Computer Aided Surgery, 2004; 9(1/2): 45–50

CLINICAL PAPER

NEUROGATEw: A new MR-compatible device for realizing

minimally invasive treatment of intracerebral tumors

HANS EKKEHART VITZTHUM1, DIRK WINKLER1, GERO STRAUSS2,

DIRK LINDNER1, WOLFGANG KRUPP1, JENS PETER SCHNEIDER3,
RALF SCHOBER4, & JÜRGEN MEIXENSBERGER1
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1
Department of Neurosurgery, University of Leipzig, Leipzig, Germany, 2Department of ENT, University of Leipzig, Leipzig,
Germany, 3Department of Radiology, University of Leipzig, Leipzig, Germany and 4Department of Neuropathology,
University of Leipzig, Leipzig, Germany

(Received 22 May 2001; accepted 16 December 2003)

Abstract
The authors report on the handling and the practicability of a newly developed MR-compatible device, the NEUROGATEw
(Daum GmbH, Germany), which allows precise planning, simulation and control of stereotactic biopsy in patients
For personal use only.

with suspect intracranial lesions, and which allows minimally invasive maneuvers to be performed in a comfortable way.
Twenty-eight patients were examined stereotactically in the Signa SP interventional 0.5 Tesla MRI (General Electric
Medical Systems, USA), including 15 patients with malignant intracerebral tumors and poor general medical conditions
(8 gliomas, 7 metastases) who were treated by laser-induced interstitial thermotherapy (LITT) after definite intraoperative
neuropathological diagnosis. As a special stereotactic holding device, the NEUROGATEw was favored as a reliable tool
for stereotaxy and minimally invasive procedures.

Keywords: Glioma, metastases, minimally invasive therapy, open MR, stereotaxy

Introduction intervention. The image data obtained enable defini-

Stereotactic neurosurgery is the method of choice
for diagnosis of suspect intracranial lesions, which
in turn forms a basis for further therapeutic
measures. This may comprise radiation therapy
or minimal-invasive interstitial therapy, especially in
patients with a poor prognosis where therapeutic
surgical options are lacking [1 –9]. In contrast to
the conventional surgical methods used thus far,
interventional open MR offers the possibility of
multimodal imaging with a high grade of soft
tissue discrimination, and allows the visualization
of anatomical and pathological structures, as well
as eloquent regions and areas of risk, without any
shift artefacts during the process of stereotaxy and
tive virtual planning of the access approach route
and virtual definition of entry and target coordinates.
Exact and precise planning of a biopsy trajectory
as the basis of stereotactic surgery, intraoperative
orientation in the parenchymatous brain, and
radiological control of the maneuver in near real
time contribute to a safer intervention and better
surgical outcome. To improve intraoperative hand-
ling during stereotactic brain biopsy and subsequent
interstitial intervention, a new MR-compatible
device was developed and used routinely. The
NEUROGATEw represents one technical solu-
tion among available MR-compatible devices,
and is comparable to the Magnetic VisiOn (Magnetic
VisiOn GmbH, Switzerland), the Heidelberger

