Initial experience of real-time intraoperative C-arm computed-tomography-guided navigation surgery for pituitary tumors

Objective: We report our initial experience of real-time intraoperative C-arm computed tomography (C-arm CT: DynaCT)-guided navigation surgery for pituitary tumors.

Methods: Recent advancement in flat panel technology makes it possible to obtain CT-like images by using rotation of the C-arm of a digital subtraction angiography (DSA) system. A specially designed new suite, which has C-arm CT-imaging-capable DSA in combination with a navigation system (VectorVision Sky, BrainLAB AG, Munich, Germany), allows neurosurgeons to perform endoscopic transsphenoidal procedures under real-time navigation support. Thirty-one pituitary tumor patients were examined. During or after tumor removal, contrast-enhanced DynaCT was conducted to rule out residual tumor in 12 cases. When enhanced tumor was confirmed, additional removal was continued without moving the patients.

Results: DynaCT and subsequent image transfer to navigation system was performed in all cases without difficulties, requiring only an additional 15 minutes of surgical time. Sellar fenestration in relation to tumors and absence of hidden hematomas was confirmed in all cases. The contrast-enhanced DynaCT was found to be contributing to a better handling of the residual tumor. In 9 of these 12 cases (75%), residual tumor was detected on DynaCT; consequently, further removal was considered. In 2 cases (16%) there was no enhanced lesion, indicating complete removal.

Conclusions: The proposed technique of intraoperative visualization in the hybrid operating room can be easy to perform and may be a useful adjunct to conventional transsphenoidal surgery for an improved resection rate and less cavernous sinus and internal carotid artery injury.