Low-cost and open-source three-dimensional (3D) printing in neurosurgery: A pilot experiment using direct drive modification to produce multi-material neuroanatomical models.

BACKGROUND: 3-dimensional (3D) printing carries a genuine potential for pre-operative planning in neurosurgery. Entry-level 3D printers offer practicality in low resource settings, but are often limited by the range of filament materials as well as the capability of open-source segmentation software. OBJECTIVE: We intended to demonstrate that 3D printing of neuroanatomical structures is possible using an entry-level 3D printer equipped with the direct drive (DD) modification, which supported flexible filaments, with the models segmented using an open-source software. METHODS: A DD system was installed onto the Ender 3 Pro printer. An attempt to print neurosurgical models using a low-cost 3D printer was conducted, where four patient-based neuroanatomical models were printed: skull base-vasculature, skull base-tumour, cervical spine, and ventricular system. The results were discussed and compared to similar endeavours in past literature. RESULTS: Although DD installation was challenging and led to vibration and longer print time, which ultimately warranted an inferior printing speed, DD system enabled the printing with thermoplastic polyurethane (TPU), a versatile elastomer; in addition to producing equal amount of detail to those printed with high-end printers and advanced image segmentation software. Fitting the frame well, changing infill type, and avoiding warping and stringing will improve print quality with the DD system. CONCLUSION: 3D printing with entry-level 3D printers equipped with DD system has been proven to be a reliable way of accurately reproducing patient-specific neuroanatomical constructs. Follow-up studies are necessary to implement 3D printing for neurosurgical planning in low-resource settings.

A case involving a giant aberrant craniocervical arteriovenous malformation.

BACKGROUND: Spinal cord arteriovenous malformations (AVMs) comprise about 3%-4% of primary intraspinal masses and are only rarely found external to the C2-C7 cervical vertebral foramen. CASE DESCRIPTION: A 21-year-old female presented with neck pain and a spastic quadriparesis of 1 year duration. The cervical magnetic resonance imaging and three-dimensional computed tomography angiograms documented an AVM/dural arteriovenous fistula on the right fed by multiple arteries located in the C5-C6 and C6-C7 foramen intervertebralis; utilizing a laminectomy, the large feeding arteries were double-clipped. This allowed for devascularization of the AVM and facilitated resection while preserving the aberrant vertebral artery. The patient was discharged within 1 week and, 2 months later, was able to ambulate to the outpatient clinic. CONCLUSION: Double clipping of the two main right-sided arterial feeders at the C5-C6 and C6-C7 levels allowed for devascularization and resection of this large cervical AVM while carefully preserving the aberrant vertebral artery.

The Bandung neurosurgery patient outcomes project, Indonesia (Part I): Methods, participant characteristics, and pre-discharge outcomes.

INTRODUCTION: Little is known about neurosurgery patient outcomes in Indonesia. Our study sought to describe patient characteristics, health care pathways, health-related quality of life, and health/rehabilitation care needs of patients admitted to, and discharged from, a major neurosurgery department. METHODS: Eligible patients were aged ≥18 years admitted to the Neurosurgery Department in a regional referral hospital in Bandung, Indonesia. Baseline data was collected on admission. An in-person interview (in the Indonesian language) was held 1 to 2 days pre-discharge. Sociodemographic along with clinical characteristics, Glasgow Coma Scale (GCS), and EQ-5D-5L data were collected. RESULTS: A total of 217 patients were admitted, 37 died before discharge, and a pre-discharge interview was undertaken by 178 (82%). Almost half (48%) were admitted because of injury, 38% brain tumour, 10% acute illness, and 4% other conditions. The mean age was 41 years. On admission, 63% had a mild Glasgow Coma Scale, 31% moderate, and 3% severe. The average hospital stay was 8 days for injury and 24 days for illness patients. Prior to discharge, one-third, or less, of the 178 patients interviewed reported "no problems" in the EQ-5D dimensions of mobility (32%), self-care (27%), usual activities (16%), and pain/discomfort (32%), whereas 70% reported "no problems" with anxiety/depression. CONCLUSION: A large proportion of patients are being discharged with considerable levels of difficulty in four of the five EQ-5D dimensions. This stresses the importance of providing good follow-up and support of patients and their families.

The Bandung neurosurgery patient outcomes project, Indonesia (Part II): Patient pathways and feasibility and acceptability of telephone follow-up.

