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Robot assisted laser-interstitial thermal therapy with iSYS1 and Visualase: how I do it

  • How I Do it - Neurosurgical technique evaluation
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Abstract

Background

Laser-interstitial thermal therapy (LITT) is an ablative treatment based on a surgically implanted laser-emitting catheter to induce a focal ablation of the pathological tissue. The main indications in neurosurgery are primary brain tumors, metastases, radiation necrosis, and pediatric brain tumors. Several approaches have been proposed to implant the laser-emitting catheter, both in frameless and frame-based conditions.

Methods

We report our approach for Robot assisted laser-interstitial thermal therapy of brain lesions with iSYS1 and Visualase (Medtronic).

Conclusions

iSYS1 represents a significant adjunct to LITT procedures and may be safely implemented in routine laser-catheter positioning.

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Acknowledgements

We thank Dr. Giovanni Carone for his help in mounting and editing the video.

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Authors and Affiliations

  1. Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, via Celoria 11, 20133, Milan, Italy

    Cecilia Casali, Massimiliano Del Bene, Giuseppe Messina, Federico Legnani & Francesco DiMeco

  2. Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy

    Massimiliano Del Bene

  3. Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy

    Francesco DiMeco

  4. Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, MD, USA

    Francesco DiMeco

Authors
  1. Cecilia Casali
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  2. Massimiliano Del Bene
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  3. Giuseppe Messina
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  4. Federico Legnani
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  5. Francesco DiMeco
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Corresponding author

Correspondence to Cecilia Casali.

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Conflict of interest

The authors declare no competing interests.

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Key points

1. LITT can be a viable option only for a limited number of patients due to its intrinsic limitations and to its indication still not universally agreed.

2. Robot assisted positioning might be indicated in those cases in which accuracy is particularly relevant.

3. Trajectory planning must respect the general rules of stereotaxy as well as the morphology of the lesion in relation to the shape of laser emission.

4. Several simulations are needed to find the best solution in regard to number of catheters and relative trajectories.

5. Skin fiducial-based registration offers a level of accuracy comparable to bone fiducials and better than surface match.

6. The metal bone anchor provides a better accuracy than plastic anchor and should be preferred, even if in superficial lesions, it could slightly interfere with thermometry MRI.

7. During robot-assisted positioning, in the effort to maximize the accuracy, two entry points have to be defined. The first is on the bone, to perform the drilling, while the second is on the extension of the trajectory (5cm away from the bone), to accommodate the bone-anchor under the guidance sheath.

8. Before initiating thermal ablation, it is extremely important to acquire an MRI scan to exclude potential errors in catheter positioning and complications occurrence (e.g., hematoma).

9. The entire workflow of the procedure must be proven and standardized. Ideally, the best setting is represented by a hybrid operating room with an intraoperative MRI.

10. Follow-up protocol should embrace multiple MRI scans acquired at the end of the treatment, 24h post, 1month post, and every 3 months. The aim is to assess edema evolution over-time, and the potential lesion relapse/progression. Perfusion-weighted images can help in distinguishing between post-treatment modifications and true relapse.

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This article is part of the Topical Collection on Neurosurgical Technique Evaluation

Supplementary information

Below is the link to the electronic supplementary material.

Supplementary file1. Robot assisted Laser-Interstitial Thermal Therapy with iSYS1 and Visualase in a case of single left parietal brain metastasis from kidney. The patient underwent whole brain radiotherapy 20mos before treatment, the systemic disease was under control while the single brain metastasis had demonstrated continuous growth in 2 consecutive MRI. (MP4 156727 KB)

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Casali, C., Del Bene, M., Messina, G. et al. Robot assisted laser-interstitial thermal therapy with iSYS1 and Visualase: how I do it . Acta Neurochir 163, 3465–3471 (2021). https://doi.org/10.1007/s00701-021-04883-3

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  • DOI: https://doi.org/10.1007/s00701-021-04883-3

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