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Fanizzi C, Carone G, Rocca A, Ayadi R, Petrenko V, Casali C, Rani M, Giachino M, Falsitta LV, Gambatesa E, Galbiati TF, Orena EF, Tramacere I, Riker NI, Mocca A, Schaller K, Meling TR, DiMeco F, Perin A. Simulation to become a better neurosurgeon. An international prospective controlled trial: The Passion study. BRAIN & SPINE 2024; 4:102829. [PMID: 38812880 PMCID: PMC11134543 DOI: 10.1016/j.bas.2024.102829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/31/2024]
Abstract
Introduction Surgical training traditionally adheres to the apprenticeship paradigm, potentially exposing trainees to an increased risk of complications stemming from their limited experience. To mitigate this risk, augmented and virtual reality have been considered, though their effectiveness is difficult to assess. Research question The PASSION study seeks to investigate the improvement of manual dexterity following intensive training with neurosurgical simulators and to discern how surgeons' psychometric characteristics may influence their learning process and surgical performance. Material and methods Seventy-two residents were randomized into the simulation group (SG) and control group (CG). The course spanned five days, commencing with assessment of technical skills in basic procedures within a wet-lab setting on day 1. Over the subsequent core days, the SG engaged in simulated procedures, while the CG carried out routine activities in an OR. On day 5, all residents' technical competencies were evaluated. Psychometric measures of all participants were subjected to analysis. Results The SG demonstrated superior performance (p < 0.0001) in the brain tumour removal compared to the CG. Positive learning curves were evident in the SG across the three days of simulator-based training for all tumour removal tasks (all p-values <0.05). No significant differences were noted in other tasks, and no meaningful correlations were observed between performance and any psychometric parameters. Discussion and conclusion A brief and intensive training regimen utilizing 3D virtual reality simulators enhances residents' microsurgical proficiency in brain tumour removal models. Simulators emerge as a viable tool to expedite the learning curve of in-training neurosurgeons.
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Affiliation(s)
- Claudia Fanizzi
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Giovanni Carone
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Alessandra Rocca
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Roberta Ayadi
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Veronika Petrenko
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Cecilia Casali
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Martina Rani
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan,
Italy
| | - Marta Giachino
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan,
Italy
| | - Lydia Viviana Falsitta
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Enrico Gambatesa
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Tommaso Francesco Galbiati
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Eleonora Francesca Orena
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
| | - Irene Tramacere
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
| | - Nicole Irene Riker
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
| | - Alessandro Mocca
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan,
Italy
| | - Karl Schaller
- Department of Clinical Neurosciences, Division of Neurosurgery, Geneva
University Hospitals & Faculty of Medicine, Geneva, Switzerland
- Department of Clinical Neurosciences, Division of Neurosurgery, Geneva
University Hospitals & Faculty of Medicine, and SFITS, Geneva,
Switzerland
| | - Torstein Ragnar Meling
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
- Department of Neurosurgery, The National Hospital of Denmark,
Rigshospitalet, Copenhagen, Denmark
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
- Department of Pathophysiology and Transplantation, University of Milano,
Milano, Italy
- Department of Neurological Surgery, Johns Hopkins Medical School,
Baltimore, MD, USA
| | - Alessandro Perin
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico
“C. Besta”, Milano, Italy
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico
Nazionale "C. Besta", Milano, Italy
- Department of Life Sciences, University of Trieste, Trieste,
Italy
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Yilmaz R, Fazlollahi AM, Winkler-Schwartz A, Wang A, Makhani HH, Alsayegh A, Bakhaidar M, Tran DH, Santaguida C, Del Maestro RF. Effect of Feedback Modality on Simulated Surgical Skills Learning Using Automated Educational Systems- A Four-Arm Randomized Control Trial. JOURNAL OF SURGICAL EDUCATION 2024; 81:275-287. [PMID: 38160107 DOI: 10.1016/j.jsurg.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/05/2023] [Accepted: 11/01/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To explore optimal feedback methodologies to enhance trainee skill acquisition in simulated surgical bimanual skills learning during brain tumor resections. HYPOTHESES (1) Providing feedback results in better learning outcomes in teaching surgical technical skill when compared to practice alone with no tailored performance feedback. (2) Providing more visual and visuospatial feedback results in better learning outcomes when compared to providing numerical feedback. DESIGN A prospective 4-parallel-arm randomized controlled trial. SETTING Neurosurgical Simulation and Artificial Intelligence Learning Centre, McGill University, Canada. PARTICIPANTS Medical students (n = 120) from 4 Quebec medical schools. RESULTS Participants completed a virtually simulated tumor resection task 5 times while receiving 1 of 4 feedback based on their group allocation: (1) practice-alone without feedback, (2) numerical feedback, (3) visual feedback, and (4) visuospatial feedback. Outcome measures were participants' scores on 14-performance metrics and the number of expert benchmarks achieved during each task. There were no significant differences in the first task which determined baseline performance. A statistically significant interaction between feedback allocation and task repetition was found on the number of benchmarks achieved, F (10.558, 408.257)=3.220, p < 0.001. Participants in all feedback groups significantly improved their performance compared to baseline. The visual feedback group achieved significantly higher number of benchmarks than the practice-alone group by the third repetition of the task, p = 0.005, 95%CI [0.42 3.25]. Visual feedback and visuospatial feedback improved performance significantly by the second repetition of the task, p = 0.016, 95%CI [0.19 2.71] and p = 0.003, 95%CI [0.4 2.57], respectively. CONCLUSION Simulations with autonomous visual computer assistance may be effective pedagogical tools in teaching bimanual operative skills via visual and visuospatial feedback information delivery.
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Affiliation(s)
- Recai Yilmaz
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.
| | - Ali M Fazlollahi
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Alexander Winkler-Schwartz
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | - Anna Wang
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Hafila Hassan Makhani
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Ahmad Alsayegh
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada; Division of Neurosurgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohamad Bakhaidar
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada; Division of Neurosurgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Dan Huy Tran
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Carlo Santaguida
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | - Rolando F Del Maestro
- Neurosurgical Simulation and Artificial Intelligence Learning Centre, Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada; Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
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3
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Cuello JF, Bardach A, Gromadzyn G, Ruiz Johnson A, Comandé D, Aguirre E, Ruvinsky S. Neurosurgical simulation models developed in Latin America and the Caribbean: a scoping review. Neurosurg Rev 2023; 47:24. [PMID: 38159156 DOI: 10.1007/s10143-023-02263-2] [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: 10/13/2023] [Revised: 12/16/2023] [Accepted: 12/24/2023] [Indexed: 01/03/2024]
Abstract
Simulation training is an educational tool that provides technical and cognitive proficiency in a risk-free environment. Several models have recently been presented in Latin America and the Caribbean (LAC). However, many of them were presented in non-indexed literature and not included in international reviews. This scoping review aims to describe the simulation models developed in LAC for neurosurgery training. Specifically, it focuses on assessing the models developed in LAC, the simulated neurosurgical procedures, the model's manufacturing costs, and the translational outcomes. Simulation models developed in LAC were considered, with no language or time restriction. Cadaveric, ex vivo, animal, synthetic, and virtual/augmented reality models were included for cranial and spinal procedures. We conducted a review according to the PRISMA-ScR, including international and regional reports from indexed and non-indexed literature. Two independent reviewers screened articles. Conflicts were resolved by a third reviewer using Covidence software. We collected data regarding the country of origin, recreated procedure, type of model, model validity, and manufacturing costs. Upon screening 917 studies, 69 models were developed in LAC. Most of them were developed in Brazil (49.28%). The most common procedures were related to general neurosurgery (20.29%), spine (17.39%), and ventricular neuroendoscopy and cerebrovascular (15.94% both). Synthetic models were the most frequent ones (38.98%). The manufacturing cost ranged from 4.00 to 2005.00 US Dollars. To our knowledge, this is the first scoping review about simulation models in LAC, setting the basis for future research studies. It depicts an increasing number of simulation models in the region, allowing a wide range of neurosurgical training in a resource-limited setting.
