Acta Neurochir (2014) 156:581588

DOI 10.1007/s00701-013-1897-4

EXPERIMENTAL RESEARCH - FUNCTIONAL

Accuracy of 3D fluoroscopy in cranial stereotactic surgery:

A comparative study in phantoms and patients
Lutz M. Weise & Sebastian Eibach & Matthias Setzer &
Volker Seifert & Eva Herrmann & Elke Hattingen

Received: 1 July 2013 / Accepted: 23 September 2013 / Published online: 19 October 2013
# Springer-Verlag Wien 2013

Abstract
Background To assess the precision and accuracy of 3D fluoroscopy (XT) in phantoms and patients compared to computed tomography (CT) in localizing stereotactic probes.
Methods Approval was obtained from the institutional research ethics board. The prospective phantom study was
compared to a retrospective patient cohort. Accuracy was
assessed by the mean error and precision by the mean dispersion between XT and CT with a cubic or a skull phantom
containing metallic spheres installed on plates or along trajectories. Significance was assessed by Friedmans and Levenes
test. Secondary endpoints were Euclidean error, other influences e.g. installed frame and radiation exposure.
Results A total of 3,342 distances were assessed in 17 XT and
13 CT phantom scans. The cubic phantom showed mean
distance errors of 0.33 mm (SD+0.46 mm) for XT compared
to 0.19 mm (SD+0.83 mm) for CT scans (p=0.0004) and a
dispersion of 0.22 mm (XT) and 0.70 mm (CT). The dispersion was 0.36 mm with and 0.63 mm without a stereotactic
Parts of this study have been presented as poster at the annual congress of
the German Neurosurgical Society (DGNC) Mai 26 29, 2013 in
Dsseldorf, Germany
Registration number of the Ethics Committee Goethe University Frankfurt:
432/12
L. M. Weise (*) : S. Eibach : M. Setzer : V. Seifert
Department of Neurosurgery, Goethe University Frankfurt,
Schleusenweg 2-16, 60528 Frankfurt, Germany
e-mail: lutz.weise@med.uni-frankfurt.de
E. Herrmann
Institute for Biostatistics and mathematic modelling, Goethe
University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt,
Germany
E. Hattingen
Department of Neuroradiology, Goethe University Frankfurt,
Schleusenweg 2-16, 60528 Frankfurt, Germany

frame (p<0.0001). The mean Euclidean error was 0.72 mm

(SD + 0.59 mm) in the skull phantom and 1.34 mm
(SD+0.82 mm) in the patient cohort. The effective dose
was 0.65 mSv for the XT and 1.12 mSv for the CT.
Conclusions The accuracy of XT imaging in phantoms revealed a slightly lower accuracy but higher precision than the
CT. The overall accuracy of XT was higher than that of the
stereotactic frame allowing stereotactic localization with about
half of the effective dose of a CT-scan.
Keywords 3D fluoroscopy . Deep brain stimulation .
Electrode localization . Accuracy . Precision . Radiation
exposure

Introduction
Intraoperative fluoroscopy verifies the stereotactic target and
surveys the implantation and fixation of deep brain stimulation
(DBS) electrodes but fails to confirm the trajectory itself. Threedimensional (3D) fluoroscopy (XT) uses cone beam computed
tomography algorithms combined with a mobile C-arm [13]. It
has shown to be effective for the guidance of neurosurgical
procedures [2, 4, 6, 8, 19]. Recently the feasibility to localize a
stereotactic trajectory intraoperatively by the use of mobile 3D
fluoroscopy (XT) has been demonstrated [1, 16, 20]. Its flexibility pushes mobile 3D fluoroscopy ahead of stationary systems
as stereotactic X-ray, intraoperative magnetic resonance (MRI)
or computed tomography (CT), but its precision has not been
tested in phantoms as static systems have been [18, 21]. We
therefore aimed to assess the precision and accuracy of 3D
fluoroscopy in both phantoms and patients, compare it with
computed tomography as gold standard and, depending on the
results, decide whether CT verification is at all necessary. High
accuracy and precision are crucial in stereotactic and functional
surgery as deviations of over 1.5 mm might be associated with

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poor clinical results [5]. As a rule of thumb, errors of scanning

devices should be below those of the stereotactic frame, which
in phantoms average 1.7 mm (SD 1.1 mm) [14].

Methods
Imaging
3D fluoroscopy
XT scans were performed using a Vision FD Vario 3D
(Ziehm Imaging, Nrnberg, Germany). Prior to scanning, we
defined the field of interest on lateral and anteroposterior 2D
fluoroscopy, then we test-rotated (136) the c-arm without
irradiation to rule out any obstacles, and finally we performed
a single 3D fluoroscopy scan and reconstructed the pulsed
images into a CT-like sequence with 0.250 mm slice distance,
512 x 512 pixels and 512 slices [20].
CT scan
CT scans were performed using a Brilliance 6 slice (Royal
Philips Electronics, Amsterdam, Netherlands). A routine stereotactic CT was performed using a single-slice mode with continuous slices of 1.5 mm thickness (512x512 pixels, 115 slices).
Phantoms
Cubic phantom
The cubic phantom was a cubic polyethylene frame (1212
12 cm) with 3 plates, each with five integrated metallic
spheres, all inserted at a known distance: a total of 15 spheres
and 105 known distances to compare with distances measured
by XT and CT (Fig. 1).
XT and CT scans were performed with and without a
mounted stereotactic head-frame (Leksell G-frame, Elekta,
Stockholm, Sweden), placing the cubic phantom with different
angulations into the gantry (0, 15, 30, and 45) in order to
simulate variable positioning of the patient (Fig. 2). Each of the
XT scans was evaluated with the on-board software of the
XT-device and a neuronavigation software (iPlan Stereotaxy
3.0, BrainLab, Feldkirchen, Germany). The CT scans were
evaluated exclusively with the neuronavigation software.
Skull phantom
The skull phantom consists of an adult human skull embedded
in non-granular plastic with similar radiological characteristics
compared to living tissue concerning specific gravity, atomic
number, absorption and secondary radiation emission
(3 M X-ray products, 3 M, Minnesota, USA).

Acta Neurochir (2014) 156:581588

Three trajectories were concentrically drilled with entry

points right and left frontal and centrally to the midline using
the Leksell stereotactic arc (Elekta, Stockholm, Sweden).
The trajectories were then filled with tubes containing a total
of 13 metallic spheres at known distances.
We measured XT and CT distances with and without a
mounted stereotactic head-frame, placing the skull phantom
with different angulations into the gantry (0 and 30) in order
to simulate variable positioning of the patient and in five
different mounting positions to simulate the clinical routine
of different localizations and asymmetric mounting of the
head frame (Figs. 1 and 2). A total of 15 trajectories were
compared between CT and XT concerning target stereotactic
coordinates (X, Y, Z), distance to target (trajectory length),
ring and arc angle (Fig.3).
Patients intended for deep brain stimulation (DBS)
We retrospectively analyzed 24 electrode trajectories in 12
consecutive patients by intraoperative XT and postoperative
CT with approval of the local ethics committee. All patients
had movement disorders (e.g., Parkinson's, tremor and dystonia) and underwent bilateral stereotactic implantation of deep
brain stimulation (DBS) electrodes under local anesthesia.
The subthalamic nucleus (STN), the nucleus ventral intermediate nucleus (VIM) or the internal globus pallidus (GPi) were
targeted. We used the same stereotactic head-frame and
Leksell arc model as in our phantom series and the same
iPlan navigation software for DBS surgery as in the phantom. Preoperative planning was based on cranial MRI sequences (1 mm) that were coregistrated to a stereotactic
CT-scan. After fixation of the DBS-electrodes and before
removal of the head frame, an intraoperative XT scan was
performed using the same 3D fluoroscope as in the phantom
series. Within 24 hours after surgery, a thin-slice CT (1.5 mm)
was performed to rule out complications and to verify the
positioning of the electrodes. Postoperative autofusion was
performed using the neuronavigation software.
Radiation exposure
Effective dose
The radiation dose and the consecutive exposure of diagnostic
X-ray (e.g., fluoroscopy) was quantified using the dose area
product (DAP) measured in Gym2. The radiation dose of a
CT scan was quantified by the dose-length-product (DLP) in
mGycm. These products cannot be directly compared or
converted in terms of radiation exposure. According to Kim
et al. the conversion factor for an uncollimated XT scan of the
entire skull using a 17 flat detector was 0.091 mSv Gy1 cm-2
(SRM 0608, Philips Healthcare, The Netherlands) [12]. CT
(DLP) scan conversion factors for the skull have been referred