INTRODUCTION: Support of neurosurgery patients following discharge from hospital is important. Currently, little is known about patients' in low- and middle-income countries before and after their hospital treatment. This companion paper reports patients' pathways before and after hospital admission and the feasibility of following up this ill-patient population by telephone. METHODS: Eligible patients were aged ≥18 years admitted to the Neurosurgery Department in Dr. Hasan Sadikin Hospital-a regional referral hospital in Bandung City, Indonesia. Clinical data were collected on admission by clinicians. In-person interviews were undertaken with a clinical research nurse 1 to 2 days pre-discharge, and telephone follow-up interviews at 1, 2, and 3 months post-discharge. Information was also collected on pathways prior to admission and following discharge. The number of contact attempts for each patient interview was documented, as was the overall acceptability of undertaking a telephone interview. RESULTS: Of 178 patients discharged from hospital, 12 later died. Of the remaining 166 patients, 95% were able to be followed up to 3 months. Two-thirds of patients had been referred from another hospital. Patients came from, and were discharged to, locations throughout the West Java region. At the 1-month interview, 84% participants reported that they had had a follow-up consultation with a health professional-mostly with a neurosurgeon. CONCLUSION: This study has shown that, with a neurosurgery nurse delegated to the role, it is feasible to conduct follow-up telephone interviews with patients after discharge from a neurosurgery ward and that in fact such follow-up was appreciated by patients.

Grüber's ligament as a useful landmark for the abducens nerve in the transnasal approach.

OBJECT: Extended endoscopic transnasal surgeries for skull base lesions have recently been performed. Some expert surgeons have attempted to remove tumors such as chordomas, meningiomas, and pituitary adenomas in the clival region using the transnasal approach and have reported abducens nerve injury as a common complication. There have been many microsurgical anatomical studies of the abducens nerve, but none of these studies has described an anatomical landmark of the abducens nerve in the transnasal approach. In this study the authors used cadaver dissections to describe Grüber's ligament as the most reliable landmark of the abducens nerve in the transnasal transclival view. METHODS: The petroclival segment of the abducens nerve was dissected in the interdural space-which is also called Dorello's canal, the petroclival venous gulf, or the sphenopetroclival venous confluence-using the transnasal approach in 20 specimens obtained from 10 adult cadaveric heads. RESULTS: The petroclival segment of the abducens nerve clearly crossed and attached to Grüber's ligament in the interdural space, as noted in the transnasal view. The average length of the dural porus to the intersection on the abducens nerve was 5.2 ± 1.0 mm. The length of the posterior clinoid process (PCP) to the intersection on Grüber's ligament was 6.4 ± 2.6 mm. The average width of Grüber's ligament at the midsection was 1.6 ± 0.5 mm. CONCLUSIONS: Grüber's ligament is considered a useful landmark, and it is visible in most adults. Thus, surgeons can find the abducens nerve safely by visualizing inferolaterally along Grüber's ligament from the PCP.

Comprehensive management of frontal and cerebellar tumor patients with personality changes and suicidal tendencies.

BACKGROUND: Brain tumor patients have a tendency to suffer from psychiatric disturbances. One of the most frequent disturbance experienced by frontal area tumor patients are personality changes. CASE DESCRIPTION: In this paper, the authors report a 28-year-old male patient who presented with headache and personality changes, with no other neurological disturbance. The patient became increasingly pensive and apathetic with frontal and cerebellopontine angle tumor. The diagnosis is based on computed tomography scanning images, and histopathological examination of the excised tumor results in meningioma. CONCLUSION: Before the operation was performed, the patient suffered from personality changes and suicidal tendencies. After the operation, the patient's suicidal tendency was gone, but the personality changes still persist. For this reason, a comprehensive management of the patient is required, including postoperative pharmacological and psychological treatment.

Development traumatic brain injury computer user interface for disaster area in Indonesia supported by emergency broadband access network.

