，Linux工作站上运行使用命令"侦察 - 所有&#39;，产生的皮质分割。 </li><li>转换使用命令"mrconvert"wmparc.mgz和ribbon.mgz文件格式nifti </li></ol></li><li>打开内部软件的Windows PC和加载数据（ 图1）。 <ol><li>注2×2窗口显示，在最左边，代表不同的图像处理工具，并在最右边选定的工具在上面的图标DataManager的。 </li><li>使用"拖放"，通过访问主菜单"文件/打开"或通过快捷按钮（图标）"打开"导入数据。通过不同的数据集滚动，以确保完整性。注意:通过右键单击和移动鼠标，和的DataManager的分层特性变焦功能，连续用图像叠加。 </li></ol></li><li> Coregister图像。 &lt;OL&gt; <li>单个图像。 <ol><li>选择速度图标NiftyReg工具。 </li><li>钆选择神经导航T1在DataManager-这将是参考图像，所有其他的成像配准到。 </li><li>选择"浮动图像"被配准到参考图像。 </li><li>定义名称和注册图像的位置。设置优化参数水平4号，级别执行3，迭代次数5，配准型刚体。 </li><li>通过点击"运行"按钮运行自动刚体配准。 </li><li>检查配准精度。注册图像检查了参考图像，并改变在DataManager的图片通过右击注册图像的透明度，并移动"不透明度"光标。通过检查明确解剖标志，如梦露的孔验证配准。 </li></ol></li><li>配对图像。 <ol><li> Coregister"空间定义图像的第一个（例如。分数各向异性地图），使用NiftyReg工具如步骤1.4.1.1 - 1.4.1.6。 </li><li>选择速度图标RegResample工具。 </li><li>选择神经导航T1与DataManager的钆作为参考图像。 </li><li>与处理的结果（ 例如 ，示踪图像）作为浮动图片选择图片。 </li><li>使用从"空间定义形象"以前注册为输入变换生成txt文件。 </li><li>定义名称和注册图像的位置。选择插值类型为0。 </li><li>通过点击"运行"按钮来运行的"处理结果"重采样。 </li><li>在DataManager的选择查看新生成的图像</li><li>检查配准精度如步骤1.4.1.6。 </li></ol></li><li>重复步骤1.4.1 - 1.4.2所有数据集。 </li></ol></li><li>段影像。 <ol><li>选择图像中的DataManager被分割，然后从高速图标分割编辑器工具。</li><li>使用先进的分割工具（手动分割，区域增长，减去）绘制的感兴趣区域在轴向成像几片，冠状面和矢状面</li><li>选择3D插值可视化3D窗口渐进分段式结构。确认分割产生分割结构的新Nifti文件。 </li><li>重复步骤1.5.1 - 1.5.3，其中手动分割显示所有图像。 </li></ol></li><li>生成大脑模型。 <ol><li>对DataManager的选择wmparc.nii形象，并确保wmparc.nii的配准参考图像使用步骤1.4.1。 </li><li>选择速度图标基本处理工具。 </li><li>应用阈值从1-5002至wmparc.nii打造皮质二进制化的面具。 </li></ol></li><li>渲染的利益，因为三维曲面的区域（ 图2，3）。注:数据集作为三维表面渲染（STL文件）的可视化可以通过两种方式来完成: <ol><li>采用表面提取ŤOOL。 <ol><li>选择表面提取图标。定义表面提取阈值，并选择应用。名DataManager的表面绘制。 </li></ol></li><li>在DataManager的右键单击Nifti文件并选择"平滑多边形表面"。 </li></ol></li><li>提取容器的表面模型（ 图4）。注:从提取致力于血管影像船（3D相衬MRI，CT血管造影，T1钆加权MRI）可以通过两种方式来完成。 <ol><li>采用表面提取工具。 <ol><li> Coregister血管摄像用NiftiReg参考图像。三维表面采用表面提取渲染图像。 </li><li>通过应用扩张，并在基本图像处理功能，收盘皮质的二进制化​​的面具产生颅内面膜。应用颅内面膜使用基本图像处理乘法函数删除颅外血管的血管影像。 </li><li>从STL FIL消除噪音e。通过外加工的内部软件，使用三维网格处理软件包。注:使用说明这个工具是免费提供在线。 </li></ol></li><li>使用VesselExtractor工具。 <ol><li>选择速度图标VesselExtractor工具。选择的血管图像数据集，并指定该容器提取Nifti文件的名称和位置。 </li><li>通过点击"运行"运行VesselExtractor。应用颅内面膜VesselExtractor的使用基本图像处理乘法函数删除颅外血管的结果。注:通过应用扩张，并在基本图像处理功能，收盘皮质的二进制化​​的面具为1.8.1.2产生颅内面具。 </li></ol></li><li> 1.8.1或1.8.2 CT血管造影，三维相位对比磁共振成像和神经导航T1钆重复的过程。 </li></ol></li><li>产生脑的体绘制（ 图5）。 <ol><li>选择wmparc.nii IM年龄对DataManager的，并确保wmparc.nii的配准参考图像使用步骤1.4.1。 </li><li>选择速度图标基本处理工具。 </li><li>应用高斯平滑到wmparc.nii图像，使用基本处理工具。 </li><li>选择卷从速度图标绘制工具，并确保平滑wmparc.nii文件中DataManager的高亮显示。 </li><li>勾选"体绘制"箱内容积渲染工具生成皮质体积渲染。 </li></ol></li></ol> 2.执行手动计划<ol><li>使用轨迹规划速度图标。 <ol><li>选择神经导航T1扫描作为参考图像。选择新计划和新轨迹。 </li><li>按"Alt键"和上单击鼠标右键，基于临床所需的解剖目标点的名单上的平面成像选择目标点。注:目标例子包括颞叶内侧结构（杏仁核，海马），岛，扣带回。 </li><li>鼠标按下"Alt键"，并选择在平面成像的入口点左键单击，根据所需的切入点由临床医生名单上。注:入口点的例子包括颞中回，中央前回，缘上回。 </li><li>观察目标和切入点之间产生的线性轨迹。 </li></ol></li><li> Visualise风险。 <ol><li>选择风险可视化速度图标来检查轨迹长度。 </li><li>选择"链接查看飞机"在主窗口探头眼观众链接到正交视平面。 </li><li>沿着轨迹滚动，检查探头眼观众，以确保无血管路径。 </li></ol></li></ol> 3.执行计算机辅助规划<ol><li>准备数据。 <ol><li>准备灰质表面。 <ol><li>选择从皮质分割软件生成的ribbon.nii文件。 </li><li>使用NiftiReg ribbon.nii文件共同注册到参考图像。 </li><li>三维表面仁德通过使用"平滑多边形表面&#39;函数r共同注册的图像。 </li></ol></li><li>准备头皮和头皮排斥模板。 <ol><li>作为选择参考图像T1神经导航图像。 </li><li>使用基本图像处理工具应用高斯转型。 </li><li>表面采用表面提取，以产生头皮表面呈现的图像。 </li><li>保存和导出图像STL文件。 </li><li>加载STL FLE到3D网格处理软件。 </li><li>对于头皮，使用清洁和编辑工具来删除颅内内容。 </li><li>对于头皮排除模板，使用手动编辑工具删除（ 即 ，脸部，耳朵，对侧大脑半球，下面小脑幕区）不适合电极入口点的区域。 </li></ol></li><li>准备表面沟面。 <ol><li>生成整个沟。 <ol><li> Binarise wmparc.nii文件中使用基本的图像处理工具，如步骤1.6.3。 </li><li>关闭二进制化3 wmparc.nii文件中使用基本的图像处理工具。 </li><li>减去使用基本图像处理工具3.1.3.1.2产生封闭二进制化的文件中生成3.1.3.1.1文件的二进制化​​。 </li></ol></li><li>在深度取下沟生成曲面沟图像。注意:使用表面沟图像作为关键的结构具有间隔轨迹的优点远离沟在大脑的表面上，并允许轨迹在深度接近沟，这是在灰质所在。 <ol><li>减少使用基本图像处理工具3.1.3.1.2产生的封闭的二进制化​​的w​​mparc文件。 </li><li>使用基本图像处理工具生成3.1.3.2.1反转文件。 </li><li>乘以在3.1.3.1.3产生的整个沟中3.1.3.2.2生成的文件，使用基本图像处理工具。 </li></ol></li></ol></li></ol></li><li>运行多轨迹规划师（ 图6）。 注:自动售货机编多轨迹规划是依赖于强大的数据准备;头皮的表面效果，头皮排除掩模，颅内脉管，表面沟，皮层和灰质是必需的。 <ol><li>选择速度图标轨迹规划。选择参考图像作为神经导航T1 MRI检查。 </li><li>选择"目标点";多个目标点可以通过&#39;转移&#39;和鼠标左键单击，或通过加载保存的目标点集合输入。注意:目标的例子包括颞叶内侧结构（杏仁核，海马），岛，扣带回。 </li><li>选择"进入点"，而所附的下拉菜单上选择头皮排除掩模。注:这有限制禁区是实施手术可行搜索可能的入口点的目的。 </li><li>选择关键结构，标志着从轨迹应避免下拉列表中选择面。选择高级设置;调整用户定义利弊关于轨道长度，入境的角度和距离之间的轨迹作为首选traints。 </li><li>选择灰色就事论事白质的评估和分层风险排序以优化在于灰质轨迹的比例。 </li><li>通过选择添加新计划，并重新计算计划运行多轨迹规划师。 </li></ol></li><li> Visualise风险（ 图7）。 <ol><li>评估风险和安全性后轨迹规划，采用可视化的风险速度图标。 注意:对于每个轨迹有对长度的度量，进入角，累积的风险，血管和灰质白质比率，再加上沿距离的关键结构的运动轨迹图形表示的最小距离。一个探头眼观众也包括在内。 </li><li>在DataManager的选择风险地图来显示一个颜色编码的等高线图上覆头皮排除掩模，以表示潜在的切入点和风险共同的相关电平阴沉编码，其中红色表示高风险，绿色代表任何选定的轨迹低风险。 </li></ol></li><li>手动调节轨迹。 <ol><li>选择轨迹。 </li><li>通过按Alt键和鼠标的新的切入点，单击鼠标右键，并通过按Alt和鼠标的新的目标点左键单击。 </li><li>评估使用风险可视化速度图标的新轨迹，如步骤3.3。 </li></ol></li></ol> 4，出口计划和模式，以手术室<ol><li>检查参考图像为DICOM格式。从速度图标选择S7导出。 </li><li>定义参考图像时，计划和轨迹和要被导出的模型，并指定保存的档案的目的地。运行S7导出工具。 </li><li>上传档案产生到U盘转移到一个神经导航在手术室，并加载存档文件夹中的神经导航系统上临床实施计划的trajectories。 </li></ol> 5.重建电极植入手术后<ol><li>收购术后CT成像。 </li><li>负载头部CT到内部软件，并加载先前保存的患者数据集。 </li><li> Coregister CT使用NiftyReg工具引用T1加权MRI检查。 </li><li>生成的使用上注册的CT的SurfaceExtractor工具电极的三维表面渲染，具有很高的阈值。 </li><li>噪声的干净的表面呈现的电极，并使用3D网格处理软件的清洁和修复机能的电线。 </li></ol>

