Name: simulator training for endovascular neurosurgery
Uploaded: 2020-05-06T12:30:00.000+00:00
Duration: 8 min 8 s
Description: Watch this Scientific Journal Video about Simulator Training for Endovascular Neurosurgery at JoVE.com

저자는 UCSD에 신경 혈관 환자의 배려에 매일 기여하는 모든 임상 팀에게 감사드립니다.

1. 시뮬레이터 설정
<ol><li>모든 절차에 앞서 그림 1에 표시된 대로 시뮬레이터를 어셈블하고 켭니다. 각 시뮬레이션을 완료하는 데 필요한 시뮬레이터 장비의 전체 목록은 표 1을 참조하십시오.</li>
	<li>연결된 랩톱(그림1C)에서소프트웨어 인터페이스를 사용하여 환자 시나리오를 선택합니다.</li>
	<li>드롭다운 메뉴에서 적절한 동맥 칼집 또는 가이드 카테터를 선택합니다. 이것은 시뮬레이션의 일부로 물리적으로 삽입 할 필요가 없지만 대퇴 액세스 사이트역할을하고 시스템에 와이어 및 카테터의 후속 입력을 허용합니다(그림 1D). 각 시나리오에 대한 특정 칼집/가이드 크기는 아래에 설명되어 있습니다.</li>
	<li>아래에 설명한 특정 시나리오에 따라 적절한 카테터, 가이드와이어 및/또는 마이크로시스템을 선택합니다(그림1D).</li>
	<li>소프트웨어 인터페이스에서 A(PA) 및 B 평면(측면) 형광법을 켭니다. 발페달(도 1H)으로불소 검사를 활성화하고 올바른 PA 및 측면 뷰가 얻어질 때까지 조이스틱(도1I)으로환자 및 이미지 강화 자세를 조정한다.</li>
</ol>2. 첫 번째 환자 시나리오 : 4 혈관 혈관 조영술
참고: 이 시나리오는 머리의 비 대비 계산 단층 촬영 (CT) 스캔에 부수적으로 발견 파열 왼쪽 경동맥류 동맥류를 가진 52 세의 남성을 묘사합니다.
<ol><li>이 시뮬레이션에서 사용할 도구로 드롭다운 메뉴에서 5-프랑스 대퇴 칼집, 가이드와이어0.035, 드롭다운 메뉴에서 4-French 진단 카테터를 선택합니다.</li>
	<li>가이드와이어를 시뮬레이션 화면에 등록할 때까지 시뮬레이터기기(그림 1D)에삽입하여 액세스가 확보되었음을 나타냅니다. 내림차순 흉부 대동맥에 시각화될 때까지 가이드와이어를 진행하고 대동맥 아치로 계속 넣습니다.</li>
	<li>가이드와이어가 대동맥 아치에 안전하게 들어오면 가이드와이어를 제자리에 고정하고 시뮬레이션된 대퇴엽 덮개를 통해 가이드와이어 위에 진단 카테터를 삽입하여 대동맥 아치에 삽입합니다.</li>
	<li>가이드와이어를 제거하고 콘트라스트 주사기(도1E)를부드럽게 눌러 형광체 퍼프 기술을 활용하여 콘트라스트 주입을 시뮬레이션하고 카테터가 원하는 동맥으로 진행됨에 따라 혈관을 잠깐 비하한다.</li>