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Affiliation(s)
| | - Ariel Bardach
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
- Centro de Investigaciones Epidemiológicas y Salud Pública (CIESP-IECS), CONICET, Buenos Aires, Argentina
| | - Guido Gromadzyn
- Neurosurgery Department, Hospital Garrahan, Buenos Aires, Argentina
| | | | - Daniel Comandé
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - Emilio Aguirre
- Neurosurgery Department, Hospital Cordero, San Fernando, Argentina
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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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5
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Burel J, Gerardin E, Papagiannaki C, Shotar E, Sourour N, Laporte C, Hermet PL, Premat K, Dacher JN, Clarençon F. Direct Aspiration versus Combined Technique for Distal Medium-Vessel Occlusions: Comparison on a Human Placenta Model. AJNR Am J Neuroradiol 2023; 44:441-446. [PMID: 36958799 PMCID: PMC10084908 DOI: 10.3174/ajnr.a7831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/23/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy appears to be a promising option for distal medium-vessel occlusions, for which intravenous thrombolysis is effective but may be insufficient when used alone. This study aimed to determine the optimal technique for these distal mechanical thrombectomies using the human placenta model. MATERIALS AND METHODS Twenty-four procedures were performed, allowing comparison of direct aspiration (n = 12) versus the combined technique (n = 12). Two positions of the aspiration catheter were tested for each of these techniques: in direct contact with the clot and at a distance from it (5-10 mm). Two types of clots were tested: red blood cell-rich clots and fibrin-rich clots. First-pass recanalization and induced arterial collapse and traction were assessed. RESULTS The first-pass recanalization was less frequent for direct aspiration than for the combined technique, without reaching statistical significance (41.7% versus 75.0%, P = .098). Full collapse (P < .001) and extended arterial traction (P = .001) were significantly less frequent for direct aspiration. For direct aspiration with the aspiration catheter not in direct contact with the clot, there was not a single first-pass recanalization and there was systematic arterial collapse, resulting in a no-flow in the aspiration syringe. CONCLUSIONS The combined technique appears to be more harmful, and although direct aspiration has a lower rate of first-pass recanalization, it seems appropriate to try direct aspiration as a first-line procedure. However, if the aspiration catheter cannot reach the clot, it is not useful or even risky to try aspiration alone. These results need to be confirmed by clinical studies.
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Affiliation(s)
- J Burel
- From the Departments of Radiology (J.B., E.G., C.P., P.-L.H., J.-N.D.)
- Groupe de Recherche Clinique BioFast (J.B., F.C.), Sorbonne University, Paris, France
| | - E Gerardin
- From the Departments of Radiology (J.B., E.G., C.P., P.-L.H., J.-N.D.)
| | - C Papagiannaki
- From the Departments of Radiology (J.B., E.G., C.P., P.-L.H., J.-N.D.)
| | - E Shotar
- Department of Neuroradiology (E.S., N.S., K.P., F.C.), Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France
| | - N Sourour
- Department of Neuroradiology (E.S., N.S., K.P., F.C.), Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France
| | - C Laporte
- Obstetrics and Gynecology (C.L.), Rouen University Hospital, Rouen, France
| | - P-L Hermet
- From the Departments of Radiology (J.B., E.G., C.P., P.-L.H., J.-N.D.)
| | - K Premat
- Department of Neuroradiology (E.S., N.S., K.P., F.C.), Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France
| | - J-N Dacher
- From the Departments of Radiology (J.B., E.G., C.P., P.-L.H., J.-N.D.)
| | - F Clarençon
- Groupe de Recherche Clinique BioFast (J.B., F.C.), Sorbonne University, Paris, France
- Department of Neuroradiology (E.S., N.S., K.P., F.C.), Assistance Publique-Hôpitaux de Paris, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France
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6
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Burel J, Cornacchini J, Garnier M, Patrier S, Guigné A, Gerardin E, Papagiannaki C, Sourour N, Shotar E, Premat K, Laporte C, Clarençon F. The human placenta as a model for training and research in mechanical thrombectomy: Clarifications and use of the chorionic plate veins. Front Neurol 2022; 13:925763. [PMID: 36203983 PMCID: PMC9530792 DOI: 10.3389/fneur.2022.925763] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
Indications for mechanical thrombectomy in acute ischemic stroke are increasing, resulting in the continuous development of new devices and techniques. Therefore, there is a need for a realistic testing and training environment that offers the opportunity to practice different procedures and test the latest devices. Some authors have described the use of the human placenta as a model for neurointerventional surgery, with striking similarities to real-life conditions. This model has many advantages, including its relatively low cost and minimal infrastructure requirements, with fewer ethical concerns compared to animal models. So far, some preparation and set-up details were missing, and only arteries from the chorionic plate were used. This article provides the necessary clarifications and a mapping of the chorionic plate veins, so that the use of this model, which is particularly well suited for mechanical thrombectomy, can be as easy and wide as possible. A video explaining how to prepare the model is provided.
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Affiliation(s)
- Julien Burel
- Department of Radiology, Rouen University Hospital, Rouen, France
- GRC BioFast, Sorbonne University, Paris, France
- *Correspondence: Julien Burel
| | - Jonathan Cornacchini
- Department of Pathology, Rouen University Hospital, Rouen, France
- Forensic Department, Rouen University Hospital, Rouen, France
| | - Matthieu Garnier
- Department of Radiology, Rouen University Hospital, Rouen, France
| | - Sophie Patrier
- Department of Pathology, Rouen University Hospital, Rouen, France
| | - Albane Guigné
- Department of Pathology, Rouen University Hospital, Rouen, France
- Forensic Department, Rouen University Hospital, Rouen, France
| | | | | | - Nader Sourour
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Sorbonne University, Paris, France
| | - Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Sorbonne University, Paris, France
| | - Kévin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Sorbonne University, Paris, France
| | - Claire Laporte
- Department of Pathology, Rouen University Hospital, Rouen, France
| | - Frédéric Clarençon
- GRC BioFast, Sorbonne University, Paris, France
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Sorbonne University, Paris, France
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7
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Lehtonen SJR, Vrzakova H, Paterno JJ, Puustinen S, Bednarik R, Hauta-Kasari M, Haneishi H, Immonen A, Jääskeläinen JE, Kämäräinen OP, Elomaa AP. Detection improvement of gliomas in hyperspectral imaging of protoporphyrin IX fluorescence - in vitro comparison of visual identification and machine thresholds. Cancer Treat Res Commun 2022; 32:100615. [PMID: 35905671 DOI: 10.1016/j.ctarc.2022.100615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/23/2022] [Accepted: 07/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND 5-aminolevulinic acid (5-ALA) - precursor of protoporphyrin IX (PpIX) - is utilized in fluorescence guided surgery (FGS) of high-grade gliomas. PpIX is used to identify traces of glioma during resection. Visual inspection of the fluorescence seems inaccurate in comparison to optic techniques such as hyperspectral imaging (HSI). AIM To characterize the limits of PpIX fluorescence detection of (i) visual evaluation and (ii) HSI analysis and to (iii) develop a classification system for visible and non-visible PpIX fluorescence. METHODS Samples with increasing concentrations (C) of PpIX and non-fluorescent controls were evaluated using a surgical microscope under blue light illumination. Similar samples were imaged with a HSI system tuned to PpIX fluorescence peak wavelength (635 nm) and control (RGB) channels. Samples' intensities were defined, leading to 96 analysed pixels after batching. RESULTS Three expert neurosurgeons assessed the PpIX samples (n = 16) and controls (n = 8) with unanimous decisions (ICC = 0.704), resulting in 63% recognition rate, 48% sensitivity, 92% specificity, 92% positive predictive value (PPV) and 47% negative predictive value (NPV). HSI image analysis, comparing mean relative values, resulted in 96%, 100%, 86%, 94%, 100%, respectively. Minimum PpIX concentration detection for experts was 0.6-1.8 μmol/l and HSI's 0.03-0.15 μmol/l. CONCLUSIONS PpIX concentrations of low-grade gliomas, and those reported on glioblastoma infiltration zones, are below experts' detection threshold. HSI analysis exceeds the performance of expert's visual inspection nearly by 20-fold. Hybrid FGS-HSI systems should be investigated in parallel to long-term outcomes. Described methods are applicable as a standard for calibration, testing and development of subvisual FGS techniques.
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Affiliation(s)
- Samu J R Lehtonen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland.
| | - Hana Vrzakova
- Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; School of Computing, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland; Institute of Photonics, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland
| | - Jussi J Paterno
- Ophthalmology Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211 Kuopio, Finland
| | - Sami Puustinen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
| | - Roman Bednarik
- School of Computing, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland; Institute of Photonics, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland
| | - Markku Hauta-Kasari
- School of Computing, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland; Institute of Photonics, UEF University of Eastern Finland, Länsikatu 15, 80110 Joensuu, Finland
| | - Hideaki Haneishi
- Center for Frontier Medical Engineering (CFME), Chiba University, 1-33 Yayoi-cho, Inage-ku, Chiba 263-8522, Japan
| | - Arto Immonen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; Eastern Finland Neuro-Oncology Group, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
| | - Juha E Jääskeläinen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; Eastern Finland Neuro-Oncology Group, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; Eastern Finland Neuro-Oncology Group, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
| | - Antti-Pekka Elomaa
- Neurosurgery Clinical Research Unit, Institute of Clinical Sciences, School of Medicine, Faculty of Health Sciences, UEF University of Eastern Finland, Yliopistonranta 1C, 70211, Kuopio, Finland; Microneurosurgery Photonics Research Group of The Microsurgery Center of Eastern Finland, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland; Eastern Finland Neuro-Oncology Group, Neurosurgery of Neurocenter, KUH Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
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Oliveira MM, Quittes L, Costa PHV, Ramos TM, Rodrigues ACF, Nicolato A, Malheiros JA, Machado C. Computer vision coaching microsurgical laboratory training: PRIME (Proficiency Index in Microsurgical Education) proof of concept. Neurosurg Rev 2021; 45:1601-1606. [PMID: 34718926 DOI: 10.1007/s10143-021-01663-6] [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: 04/07/2021] [Revised: 08/17/2021] [Accepted: 09/27/2021] [Indexed: 11/29/2022]
Abstract
Computer vision (CV) feedback could be aimed as a constant tutor to guide ones proficiency during microsurgical practice in controlled environments. Five neurosurgeons with different levels of microsurgical expertise performed simulated vessel dissection and micro-suture in an ex vivo model for posterior computer analysis of recorded videos. A computer program called PRIME (Proficiency Index of Microsurgical Education) used in this research recognized color-labeled surgical instruments, from downloading videos into a platform, with a range of motion greater than 3 mm, for objective evaluation of number of right and left hand movements. A proficiency index of 0 to 1 was pre-established in order to evaluate continuous training improvement. PRIME computer program captured all hand movements executed by participants, except for small tremors or inconsistencies that have a range of motion inferior to 3 mm. Number of left and right hand movements were graphically expressed in order to guide more objective and efficacious training for each trainee, without requiring body sensors and cameras around the operating table. Participants with previous microsurgical experience showed improvement from 0.2 to 0.6 (p < 0.05), while novices had no improvement. Proficiency index set by CV was suggested, in a self-challenge and self-coaching manner. PRIME would offer the capability of constant laboratory microsurgical practice feedback under CV guidance, opening a new window for oriented training without a tutor or specific apparatus regarding all levels of microsurgical proficiency. Prospective, large data study is needed to confirm this hypothesis.
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Affiliation(s)
- Marcelo Magaldi Oliveira
- Placentarium Department, Federal University of Minas Gerais, Rua Montes Claros 1442 - 101 Anchieta, Belo Horizonte, Minas Gerais, 30310370, Brazil.
| | - Lucas Quittes
- Placentarium Department, Federal University of Minas Gerais, Rua Montes Claros 1442 - 101 Anchieta, Belo Horizonte, Minas Gerais, 30310370, Brazil
| | - Pollyana Helena Vieira Costa
- Placentarium Department, Federal University of Minas Gerais, Rua Montes Claros 1442 - 101 Anchieta, Belo Horizonte, Minas Gerais, 30310370, Brazil
| | - Taise Mosso Ramos
- Placentarium Department, Federal University of Minas Gerais, Rua Montes Claros 1442 - 101 Anchieta, Belo Horizonte, Minas Gerais, 30310370, Brazil
| | - Ana Clara Fidelis Rodrigues
- Placentarium Department, Federal University of Minas Gerais, Rua Montes Claros 1442 - 101 Anchieta, Belo Horizonte, Minas Gerais, 30310370, Brazil
| | - Arthur Nicolato
- Placentarium Department, Federal University of Minas Gerais, Rua Montes Claros 1442 - 101 Anchieta, Belo Horizonte, Minas Gerais, 30310370, Brazil
| | - Jose Augusto Malheiros
- Placentarium Department, Federal University of Minas Gerais, Rua Montes Claros 1442 - 101 Anchieta, Belo Horizonte, Minas Gerais, 30310370, Brazil
| | - Carla Machado
- Placentarium Department, Federal University of Minas Gerais, Rua Montes Claros 1442 - 101 Anchieta, Belo Horizonte, Minas Gerais, 30310370, Brazil
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Souza JRF, Barros Filho EMD, JucÁ CEB, Rolim JPML. Endovascular technique simulator for Neuroradiology learning. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:535-540. [PMID: 32627807 DOI: 10.1590/0004-282x20200028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/17/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Vascular cerebral infarction (or stroke) is recognized as the third leading cause of death worldwide, and acute arterial occlusion comprises the main mechanism underlying ischemic stroke. Cerebrovascular diseases are treated by intracranial endovascular interventions employing minimally invasive intravascular techniques, such as neuroimaging. Conducting practical training in this area is a necessary task since patient safety is a considerably significant factor. There has been a steady increase in scientific research focused on validating endovascular simulation as a tool for training interventionists in endovascular procedures. Current literature confirms the idea that there is a beneficial role of simulation in endovascular training and skill acquisition and technique improvement. OBJECTIVE To develop an endovascular technique simulator for learning Neuroradiology. METHODS The methodology consisted of developing a simulator using 3D printing technology. RESULTS A literature search was carried out, commencing in August 2017, through consultation of the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Latin American and Caribbean Health Sciences Literature (LILACS) databases, using the PubMed and BIREME websites, respectively. Meetings were held between the neuroradiologist specialist and programmers to develop the simulator, which was carried out in three phases: design of the arterial system, design of the prototype of the arterial system in computer graphics, and confection of the arterial system simulator in 3D. CONCLUSION The simulator is ready for testing by residents and can enable the student to learn through simulations that reproduce, as realistically as possible, the situation to be subsequently experienced using a concrete tool.
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Ribeiro de Oliveira MM, Ramos TM, Ferrarez CE, Machado CJ, Vieira Costa PH, Alvarenga DL, Soares CK, Mainart LM, Aguilar-Salinas P, Gusmão S, Sauvageau E, Hanel RA, Lanzino G. Development and validation of the Skills Assessment in Microsurgery for Brain Aneurysms (SAMBA) instrument for predicting proficiency in aneurysm surgery. J Neurosurg 2019; 133:190-196. [PMID: 31200371 DOI: 10.3171/2018.7.jns173007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 07/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical performance evaluation was first described with the OSATS (Objective Structured Assessment of Technical Skills) and modified for aneurysm microsurgery simulation with the OSAACS (Objective Structured Assessment of Aneurysm Clipping Skills). These methods rely on the subjective opinions of evaluators, however, and there is a lack of objective evaluation for proficiency in the microsurgical treatment of brain aneurysms. The authors present a new instrument, the Skill Assessment in Microsurgery for Brain Aneurysms (SAMBA) scale, which can be used similarly in a simulation model and in the treatment of unruptured middle cerebral artery (MCA) aneurysms to predict surgical performance; the authors also report on its validation. METHODS The SAMBA scale was created by consensus among 5 vascular neurosurgeons from 2 different neurosurgical departments. SAMBA results were analyzed using descriptive statistics, Cronbach's alpha indexes, and multivariate ANOVA analyses (p < 0.05). RESULTS Expert, intermediate-level, and novice surgeons scored, respectively, an average of 33.9, 27.1, and 16.4 points in the real surgery and 33.3, 27.3, and 19.4 points in the simulation. The SAMBA interrater reliability index was 0.995 for the real surgery and 0.996 for the simulated surgery; the intrarater reliability was 0.983 (Cronbach's alpha). In both the simulation and the real surgery settings, the average scores achieved by members of each group (expert, intermediate level, and novice) were significantly different (p < 0.001). Scores among novice surgeons were more diverse (coefficient of variation = 12.4). CONCLUSIONS Predictive validation of the placenta brain aneurysm model has been previously reported, but the SAMBA scale adds an objective scoring system to verify microsurgical ability in this complex operation, stratifying proficiency by points. The SAMBA scale can be used as an interface between learning and practicing, as it can be applied in a safe and controlled environment, such as is provided by a placenta model, with similar results obtained in real surgery, predicting real surgical performance.
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Affiliation(s)
| | | | | | - Carla Jorge Machado
- 2Department of Preventive and Social Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | | | | | | | | | - Eric Sauvageau
- 3Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida; and
| | - Ricardo A Hanel
- 3Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida; and
| | - Giuseppe Lanzino
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Sullivan S, Aguilar-Salinas P, Santos R, Beier AD, Hanel RA. Three-dimensional printing and neuroendovascular simulation for the treatment of a pediatric intracranial aneurysm: case report. J Neurosurg Pediatr 2018; 22:672-677. [PMID: 30215588 DOI: 10.3171/2018.6.peds17696] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 06/13/2018] [Indexed: 11/06/2022]
Abstract
The use of simulators has been described in a variety of fields as a training tool to gain technical skills through repeating and rehearsing procedures in a safe environment. In cerebrovascular surgery, simulation of skull base approaches has been used for decades. The use of simulation in neurointervention to acquire and enhance skills before treating a patient is a newer concept, but its utilization has been limited due to the lack of good models and deficient haptics. The advent of 3D printing technology and the development of new training models has changed this landscape. The prevalence of aneurysms in the pediatric population is much lower than in adults, and concepts and tools sometimes have to be adapted from one population to another. Neuroendovascular rehearsal is a valid strategy for the treatment of complex aneurysms, especially for the pediatric population. The authors present the case of an 8-year-old boy with a fusiform intracranial aneurysm and documented progressive growth, who was successfully treated after the authors rehearsed the placement of a flow diverter using a patient-specific 3D-printed replicator system model.
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Affiliation(s)
- Sean Sullivan
- 1Lyerly Neurosurgery, Baptist Neurological Institute; and
| | | | - Roberta Santos
- 1Lyerly Neurosurgery, Baptist Neurological Institute; and
| | - Alexandra D Beier
- 2Division of Pediatric Neurosurgery, University of Florida Health Science Center, Jacksonville, Florida
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de Oliveira MMR, Ferrarez CE, Ramos TM, Malheiros JA, Nicolato A, Machado CJ, Ferreira MT, de Oliveira FB, de Sousa CFPM, Costa PHV, Gusmao S, Lanzino G, Maestro RD. Learning brain aneurysm microsurgical skills in a human placenta model: predictive validity. J Neurosurg 2018; 128:846-852. [DOI: 10.3171/2016.10.jns162083] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVESurgery for brain aneurysms is technically demanding. In recent years, the process to learn the technical skills necessary for these challenging procedures has been affected by a decrease in the number of surgical cases available and progressive restrictions on resident training hours. To overcome these limitations, surgical simulators such as cadaver heads and human placenta models have been developed. However, the effectiveness of these models in improving technical skills is unknown. This study assessed concurrent and predictive validity of brain aneurysm surgery simulation in a human placenta model compared with a “live” human brain cadaveric model.METHODSTwo human cadaver heads and 30 human placentas were used. Twelve neurosurgeons participated in the concurrent validity part of this study, each operating on 1 human cadaver head aneurysm model and 1 human placenta model. Simulators were evaluated regarding their ability to simulate different surgical steps encountered during real surgery. The time to complete the entire aneurysm task in each simulator was analyzed. The predictive validity component of the study involved 9 neurosurgical residents divided into 3 groups to perform simulation exercises, each lasting 6 weeks. The training for the 3 groups consisted of educational video only (3 residents), human cadaver only (3 residents), and human placenta only (3 residents). All residents had equivalent microsurgical experience with superficial brain tumor surgery. After completing their practice training, residents in each of the 3 simulation groups performed surgery for an unruptured middle cerebral artery (MCA) aneurysm, and their performance was assessed by an experienced vascular neurosurgeon who watched the operative videos.RESULTSAll human cadaver heads and human placentas were suitable to simulate brain aneurysm surgery. In the concurrent validity portion of the experiment, the placenta model required a longer time (p < 0.001) than cadavers to complete the task. The placenta model was considered more effective than the cadaver model in simulating sylvian fissure splitting, bipolar coagulation of oozing microvessels, and aneurysm neck and dome dissection. Both models were equally effective in simulating neck aneurysm clipping, while the cadaver model was considered superior for simulation of intraoperative rupture and for reproduction of real anatomy during simulation. In the predictive validity portion of the experiment, residents were evaluated for 4 tasks: sylvian fissure dissection, microvessel bipolar coagulation, aneurysm dissection, and aneurysm clipping. Residents trained in the human placenta simulator consistently had the highest overall performance scores when compared with those who had trained in the cadaver model and those who had simply watched operative videos (p < 0.001).CONCLUSIONSThe human placenta biological simulator provides excellent simulation for some critical tasks of aneurysm surgery such as splitting of the sylvian fissure, dissection of the aneurysm neck and dome, and bipolar coagulation of surrounding microvessels. When performing surgery for an unruptured MCA aneurysm, residents who had trained in the human placenta model performed better than residents trained with other simulation scenarios/models. In this age of reduced exposure to aneurysm surgery and restrictions on resident working hours, the placenta model is a valid simulation for microneurosurgery with striking similarities with real surgery.
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Affiliation(s)
- Marcelo Magaldi Ribeiro de Oliveira
- 1Microsurgical Laboratory, Medical School, and
- 3Neurosurgical Simulation Research and Training Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; and
| | | | | | | | | | - Carla Jorge Machado
- 2Department of Preventive and Social Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | | | | | | | - Giuseppe Lanzino
- 4Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Rolando Del Maestro
- 3Neurosurgical Simulation Research and Training Centre, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada; and
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Okada H, Chung J, Heiferman DM, Lopes DK. Assessment of human placenta as an ex-vivo vascular model for testing of liquid embolic agent injections with adjunctive techniques. J Neurointerv Surg 2017; 10:892-895. [PMID: 29273647 DOI: 10.1136/neurintsurg-2017-013474] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 11/04/2022]
Abstract
PURPOSE This project sought to test the utility of post-delivery human placenta (HP) as a vascular model for liquid embolic agent (LEA) simulation, along with adjunctive techniques. MATERIALS AND METHODS Twelve LEA injections were performed under fluoroscopy in HP with two reflux control methods: dual lumen 'mini' balloon-catheter (n=9); and injection after proximal nBCA plug formation through a second microcatheter ('pressure cooker') (n=3). Measured outcomes included liquid embolic agent (LEA) advancement and reflux. Reflux was categorized into three grades: grade 0=no reflux; grade 1=occlusion of side branches without reflux beyond the balloon or plug; and grade 2=reflux beyond the balloon or plug. RESULTS Simulation success was greater when a balloon was used rather than with a nBCA plug (89% vs 33%, P=0.054). In eight successful balloon-assisted injections, the reflux grades were: 50% grade 0; 12.5% grade 1; and 37.5% grade 2. The one successful nBCA plug injection had grade 2 reflux. All grade 2 balloon injections occurred when the balloon was positioned across a vessel bifurcation. CONCLUSIONS HP provides excellent simulation for liquid embolic agents with a dual lumen balloon catheter.
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Affiliation(s)
- Hideo Okada
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA.,Department of Neurosurgery, Wakayama Rosai Hospital, Wakayama, Japan
| | - Joonho Chung
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA.,Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.,Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Daniel M Heiferman
- Department of Neurological Surgery, Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Demetrius K Lopes
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
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