Technical Assessment of Microvascular Decompression for Trigeminal Neuralgia Using a 3-Dimensional Exoscope

Operative Neurosurgery 23:374–381, 2022

Detailed anatomic visualization of the root entry zone of the trigeminal nerve is crucial to successfully perform microvascular decompression surgery (MVD) in patients with trigeminal neuralgia.

OBJECTIVE: To determine advantages and disadvantages using a 3-dimensional (3D) exoscope for MVD surgery.

METHODS: A 4K 3D exoscope (ORBEYE) was used by a single surgical team for MVD in a retrospective case series of 8 patients with trigeminal neuralgia in a tertiary center. Clinical and surgical data were collected, and advantages/disadvantages of using the exoscope for MVD were recorded after each surgery. Descriptive statistics were used to summarize the data.

RESULTS: Adequate MVD of the trigeminal nerve root was possible in all patients by exclusively using the exoscope. It offered bright visualization of the cerebellopontine angle and the root entry zone of the trigeminal nerve that was comparable with a binocular operating microscope. The greatest advantages of the exoscope included good optical quality, the pronounced depth of field of the image for all observers, and its superior surgeon ergonomics. Disadvantages were revealed with overexposure at deep surgical sites and the lack of endoscope integration. In 6 patients, facial pain improved significantly after surgery (Barrow Neurological Institute pain intensity score I in 5 and III in 1 patient), whereas it did not in 2 patients (Barrow Neurological Institute score IV and V). No complications occurred.

CONCLUSION: Utilization of a 3D exoscope for MVD is a safe and feasible procedure. Surgeons benefit from better ergonomics, excellent image quality, and an improved experience for observers.

Intracranial Tubular Retractor Systems: A Comparison and Review of the Literature of the BrainPath, Vycor, and METRx Tubular Retractors in the Management of Deep Brain Lesions

World Neurosurg. (2020) 143:134-146

In neurosurgery, parenchymal injury resulting from focal exertion of pressure on retracted tissue is a common complication associated with the use of plate and self-sustaining retractors to access deep intraparenchymal lesions. Tubular retractors, including Vycor, BrainPath, and METRx, were developed to reduce retraction injuries via radial dispersion of force.

Our study seeks to compare these retraction systems and assess their respective indications, benefits, and associated complications. A systematic review of PubMed MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, and Cochrane Database of Systematic Reviews was performed. Twenty-nine articles (n [ 289 patients) for BrainPath, 12 articles (n [ 106 patients) for Vycor, and 3 articles for METRx (n [ 31 patients) met the inclusion criteria.

This report is the first formal comparison of the BrainPath, Vycor, and METRx tubular retraction systems. We found that all 3 retractors were effective in accessing intraparenchymal lesions. Although we found that the retractor systems were used more commonly in different locations and for different diseases, there was no significant difference in complications or mortality among the 3 retractors.

Prospects of Photo- and Thermoacoustic Imaging in Neurosurgery

Neurosurgery 87:11–24, 2020

The evolution of neurosurgery has been, and continues to be, closely associated with innovations in technology.

Modern neurosurgery is wed to imaging technology and the future promises even more dependence on anatomic and, perhaps more importantly, functional imaging.

The photoacoustic phenomenon was described nearly 140 yr ago; however, biomedical applications for this technology have only recently received significant attention.

Light-based photoacoustic and microwave-based thermoacoustic technologies represent novel biomedical imaging modalities with broad application potential within and beyond neurosurgery. These technologies offer excellent imaging resolution while generally considered safer,more portable, versatile, and convenient than current imaging technologies. In this review,we summarize the current state of knowledge regarding photoacoustic and thermoacoustic imaging and their potential impact on the field of neurosurgery.

Unruptured intracranial aneurysm growth trajectory: occurrence and rate of enlargement in 520 longitudinally followed cases

J Neurosurg 132:1077–1087, 2020

As imaging technology has improved, more unruptured intracranial aneurysms (UIAs) are detected incidentally. However, there is limited information regarding how UIAs change over time to provide stratified, patient-specific UIA follow-up management. The authors sought to enrich understanding of the natural history of UIAs and identify basic UIA growth trajectories, that is, the speed at which various UIAs increase in size.

