Name: neuronavigation and laparoscopy guided ventriculoperitoneal shunt insertion for the treatment of hydrocephalus
Uploaded: 2022-10-14T12:30:00.000+00:00
Duration: 14 min 59 s
Description: Watch this Scientific Journal Video about Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus at JoVE.com

We thank Mr. Quentin Collier for his assistance with the creation of the video.

The following protocol follows the guidelines of the University of Calgary Conjoint Health Research Ethics Board. Informed media consent for the procedure was obtained and the patient provided written consent for this publication.
1. Positioning and pre-procedure setup
<ol>
	<li>Obtain a preoperative cranial MRI or computed tomography (CT) with the appropriate neuronavigation protocol.</li>
	<li>Place the patient supine on a donut headrest with the head turned toward the contralateral side and place a shoulder roll to augment the exposure of the occipital region (Figure 3).</li>
	<li>Upload the patient&#39;s preoperative cranial MRI or CT, register it to the neuronavigation system, and complete the neuronavigation workstation planning.</li>
	<li>Select an entry point and target for the proximal catheter and mark the specific entry location on the patient&#39;s scalp. 
	NOTE: By standard, a right-sided posterior approach is preferred, unless precluded by the patient&#39;s circumstances. An ideal entry point is one with a trajectory that traverses minimal parenchyma while missing any identifiable vessels in its path to the body of the right lateral ventricle (Figure 3).</li>
	<li>Mark an inverted u-shaped (horseshoe-shaped) incision to incorporate the entry point. Shave any hair surrounding the incision with a clipper (Figure 3).</li>
	<li>Mark a 1 cm para-midline abdominal incision at the junction, immediately inferior and right lateral to the xiphisternum.</li>
	<li>Infiltrate the scalp incision with a local anesthetic.</li>
	<li>Adhere to a strict infection-prevention protocol (bundle) (Figure 4)38.</li>
	<li>Prepare the entire surgical field with a 2% chlorhexidine gluconate/70% isopropyl alcohol solution and allow it to dry for at least 3 min before starting the operative draping. 
	&#8203;NOTE: Prior to operative draping, all scrubbed surgical staff must double glove, and must change their outer gloves for new ones after draping of the patient is completed.</li>
	<li>Drape the entire surgical field with an antimicrobial incise drape, which will help hold the drapes in place and reduce the surgical team&#39;s direct contact with the skin.</li>
	<li>Apply a standard laparoscopic drape and extend the opening in a cranial direction to the edges of the draping to allow exposure of the cranium and chest surgical field.</li>
</ol>
2. Cranial exposure
<ol>
	<li>Use a #15 scalpel to score the horseshoe-shaped incision.</li>
	<li>Use a fine-tip monopolar cautery to deepen the incision, making sure to preserve the periosteal layer.</li>
	<li>Retract the skin edges with a self-retaining retractor.</li>
	<li>Make a cruciate periosteal incision in the center of the wound to expose the skull using monopolar cautery.</li>
	<li>Make an approximately 2 cm burr hole in the center of the periosteal exposure, ensuring the underlying dura is preserved (Figure 5).</li>
</ol>
3. Subcutaneous distal catheter placement
<ol>
	<li>Make a para-midline sub-xiphisternum incision down to the perifascial fat layer.</li>
	<li>Blunt dissect the subcutaneous tissue 2-3 cm in a cranial direction.</li>
	<li>Carefully guide a tunneling stylet with its encasing plastic sheath within the subcutaneous layer and pass it toward the cranial incision, taking every caution to stay above the ribs and clavicle, and avoid piercing the skin.</li>
	<li>Once the inferior aspect of the cranial incision is pierced by the tunneller, withdraw the stylet, leaving the plastic sheath in place (Figure 5).</li>
	<li>Create a subgaleal pocket at the inferior edge of the cranial incision around the plastic sheath that is sizable enough to bury the shunt reservoir using monopolar cautery and blunt dissection with Kelly forceps.</li>
	<li>Remove the distal catheter from the sterile packaging and place it in sterile saline.</li>
	<li>Thread the distal catheter through the plastic sheath from cranial to caudal direction, minimizing contact of the shunt components with the drapes, and then remove the plastic sheath.</li>
	<li>Prime the system with sterile saline solution to remove any air.</li>
	<li>Valve attachment
	<ol>
		<li>If a programmable shunt valve is used, program it to the desired setting before it is removed from the packaging. Remove the VP shunt valve and distal catheters from the sterile packaging and place the components in sterile saline.</li>
