an image-guided tour through bwh’s advanced multimodality image guided operating (amigo) suite...

An Image-Guided Tour Through BWH’s

Advanced Multimodality Image Guided Operating

(AMIGO) SuiteImage Guided Therapy Program

Department of RadiologyBrigham and Women’s Hospital

PET/CT RoomOperating Room MRI Room

Supported by

National Center for Image Guided Therapy (NCIGT) P41 RR019703 (Jolesz, Tempany) 2005-2015

Credits

• This presentation researched and created by Mallika Winsor

• Photographs by Junichi Tokuda and Dan Kacher

Advanced Multimodality Image Guided Operating (AMIGO) Suite P41 RR019703 – National Center for Image Guided Therapy (NCIGT) 2005-2015

Ferenc Jolesz, MD Clare Tempany, MD

From Conceptualized Sketch…

...To Completed Suite

The OR and MR rooms of AMIGO



Imaging Equipment in AMIGO• Room 1: MRI Room

– Siemens 3T Verio MR scanner that moves along a ceiling track between the MRI room and the OR

• Room 2: PET-CT Room– Siemens PET-CT

• Room 3: Operating Room– BK Medical Pro Focus UltraView Surgical Ultrasound with Prostate Transducer– Siemens S2000 Ultrasound– Siemens Artis Zee ceiling mounted X-ray Fluoroscopy system with Navigation

Package and DynaCT– Zeiss Pentero surgical microscope

• Navigation– BrainLAB navigation system – Sentinelle Medical (Hologic) Aegis Navigation Workstation– St Jude Medical mapping and navigation system– IntraMedical Imaging Node Seeker and Beta Probe– Robin Medical Endoscout

The OR and MR rooms of AMIGO



Magnetic Resonance Imaging (MRI)

What Does It Do?• Strong magnetic field is applied,

causing the nuclei within the patient’s body to rotate and align– Scanner detects, records, and

combines the different rotating fields into a single image

– Gradients in all directions are combined to create a 3D image

• Strong contrast between different soft tissues within body

• Better at producing images of brain, muscles, heart, cancers than CT or x-rays

• Applications– Used to distinguish

pathological tissue from normal tissue

– Comparable resolution, much better contrast resolution (between arbitrarily different but not identical tissues) than CT

• Advantages– Harmless to patient

• What it uses– Strong magnetic fields– Non-ionizing radiation

Goal: Highly detailed anatomical images

Magnetic Resonance Imaging (MRI)Terminology

Parameters of Image Acquisition

• TE = echo time• TR = repetition time• TI = inversion time

– Time between inversion and excitation pulses

Edema• Abnormal accumulation of

fluid beneath the skin or in cavities of the body

• Caused by increased secretion of fluid into the interstitium or impaired removal of fluid

Magnetic Resonance Imaging (MRI)Basic Scans

T1-weighted MRI scan• Highlights fat deposits

– Water = dark; fat = bright• Good grey v. white matter

contrast• Commonly run clinical scan• Short TE; short TR

T2-weighted MRI scan• Highlights fluids

– Fat = dark; water = light• Good for imaging edema• Heavily used for clinical scans

of cerebral spinal fluid• Long TE; long TR

T2*-weighted MRI scan• Gradient Echo (GRE) sequence

• Additional loss over T2 decay• Air/tissue boundaries

susceptible• Increases contrast of specific

tissues• Long TE; long TR

Spin density weighted MRI scan• No contrast from either T1 or

T2 decay• Uses spin echo (sometimes

gradient echo) sequences• Short TE; long TR

Magnetic Resonance Imaging (MRI)Specialized Scans

Diffusion MRI scan• Diffusion tensor imaging (DTI) enables diffusion to be

measured in multiple directions• Make brain maps of fiber directions

– Examine connectivity of different regions of brain– Examine areas of neural degeneration and

demyelination

Fluid Attenuated Inversion Recovery (FLAIR)• Inversion-recovery pulse sequence that nulls fluid

signals– Free water = dark; edematous tissue = bright

• Most sensitive way to evaluate brain for demyelinating diseases

• Carefully-selected TI allows signal from any particular tissue to be suppressed

• Conversion of T2-weighted sequence via additional radio frequency pulse and manipulation of magnetic gradientsFunctional MRI (fMRI)

