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ANXIONNAT R, DERELLE AL, PICARD L, BRACARD S

Integrated Registration Software – Clinical interest in Radiosurgery of brain AVM using cyberknife. ANXIONNAT R, DERELLE AL, PICARD L, BRACARD S Diagnostic and interventional neuroradiology, Nancy France BUCCHEIT I, BERNIER V Anticancerous center, Nancy France

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ANXIONNAT R, DERELLE AL, PICARD L, BRACARD S

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  1. Integrated Registration Software –Clinical interest in Radiosurgery of brain AVMusing cyberknife ANXIONNAT R, DERELLE AL, PICARD L, BRACARD S Diagnostic and interventional neuroradiology, Nancy France BUCCHEIT I, BERNIER V Anticancerous center, Nancy France CHONDROU C, WIMILLE B, TROUSSET Y GE Healthcare, Buc france

  2. Cyberknife • Robotic arm • X-ray verification system • Frameless nonisocentric linac-based system • 3D imaging only • Anticancerous center since January 2007 • Radiosurgery of brain AVMs since july 2010

  3. Linac (before 2010) Brainlab Stereotactic frame Registration sofware brainscan 3DCT,3DMR, 2DSA Delineation on 2DSA and refinement on MRI (brain parenchyma) Cyberknife (since 2010) Accuray Frameless Integrated registration software (GE Healthcare) 3DCT, 3DMR, 3DXA Delineation on 3DXA and refinement on MRI (brain parenchyma) Delineation of the nidus

  4. 3D X-ray angiography • Innova 3131 – 40°/sec • 3D volume • high spatial resolution 200 microns • Shape of the nidus and analysis of the angioarchitecture on AW workstation • Oblique views • Multiplanar reformations

  5. 3DXA in brain AVMs • Better understanding of the angioarchitecture • Anxionnat R et al. 3D angiography. Clinical interest. First applications in interventional neuroradiology. J Neuroradiol 1998 • Kakizawa et al. Compartments in arteriovenous malformation nidi demonstrated with rotational three-dimensional digital subtraction angiography by using selective microcatheterization. Report of three cases. J Neurosurg 2002 • Prestigiacomo et al. Three-dimensional rotational spinal angiography in the evaluation and treatment of vascular malformations. AJNR 2003 • Delineation of the nidus prior to radiosurgery • Berger, Anxionnat, Kerrien, Picard and Sodermann. A methodology for validating a 3D imaging modality for brain AVM delineation : application to 3DRA. Computerized Medical Imaging and Graphics 2008; 32,544-53 • Colombo et al. Three dimensional angiography for radiosurgical treatment planning for arteriovenous malformations. J Neurosurg 2003;98, 536-43

  6. 3DXA analysis of the nidus on AW workstation

  7. 3DXA analysis of the nidus Shunting zones inside the nidus Global shape

  8. Segmentation of the nidus using 3D scalpel on multiple oblique reformated views

  9. Progressive refinement of the segmentation on oblique views (including axial one) Final volume (+oblique views) Initial volume (Frontal +sagittal) 20% decrease of nidus volume

  10. Integrated registration software • Multimodality frameless registration and fusion software • 3DXA, 3DMRI Gd+, 3DCT • 3D nidus segmentation, … (organs at risk …) • Automatic registration • Manual refinement if necessary • Post processing tools • Visualisation • Drawing tools • Volume measurement …

  11. Visualisation tools : transparency, checkglass …. Common points on anatomic landmarks Bone structures for CT-XA registration Vessels for XA-MR registration Registration accuracy

  12. XA-MR Registration

  13. Refinement of nidus segmentationusing integrated registration • 3DXA, 3DMRI, 3DCT, nidus volume segmented from 3DXA are co-registered • Refinement of the nidus segmentation by delineation slice by slice

  14. Refinement of the delineation slice by slice on coregistered 3DXA and 3DMR

  15. 9 brain AVMs treated by radiosurgery using LINAC and brainlab (2009) : delineation of the target on 2DSA and MRI (volume 1) New method of the target in these 9 AVMs using 3DXA and integrated registration (volume 2) Comparaison of the volume size between the 2 methods of delineation: decrease of the target volume Clinical interest of this new method of target delineation

  16. Conclusion • Use of 3DXA in the delineation of the nidus and integrated registration software • Accuracy and speed of the registration +++ • Better visualization of the nidus • Better delineation of the nidus • 3D segmentation on multiple oblique views (global shape) • Refined slice by slice • Better conformity to the nidus in a reduced target volume

  17. Work in progress • Improvement in drawing tools : • Semi-automatic (snakes …) • 3D tools • Integration of functional imaging (activation MR, tractography) • Improvement of 3DXA • Subtraction • Faster rotation

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