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Hudelist B, Prebot J, Lecarpentier E, Apra C. A realistic aneurysm clipping simulation combining 3D-printed and placenta-based models-how I do it. Acta Neurochir (Wien) 2024; 166:172. [PMID: 38592539 DOI: 10.1007/s00701-024-06068-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/28/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Neurovascular surgery, particularly aneurysm clipping, is a critical skill for aspiring neurosurgeons. However, hands-on training opportunities are limited, especially with the growing popularity of endovascular techniques. To address this challenge, we present a novel neurovascular surgical training station that combines synthetic 3D-printed models with placental vascular structures to create a semi-realistic surgical field. METHODS Our model consists of three components: a 3D-printed skull replica with anatomical landmarks, a malleable silicone parenchyma with a Sylvian fissure, and vascular layers (placenta). The placental vascular layer is catheterized and perfused to replicate pulsatile flow, offering a realistic aneurysm simulation. This innovative training station provides a cost-effective solution (approximately 200 USD once) without ethical constraints. Surgeons can practice essential skills such as Sylvian fissure dissection, managing anatomical constraints like bone, and achieving proximal vascular control. The model's realism allows for training in various scenarios, including clipping with different hand orientations and handling ruptures realistically. CONCLUSION Our neurovascular surgical station bridges the gap between existing training models, offering affordability, ecological considerations, and minimal ethical concerns. It empowers neurosurgery residents to refine their skills in handling both emergencies and elective cases under close-to-real surgical conditions, with the potential for independent practice and senior supervision.
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Affiliation(s)
- Benoit Hudelist
- Neurosurgery Department, UMR 955, Université Paris Est Créteil (UPEC)AP-HP, Henri Mondor HospitalUnitéIMRB, INSERM 15, 94000, Créteil, France.
- Department of Neurosurgery, GHU Paris - Psychiatry and Neuroscience, Sainte-Anne Hospital, Paris, France.
| | - Juliette Prebot
- Service de modélisation et d'impression 3D de l'Assistance Publique - Hopitaux de Paris (PRIM3D), Paris, France
| | - Edouard Lecarpentier
- Department of Obstetrics Gynecology and Reproductive Medicine, Centre Hospitalier Inter-Communal de Créteil, Creteil, France
- Faculté de Santé, Univ Paris Est Créteil, Créteil, France
- INSERM, Institut Cochin, Paris, France
| | - Caroline Apra
- Neurosurgery Department, UMR 955, Université Paris Est Créteil (UPEC)AP-HP, Henri Mondor HospitalUnitéIMRB, INSERM 15, 94000, Créteil, France
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Korotkov D, Rodrigues de Almeida I, Wuo-Silva R, Vilcahuamán Paitán AF, Chaddad-Neto F. Enhancing the Microneurosurgical Training: Development of the Folded Placenta Model for Simulation of the Deep Operative Field Challenges of Cranial Procedures. World Neurosurg 2024; 187:29-34. [PMID: 38593912 DOI: 10.1016/j.wneu.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND OBJECTIVE Neurosurgery relies heavily on advanced manual skills, necessitating effective training models for skill development. While various models have been utilized, the human placenta has emerged as a promising candidate for microneurosurgical training due to its anatomical similarities with cerebral vasculature. However, existing placenta models have primarily focused on simulating superficial procedures, often neglecting the complexities encountered in deep operative fields during cranial surgeries. METHODS This study obtained ethical approval and implemented a modified placenta model to address the limitations of existing training models. The key modification involved folding the placenta and placing it within a rigid container, closely mimicking the structural challenges of cranial procedures. The placenta preparation followed a standardized protocol, including the use of specialized equipment for documentation. RESULTS The primary feature of the modified model is the folded placenta within the rigid container, which replicates cranial anatomy. This innovative approach enables trainees to engage in a comprehensive range of microsurgical exercises, encompassing vessel dissection, aneurysm clipping, tumor resection, and more. The model successfully mirrors the complexities of real cranial procedures, providing a realistic training experience. CONCLUSIONS The presented modified placenta model serves as an effective tool for simulating the conditions encountered in deep cranial surgeries. By accurately replicating the challenges of deep operative fields, the model significantly enhances the training of neurosurgical residents. It successfully prepares trainees to navigate the intricacies and difficulties inherent in real cranial surgeries, thus contributing to improved surgical skills and readiness for neurosurgical practice.
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Affiliation(s)
- Dmitriy Korotkov
- Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Raphael Wuo-Silva
- Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Feres Chaddad-Neto
- Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil.
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3
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Apaza-Tintaya RA, Canache Jiménez LÁ, Salvagni Pereira F, Biondi Soares LG, Tenelema Aguaisa ED, Vilcahuamán Paitán AF, Wuo-Silva R, Chaddad-Neto F. Topographical Systematization of Human Placenta Model for Training in Microneurosurgery. World Neurosurg 2024; 182:e471-e477. [PMID: 38036172 DOI: 10.1016/j.wneu.2023.11.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/23/2023] [Accepted: 11/24/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Neurosurgical training continuously seeks innovative methods to enhance the acquisition of essential technical skills for neurosurgeons worldwide. While various training models have been employed, few truly replicate real-life conditions optimally. Human placenta is a good model for neurosurgical microsurgery training due to its anatomic similarities to neurovascular structures. Placental vessels exhibit a branching pattern and caliber comparable with intracranial vessels, making them suitable for practicing microsurgical techniques. The study aims to delineate the anatomic zones of the placenta and propose a segmented training model, resulting in a reproducible, cost-effective, and realistic neurosurgical microsurgery training environment. METHODS Twenty human placentas were meticulously prepared, injected with dyes, and categorized into zones on the basis of anatomic features. Measurements of placental vessels were recorded and compared with cerebral vessels. The placenta was divided into 4 quadrants to facilitate specific training techniques. RESULTS Our results revealed varying vessel diameters across placental zones, closely resembling cerebral vessels. Different microsurgical techniques were applied to specific placental zones, thereby optimizing training scenarios. The applicability section described exercises such as membrane dissection, vessel skeletonization, aneurysm creation, vascular bypass, and tumor dissection within the placental model, providing detailed guidance on the zones suitable for each exercise. CONCLUSIONS Human placenta serves as an effective microsurgical training model for neurosurgery, enhancing neurosurgeons' skills through anatomic segmentation. Integrating this model into training programs can significantly contribute to skill acquisition and improved surgical outcomes. Further research is warranted to refine and expand its utilization, complemented by clinical experiences and other simulation tools.
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Affiliation(s)
| | | | - Felipe Salvagni Pereira
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | - Raphael Wuo-Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil.
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4
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Höbner LM, Staartjes VE, Colombo E, Sebök M, Regli L, Esposito G. How we do it: the Zurich Microsurgery Lab technique for placenta preparation. Acta Neurochir (Wien) 2023; 165:3821-3824. [PMID: 37993631 PMCID: PMC10739554 DOI: 10.1007/s00701-023-05847-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 10/14/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Perfused placentas provide an excellent and accessible model for microvascular dissection, microsuturing and microanastomosis training - particularly in the early microsurgical learning curve. This way, a significant amount of live animals can be spared. METHOD We present the Zurich Microsurgery Lab protocol, detailing steps for obtaining, selecting, cleaning, flushing, cannulating, and preserving human placentas - as well as microsurgical training examples - in a tried-and-true, safe, cost-effective, and high-yield fashion. CONCLUSION Our technique enables highly realistic microsurgical training (microdissection, microvascular repair, microanastomosis) based on readily available materials. Proper handling, preparation, and preservation of the perfused placenta models is key.
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Affiliation(s)
- Lara Maria Höbner
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Victor E Staartjes
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Elisa Colombo
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Martina Sebök
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Luca Regli
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Giuseppe Esposito
- Zurich Microsurgery Lab, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
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Zambrano-Jerez LC, Díaz-Santamaría KD, Rodríguez-Santos MA, Alarcón-Ariza DF, Meléndez-Flórez GL, Ramírez-Blanco MA. Dye-Perfused Human Placenta for Simulation in a Microsurgery Laboratory for Plastic Surgeons. Arch Plast Surg 2023; 50:627-634. [PMID: 38143834 PMCID: PMC10736195 DOI: 10.1055/a-2113-4182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/15/2023] [Indexed: 12/26/2023] Open
Abstract
In recent decades, a number of simulation models for microsurgical training have been published. The human placenta has received extensive validation in microneurosurgery and is a useful instrument to facilitate learning in microvascular repair techniques as an alternative to using live animals. This study uses a straightforward, step-by-step procedure for instructing the creation of simulators with dynamic flow to characterize the placental vascular tree and assess its relevance for plastic surgery departments. Measurements of the placental vasculature and morphological characterization of 18 placentas were made. After the model was used in a basic microsurgery training laboratory session, a survey was given to nine plastic surgery residents, two microsurgeons, and one hand surgeon. In all divisions, venous diameters were larger than arterial diameters, with minimum diameters of 0.8 and 0.6 mm, respectively. The majority of the participants considered that the model faithfully reproduces a real microsurgical scenario; the consistency of the vessels and their dissection are similar in in vivo tissue. Furthermore, all the participants considered that this model could improve their surgical technique and would propose it for microsurgical training. As some of the model's disadvantages, an abundantly thick adventitia, a thin tunica media, and higher adherence to the underlying tissue were identified. The color-perfused placenta is an excellent tool for microsurgical training in plastic surgery. It can faithfully reproduce a microsurgical scenario, offering an abundance of vasculature with varying sizes similar to tissue in vivo, enhancing technical proficiency, and lowering patient error.
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Affiliation(s)
- Laura C. Zambrano-Jerez
- Division of Plastic and Reconstructive Surgery, Universidad Industrial de Santander, Hospital Universitario de Santander, Santander, Colombia
| | - Karen D. Díaz-Santamaría
- Division of Plastic and Reconstructive Surgery, Universidad Industrial de Santander, Hospital Universitario de Santander, Santander, Colombia
| | - María A. Rodríguez-Santos
- Division of Plastic and Reconstructive Surgery, Universidad Industrial de Santander, Hospital Universitario de Santander, Santander, Colombia
| | - Diego F. Alarcón-Ariza
- Division of Plastic and Reconstructive Surgery, Universidad Industrial de Santander, Hospital Internacional de Colombia, Santander, Colombia
| | - Genny L. Meléndez-Flórez
- Division of Plastic and Reconstructive Surgery, Universidad Industrial de Santander, Hospital Universitario de Santander, Santander, Colombia
| | - Mónica A. Ramírez-Blanco
- Division of Plastic and Reconstructive Surgery, Universidad Industrial de Santander, Hospital Internacional de Colombia, Santander, Colombia
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Fava A, Gorgoglione N, De Angelis M, Esposito V, di Russo P. Key role of microsurgical dissections on cadaveric specimens in neurosurgical training: Setting up a new research anatomical laboratory and defining neuroanatomical milestones. Front Surg 2023; 10:1145881. [PMID: 36969758 PMCID: PMC10033783 DOI: 10.3389/fsurg.2023.1145881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/13/2023] [Indexed: 03/12/2023] Open
Abstract
IntroductionNeurosurgery is one of the most complex surgical disciplines where psychomotor skills and deep anatomical and neurological knowledge find their maximum expression. A long period of preparation is necessary to acquire a solid theoretical background and technical skills, improve manual dexterity and visuospatial ability, and try and refine surgical techniques. Moreover, both studying and surgical practice are necessary to deeply understand neuroanatomy, the relationships between structures, and the three-dimensional (3D) orientation that is the core of neurosurgeons' preparation. For all these reasons, a microsurgical neuroanatomy laboratory with human cadaveric specimens results in a unique and irreplaceable training tool that allows the reproduction of patients' positions, 3D anatomy, tissues' consistencies, and step-by-step surgical procedures almost identical to the real ones.MethodsWe describe our experience in setting up a new microsurgical neuroanatomy lab (IRCCS Neuromed, Pozzilli, Italy), focusing on the development of training activity programs and microsurgical milestones useful to train the next generation of surgeons. All the required materials and instruments were listed.ResultsSix competency levels were designed according to the year of residency, with training exercises and procedures defined for each competency level: (1) soft tissue dissections, bone drilling, and microsurgical suturing; (2) basic craniotomies and neurovascular anatomy; (3) white matter dissection; (4) skull base transcranial approaches; (5) endoscopic approaches; and (6) microanastomosis. A checklist with the milestones was provided.DiscussionMicrosurgical dissection of human cadaveric specimens is the optimal way to learn and train on neuroanatomy and neurosurgical procedures before performing them safely in the operating room. We provided a “neurosurgery booklet” with progressive milestones for neurosurgical residents. This step-by-step program may improve the quality of training and guarantee equal skill acquisition across countries. We believe that more efforts should be made to create new microsurgical laboratories, popularize the importance of body donation, and establish a network between universities and laboratories to introduce a compulsory operative training program.
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Affiliation(s)
- Arianna Fava
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Italy
- Department of Neuroscience, Sapienza University, Rome, Italy
- Correspondence: Arianna Fava
| | | | | | - Vincenzo Esposito
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Italy
- Department of Neuroscience, Sapienza University, Rome, Italy
| | - Paolo di Russo
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Italy
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7
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Belykh E, Abramov I, Bardonova L, Patel R, McBryan S, Enriquez Bouza L, Majmundar N, Zhao X, Byvaltsev VA, Johnson SA, Singla A, Gupta G, Sun H, Liu JK, Nanda A, Preul MC, Lawton MT. Seven bypasses simulation set: description and validity assessment of novel models for microneurosurgical training. J Neurosurg 2023; 138:732-739. [PMID: 35932275 DOI: 10.3171/2022.5.jns22465] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Microsurgical training remains indispensable to master cerebrovascular bypass procedures, but simulation models for training that accurately replicate microanastomosis in narrow, deep-operating corridors are lacking. Seven simulation bypass scenarios were developed that included head models in various surgical positions with premade approaches, simulating the restrictions of the surgical corridors and hand positions for microvascular bypass training. This study describes these models and assesses their validity. METHODS Simulation models were created using 3D printing of the skull with a designed craniotomy. Brain and external soft tissues were cast using a silicone molding technique from the clay-sculptured prototypes. The 7 simulation scenarios included: 1) temporal craniotomy for a superficial temporal artery (STA)-middle cerebral artery (MCA) bypass using the M4 branch of the MCA; 2) pterional craniotomy and transsylvian approach for STA-M2 bypass; 3) bifrontal craniotomy and interhemispheric approach for side-to-side bypass using the A3 branches of the anterior cerebral artery; 4) far lateral craniotomy and transcerebellomedullary approach for a posterior inferior cerebellar artery (PICA)-PICA bypass or 5) PICA reanastomosis; 6) orbitozygomatic craniotomy and transsylvian-subtemporal approach for a posterior cerebral artery bypass; and 7) extended retrosigmoid craniotomy and transcerebellopontine approach for an occipital artery-anterior inferior cerebellar artery bypass. Experienced neurosurgeons evaluated each model by practicing the aforementioned bypasses on the models. Face and content validities were assessed using the bypass participant survey. RESULTS A workflow for model production was developed, and these models were used during microsurgical courses at 2 neurosurgical institutions. Each model is accompanied by a corresponding prototypical case and surgical video, creating a simulation scenario. Seven experienced cerebrovascular neurosurgeons practiced microvascular anastomoses on each of the models and completed surveys. They reported that actual anastomosis within a specific approach was well replicated by the models, and difficulty was comparable to that for real surgery, which confirms the face validity of the models. All experts stated that practice using these models may improve bypass technique, instrument handling, and surgical technique when applied to patients, confirming the content validity of the models. CONCLUSIONS The 7 bypasses simulation set includes novel models that effectively simulate surgical scenarios of a bypass within distinct deep anatomical corridors, as well as hand and operator positions. These models use artificial materials, are reusable, and can be implemented for personal training and during microsurgical courses.
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Affiliation(s)
- Evgenii Belykh
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.,2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Irakliy Abramov
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Liudmila Bardonova
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ruchi Patel
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Sarah McBryan
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Lara Enriquez Bouza
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Neil Majmundar
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.,2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Xiaochun Zhao
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Stephen A Johnson
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Amit Singla
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Gaurav Gupta
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Hai Sun
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - James K Liu
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Anil Nanda
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Mark C Preul
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Campero A, Baldoncini M, Martinez J, Villalonga JF, Lucifero AG, Luzzi S. Microneurosurgical management of aneurysms of the A1 segment of the anterior cerebral artery: Anatomy and surgical technique. Surg Neurol Int 2022; 13:310. [PMID: 35928319 PMCID: PMC9345093 DOI: 10.25259/sni_68_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/29/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Aneurysms of the A1 segment of the anterior cerebral artery (ACA) are rare and have characteristics differentiating them from other intracranial aneurysms. Their microsurgical management is challenging and requires different strategies. In this article, we review the surgical anatomy of the A1 segment of the ACA with cadaveric dissections and describe the microsurgical management of complex A1 aneurysms with illustrative cases. Methods: A right pterional craniotomy and Sylvian dissection were performed on a formalin-fixed and silicone-injected cadaver head to depict the key anatomic structures and surgical corridors for microsurgical clipping of A1 segment aneurysms. The microneurosurgical management of ruptured and unruptured aneurysms of the A1 segment of the ACA is described with case illustrations. Results: The A1 segment of the ACA can be subdivided into proximal, middle, and distal subsegments, the former having abundant perforating branches. Both patients treated with microsurgical clipping had excellent and durable outcomes and postoperative cerebral angiograms showed complete aneurysm occlusion. Conclusion: Small A1 aneurysms may require early treatment as their rupture risk appears to be higher. A1 aneurysms are usually embedded in perforators, especially those arising from the proximal A1 subsegment, and require careful distal to proximal microdissection and strategic placement of the aneurysm clip blades. The approach, arachnoid dissection, and angles of attack are carefully planned after accounting for the aneurysm dome projection, precise location of the aneurysm neck and perforators, and the presence or absence of subarachnoid hemorrhage.
