A neuroendoscopic navigation system based on dual-mode augmented reality for minimally invasive surgical treatment of hypertensive intracerebral hemorrhage

BACKGROUND AND OBJECTIVE

Hypertensive intracerebral hemorrhage is characterized by a high rate of morbidity, mortality, disability and recurrence. Neuroendoscopy has been utilized for treatment as an advanced technology. However, traditional neuroendoscopy allows professionals to see only tissue surfaces, and the field of vision is limited, which cannot provide spatial guidance. In this study, an AR-based neuroendoscopic navigation system is proposed to assist surgeons in locating and clearing hematoma.

METHODS

The neuroendoscope can be registered through the vector closed loop algorithm. The single-shot method is designed to register medical images with patients precisely. Real-time AR is realized based on video stream fusion. Dual-mode AR navigation is proposed to provide comprehensive guidance from catheter implantation to hematoma removal. A series of experiments is designed to validate the accuracy and significance of this system.

RESULTS

The average root mean square error of the registration between medical images and patients is 0.784 mm, and the variance is 0.1426 mm. The pixel mismatching degrees are less than 1% in different AR modes. In catheter implantation experiments, the average error of distance is 1.28 mm, and the variance is 0.43 mm, while the average error of angles is 1.34°, and the variance is 0.45°. Comparative experiments are also conducted to evaluate the feasibility of this system.

CONCLUSION

This system can provide stereo images with depth information fused with patients to guide surgeons to locate targets and remove hematoma. It has been validated to have high accuracy and feasibility.

Clinical efficacy and safety of neuroendoscopic surgery for severe thalamic hemorrhage with ventricle encroachment

To summarize and analyze the clinical efficacy and safety of neuroendoscopic surgery (NES) in the treatment of patients for severe thalamic hemorrhage with ventricle encroachment (THVE). Eighty-three patients with severe THVE were treated in the Neurosurgery Department of Anqing Hospital Affiliated to Anhui Medical University from July 2019 to August 2021. Our study was approved by the ethics committee. The patients were randomly divided into NES group and extraventricular drainage (EVD) group. The hospital stay, Glasgow coma scale (GCS) scores on the 1st and 14th days postoperatively, the incidence of intracranial infections, and the clearance of postoperative hematomas were compared and analyzed between the two groups. The patients had follow-up evaluations 6 months postoperatively. The prognosis was evaluated based on the activity of daily living (ADL) score. A head CT or MRI was obtained to determine whether there was hydrocephalus, cerebral infarction, or other related complications. Eighty-three patients were randomly divided into 41 cases of NES group and 42 cases of EVD group. The length of postoperative hospital stay was 17.42 ± 1.53 days, the GCS scores were 6.56 ± 0.21, and 10.83 ± 0.36 on days 1 and 14, respectively; intracranial infections occurred in 3 patients (7.31%) and the hematoma clearance rate was 83.6 ± 5.18% in the NES group, all of which were significantly better than the EVD group (P < 0.05). After 6 months of follow-up, 28 patients (68.29%) had a good prognosis, 5 patients (12.19%) died, and 4 patients (9.75%) had hydrocephalus in the NES group. In the EVD group, the prognosis was good in 15 patients (35.71%), 12 patients (28.57%) died, and 17 patients (40.47%) had hydrocephalus. The prognosis, mortality rate, and incidence of hydrocephalus in the NES group were significantly better than the EVD group (P < 0.05). Compared to traditional EVD, NES for severe THVE had a higher hematoma clearance rate, and fewer intracranial infections and patients with hydrocephalus, which together improve the clinical prognosis and is thus recommended for clinical use.

Clinical Value of 3D-Printed Navigation Technology Combined with Neuroendoscopy for Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the most common form of hemorrhagic stroke with high morbidity and mortality. Rapid and massive bleeding may compress the brain tissue, causing space-occupying and pathological effects, such as reduced local cerebral blood flow, acidosis, and inflammatory and immune responses. Although the development of minimally invasive technique provides a new option for the treatment of ICH, their application is limited due to the difficulty in achieving accurate puncture localization under the guidance of the marks on CT. We selected 30 patients treated with neuroendoscopic surgery guided by 3D-printed navigation technology (experimental group) and 30 patients treated with neuroendoscopic surgery guided by hand-painted on the patient's body surface according to the marks on CT (control group). Our results showed that patients in the experimental group had a lower number of intraoperative punctures, shorter operation time, less intraoperative blood loss, higher hematoma clearance rate, and smaller volume of perihematomal edema than the patients in the control group. Moreover, patients in the experimental group had higher Glasgow Coma Scale score at discharge, shorter postoperative hospitalization time and ICU stay, and a lower rate of postoperative complications, despite the lack of statistically significant differences. In addition, no statistically significant differences were observed in mortality and Glasgow Outcome Scale score between the two groups. In conclusion, 3D-printed navigation technology used for the neuroendoscopic hematoma removal is a more reliable and less invasive approach in the treatment of ICH. This technique has great application prospects and deserves promotion in the future clinical practice.

Pituitary Apoplexy in Long-Term Cabergoline User During Thrombocytopenia Due to Chemotherapy for Chronic Myelocytic Leukemia

BACKGROUND

Pituitary apoplexy (PA) is a life-threatening syndrome. The usage of a dopamine agonist, such as bromocriptine or cabergoline, is considered a predisposing factor for PA, which commonly occurs 1.5 years within commencement.

CASE DESCRIPTION

A 64-year-old female with a >15-year history of cabergoline therapy for pituitary prolactinoma was referred to our department of neurosurgery after complaining of headache, blurred vision, diplopia, and ptosis for 3 days during hospital admission for chemotherapy of chronic myelocytic leukemia. Computed tomography and magnetic resonance imaging revealed findings indicative of PA. As the patient was experiencing thrombocytopenia related to chemotherapy, blood transfusion was preceded, and after a platelet count of 15.0 × 104/μL was confirmed, transnasal neuroendoscopic surgery was performed 5 days from the onset of symptoms. The majority of the prolactinoma was removed, and the prolactinoma in the cavernous sinus was intentionally left. The postoperative course was generally good. The ptosis and diplopia improved, and the blurred vision resolved.

CONCLUSIONS

PA related to dopamine agonist therapy can occur in cases of elevated bleeding tendency, even in long-term users, suggesting that attention should be paid in the administration of a dopamine agonist in the patient experiencing thrombocytopenia. Surgical intervention should be performed after the preoperative platelet number and adequate response to transfusion are confirmed, and the aggressive removal of prolactinoma in the cavernous sinus should be avoided to reduce the risk of hemorrhagic complications.

Neuroendoscopic Surgery with a Combination of Image Detectable Sheath, Intraoperative Computed Tomography Scan, and Navigation System Improves Accuracy and Safety in Minimally Invasive Evacuation of Intracerebral Hematoma: Technical Note

BACKGROUND

Recent studies have confirmed the effectiveness of minimally invasive endoscopic surgery for intracerebral hematoma (ICH). However, improvements are needed because incomplete hematoma removal may offset the surgical benefits of the technique. We describe a technique of neuroendoscopic surgery using an image detectable sheath, intraoperative computed tomography (iCT) scan, and a navigation system.

METHODS

This is a retrospective study of 15 consecutive patients with spontaneous ICH who received neuroendoscopic surgery. During the surgery, a transparent sheath was fastened tightly to the scalp with 3.0 nylon. The patient's head was covered with a sterilized vinyl sheet and subsequent iCT scan visualized the orientation of the endoscopic sheath and the extent of residual hematoma, allowing the surgeon to decide to continue to remove the hematoma or to finish the treatment.

RESULTS

The median hematoma evacuation rate was 93% (interquartile range, 82.2%-95.9%). The Glasgow Coma Scale score of all patients significantly improved at 1 week after the operation (P < 0.05). No complications associated with the procedure were observed.

CONCLUSIONS

The combination of our techniques improves accuracy and safety of minimally invasive surgical evacuation of hematoma. Performing surgery with iCT scan also improves the spatial recognition of surgeons and therefore may be of educational value.

Neuroendoscopic Evacuation Improves Outcomes Compared with External Ventricular Drainage in Patients with Spontaneous Intraventricular Hemorrhage: A Systematic Review with Meta-Analyses

BACKGROUND

Spontaneous intraventricular hemorrhage (IVH) is a cause of significant morbidity and mortality. Treatment for resulting obstructive hydrocephalus has traditionally been via an external ventricular drain (EVD). We aimed to compare patient outcomes after neuroendoscopic surgery (NES) evacuation of IVH versus EVD management.

METHODS

MEDLINE, Embase, and Cochrane Library databases were searched on October 8, 2022. Of the 252 records remaining after removal of duplicates, 12 met study inclusion criteria. After extraction of outcomes data, fixed-effect and random-effects models were used to establish odds ratios (ORs) with 95% confidence intervals (CIs) for intensive care unit length of stay, rate of permanent cerebrospinal fluid diversion, Glasgow Outcome Scale score, and mortality rate.

RESULTS

The results of the pooled analysis showed that intensive care unit length of stay was shorter (OR -2.61 [95% CI -5.02, -0.19]; I2 = 97.76%; P = 0.034), permanent cerebrospinal fluid diversion was less likely (OR -0.79, 95% CI [-1.17, -0.41], I2 = 46.96%, P < 0.001), higher Glasgow Outcome Scale score was more likely (OR 0.48, 95% CI [0.04, 0.93], I2 = 60.12%, P = 0.032), and all-cause mortality was less likely (OR -1.11, 95% CI [-1.79, -0.44], I2 = 0%, P = 0.001) in the NES evacuation group compared with the EVD group.

CONCLUSIONS

NES for evacuation of spontaneous IVH results in reduced intensive care unit length of stay, reduced permanent cerebrospinal fluid diversion rates, improved Glasgow Outcome Scale score, and reduced mortality when compared with EVD. More robust prospective, randomized studies are necessary to help inform the safety and utility of NES for IVH.

Late-onset aqueductal membranous occlusion treated neuroendoscopic procedure and consideration of its pathological findings: A case report

Background

Aqueduct of Sylvius stenosis/obstruction interferes with cerebrospinal fluid (CSF) flow and leads to the non-communicating hydrocephalus. Acquired non-neoplastic causes of aqueduct of Sylvius stenosis/ obstruction include simple stenosis, gliosis, slit-like stenosis, and septal formation, but the detailed mechanisms are not clear. In the present study, we experienced a case of late-onset aqueductal membranous occlusion (LAMO) successfully treated by neuroendoscopic procedure, which allowed us to examine the pathology of the membranous structures of the aqueduct of Sylvius occlusion.

Case Description

A 66-year-old woman presented with gradually progressive gait disturbance, cognitive dysfunction, and urinary incontinenc. Brain magnetic resonance imaging (MRI) showed enlargement of the bilateral lateral ventricles and the third ventricle without dilatation of fourth ventricle, and heavily T2-weighted images showed an enlarged aqueduct of Sylvius and a membranous structure at its caudal end. Gadolinium contrast-enhanced T1-weighted images showed no neoplastic lesions. We diagnosed this case that the hydrocephalus due to late-onset idiopathic aqueductal stenosis or LAMO and the patient underwent endoscopic third ventriculostomy and endoscopic aqueduct oplasty. Membranous tissue specimens were obtained from the occluded aqueduct of Sylvius at the time of treatment. Histopathological examination revealed gliosis, and inside the gliosis, there were cell clusters that appeared to be ependymal cells and were corpora amylacea. We confirmed CSF flow at the site of obstruction of the aqueduct of Sylvius and the stoma of the third ventricle floor by MRI images. Her symptoms were improved immediately.

Conclusion

We experienced a case of LAMO successfully treated by neuroendoscopic procedure, which allowed us to examine the pathology of the membranous structure of the aqueduct of Sylvius. The pathological study of LAMO is rare, and we report it, including a review of the literature.

Beyond the bipolar disorder diagnosis: Hypothalamus and its network damage in determining neuropsychiatric and Korsakoff-like memory disorders

Craniopharyngiomas (CP's) are hypothalamic tumors often associated with psychological disorders. Nevertheless, its diagnosis is still challenging when psychiatric disorders are not associated with any other neurological symptoms. This single-case study describes a patient with a history of bipolar disorder before a diagnosis of a large CP arising the sellar and suprasellar region was posed. At the time of the present study the patient showed emotional/behavioral disorders and Korsakoff-like amnesia, that completely recovered after surgical resection of the tumor. This is one of those few cases described in literature, who presented cognitive/behavioral disorders because the compression of the diencephalic structures due to CP mass effect. This case offers further evidence on the functional neuroanatomy of the hypothalamus and its pathways.