		<li>Attach the distal port of the valve to the proximal end of the distal catheter, secure it twice with 3-0 silk ties, and prime the system with sterile saline solution to remove any residual air locks. Wrap the valve and the exposed catheter in a saline-soaked sponge making every attempt to prevent the shunt system from touching the drapes.</li>
	</ol>
	</li>
</ol>
4. Ventricular (proximal) catheter insertion
<ol>
	<li>Remove the ventricular catheter from the sterile packaging and place it in sterile saline.</li>
	<li>Create a small centrally located circular durotomy equivalent to the diameter of the proximal catheter (incorporating the underlying pia and arachnoid) using a fine tip monopolar cautery.</li>
	<li>With the navigation stylet within the proximal catheter, pass the catheter into the ipsilateral ventricle using real-time navigation along the preprogrammed trajectory to the target depth. 
	NOTE: Often, there is CSF flow at about 5 cm, however, ensure to advance the catheter further to a depth of approximately 8-10 cm (target).</li>
	<li>Once at the target depth, remove the navigation stylet probe from the ventricular catheter and confirm free CSF flow. Then clamp the catheter with a snap using booties to protect the catheter.</li>
	<li>Trim the proximal catheter, leaving about 2 cm extra from the outer table of the skull (Figure 5).</li>
	<li>Attach the distal end of the proximal catheter to the proximal outlet of the valve and secure it twice with 3-0 silk ties.</li>
	<li>Carefully place the valve into the subgaleal pocket and anchor the valve sleeve to the preserved periosteum with a 4-0 silk suture.</li>
	<li>Apply gentle traction on the distal catheter at the abdominal incision to ensure no catheter kinks exist.</li>
	<li>Confirm that the spontaneous flow of CSF is at the very distal (abdominal) end of the shunt system.</li>
</ol>
5. Intrabdominal (distal) catheter placement
NOTE: The distal catheter is placed laparoscopically within the peritoneal cavity, ideally by a general surgeon.
<ol>
	<li>Make a curvilinear periumbilical incision with a #15 scalpel followed by blunt dissection down to the abdominal wall fascia.</li>
	<li>Grasp the fascia on each side with Kocher forceps and incise it in a vertical fashion, to ensure entry into the peritoneal cavity.</li>
	<li>Place #2 polyglactin stay sutures through the fascia on either side, then insert a blunt Hasson trocar.</li>
	<li>Insufflate the abdomen with carbon dioxide (CO2).</li>
	<li>Insert a at 30&#176; angled laparoscope through the Hasson trocar access port (Figure 6).</li>
	<li>Place a 5 mm port in standard fashion under direct vision, usually on the left, but this may vary depending on the density and position of intraperitoneal adhesions (Figure 6).</li>
	<li>Perform any lysis of adhesions, that may be required.</li>
	<li>Make a small hole in the falciform ligament (from the left side of the ligament) using a combination of electrocautery and laparoscopic Metzenbaum scissors (Figure 6). The hole must be as close to both the liver and diaphragm as safely possible (cephalad).</li>
	<li>Create a transverse abdominal tunnel for the VP shunt catheter using the electrocautery hook at the incision created in step 3.1 (where the distal catheter exits from the subcutaneous space).</li>
	<li>Insert the distal VP shunt catheter into the peritoneal cavity through the path created with a 11F peel-away sheath introducer.</li>
	<li>Once the catheter is visualized in the abdominal cavity, grasp and position it, through the hole in the falciform ligament (Figure 6).</li>
	<li>Pull the remaining catheter through the falciform ligament hole from the right side and tuck it behind the liver (following medial mobilization of the right posterior liver sector). The catheter&#39;s final resting place must be the retrohepatic space (Figure 6).</li>
	<li>Trim the catheter such that the end is located just above the inferior margin of the liver. The final position of the catheter should ideally be inferior to the diaphragm but superior and posterior to the mobilized liver, immediately superior to the right pericolic gutter. Confirm there is still spontaneous CSF flow through the catheter under direct visualization (Figure 6). 
	NOTE: There is no predetermined length of the catheter. The catheter is trimmed to fit the patient&#39;s anatomy intracorporeally.</li>
	<li>Remove the residual (trimmed part of the catheter) through the 5 mm side port.</li>
	<li>Deflate the abdomen slowly and cautiously to ensure no migration of the catheter, and then remove all instruments.</li>
</ol>
6. Closure
<ol>
	<li>Close the cranial wound in a layered fashion with 3-0 polyglactin simple interrupted buried sutures in the galea layer and staples in the skin. Apply a dressing.</li>
	<li>Close the abdominal fascia using the previously placed polyglactin stay sutures followed by 4-0 poliglecaprone-25 subcuticular sutures and acrylate adhesive for skin closure. Apply a surgical dressing.</li>
</ol>