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资金来源:马克·诺埃尔，盖尔盖伊Zombori，雷切尔火花和罗马罗季奥诺夫是由卫生和威康信托基金通过卫生创新挑战基金部（HICF-T4-275，计划资助97914）的支持。 约翰·邓肯已获得机构资金支持自Eisai，UCB制药公司，葛兰素史克，西安杨森Cilag的，美敦力，以及GE医疗集团。安德鲁·麦克沃伊已获得支持，UCB，巴克斯特和Cyber​​onics公司。其余的作者有没有利益冲突。 本刊物由卫生创新挑战基金（HICF-T4-275，计划资助97914），卫生署和威康信托基金会之间的平行合作提供资金的独立研究。本出版物中表达的观点是作者（S），而不是一定是那些健康或威康信托部。

总之，图像融合和三维可视化的关键步骤是图像配准，脑的分割，血管和其它结构或感兴趣的领域，并且出口到一个神经导航系统。该方法是在组中使用市售的图像集成软件先前执行。这个管道的一个缺点是服用，服用与2的整个过程时间 - 4小时。使用我们的内部软件平台，该管道被大大简化，并且可以在1完成 - 2小时。此外，还存在对这样的软件SEEG电极轨迹手术计划，可手动或使用计算机协助来完成的附加功能。 CAP比手动规划的优点是可提高精度，降低风险和提高速度，并且已经在别处讨论（诺埃尔等 ，In出版社，Sparks 等人 ，提交）。 酒店内的软件平台是在连续ð才有发展，以新的工具和功能被添加到支持术前评估和手术管理的各个阶段。因此，有必要在每个新版本发行严格测试。该软件的当前限制包括缺乏高质量的体绘制，这是目前在其他平台，是一个有价值的除了先进的三维可视化。还出口仅与选定的神经导航公司在目前的时间兼容。这些限制都没有影响我们的单元中的软件的临床效用，并没有减缓了技术的传播到其他中心。 该软件的意义是，它消除了前面的团体已引为理由不使用3DMMI的障碍。该解决方案提供简单的在一个单一的平台上，不需要专门培训或专业技术使用的工具，是时间和成本效益，很容易转化为临床实践。有P局域网，以进一步创新添加到软件来支持癫痫手术。此外，该方法可以很容易地应用于神经外科的其他领域，如切除接近运动性语言中枢，焦损毁和有针对性的刺激交付低品位肿瘤。 3DMMI和精确的手术规划工具有可能成为现代手术日益重要，因为更具挑战性的案件采取和微创治疗进入普遍的做法。

在外科实践中是至关重要的，外科医生欣赏解剖结构以及它们在三维空间彼此的空间关系。这是在神经外科，其中外科医生工作在一个密闭的空间，用有限的可视化，并获得复杂解剖结构尤其重要。尽管如此，到目前为止大多数成像已经向外科医生在传统的平面2D的形式，不同的成像方式往往呈现一个又一个系列。因此，外科医生具有这个数据对于每个患者精神上整合，并将其放置到用于手术前规划解剖学框架。有生成个别病人的大脑，这表明了皮质的解剖3D计算机模型明显的好处，血管，任何存在的病理损伤，以及在同一空间范围1-4其他相关的3D地标。手术前医生可以旋转和改变透明胶片O˚F这些模型中，要充分了解不同的兴趣结构之间的关系，3D。这一原则被称为3D多模态成像（3DMMI）。 手术前评估为癫痫手术的目的是来推断，其中癫痫发作产生的脑的区域的定位，并确保该而不引起显著赤字5被安全地切除。有广泛的诊断成像方式有助于此，包括结构的MRI，氟正电子发射断层扫描（FDG-PET），发作性单光子发射计算机断层摄影（SPECT），脑磁图（MEG）的偶极子，功能磁共振成像（fMRI）和弥散张量成像（DTI）6。癫痫手术非常适合3DMMI，因为它需要的多个数据集的同时解释和考虑的每一个数据集如何与另一个。 在许多情况下，非侵入性的调查失败ŤØ提供的进行切除所需证据的水平。在这些情况下，颅内脑电图（IC EEG）记录是必要的，以确定必须除去，以防止癫痫发作的脑的区域。越来越多的IC脑电图由称为SEEG技术，其中一些记录深度电极放置脑内捕获与癫痫发作在3D 1,7-10相关的电活动的起源和传播进行。 SEEG注入的第一步骤是开发植入的策略，确定脑的需要被取样的区域。这涉及整合临床和非侵入性的脑电图日期，具有结构成像，与任何病变，以及功能成像数据推断癫痫的源的位置。 第二步骤是电极轨迹的精确手术计划。外科医生必须确保安全股骨头缺血性电极轨迹，围绕埃尔在脑回和远离皮质表面静脉和正交穿越骷髅冠ectrode条目。另外整个植入的安排已被精心构思，以合理的电极间距，无电极碰撞。 产生3DMMI模型来指导集成电路EEG电极植入在一个繁忙的癫痫手术实践的可行性先前已被证明11。我们还证明，使用3DMMI的加入赋予在临床决策的价值原则。在前瞻性研究中，3DMMI披露变更管理的某些方面在43/54（80％）的情况下，和特别是改变的二百十二分之一百五十八（75％）深部电极12的定位。 有一系列的软件包，可以方便3DMMI。这些措施包括盟军了在手术室使用市售神经导航平台，专业的规划软件套件与神经导航平台和研究型的独立形象整合和可视化平台。作为这些平台增加它们转化为临床实践的功能性，灵活性和通用性，实用性和可能性相应地减小。 我们已经开发的多模态图像融合，先进的三维可视化和SEEG电极放置规划为12,13治疗癫痫定制设计的软件。强调的是便于在临床方案的使用，从而允许临床医生实时使用的软件，并迅速结合到临床管道。该软件平移成像平台14，结合NiftyReg，NiftySeg和NiftyView上运行。 本文在临床实践中使用该软件的协议列明。图像配准，感兴趣区域的分割，分割大脑，提取的步骤血管从致力于血管影像15，建立3D模型，规划SEEG植入，并迅速出口车型，并计划在手术室进行了说明。一种新的工具，也用于自动多轨迹规划13描述的，增加了注入的安全性和有效性，并大大降低了规划的持续时间。

