planning trajectory cranial · 1.4 intended use indications for use trajectory planning’s...

CRANIALTRAJECTORYPLANNINGVersion 2.0

Software User GuideRevision 1.0Copyright 2017, Brainlab AG Germany. All rights reserved.

TABLE OF CONTENTS1 GENERAL INFORMATION.............................................................................................5

1.1 Contact Data ........................................................................................................................................5

1.2 Legal Information ...............................................................................................................................6

1.3 Symbols Used in This Guide............................................................................................................8

1.4 Intended Use........................................................................................................................................9

1.5 Compatibility with Medical Devices .............................................................................................101.5.1 Non-Brainlab Software .....................................................................................................................111.5.2 Non-Brainlab Medical Devices .........................................................................................................12

1.6 Training and Documentation..........................................................................................................131.6.1 Used Abbreviations ..........................................................................................................................14

2 USING TRAJECTORY ......................................................................................................15

2.1 Introduction .......................................................................................................................................15

2.2 Create, Modify and Remove Trajectories Using Trajectory (Element) ..................................172.2.1 Software Functions ..........................................................................................................................192.2.2 Modifying Trajectories ......................................................................................................................202.2.3 Trajectory Positioning Controls.........................................................................................................232.2.4 Define Trajectory Properties .............................................................................................................242.2.5 Creating 3D Shapes .........................................................................................................................252.2.6 Memorize Function...........................................................................................................................282.2.7 Lead Properties................................................................................................................................292.2.8 Defining the Lead Orientation...........................................................................................................302.2.9 AC/PC Coordinates Availability ........................................................................................................312.2.10 Repositioning .................................................................................................................................322.2.11 AC/PC Localization.........................................................................................................................332.2.12 AC/PC Localization Details.............................................................................................................35

2.3 Save as a Plan ...................................................................................................................................36

2.4 Identifying the Plan Status and Reviewing/Approving with Trajectory (Element) .............37

2.5 Data Selection View .........................................................................................................................38

2.6 Viewing and Reviewing Trajectories ............................................................................................412.6.1 Data Verification ...............................................................................................................................43

2.7 Trajectory Display and Verification...............................................................................................44

2.8 Stereotactic Planning and Localization.......................................................................................462.8.1 Localizing the Image Set ..................................................................................................................48

TABLE OF CONTENTS

Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0 3

2.8.2 Localization Status Result ................................................................................................................492.8.3 Localization Example .......................................................................................................................502.8.4 Ignoring Slices..................................................................................................................................522.8.5 Adding and Positioning Rod Markers ...............................................................................................53

2.9 Stereotactic Localizers....................................................................................................................54

2.10 Supported Arc Systems ................................................................................................................572.10.1 Leksell Stereotactic Systems..........................................................................................................582.10.2 Leksell Vantage Arc........................................................................................................................592.10.3 Leksell Multi Purpose Stereotactic Arc ...........................................................................................602.10.4 Inomed ZD Arc System ..................................................................................................................622.10.5 Radionics Arc Systems ..................................................................................................................64

2.11 Stereotactic Report ........................................................................................................................652.11.1 Report Functions ............................................................................................................................662.11.2 Report Content ...............................................................................................................................67

2.12 Ending the Session........................................................................................................................69

TABLE OF CONTENTS

4 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

1 GENERAL INFORMATION1.1 Contact Data

Support

If you cannot find information you need in this guide, or if you have questions or problems, contactBrainlab support:

Region Telephone and Fax Email

United States, Canada, Central andSouth America

Tel: +1 800 597 5911Fax: +1 708 409 1619 [email protected]

Brazil Tel: (0800) 892 1217

UK Tel: +44 1223 755 333

[email protected]

Spain Tel: +34 900 649 115

France and French-speaking regions Tel: +33 800 676 030

Africa, Asia, Australia, EuropeTel: +49 89 991568 44Fax: +49 89 991568 811

JapanTel: +81 3 3769 6900Fax: +81 3 3769 6901

Expected Service Life

Brainlab provides five years of service for software. During this period of time, software updatesas well as field support are offered.

Feedback

Despite careful review, this manual may contain errors.Please contact us at [email protected] if you have suggestions as to how we canimprove this manual.

Manufacturer

Brainlab AGOlof-Palme-Str. 981829 MunichGermany

GENERAL INFORMATION


mailto://[email protected]



1.2 Legal Information

Copyright

This guide contains proprietary information protected by copyright. No part of this guide may bereproduced or translated without express written permission of Brainlab.

Brainlab Trademarks

• Brainlab® is a registered trademark of Brainlab AG in Germany and/or the US.• SmartBrush® is a registered trademark of Brainlab AG in Germany and/or the US.

Non-Brainlab Trademarks

Microsoft® and Windows® are registered trademarks of Microsoft Corporation.

Integrated 3rd-Party Software

• This software is based in part on the work of the Independent JPEG Group.• Portions of this software are based on the work of Sun Microsystems Inc.• The Brainlab PDF-Viewer implementation is based on the PDF Direct/PDF Quick View library,

Copyright 2003-2011 soft Xpansion GmbH & Co. KG.• This product includes software developed by Telerik, Inc., Copyright © 2002 - 2016.• This product includes software developed by the Apache Software Foundation

(www.apache.org/).• This software is based in part on Xerces-C++ made available under the Apache Software

License: https://xerces.apache.org/xerces-c/This product includes software developed by the Apache Software Foundation(www.apache.org/). Copyright (c) 1999-2004 The Apache Software Foundation. All rightsreserved.

