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Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

STN DBS for Parkinson’s disease: results from a series of ten consecutive patients implanted under general anaesthesia with intraoperative use of 3D fluoroscopy to control lead placement

Artis Zeego

Acta Neurochir (2016) 158:1783–1788

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a recognised treatment for advanced Parkinson’s disease (PD). We present our results of 10 consecutive patients implanted under general anaesthesia (GA) using intraoperative robotic three-dimensional (3D) fluoroscopy (Artis Zeego; Siemens, Erlangen, Germany).

Method Ten patients (nine men, one woman) with a mean age of 57.6 (range, 41–67) years underwent surgery between October 2013 and January 2015. The mean duration of PD was 9.2 [1–10] year. The procedure was performed under GA: placement of the stereotactic frame, implantation of the electrodes (Lead 3389; Medtronic, Minnesota,MN, USA) and 3D intraoperative fluoroscopic control (Artis Zeego) with image fusion with the preoperative MRI scans. All patients were evaluated preoperatively and 6 months postoperatively.

Results The mean operative time was 240.1 (185–325) min. Themean Unified Parkinson’s Disease Rating Scale (UPDRS) II OFF medication decreased from 23.9 preoperatively to 15.7 postoperatively. The mean OFF medication UPDRS III decreased from 41 to 11.6 and the UPDRS IV decreased from 10.6 to 7. The mean preoperative and postoperative L-Dopa doses were 1,178.5 and 696.5 mg, respectively. Two complications were recorded: one episode of transient confusion (24 h) and one internal pulse generator (IPG) infection.

Conclusions With improvement in preoperative magnetic resonance imaging (MRI) and the ability to control the position of the leads intraoperatively using Artis Zeego, we now perform this procedure under GA. Our results are comparable to others reported. The significant decrease in the duration of surgery could be associated with a reduced rate of complications (infection, loss of patient collaboration). However, this observation needs to be confirmed.

A Novel Single Twist-Drill Access Device for Multimodal Intracranial Monitoring

A Novel Single Twist-Drill Access Device

Operative Neurosurgery 10:400–411, 2014

Multimodal intracranial monitoring in the neurosurgical patient requires insertion of probes through multiple craniostomies.

OBJECTIVE: To report our 5-year experience with a novel device allowing multimodal monitoring though a single twist-drill hole.

METHODS: All devices (Hummingbird Synergy, Innerspace) were placed at the Kocher point between 2008 and 2013 at our institution. An independent clinical research nurse prospectively collected data on all bedside placements. Placement accuracy was graded on computed tomography scan as grade 1 (ipsilateral frontal horn or third ventricle), grade 2 (contralateral lateral ventricle), and grade 3 (anywhere else). Infection was monitored with serial cerebrospinal fluid samples.

RESULTS: Two hundred seventy-five devices (198 at bedside, 77 in operating room) were placed in patients with spontaneous subarachnoid hemorrhage (49%), traumatic brain injury (47%), and others (4%) for a median duration of 6 days. A junior (postgraduate year 1-2), midlevel (postgraduate year 3-4), or senior resident (postgraduate year 5-6) placed 39%, 32%, and 29% of the devices, respectively. Ninety-two percent of all devices placed were draining cerebrospinal fluid, ie, were grade 1 (75%) or 2 (17%). Placement accuracy did not vary with level of training. Complications included hemorrhage (10%) and infection (4%), with 1 patient requiring intraparenchymal hematoma evacuation and a second requiring abscess drainage. These rates were lower than reported in the literature for standard external ventricular drains.

CONCLUSION: Hummingbird Synergy is a novel single-port access device for multimodal intracranial monitoring that can be placed safely at the bedside or in the operating room with placement accuracy and has a complication profile similar to or better than that for standard external ventricular drains.

Use of High-Field Intraoperative Magnetic Resonance Imaging to Enhance the Extent of Resection of Enhancing and Nonenhancing Gliomas

Use of High-Field Intraoperative Magnetic Resonance Imaging to Enhance the Extent of Resection of Enhancing and Nonenhancing Gliomas

Neurosurgery 74:339–350, 2014

Intraoperative magnetic resonance imaging (IoMRI) is used to improve the extent of resection of brain tumors. Most previous studies evaluating the utility of IoMRI have focused on enhancing tumors.

OBJECTIVE: To report our experience with the use of high-field IoMRI (1.5 T) for both enhancing and nonenhancing gliomas.