• Measures signal changes in the brain due to changing neural activity

• Low resolution, rapid rate scans• BOLD (Blood-Oxygen-Level Dependent) effect

• Increases in neural activity cause changes in MR signals via T2* changes• Increased neural activity increases demand for

oxygen• Vascular system overcompensated, increasing

oxygenated hemoglobin• High resolution 3D maps of venous vasculature

within neural tissue

Real-Time MRI• Continuous monitoring ("filming") of moving

objects in real time• Should help provide information about diseases

of the joints and heart• May make MRI examinations easier and more

comfortable for patients

Magnetic Resonance Imaging (MRI)Medical Applications

Interventional Therapy• MRI images used to guide

minimally invasive procedures both intraoperatively and interactively

• No ferromagnetic instruments used

• Some specialized systems allow imaging concurrent with surgery– Usually, surgical procedure is

temporarily interrupted so MR images can be acquired to verify success/guide subsequent surgical work

Radiation Therapy Simulation• MRIs used to specifically locate

tumors within body in preparation for radiation therapy treatments

• Patient placed in specific, reproducible, body position and scanned

• MRI system computes precise location, shape and orientation of the tumor mass, correcting for spatial distortion inherent in the system

• Patient is marked/tattooed with points that, when viewed in specified, reproducible body position, permit precise triangulation for radiation therapy

Magnetic Resonance Imaging (MRI)What is MRI Compatibility?• MR-Safe = device or implant that

is completely non-magnetic, non-electrically conductive, and non-RF reactive– Titanium and its alloys

• MR-Conditional = device that is safe, provided the safety conditions are defined and observed

• MR-Unsafe = objects that are significantly ferromagnetic and pose a clear and direct threat to persons and equipment within the magnet room

• Patients always asked for complete information about all implants prior to entering the MRI suite

Safety Concerns• Radio frequency energy

– Powerful radio transmitter can heat the body to the point of risk of hyperthermia in patients

• Peripheral Nerve Stimulation– Rapid switching on and off of the magnetic field gradients

may cause nerve stimulation• Acoustic noise

– Appropriate ear protection is necessary for anyone inside MRI scanner room during examination

• Cryogens– Cryogenic (extremely cold) liquids enable

superconducting capabilities of the electromagnetic coils– MRI support rooms should be equipped with pressure

relief mechanisms and an exhaust fan in case of a quench (shut-down of superconduction electromagnet)

• Pregnancy– Increasingly important for diagnosing and monitoring

congenital defects of the fetus (no contrast agents used)• Fetal tumors (primarily teratomas)• Facilitating open fetal surgery• Other fetal interventions• Planning to safely deliver and treat babies whose

defects would otherwise be fatal

Siemens MAGNETOM Verio 3T

AMIGO’s MRI:Siemens MAGNETOM Verio 3T

Who Can It Accommodate?• Patients up to 550 lbs• Pediatric and elderly patients• Claustrophobic patients• Intensive Care Unit patients• Patients dependent upon

medical equipment

How Does It Help BWH?• Minimizes scan rejections due

to claustrophobia• Reduces necessary sedations• Capture sharper images (due

to reduced anxiety-related movement)

• Early access in interventional MRI

• Opportunities to perform more kinematic studies

AMIGO’s MRI:Siemens MAGNETOM Verio 3TFeatures →

• VQ engine• Ultra-light (6.3 tons) magnet

with zero helium boil-off• Total Imaging Matrix (TMI)• TrueForm design

– Larger imaging volume, higher image quality, better fat saturation

– Whole body imaging up to 6' 4“• Shortest 3T system available• 70 cm Open Bore• Moves along ceiling into OR

Why this machine?• Higher speed, increased image

quality • Safer scanning environment• Increase flexibility, accuracy

and speed• Enhanced image quality for a

wide range of applications• Ensures uniform RF

distribution in all body regions (optimizes homogeneity)

Bottom Line: Exceptional diagnostic capabilities,patient comfort, and efficient workflow

A view of OR table and the MR through the PET/CT Bore



Positron Emission Tomography-Computed Tomography (PET-CT)

