Deep brain stimulation is the main type of surgery that has been performed for decades, to treat the physical symptoms of Parkinson’s, and some other movement disorders/dystonia. It involves implanting very fine wires, with electrodes at their tips, into the brain. These are connected to extensions that are tunnelled under the skin behind the ear and down the neck, which are then connected to a pulse generator (a device like a pacemaker), which is placed under the skin around the chest or stomach area. When the device is switched on, the electrodes deliver high frequency stimulation to the targeted area. This stimulation changes some of the electrical signals in the brain that cause the symptoms of Parkinson’s.

As DBS aims to improve quality of life, safety is an absolute priority. Large patient series studies have shown that an MRI-guided and MRI-verified approach carries a lower risk of haemorrhage and deficit than other surgical methods, with favourable long-term clinical outcomes.

MRI sequences can accurately localize intracranial structures directly in individual patients under general anaesthesia (GA), without the need for conscious intraoperative clinical testing or neurophysiological recording. The radiological anatomy enables direct targeting, confirms lead position, and guides relocation if required.

Additional benefits of the MRI-guided and MRI-verified approach include increased patient comfort and reduced anxiety as well as avoidance of complete medication withdrawal, and consequently less confusion experienced by the patient in the perioperative period.

Milpark Radiology Inc. in conjunction with the neurology and neurosurgical teams led by Dr D Anderson, Specialist Neurologist, and Dr M Zorio, Specialist Neurosurgeon, have the equipment and expertise to utilise the MRI guided and verified surgical technique at our institution.

Our multidisciplinary team has been fortunate to be advised and mentored by Dr L Zrinzo and the highly experienced team at University College London, and are invaluably supported by the dedicated team from Medtronic.

By observing very strict parameters and precautions, the majority of patients with implanted DBS hardware can be safely imaged with MRI.

In the past year since inception, more than 20 MRI guided and verified DBS procedures have been performed at Milpark Hospital, and numerous patients with pre-existing DBS implants have safely undergone MRI imaging for other indications in our Radiology department.

Dr Rebecca Such
MBBCh,FCRad(D)SA


MILPARK RADIOLOGY INC

 

BACKGROUND

Despite surgical treatment remaining the gold standard for the excision of tumours, thermal ablation recently emerged as an excellent alternative for the treatment of selected primary and secondary malignant lesions of the lungs. The best candidates are the patients who are not fit for or not willing to have the extensive surgery required to excise malignant tumours. The benefits of radiofrequency lung ablation include lower incidents of complications, relatively quick recovery time and lower cost.

HISTORY

69 year old female with stage 4 colon carcinoma.

After the primary tumour was managed, a liver metastasis was removed in 2013 and a lung metastasis (RLL) resected in November 2014. The histology of all the lesions was moderately differentiated colonic adenocarcinoma.

On the follow up CT chest in May 2015, two new lesions were diagnosed in the lungs (7mm in the RLL and 5mm in the LLL) and they were referred for the ablation treatment.

The procedure was done under GA. The ablation time was about 13-14 min altogether (first with the temperature setting at 90C and then 100C).

There were no immediate complications and the follow-up CT performed after 24 hours showed a well formed demarcation zone with pleural reaction and inflammatory response of the adjacent lung. Pneumothorax was minimal and did not necessitate tube insertion.

The patient tolerated the procedure well and was discharged the following day almost pain free.

The ablation of the second lesion is planned in a month time.

 

Images of the ablation team busy with the ablation

TheAblationTeam1
The ablation team
DrStanojevic1
Dr Stanojevic busy with the procedure
TheAblationSite1
The ablation site 
RightLungNodule1
Right Lung Nodule – Planning for RFA
RFAProbeintheLesion1
001 RFA Probe in the lesion
Immediatescanpostablation1
005 Immediate scan post ablation shows lesion necrosis
Day 1 - 002 24 hour scan shows well formed demarcation zone, adjacent thermal pneumonitis, pleural reaction and minimal pneumothorax

 

 

What are the indications?

Uterine fibroids (sometimes referred to as leiomyomas) are the most common tumors of the female genital tract. They are noncancerous and do not always cause symptoms. However, in some women, their size and location can lead to problems, like pain and heavy bleeding as well as pressure on urinary bladder or bowel.

Embolization is an excellent alternative to surgical removal of fibroids or the whole uterus; blockage of the arteries supplying the uterus lead to the shrinkage of the fibroid and 90% of women experience relief of the symptoms.

Procedure

Before the intervention you will need ultrasound and MRI evaluation of your uterus, which will confirm that the fibroids are the cause of your problems.

The procedure is similar to general angiography and embolization.

The radiologist will, with a help of X-rays, place the tiny tube (micro catheter) into the artery supplying the blood to the fibroids and inject contrast to outline them;

The preferred agents for occlusion of the bleeding artery are polyvinyl alcohol particles or embospheres, which will slowly flow into the uterus and nearly completely occlude selected artery. As the uterus is supplied by both right and left uterine arteries, the procedure will be repeated on the other side.

Is there any additional risk?

The possibility that the embolization agent can dislodge into the arterial system and deprive healthy tissue of blood supply is minimal. It is avoided by the careful positioning of the micro catheter supraselectively into the uterine artery.

Sometimes, the anatomy of the bleeding artery and its branches may be too complex for the safe placement of tube. In that case the radiologist will advice you that the procedure is not technically feasible and your attending doctor will present you with the other (possibly surgical) treatment options.

Some patients complain of cramping and pain in the pelvis over the next 24-48 hours after the procedure, which will necessitate administration of painkillers.

It is not uncommon to experience flu-like symptoms (post embolization syndrome) for 5-7 days after the procedure. Mild fever, nausea, aching and pain are usually managed easily with medication.

The other risks are similar to general angiography and embolization

Can I become pregnant after the procedure?

Normal pregnancies and births have been reported after the embolization. However not enough research has been done to confirm that pregnancy won't be affected by the procedure. Therefore, most physician recommend against future pregnancies after the embolization procedure.

What are the indications?

Ovarian veins embolization is a minimally invasive procedure used to block blood flow to the veins causing pelvic congestion and consequent pain.

Procedure

The procedure can be done on an outpatient or inpatient basis and is generally similar to general angiography and embolization and particularly to testicular vein embolization in males.

The radiologist will, with a help of X-rays, place the tiny tube (angiographic catheter) into the vein draining your ovaries and inject contrast to demonstrate the cluster of serpentine veins in your pelvis.

The preferred agents for embolization are coils or rarely sclerosing liquids. After administration, repeated injection of contrast will confirm that the ovarian veins are completely blocked.

The catheter will be removed and you will be monitored in the X-ray department for 2-3 hours for the possible complications.

Is there any additional risk?

The possibility that the coils can dislodge into the venous system and be flown into your lungs is minimal. Even if it happens, you will probably not notice it, as the lungs vasculature capacity is big enough to compensate. Sometimes we may need to use vascular foreign body retrieval system to catch the loose coil. You will be advised to avoid any heavy physical activity for the 5-7 days in order to prevent late dislodgement.

Sometimes, the anatomy of the ovarian veins and their branches may be too complex for the successful blockage. In that case the radiologist will advice you that the procedure is not technically feasible and your attending doctor will present you with the other treatment options.

Some patients complain of mild discomfort and pain in the pelvis over the next 24-48 hours after the procedure, which will necessitate administration of painkillers.

Pelvic pain is a very common symptom in women and it is sometimes difficult to select the patients that will benefit from embolization. As the multiple additive causes may be responsible for the symptoms, a team of physicians should be involved in order to produce desirable results.

The other risks are similar to general angiography and embolization

 

What are the indications?

Repeated episodes of severe bleeding from your nose despite adequate surgical packing and blood pressure control suggest presence of arterial-venous malformation or simply weak blood vessels at the back aspect of your nasal cavity. ENT specialist may try to cauterize ("burn") bad arteries, but it is not always technically possible. Embolization is usually the best treatment in such a case.

Procedure

The procedure is similar to general angiography and embolization.

The interventional radiologist will, with a help of X-rays, place the tiny tube (micro catheter) into the artery of interest (a branch of the artery supplying blood to your face) and administer contrast to demonstrate the site of bleeding.

The preferred agents for occlusion of the bleeding artery are polyvinyl alcohol particles or embospheres, which will permanently occlude selected arteries.

Is there any additional risk?

The possibility that the embolization agent can dislodge into the arterial system and deprive adjacent healthy tissue of blood supply is minimal. It is avoided by the careful positioning of the micro catheter supraselectively next to the bleeding spot. The radiologist will carefully check the arteries supplying your brain and eyes to demonstrate presence of any dangerous collateral vessel and avoid complications like blindness or stroke

Sometimes, the anatomy of your external carotid artery (the one supplying blood to your face) and its branches may be too complex for the safe placement of tube. The radiologist will then try to safely occlude bigger artery for the area of interest or advice you that the procedure is not technically feasible. In that case your attending doctor will present you with the other treatment options.

Very seldom you may feel mild pain in the face 24-48 hours after the procedure, which is often treated by simply warming up the face. Sometimes it will necessitate administration of painkillers.

The other risks are similar to general angiography and embolization.

 

What are the indications?

Severe bleeding from the lungs with expectoration of blood is known as haemoptysis. The common causes for the bleeding include lungs infections like chronic bronchitis, bronchiectasis, TB or cystic fibrosis. Rarely, tumors of the lungs may also bleed.

Procedure

Same as for general angiography and embolization.

The radiologist will, with a help of X-rays, place the tube into the bronchial artery and administer embolization material.

Sometimes your doctor will organize CT Angiogram before the intervention in order to better delineate vascular anatomy and identify the origin of bronchial artery.

The preferred agents for occlusion of the bleeding vessels are Polyvinyl Alcohol (PVA) particles or acrylic polymer spheres (Embospheres); they allow permanent blockage of the site of bleeding.

Is there any additional risk?

Sometimes, the bronchial artery communicates with the artery supplying your spinal cord (spinal artery) and in that case the injection of embolization material may cause cord infarct and paralysis. The doctor will perform series of X-rays to make sure that the catheter is in a stable position for the safe administration of the agent. In rare occasions, he may advice you that the procedure is technically not possible.

The possibility that the embolization agent can dislodge into the arterial system and deprive healthy organs of blood supply is minimal. It is avoided by the careful monitoring of the administration of particles by high resolution X-ray equipment.

You may feel moderate pain in the chest 24-48 hours after the procedure, which will necessitate per oral or IV administration of painkillers.

Despite using permanent embolization material, repeated infections in the chest often recruit new pathological vessels and bleeding may recur. This will necessitate repeated procedure.

The other risks are similar to general angiography and embolization

 

When Milpark Radiology Inc purchased and installed the new large bore Siemens MRI scanner planning was already in place to accommodate intraoperative MRI.

This required placing the magnet directly inline next door the new advanced neurosurgical theatre suite.

A uniquely designed special motorised door separates the theatre from the MRI suite, only operable from the neurosurgical suite side.

The patient is positioned onto a special table which is compatible with both the operating table and the scanner table facilitating movement of the patient between the neurosurgical suite and the mri scanner maintaining the exact surgical and imaging positions.

This is done before anaesthetising the patient , and positioning between sugery and imaging during anaesthesia are exactly the same, which allows for repeat scanning during surgery without changed positions easily and quickly, so there are no lesion positional changes due to intraoperative brain deformation movements.

The neurosurgical suite and MRI suite have special positive pressure air conditioners so sterility is maintained during transfer between the surgical and imaging suites Specialised anaesthetic controls maintain patient support in transferring the patient safely between the 2 facilities.

WHAT IS INTRAOPERATIVE MRI?

In most intraoperative MRI cases the patient will already have had imaging done to determine the size, position of the lesion, enhancment characteristics, tractography if necessary to show the neurology tracts related to the lesion,and if necessary, functional imaging to detect regions of eloquent brain relatedto the lesion to be resected.

This allows for safer lesion resection, gives a better guide to avoid related neurological tracts which may be affected.
Brain lesions may be difficult to distinguish from adjacent normal brain. The neurosurgeon thus relies on anatomical landmarks in guiding resections. These are frequently deformed after craniotomy because the brain changes shape during surgery, particularly with large tumours.
The average amount of displacement has been reported to be lcm.

Intraoperative MRI is typically performed after the surgeon has removed as much of the tumour as possible with no neurological deficit.
The sequences utilised include those which best depicted the lesion on preoperative scanning, may be with / without contrast depending on the lesion type.

The availability of this facility allows for more complete and safer lesion resection than previous! techniques which did not have the facility to reassess the extent of the residual lesion intraoperatively.
Previously imaging after surgical closure demonstrated some of the lesion remaining which would require repeat 2nd surgery,with its allied anaesthesia and associated risks to resect residual tumour. This second operation is­­ avoided due to imaging during surgery to allow for better localisation and lesion resection in case brain movement and subsequently lesion movement occurred intraoperatively.

If further pathology is detected the patient is returned to the operating suite for further resection, under the same anaesthesia and surgical sitting.
If not, the operation is completed and no further imaging required.
Better more complete tumoral resection occurs due to this intraoperative imaging technique.

CLINICAL INDICATIONS FOR INTRAOPERTIVE MRI

Tumours, both primary and secondary. The surgical removal of glioma's and glioblastomas is a common indication. These malignant brain tumours are best treated by the most complete resection possible.
Pituatary adenomas are also a common indication for intraoperative MRI.
These are usually approached by a trans-sphenoidal route.
Epileptic foci can be obliterated.
Vascular malformations such as cavernous malformations, AV malformations and AV fistulae can be resected.
Intraoperative MRI can also be used to check for complications such as bleeding or ischaemia.


For more information please contact Mr Brett Sher, practice manager,
at Milpark Radiology Inc, Milpark hospital, 9 Guild Road, Parktown
West on 011 7264229.

 

REFERENCES
 
Hall WA and Truwit CL (2008). Intraoperative MR-guided neurosurgery. J Magn Reson Imaging 27:368-75
 
Kuhnt D, et al. (2011). Correlation of the extent of tumour volumn resection and patient survival in surgery of glioblastoma multiforme with high-field intraoperative MRI guidance. Neuro Oncol 13:1339-48
 
Kuhnt D, et al. (2011). Quantification of glioma removal by intraoperative high-field magnetic resonance imaging: an update. Neurosurgery 69:852-62; discussion 62-3
 
Schulz C, et al. (2012). Intraoperative image guidance in neurosurgery: development, current indications, and future trends. Radiol Res Pract 2012:197364
 
Sun GC, et al. (2011). Intraoperative MRI with integrated functional neuronavigation-guided resection of supratentorial cavernous malformations in eloquent brain areas. J Clin Neurosci 18:1350-4
 
Yoon PH, et al. (2001). Pituitary adenomas: early postoperative MR imaging after transsphenoidal resection. AJNR Am J Neuroradiol 22:1097-104
 

 

What are the indications?

Varicocele is an enlargement of the veins in the scrotum (a bag containing your testicles). They usually develop slowly and only occasionally cause dull pain or pressure in the scrotum. If left unattended, they interfere with the sperm production, which may result in male infertility.

Embolization is an excellent alternative to surgical ligation. It does not involve general anesthesia, surgical incision or suture/scar in your groin or scrotum. You can go back to your active lifestyle in only a few days time.

Procedure

Before the intervention you will need ultrasound evaluation of your scrotum, which will confirm that the varicocele is the cause of your problems.

The procedure is done on an outpatient basis but is generally similar to general angiography and embolization.

The radiologist will, with a help of X-rays, place the tiny tube (angiographic catheter) into the vein draining your testicle and inject contrast to demonstrate anatomy of the veins and identify possible collaterals, which may be responsible for the recurrence.

The preferred agents are coils or sclerosing liquids. After administration, repeated injection of contrast will confirm that the testicular veins are completely blocked.

After removal of the catheter, you will be monitored in the X-ray department for 2-3 hours for the possible complications and discharged.

Is there any additional risk?