	<li>다음으로, 형광발 페달이 우울해하는 동안 대비주사기(도1E)와대조를 주입하는 로드맵 가이드를만듭니다(도 1H). 다음으로, 와이어를 다시 삽입하여 원하는 선박을 선택적으로 카테터화하여 와이어 위로 카테터를 전진시다. 후속 혈관 조영술 실행에 대한 와이어를 제거합니다. 오른쪽 및 왼쪽 내부 및 외부 경동맥과 오른쪽 및 왼쪽 척추 동맥은 모두이 기술을 사용하여 카테터화됩니다.</li>
	<li>진단 카테터 및 시뮬레이터 대비 주사기(도1E)를사용하여 주사기와 대비를 주입하면서 형광법페달(도 1H)을우울하게 하여 위의 각 순환의 혈관그램을 수행한다. 필요한 경우 동맥류의 높은 배율 보기를 얻을 수 있습니다. 카테터를 제거하기 전에 적정성에 대한 혈관 사진을 검토하십시오.</li>
	<li>필요한 이미지를 가져오면 시뮬레이션 칼집에서 진단 카테터/가이드와이어를 제거합니다. 대퇴동맥 절제술 부위의 시뮬레이션 폐쇄는 수행되지 않습니다.</li>
</ol>3. 두 번째 환자 시나리오: 경동맥류 코일링
참고: 이 시나리오는 알려진 파열 된 왼쪽 경동맥류, 심한 두통, 비초점 시험 및 글래스고 코마 스케일 점수 15로 알려진 52 세의 남성을 묘사합니다.
<ol><li>드롭다운 메뉴에서 6-French 가이드 카테터, 가이드와이어0.035, 프랑스식 진단 카테터를 선택합니다.</li>
	<li>2.2-2.3 단계와 같이 대동맥 아치에 가이드와이어 위에 진단 카테터를 삽입합니다.</li>
	<li>대퇴액세스사이트(도 1D)를통해 진단 카테터 위에 가이드 카테터를 대동맥 아치에 삽입한다.</li>
	<li>가이드와이어를 제거하고 로드맵에 의한 왼쪽 일반 경동맥의 로드맵 가이드를 생성하여, 형광발페달(도1H)이우울해하는 동안 대비를 이루는 좌측 일반 경동맥을 생성한다.1E).</li>
	<li>가이드와이어를 다시 삽입하고 왼쪽 공통 경동맥 및 내부 경동맥을 형광시경과 이미지 프로젝션모니터(도 1B)에시각화한 로드맵 오버레이를 사용하여 가이드와이어로 선도하고 진단 카테터및 가이드 카테터를 안전하게 접근할 수 있게 되면 선택적으로 카테터를 증식한다.</li>
	<li>가이드 카테터가 내부 경동맥 내에 있을 때, 진단 카테터및 와이어를 제거하고 주사기와 대조를 이루는 동안 형광법페달(도 1H)을우울하게 하여 좌측 내부 경동맥 순환의 혈관 질 적 실행을 수행한다(도 1E).</li>
	<li>소프트웨어인터페이스(그림 1C)에서계산 옵션을 사용하여 동맥류를 측정합니다. 첫 번째 코일의 코일 직경은 평균 동맥류 직경보다 1mm 넓어야 하며 적절한 코일을 선택합니다.</li>
	<li>드롭다운 메뉴에서 마이크로카테터와 마이크로와이어를 선택합니다.</li>
	<li>대퇴액세스사이트(도1D)를통해 마이크로카테터및 마이크로와이어를 삽입하고, 3.6단계에서와 같이 얻어진 로드맵 지침에 따라, 마이크로시스템으로 동맥류를 선택적으로 카테터화한다.</li>
	<li>마이크로와이어를 제거하고, 대퇴액세스사이트(도 1D)를통해 이전에 선택된 코일을 삽입하고 동맥류로 천천히 전진한다.</li>
