Preclinical Evaluation of a Novel Steerable Robotic Neuroendoscope Tool.

BACKGROUND AND OBJECTIVES: To improve the outcomes of minimally invasive, endoscopic, intracranial procedures, steerable robotic tools have been developed but still require thorough evaluation before use in a clinical setting. This paper compares a novel steerable robotic neuroendoscope tool against a standard rigid tool. METHODS: Seventeen participants, 8 nonmedical and 9 medical (neurosurgery residents and fellows), were recruited. The evaluation trial consisted of a task that was completed using either a rigid tool or the steerable tool, followed by the completion of a qualitative survey. Target reach time and tool movement volume (TMV) were recorded for each trial and analyzed. The tools were evaluated within a realistic phantom model of the brain. RESULTS: Preclinical evaluation of both tools showed that average target reach time for the steerable tool among medical personnel (15.0 seconds) was longer than that of the rigid tool (5.9 seconds). However, the average TMV for the steerable tool (0.178 cm 3 ) was much lower than that of the rigid tool (0.501 cm 3 ) for medical personnel, decreasing the TMV by 64.47%. CONCLUSION: The steerable tool required more training and practice in comparison with the standard rigid tool, but it decreased the overall endoscope movement volume, which is a source of parenchymal injury associated with endoscopic procedures.

Neuroendoscopic transventricular transchoroidal approach for access to the posterior zone of the third ventricle or pineal region.

The endoscopic transventricular transchoroidal approach facilitates entry into the posterior part of the third ventricle, allowing a visualization field from the foramen of Monro to the pineal region through this anatomical corridor. Combined surgery to treat the target lesion and possible endoscopic third ventriculostomy (ETV) can be performed through a single burr hole. A detailed description of this surgical technique is given, and a series of cases from our center is presented. This retrospective study included patients with lesions in the pineal region or posterior zone of the third ventricle who underwent surgery between 2004 and 2022 in our center for tumor biopsy or endoscopic cyst fenestration. In nine cases, the transchoroidal approach was performed. Demographic and clinical variables were collected: sex, age at diagnosis, clinical presentation, characteristics of the lesion, pathological diagnosis, characteristics of the procedure, complications, subsequent treatments, evolution, follow-up time, and degree of success of the endoscopic procedure. The mean and range of the quantitative variables and frequency of the qualitative variables were analyzed, together with the statistical significance (p < 0.05). Surgical planning was carried out by performing a preoperative MRI, calculating the ideal entry point and trajectory for each case. The preoperative planning of the surgical technique is described in detail. Of our sample, 55.6% were women, with a mean age of 35 years (7-78). The most common clinical presentation was intracranial hypertension (55.6%), with or without a focus. Eight patients presented hydrocephalus at diagnosis. The most frequent procedure was endoscopic biopsy with ETV (66.7%). The pathological diagnosis varied widely. Procedure-related complications included one case of self-limited bleeding of the choroidal fissure at its opening and one intraventricular hemorrhage due to tumor bleeding in the postoperative period. Non-procedure-related complications comprised two ETV failures and one case of systemic infection, while late complications included one case of disease progression and one case of radionecrosis. Four patients died, one due to poor neurological evolution after post-surgical tumor bleeding and three due to causes unrelated to the procedure. The rest of the patients had a favorable evolution and were asymptomatic or stable. The transchoroidal approach through a single burr hole is a feasible and safe option for access to the posterior part of the third ventricle. Proper planning of each case is necessary to avoid complications.

Neuroendoscopy: history, endoscopes, and instrumentation.

INTRODUCTION: Endoscopy was first employed in the surgical treatment of neurosurgical diseases early in the twentieth century, but did not become an established practice for a long time, mainly because of poor technology and clinical results. After a slow re-appearance in the 1980s, the 1990s saw an explosion of techniques and instrumentation. Continuing technological improvement has led to further expansion of surgical techniques and indications for use of neuroendoscopy. DISCUSSION: The expansion of ventricular endoscopy has led to significant understanding of CSF disorders. Aqueduct stenosis as cause of hydrocephalus and arachnoid cysts are an example of pathologies, the concept and understanding of which now is considerably enhanced, due to the application of neuroendoscopy in their treatment. Management of loculated hydrocephalus has been facilitated considerably with the use of the endoscope. The concepts of aqueductoplasty, septostomy, and foraminoplasty of the foramina of Monro and Magendie emerged, which were previously unknown. Skull base surgery, especially surgery for craniopharyngioma, has seen dramatic improvement in results with the use of the endoscope. Coupling of the endoscope with neuronavigation has expanded technical capabilities even further. Overall, we can do a lot more with the endoscope now in comparison to 30 years ago. CONCLUSION: We should always remember that the endoscope is only a tool. Its use has indications and limitations related to its design and our ability to extract the maximum, in the context of its shortcomings. Further technological advances will push surgical frontiers even more in years to come.

