Cochlear imaging in the era of cochlear implantation : from silence to sound

Cochlear implants (CIs) are a well accepted treatment for hearing impaired people. In pre- and postoperative assessment of CI-candidates imaging plays an important role to analyze anatomy, rule out pathology and determine intracochlear positioning and integrity of the implant. Developments in CI-design, differences in surgical approach and broadening of treatment indications have raised new questions to radiologists, which were the subject of several studies described in this thesis. For optimal, a-traumatic positioning of a CI precise information about the inner ear anatomy is mandatory. We describe the development, validation and application of a method for 3-dimensional medical image exploration of the inner ear. This renders a tool to obtain cochlear dimensions on clinical computer tomography (CT) images. This will be useful for patientspecific implantplanning. It also shows an anatomical substrate for cochlear trauma during insertion. For postoperative imaging we studied the value of multislice-CT for optimal visualization of the implant within the cochlea. Its role to evaluate operation technique and electrode design, to study frequency mapping and to assess cochlear trauma is discussed. Moreover an international consensus for an objective cochlear framework is presented, forming a common ground for clear and easy exchange of findings in scientific and clinical studies.AB, de Nationale Hoorstichting/Sponsor Bingo Loterij, Foundation Imago, Bontius Stichting inz. Doelfonds BeeldverwerkingUBL - phd migration 201

Evaluating and Improving Cochlear Length Measurements on Clinical Computed Tomography Images

Cochlear implants provide the sensation of sound to deaf individuals. An accurate estimate of cochlear duct length (CDL) is required for pre-operative implant electrode selection and can be obtained from clinical computed tomography (CT) by measuring the “A-value”. The objectives of this work were to estimate the accuracy and variability in manual A-value measurements, and to automate measurements. Four specialists repeatedly measured the A-value on clinical CT images from which the inter- and intra-observer variability were calculated. Accuracy was assessed by comparison to measurements on higher resolution micro-CT images. Motivated by this study, software was developed to automate the A-value measurement by registering an annotated atlas to unlabelled images. There was significant variability in manual A-value measurements made using either standard clinical or multi-planar reformatted views with the latter exhibiting higher variability but better accuracy. The automated approach eliminated variability and improved accuracy, enabling the correct selection of electrode length

Should patients with brain implants undergo MRI?

Patients suffering from neuronal degenerative diseases are increasingly being equipped with neural implants to treat symptoms or restore functions and increase their quality of life. Magnetic resonance imaging (MRI) would be the modality of choice for diagnosis and compulsory post-operative monitoring of such patients. However, interactions between the MR environment and implants pose severe health risks to the patient. Nevertheless, neural implant recipients regularly underwent MRI examinations, and adverse events were reported rarely. This should not imply that the procedures are safe. More than 300.000 cochlear implant recipients are excluded from MRI unless the indication outweighs excruciating pain. For 75.000 DBS recipients quite the opposite holds: MRI is considered essential part of the implantation procedure and some medical centres deliberately exceed safety regulations which they referred to as crucially impractical. MRI related permanent neurological dysfunctions in DBS recipients have occurred in the past when manufacturer recommendations were exceeded. Within the last decades extensive effort has been invested to identify, characterise, and quantify the occurring interactions. Today we are far from a satisfying solution to achieve a safe and beneficial MR procedure for all implant recipients. To contribute, we intend to raise awareness of a growing concern and want to summon the community to stop absurdities and instead improve the situation for the increasing number of patients. Therefore, we review implant safety in the MRI literature from an engineering point of view, with a focus on cochlear and DBS implants as success stories in clinical practice. We briefly explain fundamental phenomena which can lead to patient harm, and point out breakthroughs and errors made. We end with conclusions and strategies to avoid future implants from being contraindicated to MR examinations. We believe that implant recipients should enter MRI, but before doing so, we should make sure that the procedure is reasonable

AUGMENTED REALITY AND INTRAOPERATIVE C-ARM CONE-BEAM COMPUTED TOMOGRAPHY FOR IMAGE-GUIDED ROBOTIC SURGERY

Minimally-invasive robotic-assisted surgery is a rapidly-growing alternative to traditionally open and laparoscopic procedures; nevertheless, challenges remain. Standard of care derives surgical strategies from preoperative volumetric data (i.e., computed tomography (CT) and magnetic resonance (MR) images) that benefit from the ability of multiple modalities to delineate different anatomical boundaries. However, preoperative images may not reflect a possibly highly deformed perioperative setup or intraoperative deformation. Additionally, in current clinical practice, the correspondence of preoperative plans to the surgical scene is conducted as a mental exercise; thus, the accuracy of this practice is highly dependent on the surgeon’s experience and therefore subject to inconsistencies. In order to address these fundamental limitations in minimally-invasive robotic surgery, this dissertation combines a high-end robotic C-arm imaging system and a modern robotic surgical platform as an integrated intraoperative image-guided system. We performed deformable registration of preoperative plans to a perioperative cone-beam computed tomography (CBCT), acquired after the patient is positioned for intervention. From the registered surgical plans, we overlaid critical information onto the primary intraoperative visual source, the robotic endoscope, by using augmented reality. Guidance afforded by this system not only uses augmented reality to fuse virtual medical information, but also provides tool localization and other dynamic intraoperative updated behavior in order to present enhanced depth feedback and information to the surgeon. These techniques in guided robotic surgery required a streamlined approach to creating intuitive and effective human-machine interferences, especially in visualization. Our software design principles create an inherently information-driven modular architecture incorporating robotics and intraoperative imaging through augmented reality. The system's performance is evaluated using phantoms and preclinical in-vivo experiments for multiple applications, including transoral robotic surgery, robot-assisted thoracic interventions, and cocheostomy for cochlear implantation. The resulting functionality, proposed architecture, and implemented methodologies can be further generalized to other C-arm-based image guidance for additional extensions in robotic surgery

Accuracy of image guided robotic assistance in cochlear implant surgery

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Cone-Beam Computed Tomography for Oral and Maxillofacial Imaging

The invention of computed tomography (CT) technique revolutionized diagnostic imaging. Compared to conventional X-ray imaging procedures, CT involves higher radiation doses. Recently, cone-beam CT (CBCT) specifically designed for maxillofacial imaging was introduced. CBCT technique is based on a cone-shaped X-ray beam centered on a two-dimensional (2D) detector. The detector system performs one rotation around the patient, producing a series of 2D images which are then reconstructed in a 3D data set. The contemporary knowledge regarding CBCT and its proper application guides the practitioner for improvement in diagnostic purposes and treatment planning. The aim of this chapter is to focus on the details, advantages, drawbacks, and clinical applications of CBCT as a headmost CT imaging technique in the oral and maxillofacial (OMF) region. The main clinical applications of CBCT in the OMF region are dentistry including dentoalveolar and maxillofacial surgery, orthodontics, endodontics, and periodontics; and otolaryngology. The aforementioned clinical use of CBCT was described in detail with illustrated sample cases. In most of the cases in OMF region, CBCT takes the place of multi-slice CT. Thus, clinicians should know the clinical applications and capabilities of CBCT technique with its drawbacks