Neurosurgery o/the Future: Computers and Robots in Clinical Neurosurgical Practice and in Training - a Philosophical Journey into the Future Many present day neurosurgeons believe that they already obtain good results in operative surgery with the benefit of the operating microscope and other aids which have become available in the last three decades and that the introduction of computers and robots to the operating theatre is superfluous. However, it is clear from analogy with the function of the airline pilot, another profession where there are great demands on manual skill and on spatial awareness, that these devices do have much to offer neurosurgery. Classical neurosurgery, in the time of Cushing, Dandy and Scarff, was based on a three dimensional picture of the patient's brain formed in the surgeon's mind and often illustrated in elegant drawings. Such pictures were based on neuroradiological studies by pneumoencephalography, ventriculography or by angiography. Generally these stud ies showed the presence and position of a lesion by displacement of normal brain structures and the picture was built up by interference. This was then converted by the experienced neurosurgeon into a plan for the craniotomy site and the trajectory of the surgical approach. Once the brain was exposed further pre-operative information was obtained by visual inspection and by palpation with the brain needle. These classical forms ofneuroradiology have largely been superseded by computerised tomography and by magnetic resonance imaging."

More than 40 years ago British and German neurosurgeons met in Berlin and Breslau to exchange their experiences, to strengthen their friendly bonds, and to enjoy the attractions of both cities and their surroundings. In 1960 a joint meeting of the Dutch and German societies took place in Rotterdam by invitation of the Nederlandse Vereniging van Neurochirurgen. All who attended this meeting thankfully remember the great hospitality during these unforgettable days. In 1970, by courtesy of the Society of British Neurological Surgeons, German neurosurgeons had the pleasure to become acquainted with the great tradition of British sciences at one of the most famous places during the meeting in Cambridge. These impressions were deepened by visits to other famous sources of British scientific tradition during the European Congress in Oxford in 1975. The critical distance sometimes necessary towards our own discipline is implicit in the major themes of this meeting. Complications following shunting procedures for hydrocephalus have been discussed on the basis of the results of a cooperative study of some German neurosurgical departments. The second main topic was problems and diagnostic errors in computer tomography. The papers presented contain critical considerations about the findings obtained by this method, as well as on its possibilities and limitations. German neurosurgeons felt deeply indebted to their British and Dutch colleagues and wanted to return their kindness at this joint meeting in Berlin. We hope that all participants will retain pleasant memories of the days in this city.

Since the establishment of magnetic resonance imaging the clinical diagnostic of the head and neck has improved substantially and, therefore, in many cases this technique is used in the first place of radiological diagnosis. The feasibility of non-invasive MR angiography and 3-dimensional reconstruction has enlarged the indication field of MRI. This book presents the meaning of this imaging technique for the diagnosis of diseases in head and neck. Excellent figures show the technicaland diagnostical possibilities of this method, the advantages and limitations of which are explained as well. A comprehensive diagnostic strategy for each diagnostic region is presented. This book is disigned for the use of especially radiologists, ENT specialists and surgeins.

Radiology Today 3 presents papers and panel discussions from a multi national faculty at the biannual Salzburg Symposium, which this time covered three important topics: critical diagnostic pathways in gastro" intestinal and genitourinary radiology, interventional radiology of the abdomen, and cost containment in radiology. The choice of these topics illustrates the changing role of the radiolo gist in the practice of medicine today and in the foreseeable future. He will have to serve as a consultant more than ever before, assuming in creasing responsibility for sequencing of imaging procedures and par ticipating more and more in therapeutic intervention. In order to pro vide meaningful assistance, the imaging consultant must be aware of the efficacy and the limitations of every procedure. In this context, cost containment is a worldwide public concern, and the most appropriate procedures must be identified. Radiology Today 3 demonstrates how the radiologist functions as a member of diagnostic and management teams to provide optimal in formation and efficient, low-risk patient care at the lowest possible cost. Martin W. Donner Friedrich H. W. Heuck Contents Critical Diagnostic Pathways Abdomen 3 G. MARCHAL, A L. BAERT, K. GEBOES, E. PONETTE, 1. FEVERY The Diagnosis of Pancreatic Cancer ............ 3 W. REICHARDT Localization Techniques for Hormonally Active Pancreatic Tumors ........... . 7 AR. MARGULIS, S. MCCARTHY Hepatic Mass Lesions .... 12 M. KORMANO, K. PARTANEN, 1. KUIKKA Dynamic Liver CT and New Contrast Agents ....... . 17 W. FROMMHOLD, J. PIRSCHEL 20 Gallbladder Diseases: Imaging Sequences 1.A KIRKPATRICK, Jr."

