|Year : 2019 | Volume
| Issue : 3 | Page : 174-181
Computer-assisted brain surgery (neuronavigation) in Abuja, North Central Nigeria: A 3-year retrospective review and practical challenges
Ugwuanyi Charles1, Anigbo Anthony1, Nwaribe Evaristus1, Salawu Morayo2, Jibrin Paul3, Arua Chinedu4
1 Department of Surgery, Neurosurgery Unit, Wellington Neurosurgery Center, Abuja and National Hospital, Abuja, Nigeria
2 Department of Anasthesia, Neuroanasthesia Unit, National Hospital, Abuja, Nigeria
3 Department of Pathology, Neuropathology Unit, National Hospital, Abuja, Nigeria
4 Department of Radiation Medicine, Neuro-Oncology and Radiation Medicine Unit, National Hospital, Abuja, Nigeria
|Date of Web Publication||13-Aug-2019|
Dr. Ugwuanyi Charles
Wellington Neurosurgery Center, Neurosurgery Unit, National Hospital, Abuja
Source of Support: None, Conflict of Interest: None
Introduction: Neuronavigation has become a standard of care in contemporary neurosurgery since more than two decades and is gradually being embraced in our local practice. It is, therefore, important to share our local experience, including practical challenges encountered with this technology. Aims and Objectives: The aim of this study is to review and present our early experience with stealth neuronavigation and to discuss the practical challenges encountered with the application of this technology in this environment. Methodology: Retrospective review of all consecutive cases over a 3-year period (January 2016–December 2018). Admitting diagnosis, operations, histological diagnosis, adjuvant treatments and 6 months outcome were the major study parameters. Procedural challenges were also highlighted. Data were analysed using simple descriptive statistics, and results were presented in tables and figures. Results: A total of 30 procedures were conducted. Nineteen males and 11 females (male: female = 1.7:1). Youngest was 8 months, oldest was 71 years, mean = 39 and standard deviation (SD) = 19.3. Operations performed were resection of mass lesion 18/30 (60%) and biopsy of mass lesion in 12/30 (40%) cases. Histological diagnostic yield was 100%. Mean duration of hospital stay was 2 days (SD = 0.25) for the biopsy group and 8 days (SD = 1.7) for the resection group. At 6 months review, 10/30 (33.3%) have died following progression and/or complications of their primary pathology. Conclusions: Wide spectrum of brain lesions were approached confidently with precision and minimal morbidity. No procedure-related mortality was recorded. Adjuvant treatments were easily deployed in line with a precise histological diagnosis. Practical challenges did not compromise the navigation process.
Keywords: Brain surgery, neuronavigation, practical challenges with neuronavigation, stealth-guided brain surgery
|How to cite this article:|
Charles U, Anthony A, Evaristus N, Morayo S, Paul J, Chinedu A. Computer-assisted brain surgery (neuronavigation) in Abuja, North Central Nigeria: A 3-year retrospective review and practical challenges. Niger Postgrad Med J 2019;26:174-81
|How to cite this URL:|
Charles U, Anthony A, Evaristus N, Morayo S, Paul J, Chinedu A. Computer-assisted brain surgery (neuronavigation) in Abuja, North Central Nigeria: A 3-year retrospective review and practical challenges. Niger Postgrad Med J [serial online] 2019 [cited 2020 Aug 15];26:174-81. Available from: http://www.npmj.org/text.asp?2019/26/3/174/264390
| Introduction|| |
A sound knowledge of neuroanatomy remains a prerequisite for safe surgical corridor into the brain. In certain situations, it becomes difficult and unsafe to rely on raw knowledge of neuroanatomy. Neuronavigation is not new, and the various applications in brain surgery have been widely reported for almost two decades. According to a study in 2000, researchers already anticipated that a significant portion of neurosurgery would be performed using computer-based interventions. Stealth navigation system creates a translational map between all points on the preoperatively acquired patient images (imaging coordinates) and the corresponding points on the actual patient anatomy (anatomical coordinates). Following the accurate establishment of this map by a mandatory process of co-registration of both imaging and anatomical coordinates, a special tracked instrument or pointing device is used intraoperatively to identify corresponding points on these images. The system determines the position of tracking instruments and patient anatomy by the use of infrared cameras to track the positions of optical markers affixed to both. For the tracking instruments, the optical markers are affixed directly on them, but for the actual anatomy such as patient's head, the optical markers are attached to a dynamic reference frame connected to the actual anatomy through an articulating system. There are two types of optical system, namely the light-emitting diodes which generate and emit infrared light and the sterile spheres which reflect the emitted infrared lights. The logistics involved in the neuronavigation process is expensive. It includes the