• This product includes libtiff 4.0.4 beta, copyright © 1988 - 1997 Sam Leffler and copyright ©1991 - 1997 Silicon Graphics. For a full description of copyrights and license see:www.remotesensing.org

• This software is based in part on libjpeg-turbo. The full license and copyright notice can befound here: https://github.com/libjpeg-turbo/libjpeg-turbo/blob/master/LICENSE.md

• This software is based in part on OpenJPEG. The full license and copyright notice can befound here: https://github.com/uclouvain/openjpeg/blob/master/LICENSE

CE Label

The CE label shows that the Brainlab product complies with the essential re-quirements of the Medical Device Directive (MDD).According to the MDD, Council Directive 93/42/EEC, Trajectory Planning isa Class IIb product.

NOTE: The validity of the CE label can only be confirmed for products manufactured by Brainlab.

Legal Information


http://www.apache.org

http://www.apache.org

Disposal Instructions

Only dispose of electrical and electronic equipment in accordance with statutoryregulations. For information regarding the WEEE (Waste Electrical and ElectronicEquipment) directive, visit: http://www.brainlab.com/en/sustainability/

Sales in the US

US federal law restricts this device to sale by or on the order of a physician.

GENERAL INFORMATION


http://www.brainlab.com/en/sustainability/

1.3 Symbols Used in This Guide

Warnings

Warnings are indicated by triangular warning symbols. They contain safety-criticalinformation regarding possible injury, death or other serious consequences associatedwith equipment misuse.

Cautions

Cautions are indicated by circular caution symbols. They contain safety-critical informationregarding possible problems with the device. Such problems include device malfunctions,device failure, damage to device or damage to property.

Notes

NOTE: Notes are formatted in italic type and indicate additional useful hints.

Symbols Used in This Guide


1.4 Intended Use

Indications for Use

Trajectory Planning’s indications for use are the viewing, presentation and documentation ofmedical imaging, including different modules for image processing, image fusion, atlas assistedvisualization and segmentation, intraoperative functional planning where the output can be usede.g., with stereotactic image guided surgery or other devices for further processing andvisualization.Example procedures include but are not limited to:• Planning and simulation of cranial surgical procedures such as shunt placement, minimal

invasive stereotactic interventions, biopsy, planning and simulation of trajectories for stimulationand electrode recording.

Typical users of Trajectory Planning are medical professionals, including but not limited tosurgeons and radiologists.

Intended User

The operators of Trajectory Planning are trained healthcare professionals, e.g.:• Neurosurgeon• Stereotactic Neurosurgeon

Place of Use

The place of use is determined to be indoors, normally in a hospital or clinical setting.

Careful Handling

Only trained medical personnel may operate system components and accessoryinstrumentation.

Plausibility Review

Before patient treatment, review the plausibility of all information input to and output fromthe system.

Responsibility

This system solely provides additional assistance to the surgeon or user and does not byany means substitute or replace the surgeon’s or user’s experience and/or responsibilityduring its use.

GENERAL INFORMATION


1.5 Compatibility with Medical Devices

Instrument Use

Only use instruments and spare parts specified by Brainlab with Trajectory. Usingunauthorized instruments/spare parts may adversely affect safety and/or effectiveness ofthe medical device and endanger safety of patient, user and/or environment.

Compatible Brainlab Medical Software

Trajectory (Element) 2.0 is compatible with:• Fibertracking 1.0• Image Fusion 1.0, 2.0 and 3.0• iPlan Stereotaxy 3.0• Lead Localization 1.0• Object Manager 1.0• Patient Data Manager 2.4

- Content Manager- Patient Selection- DICOM Viewer

• SmartBrush 2.0, 2.1 and 2.5

Other Brainlab Software

Other compatible Brainlab software may become available after the release of this user guide. Ifyou have questions regarding compatibility of software, contact Brainlab support.If you are running software versions other than those specified above, contact Brainlab support forclarification regarding compatibility with Brainlab devices.

Compatibility with Medical Devices


1.5.1 Non-Brainlab Software

Authorization

Only authorized Brainlab employees may install software on the Brainlab system. Do notinstall or remove any software applications.

Compatible Non-Brainlab Software

Trajectory (Element) 2.0 is compatible with:• Microsoft Windows 7• Microsoft Windows 8.1• Microsoft Windows 10• Microsoft Windows Server 2008• Microsoft Windows Server 2012 R2

For detailed and up-to-date information regarding compatible operating systems, please contactBrainlab support.Brainlab recommends protecting the system by state-of-the-art malware protection measures(e.g., installation of a virus scanner). Be aware that some malware protection measures cannegatively affect the system performance (e.g., if realtime scans are performed and each fileaccess is monitored, then loading and saving patient data may be slow).NOTE: The Brainlab system is a medical device and shall be used according to the intended useand the end user license agreement of the system. Using third party software can adversely affectthe reliability of the system.

Only critical operating system updates or malware protection measures are recommended.Driver updates are not allowed. Do not download or install updates during treatmentplanning. Please contact Brainlab support for further information.

DICOM Conformance

DICOM conformance statements can be found on the Brainlab homepage: www.brainlab.com/DICOM

Medical Electrical Systems

For information regarding the configuration of medical electrical systems, see the relevant SystemUser Guide and Technical User Guide.