Correspondence: Hans Ekkehart Vitzthum, Department of Neurosurgery, University of Leipzig, 04103 Leipzig, Liebig Str. 20, Germany.
Tel: 0049-341-9717512. Fax: 0049-341-9717509. E-mail: vithe@medizin.uni-leipzig.de
ISSN 1092-9088 print=ISSN 1097-0150 online # 2004 Taylor & Francis
DOI: 10.1080=10929080400006358
 46 H. E. Vitzthum et al.
Interventions-Trajektor (Pilling Weck Chirurgische
Produkte GmbH, Karlstein, Germany) and the
Navigus trajectory guide (Image-Guided Neurolo-
gics, Inc., Melbourne, FL, USA).
All these devices are intended to provide, albeit
in different ways, stereotactic guidance for biopsies,
placement of instruments and treatment within
the MR environment and in conjunction with MR
imaging. In summary, the advantages offered by all
these bio- and MR-compatible (as well as nearly
artefact-free) instruments are:
1. The possibility of real-time planning proce-
dures for biopsies, instrument trajectories
and interventional maneuvers, corresponding
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to the target region as well as intersecting
structures before and during surgery, using
light-emitting diode (LED)-based FlashPoint
guidance, and
2. Fixation and positioning of instruments and
devices in the burr hole, allowing a precise
definition and modification of the trajectory
and guaranteeing a safe and reproducible
measurement-based intervention as well.
For personal use only.
Material and methods
Between 1997 and 2000, a total of 28 patients with
suspected tumors in the cerebrum were biopsied
in a Signa SP 0.5 Tesla superconducting MR system
(General Electric Medical Systems, Milwaukee, WI)
Figure 1. View of the special broach (article number 15260; left) and grip (article number 15250; right) which are used for fixation of
the NEUROGATEw in the burr hole at the beginning of surgery.
at the Neurosurgical Department of the University of
Leipzig. Fifteen of the 28 patients subsequently
underwent laser-induced interstitial thermotherapy
(LITT) as a minimally invasive procedure.
After positioning of the anaesthetized patient
and attachment of the flex coil in the open MR, the
localization of the tumor lesion was determined
using the FlashPoint position encoder (Image
Guided Technologies, Inc., Boulder, CO, USA)
with three LEDs. FlashPoint allows interactive
selection of axial, coronal and sagittal T1- and
T2-weighted images. In cases of enhancing lesions
known from previous investigations, Gd-DTPA
(Magnevist, Schering, Germany) was administered
(0.1 mmol/kg body weight). The virtual axis for
each biopsy, including the planned surgical approach
and the definition of the optimal site for the craniot-
omy, was determined to obtain a three-dimensional
visualization of the planned cannula in relation
to the anatomic structures and the pathological
lesion. The biopsy trajectory was chosen in such
a way that vulnerable structures were avoided
whenever possible. Following a skin incision, a
standardized burr hole is made with a vertical
bone wall and suitable dimensions for fixing the
NEUROGATEw (Patent No. 19726141.8), once
the dura incision is realized, using a special broach
and grip (Figure 1). A self-cutting thread allowed a
variable and safe positioning of the NEUROGATEw.
The central guide element is flexible and maneuver-
able after releasing the thumb screw with a special
 New MR-compatible device 47
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Figure 2. The NEUROGATEw and the special hexagonal screw driver used for free fixation of the flexible central guide element.
For personal use only.

hexagonal screw driver (Figures 2 and 3). Onto the
thumb shawl nut of the guide element, which
enables fixation of the biopsy cannula with respect
to the laser fiber, was placed a standardized con-
necting piece with a central drill. During surgery,
placement of the biopsy cannula or sheath could be
changed at any time and was supported by the
LED tracking system and MR guidance (Figure 4).
Biopsy specimens were taken as a serial biopsy and
were examined histologically. After biopsy and
histological analysis in 15 of 28 patients, a light
guide for further minimally invasive treatment was
inserted under MR guidance (Figure 5). Interactive
monitoring of temperature courses was achieved
with special processing software (RTIP, General
Electric Medical Systems, Milwaukee, WI), thus
allowing evaluation of the procedure and immediate
adjustment of therapy if necessary [10].
Results
All 28 patients (15 female, 13 male) could be exa-
mined stereotactically. The patients and surgical
data, as well as the details of the tumor entities, are
shown in Tables I and II. Tumor lesions were situated
in all parts of the cerebrum and were punctured
successfully under general anesthesia. In our series
of 28 patients, a diagnosis was established in all