3DSlicer software-assisted neuroendoscopic surgery compared with traditional surgery on surgical effects, complications, and safety evaluation in patients with intracerebral hemorrhage: A systematic review and meta-analysis

OBJECTIVE

This study aims to comprehensively evaluate the complications, effectiveness, and safety of neuroendoscopic surgery (NS) assisted by 3DSlicer software, compared to traditional surgery in patients with intracerebral hemorrhage (IH).

METHODS

We searched for case-control trials from the Chinese Biomedical Literature data (CBM) online database, Wanfang Database, EMBASE, VIP Full-text Database, China National Knowledge Infrastructure (CNKI), Science Direct, Cochrane Library, and PubMed. The studies, published since January 2010, involved NS or traditional surgery for IH patients assisted by 3DSlicer software. Data were independently retrieved by two researchers, and the risk of bias in each study was evaluated using the Cochrane Handbook 5.3 standard.

RESULTS

A total of 591 patients from seven controlled clinical studies were included. Fixed-effect model analysis revealed a significantly higher treatment effectiveness rate in the study group (SG) (P < 0.05). Random-effects model (REM) analysis indicated that the operation time in the SG was significantly shorter (P < 0.05). Furthermore, the SG group experienced significantly shorter hospitalization time (P < 0.05). NIHSS scores in the SG were notably lower (P < 0.05). Fixed-effect model analysis also showed that the incidence of postoperative complications in the SG was significantly lower (P < 0.05).

CONCLUSION

Neuroendoscopic surgery assisted by 3DSlicer software is more effective in treating IH, enhancing prognosis, improving neurological function, and reducing complication rates. This approach appears to be a promising candidate for clinical adoption.

Clinical outcomes of the neuroendoscopic far lateral supracerebellar infratentorial approach for resection of deep brain lesions

Resection of deep cerebral lesions presents significant challenges for neurosurgeons. However, advancements in neuroendoscopic techniques have led to the adoption of endoscopic surgery via the supracerebellar infratentorial approach for addressing deep cerebral lesions located in the petroclival region, cerebellopontine angle, and pineal region. The aim of this study was to explore the curative effects and analyse the characteristics of the neuroendoscopic far-lateral supracerebellar infratentorial approach for treating these lesions. Sixteen cases of deep cerebral lesions treated with this method were reviewed, and the surgical outcomes and patients' postoperative conditions were assessed to evaluate the approach's effectiveness. Among the 16 patients, ten were diagnosed with petroclival region meningiomas, two with epidermoid cysts in the cerebellopontine angle, two with germ cell tumours in the pineal region, one with a trigeminal schwannoma, and one with a thalamic haematoma. Notably, only two patients (12.5%) experienced postoperative complications, and during follow-up, three patients (18.6%) exhibited no symptom improvement. These findings indicate that the neuroendoscopic far-lateral supracerebellar infratentorial approach enhances lesion exposure, improves the surgeon's view of the surgical field, minimizes the risk of intraoperative injury, and reduces the risk of postoperative complications, demonstrating significant potential for the clinical treatment of skull base lesions due to its effectiveness and safety.

Stereotactic puncture surgery combined with early hyperbaric oxygen therapy may be better for long-term functional recovery in patients with moderate amounts of thalamic-inner capsule region haemorrhage

BACKGROUND

The prognosis of patients with thalamic hemorrhage is poor, and their long-term neurological impairment is heavy, which seriously affects their work and life.To comparatively analyse the efficacy and prognosis of patients with moderate hemorrhage in the thalamic region who underwent conservative treatment, stereotactic puncture surgery and neuroendoscopic surgery.

METHOD

This study retrospectively analyzed hospitalization data from 139 adult patients with moderate-volume cerebral hemorrhage in the thalamo-endocapsular region. They were categorized into a stereotactic group (39cases), a neuroendoscopic group (36cases), and a conventional conservative group (64cases). Logistic regression analysis was used to assess risk factors for severe neurological deficits in patients. Multivariate regression modeling was used to compare the correlation of severe neurological deficits among the three groups of patients.

RESULTS

Patients with thalamic moderate-volume cerebral hemorrhage had statistically significantly higher Assessment of Daily Living (ADL) scores in the stereotactic surgery group than in the conservative treatment group and the neuroendoscopic surgery group after 6 months of treatment (p< 0.001).The amount of residual hematoma was significantly lower in the surgery groups than in the conservative treatment group at 3 days, 7 days, and 2 weeks after the onset of the disease (P< 0.001).In multivariate logistic regression analyses, after adjusting for all covariates, the odds ratios for severe neurologic dysfunction in the stereotactic group and the neuroendoscopy group were, respectively, OR: 0.37 (0.12-0.87), P< 0.001 and 0.42 (0.23-1.13), P=0.361).

CONCLUSION

In patients with moderate volume cerebral hemorrhage in the thalamus-inner capsule region cerebral hemorrhage, patients treated with stereotactic surgery combined with early hyperbaric oxygen therapy may have better long-term neurological recovery compared with conservative and neuroendoscopic surgical treatments.

Neuroendoscopic surgery for acute presentation of cystic craniopharyngiomas

Acute presentation of cystic craniopharyngioma is a potentially life-threatening condition, characterized by disability and increased mortality risk, often caused by large cysts with or without hydrocephalus. This study evaluated the applicability of minimally invasive neuroendoscopic surgery (NES) for rapid intracranial pressure relief and tumor control as an alternative to emergent microsurgical resection. A retrospective review of the electronic medical record database of patients with craniopharyngiomas treated at our institution between June 2007 and October 2024 identified 13 non-consecutive cases of acute presentation of cystic craniopharyngioma managed with NES. Interventions included pellucid septostomy (n = 2), ventriculoperitoneal shunt surgery (n = 2), and Ommaya reservoir placement (n = 6). Clinical and radiological data were analyzed to assess treatment outcomes. The most common acute symptoms were severe headache (69.2%), frequent vomiting (53.8%), sudden onset of consciousness disturbance (38.5%), visual impairment (46.2%), gait instability (23.1%), and cognitive dysfunction (15.4%). Ten patients had hydrocephalus at admission. All patients experienced symptom relief following NES, with no procedure-related mortality or complications. Hydrocephalus resolved in all cases, and subjective visual function improved in 83.3% of patients postoperatively. Endocrine function remained stable. At a median follow-up of 62 months (range, 38-130), local tumor control was achieved in 8 patients (61.5%) without requiring adjuvant therapy. NES is a safe, effective approach for managing acute presentation of cystic craniopharyngioma, particularly in patients with hydrocephalus. It offers rapid symptom relief and tumor control and is a potential staging treatment in selected cases.

The impact of neuroendoscopic drainage in intraventricular hemorrhage: an updated meta-analysis

External ventricular drainage (EVD) is a mainstay for intraventricular hemorrhage (IVH) treatment, improving ventricular clearance and reducing mortality but with suboptimal complications and morbidity. Meanwhile, several studies have shown that neuroendoscopic drainage (NED) provides superior results and is a promising therapy. Thus, we aimed to compare NED and EVD in patients with IVH. A systematic literature review was conducted using Embase, PubMed, and Cochrane databases. The primary outcome was shunt dependency. Secondary outcomes were infection, length of intensive care unit (ICU) and hospital stay, mortality, and functional outcome. Inclusion criteria: studies comparing NED and EVD with predefined outcomes. Exclusion criteria: age < five years. Statistical analysis was performed using RStudio 2024.04.1 + 748. Sensitivity analysis was performed with subgroup analysis. The risk of bias was assessed using ROBINS-I and RoB-2. Of 234 potential articles, 17 met our criteria, involving 1043 patients, with 495 undergoing NED and 548 receiving only EVD. Patients who underwent NED had lower odds of shunt dependency (OR 0.17; 95% CI 0.12,0.25; p < 0.001), infection (OR 0.29; 95% CI 0.16,0.53; p < 0.001), and mortality at one month (OR 0.44; 95% CI 0.20,0.96; p = 0.039) and six months (OR 0.31; 95% CI 0.16,0.58; p < 0.001), shorter hospital (MD -6.02; 95% CI -9.58,-2.45; p < 0.001) and ICU stay (MD -6.64; 95% CI -10.46,-2.83; p < 0.001), and better functional outcomes according to Glasgow Outcome Scale (MD -0.65; 95% CI -0.98,-0.32; p < 0.001) and modified Rankin Scale (MD -1.25; 95% CI -1.90,-0.60; p < 0.001) compared to patients who underwent EVD. To confirm the robustness of the results, we performed sensitivity analyses with subgroups of the RCT, which also showed significant superiority of NED over EVD. Our results suggest that NED has a positive impact on patients with IVH and may be a breakthrough intervention in this scenario.

Neuroendoscopic Surgery Versus Stereotactic Aspiration in the Treatment of Supratentorial Intracerebral Hemorrhage: A Meta-Analysis

BACKGROUND

Debate persists over the relative merits of neuroendoscopic surgery (NS) compared to stereotactic aspiration (SA) for treating supratentorial intracerebral hemorrhage (ICH). Consequently, we undertook this meta-analysis to assess the efficacy and safety of NS versus SA.

METHODS

We searched for the all-relevant studies systematically from English databases including PubMed, Embase, Web of Science, and the Cochrane Library. Three independent researchers identified and selected these literatures that met the inclusion criteria. Then we evaluated the quality of these studies according to the Cochrane Collaboration's risk of bias tool and the Newcastle-Ottawa Scale. RevMan 5.4 statistical software was used to conduct this meta-analysis.

RESULTS

Sixteen studies, including 2722 supratentorial ICH patients, were included in our meta-analysis. The pooled results showed that NS could effectively improve the functional prognosis (P = 0.002), reduce the postoperative mortality (P < 0.00001), and increase the hematoma evacuation rate (P < 0.00001). In addition, SA had more advantages in shortening operation time (P < 0.00001) and reducing intraoperative blood loss (P < 0.0001). However, there was no obvious statistical difference in intensive care unit stays (P = 0.23) between NS and SA. Besides, no sufficient evidence could support a significant difference in hospital stays. In the aspect of complications, NS was discovered to have a positive effect on preventing rebleeding (P = 0.005) and intracranial infection (P = 0.003). However, no significant differences between the 2 groups in digestive tract ulcer (P = 0.34), epilepsy (P = 0.99), and pneumonia (P = 0.58) were discovered. In the subgroup analysis, factors including publication time, Glasgow Coma Scale score, age, and follow-up, all significantly influenced the good functional outcome and mortality. Meanwhile, NS behaved more advantageous in improving functional prognosis for patients with hematoma located in the basal ganglia.

CONCLUSIONS

NS may hold more advantages over SA in the treatment of supratentorial ICH. However, SA is also an effective and suitable alternative for elderly patients, especially those with multiple comorbidities intolerant to extended surgical procedures. Further high-quality studies are warranted to substantiate our findings in the future.

Efficacy and safety of NeuroEndoscopic Surgery for IntraCerebral Hemorrhage: A randomized, controlled, open-label, blinded endpoint trial (NESICH)

BACKGROUND

Neuroendoscopy is a minimally invasive procedure for clot evacuation in intracerebral hemorrhage (ICH) which may have advantages compared with open surgical evacuation procedures. The application of neuroendoscopy in ICH has attracted increasing attention in recent years. However, it remains unclear whether it could improve outcomes in patients with ICH.

OBJECTIVE

The aim of this study is to explore the efficacy and safety of neuroendoscopic hematoma evacuation surgery compared with standard conservative treatment for spontaneous deep supratentorial cerebral hemorrhage.

METHODS

The Efficacy and safety of NeuroEndoscopic Surgery for IntraCerebral Hemorrhage (NESICH) Trial is a multicenter, randomized, controlled, open-label, blinded-endpoint clinical trial. Up to 560 eligible subjects with acute deep supratentorial ICH will be randomly assigned (1:1) to receive either neuroendoscopic hematoma evacuation or standard conservative treatment at more than 30 qualified neurosurgery centers in China.

OUTCOMES

The primary endpoint is the proportion of patients with a good functional outcome (mRS score 0-3) in both groups at 180 days after onset. The main safety endpoints include all-cause mortality at 7, 30, and 180 days, rebleeding at 3, 7, and 30 days, and serious complications within 180 days.

DISCUSSION

NESICH will provide high-quality evidence for the efficacy and safety of neuroendoscopic hematoma evacuation surgery in ICH patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05539859.