METHODS: An institutional review board–approved retrospective review was performed of 102 consecutive glioma patients (104 surgeries, 2010-2012). Pre-, intra-, and postoperative tumor volumes were assessed. Analysis was performed with the use of volumetric T2 images in 43 nonenhancing and 13 minimally enhancing tumors and with postcontrast volumetric magnetization-prepared rapid gradient-echo images in 48 enhancing tumors.

RESULTS: In 58 cases, preoperative imaging showed tumors likely to be amenable to complete resection. Intraoperative electrocorticography was performed in 32 surgeries, and 14 cases resulted in intended subtotal resection of tumors due to involvement of deep functional structures. No further resection (complete resection before IoMRI) was required in 25 surgeries, and IoMRI showed residual tumor in 79 patients. Of these, 25 surgeries did not proceed to further resection (9 due to electrocorticography findings, 14 due to tumor in deep functional areas, and 2 due to surgeon choice). Additional resection that was performed in 54 patients resulted in a final median residual tumor volume of 0.21 mL (0.6%). In 79 patients amenable to complete resection, the intraoperative median residual tumor volume for the T2 group was higher than for the magnetization-prepared rapid gradient-echo group (1.088 mL vs 0.437 mL; P = .049), whereas the postoperative median residual tumor volume was not statistically significantly different between groups.

CONCLUSION: IoMRI enhances the extent of resection, particularly for nonenhancing gliomas.

Validating the Use of Smartphone-Based Accelerometers for Performance Assessment in a Simulated Neurosurgical Task

Validating the Use of Smartphone-Based Accelerometers for Performance Assessment in a Simulated Neurosurgical Task

Operative Neurosurgery 10:57–65, 2014

Reductions in working hours affect training opportunities for surgeons. Surgical simulation is increasingly proposed to help bridge the resultant training gap. For simulation training to translate effectively into the operating theater, acquisition of technical proficiency must be objectively assessed. Evaluating “economy of movement” is one way to achieve this.

OBJECTIVE: We sought to validate a practical and economical method of assessing economy of movement during a simulated task. We hypothesized that accelerometers, found in smartphones, provide quantitative, objective feedback when attached to a neurosurgeon’s wrists.

METHODS: Subjects (n = 25) included consultants, senior registrars, junior registrars, junior doctors, and medical students. Total resultant acceleration (TRA), average resultant acceleration, and movements with acceleration .0.6g (suprathreshold acceleration events) were recorded while subjects performed a simulated dural closure task.

RESULTS: Students recorded an average TRA 97.0 6 31.2 ms22 higher than senior registrars (P = .03) and 103 6 31.2 ms22 higher than consultants (P = .02). Similarly, junior doctors accrued an average TRA 181 6 31.2 ms22 higher than senior registrars (P , .001) and 187 6 31.2 ms22 higher than consultants (P , .001). Significant correlations were observed between surgical outcome (as measured by quality of dural closure) and both TRA (r = .44, P , .001) and number of suprathreshold acceleration events (r = .33, P, .001). TRA (219 6 66.6 ms22; P = .01) and number of suprathreshold acceleration events (127 6 42.5; P = .02) dropped between the first and fourth trials for junior doctors, suggesting procedural learning. TRA was 45.4 6 17.1 ms22 higher in the dominant hand for students (P = .04) and 57.2 6 17.1 ms22 for junior doctors (P = .005), contrasting with even TRA distribution between hands (acquired ambidexterity) in senior groups.

CONCLUSION: Data from smartphone-based accelerometers show construct validity as an adjunct for assessing technical performance during simulation training.

Flexible Omnidirectional Carbon Dioxide Laser as an Effective Tool for Resection of Brainstem, Supratentorial, and Intramedullary Cavernous Malformations

Ponto-mesencephalic cavernoma

Operative Neurosurgery 10:34–45, 2014

Lasers have a long history in neurosurgery, yet bulky designs and difficult ergonomics limit their use. With its ease of manipulation and multiple applications, the OmniGuide CO2 laser has reintroduced laser technology to the microsurgical resection of brain and spine lesions. This laser, delivered through a hollow-core fiber lined with a unidirectional mirror, minimizes energy loss and allows precise targeting.

OBJECTIVE: To analyze resections performed by the senior author from April 2009 to March 2013 of 58 cavernous malformations (CMs) in the brain and spine with the use of the OmniGuide CO2 laser, to reflect on lessons learned from laser use in eloquent areas, and to share data on comparisons of laser power calibration and histopathology.