<table border="0" cellpadding="0" cellspacing="0" style="border-collapse:
 collapse" width="651">
	<tbody>
		<tr height="15">
			<td class="xl24" height="15" width="185">EpiNav</td>
			<td class="xl24" width="221">UCL</td>
			<td class="xl24" width="102"></td>
			<td class="xl24" width="143">Inhouse software platform for image integration, segmentation, visualisation and surgical planning</td>
		</tr>
		<tr height="15">
			<td class="xl24" height="15">Freesurfer</td>
			<td class="xl24">Martinos Centre for Biomedical Imaging</td>
			<td class="xl24"></td>
			<td class="xl24">Software for cortical segmentation</td>
		</tr>
		<tr height="15">
			<td class="xl24" height="15">S7 Stealthstation</td>
			<td class="xl24">Medtronic</td>
			<td class="xl24"></td>
			<td class="xl24">Neuronavigation system</td>
		</tr>
		<tr height="15">
			<td class="xl24" height="15">MeshLab</td>
			<td class="xl24">ISTI-CNR</td>
			<td class="xl24"></td>
			<td class="xl24">3D mesh processing software</td>
		</tr>
		<tr height="15">
			<td class="xl24" height="15">NiftiK</td>
			<td class="xl24">UCL</td>
			<td class="xl24"></td>
			<td class="xl24">Translational imaging platform</td>
		</tr>
		<tr height="15">
			<td class="xl24" height="15">AMIRA</td>
			<td class="xl24">Visualisation Sciences Group</td>
			<td class="xl24"></td>
			<td class="xl24">Image integration software</td>
		</tr>
		
	</tbody>
</table>

a pipeline for 3d multimodality image integration and computer-assisted planning in epilepsy surgery

癫痫手术是具有挑战性和使用3D多模态融合图像（3DMMI），以帮助手术前设计是行之有效的。多模态形象整合可以技术要求高，并在临床实践中没有得到充分利用。我们已经开发出形象整合，三维可视化和手术计划的单一软件平台。这里，我们的管道在一步一步的方式描述的，开始图像获取，通过图像配准，手工分割，脑和血管提取，三维可视化和stereoEEG（SEEG）植入的人工规划进行。用软件的传播这个管道可以在其他中心被再现，允许其它组从3DMMI受益。我们还描述了使用自动，多轨迹规划师产生stereoEEG植入计划。初步研究表明，这是规划SEEG植入一个快速，安全，有效的辅助手段。最后，一​​个简单的soluti对计划和车型出口到商业神经导航系统的实施在手术室计划描述。这个软件是一个有价值的工具，可以支持整个癫痫手术途径的临床决策。

