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Stereotactic Frames: Technical Considerations
Ashwini D. Sharan and David W. Andrews
Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.



The term stereotaxis, derived from the Greek stereo- for ‘‘three-dimensional’’ and -taxic for ‘‘an arrangement,’’ was coined by Horsley and Clarke in 1908 [1]. It was their use of a three-dimensional Cartesian coordinate system that provided the basis for all stereotactic systems used in modern day neurosurgery. Human stereotaxy was initially developed for the placement of deep lesions in patients with Parkinson’s disease but lost favor with the development of dopamine agonist medications. The introduction of computed tomography (CT) renewed interest in stereotaxy and, together with the subsequent introduction of magnetic resonance imaging (MRI), broadened indications for stereotactic approaches dramatically as deeper areas of the brain could now be targeted with great accuracy. As radiosurgery developed, indications for the use of stereotactic frames broadened further. A thorough review of the history of stereotaxy and the development of frame-based systems can be found in Gildenberg and Tasker’s definitive textbook [2]. This chapter will be devoted to three current frames systems, including technical aspects of frame application and target localization. Other frames will

Copyright 2003 by Marcel Dekker, Inc. All Rights Reserved.

With a fixed relationship between the patient’s head and the fiducial localizers [3]. which may obscure the target if small. Before applying the frame. the surgeon must remember that the headpins may cause significant artifact. Our preference is to sterilize the scalp with an alcohol or betadine prep without shaving hair. or angiography. 1A). The ring should be applied parallel to the cranial floor through the use of ear bars. stipulate a mechanical accuracy below 1 mm [4]. 2. the arc method is used to direct a probe to the selected target and carry out the remainder of the procedure. whereas the zaxis refers to a base–vertex location. Frame application may be performed at the bedside or in the operating room and is most easily accomplished with the patient in the sitting position. the neurosurgeon must have a clear idea of the anatomical localization of the lesion and should bear in mind a suitable entrance point for the probe. The assistant stands either behind or on the side of the patient and stabilizes the ring. but the most popular method uses posts with an ‘‘N’’ shape configuration where the position of the oblique rod relative to the vertical rods defines the z plane of the slice [3].1 Frame Application With experience and assistance. Within a Cartesian coordinate system. When using CT data. As one exception. . 2 GENERAL PRINCIPLES The stereotactic approach to intracranial targets involves the rigid application of a stereotactic frame. a stereotactic frame application should take minimal time. These features are discussed in more detail below. the frame must be shifted as much as possible to center the lesion in Leksell space (Fig. All Rights Reserved. When applying a Leksell frame for radiosurgery. Failure to do so may result in a collision with the collimation helmet. specified by the American Society for Testing and Materials. as might the beam-hardening artifacts of the temporal bone if the lesion is located in a low temporal or posterior fossa location. and an image data set derived from either CT. our goal is to describe some of the theoretical underpinning for the use of stereotactic frames in the era of digital imaging. Inc. The standard performance specifications for cerebral stereotactic systems. but some frame parallax is acceptable. a localizer. the x. Many methods have been outlined to determine the z-axis. Once the target is localized. described elsewhere in the book. respectively. Leksell frame application must be within 3Њ Copyright 2003 by Marcel Dekker.and y-axes refer to a medial–lateral and anterior–posterior location. any intracranial target can be reached with an optimal trajectory and great accuracy.

Technical FIGURE 1 A. Inc. Copyright 2003 by Marcel Dekker. All Rights Reserved. Axial gadolinium-enhanced T-1-weighted image with field-of-view including Leksell stereotactic coordinates. . and z measurements. Note the annotations that depict x. Axial gadolinium-enhanced T-1weighted image with field-of-view including Leksell stereotactic coordinates for treatment of a right frontal brain metastasis. y. The frame was shifted to the patient’s left to center an acoustic tumor in the stereotactic field for radiosurgery. B.

