Clinical Application
OPE
Using the OPESCOPE PLENO
Surgical Mobile C-Arm Imaging System
Kazuyuki Fukusada
Department of Radiology, Ishizaka Neurosurgical Clinic
1. Introduction
Our clinic located in Sasebo City (Fig. 1) near Huis Ten
Bosch, provides emergency medical care and inpatient
care services (neurosurgery, neurology and physical
therapy departments). Established in 1989, the hospital
now performs over 120 surgeries per year, including
spinal regions.
With the establishment in 2002 of “Kirara”, a daytime
care facility next door to the hospital that was eagerly
anticipated even by all the staff, we are committed to all
types of care, from acute to chronic care and physical
therapy. Though we are relatively small in scale, we offer
a high level of medical services and have taken on a wide
variety of programs. We are working hard to improve the
level of medicine in our region and sincerely desire the
recovery of each one of our patients.
Fig. 1
2. Purchase Decision Background
In consideration of economy and space requirements,
the hospital has been using an OPESCOPE 50N system
from some time ago, taking full advantage of its mobility
by using it not only for angiography, but also for
myelography and surgical fluoroscopy. Though separated
by an elevator, the laboratory and operating room are in
fairly close proximity, so fluoroscopic needs for both
surgery and examination were satisfied with one unit.
However, as the X-ray tube began to age, the hospital
was faced with having to replace the instrument.
Anticipating improvements in image quality
Mr. Kazuyuki Fukusada
operability, and further reductions in radiation dose, the
hospital decided to purchase an OPESCOPE PLENO
surgical mobile C-arm imaging system. We have only
been using it for several months, but would like to provide
this report of our experience using the instrument for
neurosurgical applications, how we are utilizing it, and our
impressions.
3. Instrument Features and Characteristics
The OPESCOPE PLENO system was developed to
achieve two opposing concepts, high definition and
reduced exposure dose. The 100 kHU X-ray tube (0.6
mm focus size) has the industry’s largest stationary
anode, which allows a maximum frame rate of 15 fps for
pulsed fluoroscopy (DSA includes a program sequence
feature with a maximum 7.5 fps). Picture quality is
dramatically better with the 1024 x 1024, 12-bit CCD
camera and the image tube has a variable 9 or 6-inch
field of view. In addition to the normal radiation mode, the
fluoroscopy feature allows switching to a high radiation
high quality mode or a low dose mode with a single press
of a button, allowing the operator to quickly accommodate
different diagnostic situations.
In addition, the system is very stylish, with a clean
compact design that is not intimidating to patients. It is
equipped with two adjustable-height/tilt 18-inch LCD
monitors (live monitor and reference monitor) that can be
adjusted to the optimal height desired by the operator,
depending on situation or type of examination. The
reference monitor is an optional touch-panel type screen,
where images referred to from the live monitor are
automatically recorded on the reference monitor (memory
for up to 14 images) and can be recalled at any time with
one touch of a button. The touch panel configuration is
useful for instantly performing basic operations and is
very popular with our doctors.
The live monitor image can be shown on the panel on
the C-arm and even detailed operations that are
performed on the reference monitor, such as processing
or sending images or changing fluoroscopic parameters,
can be performed via the C-arm. This has made our
imaging work flow dramatically smoother (Fig. 2).
and In addition, the OPESCOPE PLENO system includes a
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virtual movement feature that allows reducing the particular, since even the borders of the vertebral bodies
exposure dose. This feature takes the normal LIH (Last now can be seen clearly, our ability to visually confirm
Image Hold) image after fluoroscopic imaging and procedures, such as inserting cages or screws, becomes
virtually rotates the image, inserts the octagonal much higher (Fig. 4).
collimator, and opens/closes the parallel collimator, so the
next time a fluoroscopic image is taken, that same
rotational position can be reproduced and the dose
associated with fluoroscopic images taken only for
positioning purposes can be minimized. (The next image
can be taken after the image rotation process catches up
with the virtual image.) Of course, this feature is also
available via the C-arm cart, too.

Fig. 3

Fig. 2

4. Examples of Clinical Applications

4.1 Fluoroscopic Imaging During Surgery (Fig. 3)

At this hospital surgical imaging is used for procedures

such as anterior fusion and/or expansive laminoplasty for
cervical spondylosis, posterior fusion (interbody) for
herniated lumbar disks or scoliosis, and checking the tip
of shunt tubes during VA (ventriculo-atrial) shunt surgery.
Fluoroscopic imaging of the spinal column mainly
involves lateral images, such as verifying the spine level,
which requires quickly moving the C-arm cart in a parallel
motion. This instrument is equipped with large diameter
double wheels (with cable guards) and moves much more
easily than the previous model. The cart portion itself is
smaller, but the stability during movement has increased.
This allows obtaining parallel motion images with very
little C-arm-shake. Two brakes are provided (one on
either side), where both brakes are applied more often
than expected. The C-arm movement (completely
manual) is smooth and moves easily enough that it can
be manipulated with few unintended movements, so this
results in quick positioning.
The picture quality is clearly improved and so far
leaves nothing to be desired for surgical applications. In
Fig. 4
4.2 Myelography
Cervical myelography involves inserting a needle
between the inferior margin of the occipital bone and the
spinous process of the atlas and directing it toward the
dura mater spinalis. By providing sufficient clarity and
contrast with respect to the tissue, this OPESCOPE
system increases the ability to visually confirm the
position of the needle tip and allows the procedure to be
performed without stress. Figure 5 shows a “spot shot”
image taken immediately after the contrast medium was
injected. It maintains sufficient contrast for the spinal
cavity and even the extent of spinal compression can be
clearly confirmed. We perform myeolography not only for
identifying the location of problems, but believe it should
always be performed to evaluate mobility and stability
 Clinical Application