Figure 3. Schematic illustration of the self-cutting thread that is placed in the burr hole using the broach and grip. Reproducible placement
of the biopsy needle and sheath is possible via the flexible central guide element in the center (substitute 14 G for 16 G).
 48 H. E. Vitzthum et al.
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Figure 4. The NEUROGATEw with the LEDs and the Neurocut-
biopsy needle (Daum GmbH Germany). The LED-tracking system
allows intraoperative multiplanar control and guidance of the
planned procedure.
For personal use only.
cases. Only one patient was operated on twice; in this
case, the real-time image acquisition and visualization
of the biopsy trajectory was disturbed as a result of
technical problems. The stereotaxy was therefore ter-
minated and was subsequently repeated, this time
with a positive result and a definite neuropathological
diagnosis. All 28 biopsies yielded diagnostic tissues
and, on the basis of histopathological results,
imaging and clinical findings, a diagnosis was estab-
Figure 5. Interstitial thermotherapy (ITT) light guide (Dornier GmbH, Germering, Germany) with the sheath (Somatex GmbH,
Rietzneuendorf, Germany) for minimal invasive therapy.
lished in each case. The mean time interval between
the beginning and end of anesthesia was 218.8 min;
the mean duration of the stereotactic procedure
itself was 164.8 min (Table I).
Neuropathological diagnoses obtained from brain
biopsies included 16 cases (57.1%) of high-grade
glioma [9 cases of glioblastoma (32.1%), and 7 of
anaplastic astrocytoma (25%)], two cases (7.1%) of
low-grade glioma (astrocytoma, grade II) and one
case of oligodendroglioma (3.6%). The diagnoses
of non-glial tumor lesions included metastatic
tumors [in 7 of 28 patients (25%)] and one case of
lymphoma (3.6%). One patient suffered from ence-
phalitis (3.6%). There were no cases of mortality
and additional neurological deficits.
In the same diagnostic session, 15 of 28 patients
(8 female, 7 male) could be treated by LITT
without any complications. The mean time interval
between the beginning and end of anesthesia was
296.1 min; the mean duration of the stereotactic
and interstitial laser procedure was 224.6 min
(Table III). The incidence of the individual tumor
entities is shown in Table IV. The neuropathological
diagnoses included 8 cases (53.3%) of high-grade
glioma (5 cases of glioblastoma, 3 of anaplastic
astrocytoma) and 7 cases (46.7%) of metastatic
tumors (Table IV). The planned LITT was success-
fully performed in all cases.
Discussion and conclusions
At present, surgery in the open MR is a variant
of image-supported procedures. The development
of navigation systems allows a wide variety of maneu-
vers, preoperative simulation of surgical therapy and
 New MR-compatible device 49

Table I. Stereotaxy: clinical and surgical data. Table III. Stereotaxy and LITT: clinical and surgical data.

Mean Min–Max Mean Min– Max

Duration of anesthesia 218.8 min 118.0–298.0 min Duration of anesthesia 296.1 min 130.0–350.0 min
Duration of stereotaxy 164.8 min 96.0–278.0 min Duration of stereotaxy 224.6 min 105.0–330.0 min
Age of patients 57.9 years 29–76 years and LITT
Age of patients 59.3 years 39–76 years

intraoperative control, as well as adaptation of the Table IV. Stereotaxy and LITT: neuropathological
planned procedure to the prevailing situation. Navi- diagnoses of mass lesions.
gational features, such as virtual simulation, image
Neuropathological
fusion and intraoperative multiplanar guidance, all diagnoses of mass lesions n ¼ 15
exert an influence on the surgical strategy with
respect to interstitial therapy, and can help to improve Glial tumor
Astrocytoma
neurosurgical performance. Stereotaxy in the open Grade IV 5
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MR is a safe and accurate procedure for biopsy. The Grade III 3

position of the biopsy tool in all spatial planes is Grade II 0
displayed on the basis of real-time image data. Three Grade I 0
planar views of the surgical target, entry point Non-glial tumor
Metastatic tumors 7
and needle trajectory help to illustrate the optimal
needle position in relation to anatomical, pathological
and functional areas. If necessary, corrections to The NEUROGATEw system, being a new device
the computer-planned trajectory could be made by developed specifically for minimally invasive treat-
adjusting the target point to avoid eloquent areas or ment in the open MR, does not interfere with MR
structures at risk near the target. In this way, visual- imaging significantly. An attached LED tracking
ization of the planned needle trajectory allowed the
For personal use only.