GENERAL INFORMATION


1.5.2 Non-Brainlab Medical Devices

Compatible Non-Brainlab Medical Devices

Manufacturer Medical Device

Leksell

Stereotactic localizer

• Leksell Vantage MR Indicator interfac-ing with Leksell Vantage Headring

• Leksell Open MR Indicator Box, Lek-sell MR Indicator Box, Leksell OpenCT Indicator Box, Leksell CT IndicatorBox interfacing with Leksell G-FrameHeadring

Arc system

• Leksell Vantage Arc interfacing withLeksell Vantage Headring

• Leksell Multi-Purpose Arc interfacingwith Leksell G-Frame Headring

Inomed


• Revision R CT/MR Localizer interfac-ing with Inomed Titanium Headring

• Revision U CT/MR Localizer interfac-ing with Inomed Open Ceramic headr-ing

Arc system• Inomed ZD Arc interfacing with Inomed

Titanium or Inomed Open CeramicHeadring

Radionics


• Radionics UCLF-0 (Universal CompactCT/MR Localizer Frame) interfacingwith Radionics UCHR (Universal Com-pact Headring)

• Radionics LL01 Luminant Localizer in-terfacing with Radionics UCHR (Uni-versal Compact Headring)

• Radionics BRW-LF Luminant interfac-ing with HRA-IM (Intubation HeadRing) Localizer

Arc system

• Radionics CRW-ASL Arc interfacingwith Radionics UCHR or RadionicsHRA-IM

• Radionics Precision CRW Arc interfac-ing with Radionics UCHR or RadionicsHRA-IM

Using medical device combinations which have not been authorized by Brainlab mayadversely affect safety and/or effectiveness of the devices and endanger safety of thepatient, user and/or environment.

Non-Brainlab Medical Devices


1.6 Training and Documentation

Intended Audience

This user guide is intended for surgeons and/or their staff.

Brainlab Training

To ensure safe and appropriate use, before using the system all users should participate in atraining program held by a Brainlab representative.

Supervised Support

Before using the system for surgical procedures where computer-aided navigation is consideredcritical, ensure you perform a sufficient number of complete procedures with a Brainlabrepresentative present to provide guidance where necessary.

Responsibility

This system solely provides assistance to the surgeon and does not substitute or replacethe surgeon’s experience and/or responsibility during its use.

Documentation

This guide describes complex medical software that must be used with care.It is therefore important that all users of the system:• Read this guide carefully before handling the equipment• Have access to this guide at all times

Available User Guides

User Guide Contents

Software User Guides• Overview of treatment planning and image-guided navigation• Description of OR system setup• Detailed software instructions

Instrument User Guides Detailed instructions on instrument handling

Cleaning, Disinfection andSterilization Guide Details on cleaning, disinfecting and sterilizing instruments

System User Guides Comprehensive information on system setup

Technical User Guides Detailed technical information on the system, including specifica-tions and compliances

GENERAL INFORMATION


1.6.1 Used Abbreviations

Abbreviations

This user guide contains the following abbreviations:

Abbreviation Definition

AC/PC Anterior Commissure/Posterior Commissure

ADC Trace Map DTI Apparent Diffusion Coefficient

B0 DTI image acquired at b=0 sec/mm2

BOLD Blood Oxygen Level Dependent

CT Computed Tomography

DICOM Digital Imaging and Communications in Medicine

DTI Diffusion Tensor Imaging

MER/S Microelectrode Recording and Stimulation

MRI Magnetic Resonance Imaging

PACS Picture Archiving and Communication System

PET Positron Emission Tomography

Used Abbreviations


2 USING TRAJECTORY2.1 Introduction

General Information

Cranial Trajectory Planning is a medical device configuration based on Trajectory (Element)delivering all necessary product functions dedicated to cranial trajectory planning, such as e.g.:identify name and status of the loaded plan, add, modify and remove trajectories, as well asreview/approve trajectory planning results. The following anatomically interrelated trajectoryplanning data is contained in a treatment plan:• AC/PC localization• Custom orientation• Image sets, including windowing• Co-registrations• Objects• Fibertracks• Trajectories

Using Trajectory, you can plan possible pathways for the surgical instruments on the scannedimages.

Typical Workflow

The goal of Cranial Trajectory Planning is to create a minimally invasive trajectory path usingTrajectory (Element).

Step

1. Start session and load patient data.Select images, objects, fibertracks, trajectories, or plans, and load data.

2. Create, modify and remove co-registrations using Image Fusion.See the Software User Guide for Image Fusion for more information.

3. Create, modify and remove objects using SmartBrush or Anatomical Mapping.For more information, see the Software User Guide for SmartBrush or the SoftwareUser Guide for Anatomical Mapping.

4. Create, modify and remove fiber bundles using Fibertracking.See the Software User Guide for Fibertracking for more information.

5. Create, modify and remove trajectories using Trajectory (Element).

6. Save as a plan.

7. Identify the plan status and review/approve the plan using Trajectory (Element).

8. End the session.

USING TRAJECTORY


How to Load Patient Data

① ②

Figure 1

Step

1.

Select a workflow e.g., Trajectory Planning ① under the specialty Cranial.Alternatively, select e.g.. Stereotactic Planning ② under the specialty Stereotaxy.Patient Selection opens.

2. Select data in Patient Selection.NOTE: If you select a plan, all data referenced in that plan will be selected.

NOTE: For further information see the Software User Guides for Content Manager, Pa-tient Browser and DICOM Viewer.

Related Links

2.8 Stereotactic Planning and Localization on page 46

Introduction


2.2 Create, Modify and Remove Trajectories UsingTrajectory (Element)

Example View

Figure 2

How to Start Trajectory (Element)

Step

1.

Select Trajectory (Element) from your specialty workflow e.g., CRANIAL - TRAJECTO-RY PLANNING in Patient Data Manager.

How to Create a New Trajectory

Step

1.Select Create New.A new trajectory is created.NOTE: This option does not allow you to directly modify the properties.

NOTE: Brainlab recommends naming and assigning different colors to distinguish betweendifferent trajectories, objects, fiber bundles etc.

USING TRAJECTORY


How to Remove Trajectories

Step

1. Select the trajectory from the list in the tool bar.

2.Click Delete.The trajectory is removed.

