Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

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Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

DOI: 10.1097/SCS.0000000000010073

Abstract

Objective: To summarize the application experience of multimodal imaging fusion technology in complex skull base tumor surgery.
Methods: A retrospective analysis of clinical data from 7 patients with complex skull base tumors who underwent preoperative multimodal imaging fusion in the Department of Neurosurgery at Zhuhai People’s Hospital from October 2019 to January 2022. The imaging data were uploaded to the GE AW workstation. The corresponding image sequences were opened at the workstation, and registration fusion and three-dimensional reconstruction were completed. A retrospective analysis of the patients’ clinical data, imaging data, and surgical strategies was performed.
Results: One case of recurrent C2 schwannoma, one case of left orbital communication tumor (recurrent spindle cell tumor), one case of left infratemporal fossa malignant tumor (recurrent lobular tumor), one case of giant cell reparative granuloma, one case of left pharyngeal process malignant tumor, one case of meningioma in the jugular foramen area, and one case of fourth ventricle vascular embryonal tumor with vascular malformation. All cases achieved complete tumor resection, with no recurrence postoperatively. Except for the patient with left pharyngeal process tumor who experienced swallowing difficulties (recovered 6 months postoperatively) and the patient with vascular embryonal tumor who experienced coordination issues (recovered after 3 months of rehabilitation), no postoperative complications occurred in the remaining patients.
Conclusion: Preoperative multimodal imaging fusion and surgical approach simulation are beneficial for the surgical treatment of complex skull base tumors. Individualized multimodal imaging assessment for complex skull base tumors can assist in formulating more reasonable surgical strategies and should be recommended.
Keywords: Complex skull base tumors, complications, microsurgery, multimodal imaging fusion, skull base reconstruction
Complex skull base tumors characterized by intracranial and extracranial communication invade the intracranial anatomical structures and originate from complex sources. They are considered one of the most challenging disciplines in neurosurgery, with a complete resection rate of 57% to 77%. Surgical treatment should be the first choice for complex skull base tumors, and the location, size, nature of the tumor, and surrounding structures are of great significance for comprehensive assessment, often requiring preoperative multimodal imaging fusion and surgical approach simulation. Research by Oishi et al. suggests that preoperative multimodal imaging fusion can help neurosurgeons design more reasonable bone windows and safe approaches. A comprehensive preoperative evaluation based on multimodal imaging fusion is very beneficial. This article summarizes the treatment experience of 7 cases of complex skull base tumors from October 2019 to January 2022.

Materials and Methods

Patient Cohort

A retrospective analysis of clinical data from 7 patients with complex skull base tumors admitted from October 2019 to January 2022. Complex cases were widely invasive tumors or recurrent tumors with surrounding anatomical abnormalities. Patient data including age, sex, clinical presentation, imaging findings, tumor location, surgical details, pathology, postoperative complications, surgical outcomes, and follow-up data were collected.

Image Acquisition and Multimodal Imaging Fusion

All patients’ CT and MRI data (DICOM format) were downloaded from the hospital information system, and then the image data were uploaded to the GE AW workstation. The corresponding image sequences were opened at the workstation, and registration fusion and three-dimensional reconstruction were completed. Automatic registration was first used, and then the fusion function was selected for automatic matching. The Smart Brush function was used to outline the tumor contour, and images such as magnetic resonance angiography and magnetic resonance venography were fused with the tumor to form a three-dimensional digital anatomical image of the tumor and vessels. Finally, the three-dimensional reconstructed image of the skull was added to the display of the tumor’s three-dimensional image with vessels, completing the multimodal imaging fusion.

Surgical Treatment

All cases were performed by a senior neurosurgeon. The surgical procedure strictly followed the preoperative multimodal imaging fusion and simulated surgical approach. Attention was paid to the relationship between the tumor and important tissues such as surrounding arteries, veins, and cranial nerves. During the surgery, the tumor boundary was followed for resection, and piecemeal resection was performed to protect surrounding structures, ensuring surgical safety.

