Suitability of 3D printing cranial trauma: Prospective novel applications and limitations of 3D replicas

3D printed reconstructions of skeletal material offer a novel, interactive and increasingly used tool to support courtroom testimony and aid juror interpretation of expert testimony. While research has begun to address the accuracy of 3D printed skeletal material, there has been little consideration of the diverse applications of prints to support trauma demonstrations, particularly in relation to gunshot trauma. This study explored the suitability of three printed human crania replicas exhibiting either gunshot trauma or blunt force trauma for identifying whether the prints were sufficiently accurate for the presentation of trauma wounds. The data indicate that metric measurement and qualitative assessment of trauma macromorphology was possible from the 3D printed reconstructions. The findings also offer an indication that it is possible to obtain data around the accuracy of 3D printing bullet wounds and for establishing a bullet path. However, some limitations of prints reconstructed from post-mortem computed tomography (PMCT) data were identified including the observation that not all fracture lines were successfully replicated which indicates that at present virtual models should be used concurrently with 3D prints in court

Augmented Reality-Assisted Craniotomy for Parasagittal and Convexity En Plaque Meningiomas and Custom-Made Cranio-Plasty: A Preliminary Laboratory Report

Background: This report discusses the utility of a wearable augmented reality platform in neurosurgery for parasagittal and convexity en plaque meningiomas with bone flap removal and custom-made cranioplasty. Methods: A real patient with en plaque cranial vault meningioma with diffuse and extensive dural involvement, extracranial extension into the calvarium, and homogeneous contrast enhancement on gadolinium-enhanced T1-weighted MRI, was selected for this case study. A patient-specific manikin was designed starting with the segmentation of the patient’s preoperative MRI images to simulate a craniotomy procedure. Surgical planning was performed according to the segmented anatomy, and customized bone flaps were designed accordingly. During the surgical simulation stage, the VOSTARS head-mounted display was used to accurately display the planned craniotomy trajectory over the manikin skull. The precision of the craniotomy was assessed based on the evaluation of previously prepared custom-made bone flaps. Results: A bone flap with a radius 0.5 mm smaller than the radius of an ideal craniotomy fitted perfectly over the performed craniotomy, demonstrating an error of less than ±1 mm in the task execution. The results of this laboratory-based experiment suggest that the proposed augmented reality platform helps in simulating convexity en plaque meningioma resection and custom-made cranioplasty, as carefully planned in the preoperative phase. Conclusions: Augmented reality head-mounted displays have the potential to be a useful adjunct in tumor surgical resection, cranial vault lesion craniotomy and also skull base surgery, but more study with large series is needed

Optimization of craniosynostosis surgery: virtual planning, intraoperative 3D photography and surgical navigation