	<li>코일이 완전히 삽입되면, 주사기와 대조를 주입하고 부모 동맥 및 동맥류 충전의 가래를 평가하면서 불소 검사 페달(도 1H)을우울시켜 진단 뇌 혈관 검사를 수행합니다. 목표는 부모 동맥의 가래성을 유지하고 동맥류를 완전히 색전시키거나 돔또는 파열 지점의 충분한 커버리지를 제공하여 파열 위험을 적절하게 줄이는 것입니다.</li>
	<li>소프트웨어인터페이스(도 1C)에서코일을 분리하고 코일 와이어를 제거합니다. 필요한 경우, ~30% 동맥류 폐색이 얻어지날 때까지 추가 코일을 가진 3.11 및 3.12 단계를 반복한다.</li>
	<li>시뮬레이션 칼집부위(도 1D)에서마이크로카테터를 제거하고 카테터를 안내합니다. 대퇴동맥 절제술 부위의 시뮬레이션 폐쇄는 수행되지 않습니다.</li>
</ol>4. 세 번째 환자 시나리오: 왼쪽 중뇌 동맥 혈전 절제술
참고: 이 시나리오는 건강 치기 규모의 국가 학회 (NIHSS) 점수의 64 세 여성을 묘사 12 실어 및 마지막으로 정상으로 알려진 오른쪽 약점에 대한 4 시간 이전. 헤드 CT는 10의 과밀 좌측 중형 동맥 (MCA) 기호및 알버타 스트로크 프로그램 초기 CT 점수 (ASPECTS)를 공개했지만 출혈은 없었습니다. CT 혈관전증은 왼쪽 M1 세그먼트의 완전한 폐색을 보여 주었다.
<ol><li>드롭다운 메뉴에서 6-French 가이드 카테터, 가이드와이어0.035, 프랑스식 진단 카테터를 선택합니다.</li>
	<li>가이드 카테터를 왼쪽 내부 경동맥에 삽입하고 3.2-3.6 단계에서 설명된 바와 같이 왼쪽 내부 경동맥 순환의 혈관 전도 실행을 수행한다.</li>
	<li>드롭다운 메뉴에서 마이크로카테터/마이크로와이어 및 스텐트 리트리버 장치를 선택합니다.</li>
	<li>마이크로카테터와 마이크로와이어를 시뮬레이션된 대퇴액세스사이트(도 1D)에삽입하고 왼쪽 내부 경동맥에 삽입한다.</li>
	<li>3.5단계에서와 같이 얻은 로드맵 지침에 따라 마이크로와이어와 마이크로카테터를 왼쪽 MCA로 전진시키고 폐색 영역을 조심스럽게 지나갑니다. 이 기동 하는 동안 잠재적인 합병증 혈관 천공 및/또는 혈전 하류를 색전 포함.</li>
	<li>마이크로와이어를 제거하고 스텐트 리트리버 장치를 시뮬레이션된 대퇴액세스사이트(도 1D)에삽입하고 MCA 단열으로 진출하여 폐색으로 진행한다. 그런 다음 마이크로 카테터를 제거하고 스텐트 리트리버를 폐색 의 수준에서 제자리에 둡깁니다.</li>
	<li>소프트웨어인터페이스(그림 1C)에서시뮬레이션된 포부를 켜고 스텐트 리트리버 장치를 마이크로와이어로 다시 당겨 가이드 카테터로 철회합니다.</li>
	<li>시뮬레이션된 대퇴 액세스 사이트에서 스텐트 리트리버를 모두 제거합니다(그림1D).</li>
	<li>교부형 의 제거를 보장하기 위해 주사기와 대조를 주입하면서 형광법 페달(도 1H)을우울시켜 가이드 카테터를 통해 혈관 그램을 수행합니다.</li>
	<li>시뮬레이션 칼집 사이트에서 가이드 카테터를제거합니다(그림 1D). 대퇴동맥 절제술 부위의 시뮬레이션 폐쇄는 수행되지 않습니다.</li>
</ol>

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	<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>

AAK는 이전에 Covidien Ltd.와 Penumbra Inc.로부터 경쟁력있는 보조금을 받았으며 스트라이커 신경 혈관, Covidien Ltd., Penumbra Inc..JSP 및 Stryker Neurovascular 및 다트 NeuroScience LLC의 의료 컨설턴트로 봉사했습니다. AAK와 JSP는 이 작업과 관련된 직접적인 재정적 이해관계가 없습니다. 나머지 저자는 이 연구 결과에 사용된 자료 또는 방법 또는 이 논문에 명시된 사실 인정에 관하여 아무 공개도 없습니다.

혈관 내 수술은 다양한 병리학에 대한 최소 침습 적 치료 접근법을 제공하는 확장 분야입니다. 그럼에도 불구하고 혈관 부상과 관련된 중요한 위험은 독특한 교육 적 과제를 제공합니다. 시뮬레이션 기반 교육의 발전으로 연수생 교육은 이제 실제 사례를 모방하는 위험없는 환경에서 연습 할 수 있습니다. 이에 따라, 혈관 내 시뮬레이션 기반 교육은 광범위한 참가자(예를 들어, 환자, 의대생, 주?...

시뮬레이션 기반 교육은 의료 연수생을위한 확립 된 교육 도구이며 혈관 내 신경 외과와 같은 고위험 분야에서 특히 유용합니다. ANGIO 멘토 시뮬레이터(심비오닉스, 공항 시티, 이스라엘) 및 VIST-C 및 VIST-G5 시뮬레이터(멘티스 AB, 예테보리, 스웨덴)와 같은 카테터 기반 시스템을 활용한 여러 가상 현실 교육 장치가 존재하며, 절차적 적성1에대한 교육의 유용성을 입증하는 중요한 데이터 바디가 있습니다. 시뮬레이터의 유용성에도 불구하고, 그들의 사용에 대한 단계별 절차 지침이 부족합니다.
발표된 ANGIO 멘토 시뮬레이터의 사용을 위한 상세한 프로토콜, 진단 뇌 혈관 조뇌, 기계 혈전 절제술 및 동맥류 코일 색전제2를포함한 일반적인 혈관 내 신경 외과 절차의 역량 향상을 지원하는 시스템이다. 선행 작업에서 모든 수준의 연수생이 ANGIO 멘토 시뮬레이터에서 5개의 시뮬레이션 된 혈관 사진, 5 혈전 및 10 개의 동맥류 코일 색전을 수행 한 후 절차 시간, 불소 검사 및 대비 용량 및 불리한 기술 이벤트2에서상당한 개선을 보였다고 보여줍니다.
다음 단계별 지침은 사례 시나리오로 나뉘며 의대생, 주민 또는 동료를 위한 학술 교육 커리큘럼에 쉽게 통합될 수 있다2. 그럼에도 불구하고 시뮬레이션 장치의 교육 잠재력을 최적화하기 위해서는 뇌동맥 해부학, 혈관 조영술 및 뇌졸중 및 동맥류 치료에 대한 기본적인 이해가 필요하다는 점에 유의해야 합니다.
아래에 설명된 모든 절차(즉, 진단 뇌 혈관사진, 경동맥류, 기계적 혈전 절제술의 코일)은 ANGIO 멘토 시뮬레이터(Simbionix Ltd.)를 사용하여 단일 작업자에 의해 수행될 수 있습니다. (그림1). 이 훈련 장치는 시뮬레이터 기반 혈관 조영술 교육2에대한 이전에 발표 된 커리큘럼을 기반으로 활용 된 세 가지 환자 시나리오와 함께 모든 기술 수준의 신경 외과 연수생이 전임상 환경에서 혈관 내 기술에 노출 될 수 있습니다. 높은 충실도와 혈관 내 기술을 재현하기 위해 시뮬레이터는 대퇴 동맥 칼집의 다이어프램과 유사한 포트를 통해 도입 된 실제 카테터와 와이어를 활용합니다. 와이어와 카테터는 모니터에 표시되는 회전 및 번역 동작을 모두 기록하는 내부 롤러를 참여시습니다. 장치 선택 및 환자 활력 징후도 시뮬레이터 운영자에게 표시됩니다.

<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

시뮬레이션 기반 교육은 특히 고위험 환경에서 수행되는 복잡한 기술을 배우기 위해 의료 전문 분야 전반에 걸쳐 일반적인 관행이 되었습니다. 혈관 내 신경 외과 분야에서 결과 및 위험없는 학습 환경에 대한 수요는 의료 연수생에게 가치있는 시뮬레이션 장치의 개발로 이어졌습니다. 이 프로토콜의 목표는 학문적 환경에서 혈관 내 신경 외과 시뮬레이터의 사용에 대한 유익한 지침을 제공하는 것입니다. 시뮬레이터는 연수생에게 해부학에 대한 지식에 대한 현실적인 피드백을 받을 수 있는 기회와 부정적인 결과 없이 카테터 기반 시스템을 처리하는 데 성공한 것을 나타내는 햅틱 피드백을 제공합니다. 다른 신경 혈관 훈련 양식과 관련하여이 특정 프로토콜의 유틸리티도 논의된다.

ANGIO 멘토 시뮬레이터는 이전에 학술 설정2에서시뮬레이션 진단 혈관 사진, 혈전 절제술 및 파열 동맥류 코일 색전을 수행 할 때 다양한 신경 혈관 증 경험과 외과 연수생의 능력을 향상시키는 것으로 나타났다. 이 연구에서는, 앞서 언급한 절차에 대한 성능 메트릭은 한 의대생, 1명의 신경외과 거주자, 2명의 진단 신경방사선학 동료 및 1명의 외반증 신경외과 동료에서 30일 동안 ...

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

Simulator Training for Endovascular Neurosurgery

복잡하고 고위험 절차의 시뮬레이션은 의료 연수생의 교육에 매우 중요합니다. 통제된 학문적 환경에서 시뮬레이터 기지를 둔 혈관 내 신경 외과 훈련을 위한 프로토콜이 기술됩니다. 이 프로토콜에는 다양한 수준의 연수생을 위한 단계별 지침이 포함되어 있으며 이 모델의 장점과 한계에 대한 토론이 포함되어 있습니다.

혈관 내 신경 외과 시뮬레이터 교육

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 조회수.  University of California. 복잡하고 고위험 절차의 시뮬레이션은 의료 연수생의 교육에 매우 중요합니다. 통제된 학문적 환경에서 시뮬레이터 기지를 둔 혈관 내 신경 외과 훈련을 위한 프로토콜이 기술됩니다. 이 프로토콜에는 다양한 수준의 연수생을 위한 단계별 지침이 포함되어 있으며 이 모델의 장점과 한계에 대한 토론이 포함되어 있습니다.

비디오: Simulator Training for Endovascular Neurosurgery

Targeting Neuronal Fiber Tracts for Deep Brain Stimulation Therapy Using Interactive, Patient-Specific Models

Deep brain stimulation (DBS), which involves insertion of an electrode to deliver stimulation to a localized brain region, is an established therapy for movement disorders and is being applied to a growing number of disorders. Computational modeling has been successfully used to predict the clinical effects of DBS; however, there is a need for novel modeling techniques to keep pace with the growing complexity of DBS devices. These models also need to generate predictions quickly and accurately. The goal of this project is to develop an image processing pipeline to incorporate structural magnetic resonance imaging (MRI) and diffusion weighted imaging (DWI) into an interactive, patient specific model to simulate the effects of DBS. A virtual DBS lead can be placed inside of the patient model, along with active contacts and stimulation settings, where changes in lead position or orientation generate a new finite element mesh and solution of the bioelectric field problem in near real-time, a timespan of approximately 10 seconds. This system also enables the simulation of multiple leads in close proximity to allow for current steering by varying anodes and cathodes on different leads. The techniques presented in this paper reduce the burden of generating and using computational models while providing meaningful feedback about the effects of electrode position, electrode design, and stimulation configurations to researchers or clinicians who may not be modeling experts.

The goal of this project is to develop an interactive, patient-specific modeling pipeline to simulate the effects of deep brain stimulation in near real-time and provide meaningful feedback as to how these devices influence neural activity in the brain.

대화형, 환자 전용 모델을 사용 하 여 깊은 두뇌 자극 치료를 위한 신경 섬유 책자를 대상으로

Deep brain stimulation (DBS), which involves insertion of an electrode to deliver stimulation to a localized brain region, is an established therapy for ...

연구

생체공학

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can be&#160;achieved by either&#160;thrombolysis with recombinant tissue-plasminogen activator (rt-PA), the standard therapy for stroke patients who present within the first hours of symptom onset without contraindications, or by an endovascular approach, if a proximal brain vessel occlusion is detected. As the efficacy of both therapies declines over time, every minute saved along the way will improve the patient&#39;s outcome.
This critical situation requires thorough work and precise communication with the patient, the family and colleagues from different professions to acquire all relevant information and reach the right decision while carefully monitoring the patient. This is a high fidelity situation. In nonmedical high-fidelity environments such as aviation, Crew Resource Management (CRM) is used to enhance safety and team efficiency.
This guide shows how a Stroke Team algorithm, which is transferable to other hospital settings, was established and how regular simulation-based trainings were performed. It requires determination and endurance to maintain these time-consuming simulation trainings on a regular basis over the course of time. However, the resulting improvement of team spirit and excellent door-to-needle times will benefit both the patients and the work environment in any hospital.
A dedicated Stroke Team of 7 persons who are notified 24/7 by a collective call via speed dial and run a binding algorithm that takes approximately 20 min, was established. To train everybody involved in this algorithm, a simulation-based team training for all new Stroke Team members was conceived and conducted at monthly intervals. This led to a relevant and sustained reduction of the mean door-to-needle time to 25 min, and enhanced the feeling of stroke readiness especially in junior doctors and nurses.

Every min counts in acute stroke care. This guide shows how to establish a Stroke Team algorithm and enhance its performance with regular simulation training. The principles of Crew Resource Management (CRM) facilitate a straight workflow, reduce door-to-needle times and increase staff satisfaction.

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can ...

의학

Establishing a Multidisciplinary Cavernous Carotid Injury Simulation to Train Neurosurgical, Otolaryngology, and Anesthesia Residents

Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for technique and algorithm development in resident learners. This study develops a realistic cadaveric model for the training of crisis resource management in the setting of cavernous carotid artery injury. An expanded endonasal approach and right cavernous carotid injury is performed on a cadaveric head. The cadaver&#39;s right common carotid artery is cannulated and connected to a perfusion pump delivering pressurized simulated blood. A simulation mannequin is incorporated into the model to allow for vital sign feedback. Surgical and anesthesia resident learners are tasked with obtaining vascular control with a muscle patch technique and medical management over the course of 3 clinical scenarios with increasing complexity. Crisis management instructions for an endoscopic endonasal approach to the cavernous carotid artery and blood pressure control were provided to the learners prior to beginning the simulation. An independent reviewer evaluated the learners on communication skills, crisis management algorithms, and implementation of appropriate skill sets. After each scenario, residents were debriefed on how to improve technique based on evaluation scores in areas of situational awareness, decision-making, communications and teamwork, and leadership. After the simulation, learners provided feedback on the simulation and this data was used to improve future simulations. The benefit of this cadaveric model is ease of set-up, cost-effectiveness, and reproducibility.

This protocol establishes a multidisciplinary model to train learners on management of cavernous carotid artery injury. Cadaveric heads undergo expanded endonasal approach and injury to the cavernous carotid artery, and perfusion pump simulates blood flow to the injury point. Learners are tasked with medical and surgical management over 3 scenarios.

Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for ...

Surgical Training for the Implantation of Neocortical Microelectrode Arrays Using a Formaldehyde-fixed Human Cadaver Model

This protocol describes a procedure to assist surgeons in training for the implantation of microelectrode arrays into the neocortex of the human brain. Recent technological progress has enabled the fabrication of microelectrode arrays that allow recording the activity of multiple individual neurons in the neocortex of the human brain. These arrays have the potential to bring unique insight onto the neuronal correlates of cerebral function in health and disease. Furthermore, the identification and decoding of volitional neuronal activity opens the possibility to establish brain-computer interfaces, and thus might help restore lost neurological functions. The implantation of neocortical microelectrode arrays is an invasive procedure requiring a supra-centimetric craniotomy and the exposure of the cortical surface; thus, the procedure must be performed by an adequately trained neurosurgeon. In order to provide an opportunity for surgical training, we designed a procedure based on a human cadaver model. The use of a formaldehyde-fixed human cadaver bypasses the practical, ethical and financial difficulties of surgical practice on animals (especially non-human primates) while preserving the macroscopic structure of the head, skull, meninges and cerebral surface and allowing realistic, operating room-like positioning and instrumentation. Furthermore, the use of a human cadaver is closer to clinical daily practice than any non-human model. The major drawbacks of the cadaveric simulation are the absence of cerebral pulsation and of blood and cerebrospinal fluid circulation. We suggest that a formaldehyde-fixed human cadaver model is an adequate, practical and cost-effective approach to ensure proper surgical training before implanting microelectrode arrays in the living human neocortex.

We designed a procedure in which a formaldehyde-fixed human cadaver is used to assist neurosurgeons in training for the implantation of microelectrode arrays into the neocortex of the human brain.

외과 훈련 Neocortical Microelectrode 배열 포름알데히드 고정 인간 수 색 모델을 사용 하 여 이식에 대 한

This protocol describes a procedure to assist surgeons in training for the implantation of microelectrode arrays into the neocortex of the human brain. ...

