Is neuronavigator an essential tool for neurosurgeons? A review of computerized neuroimaging techniques in terms of operative planning.

Introduction – At nowadays intraoperatively computerized techniques are routinely used in neurosurgical centers aiding the surgeon to better localize intracerebral lesions and respect the surrounding highly vulnerable neural structures. In this context, Neuronavigation represents the most well-known device virtually used in most of neurosurgical theatres. Due to this very comfortable and highly reliable tool less effort is given in pre-operative planning in terms of a complete neuroradiological assessment. We propose a methodology which may facilitate the pre-surgical planning and help to recognize and preserve neurovascular anatomy. Material and Methods – We present two cases of patient with cerebral lesion in eloquent areas with a high risk of post-operative neurological deficit due to the complex neurovascular relationships. We performed Digital Subtraction Angiography (DSA) with oblique and orthogonal projections and MRI scan with volumetric acquisition. Using anatomical markers (bi-callosal line, vasal segments and cerebral sulci) we obtained an overlapping between the lateral angiography and the tridimensional MRI obtained by Dicom Software OSIRIX ©. Such cortex-vascular mapping has been demonstrated to be helpful to identify the vessels which lay on cerebral sulci and understand those ones in deeper position. Results and Conclusions – The relatively easy and quick pre-operative planning along with an unequivocal exact comparison with the anatomy during the surgical procedure, gives a high reliability to this procedure especially in those lesions located in the lateral brain convexity (insula and front-temporo-parietal opercular region). This methodology could so enhance the neuronavigation standard procedures and help the surgeon in particular complex neurovascular anatomy.