Preliminary evaluation of the role of surgical microscope-integrated intraoperative FLOW 800 colored indocyanine fluorescence angiography in arteriovenous malformation surgery.

OBJECTIVE: To discuss the role of FLOW 800 innovative software for analytical color visualization and objective evaluation of fluorescence videos obtained by microscope-integrated intraoperative indocyanine green (ICG) fluorescence angiography in arteriovenous malformations (AVM) surgery. MATERIALS AND METHODS: Microscope-integrated intraoperative FLOW 800 was used and evaluated in three consecutive AVM surgeries over a period of two months. The role of FLOW 800 to distinguish feeding arteries from arterialized veins and other arteries was evaluated. Its advantages and limitations over conventional intraoperative ICG angiography were evaluated. RESULTS: This software was found to be useful in identifying arterial feeders, arterialized veins and other arteries in all the three patients and it gives additional information on the status of AVM before and after clipping suspected feeders which is sometimes difficult to interpret on conventional ICG angiography. CONCLUSION: Flow 800 is a reliable and useful addition to microscope-integrated color ICG video angiography. Although its role is limited in deep-seated AVMs, if properly dissected and exposed it can give useful information which can be easily interpretable and reproducible.

Intracanalicular epidermoid cyst. A case report.

We describe the presentation and management of a rare case of an epidermoid cyst located within canal of the left internal acoustic meatus, lying entirely within the petrous part of the temporal bone. The patient underwent surgery by an extended middle fossa approach and a total excision of a cyst containing cheesy, pearly white, avascular material was achieved. Neuroradiology provides a diagnosis with reasonable accuracy and an appropriate surgical approach can be planned for the excision of the tumour.

"Live Cadaver" Model for Internal Carotid Artery Injury Simulation in Endoscopic Endonasal Skull Base Surgery.

BACKGROUND: Intraoperative injury of the internal carotid artery (ICA) is the most dreaded complication in endoscopic endonasal surgery (EES) of skull base. Training for ICA injury is practically impossible in live operative settings. OBJECTIVE: To evaluate a pulsatile perfusion-based live cadaveric model for ICA injury simulation in a laboratory setting. The major emphasis of the study was to evaluate various means of controlling acute bleeding and evaluating the practical utility of this model for training purposes. METHODS: Five embalmed, uninjected cadaveric heads were prepared for study by connecting to a pulsatile perfusion pump system filled with artificial blood solution. EES approaches were used to evaluate different types of ICA injuries similar to operative scenarios. Various methods of managing ICA injuries such as packing, clipping, and trapping, were evaluated. The educational advantages of the live cadaver model were assessed using questionnaires given to participants in a hands-on dissection course. RESULTS: The trainee was faced with several scenarios similar to those encountered during an actual intraoperative ICA injury. Packing, clipping, and trapping of the ICA injury were successfully achieved in all segments of the ICA. Clip-based reconstruction techniques were successfully developed. All trainees reported gaining new knowledge, learning new techniques. The responses to the questionnaire confirmed the significant educational value of this model. CONCLUSION: The live cadaver model presented here provides real-life experience with major vessel injury during EES in a laboratory setting. This model could significantly improve current training for the management of intraoperative vascular injuries during EES.

Incidence, short-term outcome, and spatial distribution of stroke patients in Ludhiana, India.

OBJECTIVE: To estimate the incidence, short-term outcome, and spatial distribution of stroke patients and to evaluate the completeness of case ascertainment in Ludhiana. METHODS: This population-based prospective cohort study was conducted in Ludhiana, Punjab, Northwest India. All first-ever stroke patients (≥18 years) were included between March 2010 and March 2013 using WHO Stepwise Approach Surveillance methodology from the city. Stroke patient data were obtained from hospitals, scan centers, and general practitioners, and details of deaths from the Municipal Corporation. RESULTS: Out of 7,199 stroke patients recruited, 3,441 were included in final analysis. The mean age was 59 ± 15 years. The annual incidence rate was 140/100,000 (95% confidence interval [CI] 133-147) and age-adjusted incidence rate was 130/100,000 (95% CI 123-137). The annual incidence rate for stroke in the young (18-49 years) was 46/100,000 (95% CI 41-51). The case fatality at 28 days was 22%. Patients above 60 years of age (p = 0.03) and patients who were managed in public hospitals had poor survival (p = 0.01). Hot spots for cumulative incidence were seen in central and southern parts of the city, and hot spots for poor outcome were seen in the outskirts of the city. CONCLUSIONS: The incidence rates are similar to other studies from India. Stroke patient survival is poor in public hospitals. The finding of spatial analysis is of public health significance for stroke prevention and strengthening of stroke services.

FLOW 800-assisted surgery for arteriovenous malformation.

FLOW 800 is software for analytical colour visualisation and objective evaluation of fluorescence video obtained by microscope-integrated intraoperative indocyanine green fluorescence angiography. A 56-year-old male underwent surgical excision of a large complex arteriovenous malformation (AVM) of the right parietal region. FLOW 800 software was used to identify feeding arteries, arterialised veins and passing vessels. Complete excision of the AVM was achieved, confirmed by FLOW 800 and postoperative digital subtraction angiography. The role of FLOW 800, its applications and limitations in AVM surgery are discussed.