J Korean Neurosurg Soc.  2019 Jan;62(1):35-45. 10.3340/jkns.2018.0203.

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease

• Jeon HJ
• Lee JY
• Cho BM
• Yoon DY
• Oh SM

• KMID: 2434344
• DOI: http://doi.org/10.3340/jkns.2018.0203

Abstract

OBJECTIVE
To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).
METHODS
A single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation.
RESULTS
Forty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications.
CONCLUSION
Hybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

Keyword

Hybrid; Operating rooms; Cone-beam computed tomography; Cerebrovascular disorders

MeSH Terms

Aneurysm
Aneurysm, Ruptured
Angiography
Angiography, Digital Subtraction
Arteries
Arteriovenous Malformations
Blister
Cerebrovascular Disorders*
Cone-Beam Computed Tomography
Embolectomy
Embolization, Therapeutic
Emergencies
Hematoma
Intracranial Hemorrhages
Operating Rooms*
Retrospective Studies
Rupture
Surgical Instruments
Thrombectomy

Figure

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  Fig. 1. A : Configuration of the hybrid operating room during the cranial operation. B : Positioning of the fluoroscopic C-arm during the endovascular procedure.

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  Fig. 2. Brain computed tomography and digital subtraction angiography showed a dissecting aneurysm at the proximal segment of the left posterior inferior cerebellar artery (PICA) with diffuse subarachnoid hemorrhage (A and B). C : Occipital artery (OA)-PICA bypass was performed first. D : Subsequent coil embolization was performed. Complete control intraoperative angiogram showed complete occlusion of the aneurysm with patent OA-PICA bypass (E and F).

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  Fig. 3. A : Noncontrast brain computed tomography (CT) showed diffuse subarachnoid hemorrhage with a left temporal hemorrhage. B : 3-dimensional rotational angiogram revealed complex ruptured aneurysm of the left middle cerebral artery bifurcation. C : Subtotal coil embolization was done to protect ruptured point. Neck of the aneurysm was preserved. D : Partially coiled aneurysm was exposed without pre-mature rupture. E : Clip application was done with preservation of the parent artery. F : Temporal hemorrhage was exposed nearby coiled segment of the aneurysm (arrow), and it was removed under the microscope. G : Intraoperative angiography showed complete occlusion of the aneurysm. H : Postoperative brain CT revealed complete removal of the temporal hemorrhage.

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  Fig. 4. A : The left internal carotid angiogram revealed occlusion of middle cerebral artery (MCA) superior trunk. B : Superselective angiogram via microcatheter showed contrast leakage. C : Surgical embolectomy was performed. D : Arteriotomy site was closed using right-angled mini-clip. E : Superficial temporal arteryMCA bypass was performed for central artery occlusion after surgical embolectomy. Complete surgical recanalization was achieved 367 minutes after the last normal time. F : Complete control angiogram showed complete recanalization of the left MCA.

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  Fig. 5. A and B : Brain computed tomography (CT) and CT angiography showed an aneurysm at the anterior communicating artery with diffuse subarachnoid hemorrhage accompanied by intracranial hemorrhage (ICH) at the left frontal lobe. C : After clip application through the right pterional approach, ICH was aspirated under the guidance of XperGuide® system (Philips Medical Systems, Best, the Netherlands) via the left Kocher’s point. D : During progression of the needle, trajectory was shown on the fluoroscopic image as central needle path with surrounding cylinder of 1-cm safety margin. E : Post-aspiration cone-beam CT showed near-complete removal of ICH. F : Postoperative brain CT showed near-complete removal of the frontal ICH.

Reference

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