The authors thank all the clinical teams contributing daily to the care of neurovascular patients at UCSD.

1. Simulator setup
<ol>
	<li>Prior to all procedures, assemble the simulator as shown in Figure 1 and turn on. Refer to Table 1 for the full list of simulator equipment needed to complete each simulation.</li>
	<li>Select the patient scenario using the software interface on the attached laptop (Figure 1C).</li>
	<li>Select the appropriate arterial sheath or guide catheter&#160;from the drop-down menu. This does not need to be physically inserted as part of the simulation, but will act as the femoral access site and allow subsequent entry of wires and catheters into the system (Figure 1D). Specific sheath/guide sizes for each scenario are discussed below.</li>
	<li>Select the appropriate catheter(s), guidewire, and/or microsystem based on the specific scenario as discussed below (Figure 1D).</li>
	<li>Turn on A (PA) and B plane (lateral) fluoroscopy on the software interface. Activate the fluoroscopy with the foot pedals (Figure 1H) and adjust both the patient and image intensifier positions with the joysticks (Figure 1I) until the correct PA and lateral views are obtained.</li>
</ol>
2. First patient scenario: Four-vessel angiography
NOTE:&#160;This scenario depicts a 52-year-old male with an unruptured left carotid terminus aneurysm found incidentally on a non-contrast computed tomography (CT) scan of the head.
<ol>
	<li>Select a 5-French femoral sheath, a 0.035 in guidewire, and a 4-French diagnostic catheter from the drop-down menu as tools to be used in this simulation.</li>
	<li>Insert the guidewire into the simulator machine (Figure 1D) until it registers on the simulation screen, signaling that access has been gained. Advance the guidewire until it is visualized in the descending thoracic aorta and continues into the aortic arch.</li>
	<li>When the guidewire is safely in the aortic arch, hold the guidewire in place and insert a diagnostic catheter over the guidewire through the simulated femoral sheath to the aortic arch.</li>
	<li>Remove the guidewire and utilize the fluoroscopy puff technique by gently pressing the contrast syringe (Figure 1E) to simulate contrast injection and briefly opacify the vessels as the catheter is advanced into the desired artery.</li>
	<li>Next, create a roadmap guide&#160;injecting contrast with the contrast syringe (Figure 1E) while the fluoroscopy foot pedal is depressed (Figure 1H). Next, reinsert the wire to selectively catheterize the desired vessel, advancing the catheter over the wire. Remove the wire for subsequent angiography runs.&#160;The right and left internal and external carotid arteries and the right and left vertebral arteries are all catheterized using this&#160;technique.</li>
	<li>Using the diagnostic catheter and the simulator contrast syringe (Figure 1E), perform angiograms of each of the above circulations by depressing the fluoroscopy pedal (Figure 1H) while injecting contrast with the syringe. Obtain high-magnification views of the aneurysm, if necessary. Review angiograms for adequacy prior to removing the catheter.</li>
	<li>Once the necessary images are obtained, remove the diagnostic catheter/guidewire from the simulation sheath. Simulated closure of the femoral arteriotomy site is not performed.</li>
</ol>
3. Second patient scenario: Carotid terminus aneurysm coiling
NOTE:&#160;This scenario depicts a 52-year-old male with a known ruptured left carotid terminus aneurysm, severe headache, nonfocal exam, and a Glasgow Coma Scale score of 15.
<ol>
	<li>Select a&#160;6-French guide catheter, 0.035 in guidewire, and a 4-French diagnostic catheter, from the drop-down menu.</li>
	<li>Insert a diagnostic catheter over a guidewire into the aortic arch as in steps 2.2&#8211;2.3.</li>
	<li>Insert a guide catheter over the diagnostic catheter through the femoral access site (Figure 1D) to the aortic arch.</li>
	<li>Remove the guidewire and create a roadmap guide of the left common carotid artery by roadmap flourscopy foot pedal&#160;injecting contrast with the contrast syringe (Figure 1E) while the fluoroscopy foot pedal (Figure 1H) is depressed.</li>
	<li>Reinsert the guidewire and selectively catheterize the left common carotid artery and internal carotid artery using fluoroscopy and the roadmap overlay visualized on the image projection monitor (Figure 1B) by leading with the guidewire and advancing the diagnostic catheter and guide catheter once safe access is gained.</li>
	<li>When the guide catheter is within the internal carotid artery, remove the diagnostic catheter and wire and perform angiographic runs of the left internal carotid cerebral circulation by depressing the fluoroscopy pedal (Figure 1H) while injecting contrast with the syringe (Figure 1E).</li>
	<li>Measure the aneurysm using the calculation option on the software interface (Figure 1C). Keeping in mind that the coil diameter for the first coil should be 1 mm wider than the mean&#160;aneurysm diameter, select an appropriate coil.</li>
	<li>Select a microcatheter and microwire from the drop-down menu.</li>
	<li>Insert the&#160;microcatheter and microwire through the femoral access site (Figure 1D), and under roadmap guidance obtained as in step 3.6, selectively catheterize the aneurysm with the microsystem.</li>
	<li>Remove the microwire, insert the previously selected coil through the femoral access site (Figure 1D), and advance it slowly into the aneurysm.</li>
	<li>Once the coil is fully inserted, perform a diagnostic cerebral angiogram by depressing the fluoroscopy pedal (Figure 1H) while injecting contrast with the syringe and assess the patency of the parent artery and aneurysm filling. The goal is to maintain patency of the parent artery and either completely embolize the aneurysm or provide sufficient coverage of the dome or presumed rupture point to appropriately reduce rupture risk.</li>
	<li>Detach the coil on the software interface (Figure 1C) and remove the coil wire. If necessary, repeat steps 3.11 and 3.12 with additional coils until ~30% aneurysm occlusion is obtained.</li>
	<li>Remove the microcatheter and guide catheter from the simulation sheath site (Figure 1D). Simulated closure of the femoral arteriotomy site is not performed.</li>
</ol>
4. Third patient scenario: Left middle cerebral artery thrombectomy
NOTE: This scenario depicts a 64-year-old female with a National Institutes of Health Stroke Scale (NIHSS) score of 12 for aphasia and right-sided weakness who was last known to be normal 4 h earlier. Head CT revealed a hyperdense left middle cerebral artery (MCA) sign and an Alberta Stroke Program Early CT score (ASPECTS) of 10, but no hemorrhage. A CT angiogram demonstrated a left M1 segment complete occlusion.
<ol>
	<li>Select a&#160;6-French guide catheter,&#160; 0.035 in guidewire, and a 4-French diagnostic catheter,&#160;from the drop-down menu.</li>
	<li>Insert the guide catheter into the left internal carotid artery and perform angiographic runs of the left internal carotid cerebral circulation as described in steps 3.2&#8211;3.6.</li>
	<li>Select a microcatheter/microwire and a stent retriever device from the drop down menu.&#160;</li>
	<li>Insert the microcatheter and microwire into the simulated femoral access site (Figure 1D) and into the left internal carotid artery.</li>
	<li>Under roadmap guidance obtained as in step 3.5, advance the microwire and microcatheter into the left MCA and carefully past the area of occlusion. Potential complications during this maneuver include vascular perforations and/or embolizing a clot downstream.</li>
	<li>Remove the microwire and insert a stent retriever device into the simulated femoral access site (Figure 1D) and advance into the MCA distal to the occlusion. Then, remove the microcatheter, leaving the stent retriever in place at the level of the occlusion.</li>
	<li>Turn on simulated aspiration on the software interface (Figure 1C), and retract the stent retriever device into the guide&#160;catheter by pulling back on the microwire.</li>
	<li>Remove both the stent retriever from the simulated femoral access site (Figure 1D).</li>
	<li>Perform an angiogram through the guide catheter by depressing the fluoroscopy pedal (Figure 1H) while injecting contrast with the syringe to ensure removal of the occlusion.</li>
	<li>Remove the guide catheter from the simulation sheath site (Figure 1D). Simulated closure of the femoral arteriotomy site is not performed.</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 has previously received competitive grants from Covidien Ltd. and Penumbra Inc. and holds consulting arrangements for physician training with Stryker Neurovascular, Covidien Ltd., and Penumbra Inc. JSP has served as a medical consultant to Stryker Neurovascular and Dart NeuroScience LLC. AAK and JSP have no direct financial interests related to this work. The remaining authors have no disclosures concerning the materials or methods used in this study or the findings specified in this paper.

