THE ANATOMICAL RECORD (PART B: NEW ANAT.) 270B:30 –37, 2003
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Anatomy and the Access Grid: Exploiting Plastinated Brain Sections for Use in Distributed Medical Education SCOTT LOZANOFF,* BETH K. LOZANOFF, MIRCEA-CONSTANTIN SORA, JULIE ROSENHEIMER, MARCUS F. KEEP, JONATHON TREGEAR, LINDA SALAND, JOSHUA JACOBS, STANLEY SAIKI, AND DALE ALVERSON Computerized animation is becoming an increasingly popular method to provide dynamic presentation of anatomical concepts. However, most animations use artistic renderings as the base illustrations that are subsequently altered to depict movement. In most cases, the artistic rendering is a schematic that lacks realism. Plastinated sections provide a useful alternative to artistic renderings to serve as a base image for animation. The purpose of this study is to describe a method for developing animations by using plastinated sections. This application is used in Project TOUCH as a supplemental learning tool for a problem-based learning case distributed over the National Computational Science Alliance’s Access Grid. The case involves traumatic head injury that results in an epidural hematoma with transtentorial uncal herniation. In addition, a subdural hematoma is animated permitting the student to contrast the two processes for a better understanding of dural hematomas, in general. The method outlined uses P40 plastinated coronal brain sections that are digitized and to which contiguous anatomical structures are rendered. The base illustration is rendered, interpolated, and viewed while audio narration describes the event. This method demonstrates how realistic anatomical animations can be generated quickly and inexpensively for medical education purposes by using plastinated brain sections. Anat Rec (Part B: New Anat) 270B:30 –37, 2003. © 2003 Wiley-Liss, Inc. KEY WORDS: neuroanatomy; anatomy; plastination; brain; hematoma; animation; problem-based learning; PBL; medical education; traumatic head injury; TOUCH
INTRODUCTION Drs. S. Lozanoff and Rosenheimer and Ms. B. Lozanoff are in the Department of Anatomy and Reproductive Biology, University of Hawai’i School of Medicine. Dr. Sora is in the Department of Anatomy, Anatomical Institute, Vienna University, Vienna, Austria. Dr. Keep is in the Division of Neurosurgery, University of New Mexico School of Medicine. Dr. Tregear is in the Department of Media Services, University of New Mexico. Dr. Saland is in the Department of Neurosciences, University of New Mexico, School of Medicine. Dr. Jacobs is in the Department of Medicine, University of Hawai’i School of Medicine. Dr. Saiki is in the Department of Medicine, University of Hawai’i School of Medicine and the Tripler Army Medical Hospital, Honolulu. Dr. Alverson is in the Department of Pediatrics and Obstetrics and Gynecology, University of New Mexico School of Medicine. *Correspondence to: Dr. Scott Lozanoff, Professor and Chair, Department of Anatomy and Reproductive Biology, University of Hawai’i School of Medicine, 1960 East-West Road, Honolulu, HI 96822. Fax: 808-956-9841; E-mail:
[email protected] DOI 10.1002/ar.b.10006 Published online in Wiley InterScience (www.interscience.wiley.com).
© 2003 Wiley-Liss, Inc.
As part of the Telehealth Outreach for Unified Community Health (TOUCH) project (Jacobs et al., 2003), a virtual reality case involving traumatic head injury is to be presented as a problem based learning (PBL) tutorial session. The project involves the University of Hawai’i and the University of New Mexico Medical Schools, in part due to the similar approaches for the delivery of PBL teaching formats. In particular, both schools follow a corresponding tutorial process where students collect facts concerning the case, determine the patient’s problems, generate hypotheses with suitable clinical tests, and finally, generate learning issues (Anderson, 1991). Central to the process is an intersession at which time students pursue research covering their learning issues and report the findings during the following session. The core of the TOUCH project addresses the initial tutorial session where the students pursue learning issues through their
interaction with the virtual patient (Caudell et al., 2003). However, additional multimedia tools are considered essential for intersession exploration of their learning issues as well as providing students a common source of information for understanding the case. To this end, the TOUCH system includes a Web site forming a common resource that students could access from remote sites (http://hsc. unm.edu/touch). Various sources of information are included on the Web site, including links to anatomical data sets in support of the case. The TOUCH demonstration case consists of a patient with head trauma who developed an epidural hematoma (Jacobs et al., 2003). This case is selected because it provided ample anatomical and physiological basic medical science correlations ranging from the gross anatomical level to lower levels of integration and requiring a wide range of visual depictions, thus testing the integrity of the Artificial Intelligence (AI) and Flatland environ-
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ments (Caudell et al., 2003). In addition, the emergency nature of the case places the tutorial group into a decision-making situation requiring group communication and cooperation, thus testing the effectiveness of human interaction across the Access Grid (AG). A key diagnostic component of the case is to provide effective supplemental data sets that depicted key concepts involved in the case; namely, the etiology of an epidural hematoma contrasted with a subdural hematoma. The injuries and their sequelae are not easily understood through static two-dimensional images and require a more dynamic and animated depiction for full comprehension. Digital representation of anatomical features has provided a useful source of data for computer-based instructional development (Brinkley, 1991). In fact, the development of multimedia tools for anatomical learning has received much attention, spawning the new field of anatomical informatics (Trelease, 2002). But, an initial cadaveric data source is necessary to facilitate creation of multimedia supplements. Plastination serves as one human tissue preservation technique that involves the replacement of water and lipids with curable polymers that are subsequently hardened (von Hagens et al., 1987). This technique has proved particularly useful for preservation of brain tissue and should serve well as a data source for multimedia instruction particularly in the neurosciences (Weiglein, 1997). The purpose of this study is to describe the development of anatomical animations by using plastinated brain sections to contrast epidural and subdural hematomas in the TOUCH demonstration case.
ANATOMICAL ANIMATION Animation is the process of projecting sequential images to provide an illusion of movement. Used widely in the film industry, methods of animation are now becoming commonplace in the classroom. Computer technology has contributed dramatically to the development and delivery of two- and three-dimensional animations specifically directed for anatomy education in the medical curriculum (Habbal
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and Harris, 1995; Johnson and Whittaker, 1995; Lozanoff et al., 1999; Guttmann, 2000; Trelease et al., 2000; Neider et al., 2000; Gould, 2001). Due to the decreasing cost of computers as well as the wide spread availability of inexpensive software necessary to view animations, instructors can now incorporate simple animations into their presentations fast and effectively. Various inexpensive programs are used for animation, including such favorites as Adobe Photoshop, Microsoft PowerPoint, and more recently Kai’s SuperGoo, Amorphium, and SURFdriver software. In addition to ease of use of these programs and the animations they provide, students appear to find such presentations enriching (Carmichael and Pawlina, 2000). Although three-dimensional animations are produced with some effort, two-dimensional animations
Although threedimensional animations are produced with some effort, two-dimensional animations are being used extensively. are being used extensively, probably due to the fact that minimal technology is required to produce the images. Invariably, base images consist of artistic renderings; either simple line drawings produced by the instructor or somewhat more sophisticated images rendered by a medical illustrator or other specialist (Stockwell et al., 1995). Although artistic renderings are effective, in some cases complexity of the anatomical feature prevents effective capture by the artist. Due to the complexity of the internal structure of the brain, as well as the deformation and translation occurring during traumatic dural hematoma, illustration did not seem a straightforward means to prepare a brain trauma animation. Instead, we elected to use plastinated coronal brain sections that were scanned and illustrated components were added to these digital images.
The result consisted of images of scanned plastinated brain sections that were subsequently deformed and translated electronically. To our knowledge, this is the first description of an anatomical animation technique incorporating plastinated cross-sections into a two-dimensional animation. The overall method used to generate the animations consisted of four steps. First, educational objectives were articulated, and a storyboard was developed as a visual script. Second, a brain was plastinated, and coronal sections were obtained. Third, a base illustration was generated by imaging appropriate plastinated coronal sections and adding contiguous anatomical structures, including bone, dura, dural reflections, and brainstem. Finally, the base illustration was used as a template and deformed in an incremental manner by using a linear interpolant and following the visual script. Audio was added to narrate the important aspects of the animation.
Functional Neuroanatomical Correlates The initial step in the development of the animation involved the delineation of key neuroanatomical components of epidural and subdural hematomas identified by content experts (Jacobs et al., 2003). The objective of this process was to develop a storyboard comprising a logical and sequential set of visual depictions of a hematoma. An epidural hematoma is characteristically associated with skull fractures in the temporoparietal region that tear the middle meningeal artery. This artery, a branch of the maxillary artery, enters the skull through the foramen spinosum. It travels between the meningeal dura and the periosteal dura as it supplies the dura and bone of the skull with blood. Being arterial, it creates a highpressure bleeding that rapidly (within 1 to a few hours) dissects away the dura from the skull. The classic presentation is loss of consciousness from concussion, rapid return to alertness, then, headache, sleepiness, gradual loss of consciousness, pupillary changes, and ultimately coma and death as the hematoma increases
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in size. An acute subdural hematoma, on the other hand, can be caused by the rupture of superficial bridging veins that travel from the subarachnoid space through the arachnoid and meningeal dura. Subdural hematomas result from abrupt shearing forces of the brain within the skull. The slow venous bleed forms a blood clot between the dura and the brain that becomes symptomatic between 24 h and 2 weeks after injury. The symptoms, such as headache and altered mental status, may be very subtle and nonspecific. Herniation syndrome may occur as a consequence of hematomas. An uncal herniation, a form of a transtentorial herniation, is most common. The uncus is located on the medial aspect of the parahippocampal gyrus just above the tentorium cerebelli, a meningeal dural reflection that separates the cerebrum from the cerebellum. The anterior free edge of the tentorium forms the tentorial notch, anterior to which the brainstem passes. As intracranial pressure increases, the brain is forced over the tentorial notch and the uncus ipsilateral to the hematoma herniates over the edge of the tentorium cerebelli. A consequence of the uncal herniation is impingement of the ipsilateral cranial nerve III (CN III), primarily a somatomotor nerve that innervates all but two of the extraocular muscles. CN III also carries preganglionic parasympathetic fibers to the ciliary ganglion in the orbit. The postganglionic fibers innervate the ciliary muscle associated with the lens and the sphincter muscle in the iris. Contraction of these muscles during accommodation results in rounding of the lens and pupillary constriction, respectively. Pupillary constriction also can be elicited when light is shone into the ipsilateral or contralateral eye. CN III travels intradurally from the posterior to the middle cranial fossa toward the superior orbital fissure. On its route, it traverses the cavernous sinus just medial and anterior to the uncus. Consequently, it is quite vulnerable to compression during this type of herniation. Compression leads to dilation of the pupil, anisocoria (pupils of unequal size), and a sluggish light reflex in the ipsilateral pupil. Eventu-
ally, ipsilateral pupillary dilation and nonreactivity result. An accurate, dynamic graphical representation with narration describing the events of an evolving intracranial hematoma will provide the students with an appreciation of the interrelationships of structures of the brain. In addition, they could apply this knowledge to understanding the pathophysiology of intracranial hemorrhage and increased intracranial pressure, usually the result of an epidural or subdural hematoma.
Plastination A human brain was obtained at postmortem from a cadaver and fixed in 5% formalin for 2 months. Before being serially sectioned, it was washed
An accurate, dynamic graphical representation with narration describing the events of an evolving intracranial hematoma will provide the students with an appreciation of the interrelationships of structures of the brain. in running tap water for 2 days and subsequently sliced on a rotary slicer. The wet brain slices were stabilized between stainless steel grids, assembled in a stainless steel grid basket and rinsed in tap water at 5°C overnight. After precooling, the brain slices were removed from the water and dehydrated by slow immersion in cold (⫺20 to ⫺25°C) acetone with gentle agitation for approximately 5 min. Twenty liters of acetone (technical quality) were used for 12 brain slices. After 2 days, the grid baskets containing the slices were moved into a second acetone bath, also at ⫺25°C. Dehydration was completed after 1 week per the method of von Hagens (1994). The brain slices were removed from cold acetone and placed into an im-
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mersion bath of P40 solution at ⫺25°C (2 days) after dehydration. Impregnation was achieved in a vacuum chamber (2 mm Hg). By using this temperature condition, the shrinkage rate of the brain slices was reduced (Sora et al., 1999). All slices were cast in flat chambers and cured with ultraviolet light for 3 h.
Base Illustration Preparation One animation was developed to depict an epidural hematoma with an uncal transtentorial herniation. The second animation was generated to show an acute traumatic subdural hematoma. To prepare the animations, the plastinated coronal sections from the entire brain were reviewed and two were selected, including an anterior section displaying the uncus and a posterior section showing the cerebellum and midbrain. The purpose of selecting two sections was to provide a depth perspective and pseudo-three dimensionality for the final animations. These plastinated sections were photographed. The photos were digitally scanned without change in magnification and imported into Photoshop (Adobe Systems, Inc., San Jose, CA) in JPEG format. The plastinated anterior coronal section that was chosen for animation was free of distortion or artifact in the area of the uncus (Figure 1a). This section also transected the appropriate region in the temporal and parietal lobes (Figure 1a,d). The posterior section showed slight deformation of the cortex; however, it was selected because the cerebellum was well defined and would provide clear outlines for the subsequent sketch (Figure 1b,d). The two sections were scanned and saved as separate JPEG files, and each section was edited independently, removing extraneous tissue (Figure 1c, edited anterior section only). The sections were placed in separate Photoshop layers. The anterior section was rendered opaque and superimposed on the second, posterior section. The sections were aligned by using the best-fit of lateral ventricles and external cortical contours. The layers were merged, and a full-page hardcopy printout was generated. The
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Figure 1. a: Plastinated anterior coronal section showing the cortical region where the epidural hematoma (asterisk) occurred and uncus (u). Tissues not necessary for demonstrating the dural hematoma were removed, including pons (po) and basilar artery (ba). b: Plastinated posterior coronal section showing cerebellum (cb) and midbrain (m). c: Edited anterior coronal section with extraneous tissues removed (edited posterior section not shown). d: Schematic showing the approximate line of sectioning for the anterior (a,c) and posterior (b) sections used in this application. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]
two sections were superimposed, aligned, merged into one file, and printed (Figure 2a). Pencil line sketches were rendered of contiguous midbrain and non-neural tissues. This rendering was used as a template, scanned, and saved in JPEG format (Figure 2b). The image of the plastinated anterior section was then aligned with the pencil sketch establishing a rough base illustration (Figure 2c). Detail was added to the base illustration by using numerous Photoshop tools. Typically, each feature was placed in its own layer, thus permitting independent manipulation (Figure 3). First, the bony skull was rendered, followed by the dura, midbrain, and cerebellum (Figure 3a,b). CN III (oculomotor nerve) was added to demonstrate the effects of an epidural hematoma on this nerve and subsequent changes in the pupillary light reflex (Figure 3c). CN III was rendered bright yellow with a per-
spective projection (Figure 3c). For one animation, the arterial bleed of the epidural hematoma was placed external to the pale blue dura, whereas in the second animation, hemorrhaging subdural venous blood was rendered bright blue and internal to the dura (Figure 3c,d). Additional features were added to the subdural base illustration, such as arachnoid villi, so that the viewer could clearly differentiate between dural layers (Figure 3d). Once contiguous anatomical structures were rendered successfully, the composite image was used as the final base illustration for subsequent interpolation.
Animation Methodology The base illustration was reduced in size and imported as a JPEG into Kai’s SuperGoo (Scan Soft, Peabody, MA). Interpolated frames were established based on a linear transformation between key frames, creating a continu-
ous alteration of initial morphology into a final form. Each animation used a total of 28 key frames with additional features added to the base illustration were necessary. A key point occurred during key frame 18, at which point the uncus translated and became positioned medial to the tentorium. The subsequent key frames emphasized compression of the ipsilateral CN III, then the brainstem, and finally the contralateral CN III. An important learning concept to be conveyed in the epidural hematoma animation was the arterial nature of the injury. To simulate an arterial pulsation, the animation was repeated at each key frame by duplicating it three times. These extra frames caused a delay, thus simulating a diastolic pause, followed by the interpolated frames, simulating the systolic vascular contraction. The first and last key frames were repeated five times to provide a stable beginning and end to the animation. For the subdural hematoma, the arachnoid layer was added along with very small blue bruise marks within the white matter of the cortex. The key framing was repeated as with the epidural hematoma with expansion of the blue color. Because bleeding is venous and, therefore, continuous in a subdural hematoma, no duplication of the key frames was necessary to simulate pulsation, as was the case of the epidural hematoma. Key frames were generated for both epidural (Figure 4a– h) and acute subdural (Figure 4m–t) hematomas. The initial key frame consisted of base epidural illustration (Figure 4a) and acute subdural (Figure 4m) illustration. For the epidural hematoma, bleeding was expanded while maintaining a lenticular shape (Figure 4b– h). Lateral ventricular deformation is another important component of the traumatic event and this was simulated accordingly (Figure 4d– h). A crucial aspect of the animated injury was to depict the translation of the uncus over the free edge of the tentorium cerebelli with encroachment on CN III in latter key frames (Figure 4i–l). An additional animation was rendered by using Photoshop simulating a dilating pupil in response to this encroachment. The acute subdural
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white matter, and this bruising was added artistically as blue color (Figure 4u–x). The acute swelling of the brain parenchyma in response to the severe head trauma energy was displayed by increasing the size of the brain tissue. Despite the relatively small size of the actual acute subdural hematoma and internal bruising, the increased mass of the swollen brain results in uncal herniation. Similar to the epidural hematoma, the uncus translates, herniates, and impinges on CN III (Figure 4u–x). By using SuperGoo, intermediate images were generated between key frames, exported to QuickTime, and the final animations were rendered. The SuperGoo file was edited, deleting the automatic rebound of the original key frame. Then it was saved as a QuickTime output for importing into a Web-based PowerPoint presenta-
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tion. As well, narration for each animation was scripted and recorded. The audio was recorded onto an iBook computer (Apple, Cupertino, CA) running OS 9 and using iMac USB audio interface (Griffin Technology, Nashville, TN) and digital recording software (Audiorecorder 3.0, Black Cat Systems, Westminster, MD). The audio was then synchronized with the visual animation, and the animations were saved on the TOUCH Web site (http://hsc.unm.edu/ touch/datasets/datasets/links/animation. htm). This link provided students the opportunity to view and contrast an epidural hematoma and subdural hematoma to further understand the diagnostic features of the case, either over the Access Grid or at remote computers during the PBL intersection and by means of a standard Internet connection.
Figure 2. a: Superimposition of anterior and posterior plastinated sections showing good congruence between slices. b: Pencil sketch of contiguous tissues for rendering important structures involved in the dural hematomas and for providing depth perspective. c: Superimposition of the plastinated anterior coronal section on pencil sketch of the base illustration.
hematoma key frames required a smaller, more slowly progressing hematoma internal to the dura (Figure 4m–t). An important component to a traumatic acute subdural hematoma is the internal bruising seen in the
Figure 3. a: Contiguous anatomical features were added including dura (du) and bone (bo). b: The brain stem and cerebellum were shaded extensively to provide a sense of depth. c: The base epidural hematoma illustration was placed on a black background, increasing contrast, and the hematoma (arrow) was added. Cranial nerve III (arrowheads) was rendered in bright yellow with a perspective projection. d: Base subdural hematoma illustration emphasizing venous blood (bright blue) in the subdural area with details added, including arachnoid villi (av, inset).
Figure 4. Selected key frames used for the epidural (a–l) and subdural (m–x) hematomas (i–l are enlargements of e– h; u–x are enlargements of q–t). The epidural hematoma emphasized lenticular enlargement of the blood clot with eventual translation and herniation of the uncus leading to cranial nerve III impingement (i–l). The subdural hematoma emphasized linear enlargement of the blood clot with internal bruising denoted by blue coloration (u–x), swelling of the brain parenchyma caused by edema, and eventual translation and herniation of the uncus leading to cranial nerve impingement (u–x).
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DISCUSSION The hardware and software necessary to perform the animation technique was very inexpensive and should be easily obtainable. The hardware used included both a Mac G3 laptop and 9600 running OS 9 as well as an Epson Scanner. Software included Adobe Photoshop and SuperGoo; both are widely available “off the shelf” and relatively inexpensive. Likewise, most plastination laboratories have sufficient resource personnel capable of providing necessary factual input into an animation. Plastinated sections appear well suited for providing base images for animation. Complex anatomy is presented, thus limiting the amount of effort required for artistic rendering and improvement. As well, they provide a more realistic depiction of the anatomy. A potential problem in using plastinated sections is the amount of shrinkage that can result during immersion and impregnation steps. In this study, the P40 technique used has been shown to cause between 4% and 5% shrinkage when processed at ⫺25°C (Sora et al., 1999). Thus, distortion of anatomical structures should be minimal. Even so, it would be possible to enlarge the image of the plastinated section electronically, thus compensating for shrinkage. Anatomical animations traditionally use artistic renderings exclusively as key frames (Lozanoff et al., 1999; Guttmann, 2000). However, for this application, it was apparent that artistic rendering of a brain cross section would have been extremely time consuming and, ultimately, the final rendering would have lacked realism. The technique we have outlined incorporates plastinated sections, providing a more realistic animation than would have been obtained using only artistic rendering. This strategy should facilitate a greater understanding of the process by the viewer. Plastinated sections and whole brain models could be provided to the student while viewing the animation, thus facilitating a more accurate understanding and involving a learning mode well suited to the PBL process. Current work is being undertaken to evaluate the efficacy of learning by using the anima-
tions within the PBL environment (Jacobs et al., 2003). Although immersive VR systems are unlikely to replace cadaveric dissection (Aziz et al., 2002), anatomical animation has the advantage of providing dynamic information otherwise unobservable by the student. Development of digital anatomical information has proceeded rapidly over the past decade, and numerous databases have emerged as outstanding supplemental learning tools (reviewed by Trelease, 2002). Two primary systems include the Digitial Anatomist Project (Brinkley et al., 1997) and the Visible Human database (Spitzer and Whitlock, 1998). These systems used cryostat, magnetic resonance, or computed tomography images with resultant 3D models. Additional utilization of two-dimensional planar anatomical images are being used for
The hardware and software necessary to perform the animation technique we outline here was very inexpensive and should be easily obtainable. Web-based anatomical learning supplements distributed over the Next Generation Internet (Dev et al., 2002; Temkin et al., 2002). However, plastinated sections provide an additional source of two-dimensional planar images that can be processed after sectioning, facilitating excellent resolution, in some cases even at the level of nerve fascicles (Cook and Al-Ali, 1997). Therefore, plastinated sections will facilitate an excellent source of data useful for developing detailed anatomical animations.
ACKNOWLEDGMENTS The project described was partially supported by grant 2 DIB TM00003-02 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, Department of Health and Human Services. The contents of this study are solely the
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responsibility of the authors and do not necessarily represent the official views of the Health Resources and Services Administration. This project is a collaborative effort with the University of Hawai’i, Maui High Performance Computing Center, University of New Mexico, and the Albuquerque High Performance Computing Center. David Minor is thanked for assisting in the uploading of the animations on the TOUCH Web site. Dr. Robert Trelease, UCLA, is thanked for providing helpful comments during the preparation of this manuscript.
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