Development of a Cadaveric Multiport Model of Posterior Circulation Aneurysm Clipping for Neurosurgery and Otolaryngology Residents

Posterior circulation aneurysms are difficult to treat with the current methods of coiling and clipping. To address limitations in training, we developed a cadaveric model to train learners on endoscopic clipping of posterior circulation aneurysms. An endoscopic transclival approach (ETA) and a transorbital precaruncular approach (TOPA) to successfully access and clip aneurysms of the posterior circulation are described. The model has flexibility in that a colored silicone compound can be injected into the cadaveric vessels for the purpose of training learners on vascular anatomy. The other option is that the model could be connected to a vascular perfusion pump allowing real-time appreciation of a pulsatile or ruptured aneurysm. This cadaveric model is the first of its kind for training of endoscopic clipping of posterior circulation aneurysms. Learners will develop proficiency in endoscopic skills, appropriate dissection, and appreciation for relative anatomy while developing an algorithm that can be employed in a real operative arena. Going forward, various clinical scenarios can be developed to enhance the realism, allow learners from different specialties to work together, and emphasize the importance of teamwork and effective communication.

A model protocol to train neurosurgery and otolaryngology resident learners on endoscopic transclival clipping of posterior circulation aneurysms is described. Two endoscopic approaches to access the silicone-injected or perfused posterior circulation of cadaveric heads are established for training. Learners are tasked with clipping of posterior circulation based on clinical scenarios.

Posterior circulation aneurysms are difficult to treat with the current methods of coiling and clipping. To address limitations in training, we developed ...

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

로봇 수술에 긴급 도킹 해제: 시뮬레이션 커리큘럼

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

Role of Diffusion MRI Tractography in Endoscopic Endonasal Skull Base Surgery

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of benign and malignant lesions through a natural anatomical extra-cranial pathway, represented by the nasal cavities, avoiding brain retraction and neurovascular manipulation. This is reflected by the patients' prompt clinical recovery and the low risk of permanent neurological sequelae, representing the main caveat of conventional skull base surgery. This surgery must be tailored to each specific case, considering its features and relationship with surrounding neural structures, mostly based on preoperative neuroimaging. Advanced MRI techniques, such as tractography, have been rarely adopted in skull base surgery due to technical issues: lengthy and complicated processes to generate reliable reconstructions for inclusion in the neuronavigation system. 
This paper aims to present the protocol implemented in the institution and highlights the synergistic collaboration and teamwork between neurosurgeons and the neuroimaging team (neurologists, neuroradiologists, neuropsychologists, physicists, and bioengineers) with the final goal of selecting the optimal treatment for each patient, improving the surgical results and pursuing the advancement of personalized medicine in this field.

We present a protocol to integrate diffusion MRI tractography in patient work-up to endoscopic endonasal surgery for a skull base tumor. The methods for adopting these neuroimaging studies in the pre- and intra-operative phases are described.

내시경 성 상반신 두개골 기본 수술에서 확산 MRI 기관도법의 역할

Endoscopic endonasal surgery has gained a prominent role in the management of complex skull base tumors. It allows the resection of a large group of ...

신경과학

A Training and Testing System for Performing Vascular Reconstruction In Vitro

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has yet to be developed. In this study, we introduce an in vitro training and testing system using a magnetic anchoring technique with which a trainee can practice manual vascular reconstruction individually. Additionally, this system can also be used to test the quality of the reconstruction. The described system includes a vascular reconstruction training machine, magnetic tractors, and a magnetic suture puller. In this manuscript, we detail an end-to-end vein anastomosis using porcine right and left iliac veins. To identify the potential damage caused by a magnetic suture puller on the suture, we created three groups with six segments of 4-0 polypropylene sutures each: a control group with no intervention on the polypropylene suture, a group in which the polypropylene suture is manually pulled with sterile gloves 20x, and a magnetic puller group in which the magnetic puller pulled the polypropylene suture 20x. These groups were tested by light microscopy and breaking strength tests, and the effect of reconstruction was assessed. In the light microscopy test, the control group was less likely to be damaged (p &#60; 0.05) and the number of damaged points of the manual group and magnetic puller group were similar (p &#62; 0.05). The results of the breaking strength test were compared across groups and no significant difference was observed (p &#62; 0.05). The end-to-end anastomosis of the porcine iliac veins was successfully performed using this training system, and the reconstructed veins could undergo 2.0 kPa perfusion pressure. Using this training and testing system the trainee can practice manual vascular reconstruction in vitro individually with the aid of magnetic tractors and a magnetic suture puller, and the quality of the reconstruction can be tested.

Here we present a training and testing system where a trainee can complete manual vascular reconstruction in vitro individually using a magnetic anchoring technique. The system can also be used to test the quality of reconstruction.

체외에서 혈관 재건을 수행하기 위한 교육 및 테스트 시스템

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has ...

Improving Outcomes in Anteromesial Temporal Lobe Resections - A Demonstration of Resecting the Temporal Piriform Cortex

Anteromesial temporal lobe resection (ATLR) is a useful treatment option for drug-resistant mesial temporal lobe epilepsy (DRmTLE). Growing evidence suggests the piriform cortex plays a crucial role in the generation and propagation of seizures in DRmTLE - and that the resection of the temporal portion of the piriform cortex is associated with significantly improved rates of seizure freedom. 
Here, we present the resection of the temporal portion of the piriform cortex in ATLR, using high-resolution preoperative probabilistic tractography algorithms and fused anatomical masks of the structures of interest into the intraoperative neuronavigation and microscope head-up display (HUD). 
All patients undergoing comprehensive preoperative assessment and investigations for DRmTLE provided informed, written consent to record an intraoperative video of the procedure. Patients were identified by an expert multidisciplinary team of epileptologists, epilepsy neurosurgeons, neuropsychologists, neuropsychiatrists, and electrophysiologists at a large epilepsy surgery center. The preoperative imaging pipeline included the delineation of critical structures. This included the temporal piriform cortex, and high-resolution probabilistic tractography for essential tracts at risk (e.g., optic radiation and inferior fronto-occipital fasciculus). These were co-registered to the preoperative volumetric neuronavigation scan and uploaded to the intra-operative neuronavigation system. 
Presented here is a step-by-step procedure of ATLR, including the resection of the temporal portion of the piriform cortex. The protocol combines Advanced structural and diffusion MR imaging and intraoperative visual aids to integrate anatomical masks of critical grey matter structures and white matter tracts into the surgical workflow in the operating room.

Here, we demonstrate an approach to intraoperative neurosurgical guidance in anteromesial temporal lobe resections, specifically highlighting the use of tractography and anatomical masks to aid safe resection of the temporal portion of the piriform cortex - an area increasingly regarded as a crucial surgical target in drug-resistant mesial temporal lobe epilepsy.

Improving Outcomes in Anteromesial Temporal Lobe Resections - A Demonstration of Resecting the Temporal Piriform Petition(전방측두엽 절제술의 결과 개선) - 측두엽 피질 절제에 대한 시연

Anteromesial temporal lobe resection (ATLR) is a useful treatment option for drug-resistant mesial temporal lobe epilepsy (DRmTLE). Growing evidence ...

최소 침습적 신경 중재 계획을 위한 가상 현실 - 3D 모델링

Pioneering Patient-Specific Approaches for Precision Surgery Using Imaging and Virtual Reality

Endovascular treatment of complex vascular anomalies shifts the risk of open surgical procedures to the benefit of minimally invasive endovascular procedural solutions. Complex open surgical procedures used to be the only option for the treatment of a myriad of conditions like pulmonary and aortic valve replacement as well as cerebral aneurysm repair. However, due to advancements in catheter-delivered devices and operator expertise, these procedures (along with many others) can now be performed through minimally invasive procedures delivered through a central or peripheral vein or artery. The decision to shift from an open procedure to an endovascular approach is based on multi-modal imaging, often including 3D Digital Imaging and Communications in Medicine (DICOM) imaging datasets. Utilizing these 3D images, our lab generates 3D models of the pathologic anatomy, thereby allowing the pre-procedural analysis necessary to pre-plan critical components of the catheterization lab procedure, namely, C-arm positioning, 3D measurement, and idealized road-map generation. This article describes how to take segmented 3D models of patient-specific pathology and predict generalized C-arm positions, how to measure critical two-dimensional (2D) measurements of 3D structures relevant to the 2D fluoroscopy projections, and how to generate 2D fluoroscopy roadmap analogs that can assist in proper C-arm positioning during catheterization lab procedures.

저자 스포트라이트: 고급 신경혈관 중재술을 위한 세분화 및 VR

Advancements in endovascular treatment have replaced complex open surgical procedures with minimally invasive options, like valve replacement and aneurysm repair. This paper proposes using three-dimensional (3D) modeling and virtual reality to aid in C-arm positioning, angle measurements, and roadmap generation for neuro-interventional catheterization lab procedural planning, minimizing procedure time.