著者らは、UCSDの神経血管患者のケアに毎日貢献するすべての臨床チームに感謝する。

1. シミュレータのセットアップ
<ol><li>すべての手順の前に、 図 1 に示すようにシミュレーターを組み立てて、オンにします。各シミュレーションを完了するために必要なシミュレータ機器の完全なリストについては 、表1 を参照してください。</li>
	<li>接続されたラップトップのソフトウェアインターフェイスを使用して患者シナリオを選択します(図1C)。</li>
	<li>ドロップダウンメニューから適切な動脈シースまたはガイドカテーテルを選択します。これはシミュレーションの一部として物理的に挿入する必要はありませんが、大腿部のアクセスサイトとして機能し、その後のシステムへのワイヤとカテーテルの入力を可能にします(図1D)。各シナリオの特定のシース/ガイドサイズを以下に説明します。</li>
	<li>以下で説明する特定のシナリオに基づいて、適切なカテーテル、ガイドワイヤ、マイクロシステムを選択します(図1D)。</li>
	<li>ソフトウェア インターフェイスで A (PA) と B 平面 (横) の蛍光鏡をオンにします。足のペダル(図1H)で蛍光法を有効にし、正しいPAおよび横のビューが得られるまでジョイスティック(図1I)で患者と画像の両方の位置を調整します。</li>
</ol>2. 第1の患者シナリオ:4血管血管造影
注:このシナリオは、頭部の非コントラストコンピュータ断層撮影(CT)スキャンで偶然に発見された未破裂左頸動脈末動脈瘤を有する52歳の男性を描いている。
<ol><li>このシミュレーションで使用するツールとして、ドロップダウンメニューから5-フランスの大腿部シース、ガイドワイヤーの0.035、および4-フランスの診断カテーテルを選択します。</li>
	<li>シミュレーション画面に登録されるまで、ガイドワイヤーをシミュレーターマシン(図1D)に挿入し、アクセス権が得られたことを知らせます。ガイドワイヤーを進めて、胸部大動脈の下に視覚化され、大動脈弓に進みます。</li>
	<li>ガイドワイヤーが大動脈弓に安全に入っている場合は、ガイドワイヤーを所定の位置に保持し、シミュレートされた大腿骨鞘を通してガイドワイヤーの上に診断カテーテルを大動脈弓に挿入する。</li>
	<li>ガイドワイヤーを取り外し、コントラスト注射器(図1E)を軽く押してコントラスト注射をシミュレートし、カテーテルが所望の動脈に進むにつれて血管を短時間にオーパタイズすることにより、フルオロシープ技術を利用します。</li>
	<li>次に、透視足のペダルが落ち込んでいる間にコントラストシリンジ(図1E)と対比を注入するロードマップガイドを作成します(図1H)。次に、ワイヤーを再挿入して所望の容器を選択的にカテーテルし、カテーテルをワイヤー上で進める。以降の血管造影実行のためにワイヤを取り外します。右および左の内頸動脈および外的頸動脈および左右の椎骨動脈はすべてこの技術を用いてカテーテル化される。</li>
	<li>診断カテーテルとシミュレータ造影注射器(図1E)を用いて、上記の各循環の血管造影を行い、注射器との対比を注入しながら、フルオロコピーペダル(図1H)を押し下げ、上記の各循環の血管グラムを行う。必要に応じて、動脈瘤の高倍率のビューを取得します。血管を確認して、カテーテルを取り外す前に、妥当性を確認してください。</li>
	<li>必要な画像が得られたら、シミュレーションシースから診断カテーテル/ガイドワイヤーを取り外します。大腿動脈開閉部位の模擬閉鎖は行われない。</li>
</ol>3. 第2の患者シナリオ:頸動脈末動脈瘤コイリング
注:このシナリオは、左頸動脈末動脈瘤が破裂し、重度の頭痛、非焦点試験、グラスゴー昏睡スケールスコア15の既知の左頸動脈末動脈瘤を持つ52歳の男性を描いています。
<ol><li>ドロップダウンメニューから、ガイドワイヤーの0.035、および4-フランスの診断カテーテルを選択します。</li>
	<li>ステップ 2.2 – 2.3 のように、ガイドワイヤーの上に診断カテーテルを大動脈アーチに挿入します。</li>
	<li>大腿骨アクセス部位(図1D)を通して大動脈弓にガイドカテーテルを挿入します。</li>
	<li>ガイドワイヤーを取り外し、透視検査フットペダル(図1H)が落ち込んでいる間にコントラストシリンジ(図1E)と対照的に注入するロードマップ小麦粉の足のペダルによって左共通頸動脈のロードマップガイドを作成します。</li>
