FEBRUARY,

1969

PRECISE
By PAUL C.

ALIGNMENT STEREOTACTIC
HODGES, M.D., and
GAINESVILLE,

OF
FRANCISCO

X-RAY BEAMS SURGERY*

GARCIA-BENGOCHEA,

FOR
M.D.

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FLORIDA

at least one important excepthe X-ray guidance of neurosurgical instruments usually has been done at tube-film distances of 2 meters, 3 meters, or more, alignment being accomplished by means of light beams attached to the housings of the X-ray tubes. Time is saved, cost reduced and accuracy improved if tube-film distance is reduced to i meter and alignment is done with the X-ray beams themselves (Fig. 7; 8, 1 and B; and , 1 and B). We have devised an apparatus of this sort for thalamectomy and have used it successfully in over 20 operations. The construction, alignment and surgical employment of the apparatus are described in the text of this article and the legends for its 12 figures.

A7ITH

tio&

GEOMETRY

OF

STEREOTAXIS

When the patients head has been fixed in an instrument-guidance system, oriented so that its geometric center coincides with the crossing of frontal and lateral X-ray beams, preliminary roentgenograms are made. In the lateral film the image of the anatomic target on the thalamus is computed from the location of the image of the junction of the middle and posterior thirds of the intercommissural line, and in the frontal film by measurement from the midline of the brain. Almost invariably the first films will show the image of the target displaced more or less from the center of the guidance system, but because of the fact that X-rays diverge from their source, the magnitude of that displacement will be greater than the displacement of the anatomic target itself. Figure 2 shows the geometry for the frontal beam and film,
*

but the mathematics are the same for the other plane. The magnitude of displacement of the anatomic target (T) from the longitudinal axis of the frontal film (L) is designated 0 (object) and the displacement of its image (I.T.) is designated I (image). When the measured values of 0 and I are substituted in the familiar equations for the divergent distortion correction factor and its reciprocal, we acquire tools for computing the location of the image of the thalamic target relative to the midline of the brain and for determining the net amounts by which head and beamreticle assembly must be shifted to bring the target to the geometric center of the instrument-guidance system (Fig. ii, ii and B; and I 2, ii and B). Regardless of the magnitude of tube-film distance these computations must be made, and the fact that with longer distances the correction factor becomes more nearly 1.0 has no practical advantage. Long distances, however, have serious mechanical disadvantages plus the disadvantage of requiring much heavier X-ray tube loading.
APPARATUS

We employ a modification of the ToddWells head-holder, instrument-guidance system5 (Fig. 3; ; and 5) mounted on the optical bed (Fig. 6) of a beam aligning unit of our own design (Fig. i). Two small Xray generators are carried on a sturdy tubular steel bridge running on precisely aligned optical rails so that it can be rolled out of the surgical field except for the period of film exposure. A bracket on the bridge carries a feeler gauge and when the X-ray beams are to be brought into posiMadison, (Division Wisconsin; and on August University
30,

Presented

on

May

23,

1968

to the

Wisconsin

Medical

Alumni, of Surgery

1968

to The

Scandinavian of Med-

Neurosurgical Society, Ahrus, Denmark. From the Department of Radiology and icine, Gainesville, Florida.

Department

of Neurosurgery),

of Florida,

College

2.60

\oi.

io,

No.

X-Ray

Beams

for Stereotactic

Surgery

261

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FIG.

1. General view of apparatus. i. Bridge; 2. Bracket; 3. Frontal X-ray generator and its collimator; 4. Lateral generator and its collimator; . Optical bed; 6. Upper optical rail; 7. Lower optical rail (there are 2 similar rails at the other Side); 8. Control for lateral generator;* . Plastic reticles supplied by manufacturer of head holder. We substitute magnesium reticles (see Fig. 4). Wheeled base, bridge, X-ray generators and their collimators and controls constitute a unit which can be moved through standard hospital doors including elevator doors. Between periods of service it can be draped with a protective cover and stored in corridors or apparatus storage rooms. The instrument guidance system, including head holder and far reticle, is wrapped in cloth and gas sterilized and when unwrapped in the operating room is placed down on the optical bed registered in place by means of 2 dowels (see Fig. 6). The unit is not safe for use with explosive anesthetics, but our surgeons and anesthesiologists are content to work only with the nonexplosive variety. With a phantom head in position and the frontal tube operating at 8o kv., 10 ma., the dose at 2 meters is only 0.2 mr/mm. and for the lateral tube operating at 75 kv. and 12 ma., the dose is 1.0.
Generator who and prefers control to remain are the greatly appreciated gift of a

tion for filming, the surgeon has merely to see to it that the tip of the gauge touches the back of the horseshoe of the instrument guidance system in order to assure that the crossing of the 2 beams lies at the geometric center of the head-holder assembly. The reticle, a silver-filled grating ruled into a sheet of magnesium (Fig. 4), is permanently mounted on the head-holder so that its center point lies on the transverse axis exactly opposite the geometric center of the guidance system when the bridge is in filming position. A silver-filled line in the magnesium holder for the frontal film defines the longitudinal axis of that film and is centered exactly beneath the center of the frontal X-ray beam. The complete apparatus has over-all dimensions of only 24X60X74 inches in height. It is carried on rubber tired casters, will pass through standard hospital doors and can be wheeled into whatever operating room is available to the surgeon. It is not safe for use near explosive gasses, but of course explosive anesthetics are not necessary for this type of surgery.
SURGICAL DETAILS

To be used, the apparatus is wheeled into position at the end of a standard operating table, clamped to it, and floor locks set (Fig. 10). The sterilized assembly of base, horizontal arc, 2 film holders and fixed reticle of the head-holder guidance system are placed on the optical bed, being precisely located there by 2 dowels (Fig. 6). Finally, the patients head is anchored to the head-holder.
VENTRICULOGRAPHY

For the landmarks

roentgenologic identification we use a modification

of

of the

friend

anonymous.

These very iow doses are accomplished by close collimation of both beams and lead backing on both cassette holders. Since individual films require exposures of only 3-5 seconds, it is merely necessary for doctors, nurses and technicians to step back to a distance of 2 meters from the patients head in order to work safely without leaded aprons, gloves or protective screens.

262

Paul

C. Hodges

and

Francisco

Garcia-Bengochea

FEBRUARY,

1969

EFFECT

OF

ON DIVERGENT

TUBEFILM DiSTORTiON AND

DiSTANCE CD) CORRECTION FACTOR

IN NAB

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ON
EXPOSURE

CASE

REQL$RED

XRAY

SCALE
FOR If TRIANGULAR 0 PROPORTiON BY (FACTOR) FOR D 5OmmIMETER d,OANDI IOOma;IMETER

I (IMAGE) YIELDS

MULTIPLIED (OBJECT).

0 (OBJECT) MULTIPLIED YIELDS I (IMAGE)

BY

..Q_
D-d

(RECIPROCAL

FACTOR)

CAGE

CASE

2 METERS

FILM I.T. FACTOR 0.8 125 FACTOR RECIPROCAL NAB 200 0.9 1.11 FACTOR RECIPROCAL NAB 460 O3 I. 07

RECIPROCAL. NAB 50

FIG.

X =Target of frontal X-ray tube; L=Longitudinal axis of frontal film; D = Tube-film T = Anatomic target; d = Distance of anatomic target above film; 0 = Displacement of target from axis of film; I.T. = Image of target; I = Displacement of image from axis of film. In Case I , D = I meter; Case 2, D =2 meters; Case 3, D = 3 meters. If the scale had been 50 mm. = I meter for all values, T would be shown lying only 10 mm. above the film and 10 mm. displaced from the longitudinal axis, and I. T. would lie only 12.5 mm. away from the film axis. Instead, a scale of 100 mm.=i meter has been used for all values other than D. The use of 2 scales distorts the geometry so that measurement of I on the drawing is not significant, but the distortion makes the geometry more obvious. As D increases from 1 meter to 2 and then 3 meters, 0 and I differ less and less, the correction factor becoming larger and its reciprocal smaller. However, accuracy rests not on the magnitude of correction factors but rather on the precision with which the 2 X-ray sources have been lined up perpendicular to their respective films and intersecting one another exactly at the geometric center of the instrument guidance system. Such alignment is easier and more precise when D is I meter, more difficult and less precise as the magnitude of D increases. Furthermore, because of the inverse square law, the mas. required at a D of i meter must be quadrupled at 2 meters and increased nine fold at 3 meters. This drawing portrays the frontal tube and film, but the geometry is identical in the case of lateral tube and film. The application of this simple geometry is explained in connection with Figures u and i 2.
2.

Geometry.

distance;

VOL.

105,

No.

X-Ray

Beams

for Stereotactic

Surgery

263

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[::_._
FIG.
4.

FIG.

guide.

holder and instrument Base lock; 3. Instrument guide arcs; 4. Instrument guide riders; . Crown for immobilizing patients head; 6. Supports for immobilizing pins; 7. Support in which crown is clamped; 8. Pinion for moving patients head ventrally or dorsally; . Lock to arrest such movement; 10. Lateral cassette holder; II. Frontal cassette holder; 12. Base of Todd-Wells device; 13. Optical bed of our apparatus; I4. Bracket on bridge; 15. Feeler gauge on bracket. The tip of the gauge is in contact with the horseshoe as it must be when films are to be exposed; i6. Near reticle, so-called because it lies nearest to the source of radiation. This original reticle of clear plastic has inherent disadvantages and we have replaced it with one made of sheet magnesium (see Fig. 2); 17. Far reticle of clear plastic. This too has been replaced by sheet magnesium (see Fig. 2). For all positions of arc and rider a freezing instrument introduced through a hole in the rider and advanced until its tip is 135 mm. beyond the back of the rider will lie with its tip at the midpoint of an imaginary line joining the centers of the 2 lateral reticles and directly over the longitudinal axis of the frontal film. The objective of all the maneuvers presently to be described is to identify an anatomic target in the brain and bring it exactly to the geometric center of the guidance system so that a freezing
.

Todd-Wells

head

i. Horseshoe;

2.

Magnesium reticles. i. Horseshoe; 2. Base; 3. Optical bed; 4. Bracket; . Feeler gauge; 6. Far reticle of 1/32 inch sheet magnesium; 7. Strengthening rib at edge, outside the field of examination; 8. Holes for screws that hold jig during optical alignment of frontal X-ray beam (see Fig. 7); 9. Near reticle (used only during preliminary optical alignment of the 2 X-ray beams) is 1/32 inch sheet magnesium cemented to a sheet of 1/4 inch aluminum for rigidity; 10. Screws which attach reticle to horseshoe; I I. I 1/4 inch opening through aluminum at site of reticle; 12. Lateral cassette holder with built-in stationary grid; 13. lrontal cassette holder with built-in grid. A line engraved in the magnesium front and filled with silver* defines the longitudinal axis of the 8Xio inch frontal film. The original plastic reticles were somewhat unstable dimensionally and the reinforced margins showed on films and sometimes obscured landmarks. Both had to be used for each examination and beam alignment had to be checked from time to time during the course of examinations. \Vith our apparatus and our modifications of the head holder and instrument guidance system the far reticle remains in position at all times and the near one is unused once beam alignment has been accomplished. This part of the guidance system is clamped to the bed of a milling machine and before the reticles are engraved their centers are located. These centers lie on an imaginary line perpendicular to the lateral film and with its midpoint perpendicularly above the longitudinal axis of the frontal film. A similar technique (see Fig. 7) is employed for locating the shot and silver filled line in the magnesium jig for alignment of the frontal beam.
*

Eccobond Inc.,

Silver-Epoxy Canton,

Easy Massachusetts.

Mix

#s7-C

Paste.

Emerson

&

Cuming,

instrument will lie with

introduced through a hole its tip exactly at that target.

in

a rider

264

Paul

C. Hodges

and

Francisco

Garcia-Bengochea

FEBRUARY,

1969

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lic,.

#{231}. Other modifications of Todd-Wells device. Screw for transverse movement of patients head; 2. Scale for transverse movement; 3. Scale for ventral-dorsal movement of head; . Pinion for shifting horseshoe and attached Far reticle toward vertex or toward feet; . Lock for such motion; 6. Scale for such motion. The original scales were engraved in metal and hard to read. Ours are easily readable being engraved on black plastic laminated on white backing. Transverse shifting of the head formerly was done by pushing or hammering the base of the yoke along its ways. We accomplish this motion with a screw. Shifting of reticle and horseshoe assembly toward feet or toward vertex we do by means of a rack and pinion rather than by pushing or hammering. In the locks for the slotted ways in base, horseshoe and guidance arcs (see Fig. 3) the small rectangular clamping members at the ends of locking screws were free to rotate until they had been lodged within their slots. As a result a surgical assistant, in sterile attire, assembling the sterilized parts of the guidance system wasted much time maneuvering the rectangles into their slots. The i.

is injected gently in 40 to 6o seconds and the first films (lateral and anteroposterior) are exposed (Fig. ii, 4 and B; and 12, 4 and B). If the films reveal that more air is needed, it is added in small increments according to estimates based on pressure levels and the degree of ventricular filling already obtained. For thalamectomies adequate visualization of the third ventricle and rostra! aqueduct of Sylvius usually is achieved with volumes of air ranging from 20 to 30 cc. In some cases it may be necessary to remove some fluid and inject larger amounts of air, the optimum volume of air seeming to be related to atrophy and ventricular size. During the injection of air

171
FIG.

.1

difficulty

has

been

corrected

by

fixing

small

pins

in the clamps. These pins ride in free fitting holes in the blocks into which the screws are tapped, preventing the rectangles from rotating out of alignment with their respective slots.

method

of

positive

pressure

ventriculogra-

phy make

by Calvin and Coe.2 We hole on the day of the stereotactic procedure, after the patient has been fixed in the holding and guiding apparatus, and place the hole on the coronal suture, 3 cm. from the midline. Usually no fluid is removed except for the few drops lost in ascertaining that the ventricle has been entered, and in connecting rubber tubing to the brain cannula. For adults without increased intracranial pressure 15 cc. of air

described the burr

6. Optical bed. i. Bed; 2. Pads; 3. Dowels; 4. Bracket; 5. Feeler gauge; 6. Slots to receive brackets on operating table; 7. Locks to anchor operating table to apparatus; 8. Locks to fix bridge to optical rails. The bed is /8 inch in sheet aluminum bolted to the steel table top, the latter having been machined to be flat and as nearly as possible perpendicular to the 2 machined sides which carry the supports for the optical rails. To further increase accuracy the head holder rests not on the aluminum top but rather on brass pads which are threaded into the aluminum and project through the sheet plastic which is cemented to it. By means of surface gauges these pads are raised and lowered until they are within 3 thousandths of an inch of defining a plane perpendicular to the planes of the optical rails. When the head holder has been placed down on the dowels, the longitudinal axis of the frontal film will lie directly beneath the source of the frontal X-ray beam for all positions of the bridge, and when the feeler gauge makes contact with the horseshoe both beams will intersect at the geometric center of the instrument guidance system.

VOL.

105,

No.

X-Ray

Beams

for Stereotactic

Surgery

265

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R
FIG.

L
i.

7. Alignment of X-ray beams. A sheet of i/ inch magnesium (I) 6 inches wide, 12 /8 inches long and with a 5 /8 circular cut out in the center forms a jig for the alignment of the frontal beam. With the holder clamped to the bed of a milling machine (see legend Fig. ) the jig is lined up with the centers of the 2 reticles. At the upper edge a small hole is drilled exactly over the longitudinal axis of the frontal film and in the lower edge a short groove is milled out exactly parallel with the imaginary line connecting the 2 reticle centers and perpendicularly beneath the hole in the upper edge. A small shot (actually a ball bearing) is pressed into the hole in the upper edge of the jig and silverepoxy paste applied to the groove, thus providing two landmarks for optical alignment of the frontal X-ray beam (see Fig. 8); (2) is the control for the frontal generator, (3) the bracket which supports the feeler gauge (in this view concealed by the jig), () is the frontal generator, () the lateral generator and (6) the tubular steel bridge on which the two generators are mounted. Alignment of the lateral beam is described in the legend for Figure 8. When both alignments have been made the 2 generators are locked in position and the jig and near reticle are removed and not used again. The short tube-film distance of i meter in every way improves and in no respect decreases the accuracy of instrument guidance. Because at i meter an exposure of o mas. suffices, the generators may be small and of light weight so that they can be carried on a tubular steel bridge which allows no significant sag. Once alignment has been accomplished nothing short of a serious mechanical accident will disturb it. The fact that divergent distortion of images is greater than it is at greater Ds improves accuracy by magnifying the amount by which an anatomic target fails to lie at the geometric center of the guidance system. Errors in d and in the simple arithmetic required have no effect on accuracy and can merely increase somewhat the number of test films that must be made. Once a target lies at the geometric center all other factors have been eliminated and

FIG.

8. Optical alignment of frontal X-ray beam. Image of silver filled line in frontal cassette holder indicating longitudinal axis of frontal film; 2. Image of short, transverse, silver-filled line at lower edge of jig; 3. Image of small shot imbedded in upper edge of jig. (A) This drawing from a film early in a series of tests shows the shot displaced slightly above and to the left of the central crossing of film axis and transverse line. (B) Following a test series, with appropriate shift of frontal tube between tests, the shot is found to lie precisely at the central crossing of transverse line and film axis. The precision of this type of alignment is much greater than the best that could be accomplished with light beams and once such alignment has been done it need nevei be done again. In the films themselves the images of shot and transverse line, even though superimposed on the magnesium forming the upper and lower portions of the cut-out in the jig, could be well seen by transmitted light. Because such films do not lend themselves well to reproduction we have employed for this figure not film reproductions but an artists drawing made from the films.

beam alignment alone affects accuracy.* To be true the diameter of the image of the target will be larger than the target itself but since we are dealing with the center of that image its actual diameter is of no importance whatever.
*

Except

for

computation Fig.
ii).

of

location

of

image

of

target

in

frontal

film

(see

266

Paul

C. Hodges
B

and

Francisco

Garcia-Bengochea

FEBRUARY,

1969

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junction of the posterior and middle thirds of the intercommissural line. When the first films (lateral and frontal) have been exposed following the injection of air, the work-up begins and continues through subsequent films until the target has been brought to the longitudinal axis of the frontal film and the center of the reticle in the lateral film. When these two objectives

li.

. Optical alignment of lateral X-ray beam. By means of skillful and painstaking machine work (see lig. and 7) the centers of the 2 reticles are made to lie so that an imaginary line connecting them is exactly parallel with the frontal film and perpendicular to the lateral film. When this has been done and the lateral tube arranged with its target approximately in line with the 2 reticle centers, further tube alignment is accomplished by optical means. The far reticle has silver-filled vertical and transverse lines each with four transverse strokes. The near reticle consists of a silver-filled circle with strokes at IX, XII, III and VI oclock. (A) The near reticle is displaced downward and to the left relative to the far reticle indicating that the target of the lateral tube is in not quite perfect alignment. (B) After repeated tests, with shift of X-ray tube between them, the 2 reticles coincide. The tube is now locked in position and the near reticle removed. It is used merely for this preliminary alignment and clinical work employs merely the far reticle which remains permanently in place. The beam alignment illustrated here and in Figure 8 assures that the 2 beams meet at the geometric center of the instrument guidance system.

FiG.

and

the

taken avoid
fourth

making to prevent introducing ventricle.

OF

of roentgenograms, loss of pressure unnecessary air

care is and to into the

SELECTION AND BRINGING

ANATOMICAL THEM TO IHE

TARGETS CENTER

OF

INSTRUMENT
SYSTEM

GUIDANCE

on

to subsequent correction based physiologic response, the anatomic target is assumed to lie 13.6 mm. to the right or left of the midline and at a point i mm. rostra! and 3 mm. dorsal to the Subject

io. Apparatus attached to operating table. Bracket on operating table enters receptacle on our apparatus; 2. Lock holds table bracket in place; 3. Frontal X-ray generator; 4. Lateral X-ray generator; . Bridge. The 2 beams are closely collimated so that they cover a mere 6 inch circle at the films and both cassette holders are backed with lead. As a result, the output of scattered radiation is so low that doctors, nurses, technicians and others working in the operating room do not need aprons or gloves (see Fig. I). At our institution surgeons and anesthesiologists have agreed to use only nonexplosive anesthetics, whenever surgery requires the employment of Xrays. Accordingly this apparatus, like all the rest of our X-ray apparatus, carries a sign stating that it is not safe for use in explosive atmospheres.
1.

\oi.

105,

No.

X-1i

Beams

for

Stereotactic

Surgery

267

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JIG.

ii. Work-up of frontal film. In the average adult it has been found that the anatomic target in the thalamus lies 13.6 mm. lateral to the mid-line of the brain. Multiplying 13.6 by the reciprocal factor 1.25 (see Fig. 2) we obtain the value imm. as the location of the image of that target lateral to the mid-line of the brain. This value remains the same throughout the film series and we treat a mark made on the film 17 mm. lateral to the mid-line of the brain as though it were the image of a visible structure. lor example, if in a particular film that mark is found to lie 10 mm. to the left of the axis of the frontal film, we multiply that value by the correction factor o.8 obtaining 8.o mm. as the amount by which the patients head should be shifted toward the right. I. Air-filled lateral ventricles; 2. Septum pellucidum; 3. Longitudinal axis of frontal film; 4. Mark placed on film indicating computed location of anatomic target; 5. Cannula for injection of air; 6. Freezing instrument. (A) The target () lies slightly to the left of the longitudinal axis. (B) After several film exposures, with transverse shift of patients head between them, the target (4) lies squarely on the longitudinal axis and the tip of the freezing instrument (6) coincides with it.

Note: reciprocal
7).

It

must factor

be admitted (see Fig. a) but

that

the clinical

ability results

to compute in more

the than
20

location operations

of the

image

()
the

involves soundness

accurate of the

knowledge assumptions

of (d) involved

and (see

of the Fig.

indicate

have have

been been

accomplished, brought to

the

the target will center of the

For details of

techniques
others and

which
need not

have

been

described
here.

by

be repeated

instrument-guidance

system.

working-up frontal and lateral films see the legends for Figures ii and 12. Physiologic testing is carried out by conventional means and, if necessary, final slight adjustments are made in the position
of head and
steps

DISCUSSION

Objection tem requiring

has

been

raised of the

that patients

any

syshead

fixation

tube-reticle
of

assembly.

The

remaining

the

thalamectomy

follow

in the brow-up position (as in the Todd\Vells head-holder) prevents adequate distribution of contrast media, either liquid or gaseous, by making it impossible to

268

Paul

C.

Hodges

and

Francisco

Garcia-Bengochea

FEBRUARY,

1969

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V .3 .3

P
FIG.

12. Work-up of lateral film. (A) The anatomic target () lies posteriorly and toward the patients feet relative to the center of the far reticle (i). (B) After several trial film exposures, between which patients head was shifted anteriorly and the reticle-beam assembly toward his feet, the target (3) lies at the center of the reticle assuring that it is at the geometric center of the instrument guidance system. The freezing instrument () lies with its tip at the target, but before destructive freezing is done there must still be physiologic testing for further refinement of positioning. The means of identifying the intercommissural line and locating the target i mm. rostral and 3 mm. dorsal to the junction of the middle and posterior thirds of that line are explained in the text.

move velopment we were

the

head.
of

Even
new

previous
equipment,

to

the
however,

de-

cisterns

in patients

with

patent

ventricular

our

and

convinced

of positive visualization
aqueduct

head
with

from
Calvin

that the employment permitted consistent third ventricle and of Sylvius without moving the the brow-up position. We agree pressure of the
and Coe2 that with their

subarachnoid We attempt

systems. to prevent
rostra! side fourth effects

spread

of

air

beyond the only to reduce

ventricle, not but also to avoid

possible
and

obscuration
of Sylvius

of the

third

ventricle

aqueduct

by pockets

of air

in

positive pressure side effects than

ulography and

method with
pneu

there standard
ceph

are

fewer ventric-

the subarachnoid space, but while we are not always successful in this attempt and air frequently is seen in the cisterns, in no
case has it interfered critical structures.
SUMMARY

moen

alography,

with

visualization

of

and we find described by suggestion by that the tip placed caudal order to obtain the posterior parts of both

it simpler than the method Clark et al. Contrary to the Waltz and Cooper6 we believe of the cannula need not be to the foramen of Monro in consistent visualization of
third
ventricle, ventricle aqueduct,

i. stereotactic

Alignment beams
beams

of the
surgery

is

those
light
housings.

themselves
attached

X-ray beams used in best done with rather than with

to the X-ray tube

the

fourth

and

basal

VOL.

105,

No.

X-Ray

Beams

for

Stereotactic
Paul C. Hodges,

Surgery
M.D.
of Radiology

269

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2. A tube-film distance of i meter is preferable to 2 or 3 meters or more, the shorter distance improving rather than diminishing the accuracy of localization of brain targets in thalamectomy. 3. In addition to improved accuracy, the short tube-film distance makes possible the use of small X-ray generators incorporated in a self-contained unit which can be wheeled into any operating room that happens to be available to the neurosurgeon at the moment. 4. Because the X-ray beams have been permanently aligned in the machine shop, the time for stereotactic surgery is remarkably shortened with resulting diminished discomfort to the patient. #{231}. The construction, calibration and surgical employment of such an apparatus are described. 6. Positive pressure ventriculography allows visualization of the third ventricle and the aqueduct of Sylvius in the recumbent patient.

Department

University

of Florida
32601

College

of Medicine

Gainesville, Florida

REFERENCES
1.

BAILEY,

Surgery,
1958, 2. CALVIN,

P. Chairman, Detroit,
15, 239-280.

Symposium April 26, 1957.

on Stereotactic 7. Neurosurg.,

3.

T. H., JR., and sure ventriculography 7. Neurosurg., 1967,26, CLARK, L., MOSER, D.,

COE, J. E. Positive presfor stereotaxic surgery.

548-552.

and

BRACKETT,

C.

Con-

trolled
Neurosurg.,

small

volume

ventriculography.

7.

1966, 24, 777-778. 4. DOBBEN, G. D., MULLAN, S., and MO5ELEY, R. D., JR. New biplane neuroradiologic localizing instrument. Radiology, 1967, 89, 329-33!. . TODD, E. M. Manual of Stereotaxic Procedures. Privately published by Mechanical Developments Company, South Gate, California, 1967. 6. WALTZ, J. M., and COOPER, I. S. Comparative study of ventriculography and pneumoencephalography for roentgenographic landmarks during cryothalamectomy. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1966, 97, 583-587.