图像融合，可视化，人工规划和导出描述到选定的神经导航系统的协议已经2013年以来8月在全国医院神经内外科采用这包括35案件SEEG植入12个 ，与319深部电极植入。患者27/35（77％）已经进展到皮质切除植入之后，这是在植入识别发作起始的面积的一个指标。目前已涉及到深部电极的展示位置一个出血的并发症，这是保守治疗。 在术前评估过程中使用的成像方式决定的情况下，逐案的基础上，在表1中描述。该协议是柔性的，并且可以结合可以导入到DICOM或Nifti格式的任何成像模态图1展示了我们的内部软件平台的基本观众，以及图2，3，4和5中的三维多模态模型的建筑物中说明了典型的屏幕截图。 该协议为我们的临床管道，而该软件的其他中心的传播的无缝集成，是成功的一个有用的替代&#39;标记&#39;。在癫痫手术人口评估临床益处的困难是众所周知的，并且在其他地方12所述。这条管道提供了一个简化的解决方案，这是灵活的，比较方便，而且容易在其他中心进行复制。 计算机辅助规划（CAP）是近期发展已经在以前的手工计划注入16回顾了测试。初步结果表明，第产生更安全，更efficient注入，这是实现可行的，并且在一个时间完成有效的方式16. 表2说明了这一点的定量比较。在临床实践中采用CAP的前瞻性试验正在进行。驱动第算法已如前所述13。 图6示出从自动多轨迹筹办了典型的结果。已输入的临界结构是静脉，动脉和表面沟。注意对脑回皇冠上的轨迹定心，和轨道入口点到头皮排除掩模的约束。 图7所示为一个单独的轨迹的典型风险的可视化图形，以及相关指标和轨迹长度的图形表示。 <img alt="图1" src="/files/ftp_upload/53450/53450fig1.jpg"/&gt; 图1. 内部软件平台的基本浏览器显示 。左DataManager的，顶级的工具栏，快捷键包含外挂工具，右键当前插件在工具使用时，中心- 4邻视图显示， <a href="https://www.jove.com/files/ftp_upload/53450/53450fig1large.jpg" target="_blank">请点击这里查看该图的放大版本。</a> <img alt="图2" src="/files/ftp_upload/53450/53450fig2.jpg" /> 图2. 分割和三维可视化的内部软件 。 （A）轴向T1 MRI与叠加表面模型，模型（青色，脉（B）三维表面渲染，从经颅磁刺激，橙弓状束示踪，蓝领皮质示踪，pink-视放射示踪绿光手运动，黄 - 钩束示踪，紫色 - 丘脑小号egmentation）。 <a href="https://www.jove.com/files/ftp_upload/53450/53450fig2large.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <img alt="图3" src="/files/ftp_upload/53450/53450fig3.jpg" /> 图3.皮质表面模型生成 。 （A）wmparc文件的轴向视图;（B）wmparc文件从1-5002阈值处理，（C）二进制化的wmparc文件的表面绘制。 <a href="https://www.jove.com/files/ftp_upload/53450/53450fig3large.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <img alt="图4" src="/files/ftp_upload/53450/53450fig4.jpg" /> 使用Vesselness在内部软件 图4。 血管提取 。 （A）轴向CT血管造影三维相衬发展有限注册RI。静脉（青色）和动脉（红色）（B）三维表面渲染。 <a href="https://www.jove.com/files/ftp_upload/53450/53450fig4large.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <img alt="图5" src="/files/ftp_upload/53450/53450fig5.jpg" /> 图5.代皮层（灰色）和头皮表面（白色）的表面绘制的皮质体积模型三维体积渲染 。 <a href="https://www.jove.com/files/ftp_upload/53450/53450fig5large.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <img alt="图6" src="/files/ftp_upload/53450/53450fig6.jpg" /> 图6. 计算机辅助轨迹规划的3D模型的多模态 。 （A）头皮（白色），头皮排除掩模（黄色）和轨迹（Purple）。 （B）的头皮和透明的面具，以显示大脑（粉红色），沟（绿色），静脉（青色）和动脉（红色）。 （C）的头皮和掩模去除以显示轨迹和脑。 （D）的大脑中删除，以显示轨迹，表面沟，静脉和动脉。 <a href="https://www.jove.com/files/ftp_upload/53450/53450fig6large.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <img alt="图7" src="/files/ftp_upload/53450/53450fig7.jpg" /> 图7。 相关指标与个人轨迹的图形显示 。顶级长度，角度穿过颅骨，风险，G / W比值和最小距离从血管&gt; 1毫米的直径。沿弹道轨迹沿（红色动脉，青色的静脉，以结构（最多10毫米Y形 - 轴 - 距离）的长度最接近的关键结构中等图形显示，X轴 - 距离从大脑进入到目标，SM-安全边际表示为水平红线标志着轨迹为3 mm分离的关键结构）。通过灰质和白质的轨迹路径（绿颅外，灰灰质，白涂白物质）的自下而上的图形显示。 <a href="https://www.jove.com/files/ftp_upload/53450/53450fig7large.jpg" target="_blank">请点击此处查看该图的放大版本。</a> <table fo:keep-together.within-page="1"><tbody><tr><td> 情态 </td><td> 现场 </td><td> 前处理 </td><td> 视场（AP点¯xRL X是） </td><td> 素尺寸（AP点¯xRL X是） </td></tr><tr><td> 3D T1 FSPGR </td><td> ES </td><td>没有</td><td> 256×256×166 </td><td> 0.94 x 0.94英寸×1.1 </td></tr><tr><td>冠状T2 FLAIR </td><td> ES </td><td>没有</td><td> 256×160×32 </td><td> 0.94×1.5×3.5 </td></tr><tr> &lt;TD&gt;导航T1钆</td><td> NHNN </td><td>没有</td><td> 512×512×144 </td><td> 0.5×0.5×1.5 </td></tr><tr><td> MRI 3D相衬</td><td> NHNN </td><td>没有</td><td> 256×256×160 </td><td> 0.85×0.85×1 </td></tr><tr><td> CT血管造影</td><td> NHNN </td><td>没有</td><td> 512×512×383 </td><td> 0.43点¯x0.43×0.75 </td></tr><tr><td> MEG偶极</td><td> NHNN </td><td>是</td><td></td><td></td></tr><tr><td>发作，发作间期SPECT </td><td> UCLH </td><td>是</td><td> 128×128×49 </td><td> 3.9×3.9×3.9 </td></tr><tr><td> FDG-PET </td><td> UCLH </td><td>是</td><td> 128×128×47 </td><td> 1.95点¯x1.95点¯x3.3 </td></tr><tr><td> DTI </td><td> ES </td><td>是</td><td> 128×128×60 </td><td> 1.88点¯x1.88 x 2.4英寸</td></tr><tr><td>功能磁共振成像，脑电图，磁共振成像相关</td><td> ES </td><td>是</td><td> 128×128×58 </td><td&gt; 1.87点¯x1.87×2.5 </td></tr></tbody></table> 用于图像集成 （（ES-癫痫协会，NHNN，全国医院神经内外科，UCLH-伦敦大学学院医院，FSPGR-FastSpoiledGradientRecalledEcho，MEG-脑磁图，SPECT，单光子发射计算机断层扫描，FDG PET 表1. 成像方法 - 氟正电子发射断层，DTI扩散张量成像，AP-前后路，RL - 右左，IS - 劣上级）。 <table fo:keep-together.within-page="1"><tbody><tr><td></td><td> 手动规划* </td><td> 帽* </td><td> 估算差（手动-CAP） </td><td> 错误 </td><td> P值为 </td></tr><tr><td> 电极长度（mm，1 DP） </td><td> 57.9（21.8） </td><td> 53.9（15.6） </td><td> 4.74 </td><td> 1.59 </td><td> &lt;0.05 </td></tr><tr><td> 进入的角度（垂直度关闭，1 DP） </td><td> 16.2（12.8） </td><td> 13.0（7.6） </td><td> 5.89 </td><td> 1.07 </td><td> &lt;0.05 </td></tr><tr><td> 风险（归一化单位，2个DP） </td><td> 0.41（0.79） </td><td> 0.36（0.42） </td><td> 0.19 </td><td> 0.03 </td><td> &lt;0.05 </td></tr><tr><td> 从血管最小距离（mm，1 DP） </td><td> 4.5（3.0） </td><td> 4.5（3.0） </td><td> -0.56 </td><td> 0.2 </td><td> &lt;0.05 </td></tr><tr><td> 脑电极中灰质的比例（2 DP） </td><td> 0.33（0.33） </td><td> 0.48（0.28） </td><td> -0.11 </td><td> 0.02 </td><td> &lt;0.05 </td></tr></tbody></table> 手动和计算机之间阿西斯 表2 统计比较泰德计划（CAP）。*第一个值中位数，括号内的第二个值是四分范围。该表已被复制来自16个许可。