Blood Supply of Bone: Scientific Aspects provides a comprehensive description of the development and physiology of blood supply to the skeleton. Investigative techniques for different types of bone in the body are discussed and the effects of disturbed circulation and the vascular control of osteogenesis is described. This highly illustrated and authoritative volume contains much revised material and many new illustrations reflecting 25 years of advances in this research field since the publication of its well-known precursor in 1971. The wealth of information will not only be invaluable to orthopaedic surgeons, rheumatologists, and radiologists but also pathologists, sports medicine specialists and bone metabolism research workers.

In the last few years a good deal of information related to the biology and treatment of malignant lymphomas has been accumulated and published in journals and monographs. There is, however, no book that gives a concise and objective update of this information or presents a general survey of the subject. The contributors to this book are international authorities, and on the basis of their personal experience and data from the literature they have written a high-level update on malignant lymphomas which will be of interest to both specialists and nonspecialists.

This book is a supplement to Volume V/I in the present series, Diag- nostie Radiology, published in 1962. Despite the relatively long period of time whieh has elapsed sinee its publieation, that eomprehensive vol- urne is still essentially valid, even though further developments have of course oeeurred in eertain fields. In reeent years the developments in nuclear medieine and ultrasonie teehniques have led to a number of new methods of medieal investigation, whieh, in different ways, eomplement diagnostie radiology. Funetional disorders of the urinary traet ean often be detected by means of radioiso- topes. Sinee morphologie ehanges are almost always preeeeded by fune- tional disturbanees, radionuclide teehniques in many instanees produee an earlier diagnosis than radiography. Disturbances of renal blood flow, slight ureterie obstruetion, and ureterie reflux are examples of pathologie states whieh ean be deteeted early by the y scintillation eamera. Bone seans, Le., imaging of the skeletal system using a radionuclide, are used extensively to diagnose bone metastases now that it has been demonstrated that such metastatie growths are identified both earlier and with greater aeeuraey by scintigraphy than by radiographie teeh- niques.

The aim of this book is to expand the clinical information given by computed tomograms (CTs) of cerebral infarcts. Anatomical sections are displayed parallel to the CT correlate in the hope that the interpretation of pathogenesis will provide valuable clinical data at a time when the number of angiographies performed in cerebrovascular cases has diminished rapidly. For better understanding of pathogenesis our concepts concerning the process of infarction have been summarized on the basis of schematic draw ings. K.-J. ZULCH KOln Acknowledgments I am most grateful to Professor Hoeffk: en for permission to use computed tomograms from his institution, to Herr GOldner and Frau Miihlhover for their technical assistance, and to Frau Goldner for help during the editorial work. My particular thanks go to my friend Professor W.S. Fields, Houston, who undertook the great burden of styling the English text. My gratitude is expressed to Dr. Dr. h.c. multo Heinz Gotze and Springer Verlag for the excellent layout and quality of this book."

This book encompasses the proceedings of a very successful post graduate course entitled "Radiology Today" held in Salzburg in June 1980. It was organised by Dr. Martin W. Donner of Baltimore and Dr. F. H. W. Heuck of Stuttgart. It was attended by 230 radiologists from 17 countries. The aim was to select a certain number of subjects in diagnostic radiology and in each to have a broad spectrum overview reviewing recent advances presented by an acknowledged expert, followed by a series of rather more detailed papers on various aspects of that field, again given by acknowledged experts drawn from countries throughout Europe and also from the United States of America. This series of presentations on a theme was then followed later the same day by a "workshop" discussion at which the speakers, sometimes joined by other experts from collateral fields of interest, acted as a panel for discussion with the over-view speaker acting as moderator.