Create, Modify and Remove Trajectories Using Trajectory (Element)


2.2.1 Software Functions

Menu Functions

Button Function

Activates the zoom function to the region of interest.NOTE: Alternatively use CTRL and the mouse wheel.

Activates scroll functions in the displayed reconstruction (plane). For each viewand interaction option, there is a dedicated scroll increment: • Click on the inview buttons: scrolls up/down 1 mm.• Drag the mouse pointer within the main view: scrolls up/down (zoom level de-

pendent).• Turn the mouse wheel with the mouse pointer over the inline side view: scrolls

up/down 1 mm in the trajectory direction.NOTE: Some scroll functions are available independently of Scroll being activat-ed.

Pans vertical and horizontal planes.NOTE: Alternatively use CTRL and the left mouse button to pan.

• Drag left or right across the viewing area to adjust the contrast.• Drag up or down to adjust the brightness.

• Selects the active trajectory.• Toggles between trajectories.

Automatically scrolls and pans the reconstruction to display the target or entry (atthe center of the view).

Rotates the current view.• Rotates the 2D reconstruction in relation to other views.• Rotates the 3D reconstruction plane.• Adjusts the scrolling plane (in specific views).

Undo the last change made or multiple consecutive steps.

USING TRAJECTORY


2.2.2 Modifying Trajectories

Overview

You can reposition the target and entry points for the trajectory within the views or by editing theDICOM and/or AC/PC relative coordinates of the trajectory. There are two options for this:• Drag the trajectory using the mouse pointer (or finger).• Amend coordinates directly in the menu.

The displayed DICOM coordinates always relate to the active image set.

How to Select an Active Trajectory

②

①

Figure 3 You can only interact with the active trajectory. Select other trajectories as follows:

Step

1. Select your trajectory using the menu ① in the tool bar.

2. Alternatively, use the Data selection menu ②.

Modifying Trajectories


How to Drag Target and Entry Points

①

Figure 4

Step

1. Drag the target or entry points ① using the mouse pointer (or finger on touchscreens) toreposition them on screen.

How to Amend DICOM or AC/PC Relative Coordinates

Step

1. Select the tab you want to edit, (e.g., AC/PC).

2. ①

Select edit ①.

USING TRAJECTORY


Step

3.

③

②

Select the reference point ② (AC Point, MC Point, or PC Point) for the coordinate sys-tem. NOTE: Depending on your settings, a default reference point is set.

4. Set the criteria for:- Target- Direction- Length (approx. 50-70 mm)

5. Confirm your settings ③.

Modifying Trajectories


2.2.3 Trajectory Positioning Controls

Trajectory Positioning Example

①

②

③

④

Figure 5

No. Explanation

① Target positioning selection area

② Entry positioning selection area

③ DICOM and AC/PC coordinate tabs

④ Edit menu

USING TRAJECTORY


2.2.4 Define Trajectory Properties

Trajectory Menu

Figure 6 Use the Trajectories menu within the Data selection menu to define and view trajectoryproperties e.g.:• Visibility switch (displays the distance between the target and entry)• Basis (the image set in which the trajectory is co-registered)• Name• Comment• Color• Shape (e.g., diameter)• Delete

Define Trajectory Properties


2.2.5 Creating 3D Shapes

General Information

You can assign the type, shape and characteristics of an instrument as a visual aid for positioningthe target and entry of an abstract trajectory.NOTE: The 3D shape feature is not intended to visualize implants.

How to Create 3D Shapes

Step

1.

Open the Data selection menu.

2.

Select a trajectory.

3.

Select Shape.

USING TRAJECTORY


Step

4.

①

Select a 3D Shape type from the drop down menu ①.

5. Select OK.

How to Adjust Shape Parameters

①

Figure 7 Each 3D shape type has parameters that can be adjusted.

Creating 3D Shapes


Step

1. Select a 3D Shape type from the drop down menu ①.

2.

Use Add Section to add a new marked section to the 3D shape.

3. Amend the parameters as appropriate to your surgical application, e.g.:- Diameter- Tip Offset- Offset- Length

4. Select OK.

USING TRAJECTORY


2.2.6 Memorize Function

Memorize

Button Function

Saves modified parameters to use as default settings for later use.

Memorize Function


2.2.7 Lead Properties

General Information

Specific lead models can be defined by assigning the model type and various additionalparameters. Based on these parameters, a corresponding lead model is created, and can then beutilized in other applications that interpret this information.

How to Define Lead Properties

NOTE: Brainlab recommends naming and assigning different colors to distinguish betweendifferent leads, trajectories, objects, etc.

①

②

③

④

⑤

⑥

Figure 8

Step

1.

Select Properties.

2. Optional: Edit the automatically assigned lead Name ①.

3. Optional: Edit the automatically assigned lead Implant Date ②.

4. Optional: Enter a Comment ③.

5. Required: Select lead Type ④.

6. Optional: Select lead Tip Offset ⑤

7. Optional: Select Location ⑥ in which the lead is situated.

8. Optional: Select a different lead and repeat lead definition.

USING TRAJECTORY


2.2.8 Defining the Lead Orientation

How to Define the Lead Orientation

①

Figure 9 If you have defined a directional lead, the Define Orientation view opens. Drag the orientationmarker ① to rotate the orientation.Select and hold Toggle Numbering to display how the contact numbering would be if connectedto the other IPG port.

Defining the Lead Orientation


2.2.9 AC/PC Coordinates Availability

About AC/PC Coordinates

The AC/PC coordinates are only enabled if:• AC/PC localization has been performed in the selected image set, or• The selected image set has been fused to an image set that is AC/PC localized

NOTE: Modifying the AC/PC localization does not change the trajectories defined within theAC/PC function. Trajectories always retain their position relative to the image data in which theywere created.

USING TRAJECTORY


2.2.10 Repositioning

Repositioning

The information provided by the AC/PC coordinates may be incorrect, inconsistent orinaccurate due to improper localization of the AC/PC system, or due to inherentinsufficiencies of the planning methods based on the AC/PC system. To prevent patientinjury, make sure to verify all trajectory positions in the patient image views (e.g., theDICOM and AC/PC tabs).

Repositioning


2.2.11 AC/PC Localization

General Information

You can define the AC/PC localization by:• The mid-sagittal plane• The positions at which the anterior commissure (AC) and the posterior commissure (PC)

intersect the mid-sagittal plane

When is AC/PC Localization Required?

AC/PC localization is required for:• Patient orientation, which is used for the alignment of reconstructed views (e.g., axial, coronal

and sagittal) in planning tasks• Trajectory planning based on definable AC/PC coordinates

How to Add AC/PC Localization

①

Figure 10

Step

1.Select Add AC/PC ①.The default AC/PC coordinates are displayed in the image views and canbe modified as needed.

USING TRAJECTORY


How to Modify AC/PC Localization by Dragging

②①Figure 11

You can adjust the AC/PC points and planes in the image views in order to reposition the AC/PCsystem as needed.

Step

1. Drag the target and entry points ① using the mouse pointer (or finger on touchscreens) inorder to reposition them.

2. Select Done ②.

AC/PC Localization


2.2.12 AC/PC Localization Details

AC/PC Localization Example

①

②

③

Figure 12

No. Explanation

① AC positioning selection area

② Distance between AC and PC points

③ PC positioning selection area

NOTE: AC and PC points are visible in all views.

How to Remove AC/PC Localization

Step

1.

Select edit.

2.

Select Clear AC/PC to remove the AC/PC localization.

USING TRAJECTORY


2.3 Save as a Plan

General Information

Always ensure that your planning results are saved as a plan with a dedicated name. This canthen be reviewed using Trajectory (Element).See Software User Guide for Content Manager and Patient Selection for more information.

Related Links

2.4 Identifying the Plan Status and Reviewing/Approving with Trajectory (Element) on page 37

Save as a Plan


2.4 Identifying the Plan Status and Reviewing/Approving with Trajectory (Element)

Plan Status

②①

Figure 13 The plan status ② is displayed within data selection. It states if a plan, for eaxmple, is a modifiedplan.Use MORE to view patient selection.

How to View Trajectories

Step

1.

Select Data selection from the top of the functions area.

USING TRAJECTORY


2.5 Data Selection View

Example View

The basis of a trajectory is outlined below:• The image set in which the trajectory is planned• The length (target to entry distance)• The name and its properties

① ② ③ ⑥

⑦

④ ⑤

Figure 14

View or load a resection object and/or other existing objects in the data view.

No. Explanation

① Trajectory object

② Image type

③ Toggle switch for selecting/deselecting 3D shapes

④ Toggle switch to show/hide all trajectories

⑤ ACS, Inline or Overview selection

⑥ Closes Data selection

⑦

Editable trajectory properties:• Name• Comment• Color• Shape

Naming Trajectories

Assign each trajectory a unique name so that it can be clearly identified.

Data Selection View


Overview

Figure 15 Overview displays the trajectory path in one of the ACS views, for example Axial and additionallyas Inline and Perpendicular.

ACS View

Figure 16 ACS view displays slices of the selected image set in Axial, Coronal, and Sagittal views.

USING TRAJECTORY


Inline View

Figure 17 Inline view allows you to compare the trajectory path in other views.

Data Selection View


2.6 Viewing and Reviewing Trajectories

General Information

Select Data to view and manage pre-existing assets (e.g., trajectories, objects and data types foryour trajectory).By switching between Overview, ACS and Inline layouts, you can see the entire course of thetrajectory and ensure that no critical structures are penetrated. Use the Inline view to scrollthrough the data set for verification purposes.

All planned trajectories must be verified in the image views.

How to Verify Trajectories

②① ③

④⑤

Figure 18

Step

1. Select your trajectory from the list ②.

2. Select a view from the side menu ①.

3. Move to the region of interest using the Pan and Zoom functions.

USING TRAJECTORY


Step

4.Select Scroll and scroll through the scan reconstructions using the buttonson the Overview layout ③.The scan depth is indicated by a point locater⑤ in the Axial view and by a yellow line ④ in the Inline view.

5. Verify your trajectory, then select Done.

NOTE: You can also verify trajectories using the Pan and Recenter buttons.

Viewing and Reviewing Trajectories


2.6.1 Data Verification

Data Verification

Always review your content for correctness after making modifications. Adding, changingor removing content such as objects, image data, windowing, fusions or trajectories maychange what you originally planned.Always review co-registrations individually and review each trajectory within each image set tosufficiently verify acceptance of any error propagations within a fusion.Always review the planning results from an unmodified plan.

USING TRAJECTORY


2.7 Trajectory Display and Verification

Trajectory Display

An intersection point is the point in 3D space where the trajectory axis intersects the displayedreconstruction plane.An intersection point is displayed:• Beyond entry• Between target and entry• Beyond target

When the depth position is placed on the target point, after clicking Center, the intersection pointindicates the exact position of the target.

① ② ③ ④ ⑤

Figure 19

No. Explanation

① The intersection point is beyond entry

② The intersection point is the entry

③ The intersection point is between the target and entry

④ The intersection point is the target

⑤ The intersection point is beyond the target

Trajectory Display and Verification


Cranial Example

Figure 20

USING TRAJECTORY


2.8 Stereotactic Planning and Localization

General Information

With the localization planning task, you can assign the localizer to the selected image set andperform stereotactic localization. Stereotactic localization provides a headring-specific coordinatesystem in which it is possible to calculate the arc settings for a planned trajectory.

Stereotactic localization should be performed prior to planning trajectories or objects inthe image set, as well as prior to performing image fusion, to ensure consistentvisualization of planning content in all views.

Hardware

Carefully check the accuracy of your localization hardware on a regular basis.

Localization is only possible in combination with fully functional hardware. If the localizerhardware is defective or damaged, or if the rod geometry is incorrect, this can either causelocalization to fail, or lead to incorrect results.

Supported Images

Imaging modalities that cause image distortions (e.g., MR EPI data sets) or improper rod markerrepresentation (due to poor contrast) cannot be properly localized.

General Workflow

Step

1. Select the image set scanned with the localizer.

2. Select your chosen localizer from the toolbar.Localization starts automatically.

For reviewing and correcting localization results, follow these steps:

Step

1. Review each slice with regards to rod detection definition.This applies to all slices, e.g., green, yellow and red.In the case that a rod is not detected correctly, manually correct its position.In the case that a rod is not detected at all, use Add Rod to position it manually.

2. Use Ignore Slice for slices outside the localizable range (i.e., for slices outside thelocalizer geometry, showing none or insufficient number of rods).

3. Select Localize after performing the adjustments in order to get a new localizationresult based on verified and corrected rod detections.

4. Continue using Ignore Slice to exclude single slices, containing e.g., air bubbles.However, do not use Ignore Slice to correct image distortions, artifacts or defectivelocalizer hardware with e.g., loose or bent plates.

NOTE: If too many slices have been ignored (e.g., due to defective hardware or scanningartifacts), localization cannot be calculated. In this case, the localizer needs to be repaired and/ora new scan must be acquired.

Stereotactic Planning and Localization


Failed Localization

If no slices could be localized:

Step

1. Check the assigned localizer.

2. If the wrong localizer has been selected, assign the correct localizer and repeatlocalization.

3. Start the steps according to the general workflow.

How to Start Stereotaxy (Element)

Step

1.

Select Stereotaxy (Element) from your specialty workflow e.g., STEREOTAXY – STER-EOTACTIC PLANNING in Patient Data Manager.

USING TRAJECTORY


2.8.1 Localizing the Image Set

General Information

The first step in performing localization is localizer assignment. This provides a frame of referencefor the slice set.

How to Localize the Image Set

Step

1. Select the image data from Content Manager.

2.

Select Frame Planning.

3.Select Localization.The screen changes to localization mode.

4.

Select your localizer from the drop down menu. Make sure you choose the same combi-nation that was used during scanning.Localizing starts automatically.

You must select the correct localizer for localization. If an in-correct localizer is selected, all slices might be successfullylocalized, however, the subsequent coordinate system, basedon a combination of localizer, headring and arc system, will beincorrect.

Localizing the Image Set


2.8.2 Localization Status Result

Localization Status Report

Figure 21 The software localizes the available slices and displays a status report of the localization.

USING TRAJECTORY


2.8.3 Localization Example

Localization Main Screen Example

① ② ③

④⑤Figure 22

Screen Explanation

No. View Explanation

① Catalog

Depending on the localization result, the color of the slices varies:• Green: Slice successfully localized.• Yellow: Slice has been localized, but precision is low due to one or

more misplaced rod markers, poor image quality or an inaccurate lo-calizer geometry.

• Red: Slice could not be localized. Several reasons are possible,e.g., not enough rods detected.

② Main

Shows the slice currently selected in the catalog view and whether theimage slice could be localized (upper left corner).Rod marker colors:• Green: Localized rod markers.• Yellow: Rod markers with poorest localization result.• Blue: Indicates that some, but not all rod markers could be localized.

③ Functions area Use the functions to modify the localization as needed.

④Magnified axialview

Shows a magnified view of the area indicated by the white dotted cir-cle in the main view. Use this view to better examine the position of aparticular rod marker. To magnify another area, click on a different rodmarker.

⑤ 3D

3D view of all detected rod markers together with the expected localiz-er geometry.Use this view to verify the localizer rod geometry and identify sliceswith misplaced rod markers. Rod markers should reconstruct in astraight line.

Localization Example


Verifying Localization

Carefully visually verify the contents of each view, in order to ensure that localization has beensuccessful.

Verify that every slice has been localized correctly, (e.g., using the 3D view). Even if thesoftware indicates that a slice has been localized successfully (displayed in green in thecatalog view) the slice must be checked. For example, the arrangement of the rods may becorrect, but due to artefacts, the rod geometry as a whole may be displaced.

Rod Marker Positions

If a gantry tilt is used for CT scans, or if a scan is oblique (e.g., MR), the image slices must stillintersect the rods of the localizer at a perpendicular angle. Refer to the scanning instructions foracceptable gantry tilt or oblique angles.

How to Adjust the Threshold

①Figure 23

Step

1. Adjust the Threshold by using the slider ①. If necessary, adjust the threshold value usedto detect rod markers.

USING TRAJECTORY


2.8.4 Ignoring Slices

When to Ignore Slices

The Ignore Slice function allows you to exclude slices with insufficient rod marker definition fromthe localization calculation. This might be used for slices where it is not possible to manuallyposition rod markers.When you ignore such slices, the slices are no longer considered for localization calculation,however they keep their relative position within the image set.The Ignore Slice function does not delete slices from the localization.NOTE: The Ignore Slice function is contraindicated if you are using scans during which thepatient moved, or if image sets show distortions, or for correction of defective localizer hardwarecontaining impurities, (e.g., many air bubbles).

Ignored slices of a data set may lead to an inaccurate localization as a result of not usingall available rod marker information for localization. The user must make sure to localize asmany slices as possible so that the localization precision of each slice is as high aspossible. Only ignore slices that cannot be localized manually.

Localizer Hardware

Localization is only possible in combination with reliable hardware. If the localizerhardware is defective due to, for example, air bubbles in the rods, localization will not bepossible.

How to Ignore Single Slices

Step

1. Select the slice in the catalog overview.

2. Click Ignore Slice.The localization result is updated and the slice color in the catalog overview changes fromred/yellow to gray.

How to Ignore Multiple Consecutive (Intermediate) Slices

Step

1. Press SHIFT on the keyboard and select the first slice to be ignored.Keeping SHIFT pressed, select another slice to be ignored or use a double click on aslice to select all neighbored slices showing the same color.

2. Click Ignore Slice. The selected slices and all those in between are ignored from the lo-calization.The localization result is updated and the slice color in the catalog overview changes fromred/yellow to gray.

Ignoring Slices


2.8.5 Adding and Positioning Rod Markers

When to Add or Position Rod Markers

You can manually add rod markers to the slice if the software is not able to localize a slicebecause an insufficient number of rod markers have been detected (due to e.g., bubbles in therods, unfavorable scan parameters, or T1/T2 weighting).You can reposition rod markers in the selected image slice if a slice cannot be localized due tomarker rods that were incorrectly or inaccurately positioned.

How to Add Rod Markers

① ③ ②Figure 24

Step

1. Select the desired slice in the catalog overview ① and click Add Rod ②.

2. Click in the magnified view ③ to finely adjust the marker position as needed.

3. Continue in this way until the required amount of rod markers have been added.NOTE: The Add Rod function is deactivated when a sufficient number of markers hasbeen added.

How to Repeat Image Slice Localization

Step

1. After you have manually modified rod markers, click Localize.

USING TRAJECTORY


2.9 Stereotactic Localizers

General Information

Depending on the type of stereotactic localizer that you select, the scan modality and orientation,the number of rod markers and their geometry, may vary.The tables in this section provide information on the rod marker geometry for your localizer.

Leksell MR/CT Indicators

Scan Modality/Orientation Rod Marker Geometry

MR/coronal

MR/axial (including backplate)

MR/axial (without backplate)

MR/axial (without frontplate or backplate)

CT/axial

Stereotactic Localizers


Radionics BRW-LF


CT/axial

Radionics UCLF/Luminant


CT and MR/axial

MR/coronal

Inomed Rev. R


CT and MR/axial (upmount)

CT and MR/axial (without frontplate)

USING TRAJECTORY


Inomed Rev. U


CT and MR/axial (including frontplate)

CT and MR/axial (without frontplate)

Stereotactic Localizers


2.10 Supported Arc Systems

General Information

Trajectory supports the following arc systems:• Leksell Vantage Arc• Leksell Multi Purpose Stereotactic Arc• Inomed ZD Arc System• Radionics CRW-ASL Arc• Radionics Precision CRW Arc

USING TRAJECTORY


2.10.1 Leksell Stereotactic Systems

General Information

Trajectory supports:• Leksell Vantage Arc, mounted on the Leksell Vantage Headring• Leksell Multi Purpose Stereotactic Arc, mounted on the Leksell G-Frame Headring.

Leksell G-Frame Headring

The G-Frame Headring must be oriented on the patient’s head with the removable front piece(anterior part of the frame) pointing towards the anterior portion of the patient’s head.Other orientations are not supported by Trajectory.

Leksell Stereotactic Systems


2.10.2 Leksell Vantage Arc

General Information

Please consult the arc manufacturer’s manual for further information.

Leksell Vantage Arc Mounting Options

Option Illustration

Lateral right

Lateral left

USING TRAJECTORY


2.10.3 Leksell Multi Purpose Stereotactic Arc

General Information

The mounting position of the Leksell Multi Purpose Stereotactic Arc is the side of the arc wherethe X- and Y-scale can be read.In the lateral right position for example (see table), the scales point to the right side of the frameand the patient’s head, respectively.Please consult the arc manufacturer’s manual for further information.

Position Comment

Sagittal anterior The arc’s Y-scale matches with the frame’s Y-scale.Therefore, the Y-value must be read for sagittalanterior and sagittal posterior mountings.

Sagittal posterior

Lateral left The arc’s X-scale matches with the frame’s X-scale.Therefore, the X-value must be read for lateralleft and lateral right mountings.

Lateral right

Recommended Ranges

Scale Range

X 40...160 mm

Y 25...175 mm

Z 65...160 mm

Arc angle 60°...167°

Ring angle 0°...360°

Leksell Multi Purpose Stereotactic Arc Mounting Options

Option Illustration

Lateral left (X/Y-scale, see arrow)

Leksell Multi Purpose Stereotactic Arc


Option Illustration

Lateral right (X/Y-scale, see arrow)

Sagittal anterior (X/Y-scale, see arrow)

Sagittal posterior (X/Y-scale, see arrow)

USING TRAJECTORY


2.10.4 Inomed ZD Arc System

General Information

Trajectory allows for mechanical restrictions and ensures the overall stability of the Inomed ZDArc System by limiting the adjustable range of scales.The supported range of settings is therefore restricted compared to the arc system. Trajectorysupports the ranges indicated in the table.Should you need a wider range, contact Brainlab.

Recommended Ranges

Scale Location Range

A1 Right-angled drum axle 0 mm...65 mm

A2 Right-angled drum axle 20 mm...0 mm

B1 Fixation rail 0 mm...75 mm

B2 Fixation rail 75 mm...0 mm

C Right-angled drum 0 mm... 105 mm

D1 Drum axle 0°... 360°

E Arc 20°... 110°

Arc Setting Module Scale

The following table shows the relation between the stereotactic coordinate axes and the arcsetting modules (scales) for the upmount orientation:

Position of the ZD Arc on theHeadring

Stereotactic Coordinate Ax-es

Corresponding Scale of theZD Arc Setting Module

0°, anterior+X (-X)+Y (-Y)

B2 (B1)A1 (A2)

90°, lateral right+X (-X)+Y (-Y)

A1 (A2)B2 (B1)

180°, posterior+X (-X)+Y (-Y)

B2 (B1)A2 (A1)

270°, lateral left+X (-X)+Y (-Y)

A2 (A1)B2 (B1)

Inomed ZD Arc System Mounting Options

The following table shows the options for the upmount orientation:

Inomed ZD Arc System


Option Illustration

270°, lateral left

90°, lateral right

0°, anterior

180°, posterior

USING TRAJECTORY


2.10.5 Radionics Arc Systems

General Information

Trajectory supports:• Radionics CRW-ASL Arc• Radionics Precision CRW Arc

Recommended Arc Ranges

Scale Range

A-P -100...100 mm

Lateral -100...100 mm

Vertical -67...65 mm

Arc angle 60°...0°...60°

Ring angle -30°...90°...-30°

Radionics Mounting Options

Option Illustration

Probe carrier anterior or posterior (trunion ringsare in the left-to-right position)

Probe carrier lateral left or lateral right (trunionrings are in the front-to-back position)

Radionics Arc Systems


2.11 Stereotactic Report

General Information

Before you can generate a report you must first have:• Created a trajectory• Localized your image set

How to Generate a Report

Step

1.

Select Arc Settings.

2.

Select Create Report.

3.

Enter a name for your plan and choose Save. Saving a plan is always required. It allowsyou to restore the information used to create a report.

USING TRAJECTORY


2.11.1 Report Functions

Button Function

Pan around the report.

Zoom to an area of the report.

Fits the report to the width of the screen.

Closes the report.

Saves the report to a specified location.

Prints the report to a specified printer.

Report Functions


2.11.2 Report Content

About Report Content

Figure 25 The first page of the stereotactic report contains mandatory information about the selectedtrajectory and subsequent arc settings as selected in the application:• Patient information• Trajectory information• Headring coordinates of selected trajectory• Arc settings for selected mounting orientation

USING TRAJECTORY


Figure 26 The second page of the stereotactic report contains extended information about the selectedtrajectory, e.g.,• Patient information• Trajectory information• Alternative mounting positions with according arc settings• AC/PC coordinates of target point• Headring coordinates of AC/PC system• DICOM coordinates of target and entry points

Report Content


2.12 Ending the Session

Saving and Closing Trajectory Planning

Button Explanation

Returns you to Content Manager.

Selecting Done:• Saves added, modified or removed data.• Closes Trajectory (Element).

NOTE: Ensure that you have saved your changes by selecting Done within allthe Elements you are working with. This ensures that all your currently vieweddata is successfully and safely saved as a plan when you select Save as plan.

Pressing the Home button returns you to Content Manager without saving opentasks.

See the Software User Guide for Content Manager and Patient Selection for more information.

USING TRAJECTORY


Ending the Session


INDEXNumerics

3D shape.................................................................................... 25

AAC Point..................................................................................... 22AC/PC Localization.................................................................... 33active trajectory.......................................................................... 19Add AC/PC................................................................................. 33Add Section................................................................................ 27anterior commissure...................................................................33

BBack........................................................................................... 69Brainlab support........................................................................... 5

CCenter.........................................................................................19compatibility

Fibertracking...........................................................................10iPlan Stereotaxy..................................................................... 10Lead Localization....................................................................10Object Manager...................................................................... 10Patient Data Manager.............................................................10SmartBrush.............................................................................10

contact data..................................................................................5

DData selection

views.......................................................................................38defining AC/PC coordinates....................................................... 33Diameter................................................................................26,27disposal instructions..................................................................... 7documentation............................................................................13Done...........................................................................................69

Ffeedback.......................................................................................5

Gguides.........................................................................................13

HHome button...............................................................................69

IImage Fusion..............................................................................10instrument shape........................................................................25

LLength........................................................................................ 27loading data................................................................................16

Mmanuals......................................................................................13manufacturer................................................................................ 5MC Point.....................................................................................22Memorize....................................................................................28mid-sagittal plane....................................................................... 33modified plan.............................................................................. 37

NNeedle........................................................................................ 26new trajectory............................................................................. 17

Oobject information....................................................................... 37Offset..........................................................................................27

PPan........................................................................................ 19,66patient data.................................................................................16PC Point..................................................................................... 22plan status.................................................................................. 37planning......................................................................................15posterior commissure................................................................. 33Print............................................................................................ 66Probe..........................................................................................26

Rremove trajectories.....................................................................18Report

report functions.......................................................................66repositioning coordinates

ac/pc.................................................................................. 21,32amending................................................................................21DICOM....................................................................................21dragging.............................................................................21,34

repositioning trajectories............................................................ 20Rotate.........................................................................................19

SSave

Save....................................................................................... 66Screw......................................................................................... 26Scroll.......................................................................................... 19SmartBrush................................................................................ 10start stereotaxy...........................................................................47start trajectory.............................................................................17support......................................................................................... 5sustainability.................................................................................7

TTip Offset.................................................................................... 27training........................................................................................13Trajectory

how toclose Trajectory...................................................................69

INDEX


how to close............................................................................69

UUndo...........................................................................................19user guides.................................................................................13

VVerify Trajectories

how to..................................................................................... 41Views

image overview.......................................................................38

WWEEE...........................................................................................7Windowing..................................................................................19workflow..................................................................................... 15

ZZoom..................................................................................... 19,66

INDEX


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