Watch this Scientific Journal Video about A Pipeline for 3D Multimodality Image Integration and Computer-assisted Planning in Epilepsy Surgery at JoVE.com

A Pipeline for 3D Multimodality Image Integration and Computer-assisted Planning in Epilepsy Surgery

我们描述的步骤来使用我们的形象整合，可视化和规划癫痫外科的定制设计的软件。

管道在癫痫手术3D多模图像集成和计算机辅助规划

Epilepsy surgery is challenging and the use of 3D multimodality image integration (3DMMI) to aid presurgical planning is well-established. Multimodality ...

a-pipeline-for-3d-multimodality-image-integration-computer-assisted

Research

JoVE Journal

Medicine

12.0K 次观看.  UCL Institute of Neurology. 我们描述的步骤来使用我们的形象整合，可视化和规划癫痫外科的定制设计的软件。 

视频: A Pipeline for 3D Multimodality Image Integration and Computer-assisted Planning in Epilepsy Surgery

Accuracy in Dental Medicine, A New Way to Measure Trueness and Precision

Reference scanners are used in dental medicine to verify a lot of procedures. The main interest is to verify impression methods as they serve as a base for dental restorations. The current limitation of many reference scanners is the lack of accuracy scanning large objects like full dental arches, or the limited possibility to assess detailed tooth surfaces. A new reference scanner, based on focus variation scanning technique, was evaluated with regards to highest local and general accuracy. A specific scanning protocol was tested to scan original tooth surface from dental impressions. Also, different model materials were verified. The results showed a high scanning accuracy of the reference scanner with a mean deviation of 5.3 &#177; 1.1 &#181;m for trueness and 1.6 &#177; 0.6 &#181;m for precision in case of full arch scans. Current dental impression methods showed much higher deviations (trueness: 20.4 &#177; 2.2 &#181;m, precision: 12.5 &#177; 2.5 &#181;m) than the internal scanning accuracy of the reference scanner. Smaller objects like single tooth surface can be scanned with an even higher accuracy, enabling the system to assess erosive and abrasive tooth surface loss. The reference scanner can be used to measure differences for a lot of dental research fields. The different magnification levels combined with a high local and general accuracy can be used to assess changes of single teeth or restorations up to full arch changes.

Accuracy is a major demand in dental medicine. To verify accuracy, reference scanners are needed. This article presents a new reference scanner with an adjusted scanning method to acquire a broad variety of dental morphologies with high trueness and precision.

精度在牙科医学，一种新的方法来测量正确度与精密度

Reference scanners are used in dental medicine to verify a lot of procedures. The main interest is to verify impression methods as they serve as a base ...

科研

医学

Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, there is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum. Anterior sternal plating provides the best stability and is therefore increasingly used in most cases. However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications such as difficulties in preoperative planning, severe injuries to mediastinal organs, or failure of the performed method.
This manuscript describes one possible safe way to stabilize different types of sternal fractures in a step by step guidance for anterior sternal plating using low profile locking titanium plates. Before surgical treatment, a detailed survey of the patient and a three dimensional reconstructed computed tomography is taken out to get detailed information of the fracture&#8217;s morphology. The surgical approach is usually a midline incision. Its position can be described by measuring the distance from upper sternal edge to the fracture and its length can be approximated by the summation of 60 mm for the basis incision, the thickness of presternal soft tissue and the greatest distance between the fragments in case of multiple fractures.
Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates prevents injuries to mediastinal organs and vessels.
Transverse fractures and oblique fractures at the corpus sterni are plated longitudinally, whereas oblique fractures of manubrium, sternocostal separation and any longitudinally fracture needs to be stabilized by a transverse plate from rib to sternum to rib. Usually the high convenience of a patient is seen during follow up as well as a precise reconstruction of the sternal morphology.

Here we present a method to stabilize sternal fractures by using locked titanium plates in a low profile design. Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates provides a safe surgical way.

胸骨骨折内固定手术:术前设计和安全的手术技术采用锁定钛板和深度钻探有限公司

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

在耐药性颞叶癫痫患者卵圆孔电极记录的网络分析

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Interictal High Frequency Oscillations Detected with Simultaneous Magnetoencephalography and Electroencephalography as Biomarker of Pediatric Epilepsy

Crucial to the success of epilepsy surgery is the availability of a robust biomarker that identifies the Epileptogenic Zone (EZ). High Frequency Oscillations (HFOs) have emerged as potential presurgical biomarkers for the identification of the EZ in addition to Interictal Epileptiform Discharges (IEDs) and ictal activity. Although they are promising to localize the EZ, they are not yet suited for the diagnosis or monitoring of epilepsy in clinical practice. Primary barriers remain: the lack of a formal and global definition for HFOs; the consequent heterogeneity of methodological approaches used for their study; and the practical difficulties to detect and localize them noninvasively from scalp recordings. Here, we present a methodology for the recording, detection, and localization of interictal HFOs from pediatric patients with refractory epilepsy. We report representative data of HFOs detected noninvasively from interictal scalp EEG and MEG from two children undergoing surgery.
The underlying generators of HFOs were localized by solving the inverse problem and their localization was compared to the Seizure Onset Zone (SOZ) as this was defined by the epileptologists. For both patients, Interictal Epileptogenic Discharges (IEDs) and HFOs were localized with source imaging at concordant locations. For one patient, intracranial EEG (iEEG) data were also available. For this patient, we found that the HFOs localization was concordant between noninvasive and invasive methods. The comparison of iEEG with the results from scalp recordings served to validate these findings. To our best knowledge, this is the first study that presents the source localization of scalp HFOs from simultaneous EEG and MEG recordings comparing the results with invasive recordings. These findings suggest that HFOs can be reliably detected and localized noninvasively with scalp EEG and MEG. We conclude that the noninvasive localization of interictal HFOs could significantly improve the presurgical evaluation for pediatric patients with epilepsy.