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M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosing+idiopathic+normal-pressure+hydrocephalus.">Diagnosing idiopathic normal-pressure hydrocephalus.</a> Neurosurgery. 57, 4-16 (2005).</li><li>Muram, 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=A+standardized+infection+prevention+bundle+for+reduction+of+CSF+shunt+infections+in+adult+ventriculoperitoneal+shunt+surgery+performed+without+antibiotic-impregnated+catheters.">A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters.</a> Journal of Neurosurgery. , 1-9 (2022).</li><li>Hamilton, M., Fung, A., Liam-Li, D., Isaacs, A., Conly, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+and+application+of+a+surgical+site+infection+prevention+bundle+for+shunt-related+insertions+and+revisions.">Development and application of a surgical site infection prevention bundle for shunt-related insertions and revisions.</a> Fluids and Barriers of the CNS. 15, (2018).</li></ol>

Patients tolerate the procedure well, are extubated immediately postop and are suitable for non-acute wards for overnight monitoring. It has been our practice to obtain a plain CT scan of the head the next morning to confirm the proximal catheter placement and as baseline imaging for future management. In addition, we obtain an abdominal x-ray to confirm the postoperative position of the abdominal catheter. The majority of our patients are assessed by both occupational therapy and physiotherapy and deemed safe by allied ...

Hydrocephalus, a common neurological disorder affecting approximately 175 per 100,000 adults worldwide1 is characterized by the accumulation of cerebrospinal fluid (CSF) within the cerebral ventricles due to an imbalance between CSF production and uptake processes in the brain2. As various non-surgical therapies have been unsuccessful3, the only viable treatment of hydrocephalus is the surgical diversion of the CSF from the cerebral ventricles. The most common approach utilized in adults is the placement of a shunt that drains the ventricular CSF into the peritoneal cavity (ventriculoperitoneal [VP] shunt)4,5.
A VP shunt has three subcutaneously located components: a proximal ventricular catheter inserted into a CSF ventricle through a skull burr hole, a valve to regulate the flow, and a distal catheter to connect the valve to the peritoneal cavity where the CSF is deposited and reabsorbed (Figure 1). Alternatively, a shunt can drain into the venous system at the level of the right atrium (ventriculoatrial [VA] shunt)6,7 or divert the spinal CSF from the spine into the peritoneal cavity (lumboperitoneal [LP] shunt)8. There is currently no evidence to support the superiority of VP versus VA versus LP shunt systems. In adults, 15%-25%9,10,11,12 of new VP shunts fail, typically within the first 6 months, and upward of 50% fail in high-risk populations13.VP shunt failure may be secondary to a shunt infection, valve malfunction, or catheter failure at the proximal or distal sites12,14,15,16,17. Each shunt failure requires repeat surgery, which is associated with a cumulative risk for perioperative complications18,19 and stress for patients and families, in addition to increased healthcare infrastructure costs20,21,22,23,24.
The &#34;traditional&#34; VP shunt insertion technique involves freehand insertion of the proximal catheter using surface anatomical landmarks and placement of the distal catheter either via a mini-laparotomy or a trocar conduit25,26,27. These techniques do not allow for real-time tracking or direct visualization of the final location during or after catheter insertion. Failure to achieve an ideal position for these catheters can lead to shunt failure, which is the most frequent long-term complication associated with VP shunt treatment of hydrocephalus10,28. Proximal catheters typically fail due to malposition and/or subsequent occlusion by the choroid plexus tissues or intraventricular debris. The leading causes of distal catheter failure in adults include catheter mispositioning, migration, and/or occlusion by omental tissues, bowel, and intrabdominal debris or adhesions11, 28,29,30,31.
There is recent evidence to suggest that the modification of VP shunt insertion techniques by placing the proximal and distal catheters under neuronavigation and laparoscopic guidance respectively, are associated with reduced risks of shunt failures26,32,33. In addition, compliance with shunt infection reduction protocols has been shown to reduce the risks of shunt failure secondary to infections34. Furthermore, Svoboda et al. described a &#34;falciform technique&#34; where the distal catheter was anchored to the falciform ligament and placed in the perihepatic space away from the omentum, which helped reduce the risk of catheter migration and obstruction by the omentum35. To our knowledge, while the use of neuronavigation and laparoscopy have been independently assessed, their combined benefits have not been reported, and the surgical techniques have not been adequately described in the literature.
We recently completed a 7 year prospective quality improvement study that combined neuronavigation, laparoscopy, the falciform technique and a shunt infection reduction protocol in adult hydrocephalus patients36. With our combined approach, the overall risk of shunt failure was reduced by 44%36. The objective of this paper is to present a surgical video accompanied by a step-by-step guide of the operative techniques to promote a paradigm shift toward the use of these adjuncts to reduce the risks of shunt failures in adults.
The surgical approach presented here can be performed for any VP shunt insertion surgery. We describe the case of a 72-year-old male who was diagnosed with idiopathic normal pressure hydrocephalus (iNPH) and met the criteria for a VP shunt insertion37. The patient presented with a 1 year history of progressive gait and cognitive impairment, with intermittent urinary incontinence. His past medical history was significant for hypertension and the surgical treatment of bladder cancer. A magnetic resonance imaging (MRI) brain evaluation of the patient showed ventriculomegaly with an Evan&#39;s index of 0.41. An MRI evaluation completed 4 years earlier did not demonstrate ventriculomegaly with an Evan&#39;s index of 0.29 (Figure 2). His neurological examination confirmed that he had a wide-based shuffling gait with low steppage and an abnormally slow gait velocity of 0.83 m/s. He had no signs of myelopathy. His Montreal Cognitive Assessment (MoCA) version 7.1 score was 22/30, which confirmed his mild-moderate cognitive impairment. After a 3 day external lumbar drain (ELD) trial with hourly CSF removal to test CSF removal symptom responsiveness, his gait velocity improved to 1.2 m/s and his MoCA score increased by 3 points.

<table><tbody><tr><td>30-degree angle laparoscope&amp;nbsp;</td><td>Stryker</td><td>0502-937-030</td><td></td></tr><tr><td>Barium impregnated proximal catheter&amp;nbsp;</td><td>Medtronic</td><td>41101</td><td></td></tr><tr><td>Bowel grasper</td><td>Richard Wolf</td><td>8393.25</td><td></td></tr><tr><td>Certas Valve inline&amp;nbsp;</td><td>Codman</td><td>82-8800</td><td></td></tr><tr><td>Chloraprep</td><td>3M</td><td>355-S10325/103.25</td><td></td></tr><tr><td>Electrocautery</td><td>Karl Storz</td><td>28160KA</td><td></td></tr><tr><td>Frameless-based neuronavigation system with magnetic tracking (AxiEM)</td><td>Medtronic</td><td>9735428/9734887</td><td></td></tr><tr><td>Hasson trocar&amp;nbsp;</td><td>Applied Medical Inc</td><td>C0R95</td><td></td></tr><tr><td>Ioban</td><td>3M</td><td>6661EZ</td><td></td></tr><tr><td>Monocryl</td><td>Ethicon</td><td>D8550</td><td></td></tr><tr><td>Open barium impregnated proximal catheter&amp;nbsp;</td><td>Medtronic</td><td>23092</td><td></td></tr><tr><td>Pneumatic surgical drill</td><td>Medtronic</td><td>PM100</td><td></td></tr><tr><td>Steri-Strips</td><td>3M</td><td>R1547</td><td></td></tr><tr><td>Video System Endoscopy</td><td>Stryker</td><td>Not Available</td><td></td></tr></tbody></table>

neuronavigation and laparoscopy guided ventriculoperitoneal shunt insertion for the treatment of hydrocephalus

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ventriculoperitoneal (VP) shunt is the most common type. Unfortunately, the failure rates of VP shunts are alarmingly high, with up to 50% of patients requiring revision surgery within 2 years. VP shunt failure may occur due to infection, or catheter mispositioning, migration, and occlusion. We undertook a joint neurosurgery and general surgery collaboration in a 7-year prospective non-randomized consecutive quality improvement cohort study to reduce the rates of ventriculoperitoneal (VP) shunt failures in 224 adult patients at a tertiary care institution. The initiative combined the use of electromagnetic stereotactic neuronavigation to guide the placement of the proximal catheter and laparoscopy to place the distal catheter under direct visualization. With laparoscopic assistance, the distal catheter was anchored through a small hole created in the falciform ligament and placed into the right retrohepatic space, free from the omentum, adhesions, or bowel that might obstruct the catheter tip. The surgeries were performed using a shunt infection prevention protocol to reduce the risk of shunt infections. Here, we present an intraoperative video of the surgical procedure. Compliance with shunt infection reduction strategies and the combined utilization of neuronavigation and laparoscopy techniques in adult VP shunt surgery resulted in a 44% reduction in the risk of overall shunt failure. The significant positive impact with regard to shunt-failure-free patient outcomes among patients who underwent VP shunt surgery using this strategy underscores the value associated with the use of these modern intraoperative techniques and cross-specialty collaboration during VP shunt surgery.

On postoperative day #1, the patient presented in the video underwent a CT of the head and an x-ray of the abdomen (Figure 7). This imaging, respectively, demonstrated optimal proximal catheter placement in the right lateral ventricle and the location of the distal catheter in the peri-hepatic space. At the patient's 3-month and 1-year postoperative clinic assessments following placement of the VP shunt, his gait velocity had improved from a preoperative 0.83 m/s to 1.4 m/s and his MoCA scor...

Watch this Scientific Journal Video about Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus at JoVE.com

Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus

Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor due to high shunt failure rates. We present intraoperative footage of VP shunt insertion using neuronavigation and laparoscopy guidance, with the goal to reduce the risks of proximal and distal shunt catheter failures, respectively.

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ...

neuronavigation-laparoscopy-guided-ventriculoperitoneal-shunt

Research

JoVE Journal

Medicine

6.9K Views.  University of Calgary. Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor due to high shunt failure rates. We present intraoperative footage of VP shunt insertion using neuronavigation and laparoscopy guidance, with the goal to reduce the risks of proximal and distal shunt catheter failures, respectively. 

Video: Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure&#x2014;with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.
In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

A Pipeline for 3D Multimodality Image Integration and Computer-assisted Planning in Epilepsy Surgery

Epilepsy surgery is challenging and the use of 3D multimodality image integration (3DMMI) to aid presurgical planning is well-established. Multimodality image integration can be technically demanding, and is underutilised in clinical practice. We have developed a single software platform for image integration, 3D visualization and surgical planning. Here, our pipeline is described in step-by-step fashion, starting with image acquisition, proceeding through image co-registration, manual segmentation, brain and vessel extraction, 3D visualization and manual planning of stereoEEG (SEEG) implantations. With dissemination of the software this pipeline can be reproduced in other centres, allowing other groups to benefit from 3DMMI. We also describe the use of an automated, multi-trajectory planner to generate stereoEEG implantation plans. Preliminary studies suggest this is a rapid, safe and efficacious adjunct for planning SEEG implantations. Finally, a simple solution for the export of plans and models to commercial neuronavigation systems for implementation of plans in the operating theater is described. This software is a valuable tool that can support clinical decision making throughout the epilepsy surgery pathway.

We describe the steps to use our custom designed software for image integration, visualization and planning in epilepsy surgery.

Epilepsy surgery is challenging and the use of 3D multimodality image integration (3DMMI) to aid presurgical planning is well-established. Multimodality ...

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

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

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

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

Neuroscience

A Spine Robotic-Assisted Navigation System for Pedicle Screw Placement

Pedicle screw implantation has excellent treatment effects and is often used by surgeons in spinal fusion surgery. However, due to the complexity of human body anatomy, this surgical procedure is difficult and challenging, especially in minimally invasive surgery or patients with congenital anomalies and kyphoscoliosis deformity. In addition to the abovementioned factors, the surgical experience and technique of the surgeon also affect the recovery rates and complications of the patients after the surgical operation. Therefore, accurately performing pedicle screw implantation has is a constant topic of common concern for surgeons and patients. In recent years, with the technological development, robot-assisted navigation systems have gradually become adopted. These robot-assisted navigation systems provide surgeons with complete preoperative planning before surgery. The system provides 3D reconstructed images of each vertebra, allowing surgeons to understand the patient&#39;s physiological characteristics more quickly. It also provides 2D images of sagittal, coronal, axial and oblique planes so that surgeons can accurately perform pedicle screw placement plan.
Previous studies have demonstrated the effectiveness of robot-assisted navigation systems for pedicle screw implantation procedures, including accuracy and safety assessments. This step-by-step protocol aims to outline a standardized surgical technique note for robotic-assisted pedicle screw placement.

This article presents a standardized surgical technique for robotic-assisted pedicle screw placement by using robotic-assisted navigational systems. We present a step-by-step protocol and describe the workflow and precautions of this procedure.

Pedicle screw implantation has excellent treatment effects and is often used by surgeons in spinal fusion surgery. However, due to the complexity of human ...

Bioengineering

Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based treatment options for this devastating disease process. In the past decade, a number of minimally invasive surgeries have emerged to address this issue, one of which is endoscopic evacuation. Stereotactic ICH Underwater Blood Aspiration (SCUBA) is a novel endoscopic evacuation technique performed in a fluid-filled cavity using an aspiration system to provide an additional degree of freedom during the procedure. The SCUBA procedure utilizes a suction device, endoscope, and sheath and is divided into two phases. The first phase involves maximal aspiration and minimal irrigation to decrease clot burden. The second phase involves increasing irrigation for visibility, decreasing aspiration strength for targeted aspiration without disturbing the cavity wall, and cauterizing any bleeding vessels. Using the endoscope and aspiration wand, this technique aims to maximize hematoma evacuation while minimizing collateral damage to the surrounding brain. Advantages of the SCUBA technique include the use of a low-profile endoscopic sheath minimizing brain disruption and improved visualization with a fluid-filled cavity rather than an air-filled one.

This paper details the surgical protocol for minimally invasive endoscopic intracerebral hemorrhage evacuation using the SCUBA technique.

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and poor functional outcomes, largely because there are no evidence-based ...

A High-Throughput Image-Guided Stereotactic Neuronavigation and Focused Ultrasound System for Blood-Brain Barrier Opening in Rodents

The blood-brain barrier (BBB) has been a major hurdle for the treatment of various brain diseases. Endothelial cells, connected by tight junctions, form a physiological barrier preventing large molecules (&#62;500 Da) from entering the brain tissue. Microbubble-mediated focused ultrasound (FUS) can be used to induce a transient local BBB opening, allowing larger drugs to enter the brain parenchyma.
In addition to large-scale clinical devices for clinical translation, preclinical research for therapy response assessment of drug candidates requires dedicated small animal ultrasound setups for targeted BBB opening. Preferably, these systems allow high-throughput workflows with both high-spatial precision as well as integrated cavitation monitoring, while still being cost effective in both initial investment and running costs.
Here, we present a bioluminescence and X-ray guided stereotactic small animal FUS system that is based on commercially available components and fulfills the aforementioned requirements. A particular emphasis has been placed on a high degree of automation facilitating the challenges typically encountered in high-volume preclinical drug evaluation studies. Examples of these challenges are the need for standardization in order to ensure data reproducibility, reduce intra-group variability, reduce sample size and thus comply with ethical requirements and decrease unnecessary workload. The proposed BBB system has been validated in the scope of BBB opening facilitated drug delivery trials on patient-derived xenograft models of glioblastoma multiforme and diffuse midline glioma.

The blood-brain barrier (BBB) can be temporarily disrupted with microbubble-mediated focused ultrasound (FUS). Here, we describe a step-by-step protocol for high-throughput BBB opening in vivo using a modular FUS system accessible for non-ultrasound experts.

The blood-brain barrier (BBB) has been a major hurdle for the treatment of various brain diseases. Endothelial cells, connected by tight junctions, form a ...

Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is performed under general anesthesia and neuromonitoring. The patient is placed in a prone position on an operating carbon table. A navigation reference frame is placed percutaneously into the contralateral sacroiliac joint or spinous process. Then, CT scan images are obtained. After instrument registration, the L5-S1 foraminal level is confirmed with a navigated probe, and the entry point is marked. Using an approximately 2 cm skin incision, the subcutaneous tissue and muscles are dissected. The navigated first dilator is aimed at the L5-S1 Kambin&#39;s triangle, and sequential dilation is performed. The 18 mm tube is used and fixed to the frame. The bone around the Kambin&#39;s triangle is removed with a navigated burr. For lateral disc herniation, the L5 nerve root is identified and retracted, and the disc fragment is removed. The navigation-guided tubular endoscopic decompression is an effective procedure. There is no radiation hazard to the surgeon or the operating room staff.

Presented here is a novel technique of C-arm free transtubular posterolateral decompression for lumbar foraminal stenosis and lateral disc herniation under O-arm navigation.

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is ...

Clinical Indications for Rapid Sequence MRI in Pediatric Neurosurgical Patients and the Limitations and Barriers to Implementation

Rapid and fast magnetic resonance imaging (MRI) protocols have become increasingly popular for pediatric neurosurgical patients as they are a great way to reduce ionizing radiation and sedation. While their popularity has increased, there are hurdles to overcome when transitioning to using them clinically, such as cost, staffing training, and motion artifact. Through this paper, we developed a protocol for clinical applications where rapid MRI can be a substitute or adjuvant in diagnostic workup. Further, we outline the relevant literature for the use of RS-MRI for the spine, TBI, and hydrocephalus pathologies while expanding upon the limitations and logistical barriers when transitioning to their use, a few of which are discussed above. Through this, we conclude that RS-MRI can be used diagnostically for spinal pathologies such as syrinx and hydrocephalus. Further, its lack of sensitivity for TBI findings makes rapid sequence magnetic resonance imaging (RS-MRI) a strong adjuvant with other advanced imaging or computed tomography (CT) for traumatic brain injury (TBI) pathologies.

Here, we present a protocol to increase the use of rapid sequence magnetic resonance imaging (RS-MRI) for pediatric patients for spine, traumatic brain injury (TBI), and hydrocephalus while documenting limitations and barriers to universal implementation.

