title: Intraoperative fiducial-less patient registration using volumetric 3D ultrasound: a prospective series of 32 neurosurgical cases.
abstract: OBJECTIVE
  Fiducial-based registration (FBR) is used widely for patient registration in image-guided neurosurgery. The authors of this study have developed an automatic fiducial-less registration (FLR) technique to find the patient-to-image transformation by directly registering 3D ultrasound (3DUS) with MR images without incorporating prior information. The purpose of the study was to evaluate the performance of the FLR technique when used prospectively in the operating room and to compare it with conventional FBR.
  
  
  METHODS
  In 32 surgical patients who underwent conventional FBR, preoperative T1-weighted MR images (pMR) with attached fiducial markers were acquired prior to surgery. After craniotomy but before dural opening, a set of 3DUS images of the brain volume was acquired. A 2-step registration process was executed immediately after image acquisition: 1) the cortical surfaces from pMR and 3DUS were segmented, and a multistart sum-of-squared-intensity-difference registration was executed to find an initial alignment between down-sampled binary pMR and 3DUS volumes; and 2) the alignment was further refined by a mutual information-based registration between full-resolution grayscale pMR and 3DUS images, and a patient-to-image transformation was subsequently extracted.
  
  
  RESULTS
  To assess the accuracy of the FLR technique, the following were quantified: 1) the fiducial distance error (FDE); and 2) the target registration error (TRE) at anterior commissure and posterior commissure locations; these were compared with conventional FBR. The results showed that although the average FDE (6.42 ± 2.05 mm) was higher than the fiducial registration error (FRE) from FBR (3.42 ± 1.37 mm), the overall TRE of FLR (2.51 ± 0.93 mm) was lower than that of FBR (5.48 ± 1.81 mm). The results agreed with the intent of the 2 registration techniques: FBR is designed to minimize the FRE, whereas FLR is designed to optimize feature alignment and hence minimize TRE. The overall computational cost of FLR was approximately 4-5 minutes and minimal user interaction was required.
  
  
  CONCLUSIONS
  Because the FLR method directly registers 3DUS with MR by matching internal image features, it proved to be more accurate than FBR in terms of TRE in the 32 patients evaluated in this study. The overall efficiency of FLR in terms of the time and personnel involved is also improved relative to FBR in the operating room, and the method does not require additional image scans immediately prior to surgery. The performance of FLR and these results suggest potential for broad clinical application.
authors.affiliation: Thayer School of Engineering and.
authors.forename: Xiaoyao
authors.initials: X
authors.lastname: Fan
authors.affiliation: Geisel School of Medicine, Dartmouth College, Hanover; and.|Norris Cotton Cancer Center and.|Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: David W
authors.initials: DW
authors.lastname: Roberts
authors.affiliation: Thayer School of Engineering and.|Geisel School of Medicine, Dartmouth College, Hanover; and.
authors.forename: Songbai
authors.initials: S
authors.lastname: Ji
authors.affiliation: Thayer School of Engineering and.|Norris Cotton Cancer Center and.
authors.forename: Alex
authors.initials: A
authors.lastname: Hartov
authors.affiliation: Thayer School of Engineering and.|Geisel School of Medicine, Dartmouth College, Hanover; and.|Norris Cotton Cancer Center and.
authors.forename: Keith D
authors.initials: KD
authors.lastname: Paulsen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001921:Brain / Q000601:surgery*; D003399:Craniotomy; D005260:Female; D057918:Fiducial Markers; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D011446:Prospective Studies; D025321:Surgery, Computer-Assisted / Q000379:methods*; D016896:Treatment Outcome; D055815:Young Adult
keywords: 3DUS = 3D ultrasound; 3DUS-MR registration; AC = anterior commissure; FBR = fiducial-based registration; FDE = fiducial distance error; FLR = fiducial-less registration; FRE = fiducial registration error; OR = operating room; PC = posterior commissure; SBR = surface-based registration; TRE = target registration error; diagnostic and operative techniques; image-guided neurosurgery; pMR = preoperative MR images; patient registration; volumetric 3D ultrasound