What Does It Do?• Hybrid modality of PET and x-ray CT• Takes both types of images

sequentially, in the same session• Images can be combined into a

single 2D or 3D superposed image• Detecting changes in molecular

activity:– Reveal primary tumors– Detect metastases– Quantify uptake– Improves accuracy in oncology,

surgical planning, radiation therapy, cancer staging

• Increased image quality, speed, and accuracy of diagnosis

How Does It Work?• Patient fasts for 4 hours or more• Intravenous bolus (tracer) injected patient's arm• 1-2 hours later, patient placed into PET-CT,

usually with arms at the sides or above the head• Automatic bed moves head first into the gantry,

first obtaining a topogram (whole body flat sagittal section)

• Operator uses PET-CT console to identify patient and examination, selects the scanning parameters and starts image acquisition period

• Patient automatically moved head-first into CT gantry, where x-ray tomogram is acquired

• Patient automatically moved through PET gantry, parallel to CT gantry; PET slices acquired

• Software reconstructs/aligs PET and CT images• Whole body scan (mid-thigh to top of head) takes

5-40 min

Goal: Precise localization of metabolic functions

Positron Emission Tomography-Computed Tomography (PET-CT)

Positron Emission Tomography• Uses radionucleotide decay to

generate 3D image of functional processes in the body– Detects gamma rays emitted by a

positron-emitting radionucleotide ("tracer")• Tracer enters patient's body via a

biologically active molecule• FDG is a tracer used to display

metabolic activity of tissue in terms of regional glucose uptake

– Computer analyzes location/concentration of tracer within patient to construct 3D images

X-ray Computed Tomography• Uses computer processed

tomography to generate 3D images from a collection of 2D x-ray images taken around a single axis of rotation– Tomography = imaging by

sections– Supplements x-rays and

medical ultrasonaography– Used in

preventative/screening medicine

TIME Magazine declared PET-CT "Medical Invention of the Year" in 2000

AMIGO’s PET-CT:Siemens Biograph TruePoint

Features →• World's first HD PET platform• 190 cm patient scan range• 6-, 16-, 40- or 64- slice CT

– 0.33 second rotation time on 64-slice CT• Customizable:

– Multisclice CT configurations, – High or standard resolution options– Clinical configuration options

• 21.6 cm axial PET field of view with TrueV• Best NEMA spatial resolution in the industry

• 2 mm uniform PET resolution• 2x improvement signal-to-noise• Distortion-free throughout entire field of

view• More accurate visualization of fine detail at

all angles

Benefits• Extremely sharp, highly-detailed

images• Wide range of performance options• Largest PET field of view in the

industry, increasing count rate performance by over 70%

• 10 minute whole-body PET•CT imaging with TrueV

• Exceptional lesion detectability

• More accurate visualization of fine detail at all angles

• Enhanced detectability and highest level of detail

• Sharper images• Greater distinction within image

AMIGO’s PET-CT:Siemens Biograph TruePoint

• Lutetium Scintillator Oxyorthosilicate (LSO) crystal– Faster scans

• HI-REZ– Exceptional resolution

• TrueV– Longest axial field of view

available

• TrueC– Model-based scatter correction

Technological Features

• Ultra-Fast Ceramic (UFC) detector– Stunning CT image quality

• SureView– Maximum image quality at

any scan speed

• CARE Dose4D– Real-time dose modulation

• z-Sharp– Highest spatial resolution

available

Siemens Artis Zee Ceiling-Mounted C-Arm, Operating Table and MRI in OR of AMIGO



AMIGO’s Angiogram:Siemens Artis Zee Ceiling-Mounted C-Arm

Features• Large flat detector• Easy patient access• Full body coverage• Ergonomically designed

controls

56" full-color medical-grade screen• View multiple inputs

simultaneously• Get the "whole picture" directly,

at tableside• Change layout according to

individual workflow step• Extremely high resolution (4x

that of standard HD)• 8 megapixel resolution at 4 x HD

(3840 x 2160 pixels)• Over 200 layout combinations• 21 video source inputs• Fully integrated tableside

control

Siemens Artis Zee Ceiling-Mounted C-Arm

AMIGO’s Angiogram:Siemens Artis Zee Ceiling-Mounted C-Arm

CARE program• Reduces patient and operator

radiation dose to a minimum– Addresses broader patient base

of dose-sensitive patients (ex: children)

• Provides dose monitoring during procedure

• Enhances in-house reporting• Standard with all Artis Zee

systems

• Imaging• Improved visualization of

therapeutic devices• Advanced 3D applications,

allow greater speed and precision

• Workflow• Ergonomically designed

controls• Streamline workflow,

increased efficiency

Ultrasound

What is Ultrasound?• Cyclic sound pressure with a frequency (20 kHz -

200 MHz) greater than the upper limit of human hearing (typically 20,000 hertz in healthy young adults)

• Uses many different fields to penetrate a medium and measure the reflection signature or supply focused energy– Reflection signature can reveal details about the inner

structure of the medium• This property is used by bats to locate prey while

hunting• Most well-known application is use in sonography to

image a fetus in a human womb– Diagnostic sonography (AKA ultrasonography) =

ultrasound-based diagnostic imaging technique used to visualize subcutaneous body structures such as tendons, muscles, joints, vessels and internal organs for possible pathology or lesions)• Able to determine size, structure, and any

pathological lesions using real-time tomographic images

Applications• Soft tissue imaging

– Cardiac (heart)– Renal (kidney)– Hepatic (liver and gallblader)– Muscuko-skeletal (muscles, ligaments,

tendons)– Ophthalmic (eyes)– Superficial (just under the skin) structures

• Ex: testicles, thyroid, salivary glands, lymph nodes

• Guiding interventional procedures in real time– Fine needle aspiration/biopsy (FNA/NAB) =

diagnostic procedure– Biopsy of masses for cytology or histology

testing in breast, thyroid, liver, kidney, lymph nodes, muscles, joints

UltrasoundObstetric Imaging• Used to identify many conditions harmful to

both mother and fetus– Risk of leaving such conditions undiagnosed is far

greater than the small risk associated with undergoing the actual US scan

• Primary uses:– Assess gestational age– Confirm fetal viability– Determine location of fetus, intrauterine v.

ectopic (displaced anywhere besides uterine wall)– Check the location of the placenta in relation to

the cervix– Detect multiple pregnancies– Detect major physical abnormalities– Assess fetal growth for evidence of intrauterine

growth restriction (IUGR)– Check for fetal movement and heartbeat– Determine the sex of the baby

Emergency Ultrasound• Specialized application by emergency

responders to guide immediate first aid care• Pros

– Images muscle, soft tissue, and bone surfaces well; particularly good at delineating interfaces between solid and fluid-filled spaces

– Renders "live" images, helps narrow down problem area

– Determines severity and sources of trauma within region

– Portable, narrowly-focused, easy to use• Cons

– Cannot penetrate bone– Depth of penetration limited, especially in obese

patients– Operator-dependent (high skill needed for good

quality images and accurate diagnoses)• Scanning methodologies

– Focused Assessment with Sonography for Trauma (FAST)• Detects internal bodily fluid in between organs in

cases of blunt abdominal trauma• Screening test for blood around the heart or

abdominal organs after trauma– CARDIASOUND

• Detects blockages/clots/penetrations of the heart

UltrasoundBiomedical Applications• Detection of pelvic abnormalities, involving abdominal/vaginal/rectal US• Break calculi (stones formed in the body) into fragments small enough to

be passed without excessive difficulty via lithotripsy• Ablate tumors non-invasively via High Intensity Focused Ultrasound (HIFU)

– Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) = guided by MRI, a lower frequency (250-2000 kHz) than medical diagnostic ultrasound is applied in significantly higher time-averaged intensities

• Acoustic Targeted Drug Delivery (ATDD) = enhanced transportation of molecules across specified tissues via high frequency ultrasound (frequency: 1-10 MHz; sound intensity: 0-30 watts/cm2)

• Cataract treatment via phacoemulsification (surgery in which the eye's internal lens is emulsified with an ultrasonic handpiece and aspirated from the eye; aspirated fluids replaced with balanced salt solution)

• Low-intensity pulsed ultrasound used to stimulate bone and tooth regeneration, disrupt blood-brain barrier for drug delivery

• Ultrasound-guided sclerotherapy and endovenous laser treatment– Ultrasound-guided sclerotherapy = ultrasound is used to visualize the

underlying vein, allowing the physician to deliver and monitor the injection of the vein-shrinking drug

– Endovenous Laser Treatment (ELT) = minimally-invasive ultrasound-guided technique used to treat varicose veins with laser energy

