The Stanford Neurosurgical Training and Innovation Center
Surgical Neuroanatomy (Brain and Skull Base), Fiber Tractography and Connectomics, Virtual Reality Simulation and Surgical Planning
The Stanford Neurosurgical Training and Innovation Center, under the direction of Juan C. Fernandez-Miranda, MD, has a dual educational and research role aiming to improve surgical techniques and outcomes by mastering knowledge of relevant surgical neuroanatomy. Our aim is to further and adhere to the working philosophy of Albert L. Rhoton, Jr., MD: to perform meticulous and exquisite anatomical microdissections to better understand the intricate complex anatomy of the human brain and skull base. The main theme of the laboratory is “From the Lab to the OR” as a reflection of a true translational effort to introduce novel anatomical concepts and innovative surgical technique into real surgical practice. The research and education activity of the laboratory pertain to four different areas: endoscopic skull base anatomy; microsurgical neuroanatomy; white matter dissection with advanced white matter imaging and tractography; and virtual reality for surgical simulation and planning.
Endoscopic Skull Base Anatomy
The Endoscopic Endonasal Approach (EEA) has revolutionized skull base surgery. Dr. Fernandez-Miranda is a leader in this field and has been at its forefront with innovative contributions to the development and refinement of endoscopic endonasal skull base surgery. Multiple projects under his direction have detailed the surgical and anatomical nuances underlying complex endonasal endoscopic corridors to the skull base. These projects have underlined the importance of intense and constant interaction between the laboratory and the operating room. The goal is to continue contributing to the education of residents, fellows and neurosurgeons worldwide interested in endoscopic endonasal skull base surgery. Acquisition of complex skull base anatomy from an endonasal perspective is critical towards safe application of the endoscopic endonasal surgery. Using intricate dissections of the skull base, as pertinent to these approaches, we aim to continue making landmark contributions to the skull base community over the coming years with the ultimate aim of improving surgical and patient outcomes.
In addition, the lab will expand into newer “minimally invasive” routes into the brain and skull base, exploring the applications and limitations of transorbital, transfacial (transmaxillary, transglabellar), and keyhole (preauricular, postauricular) endoscopic approaches.
A contemporary skull base neurosurgeon requires a 360 degree understanding of the skull base anatomy both from an open and ventral endoscopic perspective. This is fundamental towards knowing the limitations and indications of the contemporary skull base approaches. Such an understanding will facilitate judicious use of different approaches in a complementary fashion rather than use of an approach (open or endoscopic) beyond its indication. The latter compromise leads to suboptimal surgical and clinical outcomes. With this philosophy in mind, our laboratory will undertake conventional skull base approaches and compare them with novel endoscopic endonasal approaches to evaluate the indications and limitations of different yet complementary skull base approaches.
Similarly, brain tumor surgeons require profound understanding of the microsurgical anatomy of the brain sulci, gyri, and fissures, along with the microvascular, cisternal, and ventricular anatomy. Dr. Fernandez-Miranda has contributed with key studies in these areas, and these will continue to be investigated in the lab.
White Matter Anatomy and Fiber Tractography
Dissection of the white matter fiber tracts provides a unique insight into the complex intrinsic architecture of the brain and builds up an essential knowledge for operating on intra-axial tumors. A unique feature of our white matter studies is the combination with advanced imaging techniques, such as High-Definition Fiber Tractography (HDFT), to facilitate greater understanding of brain connectivity “in-vivo” and in neurosurgery patients. Innovative studies using data from the Human Connectome Project are being completed to further elucidate the complex anatomy of the white matter pathways in large scale populations.
Dr. Fernandez-Miranda has been a pioneer in the combination of anatomical and imaging studies to better delineate the trajectory, connectivity, asymmetry, and spatial relationships of the fiber tracts, and has shown the importance of HDFT for presurgical planning and intraoperative navigation to facilitate brain function preservation and improve resection rates in patients with complex brain lesions. HDFT provides a superior presurgical evaluation of the fiber tracts for patients with complex brain lesions, including low grade and high grade gliomas. Presurgical studies are built upon precise and accurate neuroanatomical knowledge, which allows surgeons to reconstruct perilesional or intralesional fiber tracts, design the less invasive trajectory into the target lesion, and apply more effectively intraoperative electrical mapping techniques for maximal and safe tumor resection in eloquent cortical and subcortical regions.
Neurosurgical Simulation and Virtual Reality Center
The Department of Neurosurgery at Stanford opened its Neurosurgical Simulation and Virtual Reality Center in 2016 with the aim of using patient-specific, 3-D virtual reality (VR) technology across the neurosurgery clinics and operating room. We have already used this technology to further the education of residents and promote patient engagement. Using advanced computer algorithms and patients’ unique arterial, venous and parenchymal anatomy derived from their MRI and CT scans, a 3D model is constructed. The surgeon or the trainee can then use the VR headset to ‘fly’ through this virtual anatomy and simulate and compare surgical approaches, for example for resection of a petroclival meningioma, craniopharyngioma or clival chordoma,
As an integral part of the laboratory, the virtual reality center will contribute to the field of skull base neurosurgery in multiple ways. Complex endonasal and open skull base approaches can be simulated in preparation for surgery by residents, fellows, faculty and course participants. This will complement the open and endonasal dissection of the anatomical specimens and relevant to research projects in the skull base anatomy, feasibility of innovative skull base approaches can be assessed taking into account osseous and neurovascular anatomy. As a priority, the lab will incorporate HDFT and functional MRI studies into VR simulation to implement surgical planning in patients with intrinsic tumors such as low and high-grade gliomas. Our goal is to further improve the quality of VR simulation for presurgical planning and simulation by increasing its imaging quality and fidelity, and its interactive features.
Vera Vigo, MD
Yuanzhi "Julius" Xu, MD
Research fellowship positions are offered in the lab throughout the year. Minimum length of the fellowship program is 12 months; shorter periods of time might be considered under special circumstances.
Funding for personal expenses is not available, but the lab will provide the anatomical and technical material needed to complete your training and research projects. Fellows will focus on areas of their interest under the guidance of the lab faculty.
Those interested in applying for the research fellowship position should please contact us at firstname.lastname@example.org and send an updated curriculum vitae and two letters of recommendation.
Equipment available to Surgical Neuroanatomy Laboratory personnel include the following:
- Two (2) operating microscopes
- Four (4) HD endoscopic stations (courtesy of Storz and Stryker)
- One (1) image-guidance system (courtesy of Medtronic)
- Two (2) high-speed electric drills (courtesy of Stryker)
- Abundant and high-quality anatomical specimens
- 3D stereoscopic curved HD-TV for educational presentations
- Research fellow office with two (2) High-Definition Fiber Tracking (HDFT) stations (CPU 17, 3.07GHz, QuadCore w/hyperthreating, 12 Gb RAM, nVidia QuadroFX 5800 w/4Gb RAM)
- 3D-HD TV 55 inches
- Microsurgical instrumentation (courtesy of MIZUHO)
- Endoscopic instrumentation (courtesy of Storz)
Department of Neurosurgery
The Stanford Surgical Neuroanatomy, Fiber Tractography, and Virtual Reality Laboratory is part of the Stanford School of Medicine's Department of Neurosurgery.
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