Over a mere 5 years, neonatal cranial sonography has evolved from an obscure and largely experimental imaging possibility to the modality of preference in the examination of the young brain. The almost immediate acceptance of the ultrasound examination of the neonatal brain was based on a number of coinci dent factors, the most important of which was the emergence of a burgeoning population of premature neonates who were, for the first time, surviving be yond infancy. These delicate patients were beginning to withstand the rigors of extrauterine life when not fully prepared for it; pulmonary, cardiac, and infec tious diseases no longer claimed most of them. With survival, a new specter reared its head: Would the eventual mental and neurologic status of these same children be worth the expense and time needed to bring them through their first months? This issue became increasingly pressing as evidence mounted through the 1970s that very premature neonates were at a high risk for intracranial hemor rhage and posthemorrhagic complications. An imaging modality that could evaluate the premature brain was sorely needed. The CT scanner with its proven ability to diagnose intracranial hemorrhage was of little value in this regard. So too were static gray-scale or waterpath ultrasound units. These modalities all had the same limitation, lack of portability. As neonatal intensive care units proliferated, so did the technology that would soon allow cribside neonatal neuroimaging, the real-time sector scanner."

The practice of medicine changes continually, as science guides the physician to the accomplishment of his objective, the cure of the patient. Study of the history of medicine shows that often a remedy of a disease was discovered before the cause of the disease was known. Often the remedy was unnecessarily complicated, but when the cause of the trouble was discovered, the cure became simple and safe. It is with the better under standing of the true nature of thyroid disease that this book is concerned. Those who read it will be able to make their treatments of patients with diseases of the thyroid more simple and more safe. Dr. MASAYOSHI AKISADA and Dr. YOSHIHIDE FUJIMOTO have given to thyroidologists a new way of recognizing cancers of the thyroid. Taking advantage of the fact that many cancers of the thyroid contain minute areas of calcification known as psammoma bodies, they have developed a technique of roentgenographic examination of the thyroid that is sensitive enough to show these tiny opacities and to warn the internist and the surgeon that cancer is probably present. There is no question that this sensitive diagnostic test will prove to be of value comparable to that of mammography.

The purpose of this series of volumes is to present a comprehensive view of the complications that result from the use of acceptable diagnostic and thera peutic procedures. Individual volumes will deal with iatrogenic complications involving (1) the alimentary system, (2) the urinary system, (3) the respiratory and cardiac systems, (4) the skeletal system and (5) the pediatric patient. The term iatrogenic, derived from two Greek words, means physician-in duced. Originally, it applied only to psychiatric disorders generated in the patient by autosuggestion, based on misinterpretation of the doctor's attitude and comments. As clinically used, it now pertains to the inadvertent side effects and complications created in the course of diagnosis and treatment. The classic categories of disease have included: (1) congenital and developmen tal, (2) traumatic, (3) infectious and inflammatory, (4) metabolic, (5) neoplastic, and (6) degenerative. To these must be added, however, iatrogenic disorders a major, although generally unacknowledged, source of illness. While great advances in medical care in both diagnosis and therapy have been accomplished in the past few decades, many are at times associated with certain side-effects and risks which may result in distress equal to or greater than the basic condi tion. Iatrogenic complications, which may be referred to as "diseases of medical progress," have become a new dimension in the causation of human disease."

There has been increasing interest in neonatal neurology, especially since imaging techniques were introduced in the neonatal ward. Looking at the natural history of imaging techniques, we can identify three main axes of its development. Logically, it was first essential to image the brain morphologically. For this purpose, computed tomography was initially used, followed by ultra sound. However, to improve the quality of the images, magnetic resonance imaging was introduced. Major features of ultrasound and magnetic reso nance imaging are their safety and lack of ionization. Morphological imaging techniques have proved to be insufficient to ex plain the mechanisms underlying CNS injuries. Thus, it was essential to develop functional techniques to assess cerebral hemodynamics and oxy genation. The use of Doppler ultrasound, PET scanning, SPECT scanning and, more recently, NIRS have widened our knowledge of general neurolog ical problems. Finally, to achieve our goal of attaining a better understanding of CNS injuries, it is important to assess cerebral cellular metabolism. Magnetic resonance spectroscopy was introduced to achieve this goal. We hope that this book links these different techniques in order to widen our horizon. The future is promising and bound to provide further develop ments, which however can only be understood if we grasp the present level of development.