• An optical fiber is inserted into the vein to be treated, a laser light is shone into the interior of that vein, causing the vein to contract; optical fiber is slowly withdrawn

• Elastography = non-invasive method in which stiffness or strain images of soft tissue are used to detect and classify tumors– When a mechanical compression or vibration is applied, the tumor deforms

less than the surrounding tissue (strain in the tumor is less than that in the surrounding tissue)

– Elasticity can discern health from unhealthy tissue in specific organs/growths

• Ultrasound Identification (USID)– Real Time Locating System (RTLS) or Indoor

Positioning System (IPS)• RTLS = used to wirelessly track and identify the

location of objects in real time– Does not include speed, direction, or

spatial orientation• IPS = network of devices used to wirelessly

locate objects or people inside a building• Nonlinear propagation effects

– US waves usually display nonlinear propagation (distortion) due to their high amplitude to wavelength ratio

• Safety Concerns– Occupational exposure to ultrasound in

excess of 120 dB may lead to hearing loss– Exposure in excess of 155 dB may produce

heating effects harmful to the human body– Exposures above 180 dB may lead to death– Recommended to avoid routine use of

ultrasound scans in low risk pregnancies

AMIGO’s Ultrasound #1:BK Pro Focus UltraView

Capabilities• Locate and map lesions, evaluate blood flow,

biopsy suspicious areas• Easy-to-create images for accurate diagnosis• Full line of specialized transducers

– Breast, abdominal, vascular, cardiac, obstetric, gynecological

– Compatible with many other contrast-enhancing transducers

• Monitor therapeutic interventions– Breast biopsy, cyst drainage, radioactive seed

implantation, other therapies (RFA, cryotherapy, microwave, laser)

– Guide tip of catheter during RF ablation and drainage

• Intuitive keyboard and simple user interface makes scanner simple to learn and use

• Compact, mobile design• High contrast imaging• HistoScanning interface

Features• IQPAC technology (for abdominal imaging)

– Angular Compound Imaging (ACI): organ definition• Reduced presence of artifacts, shadowing and

speckle• Compounds images from up to 5 different angles

into a single, enhanced image• Enhances anatomical structures (tissue structure,

vessel borders) during acquisition– Enhanced Tissue Definition (ETD): reduced speckle noise

• Smooth out potential irregularities in an image• Speckle suppression algorithm continuously

analyzes ultrasound image for irregularities, then smoothes them out without loss of frame rate

• Improved anatomically correct continuous border• Improved ability to visualize lesion margins

AMIGO’s Ultrasound #1:BK Pro Focus UltraView

SpecificsScanning Modes B- and M-mode

CFM, PW and CW DopplerTissue HarmonicContrast imaging

Display 19” LCD flat screen

Features IQPACCoded excitationAuto DopplerAuto GainCHI acc.Split screen3DDICOMPalm Control

Dimensions (approx) Height: 1475-1565Width: 525mmDepth: 765mm

Weight 70kg

Ultrasound Transducer #1:BK 8818 Triplane Prostate

Features• Images all three prostate planes

– Switches between planes at the click of a button

– Increases diagnostic value with 3D, Contrast and Doppler

• Sterile single-use needle guides– Individually sterile-packed, pre-

assembled and ready to use• UA1322-S Biplane guide

– Simultaneously biopsy the peripheral, transition and central zones

• UA1323-S Endfire guide– Apical biopsies

• UA1329-S Dual guide– Minimal manipulation

• All are suitable for 17G needles

Applications• Transrectal prostate scanning• Transrectal puncture and

biopsy• Transperineal puncture and

biopsy• Transvaginal scanning• Spectral and CFM Doppler

examinations• Tissue harmonic imaging• Contrast imaging

Ultrasound Transducer #1:BK 8818 Triplane Prostate

SpecificationsFrequency range 4 - 12 MHz

Contact surface (acoustic) 34.4 x 5.5 mm

Focal range 3 - 60 mm

Scanning modes B, M,BCFM, Doppler, Contrast*, Tissue Harmonic

Frame Rate 60 Hz

Image field (expanded) Triplane / 140°

Dimensions 36 x 39 x 323 mm

Weight 230 g

Disinfection ImmersionSTERIS SYSTEM 1STERIS SYSTEM 1ESTERRAD 50, 100S and 200

Ultrasound Transducer #2:BK 8838 Endocavity 3D

• High Resolution Color and 3D Imaging– World's first electronic transducer, for endovaginal, endoanal and transrectal imaging, with

built-in high resolution 3D• Built-In 3D Acquisition

– Built-in linear array rotates 360° inside the transducer– No need for additional accessories or mover– No moving parts come in contact with the patient, for excellent patient comfort