system guarantees continuous feedback during place-

surgeon to assess the surgical safety of the chosen ment of the biopsy cannula or the sheath. The device
direction and depth of biopsy needle. The described is biocompatible, sterilizable, and can be used several
stereotactic biopsy, as well as the minimally invasive times. The NEUROGATEw appears to be a reliable
LITT techniques, was an accurate procedure, device facilitating accurate placement and fixation of
allowing safe and reproducible handling for the a biopsy cannula, sheath and light guide.
neurosurgeon and helping to prevent any surgery-
associated complications [2, 4]. The role of minimally
invasive interstitial therapy as an alternative option
in the palliative treatment of deep-seated and malig- References
nant intracerebral tumors has still to be defined.
[1] Anzai Y, Lufkin R, DeSalles A, Hamilton DR, Farahani K,
Until now, the precise and reproducible placement
Black KL. Preliminary experience with MR-guided thermal
of a biopsy cannula, sheath and probe tips has been a ablation of brain tumors. AJNR 1995;16:39 –48.
technical problem, but this could be solved by using [2] Cooper IS, Stellar A, Roos MS. Cryogenic freezing of brain
an MR-compatible device—the NEUROGATEw. tumours for excision or destruction in situ. J Neurosurg
1963;20:921–30.
[3] Ebel H, Rust DS, Scheuerle A. Value of stereotaxy in
Table II. Stereotaxy: neuropathological diag- neurosurgery. Indications and analysis of results of 71 cases.
noses of mass lesions. Nervenarzt 1996;67:650–8.
[4] Kahn T, Bettag M, Ulrich F, Schwarzmaier HJ, Schober R,
Neuropathological
Furst G, Modder U. MRI-guided laser-induced interstitial
diagnoses of mass lesions n ¼ 28
thermotherapy of cerebral neoplasms. J Comput Assist
Glial tumor Tomogr 1994;18:519– 32.
Astrocytoma [5] Maroon JC, Onik G, Quigley MR, Bailes JE, Wilberger JE,
Grade IV 9 Kennerdell JS. Cryosurgery re-visited for the removal and
Grade III 7 destruction of brain, spinal and orbital tumours. Neurol
Grade II 2 Res 1992;14:294–302.
Grade I 0 [6] Matsumoto K, Tomita S, Higashi H, Nakagawa M, Adachi
Oligodendroglioma 1 H, Tada E, Maeda Y, Ohmoto T. Image guided stereotactic
biopsy for brain tumors: experience of 71 cases. No Shindei
Non-glial tumor Geka 1995;23:897– 903.
Metastatic tumors 7 [7] Menovsky T, Beek JF, van Gemert MJ, Roux FX, Bown SG.
Lymphoma 1 Interstitial laser thermotherapy in neurosurgery: a review.
Non-neoplastic mass lesion Acta Neurochir 1996;138:1019–26.
Encephalitis 1 [8] Reimer P, Bremer C, Horch C, Morgenroth C, Allkemper T,
Schuierer G. MR-monitored LITT as a palliative concept
 50 H. E. Vitzthum et al.

in patients with high grade gliomas: preliminary clinical [10] Stollberger R, Ascher PW, Huber D, Renhart W, Radner H,
experience. J Magn Reson Imaging 1998;8:240–4. Ebner F. Temperature monitoring of interstitial thermal
[9] Schwarzmaier HJ, Kahn T. Magnetic resonance imaging tissue coagulation using MR phase images. J Magn Reson
of microwave induced tissue heating. Magn Reson Med Imaging 1998;8:188-96.
1995;33:729–31.
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For personal use only.