Isolated entrapment of the lateral ventricle after neuroendoscopic resection of colloid cysts: single - center experience and management.

BACKGROUND: A minimally invasive option of colloid cyst surgical treatment is endoscopic resection, well validated in various reports and clinical practice. A rare complication of the surgical treatment, previously reported only once in literature, is the entrapment of the lateral ventricle. In this study we aim to outline our experience in the management of this occurrence, hypothesizing possible etiopathogenetic causes. METHODS: Among patients who underwent neuroendoscopic resection for a colloid cysts at our Institution between 2013 and 2022, cases who developed a postoperative lateral ventricle entrapment were retrospectively reviewed and included. Clinical history, imaging and treatment were reported. RESULTS: Among 34 patients treated for a colloid cysts, two (5.9 %) patients developed an ipsilateral ventricular entrapment with dilation from two to five months after the resection. Both patients were substantially asymptomatic and neurologically intact, and therefore treated conservatively. One case underwent complete spontaneous radiological resolution one month later, and the other one has remained neurological asymptomatic at follow-up. CONCLUSIONS: Isolated asymptomatic ventricular entrapment with significant dilation after endoscopic colloid cyst resection is a rare occurrence which can be plausibly caused by scar tissue at the level of the foramen of Monro. Because they can have an indolent course with spontaneous resolution, conservative treatment is a viable option, with strict radiological and clinical follow - up. Given the rarity of the occurrence, further studies with larger cohorts are warranted to confirm the etiopathogenetic hypothesis and validate the clinical management.

A Single Vertebral Surgical Approach for Spinal Extradural Meningeal Cysts Spanning Multiple Vertebral Segments by Auxiliary Neuroendoscope.

BACKGROUND: Spinal extradural meningeal cysts (SEMCs) are rare lesions, especially those spanning multiple vertebral segments, and the surgical strategy has remained controversial. In the present study, we have described the outcomes of 4 patients with SEMCs treated with dural defect repair alone assisted by neuroendoscopy. METHODS: From January 2018 to January 2020, 4 patients with SEMCs spanning multiple vertebral segments had undergone single-vertebral laminectomy or hemilaminectomy. RESULTS: The SEMCs in all 4 patients had spanned multiple vertebral segments, from T11 to L2. Using magnetic resonance imaging, the location of the dural defect was predicted correctly for 3 patients. Single-vertebral laminectomy was used in 2 patients and single-vertebral hemilaminectomy in 2 patients. Intraoperatively, the entire cyst, including the upper pole, lower pole, and middle segment of the cyst, was explored using neuroendoscopy. In each patient, only 1 dural defect was found, which had been located in the middle segment of the cyst (T12-L1). All cyst dural defects had been sutured under a microscope. In all cases, the cyst wall was not removed. Postoperatively, the symptoms for all the patients had improved significantly, and subsequent magnetic resonance imaging studies showed obvious cyst regression. During the follow-up period of 15-44 months, no recurrence was observed. CONCLUSIONS: For SEMCs spanning multiple vertebral segments, dural defect repair without cyst wall resection through single-vertebral hemilaminectomy or laminectomy can be effective. Intraoperative neuroendoscopy can assist, not only in finding the dural defect, but also in avoiding the omission of multiple dural defects as much as possible.

Outcome of Initial 3 Years of Cranial Endoscopy at DG Khan Medical College and Teaching Hospital, Dera Ghazi Khan.