	<li>ガイドワイヤーを再挿入し、画像投影モニター(図1B)に可視化されたロードマップオーバーレイを使用して、左共通頸動脈および内部頸動脈を選択的にカテーテルし、ガイドワイヤーを導き、安全なアクセスが得られたら診断カテーテルとガイドカテーテルを進めます。</li>
	<li>ガイドカテーテルが頸動脈内にある場合、診断カテーテルとワイヤーを取り外し、注射器との対比を注入しながら、透視検査ペダル(図1H)を押し下げ、左の頸動脈内脳循環の血管造影を行う(図1E)。</li>
	<li>ソフトウェアインターフェイスの計算オプションを使用して動脈瘤を測定します (図 1C)。最初のコイルのコイル直径は平均動脈瘤直径より1mm広くなるべきであることを念頭に置いて、適切なコイルを選択してください。</li>
	<li>ドロップダウン メニューからマイクロカテーテルとマイクロワイヤを選択します。</li>
	<li>大腿部アクセス部位(図1D)を介してマイクロカテーテルとマイクロワイヤーを挿入し、ステップ3.6のように得られたロードマップガイダンスの下で、マイクロシステムで動脈瘤を選択的にカテーテル化する。</li>
	<li>マイクロワイヤーを取り外し、以前に選択したコイルを大腿部アクセスサイト(図1D)に挿入し、ゆっくりと動脈瘤に進めます。</li>
	<li>コイルが完全に挿入されたら、注射器との対比を注入しながら蛍光検査ペダル(図1H)を押し下げ、親動脈および動脈瘤充填の開存を評価することによって診断脳血管造影を行う。目標は、親動脈の開口を維持し、動脈瘤を完全に塞栓するか、またはドームまたは推定破裂点の十分なカバレッジを提供して破裂リスクを適切に軽減することです。</li>
	<li>ソフトウェアインターフェイス(図1C)のコイルを取り外し、コイルワイヤを取り外します。必要に応じて、3.11と3.12を追加コイルで、30%動脈瘤閉塞が得られるまで繰り返します。</li>
	<li>シミュレーションシース部位からマイクロカテーテルとガイドカテーテルを取り外します(図1D)。大腿動脈開閉部位の模擬閉鎖は行われない。</li>
</ol>4. 第3の患者シナリオ: 左中大脳動脈血栓切開術
注:このシナリオは、失語症と右辺の弱点のために12の国立衛生脳卒中スケール(NIHSS)スコアを持つ64歳の女性を描いています。頭部CTは、過密度左中大脳動脈(MCA)徴候とアルバータ脳卒中プログラム早期CTスコア(態様)10のを明らかにしたが、出血はなかった。CT血管造影は左M1セグメント完全な閉塞を実証した。
<ol><li>ドロップダウンメニューから、ガイドワイヤーの0.035、および4-フランスの診断カテーテルを選択します。</li>
	<li>ガイドカテーテルを左の頸動脈に挿入し、手順3.2~3.6で説明したように、左頸動脈脳循環の血管造影を行います。</li>
	<li>ドロップダウンメニューからマイクロカテーテル/マイクロワイヤーおよびステントレトリバーデバイスを選択します。</li>
	<li>マイクロカテーテルとマイクロワイヤーを、シミュレートされた大腿骨アクセス部位(図1D)と左の頸動脈に挿入します。</li>
	<li>ステップ3.5のように得られたロードマップガイダンスの下で、マイクロワイヤーとマイクロカテーテルを左MCAに進め、慎重に閉塞の領域を過ぎて下さい。この操縦中の潜在的な合併症には、下流の血栓の穿圧および/または塞栓が含まれる。</li>
	<li>マイクロワイヤを取り外し、シミュレートされた大腿骨アクセスサイト(図1D)にステントレトリバー装置を挿入し、MCA遠位から閉塞まで進みます。次に、マイクロカテーテルを取り外し、ステントレトリバーを閉塞のレベルで所定の位置に残します。</li>
	<li>ソフトウェアインターフェイス(図1C)でシミュレーションされた吸引をオンにし、マイクロワイヤを引き戻してステントレトリバーデバイスをガイドカテーテルに引き込みます。</li>
	<li>シミュレートされた大腿部アクセスサイトから両方のステントレトリバーを取り外します(図1D)。</li>
	<li>遮蔽を除去するために注射器との対比を注入しながら、透視検査ペダル(図1H)を押し下げ、ガイドカテーテルを通して血管造影を行います。</li>
	<li>シミュレーションシースサイトからガイドカテーテルを取り外します(図1D)。大腿動脈開閉部位の模擬閉鎖は行われない。</li>
</ol>

