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Legeza PT, Lettenberger AB, Murali B, Johnson LR, Berczeli M, Byrne MD, Britz G, O'Malley MK, Lumsden AB. Evaluation of Robotic-Assisted Carotid Artery Stenting in a Virtual Model Using Motion-Based Performance Metrics. J Endovasc Ther 2024; 31:457-465. [PMID: 36147025 DOI: 10.1177/15266028221125592] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE Robotic-assisted carotid artery stenting (CAS) cases have been demonstrated with promising results. However, no quantitative measurements have been made to compare manual with robotic-assisted CAS. This study aims to quantify surgical performance using tool tip kinematic data and metrics of precision during CAS with manual and robotic control in an ex vivo model. MATERIALS AND METHODS Transfemoral CAS cases were performed in a high-fidelity endovascular simulator. Participants completed cases with manual and robotic techniques in 2 different carotid anatomies in random order. C-arm angulations, table position, and endovascular devices were standardized. Endovascular tool tip kinematic data were extracted. We calculated the spectral arc length (SPARC), average velocity, and idle time during navigation in the common carotid artery and lesion crossing. Procedural time, fluoroscopy time, movements of the deployed filter wire, precision of stent, and balloon positioning were recorded. Data were analyzed and compared between the 2 modalities. RESULTS Ten participants performed 40 CAS cases with a procedural success of 100% and 0% residual stenosis. The median procedural time was significantly higher during the robotic-assisted cases (seconds, median [interquartile range, IQR]: 128 [49.5] and 161.5 [62.5], p=0.02). Fluoroscopy time differed significantly between manual and robotic-assisted procedures (seconds, median [IQR]: 81.5 [32] and 98.5 [39.5], p=0.1). Movement of the deployed filter wire did not show significant difference between manual and robotic interventions (mm, median [IQR]: 13 [10.5] and 12.5 [11], p=0.5). The postdilation balloon exceeded the margin of the stent with a median of 2 [1] mm in both groups. Navigation with robotic assistance showed significantly lower SPARC values (-5.78±3.14 and -8.63±3.98, p=0.04) and higher idle time values (8.92±8.71 and 3.47±3.9, p=0.02) than those performed manually. CONCLUSIONS Robotic-assisted and manual CAS cases are comparable in the precision of stent and balloon positioning. Navigation in the carotid artery is associated with smoother motion and higher idle time values. These findings highlight the accuracy and the motion stabilizing capability of the endovascular robotic system. CLINICAL IMPACT Robotic assistance in the treatment of peripheral vascular disease is an emerging field and may be a tool for radiation protection and the geographic distribution of endovascular interventions in the future. This preclinical study compares the characteristics of manual and robotic-assisted carotid stenting (CAS). Our results highlight, that robotic-assisted CAS is associated with precise navigation and device positioning, and smoother navigation compared to manual CAS.
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Affiliation(s)
- Peter T Legeza
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Ahalya B Lettenberger
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Barathwaj Murali
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Lianne R Johnson
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Marton Berczeli
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Michael D Byrne
- Department of Psychological Sciences, Rice University, Houston, TX, USA
| | - Gavin Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Marcia K O'Malley
- Department of Mechanical Engineering, Mechatronics and Haptic Interfaces Laboratory, Rice University, Houston, TX, USA
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
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2
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Denny MC, Rosendale N, Gonzales NR, Leslie-Mazwi TM, Middleton S. Addressing Disparities in Acute Stroke Management and Prognosis. J Am Heart Assoc 2024; 13:e031313. [PMID: 38529656 DOI: 10.1161/jaha.123.031313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/03/2024] [Indexed: 03/27/2024]
Abstract
There are now abundant data demonstrating disparities in acute stroke management and prognosis; however, interventions to reduce these disparities remain limited. This special report aims to provide a critical review of the current landscape of disparities in acute stroke care and highlight opportunities to use implementation science to reduce disparities throughout the early care continuum. In the prehospital setting, stroke symptom recognition campaigns that have been successful in reducing prehospital delays used a multilevel approach to education, including mass media, culturally tailored community education, and professional education. The mobile stroke unit is an organizational intervention that has the potential to provide more equitable access to timely thrombolysis and thrombectomy treatments. In the hospital setting, interventions to address implicit biases among health care providers in acute stroke care decision-making are urgently needed as part of a multifaceted approach to advance stroke equity. Implementing stroke systems of care interventions, such as evidence-based stroke care protocols at designated stroke centers, can have a broader public health impact and may help reduce geographic, racial, and ethnic disparities in stroke care, although further research is needed. The long-term impact of disparities in acute stroke care cannot be underestimated. The consistent trend of longer time to treatment for Black and Hispanic people experiencing stroke has direct implications on long-term disability and independence after stroke. A learning health system model may help expedite the translation of evidence-based interventions into clinical practice to reduce disparities in stroke care.
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Affiliation(s)
- M Carter Denny
- Department of Neurology Georgetown University School of Medicine Washington DC USA
- Department of Neurology, MedStar Health Washington DC USA
| | - Nicole Rosendale
- Department of Neurology University of California San Francisco San Francisco CA USA
- Weill Institute for Neurosciences, University of California San Francisco San Francisco CA USA
| | - Nicole R Gonzales
- Department of Neurology University of Colorado Anschutz Medical Campus Aurora CO USA
| | | | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University Darlinghurst Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University Darlinghurst Australia
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3
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Ghosh R, Wong K, Zhang YJ, Britz GW, Wong STC. Automated catheter segmentation and tip detection in cerebral angiography with topology-aware geometric deep learning. J Neurointerv Surg 2024; 16:290-295. [PMID: 37344174 DOI: 10.1136/jnis-2023-020300] [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: 03/07/2023] [Accepted: 04/20/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Visual perception of catheters and guidewires on x-ray fluoroscopy is essential for neurointervention. Endovascular robots with teleoperation capabilities are being developed, but they cannot 'see' intravascular devices, which precludes artificial intelligence (AI) augmentation that could improve precision and autonomy. Deep learning has not been explored for neurointervention and prior works in cardiovascular scenarios are inadequate as they only segment device tips, while neurointervention requires segmentation of the entire structure due to coaxial devices. Therefore, this study develops an automatic and accurate image-based catheter segmentation method in cerebral angiography using deep learning. METHODS Catheters and guidewires were manually annotated on 3831 fluoroscopy frames collected prospectively from 40 patients undergoing cerebral angiography. We proposed a topology-aware geometric deep learning method (TAG-DL) and compared it with the state-of-the-art deep learning segmentation models, UNet, nnUNet and TransUNet. All models were trained on frontal view sequences and tested on both frontal and lateral view sequences from unseen patients. Results were assessed with centerline Dice score and tip-distance error. RESULTS The TAG-DL and nnUNet models outperformed TransUNet and UNet. The best performing model was nnUNet, achieving a mean centerline-Dice score of 0.98 ±0.01 and a median tip-distance error of 0.43 (IQR 0.88) mm. Incorporating digital subtraction masks, with or without contrast, significantly improved performance on unseen patients, further enabling exceptional performance on lateral view fluoroscopy despite not being trained on this view. CONCLUSIONS These results are the first step towards AI augmentation for robotic neurointervention that could amplify the reach, productivity, and safety of a limited neurointerventional workforce.
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Affiliation(s)
- Rahul Ghosh
- Systems Medicine and Bioengineering, Houston Methodist Research Institute, Houston, Texas, USA
- Biomedical Engineering, Texas A&M University System, College Station, Texas, USA
| | - Kelvin Wong
- Systems Medicine and Bioengineering, Houston Methodist Research Institute, Houston, Texas, USA
- Texas A&M University School of Medicine, Bryan, Texas, USA
| | | | - Gavin W Britz
- Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
- Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Stephen T C Wong
- Systems Medicine and Bioengineering, Houston Methodist Research Institute, Houston, Texas, USA
- Texas A&M University School of Medicine, Bryan, Texas, USA
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Consoli A, Cancelliere NM, Charbonnier G, Spears J, Marotta TR, Pereira VM. Perspectives on Remote Robotic-Assisted Stroke Treatment: A Commentary Paper. AJNR Am J Neuroradiol 2024:ajnr.A8085. [PMID: 38216300 DOI: 10.3174/ajnr.a8085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/26/2023] [Indexed: 01/14/2024]
Abstract
The proved feasibility of robotic-assisted endovascular treatment of intracranial aneurysms has stimulated the idea of a potential application of remote robotics for the treatment of acute ischemic stroke. The possibility of developing a more advanced remote-controlled robotic system capable of performing a complete mechanical thrombectomy procedure would help bridge the health care gap of lack of technical expertise in isolated areas. This possibility could allow a more equitable access to mechanical thrombectomy to a larger number of patients and be a breakthrough for acute ischemic stroke care worldwide. Many aspects around the technical, human, financial, and regulatory requirements should be discussed to implement remote robotic-assisted procedures. In this State of Practice article, we aimed to outline the major challenges that must be considered, as well as proposed solutions. However, different solutions may be applied in different health care systems on the basis of the availability of human and financial resources.
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Affiliation(s)
- Arturo Consoli
- From the Diagnostic and Interventional Neuroradiology Department (A.C.), Foch Hospital, Suresnes, France
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Nicole Mariantonia Cancelliere
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Guillaume Charbonnier
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Interventional Neuroradiology Department (G.C.), Besançon University Hospital, Besançon, France
| | - Julian Spears
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Thomas R Marotta
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology (T.R.M.), Department of Medical Imaging, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vitor Mendes Pereira
- Division of Neurosurgery (A.C., N.M.C., G.C., J.S., T.R.M., V.M.P.), Department of Surgery, RADIS Lab, Li Ka-shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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5
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Morrison JD, Joshi KC, Beer Furlan A, Kolb B, Radaideh Y, Munich S, Crowley W, Chen M. Feasibility of robotic neuroendovascular surgery. Interv Neuroradiol 2023:15910199221097898. [PMID: 37543370 DOI: 10.1177/15910199221097898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Several recent reports of CorPath GRX vascular robot (Cordinus Vascular Robotics, Natick, MA) use intracranially suggest feasibility of neuroendovascular application. Further use and development is likely. During this progression it is important to understand endovascular robot feasibility principles established in cardiac and peripheral vascular literature which enabled extension intracranially. Identification and discussion of robotic proof of concept principals from sister disciplines may help guide safe and accountable neuroendovascular application. OBJECTIVE Summarize endovascular robotic feasibility principals established in cardiac and peripheral vascular literature relevant to neuroendovascular application. METHODS Searches of PubMed, Scopus and Google Scholar were conducted under PRISMA guidelines1 using MeSH search terms. Abstracts were uploaded to Covidence citation review (Covidence, Melbourne, AUS) using RIS format. Pertinent articles underwent full text review and findings are presented in narrative and tabular format. RESULTS Search terms generated 1642 articles; 177, 265 and 1200 results for PubMed, Scopus and Google Scholar respectively. With duplicates removed, title review identified 176 abstracts. 55 articles were included, 45 from primary review and 10 identified during literature review. As it pertained to endovascular robotic feasibility proof of concept 12 cardiac, 3 peripheral vascular and 5 neuroendovascular studies were identified. CONCLUSIONS Cardiac and peripheral vascular literature established endovascular robot feasibility and efficacy with equivalent to superior outcomes after short learning curves while reducing radiation exposure >95% for the primary operator. Limitations of cost, lack of haptic integration and coaxial system control continue, but as it stands neuroendovascular robotic implementation is worth continued investigation.
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Affiliation(s)
- Joseph D Morrison
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Krishna C Joshi
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Andre Beer Furlan
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Bradley Kolb
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Yazan Radaideh
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Stephan Munich
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Webster Crowley
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Michael Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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Calixte A, Lartigue S, McGaugh S, Mathelier M, Patel A, Siyanaki MRH, Pierre K, Lucke-Wold B. Neurointerventional Radiology: History, Present and Future. JOURNAL OF RADIOLOGY AND ONCOLOGY 2023; 7:26-32. [PMID: 37795208 PMCID: PMC10550195 DOI: 10.29328/journal.jro.1001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Neurointerventional Radiology (NIR), encompassing neuroendovascular surgery, endovascular neurosurgery, and interventional neurology, is an innovative and rapidly evolving multidisciplinary specialty focused on minimally invasive therapies for a wide range of neurological disorders. This review provides a comprehensive overview of NIR, discussing the three routes into the field, highlighting their distinct training paradigms, and emphasizing the importance of unified approaches through organizations like the Society of Neurointerventional Surgery (SNIS). The paper explores the benefits of co-managed care and its potential to improve patient outcomes, as well as the role of interdisciplinary collaboration and cross-disciplinary integration in advancing the field. We discuss the various contributions of neurosurgery, radiology, and neurology to cerebrovascular surgery, aiming to inform and educate those interested in pursuing a career in neurointervention. Additionally, the review examines the adoption of innovative technologies such as robotic-assisted techniques and artificial intelligence in NIR, and their implications for patient care and the future of the specialty. By presenting a comprehensive analysis of the field of neurointervention, we hope to inspire those considering a career in this exciting and rapidly advancing specialty, and underscore the importance of interdisciplinary collaboration in shaping its future.
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Affiliation(s)
- Andre Calixte
- New York Medical College, Valhalla, New York, 10595, USA
| | - Schan Lartigue
- New York Medical College, Valhalla, New York, 10595, USA
| | - Scott McGaugh
- University of Florida College of Medicine, Gainesville, Florida, 32608, USA
| | - Michael Mathelier
- University of Florida College of Medicine, Gainesville, Florida, 32608, USA
| | - Anjali Patel
- University of Florida College of Medicine, Gainesville, Florida, 32608, USA
| | | | - Kevin Pierre
- University of Florida Department of Radiology, Gainesville, Florida, 32608, USA
| | - Brandon Lucke-Wold
- University of Florida Department of Neurosurgery, Gainesville, Florida, 32608, USA
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7
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Gariscsak PJ, Salaheen Z, Godfrey C, Tampieri D, Appireddy R. Objective performance metrics in human robotic neuroendovascular interventions: a scoping review protocol. JBI Evid Synth 2022; 20:2815-2823. [PMID: 36081373 DOI: 10.11124/jbies-21-00383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The objective of this scoping review is to review the available information on objective performance metrics used during robotic neuroendovascular intervention procedures on humans. INTRODUCTION Robotic neuroendovascular intervention is defined as any endovascular procedure within the vasculature of the central nervous system with the assistance of a robotic system for diagnostic or therapeutic procedures. Robotic systems are described as a 2-component system consisting of a patient-side mechanical robot, and a separate operator control station. Robotic neuroendovascular intervention is a growing field and there is a need to establish objective performance metrics for furthering evidence-based reporting of the literature. INCLUSION CRITERIA This scoping review will consider all studies involving humans that utilize robotic neuroendovascular intervention. We will consider all types of studies, reports, and reviews as well as gray literature. Studies will be included if they describe the use of an objective performance metric during robotic neuroendovascular intervention. This review is not limited to a particular country or health care system, and will consider all study designs, regardless of their rigor or language. METHODS Utilizing a 3-step framework as a guide, we will perform a systematic search in Embase, Cochrane Library, and MEDLINE. Available literature from inception to the present will be considered. Studies will be independently screened according to the inclusion criteria by 2 reviewers based on title, abstract, and full text. Data will be extracted, sorted, and presented in both a narrative summary as well as table and diagram based on the objective of the scoping review.
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Affiliation(s)
| | - Zaid Salaheen
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christina Godfrey
- School of Nursing, Queen's University, Kingston, ON, Canada.,Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence, Queen's University, Kingston, ON, Canada
| | | | - Ramana Appireddy
- Department of Medicine, Queen's University, Kingston, ON, Canada
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8
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Song C, Xia S, Zhang H, Zhang L, Li X, Wang K, Lu Q. Novel Endovascular Interventional Surgical Robotic System Based on Biomimetic Manipulation. MICROMACHINES 2022; 13:mi13101587. [PMID: 36295940 PMCID: PMC9611341 DOI: 10.3390/mi13101587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 05/14/2023]
Abstract
Endovascular therapy has emerged as a crucial therapeutic method for treating vascular diseases. Endovascular surgical robots have been used to enhance endovascular therapy. However, to date, there are no universal endovascular surgical robots that support molds of different types of devices for treating vascular diseases. We developed a novel endovascular surgical robotic system that can independently navigate the intravascular region, advance and retract devices, and deploy stents. This robot has four features: (1) The bionic design of the robot can fully simulate the entire grasping process; (2) the V-shaped relay gripper waived the need to redesign special guidewires and catheters for continuous rotation; (3) the handles designed based on the feedback mechanism can simulate push resistance and reduce iatrogenic damage; and (4) the detachable design of the grippers can reduce cross-infection risk and medical costs. We verified its performance by demonstrating six different types of endovascular surgeries. Early evaluation of the novel endovascular robotic system demonstrated its practicability and safety in endovascular surgeries.
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Affiliation(s)
- Chao Song
- Department of Vascular Surgery, Shanghai Changhai Hospital, Navy Medical University, Shanghai 200433, China
| | - Shibo Xia
- Department of Vascular Surgery, Shanghai Changhai Hospital, Navy Medical University, Shanghai 200433, China
| | - Hao Zhang
- Department of Vascular Surgery, Shanghai Changhai Hospital, Navy Medical University, Shanghai 200433, China
| | - Lei Zhang
- Department of Vascular Surgery, Shanghai Changhai Hospital, Navy Medical University, Shanghai 200433, China
| | - Xiaoye Li
- Department of Vascular Surgery, Shanghai Changhai Hospital, Navy Medical University, Shanghai 200433, China
| | - Kundong Wang
- Department of Instrument Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
- Correspondence: (K.W.); (Q.L.)
| | - Qingsheng Lu
- Department of Vascular Surgery, Shanghai Changhai Hospital, Navy Medical University, Shanghai 200433, China
- Correspondence: (K.W.); (Q.L.)
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9
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Pennington Z, Michalopoulos GD, Biedermann AJ, Ziegler JR, Durst SL, Spinner RJ, Meyer FB, Daniels DJ, Bydon M. Positive impact of the pandemic: the effect of post-COVID-19 virtual visit implementation on departmental efficiency and patient satisfaction in a quaternary care center. Neurosurg Focus 2022; 52:E10. [PMID: 35921181 DOI: 10.3171/2022.3.focus2243] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The coronavirus disease 2019 (COVID-19) pandemic has significantly changed clinical practice across US healthcare. Increased adoption of telemedicine has emerged as an alternative to in-person contact for patient-physician interactions. The aim of this study was to analyze the impact of telemedicine on workflow and care delivery from January 2019 to December 2021 in a neurosurgical department at a quaternary care center. METHODS Prospectively captured data on clinic appointment utilization, duration, and outcomes were queried. Visits were divided into in-person visits and telemedicine appointments, categorized as follow-up visits of previously surgically treated patients, internal consultations, new patient visits, and early postoperative returns after surgery. Appointment volume was compared pre- and postpandemic using March 2020 as the pandemic onset. Clinical efficiency was measured by time to appointment, rate of on-time appointments, proportion of appointments resulting in surgical intervention (surgical yield), and patient-reported satisfaction, the latter measured as the proportion of patients indicating "high likelihood to recommend practice." RESULTS A total of 54,562 visits occurred, most commonly for follow-up for previously operated patients (51.8%), internal new patient referrals (24.5%), and external new patient referrals (19.8%). Total visit volume was stable pre- to postpandemic (1521.3 vs 1512, p = 0.917). However, in-person visits significantly decreased (1517/month vs 1220/month, p < 0.001), with a nadir in April 2020, while telemedicine appointment utilization increased significantly (0.3% vs 19.1% of all visits). Telemedicine utilization remained stable throughout the 1st calendar year following the pandemic. Telemedicine appointments were associated with shorter time to appointment than in-person visits both before and after the pandemic onset (0-5 days from appointment request: 60% vs 33% vs 29.8%, p < 0.001). Patients had on-time appointments in 87% of telemedicine encounters. Notably, telemedicine appointments resulted in surgery in 31.8% of internal consultations or new patient visits, a significantly lower rate than that for in-person visits (51.8%). After the widespread integration of telemedicine, patient satisfaction for all visits was higher than before the pandemic onset (85.9% vs 88.5%, p = 0.027). CONCLUSIONS Telemedicine use significantly increased following the pandemic onset, compensating for observed decreases in face-to-face visits. Utilization rates have remained stable, suggesting effective integration, and delays between referrals and appointments were lower than for in-person visits. Importantly, telemedicine integration was not associated with a decrease in overall patient satisfaction, although telemedicine appointments had a lower surgical yield. These data suggest that telemedicine smoothened the impact of the pandemic on clinical workflow and helped to maintain continuity and quality of outpatient care.
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Affiliation(s)
- Zach Pennington
- 1Department of Neurologic Surgery and.,2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Giorgos D Michalopoulos
- 1Department of Neurologic Surgery and.,2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | | | - Mohamad Bydon
- 1Department of Neurologic Surgery and.,2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
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10
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Kim Y, Genevriere E, Harker P, Choe J, Balicki M, Regenhardt RW, Vranic JE, Dmytriw AA, Patel AB, Zhao X. Telerobotic neurovascular interventions with magnetic manipulation. Sci Robot 2022; 7:eabg9907. [PMID: 35417201 PMCID: PMC9254892 DOI: 10.1126/scirobotics.abg9907] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Advances in robotic technology have been adopted in various subspecialties of both open and minimally invasive surgery, offering benefits such as enhanced surgical precision and accuracy with reduced fatigue of the surgeon. Despite the advantages, robotic applications to endovascular neurosurgery have remained largely unexplored because of technical challenges such as the miniaturization of robotic devices that can reach the complex and tortuous vasculature of the brain. Although some commercial systems enable robotic manipulation of conventional guidewires for coronary and peripheral vascular interventions, they remain unsuited for neurovascular applications because of the considerably smaller and more tortuous anatomy of cerebral arteries. Here, we present a teleoperated robotic neurointerventional platform based on magnetic manipulation. Our system consists of a magnetically controlled guidewire, a robot arm with an actuating magnet to steer the guidewire, a set of motorized linear drives to advance or retract the guidewire and a microcatheter, and a remote-control console to operate the system under real-time fluoroscopy. We demonstrate our system's capability to navigate narrow and winding pathways both in vitro with realistic neurovascular phantoms representing the human anatomy and in vivo in the porcine brachial artery with accentuated tortuosity for preclinical evaluation. We further demonstrate telerobotically assisted therapeutic procedures including coil embolization and clot retrieval thrombectomy for treating cerebral aneurysms and ischemic stroke, respectively. Our system could enable safer and quicker access to hard-to-reach lesions while minimizing the radiation exposure to physicians and open the possibility of remote procedural services to address challenges in current stroke systems of care.