OBJECTIVE: With the evolution of surgical approaches, endoscopic skull base surgery has emerged as a suitable alternative to many other invasive methods. The aim of this study was to investigate the efficacy and outcome of cranial endoscopy in treating various neurosurgical intracranial pathologies in terms of procedural success and complications. METHODS: This observational, prospective case series was conducted at the Department of Neurosurgery of DG Khan Medical College from November 2017 to October 2020. The study enrolled 74 patients with indications for cranial neuroendoscopy. Clinical examination was performed, and a detailed history of the disease was obtained. Follow-up was conducted in the outpatient department. The collected data were analyzed using statistical analysis software. RESULTS: Of 77 procedures performed, endoscopic third ventriculostomy, arachnoid cyst fenestration, septostomy, colloid cyst excision, endoscopic assisted ventricular catheter placement, and intraventricular tumor biopsy were performed in 53.3%, 18.2%, 10.4%, 7.8%, 6.5%, and 3.9% of patients. Aqueductal stenosis was identified as the most common cause of obstructive hydrocephalus. Seizures and cerebrospinal fluid leaks were the most commonly reported complications (12% and 8.1%, respectively). The observed mortality rate was 2.7%. CONCLUSIONS: Neuroendoscopic surgery has become safe and effective, as surgeon experience and learning have lowered the risk of complications, and offers a low-cost alternative intervention.

Neuroendoscopic surgery in neonates - indication and results over a 10-year practice.

PURPOSE: Neuroendoscopic procedures for treatment of term and preterm newborn infants, such as endoscopic lavage for posthemorrhagic hydrocephalus, are gaining popularity despite sparse data. This single-institution report compiles all neuroendoscopic surgical procedures performed in neonates during a 10-year period. METHODS: Charts and electronic records were reviewed of all consecutive newborns who underwent a neuroendoscopic procedure before reaching a postmenstrual age of 44 weeks between 09/2010 and 09/2020. Available documentation was reviewed regarding the performed neuroendoscopic procedure, course of disease, complications, and all re-operations throughout the first year of life. RESULTS: During the 10-year study period, 116 infants (median gestational age at birth: 29 1/7 weeks) underwent a total of 153 neuroendoscopic procedures (median postmenstrual age at surgery: 35 0/7 weeks). The most common indication at the time of the neuroendoscopic procedures (n = 153) was intraventricular hemorrhage (IVH, n = 119), intraventricular infection (n = 15), congenital malformation (n = 8), isolated 4th ventricle (n = 7), multiloculated hydrocephalus (n = 3), and tumor (n = 1). Thirty-eight of 116 children (32.8%) underwent 43 operative revisions after 153 neuroendoscopic procedure (28.1%). Observed complications requiring surgical revision were secondary infection (n = 11), CSF fistula (n = 9), shunt dysfunction (n = 8), failure of ETV (n = 6), among others. 72 children (62%) of 116 children required permanent CSF diversion via a shunt. The respective shunt rates per diagnosis were 47 of 80 (58.8%) for previously untreated IVH, 11 of 13 (84.6%) for intraventricular infection. Shunt survival rate for the first year of life was 74% for the whole cohort. CONCLUSION: The experience with this large cohort of neonates demonstrates the feasibility of neuroendoscopic technique for the treatment of posthemorrhagic or postinfectious hydrocephalus. Rate and type of complications after neuroendoscopic procedures were within the expected range. Assessing the potential long-term benefits of neuroendoscopic techniques has to await results of ongoing studies.

[Application of Neuroendoscope and Exoscope for Glioma Surgery].

The recent progress of neuroendoscopy and exoscopy has yielded new strategies in neurosurgery, especially in glioma surgery. Neuroendoscopic port surgery makes it possible to remove deep-seated gliomas with minimal invasiveness. In port surgery, it is important to control tumor bleeding during intratumoral removal. As exoscopic systems have high flexibility of the video camera position, the surgical approach can be selected with various visual axes, which is difficult when using microscopic systems. Considering the characteristics of exoscopes, exoscopic surgery can be applied for the removal of superficial gliomas, and exoscopes are useful for glioma resection under awake craniotomy. However, there are outstanding tasks to improve surgical devices for neuroendoscopic surgery. The video quality and deep lighting of exoscopes are insufficient for general usage. Moreover, there are few training courses available for these surgical techniques. In the near future, based on these developments, neuroendoscopic and exoscopic surgeries may become more common treatments.

Neuroendoscopic training in neurosurgery: a simple and feasible model for neurosurgical education.

BACKGROUND: The development of high levels of technical competence and excellent decision-making skills are key goals of all neurosurgical residency training programs. This acquisition of technical skills is becoming increasingly difficult due to many factors including less exposure to operative cases, demand for more time and cost-effective practices, and resident work hour restrictions. We describe a step-by-step method for how to build a low-cost and feasible model that allows residents to improve their neuroendoscopic skills. METHODS: The bell pepper-based model was developed as an endoscopic training model. Using continuous irrigation, several hands-on procedures were proposed under direct endoscopic visualization. Endoscope setup, endoscopic third ventriculostomy, septostomy, and tumor biopsy procedures were simulated and video recorded for further edition and analysis. RESULTS: The model can be setup in less than 15 min with minimal cost and infrastructure requirements. A single model allows simulation of all the exercises described above. The model allows exposure to the camera skills, instrument handling, and hand-eye coordination inherent to most neuroendoscopic procedures. CONCLUSION: Minimal infrastructure requirements, simplicity, and easily setup models provide a proper environment for regular training. The bell pepper-based model is inexpensive, widely available, and a feasible model for routine training. Neurosurgery residents may benefit from the use of this model to accelerate their learning curve and familiarize themselves with the neuroendoscopic core principles in a risk-free environment without time or resource constraints.

Benefits of Endoscopic Sheath in Intraventricular Neuroendoscopy: Technical Note.

BACKGROUND: The usefulness of the endoscopic sheath is underreported in the literature. OBJECTIVE AND METHODS: To explain the use of an endoscopic sheath and to highlight its benefits. RESULTS: In addition to protecting the surrounding brain parenchyma when inserting the endoscope, the endoscopic sheath is a very useful tool to retract neurovascular structures, achieve hemostasis, and create adequate working space within narrow ventricles. The sheath can be moved within the ventricular system, and the endoscope can be moved independently within the sheath. These movements represent all the advantages of the endoscopic sheath. CONCLUSIONS: We used an endoscopic sheath in ∼ 300 intraventricular neuroendoscopic procedures and consider the sheath an essential part of a ventriculoscopic system. Proper use of the sheath can help avoid or manage endoscopic complications.

Effect of endoscope flexibility on tissue dissection profile assessed with pulsed water jet device: ensuring safety, efficacy, and handling of thin devices for neuroendoscopic surgery.

OBJECTIVE: We developed an actuator-driven pulsed water jet device (ADPJ) for flexible neuroendoscopy to achieve effective tissue dissection with vasculature preservation. Although flexibility is a strong advantage for minimally invasiveness, the effect of the ductile curvature on the dissection profiles remains unknown. The purpose of this study was to clarify the impact of the curvature change of the ADPJ connecting tube on the dissection safety and efficacy. RESULTS: Three ADPJ connecting tubes with different inner diameters (1.0, 0.75, 0.5 mm) were used to dissect the brain phantom. They were bent at 3 angles: 0°, 60°, and 120°. The dissection profiles were evaluated using the mean depth and coefficient of variation (CV) for efficacy and safety, respectively.The larger inner diameter connecting tube dissected more deeply. The dissection depth was not changed regardless of the curvature degree in each tube. There was no significant difference in CVs regardless of inner diameter and curvature. The ductile curvature of the flexible neuroendoscope did not affect the efficacy and safety of the ADPJ dissection profile. Among the numerous instruments, tube-formed devices, including suction and injecting devices such as ADPJ, can be used safely and effectively without flexibility-related limitations.

Exoscopic to Endoscopic Channel-Based Trans-Sulcal Resection of a Third Ventricular Cavernous Malformation: Technical Case Illustration.

Cavernous malformations are angiographically occult vascular hamartomas without intervening neural tissue that represent an estimated 10% of central nervous system vascular pathologies.1 Management is often dictated by lesion location, intranidal versus extranidal hemorrhage, presenting symptoms, acuity of onset, and surgical accessibility. Deep-seated cavernous malformations are often adjacent to eloquent structures, including functional white matter tracts that must be accounted for during surgical planning and respected during resection of the cavernoma. Exoscopic-guided channel-based approaches can help minimize retraction of brain tissue while providing a navigated, direct path to the target lesion.2 We report a case of an 18-year-old man who presented with seizures and was found to have a hemorrhagic third ventricular cavernous malformation resulting in hydrocephalus. A right frontal trans-sulcal approach using an exoscope and channel-based retractor was performed and directed along the long axis of the lesion to minimize displacement of surrounding eloquent structures and manipulation of the fornix. An uneventful gross total resection was achieved and confirmed using an angled endoscope to inspect the cavity walls, the "exoscopic to endoscopic or E2E approach" (Video 1). The patient developed transient short-term memory dysfunction in the immediate postoperative period, likely due to retraction of the fornix, which dramatically improved with speech therapy and rehabilitation. The patient provided informed consent for surgery and video recording.

Flexible endoscopic assistance in the surgical management of vestibular schwannomas.

Endoscopic-assisted techniques have extensively been applied to vestibular schwannoma (VS) surgery allowing to increase the extent of resection, minimize complications, and preserve facial nerve and auditory functions. In this paper, we retrospectively analyze the effectiveness of flexible endoscope in the endoscopic-assisted retrosigmoid approach for the surgical management of VS of various sizes. The authors conducted a retrospective analysis on 32 patients who underwent combined microscopic and flexible endoscopic resection of VS of various sizes over a period of 16 months. Flexible endoscopic-assisted retrosigmoid approach was performed in all cases, and in 6 cases, flexible and rigid endoscopic control were used in combination to evaluate the differences between the two surgical instruments. The surgical results were additionally compared with a previous case series of 141 patients operated for VS of various sizes without endoscopic assistance. Gross-total resection was achieved in 84% of the cases and near-total resection was accomplished in the rest of them. Excellent or good facial nerve function was observed in all except one case with a preoperative severe facial palsy. Hearing preservation surgery (HPS) was attempted in 11 cases and accomplished in 9 (81.8%). A tumor remnant was endoscopically identified in the fundus of the IAC in all cases (100%). Endoscopic assistance increased the rate of total removal and no intrameatal residual tumor was seen at radiological follow-up. Comparative analysis with a surgical cohort of patients operated with the sole microsurgical technique showed a significative association between endoscopic assistance and intracanalicular extent of resection. Combined microsurgical and flexible endoscopic assistance provides remarkable advantages in the pursuit of maximal safe resection of VS and preservation of facial nerve and auditory functions, minimizing the risk of post-operative complications.

The Evolution of Transforaminal Endoscopic Spine Surgery.

Transforaminal endoscopic spine surgery (T-ESS) has become a well-accepted technique. The first attempts at percutaneous discectomy by Kambin and Hijikata opened a new chapter of endoscopic spine surgery. By the last quarter of the twentieth century, spine surgeons had begun to adopt this novel technique. Many researchers helped advance endoscopic spine surgery, but the turning point was the description of a safe transforaminal triangle of safety by Parviz Kambin. Since then, the indications for T-ESS have increased as a result of the description of different surgical approaches such as inside-out, outside-in, and half-and-half. We present a review of crucial historical advancements in T-ESS and also discuss the evolution of endoscopes, the techniques used, development of endoscopic instruments and equipment, transforaminal thoracic endoscopy, transforaminal endoscopic interbody fusions, the growth of extended indications, and the future direction of T-ESS. This review provides a detailed description of key historical moments and a bird's-eye view of the vast scope of T-ESS.

Neuroendoscopic treatment of giant cystic craniopharyngioma in the foramen magnum: report of two cases.

Pediatric craniopharyngioma is typically characterized by cystic changes and calcifications. It can grow from the suprasellar area to the posterior fossa (4%). This work reports that it is very rare for craniopharyngioma to grow from the suprasellar area to or beyond the level of the foramen magnum. Twelve patients with this disease have undergone one or several microsurgeries, and the microsurgical approaches are different. Among them, two cases died, and most of the remaining patients had certain complications such as endocrine dysfunction, nerve palsy, and subdural effusion. We treated two patients whose tumors had grown to the level of the foramen magnum, one of which reached C2 levels. Both cases were treated with a neuroendoscopy. There were no deaths and no complications. Our cases are the longest follow-up of this type of craniopharyngioma.

[Unilateral Transcranial Endoscopic Surgical Removal for Large Intraventricular Tumor Assisted by Contralateral Neuroendoscope].