Mención Internacional en el título de doctorCraniosynostosis is a congenital defect defined as the premature fusion of one or more cranial sutures. This fusion leads to growth restriction and deformation of the cranium, caused by compensatory expansion parallel to the fused sutures. Surgical correction is the preferred treatment in most cases to excise the fused sutures and to normalize cranial shape. Although multiple technological advancements have arisen in the surgical management of craniosynostosis, interventional planning and surgical correction are still highly dependent on the subjective assessment and artistic judgment of craniofacial surgeons. Therefore, there is a high variability in individual surgeon performance and, thus, in the surgical outcomes. The main objective of this thesis was to explore different approaches to improve the surgical management of craniosynostosis by reducing subjectivity in all stages of the process, from the preoperative virtual planning phase to the intraoperative performance. First, we developed a novel framework for automatic planning of craniosynostosis surgery that enables: calculating a patient-specific normative reference shape to target, estimating optimal bone fragments for remodeling, and computing the most appropriate configuration of fragments in order to achieve the desired target cranial shape. Our results showed that automatic plans were accurate and achieved adequate overcorrection with respect to normative morphology. Surgeons’ feedback indicated that the integration of this technology could increase the accuracy and reduce the duration of the preoperative planning phase. Second, we validated the use of hand-held 3D photography for intraoperative evaluation of the surgical outcome. The accuracy of this technology for 3D modeling and morphology quantification was evaluated using computed tomography imaging as gold-standard. Our results demonstrated that 3D photography could be used to perform accurate 3D reconstructions of the anatomy during surgical interventions and to measure morphological metrics to provide feedback to the surgical team. This technology presents a valuable alternative to computed tomography imaging and can be easily integrated into the current surgical workflow to assist during the intervention. Also, we developed an intraoperative navigation system to provide real-time guidance during craniosynostosis surgeries. This system, based on optical tracking, enables to record the positions of remodeled bone fragments and compare them with the target virtual surgical plan. Our navigation system is based on patient-specific surgical guides, which fit into the patient’s anatomy, to perform patient-to-image registration. In addition, our workflow does not rely on patient’s head immobilization or invasive attachment of dynamic reference frames. After testing our system in five craniosynostosis surgeries, our results demonstrated a high navigation accuracy and optimal surgical outcomes in all cases. Furthermore, the use of navigation did not substantially increase the operative time. Finally, we investigated the use of augmented reality technology as an alternative to navigation for surgical guidance in craniosynostosis surgery. We developed an augmented reality application to visualize the virtual surgical plan overlaid on the surgical field, indicating the predefined osteotomy locations and target bone fragment positions. Our results demonstrated that augmented reality provides sub-millimetric accuracy when guiding both osteotomy and remodeling phases during open cranial vault remodeling. Surgeons’ feedback indicated that this technology could be integrated into the current surgical workflow for the treatment of craniosynostosis. To conclude, in this thesis we evaluated multiple technological advancements to improve the surgical management of craniosynostosis. The integration of these developments into the surgical workflow of craniosynostosis will positively impact the surgical outcomes, increase the efficiency of surgical interventions, and reduce the variability between surgeons and institutions.Programa de Doctorado en Ciencia y Tecnología Biomédica por la Universidad Carlos III de MadridPresidente: Norberto Antonio Malpica González.- Secretario: María Arrate Muñoz Barrutia.- Vocal: Tamas Ung

A finite element study of the human cranium : the impact of morphological variation on biting performance

This thesis investigated the relationship between craniofacial morphology and masticatory mechanics using finite element analysis (FEA). Chapter 1 is a literature review of the relevant background: bone mechanics, jaw-elevator muscle anatomy, imaging techniques, FEA and geometric morphometrics.The second, third and fourth chapters comprise experimental work aiming to provide a framework for FE model construction and loading. The second chapter aimed to validate the method for FE model building and assess the sensitivity of models to simplifications. Models with simplified bone anatomy and resolution predicted strains close to those measured experimentally. The third chapter assessed the predictability of muscle cross-sectional area (CSA) from bony features. It was found that muscle CSA, an estimator of muscle force, has low predictability. The fourth chapter assessed FE model sensitivity to variations in applied muscle forces. Results showed that a cranial FE model behaved reasonably robustly under variations in the muscle loading regimen.Chapter 5 uses the conclusions from the previous studies to build FE models of six human crania, including two individuals with artificial deformations of the neurocranium. Despite differences in form and the presence of deformation, all performed similarly during biting, varying mainly in the magnitudes of performance parameters. The main differences related to the form of the maxilla, irrespective of neurocranial deformation. The most orthognatic individuals with the narrowest maxilla showed the most distinctive deformation during incisor and molar bites, and achieved the greatest bite force efficiency. However, bite forces were similar among individuals irrespective of the presence of artificial deformation. This appears to relate to the preservation of normal dental occlusion, which in turn maintains similar loading and so morphogenesis of the mid face. Altogether, the results of this thesis show that FEA is reliable in comparing masticatory system functioning and point to how variations in morphology impact skeletal performance

Simulation methods and tissue property models for non-invasive transcranial focused ultrasound surgery