High Frequency Oscillations (HFOs) have emerged as presurgical biomarkers for the identification of the epileptogenic zone in pediatric patients with medically refractory epilepsy. A methodology for the noninvasive recording, detection, and localization of HFOs with simultaneous scalp electroencephalography (EEG) and magnetoencephalography (MEG) is presented.

同时用脑磁图和脑电图为小儿癫痫的生物标志物检测发作间期高频振动

Crucial to the success of epilepsy surgery is the availability of a robust biomarker that identifies the Epileptogenic Zone (EZ). High Frequency ...

Radiation Planning Assistant - A Streamlined, Fully Automated Radiotherapy Treatment Planning System

The Radiation Planning Assistant (RPA) is a system developed for the fully automated creation of radiotherapy treatment plans, including volume-modulated arc therapy (VMAT) plans for patients with head/neck cancer and 4-field box plans for patients with cervical cancer. It is a combination of specially developed in-house software that uses an application programming interface to communicate with a commercial radiotherapy treatment planning system. It also interfaces with a commercial secondary dose verification software. The necessary inputs to the system are a Treatment Plan Order, approved by the radiation oncologist, and a simulation computed tomography (CT) image, approved by the radiographer. The RPA then generates a complete radiotherapy treatment plan. For the cervical cancer treatment plans, no additional user intervention is necessary until the plan is complete. For head/neck treatment plans, after the normal tissue and some of the target structures are automatically delineated on the CT image, the radiation oncologist must review the contours, making edits if necessary. They also delineate the gross tumor volume. The RPA then completes the treatment planning process, creating a VMAT plan. Finally, the completed plan must be reviewed by qualified clinical staff.

Radiation therapy is a highly complex cancer treatment that requires multiple specialists to create a treatment plan and provide quality assurance (QA) prior to delivery to a patient. This protocol describes the use of a fully automated system, the Radiation Planning Assistant (RPA), to create high-quality radiation treatment plans.

放射规划助理-一个流线型的全自动放疗治疗计划系统

The Radiation Planning Assistant (RPA) is a system developed for the fully automated creation of radiotherapy treatment plans, including volume-modulated ...

A Postoperative Evaluation Guideline for Computer-Assisted Reconstruction of the Mandible

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging modalities, mandibular defect classification, and evaluation methodologies between studies. This guideline uses a step-by-step approach guiding the process of imaging, classification of mandibular defects and volume assessment of three-dimensional (3D) models, after which a legitimized quantitative accuracy evaluation method can be performed between the postoperative clinical situation and the preoperative virtual plan. The condyles and the vertical and horizontal corners of the mandible are used as bony landmarks to define virtual lines in the computer-assisted surgery (CAS) software. Between these lines the axial, coronal, and both sagittal mandibular angles are calculated on both pre- and postoperative 3D models of the (neo)mandible and subsequently the deviations are calculated. By superimposing the postoperative 3D model to the preoperative virtually planned 3D model, which is fixed to the XYZ axis, the deviation between pre- and postoperative virtually planned dental implant positions can be calculated. This protocol continues and specifies an earlier publication of this evaluation guideline.

Here, we propose a practical, feasible and reproducible evaluation guideline for computer-assisted reconstruction of the mandible in order to create uniformity between studies regarding postoperative accuracy evaluation. This protocol continues and specifies an earlier publication of this evaluation guideline.

可读机辅助重建术后评估指南

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging ...

Assessment of Static Graviceptive Perception in the Roll-Plane using the Subjective Visual Vertical Paradigm

Vestibular disorders are among the most common syndromes in medicine. In recent years, new vestibular diagnostic systems have been introduced that allow the examination of all semicircular canals in the clinical setting. Assessment methods of the otolithic system, which is responsible for the perception of linear acceleration and perception of gravity, are far less in clinical use. There are several experimental approaches for measuring the perception of gravity. The most frequently used method is the determination of the subjective visual vertical. This is usually measured with the head in an upright position. We present here an assessment method for testing otolith function in the roll plane. The subjective visual vertical is measured in the head upright position as well as with head inclination of &#177; 15&#176; and &#177; 30&#176; in the roll plane. This extended functional paradigm is an easy-to-perform clinical test of otolith function and ensures increased information content for the detection of impaired graviceptive perception.

The perception of gravity is commonly determined by the subjective visual vertical in the head upright position. The additional assessment at head tilts of &#177; 15&#176; and &#177; 30&#176; in the roll plane ensures increased information content for the detection of impaired graviceptive perception.

使用主观视觉垂直范式对卷平面中的静态视觉感知的评估

Vestibular disorders are among the most common syndromes in medicine. In recent years, new vestibular diagnostic systems have been introduced that allow ...