5% Marcaine (bupivicaine) and 1 part sodium bicarbonate. For deep grey matter lesions. coronal and sagittal images provide ring and slide angles for isocentric frames (Fig. Basic principles that should be applied when planning a trajectory to target. the patient can return to the bed with a pillow under the neck for comfort. less accurate because of volume averaging. before using the wrench. 2. eliminating the coordinate in each orthogonal plane which is. For brainstem lesions near midline. We always select a contrast-enhancing target if present. which reduces the burning sensation of the local anesthetic. additionally. temporal lobe or the pineal region. thalamus. 2A and B). be approached laterally and cerebellar lesions approached posteriorly. with a two-fingers method. During the frame application. we obtain fiducial and target coordinates in all three orthogonal planes and average the three paired coordinates with the greatest spatial accuracy. by definition. we have obviated the need for sedation. With the patient still in the scanner. basal ganglia. MRI. it is important to ensure that all fiducial markers are visible on all images. Inc. if not. The instrument’s trajectory should avoid eloquent brain and breach only one pial surface to minimize the change of hemorrhage. we recommend frontal lobe entry points with long-axis trajectories to avoid additional pial planes. especially when interested in brainstem lesions. For lesions in the occipital. We prefer to place the two posterior pins first and then we place the anterior pins and hand tighten all four pins. With the advent of MRI-compatible localizers. Otherwise. . For such cases. parietal. or abnormal signal visualized in a FLAIR sequence. Copyright 2003 by Marcel Dekker. When possible. the patient may be injected with intravenous contrast if the localization scan is to be performed immediately after the procedure. the majority of the cerebrum. or angiography. This is particularly true for lesions near the sylvian fissure or pineal region. We anesthetize the scalp and periosteum with a mixture of 9 parts 0. MRI has provided superior target identification. Typically an axial T-1-weighted gadolinium-enhanced image will provide enough spatial information for target localization. and brainstem can be approached with entry points anterior to the coronal suture. a superior parieto-occipital approach is better.2 Target Localization for Stereotactic Biopsy Imaging modality should depend on the modality that best demonstrates the lesion: either CT. All Rights Reserved. With adequate local anesthesia.of the coaxial imaging plane of Leksell Gamma Plan rejects further attempts at treatment planning for radiosurgery. the instrument should penetrate the brain parallel to white matter tracts. Generally. Temporal lesions may.

Copyright 2003 by Marcel Dekker. This lesion was biopsied and diagnosed as a pilocytic astrocytoma. A. All Rights Reserved.Technical FIGURE 2 Patient with a small punctate contrast-enhancing lesion near speech that was discovered during evaluation for a new-onset seizure disorder. which will establish the ring or trunion angle on the CRW stereotactic frame. B. Coronal gadolinium-enhanced T-1-weighted image with annotation reflecting coronal angle of trajectory. Inc. . Sagittal gadolinium-enhanced T-1-weighted image with annotation reflecting sagittal angle of trajectory. which will establish the slide angle on the CRW stereotactic frame.

The x and y coordinates for each of the nine fiducial rods are identified on Copyright 2003 by Marcel Dekker. . y < 100. 2. and superior. and stereotactic space is designated in a Cartesian coordinate system with center established. The frame center at x and y = 100 is determined at the center of the intersecting lines drawn from the fiducial points at the corners of the localizing frame. as long as the frame is maintained in an orthogonal relationship with the scanner table. Finally. Theodore Roberts and a third-year medical student. posterior. Additionally. its location should be associated with x > 100. Inc. This originally CT-based system consists of a skull base ring with carbon epoxy head posts that offers minimal CT interference.4 BRW/CRW Frames In 1977.3 The Leksell Frame After an inspiring visit with Spiegel and Wycis in Philadelphia. Russel Brown. Alternatively. posterior. The radius of the arc in the Leksell system is 190 mm. and superior. and z directions to allow for any entry point above the head ring. It is this latter ‘‘N’’ construct that establishes the axial CT plane relative to the skull base by calculating the relative distance of the oblique to the vertical rods. and z < 100. Leksell developed his first stereotactic frame [5]. by convention. y. The localizer unit is secured to the ring with three ball-andsocket interlocks and consists of six vertical posts and three diagonal posts. The ring is attached to the patient with screws that are tightened into the skull. and z = 100 and zero. is right. periodic adjustments of the frame attachment to the table may be needed. The Leksell z coordinate is established by measuring the distance from the ipsilateral superior fiducial coordinate to the diagonal coordinate and adding 40 mm (Fig. If a lesion is left. the images can be transferred by tape or ethernet to a surgical planning system. All Rights Reserved. there is no phantom frame with this system. For stereotactic surgery. This elegant system allows the surgeon the opportunity to quickly and easily establish the target’s coordinates on the MRI or CT monitor. His design included an arc system that was attached to a patient’s head with pins such that the center of the arc corresponded to the selected target. the arc can be moved in the x. y = 100. For Gamma Knife radiosurgery.2. This may be confirmed with a carpenter’s level. 1A and B). there is a localizer that can determine coordinates for angiographically obtained targets. Target coordinates are established by first identifying the axial slice that best features the lesion. and the titanium frame is both CT and MRI compatible. for example. we cross-check the treatment planning software determination (Leksell Gamma Plan) with the manually derived coordinates. at x = 100. creating an ‘‘N’’ shaped appearance [7]. were responsible for developing the Brown-Roberts-Wells System (BRW) at the University of Utah [6]. in millimeters.