METHODS From January 2005 to December 2015, 382 patients diagnosed with UIAs (n = 520) were followed up at UCLA Medical Center through serial imaging. UIA characteristics and patient-specific variables were studied to identify risk factors associated with aneurysm growth and create a predicted aneurysm trajectory (PAT) model to differentiate aneurysm growth behavior.

RESULTS The PAT model indicated that smoking and hypothyroidism had a large effect on the growth rate of large UIAs (≥ 7 mm), while UIAs < 7 mm were less influenced by smoking and hypothyroidism. Analysis of risk factors related to growth showed that initial size and multiplicity were significant factors related to aneurysm growth and were consistent across different definitions of growth. A 1.09-fold increase in risk of growth was found for every 1-mm increase in initial size (95% CI 1.04–1.15; p = 0.001). Aneurysms in patients with multiple aneurysms were 2.43-fold more likely to grow than those in patients with single aneurysms (95% CI 1.36–4.35; p = 0.003). The growth rate (speed) for large UIAs (≥ 7 mm; 0.085 mm/month) was significantly faster than that for UIAs < 3 mm (0.030 mm/month) and for males than for females (0.089 and 0.045 mm/month, respectively; p = 0.048).

CONCLUSIONS Analyzing longitudinal UIA data as continuous data points can be useful to study the risk of growth and predict the aneurysm growth trajectory. Individual patient characteristics (demographics, behavior, medical history) may have a significant effect on the speed of UIA growth, and predictive models such as PAT may help optimize follow-up frequency for UIA management.

sEVD—smartphone-navigated placement of external ventricular drains

Acta Neurochirurgica (2020) 162:513–521

Currently, the trajectory for insertion of an external ventricular drain (EVD) is mainly determined using anatomical landmarks. However, non-assisted implantations frequently require multiple attempts and are associated with EVD malpositioning and complications. The authors evaluated the feasibility and accuracy of a novel smartphone-guided, angleadjusted technique for assisted implantations of an EVD (sEVD) in both a human artificial head model and a cadaveric head.

Methods After computed tomography (CT), optimal insertion angles and lengths of intracranial trajectories of the EVDs were determined. A smartphone was calibrated to the mid-cranial sagittal line. Twenty EVDs were placed using both the premeasured data and smartphone-adjusted insertion angles, targeting the center of the ipsilateral ventricular frontal horn. The EVD positions were verified with post-interventional CT.

Results All 20 sEVDs (head model, 8/20; cadaveric head, 12/20) showed accurate placement in the ipsilateral ventricle. The sEVD tip locations showed a mean target deviation of 1.73° corresponding to 12 mm in the plastic head model, and 3.45° corresponding to 33mm in the cadaveric head. The mean duration of preoperative measurements on CT data was 3 min, whereas sterile packing, smartphone calibration, drilling, and implantation required 9 min on average.

Conclusions By implementation of an innovative navigation technique, a conventional smartphone was used as a protractor for the insertion of EVDs. Our ex vivo data suggest that smartphone-guided EVD placement offers a precise, rapidly applicable, and patient-individualized freehand technique based on a standard procedure with a simple, cheap, and widely available multifunctional device.

Use of Vycor Tubular Retractors in the Management of Deep Brain Lesions

World Neurosurg. (2020) 133:283-290

Traditional manual retraction to access deep-seated brain lesions has been associated with complications related to vascular compromise of cerebral tissue. Various techniques have been developed over time to minimize injury, such as self-sustaining retractors, neuronavigation, and endoscopic approaches. Recently, tubular retractors, such as the ViewSite Brain Access System (VBAS), have been developed to reduce mechanical damage from retraction by dispersing the force of the retractor radially over the parenchyma. Therefore, we sought to review the current literature to accurately assess the indications, benefits, and complications associated with use of VBAS retractors.

METHODS: A literature search for English articles published between 2005 and 2019 was performed using the MEDLINE database archive with the search terminology “Vycor OR ViewSite OR Brain-Access-System NOT glass.” The VBAS website was also examined. Only articles detailing neurosurgical procedures using the VBAS tubular retractor system alone, or in combination with other retractors, were included. Postoperative morbidity and mortality were analyzed to estimate complications linked to using the retractor.

RESULTS: Twelve publications (106 patients) met the inclusion criteria. The VBAS retractor was used for tumor resections, hematoma evacuations, cyst removal, foreign body extractions, and lesion resection in toxoplasmosis and multiple sclerosis. These cases were subdivided into groups based on lesion location, size, and resection volume for further analysis. Gross total resection was achieved in 63% of tumor excisions, and subtotal resection was achieved in 37%. Hematoma evacuation was successful in all cases. There were 3 shortterm postoperative complications linked to the retractor, with an overall complication rate of 2.8%. –

CONCLUSIONS: This report is the first formal assessment of the VBAS, highlighting technical considerations of the retractor from the surgeon’s perspective, patient outcomes, and complications. The retractor is a safe and efficacious tubular retraction system that can be used for tumor biopsy and resection, colloid cyst removal, hematoma evacuation, and removal of foreign bodies. However, further randomized controlled trials are indicated to accurately assess complication rates and outcomes.

Ultrasonic aspiration in neurosurgery: comparative analysis of complications and outcome for three commonly used models

Acta Neurochirurgica (2019) 161:2073–2082

Ultrasonic aspiration (UA) devices are commonly used for resecting intracranial tumors, as they allow for internal debulking of large tumors, hereby avoiding damage to adjacent brain tissue during the dissection. Little is known about their comparative safety profiles.

Methods and materials We analyzed data from a prospective patient registry. Procedures using one of the following UA models were included: Integra® CUSA, Söring®, and Stryker® Sonopet. The primary endpoint was morbidity at discharge, defined as significant worsening on the Karnofsky Performance Scale. Secondary endpoints included morbidity and mortality until 3 months postoperative (M3), occurrence, type, and etiology of complications.

Results Of n = 1028 procedures, the CUSA was used in n = 354 (34.4 %), the Söring in n = 461 (44.8 %), and the Sonopet in n = 213 (20.7 %). There was some heterogeneity of study groups. In multivariable analysis, patients in the Söring (adjusted odds ratio (aOR) 1.29; 95 % confidence interval (CI), 0.80–2.08; p = 0.299), and Sonopet group (aOR, 0.86; 95 % CI, 0.46–1.61; p = 0.645) were as likely as patients in the CUSA group to experience discharge morbidity. At M3, patients in the Söring (aOR, 1.20; 95 % CI, 0.78–1.86; p = 0.415) and Sonopet group (aOR, 0.53; 95 % CI, 0.26–1.08; p = 0.080) were as likely as patients in the CUSA group to experience morbidity. There were also no differences for M3 morbidity in subgroup analyses for gliomas, meningiomas, and metastases. The grade (p = 0.608) and etiology (p = 0.849) of postoperative complications were similar.

Conclusions Neurosurgeons select UA types with regard to certain case-specific characteristics. The safety profiles of three commonly used UA types appear mostly similar.

Prospective Tractography-Based Targeting for Improved Safety of Focused Ultrasound Thalamotomy

Neurosurgery 84:160–168, 2019

Focused ultrasound thalamotomy (FUS-T) was recently approved for the treatment of refractory essential tremor (ET). Despite its noninvasive approach, FUS-T reinitiated concerns about the adverse effects and long-term efficacy after lesioning.

OBJECTIVE: To prospectively assess the outcomes of FUS-T in 10 ET patients using tractography-based targeting of the ventral intermediate nucleus (VIM).

METHODS: VIM was identified at the intercommissural plane based on its neighboring tracts: the pyramidal tract and medial lemniscus. FUS-T was performed at the center of tractography-defined VIM. Tremor outcomes, at baseline and 3 mo, were assessed independently by the Tremor Research Group.We analyzed targeting coordinates, clinical outcomes, and adverse events. The FUS-T lesion location was analyzed in relation to unbiased thalamic parcellation using probabilisitic tractography. Quantitative diffusionweighted imaging changes were also studied in fiber tracts of interest.