A Whole Body Dosimetry Protocol for Peptide-Receptor Radionuclide Therapy (PRRT): 2D Planar Image and Hybrid 2D+3D SPECT/CT Image Methods

Peptide-receptor-radionuclide-therapy (PPRT) is a targeted therapy that combines a short-range energy radionuclide with a substrate with high specificity for cancer cell receptors. After injection, the radiotracer is distributed throughout the entire body, with a higher uptake in tissues where targeted receptors are overexpressed. The use of beta/gamma radionuclide emitters enables therapy imaging (beta-emission) and post-therapy imaging (gamma-emission) to be performed at the same time. Post-treatment sequential images permit absorbed dose calculation based on local uptake and wash-in/wash-out kinetics. We implemented a hybrid method that combines information derived from both 2D and 3D images. Serial whole-body images and blood samples are acquired to estimate the absorbed dose to different organs at risk and to lesions disseminated throughout the body. A single 3D-SPECT/CT image, limited to the abdominal region, overcomes projection overlap on planar images of different structures such as the intestines and kidneys. The hybrid 2D+3D-SPECT/CT method combines the effective half-life information derived from 2D planar images with the local uptake distribution derived from 3D images. We implemented this methodology to estimate the absorbed dose for patients undergoing PRRT with 177Lu-PSMA-617. The methodology could, however, be implemented with other beta-gamma radiotracers. To date, 10 patients have been enrolled into the dosimetry study with 177Lu-PSMA-617 combined with drug protectors for kidneys and salivary glands (mannitol and glutamate tablets, respectively). The median ratio between kidney uptake at 24 h evaluated on planar images and 3D-SPECT/CT is 0.45 (range:0.32-1.23). The comparison between hybrid and full 3D approach has been tested on one patient, resulting in a 1.6% underestimation with respect to full 3D (2D: 0.829 mGy/MBq, hybrid: 0.315 mGy/MBq, 3D: 0.320 mGy/MBq). Treatment safety has been confirmed, with a mean absorbed dose of 0.73 mGy/MBq (range:0.26-1.07) for kidneys, 0.56 mGy/MBq (0.33-2.63) for the parotid glands and 0.63 mGy/MBq (0.23-1.20) for submandibular glands, values in accordance with previously published data.

A Whole Body Dosimetry Protocol for Peptide-Receptor Radionuclide Therapy PRRT: 2D Planar Image and Hybrid 2D+3D SPECT/CT Image Methods

This method estimates the absorbed dose of different structures for peptide-receptor-radionuclide-therapy (PRRT) with the possibility of avoiding organ overlap on 2D-projections. Serial whole-body planar images permit estimation of mean absorbed doses along the whole body, while the hybrid approach, combining planar images and 3D-SPECT/CT image, overcomes the limitations of structure overlapping.

肽受体放射性核素治疗（PRRT）全身多体型测定方案:2D平面图像和混合2D+3D SPECT/CT图像方法

Peptide-receptor-radionuclide-therapy (PPRT) is a targeted therapy that combines a short-range energy radionuclide with a substrate with high specificity ...

3D Planning and Printing of Patient Specific Implants for Reconstruction of Bony Defects

We are in the midst of the 3D era in most aspects of life, and especially in medicine. The surgical discipline is one of the major players in the medical field using the constantly developing 3D planning and printing capabilities. Computer-assisted design (CAD) and computer assisted manufacturing (CAM) are used to describe the 3D planning and manufacturing of the product. The planning and manufacturing of 3D surgical guides and reconstruction implants is performed almost exclusively by engineers. As technology advances and software interfaces become more user-friendly, it raises a question regarding the possibility of transferring the planning and manufacturing to the clinician. The reasons for such a shift are clear: the surgeon has the idea of what he wants to design, and he also knows what is feasible and could be used in the operating room. It allows him to be prepared for any scenario/unexpected results during the operation and allows the surgeon to be creative and express his new ideas using the CAD software. The purpose of this method is to provide clinicians with the ability to create their own surgical guides and reconstruction implants. In this manuscript, a detailed protocol will provide a simple method for segmentation using segmentation software and implant planning using a 3D design software. Following the segmentation and stl file production using segmentation software, the clinician could create a simple patient specific reconstruction plate or a more complex plate with a cradle for bone graft positioning. Surgical guides can be created for accurate resection, hole preparation for proper reconstruction plate positioning or for bone graft harvesting and re-contouring. A case of lower jaw reconstruction following plate fracture and nonunion healing of a trauma sustained injury is detailed.

This protocol describes the use of 3D planning and printing for reconstruction of bony defects. We use segmentation tools to create 3D models followed by 3D design software to create patient specific implants for reconstruction purposes concomitant to ablative surgery or as a second stage.

患者特异性植入物重建的三维规划与打印

We are in the midst of the 3D era in most aspects of life, and especially in medicine. The surgical discipline is one of the major players in the medical ...

Treatment of Facial Deformities using 3D Planning and Printing of Patient-Specific Implants

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve better results, even in the less experienced hand, or continue without it. As technology develops and becomes more user-friendly, we believe it is time to allow the surgeon the option to plan his/her operations and create his/her own patient-specific surgical guides and fixation plates allowing him full control over the process. We present here a protocol for 3D planning of the operation followed by 3D planning and printing of surgical guides and patient-specific fixation implants. During this process we use two commercial computer-assisted design (CAD) software. We also use a fused deposition&#160;modeling printer for the surgical guides and a selective laser sintering printer for the titanium patient-specific fixation implants. The process includes computed tomography (CT) imaging acquisition, 3D segmentation of the skull and facial bones from the CT, 3D planning of the operations, 3D planning of patient-specific fixation implant according to the final position of the bones, 3D planning of surgical guides for performing an accurate osteotomy and preparing the bone for the fixation plates, and 3D printing of the surgical guides and the patient-specific fixation plates. The advantages of the method include full control over the surgery, planned osteotomies and fixation plates, significant reduction in price, reduction in operation duration, superior performance and highly accurate results. Limitations include the need to master the CAD programs.

As technology develops and becomes more user-friendly, planning of operations and patient-specific surgical guides and fixation plates should be performed by the surgeon. We present a protocol for 3D planning of orthognathic skeletal movements and 3D planning and printing of patient-specific fixation plates and surgical guides.

使用患者特定植入物的 3D 规划和打印治疗面部畸形

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve ...