Os autores não têm confirmações.

declaração ética: Nosso protocolo segue as diretrizes estabelecidas por nosso comitê de ética em pesquisa humanos institucional. 1. Identificação da epilepsia refratária Pacientes <ol><li> Antes de monitorização invasiva, avaliar allpatientswith técnicas não invasivas, tais como monitoramento de vídeo-EEG, ressonância magnética, PET, ictalSPECT e estudos neuropsicológicos como descrito em 1 Após a discussão na reunião multidisciplinar a decisão se deve ou não prosseguir com monitorização invasiva com EEG deve ser feita. 1,6,7,11,14 </li><li> Formar uma hipótese sobre a localização do EZ. Desenvolver uma hipótese pré-implantação da actividade presumida EZincorporating a zona de início ictal e regiões do início (ou seja, a rápida) propagação do epiléptico (ictal) antes da intervenção. NOTA: Este passo pode ser feito em conjunto com a reunião multi-disciplinar quando é tomada a decisão de prosseguir montitoring invasivo. NOTA: EEG vs subdural grades-Com base na hipótese EZ, decidir entre EEG e monitorização da rede subdural. Critérios a considerar podem incluir 1) possível profunda EZ sentados; 2) anterior vencida monitoramento grades subdurais; 3) As indicações para a monitorização bilateral; 4) Quando a epilepsia extra-temporais não-lesional é suspeita. Também deve-se notar que benefício adicional de EEG sobre grades subdurais inclui a capacidade do EEG para gravar e estimular áreas subcorticais críticos, quando uma região eloqüente é a hipótese de estar perto do EZ. </li><li> Desenvolver uma estratégia de implantação adaptado individualmente, baseados no EZ hipotética (Figura 1) 1,7,8. NOTA: estratégia de implantação adequado deve avaliar 1) uma lesão anatômica (se houver); 2) estrutura (s) mais propensos a participar início inictal; e / ou 3) possível via (s) de propagação convulsão dentro de uma rede funcional. Além de considerações anatómicas, considerações logísticas devem também ser considerados. Paraesta razão, as trajectórias são ortogonais em geral preferencial, a fim de facilitar a implantação e, mais tarde, a interpretação das posições de eléctrodos. </li><li> Depois de desenvolver uma estratégia de implantação baseada no EZ hipotética, criar um plano de utilização da assistência robótica. Primeiro, crie um novo encontro, selecionando &quot;novo paciente&quot;, depois clique em &quot;criar trajetória&quot;, em seguida, selecione apropriada &quot;ponto de entrada&quot; e &quot;ponto final&quot;, que correspondem com a trajetória desejada. NOTA: Dependendo da hipótese pré-implantação, o número de eletrodos é normalmente entre oito e doze anos. As trajectórias e pontos de interesse são tipicamente planejado usando contrastou ressonância magnética ou angiografia rotacional. Essas imagens que mostram não só a matéria cerebral, mas os vasos cerebrais permitem planos de trajetória em corredores avasculares para evitar lesão vascular e hemorragia. </li></ol> 2. Procedimento operativo <ol><li> Um dia antes de surgery, obter, uma sequência de ressonância magnética contrastada volumétrica em T1 como descrito no por Kuzniecky et al 14. NOTA: Esta imagem é para ser usado para o registo com auxílio robótico e deve ter fatias de 1 mm. Em seguida, transferir as imagens para o software neuro-navegação estereotáxica, onde trajetórias são planejadas com base em estratégias de implantação previamente discutidas, como descrito por Kuzniecky et al. 14 </li><li> Uma vez na sala de cirurgia, colocar o paciente na mesa cirúrgica em decúbito dorsal. Em seguida, obter anestesia geral com entubação endotraqueal, conforme o protocolo do anestesiologista. NOTA: É imperativo que eles estão sob anestesia geral venosa e paralisia farmacológica completa. Em seguida, raspar a cabeça do paciente, preparar a pele com uma aplicação cirúrgica antibióticos e, em seguida, colocar a cabeça do paciente em um suporte de cabeça neurocirúrgica cabeça. A anestesia geral varia de paciente para paciente. </li><li> Depois de completaro posicionamento anexar o sistema robótico para o quadro e registo completo. No dispositivo de assistência robótica selecione &quot;registrar&quot; e siga as instruções para concluir o processo de registro. registo completo de registro marco usando superfície com base em características faciais ou marcadores fiduciais implantados. </li><li> A inserção (Figura 2) <ol><li> Use uma broca de 2,5 mm para perfurar o crânio com a assistência a orientação do sistema de estereotáxica robótico. Inserir a sonda coagulator monopolar para abrir a dura-máter. Dane-se o parafuso de implantação no crânio, também guiado pelo sistema estereotáxico robótico. </li><li> Calcule a distância profundidade final para o eletrodo (D3), utilizando as seguintes medidas: [(Target-Dura Distância) + (D1 - D2) = D3]. Medir a distância do alvo-dura usando o sistema de navegação. NOTA: D1 é medido como o comprimento do sistema de orientação para a dura-máter, D2 é medido como o comprimento do sistema de orientação para a extremidade da lingueta. O D1 - diferença D2 é o comprimento do parafuso. A soma do comprimento do parafuso e a distância do alvo-dura é o comprimento da profundidade do eléctrodo. </li><li> Criar a trajectória inicial através da inserção de uma sonda de estilete, guiada pelo parafuso implantado. Em seguida, insira o eletrodo e fixá-lo no parafuso. Isso impede que mais deslocamentos e fluidos vazamentos cefalorraquidiano (LCR). </li><li> Depois de colocar e conectar todos os eléctrodos, coloque solução de iodo gaze embebida em torno das tampas dos parafusos. E, em seguida, enrole a cabeça. </li></ol></li></ol> 3. Monitoramento / Gravação <ol><li> Antes de terminar o caso, conecte os eletrodos para a máquina de gravação de EEG para garantir o bom funcionamento. O último passo no OR é imagiologia intra-operatório (Figura 3). Execute Intraoperative raios-x ou de imagem por fluoroscopia no crânio lateral e ântero-posterior. NOTA: Obter estes para garantir trajectórias adequadas dos eléctrodos. Estas imagens não são obtained para assegurar a colocação estereotáxica, mas eles garantir a trajetória correta geral e colocação dos eletrodos. </li><li> Após a cirurgia, transferir os pacientes para a unidade de monitorização epilepsia Monitore o paciente para a atividade de apreensão clínica e eletrograficamente via a gravação eletrodo EEG. NOTA: O tempo de permanência varia, dependendo do número, qualidade e ictal e padrões interictais de gravações. Enquanto os pacientes monitorados podem ter menor dor, tratar isso com acetaminofeno. Normalmente, o tempo de permanência é de 7 dias (intervalo 3 - 28 dias). </li><li> Antes da remoção de eletrodos, discutir sobre o paciente em uma conferência multidisciplinar para avaliar gravações e hipótese. </li><li> Depois de gravar dados ictais suficientes (passo 3.2) eo paciente foi discutido na conferência, reinicie anteriores medicamentos anti-epilépticos dos pacientes, enquanto espera ou para a remoção de eléctrodos. </li></ol> 4. Regresso ou para remoção <ol><li> After gravação de dados ictais suficientes, retornar o paciente à sala de cirurgia para a remoção dos eletrodos Seeg. Executar esta sob sedação consciente; tipicamente de 2 mg de midazolam IV é suficiente. </li><li> Após anestesia obter sedação suficiente (tipicamente com midazolam [adiar a dosagem para anestesista]), remova os pacientes cabeça de envolvimento e cortar os fios dos eléctrodos. Monitorar sedação do paciente clinicamente pelos níveis de dor relatadas com a remoção ou inserção do eletrodo de sutura. Em seguida, preparar o parafuso restante e da cauda do eletrodo usando gel iodado. </li><li> Individualmente, remover cada tampa de parafuso, girando-off, seguido pelo eletrodo e por fim remover o parafuso. Retirar os eléctrodos, puxando-as suavemente para fora ao longo do eixo da sua inserção. Em seguida, retire o parafuso, girando-a para fora, normalmente faz isso usando os dedos. </li><li> Antes de passar para a próxima eletrodo, fechar o defeito deixado pelo parafuso com um ponto de fio de náilon. Repita essas etapas para cada eletrodo. após remOving todos os eletrodos, abrangem as áreas de costura com pomada antibiótica e um envoltório de cabeça solta. </li><li> Após a remoção, obter mais imagiologia quer CT ou A / P e radiografias laterais para garantir que nenhum hardware residual. NOTA: Possível ressecção-Se a ressecção cirúrgica foi acreditado para ser um benefício para a epilepsia do paciente, em seguida, planejar uma craniotomia e ressecção cerca de 6 semanas após a remoção. Este atraso é devido a preocupações infecciosas de funcionamento durante a mesma internação como o período de monitoramento. </li></ol>