RESULTS: The tractography coordinates were more anterior than the standard. Intraoperatively, therapeutic sonications at the tractography target improved tremor (>50% improvement) without motor or sensory side effects. Sustained improvement in tremor was observed at 3mo(tremor score: 18.3±6.9 vs 8.1±4.4, P=.001).Nomotorweakness and sensory deficits after FUS-T were observed during 6-mo follow-up. Ataxia was observed in 3 patients. FUS-T lesions overlapped with the VIM parcellated with probablisitic tractography. Significant microstructural changes were observed in the white matter connecting VIM with cerebellum and motor cortex.

CONCLUSION: This is the first report of prospective VIM targeting with tractography for FUS-T. These results suggest that tractography-guided targeting is safe and has satisfactory short-term clinical outcomes.

Smartphone-assisted minimally invasive neurosurgery


J Neurosurg 130:90–98, 2019

Advances in video and fiber optics since the 1990s have led to the development of several commercially available high-definition neuroendoscopes. This technological improvement, however, has been surpassed by the smartphone revolution. With the increasing integration of smartphone technology into medical care, the introduction of these high-quality computerized communication devices with built-in digital cameras offers new possibilities in neuroendoscopy. The aim of this study was to investigate the usefulness of smartphone-endoscope integration in performing different types of minimally invasive neurosurgery.

METHODS The authors present a new surgical tool that integrates a smartphone with an endoscope by use of a specially designed adapter, thus eliminating the need for the video system customarily used for endoscopy. The authors used this novel combined system to perform minimally invasive surgery on patients with various neuropathological disorders, including cavernomas, cerebral aneurysms, hydrocephalus, subdural hematomas, contusional hematomas, and spontaneous intracerebral hematomas.

RESULTS The new endoscopic system featuring smartphone-endoscope integration was used by the authors in the minimally invasive surgical treatment of 42 patients. All procedures were successfully performed, and no complications related to the use of the new method were observed. The quality of the images obtained with the smartphone was high enough to provide adequate information to the neurosurgeons, as smartphone cameras can record images in high definition or 4K resolution. Moreover, because the smartphone screen moves along with the endoscope, surgical mobility was enhanced with the use of this method, facilitating more intuitive use. In fact, this increased mobility was identified as the greatest benefit of the use of the smartphone-endoscope system compared with the use of the neuroendoscope with the standard video set.

CONCLUSIONS Minimally invasive approaches are the new frontier in neurosurgery, and technological innovation and integration are crucial to ongoing progress in the application of these techniques. The use of smartphones with endoscopes is a safe and efficient new method of performing endoscope-assisted neurosurgery that may increase surgeon mobility and reduce equipment costs.  

Clinical applications of dynamic CT angiography for intracranial lesions

Acta Neurochirurgica (2018) 160:675–680

Dynamic CT angiography (dCTA) augments traditional CTA with temporal resolution and has been demonstrated to influence operative planning in skull base surgery.

Methods Three hundred twenty-five dynamic CTA cases from a single institution were reviewed for indication of study, findings, and comparison to other modalities of imaging.

Results The most frequent application of dCTA was pre-operative surgical planning (59.4%); resection of skull base tumors represented the majority of these pre-operative studies (93.3%). It was also used to evaluate new neurological symptoms (20.9%). Of these, the most common symptoms prompting a dCTA study included headache (22.1%) and visual field deficit (11.8%). The most commonly visualized vascular lesions were partial (22.9%) and complete vascular occlusions (9.0%). Dynamic CTA has also been useful in post-operative imaging for vascular malformations (9.5%) and tumors (2.5%). Finally, dCTA was employed to evaluate ambiguous abnormal findings observed on other imaging modalities (7.7%). Cerebral dCTA ruled out inconclusive abnormal vascular findings visualized on other imaging modalities (64.0%) more frequently than it confirmed them (32.0%), and was inconclusive in a singular case (4.0%).

Conclusions Cerebral dCTA is an evolving new technology with a diverse spectrum of potential applications. In addition to its role in guiding pre-operative planning for skull base surgical cases, dynamic CTA offers excellent spatial and temporal resolution for assessment of vascular lesions.

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.


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.

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