Tag: intraoperative

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Feasibility and Accuracy of Robot-Assisted, Stereotactic Biopsy Using 3-Dimensional Intraoperative Imaging and Frameless Registration Tool

Neurosurgery 92:803–811, 2023

Robot-assisted stereotactic biopsy is evolving: 3-dimensional intraoperative imaging tools and new frameless registration systems are spreading.

OBJECTIVE: To investigate the accuracy and effectiveness of a new stereotactic biopsy procedure.

METHODS: Observational, retrospective analysis of consecutive robot-assisted stereotactic biopsies using the Neurolocate (Renishaw) frameless registration system and intraoperative O-Arm (Medtronic) performed at a single institution in adults (2019-2021) and comparisonwith a historical series from the same institution (2006-2016) not using the Neurolocate nor the O-Arm.

RESULTS: In 100 patients (55%men), 6.2 ± 2.5 (1-14) biopsy sampleswere obtained at 1.7 ± 0.7 (1-3) biopsy sites. An histomolecular diagnosis was obtained in 96% of cases. The mean duration of the procedure was 59.0 ± 22.3 min. Themean distance between the planned and the actual target was 0.7 ± 0.7 mm. On systematic postoperative computed tomography scans, a hemorrhage ≥10 mm was observed in 8 cases (8%) while pneumocephalus was distant from the biopsy site in 76%. A Karnofsky Performance Status score decrease ≥20 points postoperatively was observed in 4%. The average dose length product was 159.7 ± 63.4mGy cm. Compared with the historical neurosurgical procedure, this newprocedure had similar diagnostic yield (96 vs 98.7%; P = .111) and rate of postoperative disability (4.0 vs 4.2%, P = .914) but was shorter (57.8 ± 22.9 vs 77.8 ± 20.9 min; P < .001) despite older patients.

CONCLUSION: Robot-assisted stereotactic biopsy using the Neurolocate frameless registration system and intraoperative O-Arm is a safe and effective neurosurgical procedure. The accuracy of this robot-assisted surgery supports its effectiveness for daily use in stereotactic neurosurgery.

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Predictors of early postoperative epileptic seizures after awake surgery in supratentorial diffuse gliomas

J Neurosurg 134:683–692, 2021

Functional-based resection under awake conditions had been associated with a nonnegligible rate of intraoperative and postoperative epileptic seizures. The authors assessed the incidence of intraoperative and early postoperative epileptic seizures after functional-based resection under awake conditions.

METHODS The authors prospectively assessed intraoperative and postoperative seizures (within 1 month) together with clinical, imaging, surgical, histopathological, and follow-up data for 202 consecutive diffuse glioma adult patients who underwent a functional-based resection under awake conditions.

RESULTS Intraoperative seizures occurred in 3.5% of patients during cortical stimulation; all resolved without any procedure being discontinued. No predictor of intraoperative seizures was identified. Early postoperative seizures occurred in 7.9% of patients at a mean of 5.1 ± 2.9 days. They increased the duration of hospital stay (p = 0.018), did not impact the 6-month (median 95 vs 100, p = 0.740) or the 2-year (median 100 vs 100, p = 0.243) postoperative Karnofsky Performance Status score and did not impact the 6-month (100% vs 91.4%, p = 0.252) or the 2-year (91.7 vs 89.4%, p = 0.857) postoperative seizure control. The time to treatment of at least 3 months (adjusted OR [aOR] 4.76 [95% CI 1.38–16.36], p = 0.013), frontal lobe involvement (aOR 4.88 [95% CI 1.25–19.03], p = 0.023), current intensity for intraoperative mapping of at least 3 mA (aOR 4.11 [95% CI 1.17–14.49], p = 0.028), and supratotal resection (aOR 6.24 [95% CI 1.43–27.29], p = 0.015) were independently associated with early postoperative seizures.