navigation machine (e.g. StealthStation, BrainLab), neuro imaging equipment (magnetic resonance imaging [MRI], computed tomography [CT] and positron emission tomography [PET]). It also includes the consumables such as the fiducial button markers which are required to establish the imaging coordinates, head fixation clamps such as the Mayfield and articulating systems, and the Navigation set of instruments containing all the tracking devices. The study centre was able to assemble the minimum requirements to perform these procedures, namely the Stealth Treon Plus treatment system, GE Revolution ACT machine and recently, Hitachi Elite MRI, state-of-the-art neurosurgery theatre and neurocritical care back-up. Basic procedure of neuronavigation involves as follows: 1 – Establishment of physical coordinates which can be conventionally frame-based (Leksell stereotactic frame) or frameless with fiducial markers or surface landmarks. 2 – Establishment of imaging coordinates with any or combination of the following imaging modalities – MRI, CT, PET, single-photon emission CT, X-ray, functional MRI etc., 3 – Co-registration. 4 – Surgical planning. 5 – Navigation. Co-registration provides a means of synchronising both physical (anatomical) and imaging coordinates and forms the backbone of stereotactic surgery and neuronavigation. It helps to preoperatively plan targets, entry points and navigation trajectory for safe access to brain lesions within acceptable error margins. As a matter of fact, an inbuilt safety measure will not allow any navigation if the error margin is >5 mm. From onset, the brain tumour management protocol at the study centre incorporated neuronavigation for quality assurance purposes. Moreover in view of the complexity of the mandatory requirements as outlined above, brain tumour surgery in this centre has evolved slowly and fraught with a lot of difficulties and challenges, all in determination to respect the equally complexity of the human cerebrum and the delicate nature of brain operations. These include equipment issues, lack of basic consumables such as fiducial markers, etc., Although there are no comparative data, we consider it still necessary to share our local experience and also the challenges encountered thus far in adhering to set protocols and guidelines in this study centre with regard to the use of image-guided brain surgery.
The aim of this study, therefore, was to review our initial experience with image-guided brain surgeries and to outline the commonly encountered practical challenges and the strategies deployed to overcome some of them.
| Methodology|| |
Ethical clearance was obtained from the ethical committee of the Study Centre in December 2018 (Protocol No-WCA/016/2018) to retrospectively review case notes of all patients who consecutively had image-guided brain surgeries from January 2016 to December 2018. From onset, the brain tumour management protocol of the study centre incorporated image guidance for all surgeries related to brain tumours. This is for quality assurance purposes. Therefore, all consecutive cases involved in this study underwent the complement process of neuronavigation: 1 – Establishment of physical coordinates, which was frameless with fiducial markers (real or improvised). The real Fiducial buttons from Medtronic was in acute short supply at some point and that was the drive to source for a local alternative which we found in the improvised one (pencil eraser), but it only showed up on CT scan and not on MRI. 2 – Establishment of pre-operative imaging coordinates using either MRI or CT scan. MRI was normally preferred except logistics favour CT scan. However, both are acceptable so long as the Fiducials and the target lesion showed up clearly on relevant images. 3 – Co-registration of both physical (anatomical) and imaging coordinates after the induction of anaesthesia and fixing patients head on a rigid frame (Mayfield Pins) in the operating room. 4 – Planning of targets, entry points, navigation trajectory within acceptable error margins which is 5 mm in the local protocol. 5 – Navigation process. It was, therefore, impossible to provide a comparative data from this centre on patients who did not undergo neuronavigation-assisted brain surgery because everyone adhered to the established institutional guideline which is anchored on safety and quality assurance. This is indeed a limitation for any scientific work, but doing otherwise arguably is an ethical issue which is beyond the scope of this study. The study parameters were demography, neuroimaging findings (pre- and post-operative) diagnosis, histological yield, adjuvant treatments and outcome at 6 months. The relevant information was extracted from the case notes and institutional surgical process checklist and subsequently inputted on Microsoft excel sheet. Data were analysed using simple descriptive statistics, and results were presented in tables and figures. All practical challenges and experiences which were encountered during the navigation process were adequately documented and discussed.
| Results|| |
A total of 30 cases, 19 males and 11 females (male: female = 1.7:1). Youngest was 8 months; oldest was 71 years, mean = 39 and standard deviation (SD) = 19.3. Operations performed were resection of mass lesion in 18/30 (60%) cases and biopsy of mass lesion in 12/30 (40%) cases. The histopathological details for the diagnostic biopsy group as shown in [Table 1] indicates that toxoplasmosis was the most common 4/12 (33.3%) followed by metastatic brain tumour 3/12 (25%). The lone case of the WHO Grade II astrocytoma had obstructive hydrocephalus from thalamic involvement and subsequently died of complications of tumour progression. For the tumour resection group, only 10/18 (55.5%) were completely resected, whereas 8/18 (44.4%) was incomplete resection. The histological diagnosis of the tumour resection group as shown in [Table 2] indicates that meningioma was the most common 8/18 (44.4%) followed by ependymoma 4/18 (22.2%), then vestibular schwannoma 2/18 (11.1%) and choroid plexus papilloma, pilocytic astrocytoma, medulloblastoma and glioblastoma multiforme (GBM) in 1/18 (5.5%) each. The cases of choroid plexus papilloma and pilocytic astrocytoma (one each) have been on clinical and radiological follow-up with no evidence of recurrence. The case of medulloblastoma failed oncology follow-up after initial gross total resection and suffered a recurrence. The histological diagnostic yield was 100% in all cases. The mean duration of hospital stay was 2 days (SD = 0.25) for the biopsy group and 8 days (SD 1.7) for the resection group. All had subsequent adjuvant treatments appropriate to the histologically confirmed disease condition. At 6 months review, 10/30 (33.3%) have died following progression and or complications of their primary pathology [Table 3]. There was no mortality related to the surgical procedure.
| Discussion|| |
Surgical approach to a variety of brain lesions and their locations as listed in [Table 1] requires high precision to reduce morbidity and mortality, especially when eloquent parts of the brain were involved. Stereotactic surgery is employed when precise localisation of a target is essential, and with current wave in minimally invasive surgery, modern surgeons are leaning towards it, especially in neurosurgery.
Dwarakanath et al. in their 121 series reported that neuronavigation helped in estimating the extent of resection, especially in some skull base tumours, falcine and intraventricular meningiomas. It was also found to be invaluable in biopsies and the placement of the shunts. For volumetric tumour resection, stereotactic approach minimises the size of the skin incision and craniotomy. The direct guidance to deeper subcortical masses reduces the disruption of the neighbouring white matter tracts.
Skull base tumours including four sphenoid wing meningiomas, three cerebellopontine angle tumours and one olfactory groove meningioma constitute the most common extrinsic tumours encountered in this series. Although complete resection was not possible in some cases either due to close romance with vital neurovascular structures or torrential intraoperative primary haemorrhage, neuronavigation played a vital role in defining borders for overall safety. This has been corroborated by Schul et al. who confirmed in their study that neuronavigation was extremely helpful in providing access to the skull base tumours, delineating the margins, identifying the vascular and osseous relations and estimating the extent of resection. Further treatments were radiosurgery referral for residual meningiomas 4/8 (50%) and vestibular schwannomas 2/8 (25%) due to incomplete resection.
Ependymomas featured quite prominently in volumetric resection of intrinsic brain tumours contributing 4/18 (22.2%) in this group and second only to the meningiomas 8/18 (44.4%). Neuronavigation aimed at gross total resection of these lesions, although that was not always achievable due to the phenomenon of brain shift and location close to eloquence. The concept of brain shift is an intrinsic limitation of stealth neuronavigation because of sole reliance on preoperatively acquired imaging co-ordinates. There is no chance of intraoperative real-time image updating. The main argument against neuronavigation has been the brain shift phenomenon; however, the inaccuracies are not limited to the brain shift alone; there exist also errors of registration, but of all the intra-operative inaccuracies the most troublesome was that due to brain shift.
[Table 2] displays the diagnostic biopsy procedures conducted under image guidance. It shows that toxoplasmosis was the most common histology but closely followed by metastatic brain tumours. The overall diagnostic yield histologically was 100%. It was, therefore, easy to deploy appropriate treatments to all patients subsequently. In a related study the diagnostic yield was 94.6% and when such a non-diagnostic biopsy was encountered, follow-up surgery (either stereotactic or open biopsy or tumour decompression) was recommended. In this series, image-guided diagnostic biopsy was particularly useful in HIV/acquired immunodeficiency syndrome (AIDS) patients with various degrees of immunocompromise. It is proven that 40%–60% of all patients with AIDS will develop neurologic symptoms with one-third of these presenting initially with neurologic complaints. In view of the wide spectrum of possible central nervous system (CNS) manifestations such as toxoplasmosis, primary CNS lymphoma, astrocytoma, progressive multifocal leucoencephalopathy, tuberculoma, cryptococcal abscess, etc., and the frequent location of these lesion on deep and eloquent cerebral tissues, a precise diagnostic biopsy is invaluable in charting a pragmatic treatment plan. It is particularly useful in toxo titre negative patients. This is because the risk of open biopsy in AIDS patients may be higher than in non-immunocompromised patients and stereotactic biopsy may be especially well suited with up to 96% efficacy and low morbidity (8%) and mortality. Indeed, it was of utmost value that a precise diagnosis was established on these HIV/AIDS patient and accurate treatments administered.
Metastatic brain tumour constituted 3/30 (10%) in this series. The global prevalence of brain metastases in patients with cancer is probably around 8.5%–9.6% and the most common primary tumours responsible for brain metastases are lung cancer (19.9%), melanoma (6.9%), renal cancer (6.5%), breast cancer (5.1%) and colorectal cancer (1.8%). This prevalence will likely increase because of increasing length of survival of cancer patient, enhanced ability to diagnose CNS tumours due to availability of neuroimaging (CT/MRI), relative inability of chemotherapeutic agents to cross the blood-brain barrier well, thus providing a safe haven for tumour cells in the brain. Brain metastasis are often well circumscribed and situated on the grey-white matter junction with a lot of surrounding white matter oedema. MRI is more sensitive than CT scan because it detects multiple metastases in in up to 20% of patients who appear to have a solitary lesion on CT scan. Brain metastasis is an indicator of poor prognosis and nearly always determines a fatal outcome in patients with solid cancers. Confirmation of brain metastasis is therefore critical to further treatments decision analysis and in this circumstance a minimally invasive approach is much desirable. The first evidence-based compendium for the treatment of patients with brain metastases published a level 1 recommendation for surgical resection combined with radiation therapy to prolong life in relatively young patients with good functional status and a newly diagnosed solitary brain metastasis. All three of the metastatic brain tumours in this study were adenocarcinomas from lungs (2/3) and prostate (1/3). They were all multiple, and therefore, only the most accessible lesions were biopsied. Following histological diagnosis, they were all referred for whole brain radiation therapy and other treatments to be determined by the oncologist. There was no justification for any further operations to chase the multiple metastatic lesions.
There were a total seven cases of astrocytic related brain tumours in this study. Five had diagnostic biopsy procedures (two GBM, two anaplastic astrocytoma [AA] and one low-grade glioma). Two had tumour resection (one pilocytic astrocytoma, one GBM). The diagnostic accuracy of the biopsy group made it a lot easier to apply accurate treatments. Similarly, the precision and accuracy in the surgical resection group made the procedure worthwhile with very minimal morbidity in this group. For the GBM patients, treatment decision analysis favoured surgery in only one case. That was the case that previously had tumour debulking, adjuvant radiotherapy and temozolomide 2 years earlier and survived with good performance status and stable neuroimaging findings. He however recently suffered seizure and a repeat brain MRI confirmed an increase in tumour size. He maintained a good Karnofsky performance status which favoured further surgical decision. The use of Stealth-guided resection minimised his post-operative morbidity and he was discharged to continue temozolomide on outpatient basis. Oncology advice did not favour any further exposure of his brain to radiotherapy. The rest two cases of GBM did not have any further operations after the initial diagnostic biopsy because of very low Karnofsky score of 40 and 30, respectively. The stealth-guided biopsy did not add to their morbidity while the accurate diagnostic yield provided a very reliable evidence to avoid further surgical exposure which is potentially not beneficial and will probably facilitate their demise. Palliative care and general nursing support were pragmatic in the management of the imminent end of life especially in a resource poor setting. Although they both declined to consent, surgery to be followed by adjuvant Stupp et al., regimen