We report a case of a patient with large intraventricular tumor treated with craniotomy assisted by a neuroendoscope. A 25-year-old man, who had headache and nausea for several months, was transferred to our hospital with the diagnosis of an intraventricular tumor. Because of intracranial hypertension and hydrocephalus, we first performed a biopsy and bilateral intraventricular drainage using a neuroendoscope. Since the pathological finding indicated central neurocytoma, we secondarily attempted tumor removal. The main location of the tumor was the left lateral ventricle, protruding into the third ventricle and contralateral lateral ventricle. The operation was performed mainly under microscopic visualization through left-sided craniotomy, and the total excision was accomplished using a neuroendoscope through the right lateral ventricle. In order to accomplish the optimal removal of an intraventricular tumor, endoscope-assisted microsurgery should be considered a surgical strategy.

Neuroendoscope-Assisted Aneurysm Trapping for Ruptured Intraventricular Aneurysms in Moyamoya Disease Patients.

BACKGROUND: Intracranial hematomas associated with abnormal collateral vessels are observed in certain populations of adult patients with moyamoya disease (MMD). Of these, intraventricular hematomas resulting from rupture of intraventricular aneurysms, which are formed along an abnormal peripheral choroidal artery, are sometimes detected and could be severe. No appropriate treatment option for these ruptured aneurysms has been well established to date. Therefore in this report, we describe the case of an MMD patient with an intraventricular hematoma resulting from a ruptured intraventricular aneurysm arising along the abnormal collateral vessels near the lateral ventricular wall, which was successfully treated using a neuroendoscope. CASE DESCRIPTION: A 53-year-old female with MMD presented with an intraventricular hematoma. The patient had already undergone bilateral, combined direct/indirect cerebral revascularization surgery 3 years prior. Digital subtraction angiography revealed an aneurysm along the abnormal collateral choroidal artery near the posterior horn of the left lateral ventricle. A neuroendoscopic technique was applied to approach and treat the aneurysm; this was performed successfully by trapping using aneurysm clips without intraoperative or postoperative complications. CONCLUSIONS: Neuroendoscopic aneurysm trapping using aneurysm clips is a treatment option for an intraventricular aneurysm that causes an intraventricular hematoma in patients with MMD. This technique is minimally invasive and offers good visibility of the surgical field.

Development and validation of a synthetic 3D-printed simulator for training in neuroendoscopic ventricular lesion removal.

OBJECTIVE: Neuroendoscopic surgery using an ultrasonic aspirator represents a valid tool with which to perform the safe resection of deep-seated ventricular lesions, but the handling of neuroendoscopic instruments is technically challenging, requiring extensive training to achieve a steep learning curve. Simulation-based methods are increasingly used to improve surgical skills, allowing neurosurgical trainees to practice in a risk-free, reproducible environment. The authors introduce a synthetic, patient-specific simulator that enables trainees to develop skills for endoscopic ventricular tumor removal, and they evaluate the model's validity as a training instrument with regard to realism, mechanical proprieties, procedural content, and handling. METHODS: The authors developed a synthetic simulator based on a patient-specific CT data set. The anatomical features were segmented, and several realistic 1:1 skull models with all relevant ventricular structures were fabricated by a 3D printer. Vascular structures and the choroid plexus were included. A tumor model, composed of polyvinyl alcohol, mimicking a soft-consistency lesion, was secured in different spots of the frontal horn and within the third ventricle. Neurosurgical trainees participating in a neuroendoscopic workshop qualitatively assessed, by means of a feedback survey, the properties of the simulator as a training model that teaches neuroendoscopic ultrasonic ventricular tumor surgery; the trainees rated 10 items according to a 5-point Likert scale. RESULTS: Participants appreciated the model as a valid hands-on training tool for neuroendoscopic ultrasonic aspirator tumor removal, highly rating the procedural content. Furthermore, they mostly agreed on its comparably realistic anatomical and mechanical properties. By the model's first application, the authors were able to recognize possible improvement measures, such as the development of different tumor model textures and the possibility, for the user, of creating a realistic surgical skull approach and neuroendoscopic trajectory. CONCLUSIONS: A low-cost, patient-specific, reusable 3D-printed simulator for the training of neuroendoscopic ultrasonic aspirator tumor removal was successfully developed. The simulator is a useful tool for teaching neuroendoscopic techniques and provides support in the development of the required surgical skills.

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.