<ol>
	<li>Serletis, D., Bulacio, J., Bingaman, W., Gonzalez-Martinez, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+stereotactic+approach+for+mapping+epileptic+networks:+a+prospective+study+of+200+patients.">The stereotactic approach for mapping epileptic networks: a prospective study of 200 patients.</a> J Neurosurg. 121, 1239-1246 (2014).</li><li>Bancaud, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epilepsy+after+60+years+of+age.+Experience+in+a+functional+neurosurgical+department.">Epilepsy after 60 years of age. Experience in a functional neurosurgical department.</a> Sem Hop. 46, 3138-3140 (1970).</li><li>Bancaud, J., 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=Functional+stereotaxic+exploration+(SEEG)+of+epilepsy.">Functional stereotaxic exploration (SEEG) of epilepsy.</a> Electroencephalogr Clin Neurophysiol. 28, 85-86 (1970).</li><li>Talairach, J., Bancaud, J., Bonis, A., Szikla, G., Trottier, S., Vignal, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+therapy+for+frontal+epilepsies.">Surgical therapy for frontal epilepsies.</a> Adv Neurol. 57, 707-732 (1992).</li><li>Vadera, S., Mullin, J., Bulacio, J., Najm, I., Bingaman, W., Gonzalez-Martinez, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereo+electroencephalography+following+subdural+grid+placement+for+difficult+to+localize+epilepsy.">Stereo electroencephalography following subdural grid placement for difficult to localize epilepsy.</a> Neurosurgery. 72, 723-729 (2013).</li><li>Munari, C., 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=Stereo-electroencephalography+methodology:+advantages+and+limits.">Stereo-electroencephalography methodology: advantages and limits.</a> Acta Neurol Scand Suppl. 152, 56-69 (1994).</li><li>Gonzalez-Martinez, J., Bulacio, J., Alexopoulos, A., Jehi, L., Bingaman, W., Najm, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereoelectroencephalography+in+the+"difficult+to+localize"+refractory+focal+epilepsy+early+experience+from+a+North+American+epilepsy+center.">Stereoelectroencephalography in the "difficult to localize" refractory focal epilepsy early experience from a North American epilepsy center.</a> Epilepsia. 54, 323-330 (2013).</li><li>Gonzalez-Martinez, J., 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=Stereotactic+placement+of+depth+electrodes+in+medically+intractable+epilepsy.+Technicalnote.">Stereotactic placement of depth electrodes in medically intractable epilepsy. Technicalnote.</a> J Neurosurg. 120, 639-664 (2014).</li><li>Nathoo, N., Lu, M. C., Vogelbaum, M., Barnett, G. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=In+Touch+with+Robotics:+Neurosurgery+for+the+Future.">In Touch with Robotics: Neurosurgery for the Future.</a> Neurosurgery. 56, 421-433 (2005).</li><li>De Almeida, A. N., Olivier, A., Quesney, F., Dubeau, F., Savard, G., Andermann, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+and+morbidity+associated+with+stereoelectroencephalography+using+computerized+tomography-or+magnetic+resonance+imaging-guided+electrode+implantation.">Efficacy of and morbidity associated with stereoelectroencephalography using computerized tomography-or magnetic resonance imaging-guided electrode implantation.</a> J Neurosurg. 104, 483-487 (2006).</li><li>Cossu, 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=Stereoelectroencephalography+in+the+presurgical+evaluation+of+focal+epilepsy+a+retrospective+analysis+of+215+procedures.">Stereoelectroencephalography in the presurgical evaluation of focal epilepsy a retrospective analysis of 215 procedures.</a> Neurosurgery. 57, 706-718 (2005).</li><li>Gonzalez-Martinez, J., 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=Robot-assisted+stereotactic+laser+ablation+in+medically+intractable+epilepsy:+operative+technique.">Robot-assisted stereotactic laser ablation in medically intractable epilepsy: operative technique.</a> Neurosurgery. 10, 167-172 (2014).</li><li>Guenot, 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=Neurophysiological+monitoring+for+epilepsy+surgery:+the+Talairach+SEEG+method.+Indications,+results,+complications+and+therapeutic+applications+in+a+series+of+100+consecutive+cases.">Neurophysiological monitoring for epilepsy surgery: the Talairach SEEG method. Indications, results, complications and therapeutic applications in a series of 100 consecutive cases.</a> Stereotact Funct Neurosurg. 77, 29-32 (2001).</li><li>Kuzniecky, R. I., 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=Multimodality+MRI+in+mesial+temporal+sclerosis:+relative+sensitivity+and+specificity.">Multimodality MRI in mesial temporal sclerosis: relative sensitivity and specificity.</a> Neurology. 49 (3), 774-778 (1997).</li><li>Cardinale, F., 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=Stereoelectroencephalography:+surgical+methodology,+safety,+and+stereotacticapplication+accuracy+in+500+procedures.">Stereoelectroencephalography: surgical methodology, safety, and stereotacticapplication accuracy in 500 procedures.</a> Neurosurgery. 72 (3), 353-366 (2013).</li></ol>

Os autores não têm nada para revelar.

Aqui é apresentada a técnica de inserção EEG utilizando assistência estereotáxica robótico. Enquanto EEG foi originalmente descrita usando outros métodos de estereotaxia baseada em quadros, EEG assistida por robô oferece não só a segurança semelhante, mas superior precisão e eficiência. A literatura relata sucesso em localizar a EZ em mais de 76% dos casos, o que é solidarizar com outros estudos anteriores utilizando técnicas alternativas. 6,13,. Como com qualquer ...

In medically refractory epilepsy there are many non-invasive pre-surgical tools (scalp EEG., magnetic resonance imaging (MRI), functional MRI, single photon emission computed tomography, positron emission topography, and magnetoencephalography). If these non-invasive evaluations fail to sufficiently localize or define the epileptic zone (EZ) then invasive recording may be indicated. Currently, subdural grids or Stereo-electro-encephalo-graphy (SEEG) are the two most prevalent methods of invasive monitoring. SEEG was originally developed in France in the 1950's by Jean Talairach and Jean Bancaud; recently it has mostly been used for invasive monitoring of refractory epilepsy patients in France.2-4 SEEG is the consists of stereotactically inserting intracerebral electrodes into the brain parenchyma to record brain electrical activity for an extended period of time. With the intracerebral electrical recordings many patients are able to have their EZ defined to allow for surgical resection. 
Despite this long history of success SEEG remains relatively rarely used for invasive recording in America. However, SEEG does offer several significant advantages; SEEG allows for 1) recording of deep structures, 2) bihemispheric recordings, 3) another recording option if subdural grids failed, and 4) mapping of epileptic networks in three dimensions, mainly in patients where non-lesional extra-temporal epilepsy is suspected.5-7 All of these benefits are achieved without requiring a large craniotomy. A recent technologic advance in SEEG surgery is the used of robotic guidance. This sophisticated development allows for improved operative times but safer and more accurate surgical implantation of electrodes.Recently published literature reviews the results of using two different techniques for SEEG insertion; a more traditional method utilizing stereotactic frames and a newer technique using robotic assistante for SEEG insertion.1, 8,15 the results were similarly successful with each method. 
With the advent of improved robotic assistance, the SEEG insertion technique has resulted in improved operative times. The robotic system is classified as a supervisory controlled system which means the surgeon plans the operation off line and implicitly specifies the motion the robot must follow to perform the operation.9 The robotic assist results in expedient transitions from one trajectory to the next for the placement of each intracranial electrode.

<table border="0" cellpadding="0" cellspacing="0" width="573">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">ROSA</td>
			<td style="width:71px;">ROSA</td>
			<td style="width:119px;"></td>
			<td style="width:167px;">robotic implantation system</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">electrodes</td>
			<td style="width:71px;">adtech</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
	</tbody>
</table>

stereo-electro-encephalo-graphy (seeg) with robotic assistance in the presurgical evaluation of medical refractory epilepsy: a technical note

EEG é um método e técnica que é usada para a gravação precisa, invasivo da atividade de apreensão através de três gravações tridimensionais. Em pacientes com epilepsia que são considerados candidatos adequados para gravações invasoras, a decisão é feita para monitorar entre as grades subdurais contra EEG. neuromonitoring invasivo para epilepsia é perseguido em pacientes com complexo de epilepsia, refratária. O objetivo da monitorização invasiva é oferecer cirurgia de ressecção com a esperança de permitir a liberdade de apreensão. vantagens de Seeg incluem o acesso a estruturas corticais profundas, a capacidade de localizar a zona epileptogênica (EZ) quando grades subdurais não conseguiram fazê-lo, e em pacientes com não-lesional epilepsias extra-temporais. Neste artigo, apresentamos um panorama histórico sucinto do EEG e informar sobre a nossa experiência com estereotaxia sob robótico. Um passo imperativo da inserção EEG está a planear as trajectórias de eléctrodos. A fim de registrar de forma mais eficazatividade ictal via trajectórias Seeg deve ser planejada com base em uma hipótese de que a atividade de apreensão é originário da zona epileptogênica presumida (EZ). A hipótese EZ é baseado em um exame pré-operatório padronizado incluindo monitoramento de vídeo-EEG, MRI (ressonância magnética), PET (tomografia por emissão de pósitrons), SPECT ictal (emissão de fóton único tomografia computadorizada) e avaliação neuropsicológica. Usando um EZ suspeita, eletrodos de EEG pode ser colocado minimamente invasiva ainda manter a exatidão e precisão. Os resultados clínicos mostraram a capacidade de localizar a EZ em 78% dos difíceis de localizar pacientes epilépticos 1.

Resultados recentes indicam que, em uma série consecutiva de 78 pacientes que se submeteram à inserção EEG através de assistência robótica tinha localização bem-sucedida da EZ em 76,2% dos pacientes. 1 Nesse mesmo estudo mostrou dos pacientes que passou a ter a ressecção cirúrgica de EZ tinham grau 1 Engel apreensão liberdade em 67,8% dos doentes (Figura 4). taxa de morbidade é de 2,5%. morbidade permanente foi notado é 1 paciente (1,2%). Por el...

Watch this Scientific Journal Video about Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note at JoVE.com

Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note

Stereo-electroencephalography (SEEG) aids in localization of epileptogenic zones, however, remains relatively underutilized in the United States. The goal of this abstract is to provide a brief introduction to the technique of SEEG and further a detailed technique of using robotic assistance in the placement of SEEG electrodes.

Stereo-Electro-encéfalo-Graphy (EEG) com auxílio robótico na avaliação pré-cirúrgica de Medicina de Epilepsia Refratária: A Nota Técnica

SEEG is a method and technique which is used for accurate, invasive recording of seizure activity via three dimensional recordings. In epilepsy patients ...

stereo-electro-encephalo-graphy-seeg-with-robotic-assistance

Research

JoVE Journal

Medicine

Stereo-Electro-Encephalo-Graphy (SEEG) With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note

17.0K visualizações.  Cleveland Clinic. Stereo-electroencephalography (SEEG) aids in localization of epileptogenic zones, however, remains relatively underutilized in the United States. The goal of this abstract is to provide a brief introduction to the technique of SEEG and further a detailed technique of using robotic assistance in the placement of SEEG electrodes. 

Vídeo: Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note

Technical Aspects of the Mouse Aortocaval Fistula

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta and inferior vena cava (IVC) are exposed. The proximal infrarenal aorta and the distal aorta are dissected for clamp placement and needle puncture, respectively. Special attention is paid to avoid dissection between the aorta and the IVC. After clamping the aorta, a 25 G needle is used to puncture both walls of the aorta into the IVC. The surrounding connective tissue is used for hemostatic compression. Successful creation of the AVF will show pulsatile arterial blood flow in the IVC. Further confirmation of successful AVF can be achieved by post-operative Doppler ultrasound.

The goal is to produce an arteriovenous fistula that is simple and reproducible. This method does not use sutures or glue adhesive. Therefore the samples can be used with the least amount of foreign materials for analysis.

Aspectos técnicos da artocava Fístula Rato

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta ...

Medicina

A Multimodal Imaging- and Stimulation-based Method of Evaluating Connectivity-related Brain Excitability in Patients with Epilepsy

Resting-state functional connectivity MRI (rs-fcMRI) is a technique that identifies connectivity between different brain regions based on correlations over time in the blood-oxygenation level dependent signal. rs-fcMRI has been applied extensively to identify abnormalities in brain connectivity in different neurologic and psychiatric diseases. However, the relationship among rs-fcMRI connectivity abnormalities, brain electrophysiology and disease state is unknown, in part because the causal significance of alterations in functional connectivity in disease pathophysiology has not been established. Transcranial Magnetic Stimulation (TMS) is a technique that uses electromagnetic induction to noninvasively produce focal changes in cortical activity. When combined with electroencephalography (EEG), TMS can be used to assess the brain's response to external perturbations. Here we provide a protocol for combining rs-fcMRI, TMS and EEG to assess the physiologic significance of alterations in functional connectivity in patients with neuropsychiatric disease. We provide representative results from a previously published study in which rs-fcMRI was used to identify regions with abnormal connectivity in patients with epilepsy due to a malformation of cortical development, periventricular nodular heterotopia (PNH). Stimulation in patients with epilepsy resulted in abnormal TMS-evoked EEG activity relative to stimulation of the same sites in matched healthy control patients, with an abnormal increase in the late component of the TMS-evoked potential, consistent with cortical hyperexcitability. This abnormality was specific to regions with abnormal resting-state functional connectivity. Electrical source analysis in a subject with previously recorded seizures demonstrated that the origin of the abnormal TMS-evoked activity co-localized with the seizure-onset zone, suggesting the presence of an epileptogenic circuit. These results demonstrate how rs-fcMRI, TMS and EEG can be utilized together to identify and understand the physiological significance of abnormal brain connectivity in human diseases.

Resting-state functional-connectivity MRI has identified abnormalities in patients with a wide range of neuropsychiatric disorders, including epilepsy due to malformations of cortical development. Transcranial Magnetic Stimulation in combination with EEG can demonstrate that patients with epilepsy have cortical hyperexcitability in regions with abnormal connectivity.

A Multimodal Imaging- e baseada Estimulação método de avaliação de conectividade relacionadas com o cérebro Excitabilidade em doentes com epilepsia

Resting-state functional connectivity MRI (rs-fcMRI) is a technique that identifies connectivity between different brain regions based on correlations ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Análise de Redes de forame oval Eletrodo Recordings na epilepsia do lobo temporal Os pacientes resistentes a drogas

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Interictal High Frequency Oscillations Detected with Simultaneous Magnetoencephalography and Electroencephalography as Biomarker of Pediatric Epilepsy

Crucial to the success of epilepsy surgery is the availability of a robust biomarker that identifies the Epileptogenic Zone (EZ). High Frequency Oscillations (HFOs) have emerged as potential presurgical biomarkers for the identification of the EZ in addition to Interictal Epileptiform Discharges (IEDs) and ictal activity. Although they are promising to localize the EZ, they are not yet suited for the diagnosis or monitoring of epilepsy in clinical practice. Primary barriers remain: the lack of a formal and global definition for HFOs; the consequent heterogeneity of methodological approaches used for their study; and the practical difficulties to detect and localize them noninvasively from scalp recordings. Here, we present a methodology for the recording, detection, and localization of interictal HFOs from pediatric patients with refractory epilepsy. We report representative data of HFOs detected noninvasively from interictal scalp EEG and MEG from two children undergoing surgery.
The underlying generators of HFOs were localized by solving the inverse problem and their localization was compared to the Seizure Onset Zone (SOZ) as this was defined by the epileptologists. For both patients, Interictal Epileptogenic Discharges (IEDs) and HFOs were localized with source imaging at concordant locations. For one patient, intracranial EEG (iEEG) data were also available. For this patient, we found that the HFOs localization was concordant between noninvasive and invasive methods. The comparison of iEEG with the results from scalp recordings served to validate these findings. To our best knowledge, this is the first study that presents the source localization of scalp HFOs from simultaneous EEG and MEG recordings comparing the results with invasive recordings. These findings suggest that HFOs can be reliably detected and localized noninvasively with scalp EEG and MEG. We conclude that the noninvasive localization of interictal HFOs could significantly improve the presurgical evaluation for pediatric patients with epilepsy.

High Frequency Oscillations (HFOs) have emerged as presurgical biomarkers for the identification of the epileptogenic zone in pediatric patients with medically refractory epilepsy. A methodology for the noninvasive recording, detection, and localization of HFOs with simultaneous scalp electroencephalography (EEG) and magnetoencephalography (MEG) is presented.

Oscilações de alta frequência interictais detectado com simultânea Magnetoencefalografia e Eletroencefalografia como biomarcador da Pediatric epilepsia

Crucial to the success of epilepsy surgery is the availability of a robust biomarker that identifies the Epileptogenic Zone (EZ). High Frequency ...

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.

Desacoplamento de emergência em cirurgia robótica: um currículo de simulação

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

Assessment of Static Graviceptive Perception in the Roll-Plane using the Subjective Visual Vertical Paradigm

Vestibular disorders are among the most common syndromes in medicine. In recent years, new vestibular diagnostic systems have been introduced that allow the examination of all semicircular canals in the clinical setting. Assessment methods of the otolithic system, which is responsible for the perception of linear acceleration and perception of gravity, are far less in clinical use. There are several experimental approaches for measuring the perception of gravity. The most frequently used method is the determination of the subjective visual vertical. This is usually measured with the head in an upright position. We present here an assessment method for testing otolith function in the roll plane. The subjective visual vertical is measured in the head upright position as well as with head inclination of &#177; 15&#176; and &#177; 30&#176; in the roll plane. This extended functional paradigm is an easy-to-perform clinical test of otolith function and ensures increased information content for the detection of impaired graviceptive perception.

The perception of gravity is commonly determined by the subjective visual vertical in the head upright position. The additional assessment at head tilts of &#177; 15&#176; and &#177; 30&#176; in the roll plane ensures increased information content for the detection of impaired graviceptive perception.

Avaliação da Percepção Graviceptiva Estática no Plano de Rolagem usando o Paradigma Vertical Visual Subjetivo

Vestibular disorders are among the most common syndromes in medicine. In recent years, new vestibular diagnostic systems have been introduced that allow ...

Evaluation of Cerebral Blood Flow Autoregulation in the Rat Using Laser Doppler Flowmetry

When investigating the body&#39;s mechanisms for regulating cerebral blood flow, a relative measurement of microcirculatory blood flow can be obtained using laser Doppler flowmetry (LDF). This paper demonstrates a closed skull preparation that allows cerebral blood flow to be assessed without penetrating the skull or installing a chamber or cerebral window. To evaluate autoregulatory mechanisms, a model of controlled blood pressure reduction via graded hemorrhage can be utilized while simultaneously employing LDF. This enables the real time tracking of the relative changes in the blood flow in response to reductions in arterial blood pressure produced by the withdrawal of circulating blood volume. This paradigm is a valuable approach to study cerebral blood flow autoregulation during reductions in arterial blood pressure and, with minor modifications in the protocol, is also valuable as an experimental model of hemorrhagic shock. In addition to evaluating autoregulatory responses, LDF can be used to monitor the cortical blood flow when investigating metabolic, myogenic, endothelial, humoral, or neural mechanisms that regulate cerebral blood flow and the impact of various experimental interventions and pathological conditions on cerebral blood flow.

This article demonstrates the use of laser Doppler flowmetry to evaluate the ability of the cerebral circulation to autoregulate its blood flow during reductions in arterial blood pressure.

Avaliação da autoregulação do fluxo sanguíneo cerebral no rato usando fluimetria de laser

When investigating the body&#39;s mechanisms for regulating cerebral blood flow, a relative measurement of microcirculatory blood flow can be obtained ...

Development and Evaluation of 3D-Printed Cardiovascular Phantoms for Interventional Planning and Training

Catheter-based interventions are standard treatment options for cardiovascular pathologies. Therefore, patient-specific models could help training physicians&#39; wire-skills as well as improving planning of interventional procedures. The aim of this study was to develop a manufacturing process of patient-specific 3D-printed models for cardiovascular interventions.
To create a 3D-printed elastic phantom, different 3D-printing materials were compared to porcine biological tissues (i.e., aortic tissue) in terms of mechanical characteristics. A fitting material was selected based on comparative tensile tests and specific material thicknesses were defined. Anonymized contrast-enhanced CT-datasets were collected retrospectively. Patient-specific volumetric models were extracted from these datasets and subsequently 3D-printed. A pulsatile flow loop was constructed to simulate the intraluminal blood flow during interventions. Models&#39; suitability for clinical imaging was assessed by x-ray imaging, CT, 4D-MRI and (Doppler) ultrasonography. Contrast medium was used to enhance visibility in x-ray-based imaging. Different catheterization techniques were applied to evaluate the 3D-printed phantoms in physicians&#39; training as well as for pre-interventional therapy planning.
Printed models showed a high printing resolution (~30 &#181;m) and mechanical properties of the chosen material were comparable to physiological biomechanics. Physical and digital models showed high anatomical accuracy when compared to the underlying radiological dataset. Printed models were suitable for ultrasonic imaging as well as standard x-rays. Doppler ultrasonography and 4D-MRI displayed flow patterns and landmark characteristics (i.e., turbulence, wall shear stress) matching native data. In a catheter-based laboratory setting, patient-specific phantoms were easy to catheterize. Therapy planning and training of interventional procedures on challenging anatomies (e.g., congenital heart disease (CHD)) was possible.
Flexible patient-specific cardiovascular phantoms were 3D-printed, and the application of common clinical imaging techniques was possible. This new process is ideal as a training tool for catheter-based (electrophysiological) interventions and can be used in patient-specific therapy planning.

Here we present development of a mock circulation setup for multimodal therapy evaluation, pre-interventional planning, and physician-training on cardiovascular anatomies. With the application of patient-specific tomographic scans, this setup is ideal for therapeutic approaches, training, and education in individualized medicine.

Desenvolvimento e Avaliação de Fantasmas Cardiovasculares Impressos em 3D para Planejamento e Treinamento Intervencionista

Catheter-based interventions are standard treatment options for cardiovascular pathologies. Therefore, patient-specific models could help training ...

Repetitive Blood Sampling from the Subclavian Vein of Conscious Rat

Rats are widely used in pharmacokinetics (PK) and toxicokinetic (TK) studies that need to collect a certain amount of blood at specific time points to detect drug exposure. The rat blood sampling method determines the quality of the plasma and further affects the precision of the test results. The subclavian vein blood collection method described in this protocol collects blood samples repeatedly in the conscious state of animals to meet the needs of PK and TK tests. The skills of restraint handling and appropriate procedure of needle incision ensure the success rate of blood collection. It is easy to operate while ensuring the quality of plasma and at the same time catering to animal welfare. However, this method requires skilled operation, and an improper one may cause animal weakness, pain, lameness, and even mortality. The current method has been used in the testing facility for a 4-week oral toxicity study in Sprague Dawley (SD) rats with TK. The maximum amount of blood collected within 24 h did not exceed 20% of the animal's total blood. The animals' body weight was more than 200 g for males and females. The data showed that the animals' bodyweight increased steadily every week, and the clinical observation was normal after repetitive sample collection.

The present protocol describes a simple and efficient method for collecting blood from the subclavian vein in rats. It enables rapid, timely, and easily identifiable sampling without anesthesia and obtains high-quality blood through repetitive sample collection.

Amostragem Repetitiva de Sangue da Veia Subclávia de Rato Consciente

Rats are widely used in pharmacokinetics (PK) and toxicokinetic (TK) studies that need to collect a certain amount of blood at specific time points to ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

Hepatectomia robótica de Taj Mahal para colangiocarcinoma hilar

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...