• Unsurpassed Image Quality– For both dynamic 2D and 3D scanning– Wide frequency range 12- 4 mHz, excellent imaging capabilities across all frequencies– Enhanced focus capabilities for prostate 3D and pelvic floor imaging

• Premium Ease – Slim 16mm diameter for more comfortable patient imaging– Easy to hold and manipulate– 2D scanning plane controlled remotely from the system keyboard– Silent operation

Ultrasound Transducer #2:BK 8838

SpecificationsFrequency range 12-4 MHz

Focal range (typical) 3-60 mm0.1-2.4 in

Frame rate >150

Disinfection ImmersionSTERIS SYSTEM 1STERIS SYSTEM 1E

Scanning modes B,M,CFM, Doppler,Power Doppler, Tissue Harmonic Imaging, Contrast Imaging

Contact surface (acoustic) Transverse:65 x 5.5 mm2.6 x .2 in

Image field (expanded) 65 mm/2.6 in wide acoustic surface able to rotate 360º

Weight (approx.) 450 g1 lb

Ultrasound Transducer #3:BK 8848 Intracavity

• A resolution revolution in image guided prostate therapy. Resolute, clear and detailed images of the prostate, for accurate volume studies and source dose planning

• Image guided prostate therapy– Sagittal scanning of any size prostate from base to apex– Resolute, clear, detailed image for accurate volume studies and source dose planning– Customizable sagittal grids and preferences for brachytherapy– Clear visualization of seminal vesicles– Clear view of needle placement

• Pelvic Floor scanning– Best broad view of anterior and posterior compartments for functional and anatomical studies– Reproducible 3D studies with external mover– Detailed high-resolution biplane with 6.5 cm linear and convex views

• Applications– Prostate brachytherapy– Transrectal scanning– Transperineal puncture– Transvaginal scanning– Prostate cryotherapy– Spectral and CFM Doppler– Contrast imaging

Ultrasound Transducer #3:BK 8848 Intracavity

SpecificationsFrequency range 5-12 MHz

Focal range (typical) 3-60 mm

Frame rate >150

Disinfection Immersion,STERIS SYSTEM 1STERIS SYSTEM 1ESTERRAD 50, 100S and 200

Scanning modes B,M, Doppler, BCFM, Tissue Harmonic Imaging

Contact surface (overall) Transverse: 127 mm2Sagittal: 357 mm2

Image field (expanded) 180˚(transverse)

Weight (approx.) 250 g

Microscope

AMIGO’s Microscope:Zeiss OPMI Pentero

Features• Intra-operative

fluorescence• Integration of entire digital

video chain• Integration of surgical

microscope into hospital's information and communication infrastructure

• User-friendly solutions for OR staff

Intraoperative Fluorescence technologies (enhance efficiency via vital info)• INFRARED 800: Fluorescence-based angiography

– Immediately visualize and interpret intraoperative blood flow• Delivers critical information quickly and conveniently to surgeon• No procedural disruption• Specially tailored to requirements of neurosurgery for management of vascular diseases

(Ex: cerebral aneurysms, arteriovenous malformations (AVM, and bypass procedures)– Button activates INFRARED and guides it automatically to the point of interest

• Digital videos saved automatically• Still images easily taken and transferred to DVD/USB• AutoRecord: synchronous video of white light and infrared view• AutoGain: brightness of infrared image automatically adjusted to respective application• AutoReplay: repeat function jumps directly to start of inflow on video, skips over blank

recording• Picture-in-Picture: direct comparison of white and infrared recordings on touch screen

– Completely integrated into OPMI Pentero• FLOW 800: Visual analysis of vascular blood flow dynamics

– Analytical visualization tool for rapid and reliable interpretation of fluorescence video sequences generated using INFRARED 800

– Supports an in-depth interpretation of fluorescence videos by creating objective evaluation of results visually and in color