METHODS: Data were collected from electronic medical records, radiology reports, operative room records, OmniGuide CO2 laser case logs, and pathology records.

RESULTS: Of 58 CMs, approximately 50% were in the brainstem (30) and the rest were in supratentorial (26) and intramedullary spinal locations (2). Fifty-seven, ranging from 5 to 45 mm, were resected, with a subtotal resection in 1. Laser power ranged from 2 to 10 W. Pathology specimens showed minimal thermal damage compared with traditionally resected specimens with bipolar coagulation.

CONCLUSION: The OmniGuide CO2 laser is safe and has excellent precision for the resection of supratentorial, brainstem, and spinal intramedullary CMs. No laser-associated complications occurred, and very low energy was used to dissect malformations from their surrounding hemosiderin-stained parenchymas. The authors recommend its use for deep-seated and critically located CMs, along with traditional tools.

Utility of multimaterial 3D printers in creating models with pathological entities to enhance the training experience of neurosurgeons

Utility of multimaterial 3D printers in creating models with pathological entities to enhance the training experience of neurosurgeons

J Neurosurg 120:489–492, 2014

The advent of multimaterial 3D printers allows the creation of neurosurgical models of a more realistic nature, mimicking real tissues.

The authors used the latest generation of 3D printer to create a model, with an inbuilt pathological entity, of varying consistency and density. Using this model the authors were able to take trainees through the basic steps, from navigation and planning of skin flap to performing initial steps in a craniotomy and simple tumor excision.

As the technology advances, models of this nature may be able to supplement the training of neurosurgeons in a simulated operating theater environment, thus improving the training experience

Intraoperative angiography reloaded: a new hybrid operating theater for combined endovascular and surgical treatment of cerebral arteriovenous malformations

Intraoperative angiography reloaded

Acta Neurochir (2013) 155:2071–2078

Multimodality treatment suites for patients with cerebral arteriovenous malformations (AVM) have recently become available. This study was designed to evaluate feasibility, safety and impact on treatment of a new intraoperative flat-panel (FP) based integrated surgical and imaging suite for combined endovascular and surgical treatment of cerebral AVM.

Methods Twenty-five patients with AVMs to treat with combined endovascular and surgical interventions were prospectively enrolled in this consecutive case series. The hybrid suite allows combined endovascular and surgical approaches with intraoperative scanner-like imaging (XperCT®) and intraoperative 3D rotational angiography (3D-RA). The impact of intraoperative multimodal imaging on feasibility, workflow of combined interventions, surgery, and unexpected imaging findings were analyzed.

Results Twenty-five patients (mean age 38±18.6 year) with a median Spetzler-Martin grade 2 AVM (range 1–4) underwent combined endovascular and surgical procedures. Sixteen patients presented with a ruptured AVM and nine with an unruptured AVM. In 16 % (n=4) of cases, intraoperative imaging visualized AVM remnants ≤3 mm and allowed for completion of the resections in the same sessions. Complete resection was confirmed in all n =16 patients who had follow-up angiography one year after surgery so far. All diagnostic and therapeutical steps, including angiographic control, were performed without having to move the patients

Conclusion The hybrid neurointerventional suite was shown to be a safe and useful setup which allowed for unconstrained combined microsurgical and neuroradiological workflow. It reduces the need for extraoperative angiographic controls and subsequent potential surgical revisions a second time, as small AVM remnants can be detected with high security.

The Mirroring Technique: A Navigation-Based Method for Reconstructing a Symmetrical Orbit and Cranial Vault

Mirroring technique

Neurosurgery 73[ONS Suppl 1]:ons24–ons29, 2013

The reconstruction of orbital structures and the cranial vault curvature can be challenging after trauma or wide resections for tumors. Sophisticated methods have been developed recently, but these are resource- and time-consuming.

OBJECTIVE: We report the mirroring technique, which is an effective and costless application for navigation-guided reconstruction procedures.

METHODS: At the time of the reconstruction, high-resolution images are reloaded while forcing a left-right axial flip. The pointer subsequently enables a virtual 3- dimensional projection of the position of the contralateral normal anatomy.

RESULTS: This method was applied successfully in 2 cases of en plaque sphenoid wing meningiomas with secondary exophthalmia.

CONCLUSION: The mirroring technique represents an accurate method of outlining the contralateral normal anatomy onto the pathological side based on navigation guidance.

KEY WORDS:

Automated intracranial pressure-controlled cerebrospinal fluid external drainage with LiquoGuard®

Automated intracranial pressure-controlled CSF LiquoGuard

Acta Neurochir (2013) 155:1589–1595

LiquoGuard is a new device for intracranial pressure (ICP)-controlled drainage of cerebrospinal fluid (CSF). This present study evaluates the accuracy of ICP measurement via the LiquoGuard device in comparison with Spiegelberg. Thus, we compared data ascertained from simultaneous measurement of ICP using tip-transducer and tip-sensor devices.

Material and Methods A total of 1,764 monitoring hours in 15 patients (range, 52–219 h) were analysed. All patients received an intraventricular Spiegelberg III probe with the drainage catheter connected to the LiquoGuard system. ICP reading of both devices was performed on an hourly basis. Statistical analysis was done by applying Pearson correlation and Wilcoxon-matched pair test (p<0.05).

Results Mean ICP values were 11±5 mmHg (Spiegelberg) and 10±7 mmHg (LiquoGuard); the values measured with both devices correlated well (p=0.001; Pearson correlation =0.349; n=1,764). In two of the 15 patients with slit ventricles, episodes of significant differences in measured values could be observed. Both patients suffering from slit ventricles failed to produce reliable measurement with the external transducer of the LiquoGuard.

Conclusions LiquoGuard is a valuable new device for ICP-controlled CSF drainage. However, LiquoGuard tends to provide misleading results in slit ventricles. Thus, before these drawbacks are further analysed, the authors recommend additional ICP measurement with internal tip-sensor devices to avoid dangerous erroneous interpretation of ICP data.

Interactive presurgical simulation applying 3D techniques

Presurgical simulation 3Dimaging

J Neurosurg 119:94–105, 2013

In this paper, the authors’ goal was to report their novel presurgical simulation method applying interactive virtual simulation (IVS) using 3D computer graphics (CG) data and microscopic observation of color-printed plaster models based on these CG data in surgery for skull base and deep tumors.

Methods. For 25 operations in 23 patients with skull base or deep intracranial tumors (meningiomas, schwannomas, epidermoid tumors, chordomas, and others), the authors carried out presurgical simulation based on 3D CG data created by image analysis for radiological data. Interactive virtual simulation was performed by modifying the 3D CG data to imitate various surgical procedures, such as bone drilling, brain retraction, and tumor removal, with manipulation of a haptic device. The authors also produced color-printed plaster models of modified 3D CG data by a selective laser sintering method and observed them under the operative microscope.

Results. In all patients, IVS provided detailed and realistic surgical perspectives of sufficient quality, thereby allowing surgeons to determine an appropriate and feasible surgical approach. Surgeons agreed that in 44% of the 25 operations IVS showed high utility (as indicated by a rating of “prominent”) in comprehending 3D microsurgical anatomies for which reconstruction using only 2D images was complicated. Microscopic observation of color-printed plaster models in 12 patients provided further utility in confirming realistic surgical anatomies.

Conclusions. The authors’ presurgical simulation method applying advanced 3D imaging and modeling techniques provided a realistic environment for practicing microsurgical procedures virtually and enabled the authors to ascertain complex microsurgical anatomy, to determine the optimal surgical strategies, and also to efficiently educate neurosurgical trainees, especially during surgery for skull base and deep tumors.

Blood-based biomarkers for malignant gliomas

Blood-based biomarkers for malignant gliomas

J Neurooncol (2013) 113:345–352

Malignant gliomas remain incurable and present unique challenges to clinicians, radiologists and clinical and translational investigators. One of the major problems in treatment of these tumors is our limited ability to reliably assess tumor response or progression.

The most frequently used neuro-imaging studies (contrast-enhanced MRI and CT) rely on changes of blood–brain barrier (BBB) integrity, providing only an indirect assessment of tumor burden. In addition, the BBB can be altered by commonly used interventions including radiation, glucocorticoids and vascular endothelial growth factor inhibitors, further complicating the interpretation of scans. Newer radiologic techniques including PET and magnetic resonance spectroscopy are theoretically promising but thus far have not meaningfully changed the assessment of patients with malignant gliomas. A tumor-specific, bloodbased biomarker would be of immediate use to clinicians and investigators if sufficiently sensitive and specific.

This review discusses the potential utility of such a biomarker, the general classes of tumor-derived blood-based biomarkers and it summarizes the currently available data on circulating tumor cells, circulating nucleic acids and circulating proteins in patients with malignant gliomas. It is unclear which marker or marker class appears to be the most promising for these tumors.