During the past decade there has been a burgeoning of interest in arthritis and related rheumatic diseases. The spe ciality of rheumatology, once regarded as a "Cinderella" speciality, is now one of the leading specialties in internal medicine. Indeed, just as infant mortality is a good index of the general health of a community, so a University Med ical School can be similarly judged by the quality of its Department of Rheumatology. Perhaps no other specialty has helped to advance knowledge in medicine as has rheu matology One might have thought that little could be added to the clinical and radiologic description of one of the most studied diseases in rheumatology rheumatoid arthritis. There are several excellent large radiology textbooks on bones and joints, and it is surprising that yet another book has been published. However, the reader will soon appreciate on reading this superb radiologic text on rheumatoid arthritis that here is something new and quite different from what has been published in the past. The combination of clinician and radiologist has produced a textbook which will become a standard reference on the subject. The authors are both well known in their respective fields and they have concentrated on the early changes in the disease-not only those in the articular surfaces but also those in the soft tissues. In 1948 the late Dr Philip Ellman coined the term "rheumatoid disease," to indicate the systemic nature of rheumatoid arthritis."

The Information Processing in Medical Imaging Conference is a biennial conference, held alternatively in Europe and in the United States of America. The subject of the conference is the use of computers and mathematics in medical imaging, the evaluation of new imaging techniques, image processing, image analysis, diagnostic decision making and related fields. The conference brings together the top specialists in the field (both scientists and medical doctors) and other participants doing active research on the subject of the conference. The success of a meeting primarily depends on the enthusiasm of the participants. It also greatly depends on the financial support as well as on the personal efforts of the technical staff and collaborators of the organizers. To all who made this conference a success, the members of the organizing committee want to express their sineere thanks. In particular, the organizers want to acknowledge the help received from: De Vice-Voorzitter van de Vlaamse Executieve De Minister van Onderwijs Het Nationaal Fonds voor Wetenschappelijk Onderzoek De Vrije Universiteit Brussel Adac Agfa-Gevaert Bruker Spectrospin Byk Belga Elseint Instituut voor Radioelementen, IRE Nucleobel Solco Sonotron VII TABLE OF CONTENTS Foreword. v A. VENOT, J.L. GOLMARD, J.F. LEBRUCHEC, L. PRONZATO, E. WALTER, G. FRIJA and J.C. ROUCAYROL: "Digital Methods for Change Detection in Medical lmages."

Throughout the twentieth century, interest in sport has evidenced a major increase worldwide and a new field of sports medicine has emerged. Sport spectators hip has been stimulated in part by the increased ease of international travel and the intro duction of new means of communication. Interest in professional sports and in such events as the World Cup and the Olympic Garnes has never been higher and the general popularity of sports has drawn increasingly greater numbers of young people to sports participation. Interest in sports participation has been strength ened both by the provision of numerous sports facilities to populations throughout the world and the accumulating information base that relates regular participation in programs of sport and exercise to health enhancement. Along with in creases in interest and participation has corne a need for a better understanding of the physiological changes accompanying muscular activity and of the trauma that can result from both competitive sport and recreational exercise.

We are in the midst of major advances in medical imaging, converting static pre sentation of anatomic information into near real-time interactive imaging and displays capable of depicting both structure and function. This will have pro found impact on diagnosis and image-guided therapies. These advances have been most notable in the modalities of computed tomog raphy and magnetic resonance. These technologies have become capable of ac quiring volumetric images in short periods of time. Speed gains in MRI were very significant in the early 1990s with the development of clinically usable pulse se quences for gradient-recalled and echo-planar imaging. It appears that further speed gains in MRI will be difficult to achieve. The development of spiral CT has ushered in an era in which major speed gains in CT are also possible. This has enabled creation of new types of applica tions such as CT angiography, which has already come to replace catheter angio graphy at many medical centers throughout the world. We are very pleased that the results from industrial and academic laboratories have been transferred to the bedside to improve patient care at a speed that may be faster than in any other area of medicine. Concurrent with advances in CT technology there have been dramatic strides in the performance characteristics and costs of computer hardware and software.

When I planned this book seven years ago I had my graduate students at the University of Ulm in mind, diploma as well as doctoral students, who often asked me what literature they should work with. I used to suggest a list of ten to twenty (for my taste: excellent) treatises on NMR. Apparently this did not make them entirely happy. The difficulty which newcomers to the field face is to practise and to apply theoretical formalisms from different sources while still learning the principles of NMR and being actively engaged in NMR research. Although the text presented here is largely based on my lecture notes, the result is a "working book" rather than an introduction. It is intended to provide direct access to the basic information one needs for NMR diffusometry, relaxometry, and tomography applications. A "working book" is certainly not suitable to be read starting on page one and then carrying on until the last page. Boldly extrapolating my own reading habits to those of the typical scientist I am sure that this is not the way in which monographs of this kind are read nowadays. So my aim was to produce a treatise that offers easy and quick access for the reader to relevant matters of interest. I tried hard to ease the comprehension of NMR principles by extensive cross-referencing among the sections and chapters. Tomography, diffusometry and relaxometry are fields based on common phys ical principles."

The imaging aspects of radiography have undergone con many sources and was in general freely given when requested siderable change in the last few years and as a teacher of and this is gratefully acknowledged. In particular I would radiography for many years I have often noticed the lack of a like to express my sincere thanks for help and information to comprehensive reference book for students. This book is an Mr J. Day of DuPont (UK) Ltd. particularly for the infor attempt to correct that situation and I hope this text will be mation and illustrations in the chapter on automated film of value not only to student radiographers but also prac handling; Mr D. Harper and Mr R. Black of Kodak Ltd. ; tising radiographers as well. Fujimex Ltd. ; CEA of Sweden; 3M (UK) Ltd. ; Wardray Much of the information is based on personal experiment Products Ltd. ; D. A. Pitman Ltd. ; Agfa-Gevaert; PSR Ltd. and the knowledge gained of students' difficulties in studying for their help with information on silver recovery, and this subject. I have attempted to gather together in one book Radiatron Ltd. for their help with safelighting. All were most all the information required to understand the fundamentals helpful in my many requests for information. of the subject both for examination and for practice. Some To Mrs A. Dalton and Mrs P.

In Videofluorscopic Studies of Speech in Patients with Cleft Palate, Drs. M.L. Skolnick and E.R. Cohn present multiview videofluoroscopy as a technique for the radiological evaluation of speech defects in patients with cleft palate. Dr. Skolnick's invaluable contributions as both the originator and leading authority on the subject are discussed in a concise, clinical fashion. Topics examined include the anatomy and imaging of the velopharyngeal portal; the equipment and techniques of multiview videofluoroscopy; the interpretation of results and various patterns of velopharyngeal closure; Passavant's Ridge and patterns of velopharyngeal closure; normal and abnormal speech production; and the evaluation of test results. This book is the only source which concisely and completely describes the technique and its interpretations for those who need a description of the clinical procedure.

The visualization of human anatomy for diagnostic, therapeutic, and educational pur poses has long been a challenge for scientists and artists. In vivo medical imaging could not be introduced until the discovery of X-rays by Wilhelm Conrad ROntgen in 1895. With the early medical imaging techniques which are still in use today, the three-dimensional reality of the human body can only be visualized in two-dimensional projections or cross-sections. Recently, biomedical engineering and computer science have begun to offer the potential of producing natural three-dimensional views of the human anatomy of living subjects. For a broad application of such technology, many scientific and engineering problems still have to be solved. In order to stimulate progress, the NATO Advanced Research Workshop in Travemiinde, West Germany, from June 25 to 29 was organized. It brought together approximately 50 experts in 3D-medical imaging from allover the world. Among the list of topics image acquisition was addressed first, since its quality decisively influences the quality of the 3D-images. For 3D-image generation - in distinction to 2D imaging - a decision has to be made as to which objects contained in the data set are to be visualized. Therefore special emphasis was laid on methods of object definition. For the final visualization of the segmented objects a large variety of visualization algorithms have been proposed in the past. The meeting assessed these techniques.