Rapid and fast magnetic resonance imaging (MRI) protocols have become increasingly popular for pediatric neurosurgical patients as they are a great way to ...

Modeling Posthemorrhagic Hydrocephalus of Prematurity in Rats

Posthemorrhagic hydrocephalus of prematurity (PHHP) is a serious sequela of severe intraventricular hemorrhage (IVH) in very preterm infants less than 32 weeks gestational age (GA). PHHP is defined by the accumulation of cerebrospinal fluid (CSF) associated with clinical symptoms of elevated intracranial pressure (ICP). Infants with PHHP suffer lifelong shunt dependence, with half requiring repeat surgery in the first year of life and many requiring multiple additional surgeries throughout the lifespan. Prenatal chorioamnionitis predisposes preterm infants to severe IVH and the need for surgical treatment of PHHP trends with neonatal sepsis. These clinical features suggest that systemic inflammation is an integral component of PHHP pathophysiology. 
Here, we define an animal model that recapitulates all clinical aspects and essential features of PHHP in rats. The goal of this protocol is to illustrate how in utero chorioamnionitis and postnatal IVH using lysed red blood cells can be combined to yield PHHP. This preclinical approach yields progressive macrocephaly and domed craniums, elevated intracranial pressure, and ventriculomegaly that can be detected via magnetic resonance imaging (MRI) or via microscopy. In addition to sustained disruption in CSF dynamics, rats also have cognitive delay and functional disability into adulthood. Accordingly, this preclinical platform facilitates unique and unparalleled translational studies of PHHP that can incorporate molecular, cellular, biochemical, histologic, imaging, and functional outcome measures. It can also be used for rigorous analysis of the choroid plexus, ependymal motile cilia, and glymphatic system in parallel. Last, it can also be an invaluable preclinical tool for the investigation of novel surgical intervention strategies and non-surgical therapeutic approaches for the treatment of hydrocephalus.

Posthemorrhagic hydrocephalus of prematurity (PHHP) can be modeled in neonatal rats by combining chorioamnionitis and intraventricular hemorrhage. The combination of these prenatal and postnatal events accurately recapitulates the clinical hallmarks of PHHP, including macrocephaly, ventriculomegaly, and elevated intracranial pressure, through the lifespan.

Posthemorrhagic hydrocephalus of prematurity (PHHP) is a serious sequela of severe intraventricular hemorrhage (IVH) in very preterm infants less than 32 ...

Endoscopy from Kocher&#39;s Point Enabling Third Ventriculostomy and Pineal Biopsy

Endoscopic Third Ventriculostomy and Pineal Biopsy from a Single Entry Point

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain tumors, which is considerably higher than the &lt;1% seen in adult brain tumors. These tumors can be divided into three main categories: germ cell tumors, parenchymal pineal tumors, and tumors arising from related anatomical structures. Obtaining an accurate and minimally invasive tissue diagnosis is crucial for selecting the most appropriate treatment regimen for patients with pineal gland tumors. This is due to the diverse treatment options available and the potential risks associated with complete resection. In cases where patients present with acute obstructive hydrocephalus caused by a pineal gland tumor, immediate treatment of the hydrocephalus is necessary. The urgency stems from the potential complications of hydrocephalus, including increased intracranial pressure and neurological deficits. To address these challenges, a minimally invasive endoscopic approach provides a valuable opportunity. This technique allows clinicians to promptly relieve hydrocephalus and obtain a histological diagnosis simultaneously. This dual benefit enables a more comprehensive understanding of the tumor and assists in determining the most effective treatment strategy for the patient.

Author Spotlight: A Single-Entry Point Endoscopic Intraventricular Approach for Third Ventriculostomy and Pineal Biopsy

Pineal neoplasms frequently cause obstructive hydrocephalus and require histopathological diagnosis to decide the treatment regimen. They might be treated by surgical resection or chemoradiotherapy according to the pathological diagnosis. As a minimally invasive initial treatment, an endoscopic approach from Kocher's point enables both third ventriculostomy and biopsy.

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain ...