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Budohoski KP, Tajsic T, Bal J, Levrini V, Ling Cao JJ, Guilfoyle MR, Couldwell WT, Helmy AE, Kirollos RW, Kirkpatrick PJ, Trivedi RA. Results of Surgical Treatment of Aneurysmal Subarachnoid Hemorrhage in a Single Institution Over 12 Years. World Neurosurg 2023; 180:e341-e349. [PMID: 37769843 DOI: 10.1016/j.wneu.2023.09.070] [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: 08/29/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE For patients with aneurysmal subarachnoid hemorrhage (aSAH) in whom endovascular treatment is not the optimal treatment strategy, microsurgical clipping remains a viable option. We examined changes in morbidity and outcome over time in patients treated surgically and in relation to surgeon volume and experience. METHODS All patients who underwent microsurgery for aSAH from 2007 to 2019 at our institution were included. We compared technical complication rates and surgical outcomes between experienced (≥50 independent cases) and inexperienced (<50 independent cases) surgeons and between high-volume (≥20 cases/year) and low-volume (<20 cases/year) surgeons. RESULTS Most of the 1,003 aneurysms (970 patients, median age 56 years) were in the middle cerebral (41.4%), anterior communicating (27.6%), and posterior communicating (17.5%) arteries; 46.5% were <7 mm. The technical complication rate was 7%, resulting in postoperative infarct in 4.9% of patients. Nineteen patients (2%) died within 30 days of admission. There were no significant changes in rates of technical complication, postoperative infarct, or mortality over the study period. There were no differences in postoperative infarction and technical complication rates between experienced and inexperienced surgeons (P = 0.28 and P = 0.05, respectively), but there were differences when comparing high-volume and low-volume surgeons (P = 0.03 and P < 0.001, respectively). The independent predictors of postoperative infarctions were aneurysm size (P = 0.001), intraoperative large-vessel injury (P < 0.001), and low surgeon volume (P = 0.03). CONCLUSIONS We present real-world data on surgical morbidity and outcomes after aSAH. We demonstrated a relationship between surgeon volume and outcome for surgical treatment of aSAH, which supports the benefit of subspecialization in cerebrovascular surgery.
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Affiliation(s)
- Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA; Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK.
| | - Tamara Tajsic
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Jarnail Bal
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Virginia Levrini
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK; Department of Neurosurgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jenny Jia Ling Cao
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Mathew R Guilfoyle
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Adel E Helmy
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Ramez W Kirollos
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK; Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Peter J Kirkpatrick
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
| | - Rikin A Trivedi
- Department of Neurosurgery, Cambridge University Hospitals, Addenbrookes Hospital, Cambridge, UK
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Ghosh S, Awuah WA, Bharadwaj HR, Adebusoye FT, Ou Yong BM, Wellington J, Abdul-Rahman T, Ovechkin D. Utilizing indocyanine green video angiography to bridge intracranial aneurysm treatment gaps in low- and middle-income countries: a mini-review. J Int Med Res 2023; 51:3000605231204427. [PMID: 37862677 PMCID: PMC10590043 DOI: 10.1177/03000605231204427] [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: 04/24/2023] [Accepted: 09/13/2023] [Indexed: 10/22/2023] Open
Abstract
Intracranial aneurysms, affecting 2%-5% of the population, pose a significant challenge to neurosurgeons due to their potential to cause subarachnoid haemorrhage and high mortality rates. Intraoperative angiography is necessary for effective surgical planning and indocyanine green video angiography (ICG-VA) has emerged as a useful tool for real-time visualization of aneurysmal blood flow, aiding in better planning for potential blood flow and detection of aneurysm remnants. This mini narrative review explores the application of ICG-VA in intracranial aneurysm surgery. Compared with conventional dye-based angiography, ICG-VA is safer, more effective and more cost-effective. It can assess haemodynamic parameters, cerebral flow during temporary artery occlusion, completeness of clipping and patency of branch vessels. However, implementing ICG-VA in low- and middle-income countries presents challenges such as financial constraints, limited access to training and expertise, patient selection and consent issues. Addressing these obstacles requires capacity-building, training programmes for neurosurgeons and multidisciplinary teams, technology transfer, equipment donations, public-private partnerships, continued research and development, reducing conventional dye usage, reducing ICG wastage, exploring mechanisms to reuse ICG dyes and advocating for increased government funding and healthcare budgets.
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Affiliation(s)
| | | | | | | | - Brian M. Ou Yong
- School of Medicine, College of Medical and Veterinary Life Sciences, University of Glasgow, United Kingdom
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Scheller C, Prell J, Simmermacher S, Strauss C, Doenitz C, Schmidt NO, Schebesch KM. Insufficient Closing Forces of Yasargil Titanium Clips in Two Small Aneurysms Detected with Intraoperative Indocyanine Green Videoangiography. J Neurol Surg A Cent Eur Neurosurg 2022; 83:481-485. [DOI: 10.1055/s-0041-1740378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abstract
Background and Study Aims Aneurysm clips must have adequate closing forces because residual blood flow in clipped aneurysms may result in aneurysm recurrence. Such flow can be intraoperatively detected by visual inspection, microvascular Doppler sonography, indocyanine green videoangiography (ICG-V), angiography, and puncture.
Patients We present two patients with ruptured very small middle cerebral artery aneurysms (3 and 2.9 mm). The necks of both aneurysms were microsurgically clipped with Yasargil aneurysm clips without any complications.
Results In both aneurysms, visual inspection suggested complete occlusion, but ICG-V showed persistent residual blood flow between the middle parts of the clip blades.The first patient was treated with a 5.4-mm FT744T clip (closing force of 1.47 N). After the ICG-V finding, a second 3.9-mm FT714T clip (closing force of 1.08 N) was placed on the tips of the already implanted clip to increase the closing forces. Subsequent ICG-V did not show any further residual blood flow. In the second patient, the aneurysm was clipped with an 8.0-mm FE764K clip (closing force of 1.77 N). Intraoperative ICG-V showed persistent residual blood flow within the aneurysmal dome despite complete closure of the clip. The clip was repositioned closer to the parent vessel. Consecutive ICG-V did not show any residual blood flow.
Conclusion Visually undetected incomplete aneurysm occlusion can be revealed with ICG-V. In very small aneurysms, standard closing forces of clips may not be sufficient and complete closure of the clip branches should be intraoperatively validated with ICG-V.
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Affiliation(s)
- Christian Scheller
- Department of Neurosurgery, University of Halle-Wittenberg, Halle, Germany
| | - Julian Prell
- Department of Neurosurgery, University of Halle-Wittenberg, Halle, Germany
| | | | - Christian Strauss
- Department of Neurosurgery, University of Halle-Wittenberg, Halle, Germany
| | - Christian Doenitz
- Department of Neurosurgery, University of Regensburg, Regensburg, Germany
| | - Nils Ole Schmidt
- Department of Neurosurgery, University of Regensburg, Regensburg, Germany
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Budohoski KP, Raygor K, Tonetti DA, Narsinh KH, Winkler EA, Dowd C, Abla AA. Intraoperative Angiogram Using C-Arm Fluoroscopy and Direct Common Carotid Artery Puncture During Surgical Treatment of Paraclinoid Aneurysms. World Neurosurg 2022; 165:95-99. [PMID: 35779758 DOI: 10.1016/j.wneu.2022.06.114] [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: 04/29/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intraoperative angiography (IOA) has been shown to be a useful adjunct in surgical treatment of cerebral aneurysms. However, its use can be limited by hybrid operating room availability. On the other hand, the use of C-arm fluoroscopy can add challenges to IOA during navigation of the aortic arch and selection of the great vessels. We aimed to describe a simple method of IOA that can be applied during surgery of paraclinoid aneurysms and can be performed in a normal operating room without the need to navigate the aortic arch. METHODS In patients undergoing surgery for paraclinoid aneurysms with need for cervical carotid artery exposure, IOA was performed using a single plane C-arm fluoroscopy unit after direct puncture of the carotid artery. RESULTS Five patients were included: 2 with subarachnoid hemorrhage, 2 with unruptured aneurysm and history of subarachnoid hemorrhage, and 1 with unruptured aneurysm. There were 2 internal carotid blister aneurysms, 2 ophthalmic artery aneurysms, and 1 superior hypophyseal artery aneurysm. IOA was performed using direct carotid puncture through the neck incision required for proximal control. In all cases, intraoperative images were of sufficient quality to determine the completeness of aneurysm occlusion as well as parent and branching vessel patency. There were no postoperative infarctions and no complications related to IOA. CONCLUSIONS IOA using direct carotid puncture can be performed in a standard operating room with the use of a C-arm, eliminating the need to catheterize the great vessels of the aortic arch.
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Affiliation(s)
- Karol P Budohoski
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
| | - Kunal Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher Dowd
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Grasso G, Torregrossa F, Cohen-Gadol AA. Avoiding Complications in Aneurysm Ligation: Operative Tips and Tricks. World Neurosurg 2022; 159:259-265. [PMID: 35255627 DOI: 10.1016/j.wneu.2021.10.181] [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: 09/27/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 11/24/2022]
Abstract
Preventing possible complications during brain aneurysm surgery is mandatory to ensure a better outcome for patients. Currently, it is possible to rely on some technologic innovations such as motor evoked potential, endoscope-assisted surgery, dye with indocyanine green, and video angiography capable of supporting the surgeon's work. The innovation process has mainly assisted the endovascular technique compared with surgery. The latter, apart from some new technical expedients, always requires anatomic knowledge and optimal technical preparation. A careful patient selection, adequate surgical exposure, use of microsurgical techniques in expert hands, and meticulous postoperative management represent the key to success for the surgical treatment of cerebral aneurysms.
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Affiliation(s)
- Giovanni Grasso
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy.
| | - Fabio Torregrossa
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Aaron A Cohen-Gadol
- Indiana University, Department of Neurosurgery and the Neurosurgical Atlas, Bloomington, Indiana, USA
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Aguilar-Salinas P, Gutierrez-Aguirre SF, Avila MJ, Nakaji P. Current status of augmented reality in cerebrovascular surgery: a systematic review. Neurosurg Rev 2022; 45:1951-1964. [PMID: 35149900 DOI: 10.1007/s10143-022-01733-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/01/2021] [Accepted: 01/05/2022] [Indexed: 12/29/2022]
Abstract
Augmented reality (AR) is an adjuvant tool in neuronavigation to improve spatial and anatomic understanding. The present review aims to describe the current status of intraoperative AR for the treatment of cerebrovascular pathology. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following databases were searched: PubMed, Science Direct, Web of Science, and EMBASE up to December, 2020. The search strategy consisted of "augmented reality," "AR," "cerebrovascular," "navigation," "neurovascular," "neurosurgery," and "endovascular" in both AND and OR combinations. Studies included were original research articles with intraoperative application. The manuscripts were thoroughly examined for study design, outcomes, and results. Sixteen studies were identified describing the use of intraoperative AR in the treatment of cerebrovascular pathology. A total of 172 patients were treated for 190 cerebrovascular lesions using intraoperative AR. The most common treated pathology was intracranial aneurysms. Most studies were cases and there was only a case-control study. A head-up display system in the microscope was the most common AR display. AR was found to be useful for tailoring the craniotomy, dura opening, and proper identification of donor and recipient vessels in vascular bypass. Most AR systems were unable to account for tissue deformation. This systematic review suggests that intraoperative AR is becoming a promising and feasible adjunct in the treatment of cerebrovascular pathology. It has been found to be a useful tool in the preoperative planning and intraoperative guidance. However, its clinical benefits remain to be seen.
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Affiliation(s)
- Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | | | - Mauricio J Avila
- Department of Neurosurgery, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Peter Nakaji
- Department of Neurosurgery, Banner University Medical Center, University of Arizona, 755 E. McDowell Rd, Phoenix, AZ, 85006, USA.
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Lee KS, Zhang JJY, Nguyen V, Han J, Johnson JN, Kirollos R, Teo M. The evolution of intracranial aneurysm treatment techniques and future directions. Neurosurg Rev 2021; 45:1-25. [PMID: 33891216 PMCID: PMC8827391 DOI: 10.1007/s10143-021-01543-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/21/2021] [Accepted: 04/07/2021] [Indexed: 01/06/2023]
Abstract
Treatment techniques and management guidelines for intracranial aneurysms (IAs) have been continually developing and this rapid development has altered treatment decision-making for clinicians. IAs are treated in one of two ways: surgical treatments such as microsurgical clipping with or without bypass techniques, and endovascular methods such as coiling, balloon- or stent-assisted coiling, or intravascular flow diversion and intrasaccular flow disruption. In certain cases, a single approach may be inadequate in completely resolving the IA and successful treatment requires a combination of microsurgical and endovascular techniques, such as in complex aneurysms. The treatment option should be considered based on factors such as age; past medical history; comorbidities; patient preference; aneurysm characteristics such as location, morphology, and size; and finally the operator’s experience. The purpose of this review is to provide practicing neurosurgeons with a summary of the techniques available, and to aid decision-making by highlighting ideal or less ideal cases for a given technique. Next, we illustrate the evolution of techniques to overcome the shortfalls of preceding techniques. At the outset, we emphasize that this decision-making process is dynamic and will be directed by current best scientific evidence, and future technological advances.
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Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK. .,Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.
| | - John J Y Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vincent Nguyen
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK.,Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Julian Han
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Ramez Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, UK
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Świątnicki W, Urbaniak F, Szymański J, Szymańska A, Komuński P. Intra-operative fluorescein videoangiography-related nephrotoxicity in intracranial aneurysm surgery: Single center, observational cohort study. Clin Neurol Neurosurg 2021; 203:106597. [PMID: 33725507 DOI: 10.1016/j.clineuro.2021.106597] [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: 01/13/2021] [Revised: 02/08/2021] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Intra-operative fluorescein video angiography (FL-VA) has been given increasing attention recently and several studies reported its high utility in neurovascular surgery. The aim of this study was to evaluate the safety of FL-VA in a prospective, single-center cohort of patients operated due to cerebral aneurysms. PATIENTS AND METHODS This is an observational cohort study including 150 patients operated due to intracranial aneurysms. The study group consisted of 70 consecutive patients operated with the use of fluorescein video angiography. Post-operative acute kidney injury (AKI) occurrence as well as systemic adverse reactions were reported and further compared with 80 matched controls where FL-VA was not used. Statistical analysis was performed using non-parametric tests (Fisher's exact test). RESULTS Post-operative AKI was observed in 17,1% of patients in the study group with only half presenting with acute functional impairment. All of these patients presented initially due to aneurysm rupture. Pre-existing renal dysfunction and hypertension occurred in 16,7% and 33,3%, respectively. No systemic complications following FL-VA were reported. When compared to matched controls, no statistically significant difference regarding AKI occurrence was observed between these two patient populations. CONCLUSION Intra-operative fluorescein video angiography proved to have a good safety profile in our cohort. The results of this study suggest that post-operative acute kidney injury observed in patients with subarachnoid hemorrhage is not related to fluorescein use.
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Affiliation(s)
- Wojciech Świątnicki
- Department of Neurosurgery, Maria Skłodowska-Curie Regional Specialist Hospital, District of Łódź-North, Zgierz, Poland.
| | - Filip Urbaniak
- Department of Neurosurgery, Maria Skłodowska-Curie Regional Specialist Hospital, District of Łódź-North, Zgierz, Poland
| | | | - Anna Szymańska
- Faculty of Economics and Sociology, University of Lodz, Poland
| | - Piotr Komuński
- Department of Neurosurgery, Maria Skłodowska-Curie Regional Specialist Hospital, District of Łódź-North, Zgierz, Poland
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Hardy NP, Dalli J, Khan MF, Andrejevic P, Neary PM, Cahill RA. Inter-user variation in the interpretation of near infrared perfusion imaging using indocyanine green in colorectal surgery. Surg Endosc 2021; 35:7074-7081. [PMID: 33398567 DOI: 10.1007/s00464-020-08223-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/03/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Despite increasing endorsement of near-infrared perfusion assessment using indocyanine green (ICG) during colorectal surgery, little work has yet been done regarding learning curve and interobserver variation most especially on surgical video reflective of real-world usage. METHODS Surgeons with established expertise in ICG usage were invited to participate in the study along with others without such experience including trainees. All participants completed an opinion questionnaire and interpreted video presentations of fluorescence angiograms in a variety of colorectal case scenarios. An interactive video platform (Mindstamp) enabled dynamic annotation. Statistical analysis of data was performed using Kruskal-Wallis and Mann-Whitney testing as well as Intraclass Correlation Coefficients and Fleiss Multi-rater Kappa Scoring. RESULTS Forty participants (six experts) completed questionnaire data and provided judgement of 14 videos (nine showing proximal colonic transection site perfusion, four showing completed anastomoses and one an acutely strangulated bowel). 70% felt > 10 cases were needed for competency in use with the majority of experts advocating > 50 (p < 0.05). Overall agreement among experts was "good" for videos showing colonic transection perfusion (versus "moderate" among in-experts) with experts clustering more distally. In contrast, there was no interpretation concordance among experts or in-experts when judging ICG perfusion sufficiency on a yes/no basis. CONCLUSION Significant experience is recommended before reliance on ICG perfusion angiograms. ICG fluorescence assessment is prone to variable interpretation and influenced by experience and, perhaps, knowledge of preassessment operative steps suggesting a role for objective flow analysis with artificial intelligence methods as the next phase of this technology.
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Affiliation(s)
- Niall P Hardy
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Jeffrey Dalli
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Mohammad Faraz Khan
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, 47 Eccles Street, Dublin 7, Ireland
| | | | - Peter M Neary
- Department of Surgery, University Hospital Waterford, University College Cork, Waterford, Ireland
| | - Ronan A Cahill
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland.
- Department of Surgery, Mater Misericordiae University Hospital, 47 Eccles Street, Dublin 7, Ireland.
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Kim J, El Ahmadieh TY, Aoun SG, Batjer H. Commentary: Microsurgical Treatment of Unruptured Anterior Communicating Artery Aneurysms: Approaches and Outcomes in a Large Contemporary Series and Review of the Literature. Oper Neurosurg (Hagerstown) 2020; 19:E564-E565. [PMID: 32970122 DOI: 10.1093/ons/opaa286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/11/2020] [Indexed: 12/25/2022] Open
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11
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Carl B, Bopp M, Benescu A, Saß B, Nimsky C. Indocyanine Green Angiography Visualized by Augmented Reality in Aneurysm Surgery. World Neurosurg 2020; 142:e307-e315. [PMID: 32640326 DOI: 10.1016/j.wneu.2020.06.219] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/25/2020] [Accepted: 06/28/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We prospectively investigated how to integrate indocyanine green (ICG) angiography in an augmented reality (AR) setting for aneurysm surgery. METHODS In 20 patients with a total of 22 aneurysms, the head-up display of the operating microscope (Kinevo900) was used for AR. ICG-AR was established directly by the head-up display superimposing the ICG angiography as green live video overlay. In addition, the reconstructed outline of the three-dimensional (3D) vessel architecture was visualized by AR applying intraoperative low-dose computed tomography (vessel-AR). RESULTS In all patients, ICG-AR and vessel-AR were successfully implemented. The flow in the vessels could be observed directly in the white light view of the microscope oculars without being distracted from the surgical site by looking on separate screens. This factor enabled also surgical manipulation during ICG angiography. In parallel, AR additionally visualized the 3D vessel architecture, enhancing the understanding of the 3D anatomy (target registration error, 0.71 ± 0.21 mm; intraoperative low-dose computed tomography effective dose, 42.7 μSv). Linear (n = 28; range, 1-8.5 mm) and rotational (n = 3; range, 2.9°-14.4°) navigation adjustments performed in 18 of 20 patients resulted in a close matching of the vessel-AR outline with the real vessel situation after preparation, compensating for shifting. CONCLUSIONS ICG-AR could be successfully implemented. It facilitated surgical manipulation and flow interpretation during ICG angiography because it could be observed directly while looking through the microscope oculars in white light instead of being distracted from the surgical site while looking on separate screens. Additional AR visualizing the vessel architecture improved understanding of 3D anatomy for preparation and clipping.
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Affiliation(s)
- Barbara Carl
- Department of Neurosurgery, University Marburg, Marburg, Germany; Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Miriam Bopp
- Department of Neurosurgery, University Marburg, Marburg, Germany; Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| | - Andreea Benescu
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | - Benjamin Saß
- Department of Neurosurgery, University Marburg, Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University Marburg, Marburg, Germany; Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany.
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