Thesis (Ph. D.)--Harvard-MIT Division of Health Sciences and Technology, 2005.Includes bibliographical references.Many brain tumors are localized deeply and are currently surgically inaccessible without causing severe damage to the overlying structures of the brain. The current spectrum of non-invasive methods for treating such tumors includes radiotherapy, which requires exposure to ionizing radiation, and chemotherapy, which is systemically toxic. However, these tumors may also potentially be attacked by focusing highly intense ultrasound onto them. Focused ultrasound surgery is without the side effects of radiotherapy and chemotherapy, and the therapeutic effect of ultrasound therapy can be monitored in real- time using the proton chemical shift MRI technique. However, in order for brain tumors to be treated non-invasively, the ultrasound must be focused onto the targeted brain tissue through the intact cranium. Transcranial focusing of ultrasound is a longstanding and difficult problem as skull is a highly heterogeneous material. As the ultrasound field propagates through the bones of the skull, it undergoes substantatial distortion due to the variations in density and speed of sound therein. There is substantial individual variation in skull size, thickness and composition. Furthermore, the acoustic attenuation coefficient in bone is high, so the skull may also be heated by the ultrasound propagating through it. This thesis contains novel simulation techniques for analyzing transcranial acoustic propagation and for analyzing the temperature changes so produced in the brain, skull and scalp. These techniques have also been applied to modeling non-invasive treatment of the liver, and to producing therapeutic ultrasound fields that harness non-linear acoustic effects advantageously.(cont.) The thesis also contains unified models for the speed of sound and the acoustic attenuation coeffiecient in human skull. These models were generated by combining genetic optimization algorithms, acoustic propagation modeling and empirical measurement of intracranial ultrasound fields; they are valid across the full range of trabecular and cortical cranial bone.by Christopher W. Connor.Ph.D

Towards a radiation free numerical modelling framework to predict spring assisted correction of scaphocephaly

Sagittal Craniosynostosis (SC) is a congenital craniofacial malformation, involving premature sagittal suture ossification; spring-assisted cranioplasty (SAC) – insertion of metallic distractors for skull reshaping – is an established method for treating SC. Surgical outcomes are predictable using numerical modelling, however published methods rely on computed tomography (CT) scans availability, which are not routinely performed. We investigated a simplified method, based on radiation-free 3D stereophotogrammetry scans.Eight SAC patients (age 5.1 ± 0.4 months) with preoperative CT and 3D stereophotogrammetry scans were included. Information on osteotomies, spring model and post-operative spring opening were recorded. For each patient, two preoperative models (PREOP) were created: i) CT model and ii) S model, created by processing patient specific 3D surface scans using population averaged skin and skull thickness and suture locations. Each model was imported into ANSYS Mechanical (Analysis System Inc., Canonsburg, PA) to simulate spring expansion. Spring expansion and cranial index (CI - skull width over length) at times equivalent to immediate postop (POSTOP) and follow up (FU) were extracted and compared with in-vivo measurements.Overall expansion patterns were very similar for the 2 models at both POSTOP and FU. Both models had comparable outcomes when predicting spring expansion. Spring induced CI increase was similar, with a difference of 1.2%±0.8% for POSTOP and 1.6%±0.6% for FU.This work shows that a simplified model created from the head surface shape yields acceptable results in terms of spring expansion prediction. Further modelling refinements will allow the use of this predictive tool during preoperative planning

Quantitative 3D imaging of the cranial microvascular environment at single-cell resolution

Vascularization is critical for skull development, maintenance, and healing. Yet, there remains a significant knowledge gap in the relationship of blood vessels to cranial skeletal progenitors during these processes. One of the key challenges to studying the cranial microvascular environment is the lack of adequate imaging technologies to observe 3D cellular structures throughout the skull. The objective of this thesis is to engineer a platform to visualize and analyze the microvascular environment of the entire murine calvarium at single-cell resolution. In Aim 1, a quantitative light-sheet microscopy (QLSM) platform capable of imaging and quantifying cellular structures in the calvarium is developed by combining whole-mount immunostaining, optical tissue clearing, light-sheet microscopy, and advanced 3D image analysis. This platform is then applied to generate single-cell resolution 3D maps of blood vessel and skeletal progenitor subtypes in the frontoparietal bones. From these maps, it was discovered that Osterix+ osteoprogenitors and Gli1+ skeletal stem cells were spatially correlated with CD31hiEmcnhi vessels, especially inside and nearby the transcortical canals. Aims 2 and 3 build upon these findings by studying how the prevalence and spatial distribution of blood vessels and skeletal progenitors change during postnatal growth, remodeling, and healing. These Aims collectively show that the relationship between CD31hiEmcnhi vessels and skeletal progenitors is maintained during postnatal cranial bone growth, stimulated remodeling, and healing. However, this relationship is significantly weakened by conditionally knocking down platelet-derived growth factor-BB (PDGF-BB) in TRAP+ preosteoclasts/osteoclasts, suggesting that these cells could play an important role in maintaining the cranial microvascular niche. These findings provide a foundational framework for understanding how blood vessels and skeletal progenitors spatially interact in cranial bone and will enable more targeted studies into the mechanisms of skull pathologies and treatments. Additionally, the QLSM platform developed in this thesis can be readily adapted to study numerous cell types and investigate other elusive phenomena in cranial bone biology