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Affiliation(s)
- Alvaro Campero
- Department of Neurosurgery, LINT, Facultad de Medicina, Universidad Nacional de Tucumán,
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina
| | - Matías Baldoncini
- Department of Neurological Surgery, Hospital San Fernando, Argentina
- Laboratory of Microsurgical Neuroanatomy, Second Chair of Gross Anatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina,
| | - Jaime Martinez
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA,
| | - Juan F. Villalonga
- Department of Neurosurgery, LINT, Facultad de Medicina, Universidad Nacional de Tucumán,
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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9
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Paraclinoid aneurysms: Outcome analysis and technical remarks of a microsurgical series. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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10
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Baldoncini M, Luzzi S, Giotta Lucifero A, Flores-Justa A, González-López P, Campero A, Villalonga JF, Lawton MT. Optic Foraminotomy for Clipping of Superior Carotid-Ophthalmic Aneurysms. Front Surg 2021; 8:681115. [PMID: 34957196 PMCID: PMC8695686 DOI: 10.3389/fsurg.2021.681115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Carotid-ophthalmic aneurysms usually cause visual problems. Its surgical treatment is challenging because of its anatomically close relations to the optic nerve, carotid artery, ophthalmic artery, anterior clinoid process, and cavernous sinus, which hinder direct access. Despite recent technical advancements enabling risk reduction of this complication, postoperative deterioration of visual function remains a significant problem. Therefore, the goal of preserving and/or improving the visual outcome persists as a paramount concern. Objective: We propose optic foraminotomy as an alternative microsurgical technique for dorsal carotid-ophthalmic aneurysms clipping. As a secondary objective, the step by step of that technique and its benefits are compared to the current approach of anterior clinoidectomy. Methods: We present as an example two patients with superior carotid-ophthalmic aneurysms in which the standard pterional craniotomy, transsylvian approach, and optic foraminotomy were performed. Surgical techniques are presented and discussed in detail with the use of skull base dissections, microsurgical images, and original drawings. Results: Extensive opening of the optic canal and optic nerve sheath was successfully achieved in all patients allowing a working angle with the carotid artery for correct visualization of the aneurysm and further clipping. Significant visual acuity improvement occurred in both patients because of decompression of the optic nerve. Conclusion: Optic foraminotomy is an easy and recommended technique for exposing and treating superior carotid-ophthalmic aneurysms and allowing optic nerve decompression during the first stages of the procedure. It shows several advantages over the current anterior clinoidectomy technique regarding surgical exposure and facilitating visual improvement.
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Affiliation(s)
- Matias Baldoncini
- Department of Neurological Surgery, San Fernando Hospital, Buenos Aires, Argentina.,Laboratory of Microsurgical Neuroanatomy, Second Chair of Gross Anatomy, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Ana Flores-Justa
- Department of Neurosurgery, University General Hospital of Alicante, Alicante, Spain
| | - Pablo González-López
- Department of Neurosurgery, University General Hospital of Alicante, Alicante, Spain
| | - Alvaro Campero
- Department of Neurological Surgery, Padilla Hospital, Tucumán, Argentina
| | - Juan F Villalonga
- Department of Neurological Surgery, Padilla Hospital, Tucumán, Argentina
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
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11
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Giotta Lucifero A, Gragnaniello C, Baldoncini M, Campero A, Savioli G, Tartaglia N, Ambrosi A, Luzzi S. Rating the incidence of iatrogenic vascular injuries in thoracic and lumbar spine surgery as regards the approach: A PRISMA-based literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3172-3190. [PMID: 34410504 DOI: 10.1007/s00586-021-06956-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/02/2021] [Accepted: 08/06/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess the rate, timing of diagnosis, and repairing strategies of vascular injuries in thoracic and lumbar spine surgery as their relationship to the approach. METHODS PubMed, Medline, and Embase databases were utilized for a comprehensive literature search based on keywords and mesh terms to find articles reporting iatrogenic vascular injury during thoracic and lumbar spine surgery. English articles published in the last ten years were selected. The search was refined based on best match and relevance. RESULTS Fifty-six articles were eligible, for a cumulative volume of 261 lesions. Vascular injuries occurred in 82% of instrumented procedures and in 59% during anterior approaches. The common iliac vein (CIV) was the most involved vessel, injured in 49% of anterior lumbar approaches. Common iliac artery, CIV, and aorta were affected in 40%, 28%, and 28% of posterior approaches, respectively. Segmental arteries were injured in 68% of lateral approaches. Direct vessel laceration occurred in 81% of cases and recognized intraoperatively in 39% of cases. CONCLUSIONS Incidence of iatrogenic vascular injuries during thoracic and lumbar spine surgery is low but associated with an overall mortality rate up to 65%, of which less than 1% for anterior approaches and more than 50% for posterior ones. Anterior approaches for instrumented procedures are at risk of direct avulsion of CIV. Posterior instrumented fusions are at risk for injuries of iliac vessels and aorta. Lateral routes are frequently associated with lesions of segmental vessels. Suture repair and endovascular techniques are useful in the management of these severe complications.
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Affiliation(s)
- Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Neurosurgery Unit, University of Pavia, Polo Didattico "Cesare Brusotti", Viale Brambilla, 74, 27100, Pavia, Italy
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Il 1200 W Harrison St, Chicago, IL, 60607, USA
| | - Matias Baldoncini
- Laboratory of Neuroanatomic Microsurgical-LaNeMic-II Division of Anatomy, School of Medicine, University of Buenos Aires, CABA C1053, Buenos Aires, Argentina
| | - Alvaro Campero
- LINT, Facultad de Medicina, Universidad Nacional de Tucumán, T4000, Tucumán, Argentina.,Department of Neurological Surgery, Hospital Padilla, T4000, Tucumán, Argentina
| | - Gabriele Savioli
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100, Pavia, Italy.,PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Polo Didattico "Cesare Brusotti", Viale Brambilla, 74, 27100, Pavia, Italy
| | - Nicola Tartaglia
- Department of Medical and Surgical Sciences, University of Foggia, Italy Via A.Gramsci 89/91, 71100, Foggia, Italy
| | - Antonio Ambrosi
- Department of Medical and Surgical Sciences, University of Foggia, Italy Via A.Gramsci 89/91, 71100, Foggia, Italy
| | - Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Neurosurgery Unit, University of Pavia, Polo Didattico "Cesare Brusotti", Viale Brambilla, 74, 27100, Pavia, Italy. .,Department of Surgical Sciences, Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100, Pavia, Italy.
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The Preoperative Functional Downgrading of Brain AVMs. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33973037 DOI: 10.1007/978-3-030-63453-7_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
The actual role of preoperative embolization of brain arteriovenous malformations (AVMs) is undervalued.The present study aims to describe the effectiveness, safety, technics, and results of the endovascular-based functional downgrading of brain AVMs.Data regarding 31 Spetzler-Martin (SM) grade III AVMs that consecutively underwent a combined endovascular-surgical treatment were reviewed. Clinical and radiological outcomes were evaluated according to modified Ranking Scale score (mRS) and postoperative angiography, respectively.Low-density Onyx was used in all cases, and the timeframe between the embolizations was 10-15 days. Procedures were 1.6 (±0.6) on average. Superselective nidal catheterization was essential to reach the deepest parts of the AVMs, which were the targets. Onyx made the nidus compact and easier to dissect. The Average obliteration rate was 29.6%, with negligible morbidity. Surgery was performed after 3.7 days on average and the AVM exclusion was complete in 83.4% of cases. An mRS score between 0 and 2 was reported in 77.5% of patients, while the best outcome was achieved in small and medium-deep malformations.An effective and safe functional downgrading of brain AVMs must be based upon specific technical key aspects, which make surgery easier and, ultimately, allow for the achievement of the best outcome.