Results

Clinical Characteristics

A total of 7 patients were included, 4 males and 3 females. Ages ranged from 29 to 58 years, with an average age of (47.11±11.62) years. This article reports one case of recurrent C2 schwannoma, one case of left orbital communication tumor (recurrent spindle cell tumor), one case of left infratemporal fossa malignant tumor (recurrent lobular tumor), one case of giant cell reparative granuloma, one case of left pharyngeal process malignant tumor, one case of meningioma in the jugular foramen area, and one case of fourth ventricle vascular embryonal tumor with vascular malformation. All cases achieved complete tumor resection, with no recurrence postoperatively. Except for the patient with left pharyngeal process tumor who experienced swallowing difficulties (recovered 6 months postoperatively) and the patient with vascular embryonal tumor who experienced coordination issues (recovered after 3 months of rehabilitation), no postoperative complications occurred in the remaining patients. Follow-up was conducted for 7 patients, with follow-up times ranging from 12 to 24 months (average 14 months), and no new complications or recurrences were observed in all cases.

Multimodal Imaging Fusion Results

All cases underwent multimodal imaging fusion and reconstruction preoperatively, and the spatial positions of the reconstructed tumors and surrounding structures were consistent with the intraoperative findings. The reconstructed vessels, venous sinuses, and cranial nerves were consistent with the intraoperative observations in all cases.

Case Presentation

Case 1: A 32-year-old male patient presented with left neck pain for 1 week. Physical examination revealed limited cervical spine movement. MR scan showed a tumor surrounding and compressing the spinal cord. The multimodal fused image was used to design the surgical path and simulate the resection process. An enlarged midline suboccipital approach was adopted to fully expose the anterior and lateral aspects of the tumor. The extradural portion of the tumor was first resected, followed by the subdural portion, ultimately achieving complete tumor resection (Figure 1).

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Figure 1. Preoperative multimodal imaging fusion used for approach simulation and surgical treatment of recurrent C2 schwannoma (Case 1). (A-C) Multimodal imaging fusion used to identify the relationship between the tumor, vertebral artery, and bony structures. (D-I) The tumor resection process followed the sequence from extradural to subdural, with the vertebral artery always visible during the tumor resection. (J-O) Comparison of preoperative and postoperative MR scans, achieving complete tumor resection.

Case 2: A 64-year-old male patient presented with left exophthalmos and vision loss for 6 months. Physical examination revealed that the left eyeball was protruding outward due to tumor pressure, with complete loss of vision in the left eye. MR scan showed the tumor with heterogeneous enhancement, widely eroding the anterior skull base. The multimodal imaging fusion was used to design the surgical path and simulate the resection process. An enlarged frontal-temporal approach was adopted, fully exposing the left orbit. The extradural portion of the tumor was first resected, followed by the subdural portion, ultimately achieving complete tumor resection (Figure 2).

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Figure 2. Preoperative multimodal imaging fusion used for approach simulation and surgical treatment of left frontal-orbital spindle cell tumor (Case 2). (A-B) Multimodal imaging fusion used to identify the relationship between the tumor and the superficial temporal artery, bony structures. (C) Surgical incision and approach designed based on preoperative multimodal imaging fusion, adopting a frontal-temporal approach. (D) Removal of the bone flap, fully exposing the orbital cavity. (E) Dural opening, revealing tumor invasion into the subdural cavity. (F) Tumor resection to the edge of the nasal concha. (G-H) Reconstruction of the skull base using fat and titanium mesh. (I) Tumor invasion into the dura. (J-O) Comparison of preoperative and postoperative MR scans, achieving complete tumor resection.

Case 3: A 59-year-old female patient presented with left cheek pain for 2 weeks. Physical examination revealed limited mouth opening. MR scan showed the tumor with heterogeneous enhancement, and CT scan showed erosion of the lateral wall of the maxillary sinus by the tumor. The multimodal imaging fusion was used to design the surgical path and simulate the resection process. The zygomatic arch was removed to fully expose and completely resect the tumor tissue while preserving the coronoid process of the mandible (Figure 3).

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Figure 3. Preoperative multimodal imaging fusion used for approach simulation and surgical treatment of left infratemporal fossa lobular malignant tumor (Case 3). (A-B) Multimodal imaging fusion used to identify the relationship between the tumor and the maxillary internal artery, zygomatic arch, and coronoid process. (C) Bony defect of the maxillary sinus. (D) Tumor resection according to preoperative simulation steps. (E) Tumor resection to the upper margin of the oral cavity, mucosa was incised and sutured, and gelatin sponge was used to fill the wound. (F) Zygomatic arch repair. (G-L) Comparison of preoperative and postoperative MR scans, achieving complete tumor resection.

Case 4: A 57-year-old female patient presented with right cheek pain for 3 months. Physical examination revealed decreased bite force on the right side. MR scan showed heterogeneous enhancement, and CT scan showed extensive bony destruction in the right infratemporal fossa, with the right temporomandibular joint eroded by the tumor. Computed tomography angiography (CTA) showed that the right internal carotid artery (ICA) and the right external carotid artery were possibly adhered to the tumor. The multimodal imaging fusion was used to design the surgical path and simulate the resection process; however, it clearly showed that the internal carotid artery and external carotid artery were not adhered to the tumor and had almost a 5mm distance. An enlarged middle cranial fossa approach was adopted to fully expose the tumor. First, we opened the extradural tumor, ensuring that the internal carotid artery was not eroded, then made a bone flap to expose the invasive tumor in the right temporal lobe area that entered the subdural space. The tumor was completely resected, and the patient’s temporomandibular joint remained intact, with no neurological functional deficits (Figure 4).

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Figure 4. Preoperative multimodal imaging fusion used for approach simulation and surgical treatment of left infratemporal giant cell reparative granuloma (Case 4). (A) Multimodal imaging fusion used to identify the relationship between the tumor and the internal carotid artery, bony defects of the temporal fossa. (B) Showing bony defects of the skull base. (C) Approach and incision designed based on multimodal imaging fusion results. (D) Bone flap lower limit to the temporal base. (E) Tumor resection along the extradural boundary. (F) Reconstruction of the skull base with temporal muscle fascia. (G-I) Postoperative CT reconstruction. (I-O) Comparison of preoperative and postoperative MR scans, achieving complete tumor resection.

Case 5: A 39-year-old male patient presented with right neck pain for 2 weeks before admission. Physical examination showed positive Hoffman sign bilaterally. MR scan showed heterogeneous enhancement, with extensive invasion from the pharyngeal process to the posterior cranial fossa. CT scan showed extensive erosion of the bony structures in the right petrous region. CTV and CTA showed occlusion of the right sigmoid sinus, with the right internal carotid artery and vertebral artery wrapped by the tumor. To ensure complete exposure, we adopted an enlarged far lateral approach. The mastoid was used as an anatomical marker for tumor localization. The extradural portion of the tumor was removed from the parapharyngeal space, carefully separating the right internal carotid artery. The bony structures of the petrous region were drilled to expose the intracranial portion of the tumor, and the posterior cranial nerves were highly adherent to the tumor, leading to postoperative swallowing difficulties due to nerve injury during tumor resection (Figure 5).

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Figure 5. Preoperative multimodal imaging fusion used for approach simulation and surgical treatment of right pharyngeal process lobular malignant tumor (Case 5). (A) Multimodal imaging fusion used to identify the relationship between the tumor and the internal carotid artery, vertebral artery, and the venous sinuses of the middle and posterior cranial fossa. (B) Tumor, internal carotid artery, vertebral artery, infratemporal fossa, and posterior cranial fossa sagittal view. (C) Coronal view of the tumor and arteries. (D) Incision design. (E) Mastoid and tumor exposure; (F) Tumor invading the sigmoid sinus. (G) After sufficient drilling and exposure, resection of the tumor tissue invading the sigmoid sinus. (H-I) Internal carotid artery and vertebral artery preserved intact. (J-L) Preoperative MR scan and postoperative MR scan.

Case 6: A 47-year-old female patient presented with right cheek pain for 4 months. Physical examination revealed right facial numbness. MR scan showed heterogeneous enhancement, and CT scan showed extensive bony destruction in the right infratemporal fossa, with the right temporal apex eroded by the tumor. An enlarged middle cranial fossa approach was adopted to fully expose the tumor. A drill was used to expose the tumor at the petrous ridge, and complete resection was performed, with no neurological functional deficits (Figure 6).

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Figure 6. Preoperative multimodal imaging fusion used for approach simulation and surgical treatment of right petrous meningioma (Case 6). (A-B) Multimodal imaging fusion used to identify the relationship between the tumor and the internal carotid artery, vertebral artery, and bony structures of the petrous region; (C) Incision design; (D) Lifting the right temporal lobe to expose the cerebellar tentorium, with part of the tumor visible along the lateral margin; (E) Opening the cerebellar tentorium from the margin to expose the tumor within the posterior cranial fossa; (F) Drilling the temporal bone under the dura to expand exposure; (G) Tumor exposure under the microscope; (H) Cerebellum exposed after tumor resection; (I) Trochlear nerve preserved intact; (J-O) Comparison of preoperative and postoperative MR scans, achieving complete resection of the tumor.
Case 7: A 46-year-old male patient presented with bilateral limb weakness for 3 weeks. Positive eye-closing instability sign. MR scan showed homogeneous enhancement, and CTA showed vascular malformation accompanied by the tumor on the right side. The multimodal imaging fusion was used to design the surgical method and simulate the resection process. Preoperative vascular embolization was performed before craniotomy. A midline suboccipital approach was adopted to fully expose the tumor. Preoperative anatomical assessment of the feeding arteries enabled complete tumor resection. The patient experienced post-surgical coordination issues, which were treated conservatively (Figure 7).

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Figure 7. Preoperative multimodal imaging fusion applied to the approach simulation and surgical treatment of fourth ventricle cavernous hemangioma (Case 7). (A-B) Multimodal imaging fusion technology clarifies the relationship between the tumor and the vertebral artery, basilar artery, and nearby venous sinuses; (C-D) DSA fusion; (E-I) Tumor resection; (J-O) Preoperative MR scan and postoperative MR scan.

Discussion

Surgical Method Design and Surgical Simulation

Complex skull base tumors are often accompanied by extensive skull base invasion, making single traditional surgical methods unable to completely resect the tumor. Preoperative multimodal imaging fusion and reconstruction may be an important method for formulating individualized surgical approaches. In Case 5, a 39-year-old male was diagnosed with a right parapharyngeal malignant tumor. Preoperative multimodal imaging fusion and three-dimensional image reconstruction clearly showed that the tumor was located in the left parapharyngeal space, invading the cistern, right petrous bone, and right sigmoid sinus. The tumor had a wide range of invasion, and traditional surgical approaches could not simultaneously expose intracranial and extracranial tumors. After preoperative multimodal fusion, a highly lateral approach was designed using 3D images, with an arched scalp incision turning anteriorly, exposing bony structures such as the parapharyngeal space, right mastoid, right occipital bone, and right occipital foramen. Both the right internal carotid artery and the right vertebral artery were clearly exposed during the surgery. Since the right sigmoid sinus was invaded and occluded by the tumor, we resected the right mastoid bone without changing position and directly removed the tumor. The extracranial portion of the tumor was completely resected along the parapharyngeal space, and the intracranial tumor in the CPA region was completely resected. Due to the sufficient exposure of the internal carotid artery, vertebral artery, and other structures, all vessels were well protected. Postoperatively, the patient experienced temporary swallowing difficulties due to interference with the glossopharyngeal nerve during tumor resection. After tracheostomy and rehabilitation treatment, swallowing function recovered after 6 months.

Multimodal imaging fusion and 3D reconstruction can assist neurosurgeons in simulating surgical procedures. Visualizing the surgical position and exposure, as well as the tumor and surrounding structures, is of great significance for surgical planning. In Case 3, for the lobular tumor in the left infratemporal fossa, we simulated the tumor resection process based on multimodal imaging fusion, finding that sufficient surgical space for complete tumor resection was still available while only cutting the zygomatic arch and preserving the coronoid process. It was confirmed that the actual surgical process was consistent with the simulation. After complete tumor resection, the zygomatic arch was preserved.Multimodal imaging fusion technology improves surgical precision and reduces surgical trauma.

Vascular Protection

In terms of vascular protection, based on multimodal 3D reconstruction, the relationship between vessels, tumors, and surrounding structures can be vividly displayed. In Case 1, a 29-year-old patient with recurrent C2 schwannoma, we found that the vertebral artery was located ventrally to the tumor, which helped us determine the safe area for tumor resection. We used a midline suboccipital approach, first identifying the vertebral artery, then separating the tumor along the vertebral artery path. Ultimately, the tumor was completely resected, perfectly preserving the vertebral artery. Additionally, in Cases 4 and 6 with petrous region tumors, multimodal imaging fusion vividly displayed the relationship between the internal carotid artery and the tumor, and this preoperative information helped us confidently protect the arteries during the surgery.

Skull Base Reconstruction

Preoperative multimodal imaging fusion and reconstruction technology can display the tumor and surrounding structures in three dimensions. Compared to traditional 2D images, it can provide comprehensive image information for surgeons preoperatively, including the extent of the tumor and the area of skull bone invasion. In Case 2, a 52-year-old male was diagnosed with a right orbital-anterior skull base recurrent spindle cell tumor, which grew into the intracranial and extracranial regions through the ethmoid sinus and superior orbital fissure. Preoperative three-dimensional images clearly showed multiple directions of bony defects in the lateral wall of the orbit, the sella turcica, and the medial wall of the orbit. We adopted a frontal-temporal approach during the surgery. Preoperatively, appropriately sized titanium plates were prepared based on the area of bony defects. During the surgery, the frontal bone surface was preserved, and the titanium plate reconstructed the orbital wall and anterior skull base structures, with no cerebrospinal fluid leakage occurring postoperatively. Image fusion provided a spatial anatomical relationship of the skull defect and a visual display of quantitative data, which is beneficial for tumor resection and skull base reconstruction.

Complications

Cerebrospinal fluid leakage is the most common complication of complex skull base tumor surgery. The basic principle we follow is to be careful and gentle when separating the tumor attached to the meninges during the surgery to maintain the integrity of the tumor. When resecting the tumor during the surgery, care should be taken to preserve the residual meninges of the skull base and not to excessively resect the meninges in emphasizing complete tumor resection. In these cases, none of the patients experienced cerebrospinal fluid leakage. Protection of cranial nerves should also follow the same principle. One case of parapharyngeal interstitial malignant tumor resulted in postoperative swallowing difficulties due to the high adhesion between the glossopharyngeal nerve and the tumor. In Case 7, a fourth ventricle vascular embryonal tumor accompanied by vascular malformation resulted in brainstem infarction due to preoperative vascular embolization, leading to coordination issues in the patient. During the surgery, all vessels were well protected, and the coordination issues resolved after 3 months of conservative treatment.

Practicality and Limitations of 3D Multimodal Software

Regarding the software for preoperative multimodal imaging fusion technology, this study mainly used the GE-AW workstation, which has significant advantages in multimodal imaging fusion of the brainstem, cranial nerves, vessels, and skull. However, it also has some disadvantages, including that the details of skull reconstruction are not as precise as in 3D slicer, which can display various structures of the skull in higher resolution. To achieve better performance in reconstruction, the MR and CT scan thickness should be 2.0mm or less.

Conclusion

The choice of surgical approach depends on the growth characteristics of the tumor and the extent of venous or sinus involvement. Preoperative multimodal imaging fusion technology can provide a wealth of valuable visual information for skull base tumor surgery. For complex skull base tumors, due to their deep location and complex anatomical relationships, preoperative surgical simulation based on multimodal imaging fusion can ensure a safer surgical process.

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Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery
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Corresponding Author Introduction

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Chen Gang, Chief Physician

Zhuhai People’s Hospital

  • Chief physician, Doctor of Medicine, Director of the Department of Neurosurgery, Zhuhai People’s Hospital

  • Standing member of the Neurosurgery Anatomy Branch of the Chinese Anatomical Society

  • Standing member of the Cerebral Hemorrhage Minimally Invasive Treatment Professional Committee of the Chinese Stroke Society

  • Standing member of the Neurosurgical Trauma Branch of the Chinese Association for Medical and Health International Exchange

  • Vice Chairman of the Neurosurgery Professional Committee of the Guangdong Medical Education Association

  • Vice Chairman of the Neurosurgery Professional Committee of the Guangdong Hospital Association

  • Vice Chairman of the Neurosurgery Management Branch of the Guangdong Medical Industry Association

  • Chairman of the Neurosurgery Branch of the Zhuhai Physician Association

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

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First Author Introduction

Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

Jian Zhiheng, Associate Chief Physician

Zhuhai People’s Hospital

  • Associate Chief Physician, Master’s Degree from Southern Medical University, Master’s Supervisor at Guangdong Medical University

  • Executive member of the Neurosurgery Information Application Branch of the Guangdong Health Information Network Association

  • Youth member of the Neurosurgical Oncology Branch of the Guangdong Medical Association

  • Member of the Neurosurgery Branch of the Guangdong Medical Education Association

  • Executive member and secretary of the Neurosurgery Branch of the Zhuhai Physician Association

  • Member of the Neurosurgery Branch of the Zhuhai Medical Association

  • In the past 3 years, hosted one municipal-level project, published 4 SCI papers as the first author, and 1 CSCD paper.

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Application of Preoperative Multimodal Imaging Fusion Technology in Complex Skull Base Tumor Surgery

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