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Affiliation(s)
- Yoonho Kim
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Emily Genevriere
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Pablo Harker
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jaehun Choe
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Xuanhe Zhao
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Civil and Environmental Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
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11
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Malik MH, Brinjikji W. Feasibility of telesurgery in the modern era. Neuroradiol J 2022; 35:423-426. [PMID: 35341371 PMCID: PMC9437503 DOI: 10.1177/19714009221083141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Telesurgery is not a foreign concept and dates to as early as the 1920s. The use of robots in medicine has had a very positive effect and improved outcomes with little to no adverse effects. Having global access to telemedicine and telesurgery during the COVID-19 pandemic and being able to provide top medical care to gravely ill and contagious patients without compromising the safety of the medical team would be a very big achievement. We explore the hurdles needed to make it a realistic goal and give recommendations to achieve it utilizing the major advancements that have occurred over the past few years in the fields of engineering, communication etc. The biggest issues needed to be addressed are of financial investment, legal concerns, and availability of high-speed uninterrupted data connections.
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Affiliation(s)
- Muhammad Hammad Malik
- Department of Radiology, RinggoldID:6915Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Waleed Brinjikji
- Department of Radiology, RinggoldID:6915Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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12
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Berczeli M, Britz GW, Loh T, Lumsden AB. Telerobotic Endovascular Interventions and Their Potential for Cerebrovascular Treatment. Tex Heart Inst J 2022; 49:480953. [PMID: 35481863 DOI: 10.14503/thij-21-7608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
After the introduction of the first robotic-assisted surgical procedures, the technology soon reached the world of endovascular specialists, giving rise to several publications about robotic-assisted endovascular therapy. Compared with conventional procedures, robotic-assisted procedures can be more accurate and reduce radiation exposure. The latest commercially available endovascular robotic system is the CorPath GRX, which can be operated remotely. Robotic-assisted approaches have proved applicable in the fields of coronary and peripheral vascular intervention and neurointervention. Remote intervention has already proved feasible in the coronary and peripheral vascular systems and, according to expert opinion, could revolutionize acute stroke management as well. We review current knowledge about robotic-assisted therapies and remote interventions, and the future prospects and pitfalls.
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Affiliation(s)
- Marton Berczeli
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Texas.,Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Gavin W Britz
- Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital, Houston, Texas
| | - Thomas Loh
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Texas
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Texas
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13
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Musa MJ, Carpenter AB, Kellner C, Sigounas D, Godage I, Sengupta S, Oluigbo C, Cleary K, Chen Y. Minimally Invasive Intracerebral Hemorrhage Evacuation: A review. Ann Biomed Eng 2022; 50:365-386. [PMID: 35226279 DOI: 10.1007/s10439-022-02934-z] [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: 08/03/2021] [Accepted: 02/11/2022] [Indexed: 11/01/2022]
Abstract
Intracerebral hemorrhage is a leading cause of morbidity and mortality worldwide. To date, there is no specific treatment that clearly provides a benefit in functional outcome or mortality. Surgical treatment for hematoma evacuation has not yet shown clear benefit over medical management despite promising preclinical studies. Minimally invasive treatment options for hematoma evacuation are under investigation but remain in early-stage clinical trials. Robotics has the potential to improve treatment. In this paper, we review intracerebral hemorrhage pathology, currently available treatments, and potential robotic approaches to date. We also discuss the future role of robotics in stroke treatment.
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Affiliation(s)
- Mishek J Musa
- Department of Mechanical Engineering, University of Arkansas, Fayetteville, AR, USA
| | | | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, NY, USA
| | - Dimitri Sigounas
- Department of Neurosurgery, The George Washington University, Washington, Washington, DC, USA
| | - Isuru Godage
- College of Computing and Digital Media, DePaul University, Chicago, IL, USA
| | - Saikat Sengupta
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chima Oluigbo
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
| | - Kevin Cleary
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
| | - Yue Chen
- Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Dr NW, Atlanta, GA, 30332, USA.
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14
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Berczeli M, Chinnadurai P, Legeza PT, Britz GW, Lumsden AB. Transcarotid access for remote robotic endovascular neurointerventions: a cadaveric proof-of-concept study. Neurosurg Focus 2022; 52:E18. [PMID: 34973671 DOI: 10.3171/2021.10.focus21511] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this proof-of-concept study was to demonstrate the setup and feasibility of transcarotid access for remote robotic neurointerventions in a cadaveric model. METHODS The interventional procedures were performed in a fresh-frozen cadaveric model using an endovascular robotic system and a robotic angiography imaging system. A prototype remote, robotic-drive system with an ethernet-based network connectivity and audio-video communication system was used to drive the robotic system remotely. After surgical exposure of the common carotid artery in a cadaveric model, an 8-Fr arterial was inserted and anchored. A telescopic guiding sheath and catheter/microcatheter combination was modified to account for the "workable" length with the CorPath GRX robotic system using transcarotid access. RESULTS To simulate a carotid stenting procedure, a 0.014-inch wire was advanced robotically to the extracranial internal carotid artery. After confirming the wire position and anatomy by angiography, a self-expandable rapid exchange nitinol stent was loaded into the robotic cassette, advanced, and then deployed robotically across the carotid bifurcation. To simulate an endovascular stroke recanalization procedure, a 0.014-inch wire was advanced into the proximal middle cerebral artery with robotic assistance. A modified 2.95-Fr delivery microcatheter (Velocity, Penumbra Inc.) was loaded into the robotic cassette and positioned. After robotic retraction of the wire, it was switched manually to a mechanical thrombectomy device (Solitaire X, Medtronic). The stentriever was then advanced robotically into the end of the microcatheter. After robotic unfolding and short microcatheter retraction, the microcatheter was manually removed and the stent retriever was extracted using robotic assistance. During intravascular navigation, the device position was guided by 2D angiography and confirmed by 3D cone-beam CT angiography. CONCLUSIONS In this proof-of-concept cadaver study, the authors demonstrated the setup and technical feasibility of transcarotid access for remote robot-assisted neurointerventions such as carotid artery stenting and mechanical thrombectomy. Using transcarotid access, catheter length modifications were necessary to achieve "working length" compatibility with the current-generation CorPath GRX robotic system. While further improvements in dedicated robotic solutions for neurointerventions and next-generation thrombectomy devices are necessary, the transcarotid approach provides a direct, relatively rapid access route to the brain for delivering remote stroke treatment.
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Affiliation(s)
- Marton Berczeli
- 1Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston.,2Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary; and
| | - Ponraj Chinnadurai
- 1Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston.,3Advanced Therapies, Siemens Medical Solutions USA Inc., Malvern, Pennsylvania
| | - Peter T Legeza
- 1Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston.,2Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary; and
| | - Gavin W Britz
- 4Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital, Houston, Texas
| | - Alan B Lumsden
- 1Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston
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15
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Cruz MJ, Nieblas-Bedolla E, Young CC, Feroze AH, Williams JR, Ellenbogen RG, Levitt MR. United States Medicolegal Progress and Innovation in Telemedicine in the Age of COVID-19: A Primer for Neurosurgeons. Neurosurgery 2021; 89:364-371. [PMID: 34133724 PMCID: PMC8344865 DOI: 10.1093/neuros/nyab185] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/03/2021] [Indexed: 01/14/2023] Open
Abstract
Telemedicine has received increased attention in recent years as a potential solution to expand clinical capability and patient access to care in many fields, including neurosurgery. Although patient and physician attitudes are rapidly shifting toward greater telemedicine use in light of the COVID-19 pandemic, there remains uncertainty about telemedicine's regulatory future. Despite growing evidence of telemedicine's utility, there remain a number of significant medicolegal barriers to its mass adoption and wider implementation. Herein, we examine recent progress in state and federal regulations in the United States governing telemedicine's implementation in quality of care, finance and billing, privacy and confidentiality, risk and liability, and geography and interstate licensure, with special attention to how these concern teleneurosurgical practice. We also review contemporary topics germane to the future of teleneurosurgery, including the continued expansion of reciprocity in interstate licensure, expanded coverage for homecare services for chronic conditions, expansion of Center for Medicare and Medicaid Services reimbursements, and protections of store-and-forward technologies. Additionally, we discuss recent successes in teleneurosurgery, stroke care, and rehabilitation as models for teleneurosurgical best practices. As telemedicine technology continues to mature and its expanse grows, neurosurgeons' familiarity with its benefits, limitations, and controversies will best allow for its successful adoption in our field to maximize patient care and outcomes.
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Affiliation(s)
- Michael J Cruz
- School of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Abdullah H Feroze
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - John R Williams
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Stroke and Applied Neurosciences Center, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Stroke and Applied Neurosciences Center, University of Washington, Seattle, Washington, USA
- Department of Radiology, University of Washington, Seattle, Washington, USA
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
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16
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Kamel H, Parikh NS, Chatterjee A, Kim LK, Saver JL, Schwamm LH, Zachrison KS, Nogueira RG, Adeoye O, Díaz I, Ryan AM, Pandya A, Navi BB. Access to Mechanical Thrombectomy for Ischemic Stroke in the United States. Stroke 2021; 52:2554-2561. [PMID: 33980045 DOI: 10.1161/strokeaha.120.033485] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Abhinaba Chatterjee
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Luke K Kim
- Division of Cardiology (L.K.K.), Weill Cornell Medicine, New York, NY
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Lee H Schwamm
- Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston
| | - Kori S Zachrison
- Department of Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Boston
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine, Atlanta, GA (R.G.N.)
| | - Opeolu Adeoye
- Department of Emergency Medicine, University of Cincinnati, OH (O.A.)
| | - Iván Díaz
- Division of Biostatistics and Epidemiology (I.D.), Weill Cornell Medicine, New York, NY
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (A.M.R.)
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (A.P.)
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
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17
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Atashzar SF, Carriere J, Tavakoli M. Review: How Can Intelligent Robots and Smart Mechatronic Modules Facilitate Remote Assessment, Assistance, and Rehabilitation for Isolated Adults With Neuro-Musculoskeletal Conditions? Front Robot AI 2021; 8:610529. [PMID: 33912593 PMCID: PMC8072151 DOI: 10.3389/frobt.2021.610529] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
Worldwide, at the time this article was written, there are over 127 million cases of patients with a confirmed link to COVID-19 and about 2.78 million deaths reported. With limited access to vaccine or strong antiviral treatment for the novel coronavirus, actions in terms of prevention and containment of the virus transmission rely mostly on social distancing among susceptible and high-risk populations. Aside from the direct challenges posed by the novel coronavirus pandemic, there are serious and growing secondary consequences caused by the physical distancing and isolation guidelines, among vulnerable populations. Moreover, the healthcare system's resources and capacity have been focused on addressing the COVID-19 pandemic, causing less urgent care, such as physical neurorehabilitation and assessment, to be paused, canceled, or delayed. Overall, this has left elderly adults, in particular those with neuromusculoskeletal (NMSK) conditions, without the required service support. However, in many cases, such as stroke, the available time window of recovery through rehabilitation is limited since neural plasticity decays quickly with time. Given that future waves of the outbreak are expected in the coming months worldwide, it is important to discuss the possibility of using available technologies to address this issue, as societies have a duty to protect the most vulnerable populations. In this perspective review article, we argue that intelligent robotics and wearable technologies can help with remote delivery of assessment, assistance, and rehabilitation services while physical distancing and isolation measures are in place to curtail the spread of the virus. By supporting patients and medical professionals during this pandemic, robots, and smart digital mechatronic systems can reduce the non-COVID-19 burden on healthcare systems. Digital health and cloud telehealth solutions that can complement remote delivery of assessment and physical rehabilitation services will be the subject of discussion in this article due to their potential in enabling more effective and safer NMSDK rehabilitation, assistance, and assessment service delivery. This article will hopefully lead to an interdisciplinary dialogue between the medical and engineering sectors, stake holders, and policy makers for a better delivery of care for those with NMSK conditions during a global health crisis including future pandemics.
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Affiliation(s)
- S. Farokh Atashzar
- Department of Electrical and Computer Engineering, Department of Mechanical and Aerospace Engineering, New York University, New York, NY, United States
| | - Jay Carriere
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, AB, Canada
| | - Mahdi Tavakoli
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, AB, Canada
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