Color Theory and Modeling for Computer Graphics, Visualization, and Multimedia Applications deals with color vision and visual computing. This book provides an overview of the human visual system with an emphasis on color vision and perception. The book then goes on to discuss how human color vision and perception are applied in several applications using computer-generated displays, such as computer graphics and information and data visualization. Color Theory and Modeling for Computer Graphics, Visualization, and Multimedia Applications is suitable as a secondary text for a graduate-level course on computer graphics, computer imaging, or multimedia computing and as a reference for researchers and practitioners developing computer graphics and multimedia applications.

This book is not intended as a general text on MRI. It is written as an intro duction to the field, for nonexperts. We present here a simple exposition of certain aspects of MRI that are important to understand to use this valuable diagnostic tool intelligently in a clinical setting. The basic principles are presented nonmathematically, using no equations and a minimum of symbols and abbreviations. For those requiring a deeper understanding of MRI, this book will help facilitate the transition to standard texts. Chapters 1 through 4 provide a general introduction to the phenomenon of nuclear magnetic resonance and how it is used in imaging. Chapter 1 discus ses magnetic resonance, using a compass needle as an example. In Chapter 2, the transition to the magnetic resonance of the atomic nucleus is made. Chapter 3 describes the principles of imaging. In Chapter 4, the terms T 1 and T 2 are described and their relationship to tissue characterization; the fun damental role of thermal magnetic noise in T 1 and T 2 is discussed.

The quantitative analysis of blood flow within central and peripheral blood vessels has attracted more and more interest, for with the rapid developments in vascular surgery and the introduction of percutaneous transluminal angioplasty, it is becom ing increasingly important to be able to measure regional blood flow in man. In clinical radiology, angiography has been used predominantly from the point of view of its morphological applications. However, theoretically angiography may also be regarded as a specific application of indicator-dilution measurements of blood flow. The indicator is contrast medium (CM), the changing concentration of which is re corded by cinematography or video-electronic systems at sites downstream from the point of injection. The curves of density thus obtained correspond to indicator-di lution curves. The blood flow can be calculated from the concentration-time curves ofCM in much the same way as it is estimated from other indicator-dilution curves. In our early work with clinical application of videodensitometric measurement of blood flow in the iliac artery, we found that this method did not offer as high a degree of accuracy as one would have expected from investigations by other authors. We saw that we needed to examine the following problems: 1. We had to investigate whether our conventional X-ray equipment and video densitometer could be viewed as a linear measuring system. To what extent do unavoidable nonlinear changes in the measuring signals influence the blood flow values? 2."

One of the first applications of ultrasound was in submarine sonar equip ment. Since then ultrasound has found increasing applications, particularly in industry, but increasingly in biomedicine. For many years ultrasound has been used in physical therapy, although only in the past decade or two has it evolved from laboratory curiosity to a well-established diagnostic imaging modality. Ultrasound is now a widely accepted, indeed pervasive, diagnos tic and therapeutic tool in the medical field, and its applications are increasing rapidly. Our intent in developing this book is to provide a coherent tutorial intro duction to the field of medical ultrasound at a level suitable for those en tering the area from either medical or scientific backgrounds. The topics discussed should be of interest to nearly all medical and health care per sonnel needing to understand or operate ultrasonic devices, including clini cians, medical technicians, physiotherapists, medical physicists, and other biomedical scientists interested in the field. The book opens with a description of the basic principles of propagating acoustic waves, explains how they interact with a wide range of biological systems, and outlines the effects they produce. To provide practical infor mation to operators of ultrasound equipment, we have included thorough coverage of the details of ultrasonic instrumentation and measurement techniques, and set forth the framework for an effective quality assurance program."