<ol>
	<li>See, K. W., Chui, K. H., Chan, W. H., Wong, K. C., Chan, Y. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evidence+for+Endovascular+Simulation+Training:+A+Systematic+Review.">Evidence for Endovascular Simulation Training: A Systematic Review.</a> European Journal of Vascular and Endovascular Surgery. 51 (3), 441-451 (2016).</li><li>Pannell, J. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulator-Based+Angiography+and+Endovascular+Neurosurgery+Curriculum:+A+Longitudinal+Evaluation+of+Performance+Following+Simulator-Based+Angiography+Training.">Simulator-Based Angiography and Endovascular Neurosurgery Curriculum: A Longitudinal Evaluation of Performance Following Simulator-Based Angiography Training.</a> Cureus. 8 (8), 756 (2016).</li><li>Liebig, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Metric-Based+Virtual+Reality+Simulation:+A+Paradigm+Shift+in+Training+for+Mechanical+Thrombectomy+in+Acute+Stroke.">Metric-Based Virtual Reality Simulation: A Paradigm Shift in Training for Mechanical Thrombectomy in Acute Stroke.</a> Stroke. 49 (7), 239-242 (2018).</li><li>Spiotta, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+angiography+skill+acquisition+with+a+secondary+curve+catheter:+phase+2+of+a+curriculum-based+endovascular+simulation+program.">Diagnostic angiography skill acquisition with a secondary curve catheter: phase 2 of a curriculum-based endovascular simulation program.</a> Journal of Neurointerventional Surgery. 7 (10), 777-780 (2015).</li><li>Spiotta, A. M., Rasmussen, P. A., Masaryk, T. J., Benzel, E. C., Schlenk, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulated+diagnostic+cerebral+angiography+in+neurosurgical+training:+a+pilot+program.">Simulated diagnostic cerebral angiography in neurosurgical training: a pilot program.</a> Journal of Neurointerventional Surgery. 5 (4), 376-381 (2013).</li><li>Fargen, K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Experience+with+a+simulator-based+angiography+course+for+neurosurgical+residents:+beyond+a+pilot+program.">Experience with a simulator-based angiography course for neurosurgical residents: beyond a pilot program.</a> Neurosurgery. 73, 46-50 (2013).</li><li>Fargen, K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulator+based+angiography+education+in+neurosurgery:+results+of+a+pilot+educational+program.">Simulator based angiography education in neurosurgery: results of a pilot educational program.</a> Journal of Neurointerventional Surgery. 4 (6), 438-441 (2012).</li><li>Cates, C., L&#246;nn, L., Gallagher, A. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective,+randomised+and+blinded+comparison+of+proficiency-based+progression+full-physics+virtual+reality+simulator+training+versus+invasive+vascular+experience+for+learning+carotid+artery+angiography+by+very+experienced+operators.">Prospective, randomised and blinded comparison of proficiency-based progression full-physics virtual reality simulator training versus invasive vascular experience for learning carotid artery angiography by very experienced operators.</a> BMJ Simulation and Technology Enhanced Learning. 2, 1-5 (2016).</li><li>Guo, J., Jin, X., Guo, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Study+of+the+Operational+Safety+of+a+Vascular+Interventional+Surgical+Robotic+System.">Study of the Operational Safety of a Vascular Interventional Surgical Robotic System.</a> Micromachines. 9 (3), 119 (2018).</li><li>Tedesco, M. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+endovascular+skills+assessment:+the+future+of+credentialing.">Simulation-based endovascular skills assessment: the future of credentialing.</a> Journal of Vascular Surgery. 47 (5), 1008 (2008).</li></ol>

AAKは以前、株式会社コビディエンとペヌンブラ社から競争力のある助成金を受けており、ストライカー・ニューロピカル、Covidien Ltd.、ペヌンブラ社との医師研修のコンサルティング手配を行っており.JSPストライカー神経血管およびダーツニューロサイエンスLLCの医療コンサルタントを務めています。AAKとJSPは、この作業に関連する直接的な財政的利益を持っていません。残りの著者は、本研究で使用された材料や方法、または本論文で指定された知見に関する開示を行っていない。

血管内手術は、様々な病理への低侵襲治療アプローチを提供する拡大分野である。それにもかかわらず、血管損傷に関連する重大なリスクは、ユニークな教育上の課題を提供します。シミュレーションベースのトレーニングの進歩により、研修生の教育は現在、現実のケースを模倣するリスクのない環境での実践を可能にします。したがって、血管内シミュレーションベースのトレーニング?...