• BLUE 400: Fluorescence-guided tumor resection– Visible differences

• Excellent aid for visualizing tumors clearly at any time during the procedure• Extremely clear fluorescent images• Precise definition of tumor margins during removal of malignant brain tumor tissue• Helps preserve vital and functional areas of the brain and to ensure that the patient’s

quality of life is not impaired– Workflow unchanged

• BLUE 400 integrated procedure supporting intuitive performance of fluorescent-guided tumor resection

• Activate and switch between BLUE 400 (tumor visualizing) and xenon white light (normal) views instantly


• State of the art apochromatic optics– Crystal-clear images, sharp details, natural colors– Variskop provides a larger working range and comfortable conditions– 17% field depth increase

• Convenience– Ergonomically correct design for cranial, spinal and posterior fossa procedures– Surgeon can be standing or seated– Design is 30% more compact– Allows for freedom of hand and instrument movement, short distance to surgical field– Overhead design

• Suspension system can be placed in any position (even behind surgeon)

• Several different configurations available• Stereo co-observation tube remains in same position as microscope is

repositioned• Light

– 20% more light for surgeons (more for assistants)– Spot illumination

• Precisely adjusts light cone without reflections– Two-channel illumination system

• Higher-contrast images in narrow and deep canals

• Autofocus– High-speed autofocus

• Razor-sharp images, regardless of magnification– Manual focus

• Intuitive laser-focusing aid helps select exact focal point

• Robotic X/Y movements– Can move easily in any direction

• Controls– Handgrip– Mouth switch– Foot switches

• Integrated digital visualization: immediately produce and process digital video

• Simply Unique (user-friendly solutions for OR staff)– AutoBalance: one-touch button– AutoDrape: air evacuation to precisely fit sterilization drape over

microscope– FlexiTrak: easy transportation– Superlux 330: easy to change lamps and modules

• Workflow Integration– Fast and easy connection to all leading navigation systems without external

components and wiring– Open interface system

• Use same workstation and cable with other ZEISS surgical microscopes– Binocular, color injection and superimposition of navigation data– Robotic X/Y design with three motorized axes

• Provides real tool tracking for viewing every point in working and tilting range of OPMI

– Laser-guided, high-speed autofocus system• Delivers precise navigation by focusing to a fraction of a millimeter• Precisely identifies displayed point

– MultiVision• Enables surgeon to inject information and data into the eyepiece• Touchscreen interface can be injected into MultiVision display and

controlled using the joystick


• FDA cleared for any MRI-guided intervention on MRI scanners

• Clinical procedures on open scanners– Prostate brachytherapy and cryotherapy,

RF ablation of liver tumors, cryotherapy of renal cancer, breast biopsy, brain surgery

• Research on close-bore scanners– MRI catheterization and endoscopy,

motion artifact elimination• Clinical Applications • Many MR-guided diagnostic and

therapeutic procedures: – Biopsy and aspiration (breast, brain, liver,

prostate). – Tumor RF/laser ablation (liver).– Brachytherapy (prostate, kidney).– Image-guided neurosurgery.– Pain management (nerve blockage).

• Specifications • Realtime 6 degrees-of-freedom tracking during MR imaging

with FSE, FGRE, SPGR, SSFSE. • Number of Tracking Devices: 2 out of 4 ports. • Tracking Accuracy: Location: 2mm, Orientation: 1 degree

(values represent 2 standard deviations of the tracking error population).

• Tracking Range: Up to 30cm from the center of the scanner. • Tracking Angle: Unlimited (360 degrees). • Tracking Rate: Up to 16Hz. • Input Power: 120VAC/0.8A (60Hz) or 230VAC/0.4A (50Hz). • Comes with a set of mechanical tools that help the physician

navigate a needle to a specific location inside the patient• Sensors• Acquires the location and orientation of a sensor during an

MRI scan• Sensor is a 3 dimensional magnetic field sensor made by 3

orthogonal pick up coils– Comes in different sizes and shapes, to fit the specific

application– Most popular:

• Basic cube sensor for hand held guided tool• Micro sensor with about 1.5 mm diameter for small tools,

catheters and more

To be continued…

an image-guided tour through bwh’s advanced multimodality image guided operating (amigo) suite...

Documents