Disasters bring consequences of negative impacts on the environment and human life. One of the common cause of critical condition is traumatic brain injury (TBI), namely, epidural (EDH) and subdural hematoma (SDH), due to downfall hard things during earthquake. We proposed and analyzed the user response, namely neurosurgeon, general doctor/surgeon and nurse when they interacted with TBI computer interface. The communication systems was supported by TBI web based applications using emergency broadband access network with tethered balloon and simulated in the field trial to evaluate the coverage area. The interface consisted of demography data and multi tabs for anamnesis, treatment, follow up and teleconference interfaces. The interface allows neurosurgeon, surgeon/general doctors and nurses to entry the EDH and SDH patient's data during referring them on the emergency simulation and evaluated based on time needs and their understanding. The average time needed was obtained after simulated by Lenovo T500 notebook using mouse; 8-10 min for neurosurgeons, 12-15 min for surgeons/general doctors and 15-19 min for nurses. By using Think Pad X201 Tablet, the time needed for entry data was 5-7 min for neurosurgeon, 7-10 min for surgeons/general doctors and 12-16 min for nurses. We observed that the time difference was depending on the computer type and user literacy qualification as well as their understanding on traumatic brain injury, particularly for the nurses. In conclusion, there are five data classification for simply TBI GUI, namely, 1) demography, 2) specific anamnesis for EDH and SDH, 3) treatment action and medicine of TBI, 4) follow up data display and 5) teleneurosurgery for streaming video consultation. The type of computer, particularly tablet PC was more convenient and faster for entry data, compare to that computer mouse touched pad. Emergency broadband access network using tethered balloon is possible to be employed to cover the communications systems in disaster area.

An emergency medical communications system by low altitude platform at the early stages of a natural disaster in Indonesia.

A natural disaster is a consequence of a natural hazard, such as a tsunami, earthquake or volcanic eruption, affecting humans. In order to support emergency medical communication services in natural disaster areas where the telecommunications facility has been seriously damaged, an ad hoc communication network backbone should be build to support emergency medical services. Combinations of requirements need to be considered before deciding on the best option. In the present study we have proposed a Low Altitude Platform consisting of tethered balloons combined with Wireless Fidelity (WiFi) 802.11 technology. To confirm that the suggested network would satisfy the emergency medical service requirements, a communications experiment, including performance service measurement, was carried out.

Importance of preserved periosteum around jugular foramen neurinomas for functional outcome of lower cranial nerves: anatomic and clinical studies.

BACKGROUND: Surgical removal of jugular foramen (JF) neurinomas remains controversial because of their radicality in relation to periosteal sheath structures. OBJECTIVE: To clarify the particular meningeal structures of the JF with the aim of helping to eliminate surgical complications of the lower cranial nerves (LCNs). METHODS: We sectioned 6 JFs and examined histological sections using Masson trichrome stain. A consecutive series of 25 patients with JF neurinomas was also analyzed, and the MIB-1 index of each excised tumor was determined. RESULTS: In the JF, meningeal dura disappeared at the nerve entrance, forming a jugular pocket. JF neurinomas were classified into 4 types: subarachnoid (type A by the Samii classification), foraminal (type B), epidural (type C), and episubdural (type D). After an average follow-up of 9.2 years, tumors recurred in 9 cases (36%). Type A tumors did not show regrowth, unlike type B tumors, in which all recurred. Radical surgery by the modified Fisch approach did not contribute to tumor radicality in type C and D tumors, even in cases in which LCN function was sacrificed. In preserved periosteum, postoperative LCN deterioration was decreased. Bivariate correlation analysis revealed that jugular pocket extension, tumor removal, MIB-1 greater than 3%, and reoperation or gamma knife use were significant recurrence factors. CONCLUSION: For LCN preservation, the periosteal layer covering the cranial nerves must be left intact except in patients with a subarachnoid tumor. To prevent tumor regrowth, postoperative gamma knife treatment is recommended in tumors with an MIB-1 greater than 3%.

Designing an emergency medical information system for the early stages of disasters in developing countries: the human interface advantage, simplicity and efficiency.

The means of designing an effective user interface software package varies from one application to another. Almost the entire ICT infrastructure was damaged following the impact of the tsunami tidal wave. Under such circumstances, transporting critically ill patients is a must and becomes the first priority. Many considerations are needed when designing a specific user interface for emergency situations in developing countries. In this study we proposed how to design the user interface in order to support emergency medical care in the early stages of disasters. The user interface was classified into two tabs, firstly to indicate critically ill patients and secondly to notify details of the medicine having been administered to the patients. Classifying the user interface of emergency medical care information systems by using VHF radio connections will be beneficial, especially for the early stages of disaster-stricken developing countries, in order to preserve the lives of more victims.

Greater petrosal nerve schwannomas-analysis of four cases and review of the literature.

Schwannomas arising from the greater petrosal nerve (GPN) are exceedingly rare: only 10 such cases have been reported in the English literature. We report on four cases of GPN schwannomas and discuss the surgical approach for their removal. Four patients with GPN schwannomas underwent surgery at Keio University Hospital. We present the pre- and postoperative clinical findings and describe the structures around the GPN schwannomas as observed during the surgery. Histological sections were performed around the GPN using Masson's trichrome stain to elucidate the membrane structures. Three patients presented with xerophthalmia, and one with facial palsy, hearing disturbance, and generalized convulsions. Contrast-enhanced magnetic resonance images revealed tumors in the temporal lobe. Bone-window computed tomography showed erosion of the anterior petrous apex. During the operation, the temporal lobe was retracted epidurally. The tumors were visible inside the interdural space and covered with the epineurium. In three cases, the tumors were completely removed, and in one case, the tumor was subtotally removed with intraoperative facial monitoring. In the histological sections, we confirmed that the GPN ran within the interdural space. Approaching epi- and interdurally is suitable for the removal of GPN schwannomas because the GPN is located within the interdural space. The advantage of this approach is that the landmark points can be identified. Moreover, the possibility of injuring the temporal lobe is low because the temporal lobe is not exposed in this approach.

Characteristics and risk factors for typhoid fever after the tsunami, earthquake and under normal conditions in Indonesia.

BACKGROUND: Although typhoid transmitted by food and water is a common problem in daily life, its characteristics and risk factors may differ in disaster-affected areas, which reinforces the need for rapid public health intervention. Surveys were carried out post-tsunami in Banda Aceh, post-earthquake in Yogyakarta, and under normal conditions in Bandung, Indonesia. Logistic regression analysis was used to assess the risk factors with the dependent variable of typhoid fever, with or without complications. FINDINGS: Characteristic typhoid fever with complications was found in 5 patients (11.9%) affected by the tsunami in Aceh, 8 (20.5%) after the earthquake in Yogyakarta, and 13 (18.6%) in Bandung. After the tsunami in Aceh, clean water (OR = 0.05; 95%CI: 0.01-0.47) and drug availability (OR = 0.23; 95%CI: 0.02-2.43) are significant independent risk factors, while for the earthquake in Yogyakarta, contact with other typhoid patients (OR = 20.30; 95%CI: 1.93-213.02) and education (OR = 0.08; 95%CI: 0.01-0.98) were significant risk factors. Under normal conditions in Bandung, hand washing (OR = 0.07; 95%CI: 0.01-0.50) and education (OR = 0.08; 95%CI: 0.01-0.64) emerged as significant risk factors. CONCLUSION: The change in risk factors for typhoid complication after the tsunami in Aceh and the earthquake in Yogyakarta emphasizes the need for rapid public health intervention in natural disasters in Indonesia.

Characteristic tetanus infection in disaster-affected areas: case study of the Yogyakarta earthquakes in Indonesia.

BACKGROUND: Tetanus is an infectious disease caused by the contamination of wounds from bacteria that live in soil. The tetanus mortality rate remains high in developing countries affected by natural disasters. Whether the socio-demography and geographical conditions may influence the tetanus treatment outcome on the earthquake situation in Yogyakarta, Indonesia has not been investigated. FINDINGS: We present 26 tetanus patients who were admitted to eight hospitals following the earthquakes that occurred on May, 27, 2006, in Yogyakarta, Indonesia. The independent variables were age, gender, distance, admission, hospitalization, and type of hospital with the dependent variable surviving or perishing. Data were analyzed by logistic regression methods on SPSS 17.0. The distance from the patient's place of residence to the hospital were obtained and analyzed by using geospatial tools MapInfo 7.8 SCP and Global Mapper 7. Eight of the 26 patients were dead (30.8%) and statistical results showed that the distance (OR = 1.740, 95% CI = 1.068-2.835) and type of hospital (OR = 0.067, 95% CI = 0.001-3.520) were significant predictors of death. CONCLUSION: Our findings show that in order to reduce the mortality rates, performing triage systems based on the distance and type of hospital priority for internally displaced persons could be proposed as well as making provisions for the generally old population in order to prevent an outbreak of tetanus following earthquakes in Yogyakarta, Indonesia.