Acta Neurochir (2014) 156:581588

583

Fig. 1 a Geometrical plan for

cubic phantom. b Cubic
phantom. c Geometrically
planned trajectories. d Skull
Phantom with spheres

between 0.0021 and 0.0023 mSv mGy1 cm1 measured on a

wide variety of CT devices. Based on these findings we
calculated the effective dose in mSv for both modalities.
DAP measurement
The DAP was measured using a calibrated, square-shaped
ionization chamber (KermaX plus, Iba Schwarzenbruck,

Fig. 2 a Cubic phantom in

fluoroscopic gantry. b Skull
phantom in OR setting. c Skull
phantom in CT gantry. d Skull
phantom with mounted target
device

Germany). The ionization chamber was mounted to the Xray source of the XT device during a full XT scan. The same
ionization chamber was mounted to the gantry of the CT-scan,
covering a width of 14 cm of the total circumference of the
gantry measuring 219.8 cm. The ionization chamber was
isolated to avoid radiation exposure from behind using an
8-mm lead sheet. A CT-scan using the stereotactic protocol
was performed. The measured DAP was multiplied by 15.7 in

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Acta Neurochir (2014) 156:581588

Fig. 3 Left column: CT scan;

right column: XT scan. First row:
axial; second row: sagittal; third
row: coronal

order to quantify the emitted radiation over the total

circumference.
Statistical evaluation
The primary endpoint was to compare the accuracy and precision of distance measurements between XT and CT
(means and standard deviations [SD]). We used Friedmans
test for accuracy and Levenes test for precision. Secondary
endpoints were differences between the stereotactical coordinates and angles as demonstrated by CT (gold standard) and
XT in the skull phantom and the patient cohort. The target
accuracy was assessed by calculating the Euclidian error as
described previously [10]. The influence of distance length to
the amount of the measurement error was documented using a

BlandAltman diagram. Statistical analysis was calculated

using IBM SPSS Version 19.0.0. No significance adjustment for multiple testing was done for the p-values in Table 1
due to the explorative character of these tests. All tests were
two-sided with a significance level of alpha=5 %.

Results
A total of 17 XT scans and 13 CT scans were performed using
either a cubic phantom (n=16) or a skull phantom (n=14)
mounted on a stereotactic frame. A total of 3,342 distances and
60 trajectory angles were assessed. Furthermore, a total of 16
trajectories were assessed in 8 patients undergoing DBS surgery.

Acta Neurochir (2014) 156:581588

Table 1 Influence of angulation
on variance. *In comparison to
0, ** significant differences
(p <0.005, Levenes test)

585

Device
Overall
Overall
Overall
Overall

Ring

Angle

Mean deviation (mm)

SD

Dispersion

p-value*

0
15
30
45

0.33
0.20
0.30
0.30

0.58
0.80
0.68
0.74

0.34
0.65
0.47
0.55

<0.001**
0.02**
<0.001**

Cubic phantom

Skull phantom

The results of the distance measurements in the cubic phantom

are summarised in Table1. The overall mean error between the
known distances and the measured distances (XT measured
with the integrated software or CT measured with the navigation software) was 0.3 mm with a mean SD of 0.64 mm. The
mean error of all XT scans was 0.33 mm (SD 0.46 mm)
compared to 0.19 mm (SD 0.83) for all CT scans (p =0.0004)
(Fig. 4a). The dispersion of the values was 0.22 mm (XT) and
0.70 mm (CT). The differences in standard deviation and
dispersion were significant (p <0.0001) (Fig. 4b).
Measuring XT-scans with the integrated software showed a
significantly lower dispersion compared to the navigation
software with a p-value of 0.008.
Measurements with a mounted stereotactic head frame
yielded a mean error of 0.34 mm (SD 0.61 mm) compared
to 0.23 mm (SD 0.80 mm) for the measurements without
frame (p <0.0001). The dispersion was 0.36 mm with and
0.63 mm without frame (p <0.0001).
The different angulations revealed no significant differences
concerning the distance error and significant differences
concerning the dispersion compared to the according reference
scan with 0 angulation (Table 1). The length of the measured
distance did not show any influence on the distance error (Fig. 5).