Advanced cranial navigation

Neurosurgery is performed with extremely low margins of error. Surgical inaccuracy may have disastrous consequences. The overall aim of this thesis was to improve accuracy in cranial neurosurgical procedures by the application of new technical aids. Two technical methods were evaluated: augmented reality (AR) for surgical navigation (Papers I-II) and the optical technique of diffuse reflectance spectroscopy (DRS) for real-time tissue identification (Papers III-V). Minimally invasive skull-base endoscopy has several potential benefits compared to traditional craniotomy, but approaching the skull base through this route implies that at-risk organs and surgical targets are covered by bone and out of the surgeon’s direct line of sight. In Paper I, a new application for AR-navigated endoscopic skull-base surgery, based on an augmented-reality surgical navigation (ARSN) system, was developed. The accuracy of the system, defined by mean target registration error (TRE), was evaluated and found to be 0.55±0.24 mm, the lowest value reported error in the literature. As a first step toward the development of a cranial application for AR navigation, in Paper II this ARSN system was used to enable insertions of biopsy needles and external ventricular drainages (EVDs). The technical accuracy (i.e., deviation from the target or intended path) and efficacy (i.e., insertion time) were assessed on a 3D-printed realistic, anthropomorphic skull and brain phantom; Thirty cranial biopsies and 10 EVD insertions were performed. Accuracy for biopsy was 0.8±0.43 mm with a median insertion time of 149 (87-233) seconds, and for EVD accuracy was 2.9±0.8 mm at the tip with a median angular deviation of 0.7±0.5° and a median insertion time of 188 (135-400) seconds. Glial tumors grow diffusely in the brain, and patient survival is correlated with the extent of tumor removal. Tumor borders are often invisible. Resection beyond borders as defined by conventional methods may further improve a patient’s prognosis. In Paper III, DRS was evaluated for discrimination between glioma and normal brain tissue ex vivo. DRS spectra and histology were acquired from 22 tumor samples and 9 brain tissue samples retrieved from 30 patients. Sensitivity and specificity for the detection of low-grade gliomas were 82.0% and 82.7%, respectively, with an AUC of 0.91. Acute ischemic stroke caused by large vessel occlusion is treated with endovascular thrombectomy, but treatment failure can occur when clot composition and thrombectomy technique are mismatched. Intra-procedural knowledge of clot composition could guide the choice of treatment modality. In Paper IV, DRS, in vivo, was evaluated for intravascular clot characterization. Three types of clot analogs, red blood cell (RBC)-rich, fibrin-rich and mixed clots, were injected into the external carotids of a domestic pig. An intravascular DRS probe was used for in-situ measurements of clots, blood, and vessel walls, and the spectral data were analyzed. DRS could differentiate clot types, vessel walls, and blood in vivo (p<0,001). The sensitivity and specificity for detection were 73.8% and 98.8% for RBC clots, 100% and 100% for mixed clots, and 80.6% and 97.8% for fibrin clots, respectively. Paper V evaluated DRS for characterization of human clot composition ex vivo: 45 clot units were retrieved from 29 stroke patients and examined with DRS and histopathological evaluation. DRS parameters correlated with clot RBC fraction (R=81, p<0.001) and could be used for the classification of clot type with sensitivity and specificity rates for the detection of RBC-rich clots of 0.722 and 0.846, respectively. Applied in an intravascular probe, DRS may provide intra-procedural information on clot composition to improve endovascular thrombectomy efficiency