Endovascular surgery is an expanding field that offers a minimally invasive treatment approach to a variety of pathologies. The significant risks associated with vascular injuries nonetheless provides unique educational challenges. With advances in simulation-based training, the education of trainees now allows practice in a risk-free environment that mimics real-life cases. Accordingly, endovascular simulation-based training has been shown to consistently improve performance metrics such as procedure time, fluoroscopy t...

Simulation-based training is an established educational tool for medical trainees and is particularly beneficial in high-risk fields such as endovascular neurosurgery. Multiple virtual reality training devices utilizing catheter-based systems exist, such as the ANGIO Mentor simulator (Simbionix Ltd., Airport City, Israel) and VIST-C and VIST G5 simulators (Mentice AB, Gothenburg, Sweden), with a significant body of data demonstrating the utility of training on procedural aptitude1. In spite of the usefulness of the simulators, step-by-step procedural instructions for their use are lacking.
Presented is a detailed protocol for use of the ANGIO Mentor simulator, a system that supports competency improvements in common endovascular neurosurgery procedures including diagnostic cerebral angiograms,&#160;mechanical thrombectomies, and aneurysm coil embolizations2. Prior work shows that after trainees of all levels performed five simulated angiograms, five thrombectomies, and ten aneurysm coil embolizations on the ANGIO Mentor simulator, they displayed significant improvements in procedural time, fluoroscopy and contrast doses, and adverse technical events2.
The following step-by-step instructions are divided into case scenarios and can easily be integrated into an academic training curriculum for medical students, residents, or fellows2. It should nonetheless be noted that a basic understanding of cerebral arterial anatomy, angiography, and stroke and aneurysm treatments is needed to optimize the educational potential of the simulation device.
All procedures described below (i.e., diagnostic cerebral angiogram, coiling of carotid terminus aneurysm, mechanical thrombectomy) can be performed by a single operator using the ANGIO Mentor simulator (Simbionix Ltd.) (Figure 1). This training device allows neurosurgical trainees of all skill levels to gain exposure to endovascular techniques in a preclinical setting, with the three patient scenarios utilized based on a previously published curriculum for simulator-based angiography training2. To reproduce endovascular techniques with high fidelity, the simulator utilizes actual catheters and wires introduced through a port similar to the diaphragm of a femoral artery sheath. The wires and catheters engage internal rollers that record both rotational and translational motions, which are displayed on the monitors. Device selections and patient vital signs are also visible to the simulator operator.

<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

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk environments. In the field of endovascular neurosurgery, the demand for consequence- and risk-free learning environments led to the development of simulation devices valuable for medical trainees. The goal of this protocol is to provide instructive guidelines for the use of an endovascular neurosurgery simulator in an academic setting. The simulator provides trainees with the opportunity to receive realistic feedback on their knowledge of anatomy, as well as haptic feedback indicative of their success in handling the catheter-based systems without negative consequences. The utility of this specific protocol in relation to other neuroendovascular training modalities is also discussed.

The ANGIO Mentor simulator was previously shown to improve the skills of surgical trainees with varying neuroendovascular experience when performing simulated diagnostic angiograms, thrombectomies, and ruptured aneurysm coil embolizations in an academic setting2. In this study, performance metrics for the aforementioned procedures were established over the course of 30 days in one medical student, one neurosurgery resident, two diagnostic neuroradiology fellows, and one endovascular neurosurgery f...

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

Simulator Training for Endovascular Neurosurgery

Simulation of complex, high-risk procedures is critical to the education of medical trainees. A protocol for simulator-based endovascular neurosurgery training in a controlled academic environment is described. The protocol includes stepwise guidelines for trainees of varying levels, with a discussion of the advantages and limitations of this model.

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

3.6K Views.  University of California. Simulatie van complexe, risicovolle procedures is van cruciaal belang voor de opleiding van medische stagiairs. Een protocol voor simulator-gebaseerde endovasculaire neurochirurgie training in een gecontroleerde academische omgeving wordt beschreven. Het protocol bevat stapsgewijze richtlijnen voor stagiairs van verschillende niveaus, met een bespreking van de voor- en nadelen van dit model.

Video: 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.

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

Bioengineering

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 ...

Medicine

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.

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.

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.

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 ...

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.

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.

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

Virtual Reality-3D Modeling for Minimally Invasive Neuro-Interventional Planning

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.

Author Spotlight: Segmentation and VR for Advanced Neurovascular Interventions

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.

Simulator Training for Endovascular Neurosurgery

Samenvatting

Meer video's verkennen

Hoofdstukken in deze video