CRANIAL TRAJECTORY PLANNING

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3 TABLE OF CONTENTS TABLE OF CONTENTS 1 GENERAL INFORMATION Contact Data Legal Information Symbols Used in This Guide Intended Use Compatibility with Medical Devices Non-Brainlab Software Non-Brainlab Medical Devices Training and Documentation Used Abbreviations USING TRAJECTORY Introduction Create, Modify and Remove Trajectories Using Trajectory (Element) Software Functions Modifying Trajectories Trajectory Positioning Controls Define Trajectory Properties Creating 3D Shapes Memorize Function Lead Properties Defining the Lead Orientation AC/PC Coordinates Availability Repositioning AC/PC Localization AC/PC Localization Details Save as a Plan Identifying the Plan Status and Reviewing/Approving with Trajectory (Element) Data Selection View Viewing and Reviewing Trajectories Data Verification Trajectory Display and Verification Stereotactic Planning and Localization Localizing the Image Set...48 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

4 TABLE OF CONTENTS Localization Status Result Localization Example Ignoring Slices Adding and Positioning Rod Markers Stereotactic Localizers Supported Arc Systems Leksell Stereotactic Systems Leksell Vantage Arc Leksell Multi Purpose Stereotactic Arc Inomed ZD Arc System Radionics Arc Systems Stereotactic Report Report Functions Report Content Ending the Session Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

5 GENERAL INFORMATION 1 GENERAL INFORMATION 1.1 Contact Data Support If you cannot find information you need in this guide, or if you have questions or problems, contact Brainlab support: Region Telephone and Fax United States, Canada, Central and South America Tel: Fax: Brazil Tel: (0800) us.support@brainlab.com UK Tel: Spain Tel: France and French-speaking regions Tel: Africa, Asia, Australia, Europe Tel: Fax: support@brainlab.com Japan Tel: Fax: Expected Service Life Brainlab provides five years of service for software. During this period of time, software updates as well as field support are offered. Feedback Despite careful review, this manual may contain errors. Please contact us at igs.manuals@brainlab.com if you have suggestions as to how we can improve this manual. Manufacturer Brainlab AG Olof-Palme-Str Munich Germany Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

6 Legal Information 1.2 Legal Information Copyright This guide contains proprietary information protected by copyright. No part of this guide may be reproduced or translated without express written permission of Brainlab. Brainlab Trademarks Brainlab is a registered trademark of Brainlab AG in Germany and/or the US. SmartBrush is a registered trademark of Brainlab AG in Germany and/or the US. Non-Brainlab Trademarks Microsoft and Windows are registered trademarks of Microsoft Corporation. Integrated 3rd-Party Software This software is based in part on the work of the Independent JPEG Group. Portions of this software are based on the work of Sun Microsystems Inc. The Brainlab PDF-Viewer implementation is based on the PDF Direct/PDF Quick View library, Copyright soft Xpansion GmbH & Co. KG. This product includes software developed by Telerik, Inc., Copyright This product includes software developed by the Apache Software Foundation ( This software is based in part on Xerces-C++ made available under the Apache Software License: This product includes software developed by the Apache Software Foundation ( Copyright (c) The Apache Software Foundation. All rights reserved. This product includes libtiff beta, copyright Sam Leffler and copyright Silicon Graphics. For a full description of copyrights and license see: This software is based in part on libjpeg-turbo. The full license and copyright notice can be found here: This software is based in part on OpenJPEG. The full license and copyright notice can be found here: CE Label The CE label shows that the Brainlab product complies with the essential requirements of the Medical Device Directive (MDD). According to the MDD, Council Directive 93/42/EEC, Trajectory Planning is a Class IIb product. NOTE: The validity of the CE label can only be confirmed for products manufactured by Brainlab. 6 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

7 GENERAL INFORMATION Disposal Instructions Only dispose of electrical and electronic equipment in accordance with statutory regulations. For information regarding the WEEE (Waste Electrical and Electronic Equipment) directive, visit: Sales in the US US federal law restricts this device to sale by or on the order of a physician. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

8 Symbols Used in This Guide 1.3 Symbols Used in This Guide Warnings Warnings are indicated by triangular warning symbols. They contain safety-critical information regarding possible injury, death or other serious consequences associated with equipment misuse. Cautions Cautions are indicated by circular caution symbols. They contain safety-critical information regarding possible problems with the device. Such problems include device malfunctions, device failure, damage to device or damage to property. Notes NOTE: Notes are formatted in italic type and indicate additional useful hints. 8 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

9 GENERAL INFORMATION 1.4 Intended Use Indications for Use Trajectory Planning s indications for use are the viewing, presentation and documentation of medical imaging, including different modules for image processing, image fusion, atlas assisted visualization and segmentation, intraoperative functional planning where the output can be used e.g., with stereotactic image guided surgery or other devices for further processing and visualization. Example procedures include but are not limited to: Planning and simulation of cranial surgical procedures such as shunt placement, minimal invasive stereotactic interventions, biopsy, planning and simulation of trajectories for stimulation and electrode recording. Typical users of Trajectory Planning are medical professionals, including but not limited to surgeons and radiologists. Intended User The operators of Trajectory Planning are trained healthcare professionals, e.g.: Neurosurgeon Stereotactic Neurosurgeon Place of Use The place of use is determined to be indoors, normally in a hospital or clinical setting. Careful Handling Only trained medical personnel may operate system components and accessory instrumentation. Plausibility Review Before patient treatment, review the plausibility of all information input to and output from the system. Responsibility This system solely provides additional assistance to the surgeon or user and does not by any means substitute or replace the surgeon s or user s experience and/or responsibility during its use. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

10 Compatibility with Medical Devices 1.5 Compatibility with Medical Devices Instrument Use Only use instruments and spare parts specified by Brainlab with Trajectory. Using unauthorized instruments/spare parts may adversely affect safety and/or effectiveness of the medical device and endanger safety of patient, user and/or environment. Compatible Brainlab Medical Software Trajectory (Element) 2.0 is compatible with: Fibertracking 1.0 Image Fusion 1.0, 2.0 and 3.0 iplan Stereotaxy 3.0 Lead Localization 1.0 Object Manager 1.0 Patient Data Manager Content Manager - Patient Selection - DICOM Viewer SmartBrush 2.0, 2.1 and 2.5 Other Brainlab Software Other compatible Brainlab software may become available after the release of this user guide. If you have questions regarding compatibility of software, contact Brainlab support. If you are running software versions other than those specified above, contact Brainlab support for clarification regarding compatibility with Brainlab devices. 10 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

11 GENERAL INFORMATION Non-Brainlab Software Authorization Only authorized Brainlab employees may install software on the Brainlab system. Do not install or remove any software applications. Compatible Non-Brainlab Software Trajectory (Element) 2.0 is compatible with: Microsoft Windows 7 Microsoft Windows 8.1 Microsoft Windows 10 Microsoft Windows Server 2008 Microsoft Windows Server 2012 R2 For detailed and up-to-date information regarding compatible operating systems, please contact Brainlab support. Brainlab recommends protecting the system by state-of-the-art malware protection measures (e.g., installation of a virus scanner). Be aware that some malware protection measures can negatively affect the system performance (e.g., if realtime scans are performed and each file access is monitored, then loading and saving patient data may be slow). NOTE: The Brainlab system is a medical device and shall be used according to the intended use and the end user license agreement of the system. Using third party software can adversely affect the reliability of the system. Only critical operating system updates or malware protection measures are recommended. Driver updates are not allowed. Do not download or install updates during treatment planning. Please contact Brainlab support for further information. DICOM Conformance DICOM conformance statements can be found on the Brainlab homepage: DICOM Medical Electrical Systems For information regarding the configuration of medical electrical systems, see the relevant System User Guide and Technical User Guide. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

12 Non-Brainlab Medical Devices Non-Brainlab Medical Devices Compatible Non-Brainlab Medical Devices Manufacturer Leksell Inomed Radionics Medical Device Stereotactic localizer Arc system Stereotactic localizer Arc system Stereotactic localizer Arc system Leksell Vantage MR Indicator interfacing with Leksell Vantage Headring Leksell Open MR Indicator Box, Leksell MR Indicator Box, Leksell Open CT Indicator Box, Leksell CT Indicator Box interfacing with Leksell G-Frame Headring Leksell Vantage Arc interfacing with Leksell Vantage Headring Leksell Multi-Purpose Arc interfacing with Leksell G-Frame Headring Revision R CT/MR Localizer interfacing with Inomed Titanium Headring Revision U CT/MR Localizer interfacing with Inomed Open Ceramic headring Inomed ZD Arc interfacing with Inomed Titanium or Inomed Open Ceramic Headring Radionics UCLF-0 (Universal Compact CT/MR Localizer Frame) interfacing with Radionics UCHR (Universal Compact Headring) Radionics LL01 Luminant Localizer interfacing with Radionics UCHR (Universal Compact Headring) Radionics BRW-LF Luminant interfacing with HRA-IM (Intubation Head Ring) Localizer Radionics CRW-ASL Arc interfacing with Radionics UCHR or Radionics HRA-IM Radionics Precision CRW Arc interfacing with Radionics UCHR or Radionics HRA-IM Using medical device combinations which have not been authorized by Brainlab may adversely affect safety and/or effectiveness of the devices and endanger safety of the patient, user and/or environment. 12 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

13 GENERAL INFORMATION 1.6 Training and Documentation Intended Audience This user guide is intended for surgeons and/or their staff. Brainlab Training To ensure safe and appropriate use, before using the system all users should participate in a training program held by a Brainlab representative. Supervised Support Before using the system for surgical procedures where computer-aided navigation is considered critical, ensure you perform a sufficient number of complete procedures with a Brainlab representative present to provide guidance where necessary. Responsibility This system solely provides assistance to the surgeon and does not substitute or replace the surgeon s experience and/or responsibility during its use. Documentation This guide describes complex medical software that must be used with care. It is therefore important that all users of the system: Read this guide carefully before handling the equipment Have access to this guide at all times Available User Guides User Guide Software User Guides Instrument User Guides Cleaning, Disinfection and Sterilization Guide System User Guides Technical User Guides Contents Overview of treatment planning and image-guided navigation Description of OR system setup Detailed software instructions Detailed instructions on instrument handling Details on cleaning, disinfecting and sterilizing instruments Comprehensive information on system setup Detailed technical information on the system, including specifications and compliances Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

14 Used Abbreviations Used Abbreviations Abbreviations This user guide contains the following abbreviations: Abbreviation Definition AC/PC Anterior Commissure/Posterior Commissure ADC Trace Map DTI Apparent Diffusion Coefficient B0 DTI image acquired at b=0 sec/mm 2 BOLD CT DICOM DTI MER/S MRI PACS PET Blood Oxygen Level Dependent Computed Tomography Digital Imaging and Communications in Medicine Diffusion Tensor Imaging Microelectrode Recording and Stimulation Magnetic Resonance Imaging Picture Archiving and Communication System Positron Emission Tomography 14 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

15 USING TRAJECTORY 2 USING TRAJECTORY 2.1 Introduction General Information Cranial Trajectory Planning is a medical device configuration based on Trajectory (Element) delivering all necessary product functions dedicated to cranial trajectory planning, such as e.g.: identify name and status of the loaded plan, add, modify and remove trajectories, as well as review/approve trajectory planning results. The following anatomically interrelated trajectory planning data is contained in a treatment plan: AC/PC localization Custom orientation Image sets, including windowing Co-registrations Objects Fibertracks Trajectories Using Trajectory, you can plan possible pathways for the surgical instruments on the scanned images. Typical Workflow The goal of Cranial Trajectory Planning is to create a minimally invasive trajectory path using Trajectory (Element). Step 1. Start session and load patient data. Select images, objects, fibertracks, trajectories, or plans, and load data. 2. Create, modify and remove co-registrations using Image Fusion. See the Software User Guide for Image Fusion for more information. 3. Create, modify and remove objects using SmartBrush or Anatomical Mapping. For more information, see the Software User Guide for SmartBrush or the Software User Guide for Anatomical Mapping. 4. Create, modify and remove fiber bundles using Fibertracking. See the Software User Guide for Fibertracking for more information. 5. Create, modify and remove trajectories using Trajectory (Element). 6. Save as a plan. 7. Identify the plan status and review/approve the plan using Trajectory (Element). 8. End the session. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

16 Introduction How to Load Patient Data 1 2 Figure 1 Step 1. Select a workflow e.g., Trajectory Planning 1 under the specialty Cranial. Alternatively, select e.g.. Stereotactic Planning 2 under the specialty Stereotaxy. Patient Selection opens. 2. Select data in Patient Selection. NOTE: If you select a plan, all data referenced in that plan will be selected. NOTE: For further information see the Software User Guides for Content Manager, Patient Browser and DICOM Viewer. Related Links 2.8 Stereotactic Planning and Localization on page Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

USING TRAJECTORY 2.2 Create, Modify and Remove Trajectories Using Trajectory (Element) Example View Figure 2 How to Start Trajectory (Element) Step 1.

Select Create New. A new trajectory is created. NOTE: This option does not allow you to directly modify the properties.

17 USING TRAJECTORY 2.2 Create, Modify and Remove Trajectories Using Trajectory (Element) Example View Figure 2 How to Start Trajectory (Element) Step 1. Select Trajectory (Element) from your specialty workflow e.g., CRANIAL - TRAJECTO- RY PLANNING in Patient Data Manager. How to Create a New Trajectory Step 1. Select Create New. A new trajectory is created. NOTE: This option does not allow you to directly modify the properties. NOTE: Brainlab recommends naming and assigning different colors to distinguish between different trajectories, objects, fiber bundles etc. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

18 Create, Modify and Remove Trajectories Using Trajectory (Element) How to Remove Trajectories Step 1. Select the trajectory from the list in the tool bar. 2. Click Delete. The trajectory is removed. 18 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

19 USING TRAJECTORY Software Functions Menu Functions Button Function Activates the zoom function to the region of interest. NOTE: Alternatively use CTRL and the mouse wheel. Activates scroll functions in the displayed reconstruction (plane). For each view and interaction option, there is a dedicated scroll increment: Click on the inview buttons: scrolls up/down 1 mm. Drag the mouse pointer within the main view: scrolls up/down (zoom level dependent). Turn the mouse wheel with the mouse pointer over the inline side view: scrolls up/down 1 mm in the trajectory direction. NOTE: Some scroll functions are available independently of Scroll being activated. Pans vertical and horizontal planes. NOTE: Alternatively use CTRL and the left mouse button to pan. Drag left or right across the viewing area to adjust the contrast. Drag up or down to adjust the brightness. Selects the active trajectory. Toggles between trajectories. Automatically scrolls and pans the reconstruction to display the target or entry (at the center of the view). Rotates the current view. Rotates the 2D reconstruction in relation to other views. Rotates the 3D reconstruction plane. Adjusts the scrolling plane (in specific views). Undo the last change made or multiple consecutive steps. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

20 Modifying Trajectories Modifying Trajectories Overview You can reposition the target and entry points for the trajectory within the views or by editing the DICOM and/or AC/PC relative coordinates of the trajectory. There are two options for this: Drag the trajectory using the mouse pointer (or finger). Amend coordinates directly in the menu. The displayed DICOM coordinates always relate to the active image set. How to Select an Active Trajectory 2 1 Figure 3 You can only interact with the active trajectory. Select other trajectories as follows: Step 1. Select your trajectory using the menu 1 in the tool bar. 2. Alternatively, use the Data selection menu Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

reposition them on screen. How to Amend DICOM or AC/PC Relative Coordinates Step 1.

21 USING TRAJECTORY How to Drag Target and Entry Points 1 Figure 4 Step 1. Drag the target or entry points 1 using the mouse pointer (or finger on touchscreens) to reposition them on screen. How to Amend DICOM or AC/PC Relative Coordinates Step 1. Select the tab you want to edit, (e.g., AC/PC) Select edit 1. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

22 Modifying Trajectories Step 3. 2 Select the reference point 2 (AC Point, MC Point, or PC Point) for the coordinate system. NOTE: Depending on your settings, a default reference point is set. 4. Set the criteria for: - Target - Direction - Length (approx mm) 5. Confirm your settings Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

USING TRAJECTORY 2.2.3 Trajectory Positioning Controls Trajectory Positioning Example 3 2 4 1 Figure 5 No.

23 USING TRAJECTORY Trajectory Positioning Controls Trajectory Positioning Example Figure 5 No Explanation Target positioning selection area Entry positioning selection area DICOM and AC/PC coordinate tabs Edit menu Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

24 Define Trajectory Properties Define Trajectory Properties Trajectory Menu Figure 6 Use the Trajectories menu within the Data selection menu to define and view trajectory properties e.g.: Visibility switch (displays the distance between the target and entry) Basis (the image set in which the trajectory is co-registered) Name Comment Color Shape (e.g., diameter) Delete 24 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

25 USING TRAJECTORY Creating 3D Shapes General Information You can assign the type, shape and characteristics of an instrument as a visual aid for positioning the target and entry of an abstract trajectory. NOTE: The 3D shape feature is not intended to visualize implants. How to Create 3D Shapes Step 1. Open the Data selection menu Select a trajectory. Select Shape. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

How to Adjust Shape Parameters 1 Figure 7 Each 3D shape type has

26 Creating 3D Shapes Step 4. 1 Select a 3D Shape type from the drop down menu Select OK. How to Adjust Shape Parameters 1 Figure 7 Each 3D shape type has parameters that can be adjusted. 26 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

USING TRAJECTORY Step 1. Select a 3D Shape type from the drop down menu 1. 2. Use Add Section to add a new marked section to the 3D shape. 3. Amend the parameters as appropriate to your surgical application, e.

27 USING TRAJECTORY Step 1. Select a 3D Shape type from the drop down menu Use Add Section to add a new marked section to the 3D shape. 3. Amend the parameters as appropriate to your surgical application, e.g.: - Diameter - Tip Offset - Offset - Length 4. Select OK. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

28 Memorize Function Memorize Function Memorize Button Function Saves modified parameters to use as default settings for later use. 28 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

USING TRAJECTORY 2.2.7 Lead Properties General Information Specific lead models can be defined by assigning the model type and various additional parameters.

29 USING TRAJECTORY Lead Properties General Information Specific lead models can be defined by assigning the model type and various additional parameters. Based on these parameters, a corresponding lead model is created, and can then be utilized in other applications that interpret this information. How to Define Lead Properties NOTE: Brainlab recommends naming and assigning different colors to distinguish between different leads, trajectories, objects, etc Figure 8 Step 1. Select Properties. 2. Optional: Edit the automatically assigned lead Name Optional: Edit the automatically assigned lead Implant Date Optional: Enter a Comment Required: Select lead Type Optional: Select lead Tip Offset 5 7. Optional: Select Location 6 in which the lead is situated. 8. Optional: Select a different lead and repeat lead definition. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

Defining the Lead Orientation 2.2.8 Defining the Lead Orientation How to Define the Lead Orientation 1 Figure 9 If you have defined a directional lead, the Define Orientation view opens.

30 Defining the Lead Orientation Defining the Lead Orientation How to Define the Lead Orientation 1 Figure 9 If you have defined a directional lead, the Define Orientation view opens. Drag the orientation marker 1 to rotate the orientation. Select and hold Toggle Numbering to display how the contact numbering would be if connected to the other IPG port. 30 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

31 USING TRAJECTORY AC/PC Coordinates Availability About AC/PC Coordinates The AC/PC coordinates are only enabled if: AC/PC localization has been performed in the selected image set, or The selected image set has been fused to an image set that is AC/PC localized NOTE: Modifying the AC/PC localization does not change the trajectories defined within the AC/PC function. Trajectories always retain their position relative to the image data in which they were created. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

32 Repositioning Repositioning Repositioning The information provided by the AC/PC coordinates may be incorrect, inconsistent or inaccurate due to improper localization of the AC/PC system, or due to inherent insufficiencies of the planning methods based on the AC/PC system. To prevent patient injury, make sure to verify all trajectory positions in the patient image views (e.g., the DICOM and AC/PC tabs). 32 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

33 USING TRAJECTORY AC/PC Localization General Information You can define the AC/PC localization by: The mid-sagittal plane The positions at which the anterior commissure (AC) and the posterior commissure (PC) intersect the mid-sagittal plane When is AC/PC Localization Required? AC/PC localization is required for: Patient orientation, which is used for the alignment of reconstructed views (e.g., axial, coronal and sagittal) in planning tasks Trajectory planning based on definable AC/PC coordinates How to Add AC/PC Localization 1 Step Figure Select Add AC/PC 1. The default AC/PC coordinates are displayed in the image views and can be modified as needed. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

AC/PC Localization How to Modify AC/PC Localization by Dragging 1 Figure 11 You can adjust the AC/PC points and planes in the image views in order to reposition the AC/PC system as needed. Step 1.

34 AC/PC Localization How to Modify AC/PC Localization by Dragging 1 Figure 11 You can adjust the AC/PC points and planes in the image views in order to reposition the AC/PC system as needed. Step 1. Drag the target and entry points 1 using the mouse pointer (or finger on touchscreens) in order to reposition them. 2. Select Done Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

USING TRAJECTORY 2.2.12 AC/PC Localization Details AC/PC Localization Example 1 2 3 Figure 12 No.

35 USING TRAJECTORY AC/PC Localization Details AC/PC Localization Example Figure 12 No Explanation AC positioning selection area Distance between AC and PC points PC positioning selection area NOTE: AC and PC points are visible in all views. How to Remove AC/PC Localization Step 1. Select edit. 2. Select Clear AC/PC to remove the AC/PC localization. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

36 Save as a Plan 2.3 Save as a Plan General Information Always ensure that your planning results are saved as a plan with a dedicated name. This can then be reviewed using Trajectory (Element). See Software User Guide for Content Manager and Patient Selection for more information. Related Links 2.4 Identifying the Plan Status and Reviewing/Approving with Trajectory (Element) on page Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

USING TRAJECTORY 2.4 Identifying the Plan Status and Reviewing/ Approving with Trajectory (Element) Plan Status 1 2 Figure 13 The plan status 2 is displayed within data selection.

37 USING TRAJECTORY 2.4 Identifying the Plan Status and Reviewing/ Approving with Trajectory (Element) Plan Status 1 2 Figure 13 The plan status 2 is displayed within data selection. It states if a plan, for eaxmple, is a modified plan. Use MORE to view patient selection. How to View Trajectories Step 1. Select Data selection from the top of the functions area. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

38 Data Selection View 2.5 Data Selection View Example View The basis of a trajectory is outlined below: The image set in which the trajectory is planned The length (target to entry distance) The name and its properties Figure 14 View or load a resection object and/or other existing objects in the data view. 7 No Explanation Trajectory object Image type Toggle switch for selecting/deselecting 3D shapes Toggle switch to show/hide all trajectories ACS, Inline or Overview selection Closes Data selection Editable trajectory properties: Name Comment Color Shape Naming Trajectories Assign each trajectory a unique name so that it can be clearly identified. 38 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

ACS View Figure 16 ACS view displays slices of the selected image set in Axial,

39 USING TRAJECTORY Overview Figure 15 Overview displays the trajectory path in one of the ACS views, for example Axial and additionally as Inline and Perpendicular. ACS View Figure 16 ACS view displays slices of the selected image set in Axial, Coronal, and Sagittal views. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

40 Data Selection View Inline View Figure 17 Inline view allows you to compare the trajectory path in other views. 40 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

By switching between Overview, ACS and Inline layouts, you can see the entire course of the trajectory and ensure that no

All planned trajectories must be verified in the image views. How to Verify Trajectories 1 2 3 5 4 Figure 18 Step 1.

41 USING TRAJECTORY 2.6 Viewing and Reviewing Trajectories General Information Select Data to view and manage pre-existing assets (e.g., trajectories, objects and data types for your trajectory). By switching between Overview, ACS and Inline layouts, you can see the entire course of the trajectory and ensure that no critical structures are penetrated. Use the Inline view to scroll through the data set for verification purposes. All planned trajectories must be verified in the image views. How to Verify Trajectories Figure 18 Step 1. Select your trajectory from the list Select a view from the side menu Move to the region of interest using the Pan and Zoom functions. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

42 Viewing and Reviewing Trajectories Step 4. Select Scroll and scroll through the scan reconstructions using the buttons on the Overview layout 3.The scan depth is indicated by a point locater 5 in the Axial view and by a yellow line 4 in the Inline view. 5. Verify your trajectory, then select Done. NOTE: You can also verify trajectories using the Pan and Recenter buttons. 42 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

43 USING TRAJECTORY Data Verification Data Verification Always review your content for correctness after making modifications. Adding, changing or removing content such as objects, image data, windowing, fusions or trajectories may change what you originally planned. Always review co-registrations individually and review each trajectory within each image set to sufficiently verify acceptance of any error propagations within a fusion. Always review the planning results from an unmodified plan. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

44 Trajectory Display and Verification 2.7 Trajectory Display and Verification Trajectory Display An intersection point is the point in 3D space where the trajectory axis intersects the displayed reconstruction plane. An intersection point is displayed: Beyond entry Between target and entry Beyond target When the depth position is placed on the target point, after clicking Center, the intersection point indicates the exact position of the target Figure 19 No Explanation The intersection point is beyond entry The intersection point is the entry The intersection point is between the target and entry The intersection point is the target The intersection point is beyond the target 44 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

45 USING TRAJECTORY Cranial Example Figure 20 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

46 Stereotactic Planning and Localization 2.8 Stereotactic Planning and Localization General Information With the localization planning task, you can assign the localizer to the selected image set and perform stereotactic localization. Stereotactic localization provides a headring-specific coordinate system in which it is possible to calculate the arc settings for a planned trajectory. Stereotactic localization should be performed prior to planning trajectories or objects in the image set, as well as prior to performing image fusion, to ensure consistent visualization of planning content in all views. Hardware Carefully check the accuracy of your localization hardware on a regular basis. Localization is only possible in combination with fully functional hardware. If the localizer hardware is defective or damaged, or if the rod geometry is incorrect, this can either cause localization to fail, or lead to incorrect results. Supported Images Imaging modalities that cause image distortions (e.g., MR EPI data sets) or improper rod marker representation (due to poor contrast) cannot be properly localized. General Workflow Step 1. Select the image set scanned with the localizer. 2. Select your chosen localizer from the toolbar. Localization starts automatically. For reviewing and correcting localization results, follow these steps: Step 1. Review each slice with regards to rod detection definition. This applies to all slices, e.g., green, yellow and red. In the case that a rod is not detected correctly, manually correct its position. In the case that a rod is not detected at all, use Add Rod to position it manually. 2. Use Ignore Slice for slices outside the localizable range (i.e., for slices outside the localizer geometry, showing none or insufficient number of rods). 3. Select Localize after performing the adjustments in order to get a new localization result based on verified and corrected rod detections. 4. Continue using Ignore Slice to exclude single slices, containing e.g., air bubbles. However, do not use Ignore Slice to correct image distortions, artifacts or defective localizer hardware with e.g., loose or bent plates. NOTE: If too many slices have been ignored (e.g., due to defective hardware or scanning artifacts), localization cannot be calculated. In this case, the localizer needs to be repaired and/or a new scan must be acquired. 46 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

47 USING TRAJECTORY Failed Localization If no slices could be localized: Step 1. Check the assigned localizer. 2. If the wrong localizer has been selected, assign the correct localizer and repeat localization. 3. Start the steps according to the general workflow. How to Start Stereotaxy (Element) Step 1. Select Stereotaxy (Element) from your specialty workflow e.g., STEREOTAXY STER- EOTACTIC PLANNING in Patient Data Manager. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

Localizing the Image Set 2.8.1 Localizing the Image Set General Information The first step in performing localization is localizer assignment. This provides a frame of reference for the slice set.

Select your localizer from the drop down menu. Make sure you choose the same combination that was used during scanning. Localizing starts automatically.

48 Localizing the Image Set Localizing the Image Set General Information The first step in performing localization is localizer assignment. This provides a frame of reference for the slice set. How to Localize the Image Set Step 1. Select the image data from Content Manager. 2. Select Frame Planning. 3. Select Localization. The screen changes to localization mode. 4. Select your localizer from the drop down menu. Make sure you choose the same combination that was used during scanning. Localizing starts automatically. You must select the correct localizer for localization. If an incorrect localizer is selected, all slices might be successfully localized, however, the subsequent coordinate system, based on a combination of localizer, headring and arc system, will be incorrect. 48 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

49 USING TRAJECTORY Localization Status Result Localization Status Report Figure 21 The software localizes the available slices and displays a status report of the localization. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

Localization Example 2.8.3 Localization Example Localization Main Screen Example 1 2 3 5 Figure 22 4 Screen Explanation No.

50 Localization Example Localization Example Localization Main Screen Example Figure 22 4 Screen Explanation No. View Explanation 1 2 Catalog Main Depending on the localization result, the color of the slices varies: Green: Slice successfully localized. Yellow: Slice has been localized, but precision is low due to one or more misplaced rod markers, poor image quality or an inaccurate localizer geometry. Red: Slice could not be localized. Several reasons are possible, e.g., not enough rods detected. Shows the slice currently selected in the catalog view and whether the image slice could be localized (upper left corner). Rod marker colors: Green: Localized rod markers. Yellow: Rod markers with poorest localization result. Blue: Indicates that some, but not all rod markers could be localized. 3 Functions area Use the functions to modify the localization as needed. 4 5 Magnified axial view 3D Shows a magnified view of the area indicated by the white dotted circle in the main view. Use this view to better examine the position of a particular rod marker. To magnify another area, click on a different rod marker. 3D view of all detected rod markers together with the expected localizer geometry. Use this view to verify the localizer rod geometry and identify slices with misplaced rod markers. Rod markers should reconstruct in a straight line. 50 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

USING TRAJECTORY Verifying Localization Carefully visually verify the contents of each view, in order to ensure that localization has been successful.

51 USING TRAJECTORY Verifying Localization Carefully visually verify the contents of each view, in order to ensure that localization has been successful. Verify that every slice has been localized correctly, (e.g., using the 3D view). Even if the software indicates that a slice has been localized successfully (displayed in green in the catalog view) the slice must be checked. For example, the arrangement of the rods may be correct, but due to artefacts, the rod geometry as a whole may be displaced. Rod Marker Positions If a gantry tilt is used for CT scans, or if a scan is oblique (e.g., MR), the image slices must still intersect the rods of the localizer at a perpendicular angle. Refer to the scanning instructions for acceptable gantry tilt or oblique angles. How to Adjust the Threshold 1 Figure 23 Step 1. Adjust the Threshold by using the slider 1. If necessary, adjust the threshold value used to detect rod markers. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

52 Ignoring Slices Ignoring Slices When to Ignore Slices The Ignore Slice function allows you to exclude slices with insufficient rod marker definition from the localization calculation. This might be used for slices where it is not possible to manually position rod markers. When you ignore such slices, the slices are no longer considered for localization calculation, however they keep their relative position within the image set. The Ignore Slice function does not delete slices from the localization. NOTE: The Ignore Slice function is contraindicated if you are using scans during which the patient moved, or if image sets show distortions, or for correction of defective localizer hardware containing impurities, (e.g., many air bubbles). Ignored slices of a data set may lead to an inaccurate localization as a result of not using all available rod marker information for localization. The user must make sure to localize as many slices as possible so that the localization precision of each slice is as high as possible. Only ignore slices that cannot be localized manually. Localizer Hardware Localization is only possible in combination with reliable hardware. If the localizer hardware is defective due to, for example, air bubbles in the rods, localization will not be possible. How to Ignore Single Slices Step 1. Select the slice in the catalog overview. 2. Click Ignore Slice. The localization result is updated and the slice color in the catalog overview changes from red/yellow to gray. How to Ignore Multiple Consecutive (Intermediate) Slices Step 1. Press SHIFT on the keyboard and select the first slice to be ignored. Keeping SHIFT pressed, select another slice to be ignored or use a double click on a slice to select all neighbored slices showing the same color. 2. Click Ignore Slice. The selected slices and all those in between are ignored from the localization. The localization result is updated and the slice color in the catalog overview changes from red/yellow to gray. 52 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

53 USING TRAJECTORY Adding and Positioning Rod Markers When to Add or Position Rod Markers You can manually add rod markers to the slice if the software is not able to localize a slice because an insufficient number of rod markers have been detected (due to e.g., bubbles in the rods, unfavorable scan parameters, or T1/T2 weighting). You can reposition rod markers in the selected image slice if a slice cannot be localized due to marker rods that were incorrectly or inaccurately positioned. How to Add Rod Markers Step Figure Select the desired slice in the catalog overview 1 and click Add Rod Click in the magnified view 3 to finely adjust the marker position as needed. 3. Continue in this way until the required amount of rod markers have been added. NOTE: The Add Rod function is deactivated when a sufficient number of markers has been added. How to Repeat Image Slice Localization Step 1. After you have manually modified rod markers, click Localize. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

54 Stereotactic Localizers 2.9 Stereotactic Localizers General Information Depending on the type of stereotactic localizer that you select, the scan modality and orientation, the number of rod markers and their geometry, may vary. The tables in this section provide information on the rod marker geometry for your localizer. Leksell MR/CT Indicators Scan Modality/Orientation Rod Marker Geometry MR/coronal MR/axial (including backplate) MR/axial (without backplate) MR/axial (without frontplate or backplate) CT/axial 54 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

55 USING TRAJECTORY Radionics BRW-LF Scan Modality/Orientation Rod Marker Geometry CT/axial Radionics UCLF/Luminant Scan Modality/Orientation Rod Marker Geometry CT and MR/axial MR/coronal Inomed Rev. R Scan Modality/Orientation Rod Marker Geometry CT and MR/axial (upmount) CT and MR/axial (without frontplate) Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

56 Stereotactic Localizers Inomed Rev. U Scan Modality/Orientation Rod Marker Geometry CT and MR/axial (including frontplate) CT and MR/axial (without frontplate) 56 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

57 USING TRAJECTORY 2.10 Supported Arc Systems General Information Trajectory supports the following arc systems: Leksell Vantage Arc Leksell Multi Purpose Stereotactic Arc Inomed ZD Arc System Radionics CRW-ASL Arc Radionics Precision CRW Arc Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

58 Leksell Stereotactic Systems Leksell Stereotactic Systems General Information Trajectory supports: Leksell Vantage Arc, mounted on the Leksell Vantage Headring Leksell Multi Purpose Stereotactic Arc, mounted on the Leksell G-Frame Headring. Leksell G-Frame Headring The G-Frame Headring must be oriented on the patient s head with the removable front piece (anterior part of the frame) pointing towards the anterior portion of the patient s head. Other orientations are not supported by Trajectory. 58 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

USING TRAJECTORY 2.10.2 Leksell Vantage Arc General Information Please consult the arc manufacturer s manual for further information.

59 USING TRAJECTORY Leksell Vantage Arc General Information Please consult the arc manufacturer s manual for further information. Leksell Vantage Arc Mounting Options Option Illustration Lateral right Lateral left Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

Leksell Multi Purpose Stereotactic Arc 2.10.

60 Leksell Multi Purpose Stereotactic Arc Leksell Multi Purpose Stereotactic Arc General Information The mounting position of the Leksell Multi Purpose Stereotactic Arc is the side of the arc where the X- and Y-scale can be read. In the lateral right position for example (see table), the scales point to the right side of the frame and the patient s head, respectively. Please consult the arc manufacturer s manual for further information. Position Comment Sagittal anterior The arc s Y-scale matches with the frame s Y- scale. Sagittal posterior Therefore, the Y-value must be read for sagittal anterior and sagittal posterior mountings. Lateral left The arc s X-scale matches with the frame s X- scale. Lateral right Therefore, the X-value must be read for lateral left and lateral right mountings. Recommended Ranges Scale X Y Z Range mm mm mm Arc angle Ring angle Leksell Multi Purpose Stereotactic Arc Mounting Options Option Illustration Lateral left (X/Y-scale, see arrow) 60 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

arrow) Sagittal posterior (X/Y-scale, see arrow)

61 USING TRAJECTORY Option Illustration Lateral right (X/Y-scale, see arrow) Sagittal anterior (X/Y-scale, see arrow) Sagittal posterior (X/Y-scale, see arrow) Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

62 Inomed ZD Arc System Inomed ZD Arc System General Information Trajectory allows for mechanical restrictions and ensures the overall stability of the Inomed ZD Arc System by limiting the adjustable range of scales. The supported range of settings is therefore restricted compared to the arc system. Trajectory supports the ranges indicated in the table. Should you need a wider range, contact Brainlab. Recommended Ranges Scale Location Range A1 Right-angled drum axle 0 mm...65 mm A2 Right-angled drum axle 20 mm...0 mm B1 Fixation rail 0 mm...75 mm B2 Fixation rail 75 mm...0 mm C Right-angled drum 0 mm mm D1 Drum axle E Arc Arc Setting Module Scale The following table shows the relation between the stereotactic coordinate axes and the arc setting modules (scales) for the upmount orientation: Position of the ZD Arc on the Headring 0, anterior 90, lateral right 180, posterior 270, lateral left Stereotactic Coordinate Axes +X (-X) +Y (-Y) +X (-X) +Y (-Y) +X (-X) +Y (-Y) +X (-X) +Y (-Y) Corresponding Scale of the ZD Arc Setting Module B2 (B1) A1 (A2) A1 (A2) B2 (B1) B2 (B1) A2 (A1) A2 (A1) B2 (B1) Inomed ZD Arc System Mounting Options The following table shows the options for the upmount orientation: 62 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

63 USING TRAJECTORY Option Illustration 270, lateral left 90, lateral right 0, anterior 180, posterior Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

64 Radionics Arc Systems Radionics Arc Systems General Information Trajectory supports: Radionics CRW-ASL Arc Radionics Precision CRW Arc Recommended Arc Ranges Scale A-P Lateral Vertical Range mm mm mm Arc angle Ring angle Radionics Mounting Options Option Illustration Probe carrier anterior or posterior (trunion rings are in the left-to-right position) Probe carrier lateral left or lateral right (trunion rings are in the front-to-back position) 64 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

USING TRAJECTORY 2.11 Stereotactic Report General Information Before you can generate a report you must first have: Created a trajectory Localized your image set How to Generate a Report Step 1.

65 USING TRAJECTORY 2.11 Stereotactic Report General Information Before you can generate a report you must first have: Created a trajectory Localized your image set How to Generate a Report Step 1. Select Arc Settings. 2. Select Create Report. 3. Enter a name for your plan and choose Save. Saving a plan is always required. It allows you to restore the information used to create a report. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

66 Report Functions Report Functions Button Function Pan around the report. Zoom to an area of the report. Fits the report to the width of the screen. Closes the report. Saves the report to a specified location. Prints the report to a specified printer. 66 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

67 USING TRAJECTORY Report Content About Report Content Figure 25 The first page of the stereotactic report contains mandatory information about the selected trajectory and subsequent arc settings as selected in the application: Patient information Trajectory information Headring coordinates of selected trajectory Arc settings for selected mounting orientation Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

68 Report Content Figure 26 The second page of the stereotactic report contains extended information about the selected trajectory, e.g., Patient information Trajectory information Alternative mounting positions with according arc settings AC/PC coordinates of target point Headring coordinates of AC/PC system DICOM coordinates of target and entry points 68 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

69 USING TRAJECTORY 2.12 Ending the Session Saving and Closing Trajectory Planning Button Explanation Returns you to Content Manager. Selecting Done: Saves added, modified or removed data. Closes Trajectory (Element). NOTE: Ensure that you have saved your changes by selecting Done within all the Elements you are working with. This ensures that all your currently viewed data is successfully and safely saved as a plan when you select Save as plan. Pressing the Home button returns you to Content Manager without saving open tasks. See the Software User Guide for Content Manager and Patient Selection for more information. Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

70 Ending the Session 70 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

71 INDEX INDEX Numerics 3D shape A AC Point AC/PC Localization active trajectory Add AC/PC Add Section anterior commissure...33 B Back Brainlab support... 5 C Center...19 compatibility Fibertracking...10 iplan Stereotaxy Lead Localization...10 Object Manager Patient Data Manager...10 SmartBrush...10 contact data...5 D Data selection views...38 defining AC/PC coordinates Diameter...26,27 disposal instructions... 7 documentation...13 Done...69 F feedback...5 G guides...13 H Home button...69 I Image Fusion...10 instrument shape...25 L Length loading data...16 M manuals...13 manufacturer... 5 MC Point...22 Memorize...28 mid-sagittal plane modified plan N Needle new trajectory O object information Offset...27 P Pan... 19,66 patient data...16 PC Point plan status planning...15 posterior commissure Print Probe...26 R remove trajectories...18 Report report functions...66 repositioning coordinates ac/pc... 21,32 amending...21 DICOM...21 dragging...21,34 repositioning trajectories Rotate...19 S Save Save Screw Scroll SmartBrush start stereotaxy...47 start trajectory...17 support... 5 sustainability...7 T Tip Offset training...13 Trajectory how to close Trajectory...69 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver

72 INDEX how to close...69 U Undo...19 user guides...13 V Verify Trajectories how to Views image overview...38 W WEEE...7 Windowing...19 workflow Z Zoom... 19,66 72 Software User Guide Rev. 1.0 Cranial Trajectory Planning Ver. 2.0

74 brainlab.com Art-No EN * EN*

LEAD LOCALIZATION. Version 1.0. Software User Guide Revision 1.1. Copyright 2018, Brainlab AG Germany. All rights reserved.

LEAD LOCALIZATION. Version 1.0. Software User Guide Revision 1.1. Copyright 2018, Brainlab AG Germany. All rights reserved. LEAD LOCALIZATION Version 1.0 Software User Guide Revision 1.1 Copyright 2018, Brainlab AG Germany. All rights reserved. TABLE OF CONTENTS TABLE OF CONTENTS 1 GENERAL INFORMATION...5 1.1 Contact Data...5