which can move the head within a fixed arc-quadrant and allow computer control and volumetric surgery. this system included a phantom base onto which the stereotactic frame including the arc could be placed to test the accuracy of the settings. but for any trajectory. similarly. the computation must include entry coordinates [8]. 3A). Neurosurgeons or institutions seeking to purchase their first stereotactic frame may find various reasons for making a Copyright 2003 by Marcel Dekker. an arc frame with a 160-mm radius and 2Њ of freedom to allow a multitude of trajectories. There are localizer frames that are compatible with CT. which computes the target coordinates in BRW stereotactic space. which provides more flexibility than the SCS1 laptop. New innovations included the introduction of MRIcompatible frames and localizers (Fig. This specialized frame-based system is discussed in much greater detail in Gildenberg and Tasker’s Textbook of Functional and Stereotactic Neurosurgery [2]. All coordinates are entered into a laptop computer (the SCS1). and versatility in arc-to-frame applications that enabled inferior trajectories into the posterior fossa or lateral routes into the temporal lobe. Finally. the most unique aspect of the COMPASS system is that the head frame fits into a motor-controlled slide. This is particularly helpful if data acquisition and surgery are performed on separate days. target and trajectory calculations can now be performed with the OTS intraoperative workstation. MRI. The arc system directs a stereotactic probe isocentrically around the designated target. The BRW system then further includes a movable arc and a probe holder.Technical the CT or MRI monitor. thus obviating a fixed entry point. . 3 WHICH FRAME IS ‘‘BEST?’’ The quotes around the last word sum up the answer succinctly—there is no one ‘‘best’’ system or concept. All Rights Reserved. as are the x and y coordinates for the target. The Cosman-Roberts-Wells (CRW) system included some of the same design elements as the BRW system. For institutions with the Radionics OTS frameless image guidance system. and angiogram.5 COMPASS The COMPASS system is specifically designed for volumetric tumor surgery and evolved from the Todd-Wells frame [9]. There is. 3A–C). and the same probe depth fixed at 16 cm (Fig. In the 1980s. including a phantom frame. A removable head frame can be accurately replaced. Inc. 2. The arc guidance frame has four motions that create infinite different probe pathways. the same CT localizer. Additionally. Wells and Cosman simplified and improved the BRW by designing an arc guidance frame similar to the Leksell frame.

C. B.FIGURE 3 Cosman-Roberts-Wells (CRW) stereotactic system. MRIcompatible headring with attached Universal Compact Localizing Frame (UCLF). Inc. All Rights Reserved. . The RLPP is also used for isocenter verification in the X-knife stereotactic radiosurgery system. A. Copyright 2003 by Marcel Dekker. Intraoperative view of CRW-based stereotactic biopsy for lesion in the right frontal lobe. Rectilinear phantom pointer (RLPP) with CRW stereotactic frame calibrated to phantom target.

as the zero point on the arc carrier is 19 cm from the target. Textbook of Functional and Stereotactic Neurosurgery. Tasker P. this chapter does not provide a comprehensive list of all commercially available stereotactic frames. and z coordinates can be derived quickly from a two-dimensional image without a computer. It has a phantom base that can be sterilized and used in the operating room to confirm that accurate targeting has been planned. REFERENCES 1. frames are the best method for performing point stereotaxis for biopsy and functional stereotactic neurosurgery. It is lighter than the CRW frame. With the Leksell and Radionics CRW frames being the most commonly used devices. patients may be scanned without rigid attachment of the frame to the table (although this may be desirable for other reasons. as noted. Also.Technical choice. The CRW frame is accurate without the need for orthogonal positioning of the frame. Service from a vendor may be better in a particular region for a certain system. These might include a factor as simple as familiarity with one device from one’s training. Inc. For speed. 3. All Rights Reserved. frame-based systems will remain an important tool in neurosurgical practice. . X. stereotactic coordinates can be derived directly from an image IF the scan was done with the frame in an orthogonal position. 2. Brain 1908. accuracy. y. ease. wherein the stereotactic scans and frame coordinates are automatically read by the dedicated computer workstations. Despite the development and widespread use of frameless image-guidance systems. eds. The structure and functions of the cerebellum examined by a new method. 2.31:45–124. 4 CONCLUSION Modern CT and MR-guided stereotactic frames provide spatial accuracy for both stereotactic instrumentation and stereotactic radiosurgery. Gildenberg P. Horsely V. such as. and target coordinates derived by clicking on the desired point on a particular image. The Leksell frame has a simpler system for instrument insertion to the desired target. Although not the standard method. eliminating head motion during a radiosurgical scan). New York: McGraw-Hill. These systems may be used as part of surgical navigation systems. neurosurgeons may keep in mind the following: 1. and reliability. Copyright 2003 by Marcel Dekker. Clarke R. No special measurements are necessary. 1998.

New York: McGraw-Hill.3. eds. Cascade Business Park. Kelly PJ. Development and technical features of the Cosman-Roberts-Wells (CRW) stereotactic system. New York: McGraw-Hill. Leksell D. In: Youmans JR. (800) 535-7355. 1998. American Society for Testing and Materials Committee F-4. Norcross. 5. eds. eds. F 1266-89. . Principles of stereotactic neurosurgery.. Rochester. Copyright 2003 by Marcel Dekker. www.). ed.compass. Stereotactic craniotomy.05: Standard performance specifications for cerebral stereotactic instruments. Kondziolka D.1:781–799. An overview of CT based stereotactic systems for the localization of intracranial lesions. (507) 281-2143. Levy ML. The Leksell stereotactic Elekta Instruments. 919 37th Avenue NW. Inc. MA 01803. www.. COMPANY INFORMATION Radionics. Gildenberg P. Annual Book of ASTM Standards. Lunsford LD. Gildenberg P. (formerly Stereotactic Medical Systems. Baltimore: Williams and Wilkins. In: Tasker PL. Kelly PJ. Philadelphia: 1990.8:193–196. Textbook of Stereotactic and Functional Neurosurgery. Burlington. Inc. Inc. Neurosurg Clin N Am. 3155 Northwoods Parkway NW. pp 767–785. 1996. 22 Terry Avenue. pp 65–71. Neurological Surgery. Chin LS. Thomas DGT. COMPASS International. Apuzzo MLK. 8. Comput Radiol 1984. pp 51–64. 1990. Roberts TS. 7. In: Tasker PL. All Rights Reserved. Alker G. MN 55901. Textbook of Functional and Stereotactic Neurosurgery. Cosman E. Philadelphia: WB Saunders. (888) RSA-SERV. GA 30071. pp 1–52. Inc. Handbook of Stereotaxy Using the CRW Apparatus. pp 1–6. In: Pell F. 4.elekta. USA Headquarters.. www. The BRW/CRW stereotactic apparatus.radionics. 1998. 6. Inc.