was equally offered to the two cases of histologically confirmed AA. The decision to make this offer was because cytoreductive surgery followed by external beam radiation has become the standard treatment for newly diagnosed high-grade gliomas against which other treatments are compared. The patient's decision to decline duly informed consent is much understandable because such bad news is expectedly a tough and devastating one. Therefore, there must be an unequivocal histological evidence before any such treatment is offered any patient and enough information must be provided to guarantee informed decisions. There is substantial evidence that some CNS mass lesions, including lymphomas could mimic astrocytoma radiologically and stereotactic biopsy targeted at enhancing rim is performed to resolve any diagnostic dilemma. This is to avoid operating on a lymphoma which is ordinarily responsive to radiotherapy and intrathecal chemotherapy. The lone case of the WHO Grade II astrocytoma had obstructive hydrocephalus from thalamic position and subsequently died of complications of tumour progression. It was safe enough to establish a histologic diagnosis but the location of the tumour on the thalamus was very unattractive to any consideration of resective surgery. Perhaps, the only role for surgery here was to address the emerging obstructive hydrocephalus due to pressure on the third ventricle. Further treatments available locally including non-focused brain radiotherapy and chemotherapy were not attractive to the patient who subsequently succumbed to tumour progression. For low-grade gliomas, there is an evidence that early radiotherapy prolonged progression-free survival (PFS) and disease specific survival. However, the attendant risks and side effects of such exposure, including delayed cognitive decline consequent on radiation-induced leucoencephalopathy was explained to the basic understanding of the patients and their relations and this may have informed their decision-making process. The lone cases of pilocytic astrocytoma did not have any adjuvant treatments and has been on clinical and radiological follow-up with no evidence of recurrence after 2 years. The role of stealth-guided surgery here was to target for extirpation the mural nodule which is believed to be active in the pathogenesis of the cystic component of pilocytic astrocytoma. It is known that 50% of pilocytic astrocytoma have a mural nodule. The practice guideline for adjuvant treatments in pilocytic astrocytoma was provided by Austin and Alvord Because of the high 5- and 10-year survival rates and the high complication rate of radiation therapy in face of slow growth rate of truly pilocytic astrocytoma, adjuvant radiotherapy is not recommended for pilocytic astrocytoma, rather clinical and radiological surveillance is the practice.
The lone case of medulloblastoma was in a 12-year-old child. Although he successfully underwent an initial stealth-guided gross total resection, he failed adjuvant oncology follow-up and parents did not adhere to any follow-up instructions under the impression of divine healing after the initial post-operative scan confirmed complete absence of tumour. He suffered a recurrence within 9 months. A redo resection was performed, but he succumbed to post-operative complications. Medulloblastoma is the most common malignant brain tumour in children and they are considered the WHO Grade IV on histological diagnosis. In terms of risk of recurrence stratification for this index patient, it was clear that he belonged to the standard risk group with expected 50% PFS at 5 years and more than 5-year survival of >5%. It is most likely that the non-adherence to the standard adjuvant treatment for medulloblastoma played some role in the recurrence but it is also an established fact that recurrence have also been recorded after a full complement treatment. The biological behaviour of this tumour which is reputed as Grade IV ab initio is probably more important.
The lone case of choroid plexus papilloma was completely resected from the left lateral ventricle under stealth guidance [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. This guaranteed safe dissection of the tumour off vital surrounding structures and minimised bleeding from often associated choroidal vessels. No adjuvant was given on histological confirmation and no recurrence has occurred after 2 years of this operation. There is evidence that choroid plexus papilloma is potentially curable with complete surgical excision and that even when histology suggests malignancy, complete surgical excision could provide a 5-year survival rate of 84%.
|Figure 3: Co-registration of stealth magnetic resonance imaging and actual anatomy for surgical planning and navigation|
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|Figure 4: One-week post-operative computed tomography brain coronal and axial views|
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|Figure 5: On discharge one-week post-operative and histology report – choroid plexus papilloma|
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The mean duration of hospital stay was 2 days (SD = 0.25) for the biopsy group and 8 days (SD = 1.7) for the resection group. The short hospital stay is testimony that minimal interference with normal parts of the brain and direct access to the lesion of interest will reduce unnecessary morbidity. Post-operative recovery is quick and hospital stay is reduced.