This article provides thoughts on how novel candidate blood-based markers could be discovered and tested in a more comprehensive way and why these efforts should be among the top priorities in neuro-oncologic research in the coming years.

Intraoperative fluorescence for resection of hemangioblastomas

Intraoperative fluorescence for resection of hemangioblastomas

Acta Neurochir (2013) 155:1287–1292

Resection of hemangioblastomas can be challenging due to their high vascularity and intimate association with neighboring cerebrovascular structures. The authors present their intraoperative findings using fluorescein angiography and fluorescence for removal of hemangioblastomas in an attempt to improve the safety and extent of resection.

Methods From April through August 2012, four patients were diagnosed with hemangioblastomas, 3 in the cerebellum and 1 in the medulla oblongata. Low-dose (4 mg/kg) sodium fluorescein was injected intravenously immediately before microdissection. The area of interest was inspected through a microscope-integrated fluorescent module.

Results In three superficially located tumors, the vascular pattern of feeding and draining vessels could be easily identified with fluorescein angiography. The resection of the tumors was guided using real-time fluorescence mode. For each patient, histopathologic examination of the lesion confirmed the diagnosis of hemangioblastoma. All samples of fluorescent tissue resected were confirmed to contain tumor. No patient experienced any complication.

Conclusion Low-dose sodium fluorescein used in conjunction with a microscope-integrated fluorescence module is a potentially useful tool for localization, vascular characterization, and resection of hemangioblastomas.

Interactive presurgical simulation applying 3D techniques

3D CG data and the color-printed plaster model for a left tentorial meningioma

J Neurosurg 119:94–105, 2013

In this paper, the authors’ goal was to report their novel presurgical simulation method applying interactive virtual simulation (IVS) using 3D computer graphics (CG) data and microscopic observation of color-printed plaster models based on these CG data in surgery for skull base and deep tumors.

Methods. For 25 operations in 23 patients with skull base or deep intracranial tumors (meningiomas, schwannomas, epidermoid tumors, chordomas, and others), the authors carried out presurgical simulation based on 3D CG data created by image analysis for radiological data. Interactive virtual simulation was performed by modifying the 3D CG data to imitate various surgical procedures, such as bone drilling, brain retraction, and tumor removal, with manipulation of a haptic device. The authors also produced color-printed plaster models of modified 3D CG data by a selective laser sintering method and observed them under the operative microscope.

Results. In all patients, IVS provided detailed and realistic surgical perspectives of sufficient quality, thereby allowing surgeons to determine an appropriate and feasible surgical approach. Surgeons agreed that in 44% of the 25 operations IVS showed high utility (as indicated by a rating of “prominent”) in comprehending 3D microsurgical anatomies for which reconstruction using only 2D images was complicated. Microscopic observation of color-printed plaster models in 12 patients provided further utility in confirming realistic surgical anatomies.

Conclusions. The authors’ presurgical simulation method applying advanced 3D imaging and modeling techniques provided a realistic environment for practicing microsurgical procedures virtually and enabled the authors to ascertain complex microsurgical anatomy, to determine the optimal surgical strategies, and also to efficiently educate neurosurgical trainees, especially during surgery for skull base and deep tumors.

5-aminolevulinic acid (5-ALA) fluorescence guided surgery of high-grade gliomas in eloquent areas assisted by functional mapping

5ALA and functional mapping

Acta Neurochir (2013) 155:965–972

Only few data are available on the specific topic of 5-aminolevulinic acid (5-ALA) guided surgery of high-grade gliomas (HGG) located in eloquent areas. Studies focusing specifically on the post-operative clinical outcome of such patients are yet not available, and it has not been so far explored whether such approach could be more suitable for some particular subgroups of patients.

Methods Patients affected by HGG in eloquent areas who underwent surgery assisted by 5-ALA fluorescence and intra-operative monitoring were prospectively recruited in our Department between June 2011 and August 2012. Resection rate was reported as complete resection of enhancing tumor (CRET), gross total resection (GTR) >98 % and GTR>90 %. Clinical outcome was evaluated at 7, 30, and 90 days after surgery.

Results Thirty-one patients were enrolled. Resection was complete (CRET) in 74 % of patients. Tumor removal was stopped to avoid neurological impairment in 26 % of cases. GTR>98 % and GTR>90 % was achieved in 93 % and 100 % of cases, respectively. First surgery and awake surgery had a CRET rate of 80 % and 83 %, respectively. Even though at the first-week assessment 64 % of patients presented neurological impairment, there was a 3 % rate of severe morbidity at the 90th day assessment. Newly diagnosed patients had a significantly lower morbidity (0 %) and post-operative higher median KPS. Both pre-operative neurological condition and improvement after corticosteroids resulted significantly predictive of post-operative functional outcome.

Conclusions 5-ALA surgery assisted by functional mapping makes high HGG resection in eloquent areas feasible , through a reasonable rate of late morbidity. This emerges even more remarkably for selected patients.

A Comparison of Language Mapping by Preoperative Navigated Transcranial Magnetic Stimulation and Direct Cortical Stimulation During Awake Surgery

A_Comparison_of_Language_Mapping_by_Preoperative

Neurosurgery 72:808–819, 2013

Navigated transcranial magnetic stimulation (nTMS) is increasingly used in presurgical brain mapping. Preoperative nTMS results correlate well with direct cortical stimulation (DCS) data in the identification of the primary motor cortex. Repetitive nTMS can also be used for mapping of speech-sensitive cortical areas.

OBJECTIVE: The current cohort study compares the safety and effectiveness of preoperative nTMS with DCS mapping during awake surgery for the identification of language areas in patients with left-sided cerebral lesions.

METHODS: Twenty patients with tumors in or close to left-sided language eloquent regions were examined by repetitive nTMS before surgery. During awake surgery, language-eloquent cortex was identified by DCS. nTMS results were compared for accuracy and reliability with regard to DCS by projecting both results into the cortical parcellation system.

RESULTS: Presurgical nTMS maps showed an overall sensitivity of 90.2%, specificity of 23.8%, positive predictive value of 35.6%, and negative predictive value of 83.9% compared with DCS. For the anatomic Broca’s area, the corresponding values were a sensitivity of 100%, specificity of 13.0%, positive predictive value of 56.5%, and negative predictive value of 100%, respectively.

CONCLUSION: Good overall correlation between repetitive nTMS and DCS was observed, particularly with regard to negatively mapped regions. Noninvasive inhibition mapping with nTMS is evolving as a valuable tool for preoperative mapping of language areas. Yet its low specificity in posterior language areas in the current study necessitates further research to refine the methodology.

Stereoelectroencephalography: Surgical Methodology, Safety, and Stereotactic Application Accuracy in 500 Procedures

Stereoelectroencephalography___Surgical

Neurosurgery 72:353–366, 2013

Stereoelectroencephalography (SEEG) methodology, originally developed by Talairach and Bancaud, is progressively gaining popularity for the presurgical invasive evaluation of drug-resistant epilepsies.

OBJECTIVE: To describe recent SEEG methodological implementations carried out in our center, to evaluate safety, and to analyze in vivo application accuracy in a consecutive series of 500 procedures with a total of 6496 implanted electrodes.

METHODS: Four hundred nineteen procedures were performed with the traditional 2- step surgical workflow, which was modified for the subsequent 81 procedures. The new workflow entailed acquisition of brain 3-dimensional angiography and magnetic resonance imaging in frameless and markerless conditions, advanced multimodal planning, and robot-assisted implantation. Quantitative analysis for in vivo entry point and target point localization error was performed on a sub–data set of 118 procedures (1567 electrodes).

RESULTS: The methodology allowed successful implantation in all cases. Major complication rate was 12 of 500 (2.4%), including 1 death for indirect morbidity. Median entry point localization error was 1.43 mm (interquartile range, 0.91-2.21 mm) with the traditional workflow and 0.78 mm (interquartile range, 0.49-1.08 mm) with the new one (P , 2.2 · 10216). Median target point localization errors were 2.69 mm (interquartile range, 1.89-3.67 mm) and 1.77 mm (interquartile range, 1.25-2.51 mm; P, 2.2 · 10216), respectively.

CONCLUSION: SEEG is a safe and accurate procedure for the invasive assessment of the epileptogenic zone. Traditional Talairach methodology, implemented by multimodal planning and robot-assisted surgery, allows direct electrical recording from superficial and deep-seated brain structures, providing essential information in the most complex cases of drug-resistant epilepsy.

Advanced 3-Dimensional Planning in Neurosurgery

Virtual planning of different possible approaches for the surgical treatment of a giant carotid-ophthalmic aneurysm

Neurosurgery 72:A54–A62, 2013

During the past decades, medical applications of virtual reality technology have been developing rapidly, ranging from a research curiosity to a commercially and clinically important area of medical informatics and technology. With the aid of new technologies, the user is able to process large amounts of data sets to create accurate and almost realistic reconstructions of anatomic structures and related pathologies.

As a result, a 3-dimensional (3-D) representation is obtained, and surgeons can explore the brain for planning or training. Further improvement such as a feedback system increases the interaction between users and models by creating a virtual environment. Its use for advanced 3-D planning in neurosurgery is described. Different systems of medical image volume rendering have been used and analyzed for advanced 3-D planning: 1 is a commercial “ready-to-go” system (Dextroscope, Bracco, Volume Interaction, Singapore), whereas the others are open-source-based software (3-D Slicer, FSL, and FreesSurfer).

Different neurosurgeons at our institution experienced how advanced 3-D planning before surgery allowed them to facilitate and increase their understanding of the complex anatomic and pathological relationships of the lesion. They all agreed that the preoperative experience of virtually planning the approach was helpful during the operative procedure.

Virtual reality for advanced 3-D planning in neurosurgery has achieved considerable realism as a result of the available processing power of modern computers. Although it has been found useful to facilitate the understanding of complex anatomic relationships, further effort is needed to increase the quality of the interaction between the user and the model.

Safe Resection of Arteriovenous Malformations in Eloquent Motor Areas Aided by Functional Imaging and Intraoperative Monitoring

Neurosurgery 70[ONS Suppl 2]:ons276–ons289, 2012. DOI: 10.1227/NEU.0b013e318237aac5

Arteriovenous malformations (AVMs) proximal to motor cortical areas or motor projection systems are challenging to manage because of the risk of severe sensory and motor impairment. Surgical indication in these cases therefore remains controversial.
OBJECTIVE: To propose a standardized approach for centrally situated AVMs based on functional imaging and intraoperative electrophysiological evaluation.
METHODS: We conducted a retrospective analysis of 15 patients who underwent surgical treatment for AVMs in motor cortical areas or proximal to motor projections. Preoperative assessment included functional magnetic resonance and 3-dimensional tractography. Operations were performed under continuous electrophysiological monitoring aided by direct brain stimulation. We identified critical bloody supply to the motor areas by temporary occluding the feeding vessels under electrophysiological monitoring. Clinical outcome was evaluated with the modified Rankin Scale.
RESULTS: Total resection was achieved in 12 cases, whereas electrophysiology limited total extirpation in 3 cases. A significant reduction of motor evoked potentials by up to 15% of the initial values was associated with good recovery of motor function; in contrast, the disappearance of potentials correlated with long-term impairment. The mean follow-up time was 13 months, and clinical assessments revealed overall functional improvement (P , .05). After surgery, 11 patients were asymptomatic or presented with only minor neurological deficits.
CONCLUSION: Surgical resection of AVMs in eloquent motor areas can be considered a safe option for selected cases when performed in conjunction with a detailed functional assessment. Possible selection criteria for surgical treatment are discussed in light of the presented clinical data.

Clinical Assessment of Percutaneous Lumbar Pedicle Screw Placement Using the O-Arm Multidimensional Surgical Imaging System

Neurosurgery 70:990–995, 2012 DOI: 10.1227/NEU.0b013e318237a829

Increasing popularity of minimally invasive surgery for lumbar fusion has led to dependence upon intraoperative fluoroscopy for pedicle screw placement, because limited muscle dissection does not expose the bony anatomy necessary for traditional, freehand techniques nor for registration steps in image-guidance techniques. This has raised concerns about cumulative radiation exposure for both surgeon and operating room staff. The recent introduction of the O-arm Multidimensional Surgical Imaging System allows for percutaneous placement of pedicle screws, but there is limited clinical experience with the technique and data examining its accuracy.

OBJECTIVE: We present the first large clinical series of percutaneous screw placement using navigation of O-arm imaging and compare the results with the fluoroscopyguided method.

METHODS: A retrospective review of a 24-month period identified patients undergoing minimally invasive lumbar interbody fusion. The O-arm was introduced in the middle of this period and was used for all subsequent patients. Accuracy of screw placement was assessed by examination of axial computed tomography or O-arm scans.

RESULTS: The fluoroscopy group included 141 screws in 42 patients, and the O-arm group included 205 screws in 52 patients. The perforation rate was 12.8% in the fluoroscopy group and 3% in the O-arm group (P < .001). Single-level O-arm procedures took a mean 200 (153-241) minutes, whereas fluoroscopy took 221 (178-302) minutes (P < .03).

