title: Real-time image guidance for open vascular neurosurgery using digital angiographic roadmapping.
abstract: OBJECTIVE
  Angiographic roadmapping, commonly used for catheter navigation in endovascular procedures, is the superimposition of a live fluoroscopic image on a previously stored digitally subtracted angiogram. We evaluated this technique for the first time as a method for image-guided navigation during surgical resection of intracranial and spinal vascular lesions.
  
  
  METHODS
  After obtaining Institutional Review Board approval, we retrospectively reviewed 38 procedures in 35 patients at two centers performed by one neurosurgeon in which intraoperative roadmapping was used as an image-guided navigation tool for surgical resection of cranial and spinal arteriovenous malformations or fistulae. This technique requires femoral or radial artery access and a portable vascular C-arm capable of digitally subtracted angiogram and roadmap angiography in the operating room suite. Once a roadmap identifying the vascular lesion is obtained, a sterile radiopaque instrument is placed over the skin/wound to precisely localize the lesion in multiple dimensions.
  
  
  RESULTS
  Angiographic roadmapping was used for resection of seven spinal arteriovenous malformations or fistulae, 23 cranial arteriovenous malformations or fistulae, one aneurysm, two carotid-cavernous fistulae, and transtorcular embolization of five vein of Galen malformations. In all cases, the technique helped us to make precisely localized incisions, avoid unnecessary bone removal, and readily directed us to the vascular lesion. In several cases, it allowed localization of small fistulae not visible on magnetic resonance imaging or computed tomographic angiography scans. Finally, this approach facilitated immediate angiographic confirmation of complete resection at the end of each case.
  
  
  CONCLUSIONS
  Angiographic roadmapping is an effective intraoperative navigation tool for resection of vascular lesions that has not been previously described and offers several advantages to frameless stereotaxy.
authors: Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
authors: Michael
authors: M
authors: Ayad
authors: Arthur J
authors: AJ
authors: Ulm
authors: Tom
authors: T
authors: Yao
authors: Eric
authors: E
authors: Eskioglu
authors: Robert A
authors: RA
authors: Mericle
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000792:Angiography / Q000379:methods*; D001927:Brain Diseases / Q000000981:diagnostic imaging* / Q000601:surgery*; D002648:Child; D003199:Computer Systems; D005260:Female; D006801:Humans; D066298:In Vitro Techniques; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D011856:Radiographic Image Enhancement / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods*