J Neurosurg 119:94–105, 2013

©AANS, 2013

Interactive presurgical simulation applying advanced

3D imaging and modeling techniques for skull base
and deep tumors

MAKOTO OISHI, M.D.,1 MASAFUMI FUKUDA, M.D.,1 NAOKI YAJIMA, M.D.,1 KENZO YOSHIDA, 2
MACHIKO TAKAHASHI, 2 TETSUYA HIRAISHI, M.D.,1 TETSURO TAKAO, M.D.,1
AKIHIKO SAITO, M.D.,1 AND YUKIHIKO FUJII, M.D.1
1
Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata; and 23D Solution,
Toyotsu Machinery Corporation, Tokyo, Japan

Object. In this paper, the authors’ goal was to report their novel presurgical simulation method applying interac-

Methods. For 25 operations in 23 patients with skull base or deep intracranial tumors (meningiomas, schwan-

Results.

25 operations IVS showed high utility (as indicated by a rating of “prominent”) in comprehending 3D microsurgical

Conclusions. -
niques provided a realistic environment for practicing microsurgical procedures virtually and enabled the authors to

(http://thejns.org/doi/abs/10.3171/2013.3.JNS121109)

KEY WORDS

S
URGICAL removal of tumors located in the skull base
or deep intracranial regions requires a high order
of anatomical knowledge that can be obtained only
through a large number of surgical experiences and has
therefore been recognized as a challenging category in
22
Although we have derived great
MRI, and DSA in presurgical evaluation of the spatial
locations and extensions of such tumors in relation to the
surrounding structures, reconstruction of 3D anatomy
from 2D images and integration of data sets obtained by
different modalities in the neurosurgeon’s mind remain

Application of 3D computer imaging and modeling

Abbreviations used in this paper: - techniques to neurosurgical planning has been promoted
-

94 J Neurosurg / Volume 119 / July 2013

Interactive presurgical simulation applying 3D techniques

in high hopes of enhancing both the certainty and the

11,21,23
phase after injection of the contrast agent, respective 3D
exist numerous types of 3D fusion imaging methods

come into routine use based on user-friendly software for

1,3–5,20
- Data Processing
fessional software has provided strikingly high-quality
and realistic 3D visualization of microsurgical anato- -
7,8
Not only for surveying 3D data visually but also
for using simulation with realistic tactile sensations, a
unique surgical simulation method applying haptic feed- Individual structures were extracted from the appropriate
-
2,6,9,10,24

- -

- a mask of the imaging data to extract the targeted structure

- by determining the extent of the area of interest and adjust-
els and to dissect them using surgical instruments have -
been reported in detail, especially for surgical simulation lar image intensity or density in the mask were automati-
13,14

We previously reported the value of 3D imaging

techniques in neurosurgical planning,16–19,25 and we re- data were converted to 3D data formed as triangular poly-
cently established a novel surgical simulation style called
interactive virtual simulation,15 characterized by creat-
individual structural margins on the multidirectionally re-
radiological data and then performing surgical simula-
structural 3D data set and output these data individually in

we performed IVS to create the best scenario for tumor

removal and then used a 3D color printer to produce color Interactive Virtual Simulation on 3D Computer Graphics
Data
Herein, we demonstrate the utility of this innovative pre-
surgical simulation method based on our surgical experi-
-

to freely modify the created 3D data as required by using

Patient Population intelligible 3D tools for cutting, removing, and deforming,

-
25 operations in 23 patients with skull base or deep tu- back that enabled operators to use their sense of touch to
were 11 males and 12 females, and patient age ranged be-

-
Data Acquisition
We acquired high-quality imaging data using the fol-
language–formatted data were individually imported into
- the same working space and were displayed in different
-

after venous injection of iodized contrast medium were angles by rotating it freely and making structures translu-
12 cent or invisible sequentially to understand anatomical re-

spoiled gradient recalled sequence, the 3D constructive surgical space by imitating craniotomy and retraction of
interference in steady state sequence, and the 3D time-
were simulated to determine the best surgical route and the
subtraction angiography was performed using a 3D rota-
-

J Neurosurg / Volume 119 / July 2013 95

 TABLE 1: Summary of cases, presurgical simulation, and surgical results*
96

Information Obtained by 3D Simulation Superior to Only 2D Evaluation

Given Evaluation
for the Overall
Case Location & Surgical Utility of 3D Spatial Information Arterial Venous Information on Bony Predicted Surgical
No. Pathology Approach Simulation on the Tumor Information Information Cranial Nerves Information Operative Window Removal Achievement
1 tentorial menin- ATP supportive GTR as planned
gioma
2 tentorial menin- ATP supportive irregularity of the STR as planned
gioma pyramidal
shape
3 petroclival me- 1) FT-OZ prominent tumor extension distorted nerves understanding the PR
ningioma due to the large around the visible part in moval due to
size tumor the limited route bleeding
2) RS supportive PR as planned
4 petroclival me- ATP supportive draining PR
ningioma routes due to injury of
the perforating
vessel
5 petroclival me- prominent complicated tumor draining destructed & dis- predicting the view PR as planned
ningioma ATP extension in the routes sectible parts after bone dis-
bone of the bone section
6 CPA meningi- RS supportive STR as planned
oma
7 CPA meningi- RS supportive GTR as planned
oma
8 foramen mag- RS+IL prominent complicated tumor dissectible parts predicting the view STR as planned
num menin- location of the bone after bone dis-
gioma section
9 paraclinoid me- FT-OZ supportive STR as planned
ningioma
J Neurosurg / Volume 119 / July 2013

10 vestibular RS prominent location of a location of CN dissectible parts STR as planned

schwannoma jugular VII of the bone
bulb
11 vestibular RS supportive GTR as planned
schwannoma
12 vestibular RS supportive GTR as planned
schwannoma
13 vestibular RS supportive GTR as planned
schwannoma
14 trigeminal ATP supportive destructed parts STR as planned
schwannoma of the bone

(continued)
J Neurosurg / Volume 119 / July 2013 TABLE 1: Summary of cases, presurgical simulation, and surgical results* (continued)

Interactive presurgical simulation applying 3D techniques

Information Obtained by 3D Simulation Superior to Only 2D Evaluation
Given Evaluation
for the Overall
Case Location & Surgical Utility of 3D Spatial Information Arterial Venous Information on Bony Predicted Surgical
No. Pathology Approach Simulation on the Tumor Information Information Cranial Nerves Information Operative Window Removal Achievement
15 trigeminal ATP prominent complicated tumor destructed parts predicting the view PR as planned
schwannoma location of the bone after bone dis-
section
16 jugular foramen RS+IL prominent complicated tumor location of a destructed parts predicting the view STR as planned
schwannoma extension in the jugular of the bone after bone dis-
bone bulb section
17 prepontine ATP prominent tumor extension location of destructed parts predicting the view STR as planned
(Meckel) epi- due to the large nerves pen- of the bone after bone dis-
dermoid size etrating the section
tumor
18 prepontine (mid- 1) middle prominent tumor extension predicting the view PR as planned
dle fossa) epi- fossa+ due to the large after bone dis-
dermoid ATP size section
2) RS supportive location of GTR as planned
nerves pen-
etrating the
tumor
19 prepontine epi- RS supportive location of GTR as planned
dermoid nerves pen-
etrating the
tumor
20 parasellar (cli- prominent complicated tumor relationship destructed & dis- understanding the GTR as planned
vus) chor- ATP extension in the btwn tu- sectible parts visible part in
doma bone mor & of the bone the limited route
carotid
artery
21 prepontine ATP supportive complicated tumor PR
chordoma location moval due to
bleeding
22 cerebellar pole OT prominent understanding the GTR as planned
cavernous tion of visible part in
angioma important the limited route
veins
23 pineal region OT prominent understanding the STR as planned
embryonal tion of visible part in
carcinoma important the limited route
veins

* ATP = anterior transpetrosal; FT-OZ = frontotemporal orbitozygomatic; GTR = gross-total resection; IL = infralabyrinthine; OT = occipital transtentorial; PR = partial resection; RS = retrosigmoid;
97

STR = subtotal resection.


Fig. 1. A: The operating window of image-analysis software (Zed-
View, LEXI, Inc.) for data segmentation, fusion, and surface rendering
of individual structures. B and C: Interactive virtual simulation is per-
formed using a FreeForm Modeling system (SensAble Technologies,
Inc.) characterized by unique 3D computer-assisted designing software
Anatomy
IVS, we used a commercially available 3D color printer
selective laser sintering method and can directly print a
printer creates the model one layer at a time by spread-
ing a layer of powder, and the inkjet prints a binder in
the cross-section of the part being created and then prints
each layer, one atop another, as the model is constructed
-
scopic observation and insertion of the surgical instru-
Comparison Between the Interactive Virtual Simulation
and Operative Findings
IVS and the color-printed plaster model for performing
entire surgical procedures was evaluated in individual
patients based on consensus of all surgeons familiar with
as follows: prominent, being highly advantageous in ac-
98
complishing surgery by providing information that would
-
ing that of 2D images, occasionally with a lack of some
-
dence; and worthless, misleading or confusing surgeons
evaluation for details of more advantageous information
Overall Findings
proaches, results of presurgical simulation, and surgical
diagnoses were 9 meningiomas (at the tentorium, petro-
schwannoma (4 vestibular, 2 trigeminal, and 1 jugular fo-
ramen), 3 epidermoid tumors, 2 chordomas, 1 cavernous
a petroclival meningioma and another with an epidermoid
-
-
petrosal route in 10, retrosigmoid route in 9, infralabyrin-
thine route in 2, frontotemporal orbitozygomatic route in
-
sualization of detailed 3D relationships among important
-
ing the surgical procedures through a predicted surgical
models were produced in 12 patients and gave surgeons
further intuitive comprehension of microsurgical anato-
3D simulation superiorly to only 2D evaluation are also
in most patients evaluated as prominent associated with
information about complicated tumor extension, atypical
or destructed bony shapes, and predicted operative win-
-
lated in all but 2 tumors presenting with large amounts of
of right hemiparesis probably due to intraoperative injury
A Representative Presurgical Simulation With IVS and a
Color-Printed Plaster Model
J Neurosurg / Volume 119 / July 2013
Interactive presurgical simulation applying 3D techniques

Fig. 2. The 3D color printer (Zprinter, Z Corporation, Inc.) (A) and the color-printed plaster models based on CG data modified
through IVS (B). Realistic surgical sensations can be experienced through microscopic observation of the models (C).

surgical aspects on IVS and the plaster model provided

cerebellum, tentorium, and tumor from MRI; arteries from excellent information for accomplishing petrosectomy
- -
tion and extent were comprehended especially in relation als of tumor removal and predicted the scenario for ac-
to the brainstem, nerves, arteries, and tentorium by observ- complishing total removal by considering surrounding
ing data from various angles and making structures trans-

Special Utilities of Our Simulation Method in the Present

route after anterior petrosectomy, following presurgical
Video 1, which contains the preop-
VIDEO 1.
using a virtual drill, the extradural space in the middle fossa is
exposed by retracting the temporal lobe using a virtual retractor
- demonstrated the complicated osteotomy for the fronto-
After making the sufficient surgical space, the tumor is removed
Series
Understanding Complicated Bone Dissection. In the
present series, we used the frontotemporal orbitozygo-
-
tion and the color-printed plaster model provided infor-
mation about the most appropriate site for the key bur
hole and proper lines of bone cutting, and we successfully
temporal orbitozygomatic approach, allowing even in-
experienced neurosurgeons to comprehend the anatomy

piece-by-piece debulking procedure inside and detaching the VIDEO 2. -

removal on IVS and the actual surgery are compatible, espe- plaster model for a large petroclival meningioma correspond-

comprehensively demonstrating the appropriate bur hole posi-

tion and cutting lines for the frontotemporal orbitozygomatic
Interactive virtual simulation provided appropriate re-
hearsal of the craniotomy and brain retraction needed to more intuitive comprehension of this complicated bone dissec-

J Neurosurg / Volume 119 / July 2013 99


Fig. 3. Case 1. Representative 3D CG data and the color-printed
plaster model for a left tentorial meningioma. The MR image shows the
tumor in the CPA region invading the Meckel cave (A). On the com-
pleted 3D CG data (B), in which structures are made invisible or trans-
lucent as necessary, the relationship of the tumor with the trigeminal
nerve (CN V) (C) or the feeding position of the tentorial artery (TA) (D)
simulation (E).
Exposing Canals or Foramina in the Skull Base Re-
gion.
the precise location, extent, and projection of bone dis-
In surgery for vestibular schwannoma, the precise posi-
tion of the jugular bulb in the lateral wall of the pyra-
jugular foramen schwannomas, IVS facilitated determin-
ing the bone resection needed for the infralabyrinthine
Predicting the Surgical Perspective for Deep Tumors
via the Restricted Surgical Corridor. We also performed
IVS for 2 deep tumors operated on via the occipital
surgeons to determine the cutting line on the tentorium
and to comprehend the tumor exposure in relation to the
indispensable deep veins, which have courses that vary
100
We demonstrated our novel presurgical simulation
color-printed plaster models based on IVS results in sur-
highly satisfactory in visualizing the complicated anato-
-
ronment for imitating surgical manipulations such as dis-
secting bones, retracting brain tissues, and also removing
tumors with realistic tactile and kinesthetic sensations
We previously reported on presurgical simulation
using the 3D image-analysis method applying volume-
rendering and image fusion techniques, termed 3D mul-
tifusion volumetric imaging, for skull base tumors16,17 or
18,19,25
-
tifusion volumetric imaging improved our comprehension
of the complicated anatomical relationships among the
in individual patients, but this analysis permitted only
surveying 3D data from the outside without any interac-
with a sense of hand-eye coordination can give surgeons
With this concept, to our knowledge, the Dextroscope
have the sophisticated framework and interface necessary
9,10,24
-
tem facilitated similar functions on a personal computer
without the need for expensive or large-scale equipment,
and the software was also so convenient that no special
technical knowledge was required; rather, handling it was
15
A haptic feedback device transmitted to
the user through motorized semiconstrained articulating
arms with free movements enabled integration of what
materials, has also been noted as a new trial with the ap-
Another group previously demonstrated non–patient spe-
-
13,14
-
-
soft tissues as hard plaster, the realistic 3D feeling ob-
tained through our own eyes and hands with the insertion
of surgical instruments into the imitation surgical space
of the model under an operative microscope were abso-
Virtual reality planning generally contributes to re-
ducing the surgeon’s guesswork and enables surgical pro-
cedures to be tailored for individual anatomical consider-
J Neurosurg / Volume 119 / July 2013
Interactive presurgical simulation applying 3D techniques

Fig. 4. Case 1. Interactive virtual simulation using the 3D CG data (the top is the lower part of each photo). After the temporal
craniotomy (A), the extradural space in the middle fossa is exposed by retraction of the temporal lobe (B). Microscopic view of
the plaster model confirms the realistic bony formation of this region (C). Identifying exact positions of the labyrinth (Lab), the IAC,
the internal carotid artery (ICA), and the tentorial artery (TA) and also tumor extension through the translucent skull and tentorium
(D), the anterior petrosectomy is performed on IVS (E) and similarly in actual surgery (F). Confirming the running course of the
trigeminal nerve (CN V) behind the tumor (G), the tumor removal is simulated as a piece-by-piece debulking procedure inside
and detaching the surface from surrounding structures (H) and is similarly performed in the actual surgery (I). Final views after
tumor removal on IVS (J) and the actual surgery (K) are compatible, especially in terms of the preserved CN V. Postoperative
MR image confirming gross-total removal of the tumor (L).

11,21,23

surgical planning ultimately depends on tailoring the pro-
cedures to individual patients with respect to craniotomy
and bone resection, the surgical trajectory, and the spatial
composition of the surgical target among surrounding
22
usually obstructed by an unpredictable variety of ves-
planning mandatory for determining the best surgical
resembling the actual ones also increases the surgeon’s
effect consequently allows smooth and safe completion
16,17,24 24
found that
in nearly one-quarter of cases the surgeon reached a dif-
ferent conclusion concerning the best way to perform
surgery after virtual reality planning and that even ex-
perienced neurosurgeons tended to revise their surgical

J Neurosurg / Volume 119 / July 2013 101


Fig. 5. Case 3. Representation of the frontotemporal orbitozygo-
matic craniotomy in 3D CG data and the color-printed plaster model. In
this patient with a large petroclival meningioma (A), interactive virtual
simulation on the 3D CG data comprehensively demonstrates the ap-
propriate cutting lines for frontotemporal orbitozygomatic craniotomy
and the removed pieces (B and C) and predicts the surgical view via
the frontotemporal orbitozygomatic route (D). The model provides more
intuitive comprehension of this complicated bone dissection (E and F).
the present study, the surgeons evaluated our simulation
to manage unpredicted severe bleeding or tumor tissue
hardness to minimize damage and complications associ-
- original images and reconstructed by a surface image-
dents cannot be predicted only by anatomical evaluation
-
plishing the surgical procedures can be determined only
by comparing large surgical populations with and with-
-
method, we attempted to list the advantageous points that
surgeons felt during surgery and also to demonstrate the
representative experiences of our simulation method in
information for a thorough understanding of the lesion-
bone relationship, thereby enabling surgeons to decide
the most appropriate craniotomy and bone resection for
creating the optimal surgical window to obtain the best
to widen the surgical window for tumors occupying deep-
er and higher portions of the skull base region, but it is
usually complicated for less experienced neurosurgeons
102
of the temporal bone is also an important issue in obtain-
-
rior petrosectomy via the anterior petrosal approach, our
method provided excellent assistance in determining the
bony formation to be drilled out, usually presenting a rich
variety of possibilities, and the exact tumor location and
the majority of schwannomas, removal of intracanalicular
or intraforaminar parts of the tumors is important for pre-
to the canal or the foramen in the cranial base tends to
appropriately evaluate the accessibility of the tumors in
the canal or the foramen prior to surgery and guided us
route for vestibular schwannoma or in exposing the jugu-
lar foramen via the infralabyrinthine route with facial and
Another utility of our simulation method was in evaluat-
ing the details of deep tumors exposed only through the
narrow surgical corridor, as represented by pineal region
decision regarding tentorial incisions for exposing the tu-
-
size another utility in determining the surgical strategy in
cases requiring staged operations due to large tumors that
data in visualizing nerves and vessels absolutely depends
on the resolution of the original images and the thickness
arteries, and even veins, were segmented on appropriate
thus remained a labor-intensive task in comparison with
volume rendering analysis, but it was important for cre-
stated differently, this process would be particularly use-
ful for gaining the ability to interpret detailed anatomies
We believe that our 3D simulation method applying
IVS and color-printed plaster models also has the possi-
bility of playing a new and great role in educating medi-
simulation is anticipated to be truly effective for bridging
the substantial gap between textbooks and actual opera-
-
improvement of the microsurgical senses and skills of
J Neurosurg / Volume 119 / July 2013
Interactive presurgical simulation applying 3D techniques

Fig. 6. A–E: Case 10. The retrosigmoid approach for a right vestibular schwannoma. On MRI (A), the facial nerve (CN VII,
arrow) can be followed, but its course is uncertain. Referring to the simulated view via the retrosigmoid route on the 3D CG data
(B), the reconstructed CN VII seems to be anatomically correct. Referring to the simulated view via the retrosigmoid route on the
3D CG data (B), the trigeminal nerve (CN V) and CN VII behind the tumor can be estimated on the surgical view (C). Through
the translucent skull, the tumor in the IAC and the upper margin of the jugular bulb (JB) are confirmed (D), and the drilling of the
posterior wall for opening the IAC is performed as simulated (E). F–K: Case 16. Infralabyrinthine bone resection for left jugular
foramen (JF) neuroma. Sagittal MR image (F) showing intra- and extracranial extension of the tumor (asterisk), and 3D CG data
(G) visualize the tumor as being located across from the jugular foramen. Interactive virtual simulation allows a retrosigmoid cra-
niotomy to be performed with infralabyrinthine bone resection to approach the tumor in the jugular foramen on 3D CG data (H),
and the intraosseous labyrinth (Lab) and facial nerve (CN VII) are confirmed through the translucent skull (I). The color-printed
plaster model provides realistic 3D information on the surgical space after bone resection (J). Finally, the intraforaminal part of
the tumor is exposed via the same surgical window as that simulated (K). PV = petrosal vein.

addition, while observing the display showing the surgi- edge of surgical anatomy remains important, anatomical
cal views under the microscope in the operating room, variations among individuals can be ascertained only by
referring to the plaster model helped observers to com- -
prehend more intuitively the surgical anatomies on the tive virtual reality environment to display the real-time
data on a large screen by the projection system while the
- surgeon or trainee is actually performing a simulation has

J Neurosurg / Volume 119 / July 2013 103

 Fig. 7. Case 23. Predicting the surgical perspective via the occipital transtentorial route for a pineal region tumor. On IVS using
3D CG data, after retracting the right occipital lobe, the cutting line on the tentorium is decided to adequately expose the tumor
while avoiding injury to the straight sinus (A and B). The color-printed plaster model intuitively shows the microsurgical anato-
mies via the occipital transtentorial route (C). Actual cutting of the tentorium is performed according to IVS (D). After confirming
the running courses of the basal vein (BV) and internal cerebral vein (ICV) (E), the tumor and all those veins are exposed in a
predicted form (F).
10

to be an additional effective way to discuss or to learn

neurosurgical approaches and strategies with a larger au- -

yield further useful functions via integration with other

educational systems and thereby is expected to become
-
-
yuki Noto, Department of Radiology, Niigata University Hospital,

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printed plaster models based on IVS results, provided a J
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J Neurosurg / Volume 119 / July 2013 105