CONCLUSION: Percutaneous pedicle screw placement with the O-arm Multidimensional Intraoperative Imaging System is a safe and effective technique and provided improved overall accuracy and reduced operative time compared with conventional fluoroscopic techniques.

Minimally invasive treatment for intracerebral hemorrhage

Neurosurg Focus 32 (4):E3, 2012. http://thejns.org/doi/abs/10.3171/2012.1.FOCUS11362

Spontaneous intracerebral hemorrhage is a serious public health problem and is fatal in 30%–50% of all occurrences. The role of open surgical management of supratentorial intracerebral hemorrhage is still unresolved. A recent consensus conference sponsored by the National Institutes of Health suggests that minimally invasive techniques to evacuate clots appear to be a promising area and warrant further investigation. In this paper the authors review past, current, and potential future methods of treating intraparenchymal hemorrhages with minimally invasive techniques and review new data regarding the role of stereotactically placed catheters and thrombolytics.

A minimally invasive approach to evacuate ICH has been well documented to be a safe practice. Thus far, the CLEAR and MISTIE studies have supported this assertion. An increased rate of clot lysis could potentially be achieved with a combination of mechanical and pharmaceutical approaches. However, more extensive studies need to be conducted to determine whether the additional mechanical effects via ultrasound further yield beneficial long-term outcome versus pharmacological lysis alone. Currently, catheters are being redesigned for this purpose and will be evaluated in additional future clinical trials.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain

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NeurosurgeryCNS: Surgery of AVMs in Motor Areas

NeurosurgeryCNS: The Fenestrated Yaşargil T-Bar Clip

NeurosurgeryCNS: Cotton-Clipping Technique to Repair Intraoperative Aneurysm Neck Tear Video 3

NeurosurgeryCNS: Cotton-Clipping Technique to Repair Intraoperative Aneurysm Neck Tear Video 2

NeurosurgeryCNS: Cotton-Clipping Technique to Repair Intraoperative Aneurysm Neck Tear Video 1

NeurosurgeryCNS. ‘Double-Stick Tape’ Technique for Offending Vessel Transposition in Microvascular Decompression

NeurosurgeryCNS: Advances in the Treatment and Outcome of Brain Stem Cavernous Malformation Surgery: 300 Patients

3T MRI Integrated Neuro Suite

NeurosurgeryCNS: 3D In Vivo Modeling of Vestibular Schwannomas and Surrounding Cranial Nerves Using DIT

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 7

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 6

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 5

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 4

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 3

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 2

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 1

NeurosurgeryCNS: Corticotomy Closure Avoids Subdural Collections After Hemispherotomy

NeurosurgeryCNS: Operative Nuances of Side-to-Side in Situ PICA-PICA Bypass Procedure

NeurosurgeryCNS. Waterjet Dissection in Neurosurgery: An Update After 208 Procedures: Video 3

NeurosurgeryCNS. Waterjet Dissection in Neurosurgery: An Update After 208 Procedures: Video 2

NeurosurgeryCNS. Waterjet Dissection in Neurosurgery: An Update After 208 Procedures: Video 1

NeurosurgeryCNS: Fusiform Aneurysms of the Anterior Communicating Artery

NeurosurgeryCNS. Initial Clinical Experience with a High Definition Exoscope System for Microneurosurgery

NeurosurgeryCNS: Endoscopic Treatment of Arachnoid Cysts Video 2

NeurosurgeryCNS: Endoscopic Treatment of Arachnoid Cysts Video 1

NeurosurgeryCNS: Typical colloid cyst at the foramen of Monro.

NeurosurgeryCNS: Neuronavigation for Neuroendoscopic Surgery

NeurosurgeryCNS:New Aneurysm Clip System for Particularly Complex Aneurysm Surgery

NeurosurgeryCNS: AICA/PICA Anatomical Variants Penetrating the Subarcuate Fossa Dura

Craniopharyngioma Supra-Orbital Removal

NeurosurgeryCNS: Use of Flexible Hollow-Core CO2 Laser in Microsurgical Resection of CNS Lesions

NeurosurgeryCNS: Ulnar Nerve Decompression

NeurosurgeryCNS: Microvascular decompression for hemifacial spasm

NeurosurgeryCNS: ICG Videoangiography

NeurosurgeryCNS: Inappropiate aneurysm clip applications


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