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Luzzi S, Del Maestro M, Galzio R. Posterior Circulation Aneurysms: A Critical Appraisal of a Surgical Series in Endovascular Era. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 132:39-45. [PMID: 33973027 DOI: 10.1007/978-3-030-63453-7_6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The advent of the endovascular era has apparently decreased the role of microneurosurgery for many of the posterior circulation aneurysms. This study consists of a critical appraisal of a retrospective surgical series regarding posterior circulation aneurysms, targeted to define whether microneurosurgery still has a role for some of these. In 28 years, 157 aneurysms were surgically treated, 98 of which ruptured. The Average patient age was 56.7 ± 14.2 years, while in hemorrhagic cases, the mean Hunt-Hess score was 2.17 ± 0.8. Basilar tip, vertebral artery and proximal posterior inferior cerebellar artery were the most frequently involved sites. The treatment consisted of 128 clippings, 19 trappings, 7 wrappings, and 3 bypasses. A total exclusion was achieved in 88.5% of the aneurysms. An average follow-up of 67.1 ± 61.3 months proved no recurrences. The best results were observed in patients <65 years old who harbored small-to-regular aneurysms of the basilar tip, distal cerebellar arteries, or vertebral artery.Clipping proved to be a definitive and durable treatment for a large part of posterior circulation aneurysms, whereas bypass allows for treating aneurysms not amenable for coiling, stenting, or clipping. The present study confirms that microneurosurgery continues to have a paramount role within neurovascular pathology.
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Affiliation(s)
- Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy. .,Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Mattia Del Maestro
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Renato Galzio
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Microneurosurgical Management of Posterior Inferior Cerebellar Artery Aneurysms: Results of a Consecutive Series. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 132:33-38. [PMID: 33973026 DOI: 10.1007/978-3-030-63453-7_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aneurysms of the posterior inferior cerebellar artery (PICA) are uncommon. The complex anatomy of PICA and its intimate relationships with medulla, lower cranial nerves, and jugular tubercle makes the surgical treatment of these aneurysms fascinating. The reported is study aimed at a critical review of the overall results of a personal series of PICA aneurysms, treated by the senior author, R. Galzio. Demographics, charts, videos, outcome, and follow-up of a cohort of PICA aneurysms managed in the last 10 years were retrospectively analyzed, focusing only upon those treated with microneurosurgery. Twenty-five patients, harboring a single aneurysm, were operated on. Fifteen aneurysms were ruptured. Nineteen were proximal, all of these being been treated through a far-lateral approach. Trans-condylar or trans-tubercular variants were rarely necessary and however reserved to peculiar cases. Twenty-three aneurysms underwent direct treatment consisting of clip ligation. At 6-month follow-up, 60% of patients had a modified Rankin Score (mRS) of 0-2. Given the high anatomical variability of both PICA and patients' bony anatomy, a case-by-case meticulous preoperative imaging evaluation is mandatory for the choice of the most suitable and tailored surgical corridor which, in turn, is pivotal to achieve the best outcome.
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Luzzi S, Del Maestro M, Galzio R. Microneurosurgery for Paraclinoid Aneurysms in the Context of Flow Diverters. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 132:47-53. [PMID: 33973028 DOI: 10.1007/978-3-030-63453-7_7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The advent of flow diverter (FD) stents has apparently reduced the role of microneurosurgery for paraclinoid aneurysms despite sparse high-quality evidence about their long-term effects.The present study critically reviews the overall results of a microneurosurgical series of 57 paraclinoid aneurysms.Of these aneurysms, 47.4% were regular in size while 19.3 were giant. Barami type I was predominant. In 21 aneurysms a hemorrhagic onset occurred. Pterional approach with intradural anterior clinoidectomy was preferred by far. Clipping was possible in 91.2% of aneurysms and a high-flow bypass was the choice in five cases. An mRS of 0-2 was achieved in 77.3% of patients, typically <50 years old.Visual field appeared improved or unchanged in 36.3% and 63.6% of the symptomatic patients, respectively. In 76.1% of incidental aneurysms, campimetry was unaffected by surgery.A complete aneurysm exclusion was achieved in 93% of cases using a single procedure. No recurrences were documented on an average follow-up of 54.1 ± 34 months.Microneurosurgery is still a valuable, definitive, and durable option for Barami type Ia, Ib, or II paraclinoid aneurysm, especially in patients <50 years old and visually symptomatic. Conditions other than these are ideal candidates for FD stents.
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Affiliation(s)
- Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy. .,Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Mattia Del Maestro
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Renato Galzio
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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