The possibility that the coils can dislodge into the venous system and be flown into your lungs is minimal. Even if it happens, you will probably not notice it, as the lungs vasculature capacity is big enough to compensate. Sometimes we may need to use vascular foreign body retrieval system to catch the loose coil. You will be advised to avoid any heavy physical activity for the 5-7 days in order to prevent late dislodgement.

Sometimes, the anatomy of the testicular veins and their branches may be too complex for the successful blockage. In that case the radiologist will advice you that the procedure is not technically feasible and your attending urologist will present you with the other (possibly surgical) treatment options.

Some patients complain of mild discomfort and pain at the back over the next 24-48 hours after the procedure, which rarely necessitates administration of painkillers.

The other risks are similar to general angiography and embolization

What are the chances of me becoming a father?

This will depend on different factors, but in your case mostly on duration of varicocele presence. It has been proven that pregnancy rates in infertile couples improve after varicocele repair by about 30-50%

 

What are the indications?

Severe bleeding as a consequence of polytrauma most often happens in the abdomen or pelvis. Embolization is usually the first line of treatment.

Procedure

Your attending trauma surgeon will organize CT Angiogram before the intervention in order to better delineate vascular anatomy and identify the site of bleeding (so-called "vascular blush"). The results of this test will be analyzed by the interventional radiologist who will then plan the appropriate treatment.

The procedure is similar to general angiography and embolization.

The radiologist will, with a help of X-rays, place the tiny tube (micro catheter) into the artery of interest and administer contrast to demonstrate the site of bleeding.

The preferred agents for occlusion of the bleeding artery are micro coils, which will permanently occlude selected artery combined with gelatin sponge aiming to decrease the pressure in the whole vascular territory and prevent repeated episodes of bleeding.

Is there any additional risk?

The possibility that the embolization agent can dislodge into the arterial system and deprive healthy tissue of blood supply is minimal. It is avoided by the careful positioning of the micro catheter supraselectively next to the bleeding spot.

Sometimes, the anatomy of the bleeding artery and its branches may be too complex for the safe placement of tube. In that case the radiologist will advice you that the procedure is not technically feasible and your attending doctor will present you with the other (possibly surgical) treatment options.

Very seldom you may feel mild pain 24-48 hours after the procedure, which will necessitate administration of painkillers.

The other risks are similar to general angiography and embolization.

 

What are the indications?

Severe gastrointestinal bleeding can be a consequence of arterial-venous malformation, ulcer, diverticular disease or tumor. Embolization is usually the first line of treatment of any of these causes.

Procedure

Your attending doctor will organize CT Angiogram before the intervention in order to better delineate vascular anatomy and identify the site of bleeding (so-called "vascular blush"). The results of this test will be analyzed by the interventional radiologist who will then plan the appropriate treatment.

The procedure is similar to general angiography and embolization.

The radiologist will, with a help of X-rays, place the tiny tube (micro catheter) into the artery of interest and administer contrast to demonstrate the site of bleeding.

The preferred agents for occlusion of the bleeding artery are micro coils, which will permanently occlude selected artery.

Is there any additional risk?

The possibility that the embolization agent can dislodge into the arterial system and deprive healthy bowel of blood supply is minimal. It is avoided by the careful positioning of the micro catheter supraselectively next to the bleeding spot.

Sometimes, the anatomy of your intestinal artery and its branches may be too complex for the safe placement of tube. In that case the radiologist will advice you that the procedure is not technically feasible and your attending doctor will present you with the other (possibly surgical) treatment options.

Very seldom you may feel mild pain in the abdomen 24-48 hours after the procedure, which will necessitate administration of painkillers.

The other risks are similar to general angiography and embolization.

 

What are the indications?

Common indication is to assess blocked artery as a cause of acute pain in the arm. Sometimes it is performed as an introduction to interventional procedure (like embolization of the bleeding vessel in the arm or angioplasty/stenting of the narrowed artery.

Procedure

Same as for general angiography

Is there any additional risk?

Extremely seldom manipulation of angiographic tube may damage the main artery, worsen the pain and even necessitate finger amputation. This complication is usually a consequence of pre-existing disease.

Otherwise depending on intervention. Please refer to embolization