シミュレーションベースのトレーニングは、医療研修生のための確立された教育ツールであり、血管内脳神経外科などのリスクの高い分野で特に有益です。ANGIOメンターシミュレータ(シンビオニックス社、空港都市、イスラエル)やVIST-CおよびVIST G5シミュレータ(メンティスAB、ヨーテボリ、スウェーデン)など、カテーテルベースのシステムを利用した複数のバーチャルリアリティトレーニングデバイスが存在し、手続き適性1に関するトレーニングの有用性を示す重要なデータを持つ。シミュレータの有用性にもかかわらず、その使用のためのステップバイステップの手続き手順が欠けている。
提示されたANGIOメンターシミュレータの使用のための詳細なプロトコルは、診断脳血管造影、機械的血栓切除術、および動脈瘤コイル塞栓術を含む一般的な血管内脳神経外科処置における能力改善をサポートするシステムである2。以前の研究では、すべてのレベルの研修生がANGIOメンターシミュレータ上で5つのシミュレートされた血管造影、5つの血栓切除術、および10個の動脈瘤コイル塞栓術を行った後、手続き時間、蛍視および対照用量、および有害な技術的事象2に有意な改善を示した。
次のステップバイステップの手順は、ケースシナリオに分かれており、医学生、居住者、またはフェローのための学術トレーニングカリキュラムに簡単に統合することができます2.それにもかかわらず、シミュレーション装置の教育的可能性を最大限に活用するためには、大脳動脈解剖学、血管造影、脳卒中および動脈瘤治療の基礎的理解が必要であるという点に留意すべきである。
後述するすべての手順(すなわち、脳血管造影診断、頸動脈末動脈瘤のコイリング、機械的血栓切れ)は、ANGIOメンターシミュレータ(Simbionix Ltd)を使用して単一のオペレータによって行うことができる。(図1)。このトレーニング装置は、すべてのスキルレベルの神経外科研修生が前臨床設定で血管内技術への暴露を得ることを可能にし、シミュレータベースの血管造影トレーニング2のための以前に発表されたカリキュラムに基づいて利用される3つの患者シナリオを有する。高忠実度で血管内技術を再現するために、シミュレータは大腿動脈鞘の横隔膜に類似したポートを介して導入された実際のカテーテルおよびワイヤーを利用する。ワイヤとカテーテルは、モニターに表示される回転運動と並進運動の両方を記録する内部ローラーを使用します。デバイスの選択および患者のバイタルサインは、シミュレーターオペレータにも見える。

<table>
	<tbody>
		<tr>
			<td>ANGIO Mentor simulator</td>
			<td>Simbionix Ltd., Airport City, Israel</td>
			<td>N/a</td>
			<td>The setup for the ANGIO Mentor simulator includes the simulator housing as pictured in Figure 1: (A), an external monitor for image projection (x-ray, angiography; B), a laptop for interfacing with the Simbionix Software (C), the simulated femoral artery sheath (with an outer guide-catheter, inner diagnostic microcatheter and guidewire shown; D), a contrast syringe (E), an insufflator for balloon inflation (F), a stent delivery device (G; not used in these patient scenarios), foot pedals for fluoroscopy, roadmap guidance, and angiographic runs (H), and the operator control panel on the simulator housing where the operator is able to control patient and image intensifier positioning (I).</td>
		</tr>
	</tbody>
</table>

simulator training for endovascular neurosurgery

シミュレーションベースのトレーニングは、医療専門分野、特にリスクの高い環境で実行される複雑なスキルを学習する一般的な実践となっています。血管内脳神経外科の分野では、結果的およびリスクのない学習環境の需要が、医療研修生にとって価値のあるシミュレーション装置の開発につながった。このプロトコルの目的は、学術環境での血管内脳神経外科シミュレータの使用のための有益なガイドラインを提供することです.このシミュレーターは、解剖学に関する知識に関する現実的なフィードバックを受け取る機会と、カテーテルベースのシステムを否定的な結果なしに処理する成功を示す触覚フィードバックを受け取る機会を研修生に提供します。他の神経内血管内科のモダリティに関連してこの特定のプロトコルの有用性も議論される。

ANGIOメンターシミュレータは、従来、学術環境における模擬診断血管造影、血栓切除術、および破裂した動脈瘤コイル塞栓術を行う際に、様々な神経内血管経験を有する外科研修生のスキルを向上させることが示された2。本研究では、前述の処置のパフォーマンス指標が、1人の医学生、1人の脳神経外科居住者、2人の診断神経放射線学フェロー、および1人の血管内脳神経外...

Watch this Scientific Journal Video about Simulator Training for Endovascular Neurosurgery at JoVE.com

Simulator Training for Endovascular Neurosurgery

複雑でリスクの高い手順のシミュレーションは、医療研修生の教育にとって非常に重要です。制御された学術環境におけるシミュレータ系血管内脳神経外科トレーニングのためのプロトコルについて説明する。このプロトコルには、さまざまなレベルの研修生のための段階的なガイドラインが含まれており、このモデルの利点と限界について議論しています。

血管内脳神経外科シミュレータトレーニング

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk ...

simulator-training-for-endovascular-neurosurgery

Research

JoVE Journal

Neuroscience

3.5K ビュー.  University of California. 複雑でリスクの高い手順のシミュレーションは、医療研修生の教育にとって非常に重要です。制御された学術環境におけるシミュレータ系血管内脳神経外科トレーニングのためのプロトコルについて説明する。このプロトコルには、さまざまなレベルの研修生のための段階的なガイドラインが含まれており、このモデルの利点と限界について議論してい?...

ビデオ: Simulator Training for Endovascular Neurosurgery

Focal Cerebral Ischemia Model by Endovascular Suture Occlusion of the Middle Cerebral Artery in the Rat

Stroke is the leading cause of disability and the third leading cause of death in adults worldwide1. In human stroke, there exists a highly variable clinical state; in the development of animal models of focal ischemia, however, achieving reproducibility of experimentally induced infarct volume is essential. The rat is a widely used animal model for stroke due to its relatively low animal husbandry costs and to the similarity of its cranial circulation to that of humans2,3. In humans, the middle cerebral artery (MCA) is most commonly affected in stroke syndromes and multiple methods of MCA occlusion (MCAO) have been described to mimic this clinical syndrome in animal models. Because recanalization commonly occurs following an acute stroke in the human, reperfusion after a period of occlusion has been included in many of these models. In this video, we demonstrate the transient endovascular suture MCAO model in the spontaneously hypertensive rat (SHR). A filament with a silicon tip coating is placed intraluminally at the MCA origin for 60 minutes, followed by reperfusion. Note that the optimal occlusion period may vary in other rat strains, such as Wistar or Sprague-Dawley. Several behavioral indicators of stroke in the rat are shown. Focal ischemia is confirmed using T2-weighted magnetic resonance images and by staining brain sections with 2,3,5-triphenyltetrazolium chloride (TTC) 24 hours after MCAO.

Surgical induction of ischemic brain damage in the rat is a widely used model for stroke research. Here we demonstrate the induction of focal cerebral ischemia by occlusion of the middle cerebral artery. Visualization of the resulting infarct by histological staining and magnetic resonance imaging is also shown.

ラット中大脳動脈の血管縫合閉塞による局所脳虚血モデル

Stroke is the leading cause of disability and the third leading cause of death in adults worldwide1. In human stroke, there exists a highly variable ...

神経科学

MPI CyberMotion Simulator: Implementation of a Novel Motion Simulator to Investigate Multisensory Path Integration in Three Dimensions

Path integration is a process in which self-motion is integrated over time to obtain an estimate of one's current position relative to a starting point 1. Humans can do path integration based exclusively on visual 2-3, auditory 4, or inertial cues 5. However, with multiple cues present, inertial cues - particularly kinaesthetic - seem to dominate 6-7. In the absence of vision, humans tend to overestimate short distances (&lt;5 m) and turning angles (&lt;30&deg;), but underestimate longer ones 5. Movement through physical space therefore does not seem to be accurately represented by the brain.
Extensive work has been done on evaluating path integration in the horizontal plane, but little is known about vertical movement (see 3 for virtual movement from vision alone). One reason for this is that traditional motion simulators have a small range of motion restricted mainly to the horizontal plane. Here we take advantage of a motion simulator 8-9 with a large range of motion to assess whether path integration is similar between horizontal and vertical planes. The relative contributions of inertial and visual cues for path navigation were also assessed.
16 observers sat upright in a seat mounted to the flange of a modified KUKA anthropomorphic robot arm. Sensory information was manipulated by providing visual (optic flow, limited lifetime star field), vestibular-kinaesthetic (passive self motion with eyes closed), or visual and vestibular-kinaesthetic motion cues. Movement trajectories in the horizontal, sagittal and frontal planes consisted of two segment lengths (1st: 0.4 m, 2nd: 1 m; &plusmn;0.24 m/s2 peak acceleration). The angle of the two segments was either 45&deg; or 90&deg;. Observers pointed back to their origin by moving an arrow that was superimposed on an avatar presented on the screen.
Observers were more likely to underestimate angle size for movement in the horizontal plane compared to the vertical planes. In the frontal plane observers were more likely to overestimate angle size while there was no such bias in the sagittal plane. Finally, observers responded slower when answering based on vestibular-kinaesthetic information alone. Human path integration based on vestibular-kinaesthetic information alone thus takes longer than when visual information is present. That pointing is consistent with underestimating and overestimating the angle one has moved through in the horizontal and vertical planes respectively, suggests that the neural representation of self-motion through space is non-symmetrical which may relate to the fact that humans experience movement mostly within the horizontal plane.