The overall mean deviation between the known distances and

the measured distances (XT measured with the integrated software or CT measured with the navigation software) was
0.34 mm (SD 0.28). The mean error of all XT scans was
0.28 mm (SD 0.23 mm) compared to the mean error of all CT
scans of 0.39 mm (SD 0.32 mm) (p =0.59). The statistical
dispersion was 0.05 mm (XT) and 0.10 mm (CT) (p <0.0001).
The differences in deviation and dispersion were significant in
Levenes test with a p-value <0.0001. The angulation did not
have a significant impact on the error or dispersion.
Trajectory measurementsThe mean difference was 0.3 mm
(SD 0.41 mm) for the X-coordinate, 0.4 mm (SD 0.42 mm)
for the Y-coordinate and 0.43 mm (SD 0.33 mm) for the
Z -coordinate. The mean difference in target length was
0.09 mm (SD 0.29 mm). The Euclidean error had a mean
difference of 0.72 mm (SD 0.59 mm). The mean angle
difference for the ring angle was 0.91 (SD 0.73) and 0.58
(SD 0.72) for the arc angle (Table 2).
DBS patients: The mean difference was 0.48 mm (SD
0.54 mm) for the X-coordinate, 0.65 mm (SD 0.48 mm)
for the Y-coordinate and 0.82 mm (SD 0.62 mm) for the
Z-coordinate. The Euclidean error had a mean difference of
1.31 mm (SD 0.70 mm). The mean angle difference for the

Fig. 4 a distribution of mean

errors between XT and CT scans.
b distribution of mean dispersion
between XT and CT scans

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Acta Neurochir (2014) 156:581588

Fig. 5 BlandAltmans distribution of distance errors measured by XT (a) and CT (b), without (c) and with mounted stereotactic frame. X-axis:
Calculated distances in mm between spheres. Y-axis: Measurement errors in mm

ring angle was 0.73 (SD 0.82) and 0.76 (SD 0.83) for the
arc angle (Table 2).

The DAP was 34.38 Gy cm2 for the CT scan compared to

7.14 Gy cm2 for the XT scan.

Radiation exposure
Discussion
The XT phantom scans have a constant DAP of 7.12 (SD 0.0)
Gy cm2. During the CT scans, a mean DLP of 583,06 (SD
28.3) mGy cm was measured. The calculated effective dose
was 0.65 mSv for the XT and 1.28 mSv for the CT scan.

Throughout the phantom studies, the mean accuracy of XT

was lower than that of CT but precision of XT was higher than
that of CT. Since CT is the current gold standard, a higher

Table 2 Target and trajectory accuracy (comparison between our and

previous results): current skull phantom (XT), current DBS group (XT)
and published series with DBS patients with MRI in comparison to CT,

intraoperative CT (iCT) in comparison to postoperative CT and a phantom assessed with intraoperative X-ray (iXR) compared to intraoperative
MRI (iMRI)

Coordinate

Current skull
phantom XT vs. CT

Current DBS patients

XT vs. CT

Shalaie et al. 2011 DBS

Patients iCT vs. MRI

Hunsche et al. 2007

phantom iXR vs. iMRI

Pinsker et al. 2008 DBS

patients MRI vs. CT

X
Y
Z
ring
arc
Euclidean error

0.3 mm (SD0.41)
0.4 mm (SD0.42)
0.43 mm (SD0.33)
0.91 (SD0.73)
0.58(SD0.72)
0.72 mm (SD0.59)

0.48 mm (SD0.54)
0.65 mm (SD0.48)
0.82 mm (SD0.62)
0.73 (SD0.82)
0.76 (SD0.83)
1.31 mm (SD0.70)

0.72
1.03
0.84
1.65

0.4 mm (SD0.3)
0.1 mm (SD0.3)
0.3 mm (SD0.2)
0.7 mm (SD0.3)

0.2 mm (0 0.5)
0.5 mm (0 1.1)
0.3 mm (0 0.7)
-

mm (SD0.10)
mm (SD0.17)
mm (SD0.14)

mm (SD0.19)

Acta Neurochir (2014) 156:581588

accuracy was expected. However the difference of 0.14 mm

between both groups is possibly without clinical importance.
The higher precision of XT may be due to difference in slice
thickness. The increased precision within the mounted frame
group might be the result of a more stable positioning, while
artifacts due to the frame did obviously not influence the
accuracy. The differences between various angulations
showed significant differences in precision (Table 1) without
any obvious pattern in the subgroups, probably due to multiple testing or small systematic errors in the experimental setup (e.g., inconsistencies of the phantom).
In the skull phantom, results were similar to the cubic
phantom. The mean Euclidean error (0.72 mm) being slightly
higher than the mean distance error might be explained by an
accumulation of a systematic error due to the slice thickness of
the CT and inaccuracies in image fusion. This corroborates
with a former study comparing [7] intraoperative X-ray with
an intraoperative MRI, which found a similar Euclidean error
(spatial distance) of 0.7 mm (Table 2).
The patient cohort showed an increase of the mean coordinate
and Euclidean errors compared to the phantom experiments.
This might be due to several factors, such as the involuntary
movements especially in patients undergoing DBS, constrained
positioning with the patient and sterile draping in the field. In
some cases, diminished image quality through movement artifacts might have further reduced the quality of image fusion. The
major error was found in the z-axis due to the difference between
an implanted electrode, prone to slight deviations along the
trajectory, and a sphere mounted within a phantom also showing
different types of artefact on the scans. From a clinical point of
view the z-axis is the least important in DBS surgery, as smaller
inaccuracies may be compensated by reprogramming, using one
of the four leads that are aligned on the z-axis. In addition, brain
shift might be another reason for the lower accuracy in the
patient's group [16]. The XT scan was performed intraoperatively and the CT scan one day after surgery. Therefore, a certain
amount of intraoperative brain shift might have shifted back
24 hours after the procedure. In a previous study [7, 15], MRI
evaluation was compared to CT evaluation of the DBS electrode
showing a similar mean coordinate deviation (Table 2).
However, MRI evaluation of the electrode location is limited to
dedicated MR-scanners (1.5 Tesla) applying special sequences
with a head transmitting and receiving coil [20].
The application accuracy of the Leksell stereotactic arc
and frame has been assessed earlier, showing a mean Euclidean
error of 1.7 mm (SD 1.1 mm) in a phantom study [9, 14],
which is in the range of other stereotactic frame systems [3] and
lower (higher accuracy) than frameless stereotactic systems.
Therefore, imaging accuracy within or below this range would
be one of the major conditions rendering 3D fluoroscopy
acceptable for the use in stereotactic surgery. Previous studies
have shown that fluoroscopy and XT yields less radiation
exposure than CT [11, 17].

587

The results concerning radiation exposure corroborate with

a prior study showing that a mobile cone beam scanner
delivers approximately half the radiation dose of a CT [21].
The disadvantages and limits of mobile 3D fluoroscopy
compared with computed tomography remain the restricted
field of view and the lack of soft tissue contrast. The automated
fusion process within the navigation software has to be
corrected for the field of view and complications such as
hemorrhages cannot be assessed with 3D fluoroscopy.
Therefore its use is limited to intraoperative localisation purposes and cannot replace a postoperative CT or MRI scan for
other purposes. Further limitations of this study are related to
the phantom design of this study which might be due to a lack
of movement artefacts or minimal dislocation of the spheres,
the trays or the skull.
In conclusion, the accuracy of XT imaging in phantoms
and in vivo revealed higher accuracy than the application
accuracy of the stereotactic frame. Therefore, the XT scanner
has sufficient accuracy and precision to localize electrodes
during surgery with about half of the effective dose of radiation exposure compared to a CT scan.
Acknowledgements We would like to thank Wolfgang Knobel for his
assistance constructing the phantoms for this study.
Conflicts of interest This work was supported by a grant from Ziehm
Imaging, Nrnberg, Germany for the material of the phantoms.
The first author (LW) received speakers honorary from Medtronic
GmbH Meerbusch, Germany.

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