Neuronavigation: concept, techniques and applications

Neuronavigation provides intraoperative orientation to the surgeon, helps in planning a precise surgical approach to the targetted lesion and defines the surrounding neurovascular structures. Incorporation of the functional data provided by functional MRI and magnetoencephalography (MEG) with neuronavigation helps to avoid the eloquent areas of the brain during surgery. An intraoperative MRI enables radical resection of the lesions, the possibility of immediate control for tumor remnants and updates of neuronavigation with intraoperative images to compensate for brain shift. In this study, the experience of 432 patients undergoing neuronavigation assisted neurosurgical interventions using either the pointer-based or microscope-based navigational systems at the University of Erlangen-Nuremberg, Germany is presented. The procedures included stereotactic biopsy (n=53), stereotactic cyst puncture/ventricular drainage (n=15), eloquent cortex/tumor localization to facilitate tumor resection, assessment of neurovascular structures in the vicinity of tumors of the sellar-suprasellar regions, skull base, posterior fossa and ventricular region (n=252), and, surgery for epilepsy (n=9). Functional brain mapping using fMRI and MEG and their integration with neuronavigation was carried out in 24 and 128 patients respectively. The simultaneous use of intraoperative MRI to look for the remaining tumor was done in 159 patients and the update of navigational data was carried out in 17 patients. The mean system accuracy obtained by using both the fiducial registration as well as anatomical landmark-surface fitting computer algorithm was 1.81 mm. This study reviews the relative merits and demerits of the pointer and microscope based navigational systems and also highlights the role of functional brain mapping and intraoperative MRI, when integrated with neuronavigation, in the surgical decision-making to offer the chances of more radical resections with minimal morbidity.