through functional imaging and to provide important 4.3 Angiographic Examinations of the Head and Neck
information for during and after surgery (Fig. 6).
Our hospital uses the Seldinger technique for
angiography, which is shown being performed in Figure 7.
The surgeon does not need to stand next to the monitor,
so the procedure can be performed by the surgeon and
two paramedical staff, where the surgeon makes fine
positioning adjustments by moving the examination table,
separately from operating the C-arm.

Fig. 5

Fig. 7

(a) Road Map Feature

MRA is used to produce aortograms before angiographic
procedures, but the catheter is often difficult to insert due
to the curvature of vessels or arteriosclerosis. Figure 8
shows an example of using the road map feature for the
beginning of the left vertebral artery, which meanders a
great deal. With the road map, the catheter could be
guided into the vertebral artery and allowed us to
successfully complete the vertebral angiography. There
were no problems with the density resolution of the map
feature either.

Fig. 6 Fig. 8
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(b) Imaging Bifurcations of the Carotid Arteries (c) Cerebral Angiography
For the neck area, first an image is taken from the front Normally for images of the head, a 5 fps (2 seconds) →
(and depending on the situation from both oblique 4 fps (2 seconds) → 3 fps (10 seconds) → 2 fps (5
positions also). Afterward, a side view image is taken and seconds) → 1 fps (5 seconds) program sequence is
transferred directly to the reference screen. The catheter employed. Figure 10 shows a common carotid artery
is then inserted into the internal carotid artery while image of a subarachnoid hemorrhage case, where it was
viewing the live and reference images. Then the imaging discovered that the IC-PC (internal carotid artery-
process continues on to take side views of the head. The posterior communicating artery) had formed a broad neck
imaging sequence is programmed in a 4 fps (1 second) aneurysm.
→ 5 fps (3 seconds) → 4 fps configuration in an effort to
slightly reduce radiation dosage.
Figure 9 shows a case of 95 percent stenosis of the
internal carotid artery. Ulceration is not visible however
another image using 50 percent digital subtraction
was added in consideration of using CEA (carotid
endarterectomy). Since inserting a catheter into the
internal carotid artery posed a large risk, the amount of
contrast medium was increased somewhat and an image
of the common carotid artery was taken.

Fig. 10

For imaging tumors and arteriovenous malformations,

the frame rate is increased for capillary to venous phase
and somewhat decreased for the arterial phases.
Figure 11 shows an angiogram of a brain tumor occurring
in the left thalamus. A tumor stain is apparent in the
capillary phase.
Since the system was to be used in surgery, we were
worried about its thermal capacity and ability to produce
serial images, but using the sequencing feature
mentioned above and allowing a cooling period of about
10 seconds between images (in actuality, it takes about
that long for repositioning) it is easily capable of producing
a series of consecutive images covering arterial to vein
phases, four times in a row. We mainly use 8 ml contrast
medium at 6 ml/sec flowrate but increase or decrease this
amount depending on the target location, the patient’s
physical characteristics, or the degree of arteriosclerosis,
so the overall use of contrast medium has decreased.
Regarding our evaluation of the picture quality of
angiographic images, overall it is significantly improved.
Since the system uses LCD monitors, at first we were
somewhat concerned with fundamental picture quality
variations characteristic of liquid crystal displays, but
once we got used to it, such as by viewing the monitors
Fig. 9
 Clinical Application

from a little farther away, we no longer have any such

reservations. In particular, the improvements to density
resolution are remarkable. High contrast images of
common carotid arteries that were not available before,
can now be obtained with low quantities of contrast
medium, which decreases the invasiveness and cost of
procedures. Furthermore, with respect to image
processing, it allows converting images to any format no
matter what method was used to acquire them. For
example, images obtained using DA can be post-
processed and converted to RSM-DSA images or
RSM-DSA images can be converted to regular DSA
images. This allows obtaining images with even less
motion artifacts.

5. Conclusion

The OPESCOPE PLENO more than satisfies our

requirements for “improved picture quality and operability”.
It is a high performance instrument that can handle a
wide variety of procedures, even when subtle imaging
performance is required. At this point we have had no
significant problems and are very impressed with how it
addresses so many detailed user needs. Since we have
only been using the system for a short time, we have not
fully appreciated the full potential of the PLENO system,
but we are working with the manufacturer to understand
all the capabilities of the system and produce the best
images possible. Furthermore, we are currently evaluating
the visibility of microcatheters for intravascular treatment,
and expect that increasing the range of applications will
be a significant topic in the future.

Fig. 11