CONCLUSIONS Functional-based resection under awake conditions can be safely performed with a very low rate of intraoperative and early postoperative seizures and good 6-month and 2-year postoperative seizure outcomes. Intraoperatively, the use of the lowest current threshold producing reproducible responses is mandatory to reduce seizure occurrence intraoperatively and in the early postoperative period.

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Use of the Airo mobile intraoperative CT system versus the O-arm for transpedicular screw fixation in the thoracic and lumbar spine

J Neurosurg Spine 29:397–406, 2018

Navigation-enabling technology such as 3D-platform (O-arm) or intraoperative mobile CT (iCT-Airo) systems for use in spinal surgery has considerably improved accuracy over that of traditional fluoroscopy-guided techniques during pedicular screw positioning. In this study, the authors compared 2 intraoperative imaging systems with navigation, available in their neurosurgical unit, in terms of the accuracy they provided for transpedicular screw fixation in the thoracic and lumbar spine.

METHODS The authors performed a retrospective analysis of clinical and surgical data of 263 consecutive patients who underwent thoracic and lumbar spine screw placement in the same center. Data on 97 patients who underwent surgery with iCT-Airo navigation (iCT-Airo group) and 166 with O-arm navigation (O-arm group) were analyzed. Most patients underwent surgery for a degenerative or traumatic condition that involved thoracic and lumbar pedicle screw fixation using an open or percutaneous technique. The primary endpoint was the proportion of patients with at least 1 screw not correctly positioned according to the last intraoperative image. Secondary endpoints were the proportion of screws that were repositioned during surgery, the proportion of patients with a postoperative complication related to screw malposition, surgical time, and radiation exposure. A blinded radiologist graded screw positions in the last intraoperative image according to the Heary classification (grade 1–3 screws were considered correctly placed).

RESULTS A total of 1361 screws placed in 97 patients in the iCT-Airo group (503 screws) and in 166 in the O-arm group (858 screws) were graded. Of those screws, 3 (0.6%) in the iCT-Airo group and 4 (0.5%) in the O-arm group were misplaced. No statistically significant difference in final accuracy between these 2 groups or in the subpopulation of patients who underwent percutaneous surgery was found. Three patients in the iCT-Airo group (3.1%, 95% CI 0%–6.9%) and 3 in the O-arm group (1.8%, 95% CI 0%–4.0%) had a misplaced screw (Heary grade 4 or 5). Seven (1.4%) screws in the iCT-Airo group and 37 (4.3%) in the O-arm group were repositioned intraoperatively (p = 0.003). One patient in the iCT-Airo group and 2 in the O-arm group experienced postoperative neurological deficits related to hardware malposition. The mean surgical times in both groups were similar (276 [iCT-Airo] and 279 [O-arm] minutes). The mean exposure to radiation in the iCT-Airo group was significantly lower than that in the O-arm group (15.82 vs 19.12 mSv, respectively; p = 0.02).

CONCLUSIONS Introduction of a mobile CT scanner reduced the rate of screw repositioning, which enhanced patient safety and diminished radiation exposure for patients, but it did not improve overall accuracy compared to that of a mobile 3D platform.

 

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Endoscopic endonasal odontoid resection with real-time intraoperative image-guided computed tomography

J Neurosurg 128:1486–1491, 2018

The authors present 4 cases in which they used intraoperative CT (iCT) scanning to provide real-time image guidance during endonasal odontoid resection. While intraoperative CT has previously been used as a confirmatory test after resection, to the authors’ knowledge this is the first time it has been used to provide real-time image guidance during endonasal odontoid resection. The operating room setup, as well as the advantages and pitfalls of this approach, are discussed.

A mobile intraoperative CT scanner was used in conjunction with real-time craniospinal neuronavigation in 4 patients who underwent endoscopic endonasal odontoidectomy for basilar invagination. All patients underwent a successful decompression.

In 3 of the 4 patients, real-time intraoperative CT image guidance was instrumental in achieving a comprehensive decompression. In 3 (75%) cases in which the right nostril was the predominant working channel, there was a tendency for asymmetrical decompression toward the right side, meaning that residual bone was seen on the left, which was subsequently removed prior to completion of the surgery.

Endoscopic endonasal odontoid resection with real-time intraoperative image-guided CT scanning is feasible and provides accurate intraoperative localization of pathology, thereby increasing the chance of a complete odontoidectomy. For right-handed surgeons operating predominantly through the right nostril, special attention should be paid to the contralateral side of the resection, where there is often a tendency for residual pathology.

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Guideline on Surgical Techniques and Technologies for the Management of Patients With Nonfunctioning Pituitary Adenomas

Invasion of the cavernous sinus space in pituitary adenomas- endoscopic verification and its correlation with an MRI-based classification

Neurosurgery 79:E536–E538, 2016

Numerous technological adjuncts are used during transsphenoidal surgery for nonfunctioning pituitary adenomas (NFPAs), including endoscopy, neuronavigation, intraoperative magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) diversion, and dural closure techniques.

OBJECTIVE: To generate evidence-based guidelines for the use of NFPA surgical techniques and technologies.

METHODS: An extensive literature search spanning January 1, 1966, to October 1, 2014, was performed, and only articles pertaining to technological adjuncts for NFPA resection were included. The clinical assessment evidence-based classification was used to ascertain the class of evidence.

RESULTS: Fifty-six studies met the inclusion criteria, and evidence-based guidelines were formulated on the use of endoscopy, neuronavigation, intraoperative MRI, CSF diversion, and dural closure techniques.

CONCLUSION: Both endoscopic and microscopic transsphenoidal approaches are recommended for symptom relief in patients with NFPAs, with the extent of tumor resection improved by adequate bony exposure and endoscopic visualization. In select cases, combined transcranial and transsphenoidal approaches are recommended. Although intraoperative MRI can improve gross total resection, its use is associated with an increased false-positive rate and is thus not recommended. There is insufficient evidence to recommend the use of neuronavigation, CSF diversion, intrathecal injection, or specific dural closure techniques.

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Comparison of indocyanine green fluorescent angiography to digital subtraction angiography in brain arteriovenous malformation surgery

ICG and AVM

Acta Neurochir (2015) 157:351–359

The potential utility of intraoperative microscope-integrated indocyanine green (ICG) fluorescence angiography in the surgery of brain arteriovenous malformations (AVMs) and evaluation of the completeness of resection is debatable. Postoperative catheter angiography is considered the gold standard. We evaluated the value of ICG and intraoperative catheter angiography in this setting.

Methods Between January 2009 and July 2013, 37 patients with brain AVMs underwent surgical resection of their vascular lesions. ICG videoangiography and an intraoperative catheter angiography were performed in 32 cases, and a routine postoperative angiogram was performed within 48 h to 2 weeks after surgery. The usefulness of ICG findings and the ability to confirm total resection and to identify residual nidus or persistent shunt were assessed and compared to intraoperative and postoperative digital subtraction angiography, respectively.

Results There were 7 grade 1, 11 grade 2, 11 grade 3 and 3 grade 4 Spetzler-Martin classification AVMs. ICG angiography helped to distinguish AVM vessels in 26 patients. In 31 patients, it demonstrated that there was no residual shunting. In one patient, a residual AVMwas identified and further resected. Intraoperative catheter angiography detected two additional small residuals that were missed by ICG angiography, both deep in the surgical cavity. Further resection of the AVM was performed, and total resection was confirmed by a repeat intraoperative angiogram. Postoperative angiography in a patient with a grade 4 lesion revealed one additional small deep residual AVM nidus with persistent late shunting missed on both ICG and intraoperative angiography. Overall ICG angiography missed three out of four residual AVMs after initial resection, while the intraoperative angiogram missed one.

Conclusion Although ICG angiography is a helpful adjunct in the surgery of some brain AVMs, it’s yield in detecting residual AVM nidus or shunt is low, especially for deepseated lesions and higher grade AVMs. ICG angiography should not be used as a sole and/or reliable technique. Highresolution postoperative angiography must be performed in brain AVM surgery and remains the best test to confidently confirm complete AVM resection.

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The diagnostic accuracy of brain microdialysis during surgery

Microdialysis

Acta Neurochir (2013) 155:345–353

Monitoring of brain function and metabolism during surgery may be of benefit for patient outcome. Microdialysis is the only sampling technique to date that allows continuous monitoring of drug or metabolite concentrations in the extracellular fluid of multiple tissues in the brain. This qualitative systematic review aimed to determine whether microdialysis is a valid tool for detecting changes in tissue composition as would be expected upon changes in (induced) tissue metabolic composition during brain surgery.

Methods A systematic review was conducted by performing a MEDLINE search using the terms “Intraoperative Period” (Medical Subject Heading [MeSH]) OR “Surgery” [Subheading] OR “Monitoring, Intraoperative” [MeSH] AND “Microdialysis” [MeSH] AND “Brain” [MeSH]. Two reviewers independently assessed the methodological quality of the studies. For each study the grades of recommendation were determined.

Results The search strategy yielded 46 publications in Medline. Data extraction was performed on 16 studies. The methodological quality of studies was low, with overall scores of 4 or 5. A quantitative analysis could not be performed because of lack of sufficient data. A qualitative analysis was positive with regard to the detection of different states of tissue composition by microdialysis. However, the levels of recommendation on the outcome statements were low, resulting in a grade D level of recommendation on all statements.

Conclusions The available evidence for the validity of cerebral microdialysis as a diagnostic tool during brain surgery is of low scientific quality. In order to develop cerebral microdialysis as a valid instrument for monitoring of brain metabolism during surgery, standardised clinical prospective studies in homogeneous patient populations are required.

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Surgical Management of Symptomatic Os Odontoideum With Posterior Screw Fixation Performed Using the Magerl and Harms Techniques With Intraoperative 3-Dimensional Fluoroscopy-Based Navigation

Spine 2012 ; 37 : 1839 – 1846

To evaluate the accuracy of screw fixation using intraoperative three-dimensional fluoroscopy-based navigation (ITFN) and to assess the clinical outcomes of this treatment regimen.

Summary of Background Data. The surgical management of symptomatic os odontoideum poses considerable difficulties due to the highly variable anatomy of the upper cervical spine and surrounding neurovascular structures. Various methods have been described for the treatment of symptomatic os odontoideum, all of which have limitations.

Methods. Nineteen patients with symptomatic os odontoideum were investigated. Pain scores were assessed using the visual analogue scale. Myelopathy was assessed using the Nurick scale and Odom’s criteria. Radiological imaging was carried out in all patients for diagnosis and to assess the atlantodens interval, space available for cord, and presence of intramedullary hyperintensity signals on T2-weighted images at the C1–C2 level. Posterior stabilization was performed for all patients by using ITFN.

Results. The mean Nurick score improved from 2.3 before surgery to 0.7 at the time of follow-up. The mean follow-up period was 34.7 months (range, 12–65 mo). According to Odom’s criteria, outcomes were as follows: excellent, 47%; good, 37%; fair, 11%; and poor, 5%. All patients with preoperative neck pain had symptom relief or improvement, with all of these patients having more than 83.7% improvement in visual analogue scale scores. The mean preoperative space available for cord value of 9.3 mm improved to 17.7 mm. Solid fusion and reduction of atlantoaxial dislocation were achieved in every patient without screw failure. Sixty screws were placed in 19 patients. Two C2 polyaxial screws in 2 patients and 1 transarticular screw in 1 patient slightly penetrated the transverse foramen with no vascular injury and clinical sequelae.

Conclusion. ITFN is a safe, accurate, and effective tool for screw placement in patients with symptomatic os odontoideum.

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