An efficient way to gain insight into how humans navigate themselves in three dimensions is described. The method takes advantage of a motion simulator capable of moving observers in ways unattainable by traditional simulators. Results confirm that movement in the horizontal plane is underestimated, while vertical movement is overestimated.

MPI Cyber​​Motionシミュレータ：三次元的に多感覚パスの統合を調査するための新しいモーションシミュレータの実装

Path integration is a process in which self-motion is integrated over time to obtain an estimate of one's current position relative to a starting point 1. ...

Extinction Training During the Reconsolidation Window Prevents Recovery of Fear

Fear is maladaptive when it persists long after circumstances have become safe. It is therefore crucial to develop an approach that persistently prevents the return of fear. Pavlovian fear-conditioning paradigms are commonly employed to create a controlled, novel fear association in the laboratory. After pairing an innocuous stimulus (conditioned stimulus, CS) with an aversive outcome (unconditioned stimulus, US) we can elicit a fear response (conditioned response, or CR) by presenting just the stimulus alone1,2 . Once fear is acquired, it can be diminished using extinction training, whereby the conditioned stimulus is repeatedly presented without the aversive outcome until fear is no longer expressed3. This inhibitory learning creates a new, safe representation for the CS, which competes for expression with the original fear memory4. Although extinction is effective at inhibiting fear, it is not permanent. Fear can spontaneously recover with the passage of time. Exposure to stress or returning to the context of initial learning can also cause fear to resurface3,4.
Our protocol addresses the transient nature of extinction by targeting the reconsolidation window to modify emotional memory in a more permanent manner. Ample evidence suggests that reactivating a consolidated memory returns it to a labile state, during which the memory is again susceptible to interference5-9. This window of opportunity appears to open shortly after reactivation and close approximately 6hrs later5,11,16, although this may vary depending on the strength and age of the memory15. By allowing new information to incorporate into the original memory trace, this memory may be updated as it reconsolidates10,11. Studies involving non-human animals have successfully blocked the expression of fear memory by introducing pharmacological manipulations within the reconsolidation window, however, most agents used are either toxic to humans or show equivocal effects when used in human studies12-14. Our protocol addresses these challenges by offering an effective, yet non-invasive, behavioral manipulation that is safe for humans.
By prompting fear memory retrieval prior to extinction, we essentially trigger the reconsolidation process, allowing new safety information (i.e., extinction) to be incorporated while the fear memory is still susceptible to interference. A recent study employing this behavioral manipulation in rats has successfully blocked fear memory using these temporal parameters11. Additional studies in humans have demonstrated that introducing new information after the retrieval of previously consolidated motor16, episodic17, or declarative18 memories leads to interference with the original memory trace14. We outline below a novel protocol used to block fear recovery in humans.

Conditioned fear can be diminished through an inhibitory process called extinction, but can resurface under conditions such as the passage of time or exposure to stress. Our protocol presents a novel way of preventing fear recovery by introducing extinction during the reconsolidation window (the re-storage phase of a reactivated memory).

再固定ウィンドウの間に絶滅の訓練は恐怖の回復を防ぎ

Fear is maladaptive when it persists long after circumstances have become safe. It is therefore crucial to develop an approach that persistently prevents ...

Exposure of the Pig CNS for Histological Analysis: A Manual for Decapitation, Skull Opening, and Brain Removal

Pigs have become increasingly popular in large-animal translational neuroscience research as an economically and ethically feasible substitute to non-human primates. The large brain size of the pig allows the use of conventional clinical brain imagers and the direct use and testing of neurosurgical procedures and equipment from the human clinic. Further macroscopic and histological analysis, however, requires postmortem exposure of the pig central nervous system (CNS) and subsequent brain removal. This is not an easy task, as the pig CNS is encapsulated by a thick, bony skull and spinal column. The goal of this paper and instructional video is to describe how to expose and remove the postmortem pig brain and the pituitary gland in an intact state, suitable for subsequent macroscopic and histological analysis.

The goal of this paper and instructional video is to describe how to expose and remove the postmortem pig brain and pituitary gland in an intact state, suitable for subsequent macroscopic and histological analysis.

組織学的分析のための豚CNSの露出：斬首、スカルオープニングのためのマニュアル、および脳の取り外し

Pigs have become increasingly popular in large-animal translational neuroscience research as an economically and ethically feasible substitute to ...