At 6 months review, 10/30 (33.3%) have died following progression and or complications of their primary pathology [Table 3]. There was no mortality related to the surgical procedure. This is because of adequate pre-operative planning and accuracy in surgical navigation. However of course, some pathology such as high-grade brain tumours will continue to progress irrespective of adjuvant treatments and will cause demise of the patient at some point. There is evidence that median overall survival for MGMT methylation positive astrocytoma patients treated with temozolomide and radiotherapy was 21.7 months, but radiotherapy only was 15.3 months.
Aside the perennial power supply interruptions and human resource limitations, the two main challenges for more detailed discussion include fiducial markers and neuroimaging facilities.
A fiducial marker is an object placed in the field of view of an imaging system which appears on the image produced and to be used as a reference point. One key feature of a good fiducial marker is visibility and discrimination from surrounding tissues. It has wide application also in intervention radiology especially radiosurgery for tumours. In neuronavigation it is mainly used to localize a surgical lesion.
The ideal fiducial marker for MRI neuroimaging is a sticky button affixed to specified anatomical landmarks on the patients head, namely nasion, forehead, vertex, inion in the midline and lateral canthus, front of tragus, mastoid bilaterally and making a total of ten points [Figure 1]. In the absence of fiducial markers the only alternative to effect co registration and navigation is to rely on surface and anatomical markers provided the necessary software is installed and activated on the Stealth machine and adequate training conducted.
The main practical challenges we encountered with fiducials were interruption of supply chain and premature dislodgement before the co-registration was completed.
After the initial ten cases, all neuronavigation procedures were suspended because the fiducial markers were exhausted. It can only be sourced abroad with profound logistics challenge and hurdles. Several patients could not be done because of this and we lost valuable numbers. A trial to re-use the fiducial buttons failed because the sticky buttons were worn out and did not stick firmly. They fell off prematurely. We searched locally and found that 1 cm × 1 cm blocks of pencil eraser affixed to the patients' head with sticky gum showed up on CT scan brilliantly without casting any shadows to interfere with the images [Figure 6] and [Figure 7]. Unfortunately, it was not impressive on MRI. We were, therefore, left with no choice other than to use the CT to navigate. Fortunately, with high resolution images obtained with GE Revolution ACT on-site, the intracranial target as well as the improvised surface fiducials were reasonably well visualised to enable precise navigated surgery. Therefore, our neuronavigation services are presently sustained because of this fall back option.
Premature dislodgement of fiducial markers is a common event recorded in the business of neuronavigation. It can occur: 1 – During transport to and from the radiology unit. 2 – In the wards awaiting onwards movement to the operating room while undergoing last minute nursing and pre-operative procedures. 3 – In the operating room while undergoing head manipulations during induction of anaesthesia and during head fixation on Mayfield clamps. The only strategy we have adopted so far is to exercise utmost gentility in patient handling all through this process and of course to win the confidence and cooperation of the patient and relations.
The ideal neuroimaging for neuronavigation is MRI and the recommended protocol widely used is T1 Gadolinium-enhanced volume acquisition, 1-mm thickness axial cuts only. Contrast-enhanced CT scan as well as PET scan have also been used and as a matter of fact all three modalities can be fused with special software applications on the navigation machine during the registration processes.
The absence of above-listed neuroimaging facilities on site at the onset was a major challenge. To acquire imaging coordinates patients were transferred to another facility with fiducials affixed to their head. This movement recorded cases of displaced/dislodged buttons. This did not however affect the navigation accuracy because we never lost more than four and only six buttons out of the ten are required by the machine to establish navigation accuracy.
At present, an on-site CT and MRI provides acceptable images for navigation and that completely eliminated transporting patients out of the facility.
| Conclusions|| |
There was a lot of confidence in approaching a wide spectrum of brain lesions encountered in this study irrespective of the locations. This is because the Image guidance system provided high precision, minimal morbidity and short hospital stay for both diagnostic brain biopsy and tumour resection procedures. Adjuvant treatments were also deployed with high degree of accuracy when indicated. Our encounter with Image-guided surgery thus far has not only confirmed the already known benefits in modern neurosurgery, but most importantly the practical challenges to be expected by any prospective and aspiring users in our practice environment. Realistic, locally available and workable ways to manage these challenges to achieve desired results have also been outlined. A major limitation of this study is limited numbers and lack of comparative data.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]