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs must be tailored specifically to the lesion, with surgical resection being the gold standard for small, accessible lesions. Pre-operative embolization of AVMs can reduce nidal blood flow and remove high-risk AVM features such as intranidal or venous aneurysms, thereby simplifying a challenging neurosurgical procedure. Herein, we describe our approach for the staged endovascular embolization and open resection of AVMs, and highlight the advantages of having a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team. This includes planning the craniotomy and resection to immediately follow the final embolization stage, thereby using a single session of anesthesia for aggressive embolization, and rapid resection. Finally, we provide a representative case of a 22-year-old female with an unruptured right frontal AVM diagnosed during a seizure workup, who was successfully treated via staged embolizations followed by open surgical resection.

Surgery is the gold standard for accessible arteriovenious malformations (AVMs), and pre-operative embolization can simplify this procedure. We describe our approach for staged endovascular embolization and open resection of AVMs, and provide a representative clinical example highlighting the advantages of a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team.

包括的な血管内治療、脳動静脈奇形のオープン手術の管理

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs ...

A Protocol for the Administration of Real-Time fMRI Neurofeedback Training

Neurologic disorders are characterized by abnormal cellular-, molecular-, and circuit-level functions in the brain. New methods to induce and control neuroplastic processes and correct abnormal function, or even shift functions from damaged tissue to physiologically healthy brain regions, hold the potential to dramatically improve overall health. Of the current neuroplastic interventions in development, neurofeedback training (NFT) from functional Magnetic Resonance Imaging (fMRI) has the advantages of being completely non-invasive, non-pharmacologic, and spatially localized to target brain regions, as well as having no known side effects. Furthermore, NFT techniques, initially developed using fMRI, can often be translated to exercises that can be performed outside of the scanner without the aid of medical professionals or sophisticated medical equipment. In fMRI NFT, the fMRI signal is measured from specific regions of the brain, processed, and presented to the participant in real-time. Through training, self-directed mental processing techniques, that regulate this signal and its underlying neurophysiologic correlates, are developed. FMRI NFT has been used to train volitional control over a wide range of brain regions with implications for several different cognitive, behavioral, and motor systems. Additionally, fMRI NFT has shown promise in a broad range of applications such as the treatment of neurologic disorders and the augmentation of baseline human performance. In this article, we present an fMRI NFT protocol developed at our institution for modulation of both healthy and abnormal brain function, as well as examples of using the method to target both cognitive and auditory regions of the brain.

The ability to induce and/or control neural plasticity may be critical in future treatments for neurologic disorders and the recovery from brain injury. In this paper, we present a protocol on the use of neurofeedback training with functional magnetic resonance imaging to modulate human brain function.

管理のリアルタイム fMRI ニューロフィード バック トレーニングのプロトコル

Neurologic disorders are characterized by abnormal cellular-, molecular-, and circuit-level functions in the brain. New methods to induce and control ...

Fiber Connections of the Supplementary Motor Area Revisited: Methodology of Fiber Dissection, DTI, and Three Dimensional Documentation

The purpose of this study is to show the methodology for the examination of the white matter connections of the supplementary motor area (SMA) complex (pre-SMA and SMA proper) using a combination of fiber dissection techniques on cadaveric specimens and magnetic resonance (MR) tractography. The protocol will also describe the procedure for a white matter dissection of a human brain, diffusion tensor tractography imaging, and three-dimensional documentation. The fiber dissections on human brains and the 3D documentation were performed at the University of Minnesota, Microsurgery and Neuroanatomy Laboratory, Department of Neurosurgery. Five postmortem human brain specimens and two whole heads were prepared in accordance with Klingler's method. Brain hemispheres were dissected step by step from lateral to medial and medial to lateral under an operating microscope, and 3D images were captured at every stage. All dissection results were supported by diffusion tensor imaging. Investigations on the connections in line with Meynert's fiber tract classification, including association fibers (short, superior longitudinal fasciculus I and frontal aslant tracts), projection fibers (corticospinal, claustrocortical, cingulum, and frontostriatal tracts), and commissural fibers (callosal fibers) were also conducted.

The purpose of this study is to show each step of the fiber dissection technique on human cadaveric brains, the 3D documentation of these dissections, and the diffusion tensor imaging of the anatomically dissected fiber pathways.

再考された補助的なモータ領域のファイバ接続：ファイバ解剖、DTI、および3次元文書の方法論

The purpose of this study is to show the methodology for the examination of the white matter connections of the supplementary motor area (SMA) complex ...

Optimized Management of Endovascular Treatment for Acute Ischemic Stroke

This manuscript describes a streamlined protocol for the management of patients with acute ischemic stroke, which aims at the minimization of time from hospital admission to reperfusion. Rapid restoration of cerebral blood flow is essential for the outcomes of patients with acute ischemic stroke. Endovascular treatment (EVT) has become the standard of care to accomplish this in patients with acute stroke due to large vessel occlusion (LVO). To achieve reperfusion of ischemic brain regions as fast as possible, all in-hospital time delays have to be carefully avoided. Therefore, management of patients with acute ischemic stroke was optimized with an interdisciplinary standard operating procedure (SOP). Stroke neurologists, diagnostic as well as interventional neuroradiologists, and anesthesiologists streamlined all necessary processes from patient admission and diagnosis to EVT of eligible patients. Target times for every step were established. Actually achieved times were prospectively recorded along with clinical data and imaging scores for all endovascularly treated stroke patients. These data were regularly analyzed and discussed in interdisciplinary team meetings. Potential issues were evaluated and all staff involved was trained to adhere to the SOP. This streamlined patient management approach and enhanced interdisciplinary collaboration reduced time from patient admission to reperfusion significantly and was accompanied by a beneficial effect on clinical outcomes.

The outcome of patients with acute ischemic stroke depends on swift restoration of cerebral blood flow. This protocol aims at optimizing the management of such patients by minimizing peri-procedural timings and rendering the time from hospital admission to reperfusion as short as possible.

急性期脳梗塞に対する血管内治療の最適化された管理

This manuscript describes a streamlined protocol for the management of patients with acute ischemic stroke, which aims at the minimization of time from ...

Real-Time fMRI Brain Mapping in Animals

Dynamic fMRI responses vary largely according to the physiological conditions of animals either under anesthesia or in awake states. We developed a real-time fMRI platform to guide experimenters to monitor fMRI responses instantaneously during acquisition, which can be used to modify the physiology of animals to achieve desired hemodynamic responses in animal brains. The real-time fMRI set-up is based on a 14.1T preclinical MRI system, enabling the real-time mapping of dynamic fMRI responses in the primary forepaw somatosensory cortex (FP-S1) of anesthetized rats. Instead of a retrospective analysis to investigate confounding sources leading to the variability of fMRI signals, the real-time fMRI platform provides a more effective scheme to identify dynamic fMRI responses using customized macro-functions and a common neuroimage analysis software in the MRI system. Also, it provides immediate troubleshooting feasibility and a real-time biofeedback stimulation paradigm for brain functional studies in animals.

Animal brain functional mapping can benefit from the real-time functional magnetic resonance imaging (fMRI) experimental set-up. Using the latest software implemented in the animal MRI system, we established a real-time monitoring platform for small animal fMRI.

動物におけるリアルタイムfMRI脳マッピング

Dynamic fMRI responses vary largely according to the physiological conditions of animals either under anesthesia or in awake states. We developed a ...

Endovascular Perforation Model for Subarachnoid Hemorrhage Combined with Magnetic Resonance Imaging (MRI)

The endovascular filament perforation model to mimic subarachnoid hemorrhage (SAH) is a commonly used model - however, the technique can cause a high mortality rate as well as an uncontrollable volume of SAH and other intracranial complications such as stroke or intracranial hemorrhage. In this protocol, a standardized SAH mouse model is presented, induced by endovascular filament perforation, combined with magnetic resonance imaging (MRI) 24 h after operation to ensure the correct bleeding site and exclude other relevant intracranial pathologies. Briefly, C57BL/6J mice are anesthetized with an intraperitoneal ketamine/xylazine (70 mg/16 mg/kg body weight) injection and placed in a supine position. After midline neck incision, the common carotid artery (CCA) and carotid bifurcation are exposed, and a 5-0 non-absorbable monofilament polypropylene suture is inserted in a retrograde fashion into the external carotid artery (ECA) and advanced into the common carotid artery. Then, the filament is invaginated into the internal carotid artery (ICA) and pushed forward to perforate the anterior cerebral artery (ACA). After recovery from surgery, mice undergo a 7.0 T MRI 24 h later. The volume of bleeding can be quantified and graded via postoperative MRI, enabling a robust experimental SAH group with the option to perform further subgroup analyses based on blood quantity.

Endovascular Perforation Model for Subarachnoid Hemorrhage Combined with Magnetic Resonance Imaging MRI

Here we present a standardized SAH mouse model, induced by endovascular filament perforation, combined with magnetic resonance imaging (MRI) 24 h after operation to ensure the correct bleeding site and exclude other relevant intracranial pathologies.

くも膜下出血の血管内穿孔モデルと磁気共鳴画像法(MRI)の組み合わせ

The endovascular filament perforation model to mimic subarachnoid hemorrhage (SAH) is a commonly used model - however, the technique can cause a high ...