著者は何の確認応答がありません。

倫理的な声明：私たちのプロトコルは、当社の制度、人間研究倫理委員会によって確立されたガイドラインに従っています。 医学的に難治性てんかん患者の1識別<ol><li>でなければなりませんSEEGと侵襲的なモニタリングを追求するか否かの学際的会議での議論、決定後1で説明したように侵襲的なモニタリングの前に、このようなビデオ脳波モニタリング、MRI、PET、ictalSPECT、および神経心理学的研究などallpatientswith非侵襲的技術を評価作られた。1,6,7,11,14 </li><li> EZの位置に関する仮説を形成します。介入前に発作開始ゾーンとてんかん（発作）の早期（ すなわち 、急速な）広がりの領域をEZincorporating推定される活動の移植前の仮説を開発します。 注：このステップは、決定は、侵襲性montitoringを追求するために作られたマルチ懲戒会議と併せて行うことができます。 注意：硬膜下グリッドベースのEZ仮説に対SEEGは、SEEGと硬膜下グリッド監視の間で決定します。考慮すべき基準は1）可能な根深いEZが含まれる場合があります。 2）前回失敗した硬膜下グリッド監視。 3）二国間の監視の適応; 4）非病変超時間的なてんかんが疑われる場合。また、硬膜下のグリッドを超えるSEEGの追加の利点は、記録し、説得力の領域はEZの近くであると仮定したとき、重要な皮質下の領域を刺激するSEEGの能力を含むことに留意すべきです。 </li><li>仮定EZ（ 図1）に基づいて個々に合わせた移植戦略を策定する。1,7,8 注：適切な移植戦略は、1）解剖学的病変（存在する場合）を評価しなければなりません。 2）構造（複数可）inictal発症に参加する可能性が最も高いです。および/または3）機能的ネットワーク内発作伝播の可能経路（複数可）。解剖学的考察に加えて、物流の考慮事項も考慮しなければなりません。ためにこのため、直交軌跡は、後に、移植を容易にし、するため、電極位置の解釈に優先一般的です。 </li><li>仮定EZに基づいて注入戦略を開発した後、ロボットの支援を使用して計画を作成します。まず、「新しい患者」を選択することで、新しい出会いを作成し、次いで所望の軌道に対応する適切な「エントリーポイント」と「エンドポイント」を選択し、「軌道を作成」をクリックしてください。 注：着床前の仮説に応じて、電極の数は8と12の間にあるのが典型的です。軌道と関心のポイントは、一般的に対比MRIまたは回転血管造影を使用して計画されています。だけでなく、脳の問題を示すが、脳の血管が血管損傷や出血を避けるために、無血管廊下で軌道計画を可能にするこれらのイメージ。 </li></ol> 2.手術の手順<ol><li> SU前日rgery、Kuzniecky らに記載されているように対比し、体積T1強調MRI配列を得る。14 注：この画像はロボット支援への登録に使用されるもので、1ミリメートルのスライスを持っている必要があります。その後Kuzniecky らによって記載されているように軌道が以前に議論注入戦略に基づいて計画されている定位神経ナビゲーションソフトウェアに画像を転送。14 </li><li>手術室で一旦、仰臥位で手術台に患者を置きます。その後、麻酔医」プロトコルに従って気管内挿管して全身麻酔を得ます。 注：それは彼らが一般的な静脈麻酔と完全な薬理学的麻痺の下にあることが不可欠です。そして、患者の頭を剃る、抗生物質、外科用アプリケーションで皮膚を準備をしてからヘッド脳神経外科ヘッドホルダに患者の頭を置きます。全身麻酔は、患者に患者とは異なります。 </li><li>完了したらポジショニングは、フレームと登録完了にロボットシステムを接続します。ロボット支援装置で選択し「登録」と登録プロセスを完了するために画面の指示に従ってください。顔の特徴、または移植の基準マーカーに基づいて、表面ランドマーク登録を使用して登録を完了。 </li><li>挿入（ 図2） <ol><li>ロボット定位システムからの指導支援を受けて頭蓋骨をドリルダウンする2.5 mmのドリルビットを使用します。硬膜を開くためにモノポーラ凝固プローブを挿入します。頭蓋骨の中に注入ボルトをねじ込み、またロボット定位システムによって導かれます。 </li><li> [ - = D3（ターゲット・デュラ距離）+（D2 D1）]：以下の測定を用いた電極（D3）の最終的な奥行き距離を計算します。ナビゲーションシステムを使用して、ターゲット・硬膜の距離を測定します。 注：D1は硬膜への誘導システムの長さとして測定され、D2は、ボルトの端に誘導システムの長さとして測定されます。 D1 - D2の差は、ボルトの長さです。ボルトとターゲット硬膜距離の長さの和は、電極の深さの長さです。 </li><li>移植ボルトによって導かれたスタイレットプローブを挿入することで初期軌道を作成します。その後、電極を挿入し、ボルトに固定します。これはさらに変位し、脳脊髄液（CSF）の漏れを防ぎます。 </li><li>全ての電極を配置し、接続した後、ボルトキャップの周りにヨウ素溶液に浸したガーゼを置きます。そして、その後、頭をラップ。 </li></ol></li></ol> 3.モニタリング/録音<ol><li>ケースを終了する前に、適切な機能を確保するために、脳波記録機に電極を接続します。 ORの最後のステップは、術中イメージング（ 図3）です。横方向と前後頭蓋骨におけるX線や透視撮影術中を実行します。 注：電極の適切な軌道を確保するためにこれらを入手します。これらのイメージはobtaineではありませんdは、定位配置を確保するためではなく、彼らは、電極の一般的な正しい軌道と配置を確保します。 </li><li>手術後、臨床的およびelectrographically SEEG電極記録を介して、両方の発作活動のために患者を監視てんかん監視部へ患者を移します。 注：滞在の長さは数、品質、および発作や録音の発作間のパターンによって異なります。監視対象の患者は軽微な痛みがあるかもしれないが、アセトアミノフェンでこれを扱います。一般的に、滞在期間は7日間（ - 28日の範囲3）です。 </li><li>電極を除去する前に、録音や仮説を検討する学際的な会議に患者について議論します。 </li><li>電極の除去のために待っているORつつ、十分な発作データを記録した後（ステップ3.2）、患者は会議で議論されている、患者の前に抗てんかん薬を再起動します。 </li></ol> 4.返却するか、あるいは除去のための<ol><li> Af十分な発作データを記録ター、SEEG電極を除去するための手術室に患者を戻します。意識下鎮静下でこれを実行します。一般的には2mgのミダゾラムIVは十分です。 </li><li>麻酔が十分な鎮静を取得した後（通常、ミダゾラムで[麻酔科医に投与延期]）、患者はラップヘッド削除し、電極線をカット。電極除去または縫合糸挿入と報告された痛みのレベルによって、臨床的に患者の鎮静を監視します。その後、ヨウ素化ゲルを用いた電極の残りのボルトと尾を準備を。 </li><li>個別に、電極が続き、最後にボルトを取り外し、それをねじることによって、各ボルトキャップを取り外します。そっとその挿入軸線に沿ってそれらを引き出して電極を削除します。そして、それをねじることによってボルトを取り外し、通常、指を使ってこれを行います。 </li><li>次の電極に移動する前に、ナイロン縫合糸の1ステッチでボルトによって残された欠陥を閉じます。各電極について、上記の手順を繰り返します。レム後全ての電極をoving、抗生物質軟膏とルースヘッドラップでステッチ領域をカバー。 </li><li>除去後、残留ハードウェアを確保しないように、さらにイメージングCTまたはA / Pのいずれかと横方向X線を得ます。 注：可能な外科的切除は、患者のてんかんに有益であると考えられた切除-場合、およそ6週間を除去した後に開頭し、切除のために計画しています。この遅延は、監視期間と同じ入院時の動作の感染の懸念によるものです。 </li></ol>

<ol>
	<li>Serletis, D., Bulacio, J., Bingaman, W., Gonzalez-Martinez, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+stereotactic+approach+for+mapping+epileptic+networks:+a+prospective+study+of+200+patients.">The stereotactic approach for mapping epileptic networks: a prospective study of 200 patients.</a> J Neurosurg. 121, 1239-1246 (2014).</li><li>Bancaud, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epilepsy+after+60+years+of+age.+Experience+in+a+functional+neurosurgical+department.">Epilepsy after 60 years of age. Experience in a functional neurosurgical department.</a> Sem Hop. 46, 3138-3140 (1970).</li><li>Bancaud, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+stereotaxic+exploration+(SEEG)+of+epilepsy.">Functional stereotaxic exploration (SEEG) of epilepsy.</a> Electroencephalogr Clin Neurophysiol. 28, 85-86 (1970).</li><li>Talairach, J., Bancaud, J., Bonis, A., Szikla, G., Trottier, S., Vignal, J. 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N., Olivier, A., Quesney, F., Dubeau, F., Savard, G., Andermann, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+and+morbidity+associated+with+stereoelectroencephalography+using+computerized+tomography-or+magnetic+resonance+imaging-guided+electrode+implantation.">Efficacy of and morbidity associated with stereoelectroencephalography using computerized tomography-or magnetic resonance imaging-guided electrode implantation.</a> J Neurosurg. 104, 483-487 (2006).</li><li>Cossu, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereoelectroencephalography+in+the+presurgical+evaluation+of+focal+epilepsy+a+retrospective+analysis+of+215+procedures.">Stereoelectroencephalography in the presurgical evaluation of focal epilepsy a retrospective analysis of 215 procedures.</a> Neurosurgery. 57, 706-718 (2005).</li><li>Gonzalez-Martinez, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+stereotactic+laser+ablation+in+medically+intractable+epilepsy:+operative+technique.">Robot-assisted stereotactic laser ablation in medically intractable epilepsy: operative technique.</a> Neurosurgery. 10, 167-172 (2014).</li><li>Guenot, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neurophysiological+monitoring+for+epilepsy+surgery:+the+Talairach+SEEG+method.+Indications,+results,+complications+and+therapeutic+applications+in+a+series+of+100+consecutive+cases.">Neurophysiological monitoring for epilepsy surgery: the Talairach SEEG method. Indications, results, complications and therapeutic applications in a series of 100 consecutive cases.</a> Stereotact Funct Neurosurg. 77, 29-32 (2001).</li><li>Kuzniecky, R. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multimodality+MRI+in+mesial+temporal+sclerosis:+relative+sensitivity+and+specificity.">Multimodality MRI in mesial temporal sclerosis: relative sensitivity and specificity.</a> Neurology. 49 (3), 774-778 (1997).</li><li>Cardinale, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stereoelectroencephalography:+surgical+methodology,+safety,+and+stereotacticapplication+accuracy+in+500+procedures.">Stereoelectroencephalography: surgical methodology, safety, and stereotacticapplication accuracy in 500 procedures.</a> Neurosurgery. 72 (3), 353-366 (2013).</li></ol>

著者らは、開示することは何もありません。

ここではロボットの定位支援を利用SEEG挿入する技術が提示されています。 SEEGはもともと、フレームベースの定位の他の方法を用いて説明したが、ロボット支援SEEGは、同様の安全性が、優れた精度と効率だけでなく、を提供しています。文献は、代替技術を使用して他の以前の研究と同情である、例76％以上にEZのローカライズで成功を報告します。6,13、。 任意の侵襲的な頭蓋内の手順と同様に、SEEGは、リスクがないわけではありません。幸いなことに、SEEG挿入は合併症のリスクが非常に低いことを報告している。15最も注目すべきは、頭蓋内出血が最も深刻な合併症10,11ました。これらの結果は、現在のSEEG文献と互換性があります。 SEEGためのロボット支援を利用することに有望な技術であることが実証、安全なだけでなく、効率的かつ正確なだけではありません。 一方、提供しています優れた技術、手術時間に有意な改善が、ロボット支援は完璧ではあり​​ません。自分の練習に実装する前に考慮しなければならない一つの制限要因は、製品買収の初期コストです。個々のケース番号に応じて、これは簡単に、単独での改善OR回で正当化することができました。 軽く取られてはならないもう一つの重要なステップは、前の初期の深さとそれ以降のすべての深さの配置に適切な登録の重要な性質です。精度に関する術中懸念が生じた場合、正確な登録が確認できるまで、手術を停止する必要があります。 SEEG挿入するだけでなく、現在の技術では、従来の方法に取って代わるが、他の利用率に神経外科医の装備一式を開きます。てんかんの治療のためのレーザーアブレーションはすでにロボットSEEGとの組み合わせに適しであることが示されている急成長分野である。12 我々が始めているもう一つの技術ロボットSEEGで利用することはRNSを注入する際に、電極の精密かつ正確な配置を可能にしながら、3-d機能解剖学を実証するSEEGの能力は明らかな利点である応答性神経刺激システム（RNS）の移植です。

In medically refractory epilepsy there are many non-invasive pre-surgical tools (scalp EEG., magnetic resonance imaging (MRI), functional MRI, single photon emission computed tomography, positron emission topography, and magnetoencephalography). If these non-invasive evaluations fail to sufficiently localize or define the epileptic zone (EZ) then invasive recording may be indicated. Currently, subdural grids or Stereo-electro-encephalo-graphy (SEEG) are the two most prevalent methods of invasive monitoring. SEEG was originally developed in France in the 1950's by Jean Talairach and Jean Bancaud; recently it has mostly been used for invasive monitoring of refractory epilepsy patients in France.2-4 SEEG is the consists of stereotactically inserting intracerebral electrodes into the brain parenchyma to record brain electrical activity for an extended period of time. With the intracerebral electrical recordings many patients are able to have their EZ defined to allow for surgical resection. 
Despite this long history of success SEEG remains relatively rarely used for invasive recording in America. However, SEEG does offer several significant advantages; SEEG allows for 1) recording of deep structures, 2) bihemispheric recordings, 3) another recording option if subdural grids failed, and 4) mapping of epileptic networks in three dimensions, mainly in patients where non-lesional extra-temporal epilepsy is suspected.5-7 All of these benefits are achieved without requiring a large craniotomy. A recent technologic advance in SEEG surgery is the used of robotic guidance. This sophisticated development allows for improved operative times but safer and more accurate surgical implantation of electrodes.Recently published literature reviews the results of using two different techniques for SEEG insertion; a more traditional method utilizing stereotactic frames and a newer technique using robotic assistante for SEEG insertion.1, 8,15 the results were similarly successful with each method. 
With the advent of improved robotic assistance, the SEEG insertion technique has resulted in improved operative times. The robotic system is classified as a supervisory controlled system which means the surgeon plans the operation off line and implicitly specifies the motion the robot must follow to perform the operation.9 The robotic assist results in expedient transitions from one trajectory to the next for the placement of each intracranial electrode.

<table border="0" cellpadding="0" cellspacing="0" width="573">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">ROSA</td>
			<td style="width:71px;">ROSA</td>
			<td style="width:119px;"></td>
			<td style="width:167px;">robotic implantation system</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">electrodes</td>
			<td style="width:71px;">adtech</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
	</tbody>
</table>

stereo-electro-encephalo-graphy (seeg) with robotic assistance in the presurgical evaluation of medical refractory epilepsy: a technical note

SEEGは、3次元の記録を介し発作活動の正確な、侵襲的な記録のために使用された方法および技術です。侵襲的な記録のための適切な候補とみなされているてんかん患者では、監視するための決定はSEEG対硬膜下グリッドとの間で行われます。てんかんのための侵略的neuromonitoringは、複雑な、医学的に難治性てんかんの患者で追求されています。侵襲的なモニタリングの目標は、発作の自由を可能にする希望を持ってresective手術を提供することです。 SEEGの利点は深い皮質構造へのアクセス、てんかんゾーン硬膜下グリッドはそうすることができなかった（EZ）、および非病変超時間的なてんかんの患者でをローカライズする能力を含みます。本稿では、我々はSEEGの簡潔な歴史的概観を提示し、ロボットの下のフレームレス定位の経験について報告します。 SEEG挿入の不可欠のステップは、電極の軌道を計画しています。最も効果的に記録するためにSEEG軌道を介した発作活動は、発作活動が推定されるてんかんゾーン（EZ）を発信する場所の仮説に基づいて計画する必要があります。 EZ仮説は、ビデオEEGモニタリング、MRI（磁気共鳴画像法）、PET（陽電子放射断層撮影法）、発作SPECT（単一光子放射型コンピュータ断層撮影法）、および神経心理学的評価を含む標準化された術前の精密検査に基づいています。疑わしいEZを使用して、SEEG電極は、最小限侵襲まだ正確さと精度を維持するために配置することができます。臨床結果は、てんかん患者をローカライズすることは難しいの78％にEZをローカライズする能力を示した。1

最近の結果は、ロボット支援を経由してSEEG挿入を受けた78人の患者の1の連続した一連の患者の76.2パーセントにEZの成功局在を持っていたことを示している。1その同じ研究では、持っていたグレード1 EZの外科的切除を持つようになった患者の示しました患者の67.8パーセントでエンゲル発作自由（ 図4）。罹患率は2.5％です。永久的な罹患率は、1人の患者（1.2％）で認められました。電極ごとに、それは、それぞれ0.08％の創傷感染および頭蓋内血腫率を有することが示されました。 <img alt="図1" src="/files/ftp_upload/53206/53206fig1.jpg" /> SEEG注入のパターンの1例を図。すべての挿入は、患者の提案仮説に基づいて個々にカスタマイズされています 。これらの例では、時間的、時間的、後頭部、時間的・パー（左から右へ、上から下へ）表示しますietal後頭、前頭側頭、前頭頭頂-島、perisylvian、および前頭および両側頭骨の挿入計画。黒丸は、直交様式で移植SEEG電極のエントリポイントを表します。黒い線は、電極の軌跡を表します。許可を得て転載、メディカルアート＆写真用のクリーブランド・クリニックセンター。著作権2011 - 。2013すべての権利を保有<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/53206/53206fig1large.jpg" target="_blank">。この図の拡大版をご覧になるにはこちらをクリックしてください。</a> <img alt="図2" src="/files/ftp_upload/53206/53206fig2.jpg" /> 深電極移植の図2の方法。1）頭蓋骨は、2.5 mmのドリルビットで穿孔定位システムによって案内される。2）単極凝固プローブを挿入し、硬膜が開かれた。3）注入ボルトが螺合されています頭蓋骨、またグラムへ<html> 。定位システムによってuided 4）電極（D3）の最終的な奥行き距離を算出し、測定された：[（ターゲット-デュラ距離+ D1） - D2 = D3]。最初に、軌道を注入ボルトによって導かれたスタイレットプローブ、によって作成されます。5）最終的な深さ電極の位置、およびボルトにその固定を、変位およびCSFの漏れを防止します。許可を得て転載、メディカルアート＆写真用のクリーブランド・クリニックセンター。著作権2011年から2013年。すべての著作権。 <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/53206/53206fig2large.jpg" target="_blank">この図の拡大版をご覧になるにはこちらをクリックしてください。</a> <img alt="図3" src="/files/ftp_upload/53206/53206fig3.jpg" /> 図3.術中手術APスカルX線。電極の配置を確認するために、得られた事前に計画軌道に対応しています。tp_upload / 53206 / 53206fig3large.jpg &quot;ターゲット=&quot; _空白 &quot;&gt;この図の拡大版をご覧になるにはこちらをクリックしてください。 <img alt="図4" src="/files/ftp_upload/53206/53206fig4.jpg" /> 。図4.成果患者の受けSEEG監視七十6人の患者は、彼らのEZは、ローカライズされたことができました。さらにSEEG後に67％を切除を受けた患者のはエンゲルグレード1発作自由を経験した。 <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/53206/53206fig4large.jpg" target="_blank">この図の拡大版をご覧になるにはこちらをクリックしてください。</a>

Watch this Scientific Journal Video about Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note at JoVE.com

Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note

Stereo-electroencephalography (SEEG) aids in localization of epileptogenic zones, however, remains relatively underutilized in the United States. The goal of this abstract is to provide a brief introduction to the technique of SEEG and further a detailed technique of using robotic assistance in the placement of SEEG electrodes.

医療難治性てんかんの術前評価におけるロボットの助けを借りてステレオエレクトロEncephalo-グラフィー（SEEG）：テクニカルノート

SEEG is a method and technique which is used for accurate, invasive recording of seizure activity via three dimensional recordings. In epilepsy patients ...

stereo-electro-encephalo-graphy-seeg-with-robotic-assistance

Nanyang Technological University

Research

JoVE Journal

Medicine

Stereo-Electro-Encephalo-Graphy (SEEG) With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note

17.0K ビュー.  Cleveland Clinic. Stereo-electroencephalography (SEEG) aids in localization of epileptogenic zones, however, remains relatively underutilized in the United States. The goal of this abstract is to provide a brief introduction to the technique of SEEG and further a detailed technique of using robotic assistance in the placement of SEEG electrodes. 

ビデオ: Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note

Technical Aspects of the Mouse Aortocaval Fistula

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta and inferior vena cava (IVC) are exposed. The proximal infrarenal aorta and the distal aorta are dissected for clamp placement and needle puncture, respectively. Special attention is paid to avoid dissection between the aorta and the IVC. After clamping the aorta, a 25 G needle is used to puncture both walls of the aorta into the IVC. The surrounding connective tissue is used for hemostatic compression. Successful creation of the AVF will show pulsatile arterial blood flow in the IVC. Further confirmation of successful AVF can be achieved by post-operative Doppler ultrasound.

The goal is to produce an arteriovenous fistula that is simple and reproducible. This method does not use sutures or glue adhesive. Therefore the samples can be used with the least amount of foreign materials for analysis.

マウスAortocaval瘻の技術的な側面

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta ...

医学

A Multimodal Imaging- and Stimulation-based Method of Evaluating Connectivity-related Brain Excitability in Patients with Epilepsy

Resting-state functional connectivity MRI (rs-fcMRI) is a technique that identifies connectivity between different brain regions based on correlations over time in the blood-oxygenation level dependent signal. rs-fcMRI has been applied extensively to identify abnormalities in brain connectivity in different neurologic and psychiatric diseases. However, the relationship among rs-fcMRI connectivity abnormalities, brain electrophysiology and disease state is unknown, in part because the causal significance of alterations in functional connectivity in disease pathophysiology has not been established. Transcranial Magnetic Stimulation (TMS) is a technique that uses electromagnetic induction to noninvasively produce focal changes in cortical activity. When combined with electroencephalography (EEG), TMS can be used to assess the brain's response to external perturbations. Here we provide a protocol for combining rs-fcMRI, TMS and EEG to assess the physiologic significance of alterations in functional connectivity in patients with neuropsychiatric disease. We provide representative results from a previously published study in which rs-fcMRI was used to identify regions with abnormal connectivity in patients with epilepsy due to a malformation of cortical development, periventricular nodular heterotopia (PNH). Stimulation in patients with epilepsy resulted in abnormal TMS-evoked EEG activity relative to stimulation of the same sites in matched healthy control patients, with an abnormal increase in the late component of the TMS-evoked potential, consistent with cortical hyperexcitability. This abnormality was specific to regions with abnormal resting-state functional connectivity. Electrical source analysis in a subject with previously recorded seizures demonstrated that the origin of the abnormal TMS-evoked activity co-localized with the seizure-onset zone, suggesting the presence of an epileptogenic circuit. These results demonstrate how rs-fcMRI, TMS and EEG can be utilized together to identify and understand the physiological significance of abnormal brain connectivity in human diseases.

Resting-state functional-connectivity MRI has identified abnormalities in patients with a wide range of neuropsychiatric disorders, including epilepsy due to malformations of cortical development. Transcranial Magnetic Stimulation in combination with EEG can demonstrate that patients with epilepsy have cortical hyperexcitability in regions with abnormal connectivity.

マルチモーダルImaging-とてんかんの患者で接続関連の脳の興奮性を評価するの刺激に基づく方法

Resting-state functional connectivity MRI (rs-fcMRI) is a technique that identifies connectivity between different brain regions based on correlations ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

薬剤耐性側頭葉てんかん患者における孔開存電極レコーディングのネットワーク解析

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Interictal High Frequency Oscillations Detected with Simultaneous Magnetoencephalography and Electroencephalography as Biomarker of Pediatric Epilepsy

Crucial to the success of epilepsy surgery is the availability of a robust biomarker that identifies the Epileptogenic Zone (EZ). High Frequency Oscillations (HFOs) have emerged as potential presurgical biomarkers for the identification of the EZ in addition to Interictal Epileptiform Discharges (IEDs) and ictal activity. Although they are promising to localize the EZ, they are not yet suited for the diagnosis or monitoring of epilepsy in clinical practice. Primary barriers remain: the lack of a formal and global definition for HFOs; the consequent heterogeneity of methodological approaches used for their study; and the practical difficulties to detect and localize them noninvasively from scalp recordings. Here, we present a methodology for the recording, detection, and localization of interictal HFOs from pediatric patients with refractory epilepsy. We report representative data of HFOs detected noninvasively from interictal scalp EEG and MEG from two children undergoing surgery.
The underlying generators of HFOs were localized by solving the inverse problem and their localization was compared to the Seizure Onset Zone (SOZ) as this was defined by the epileptologists. For both patients, Interictal Epileptogenic Discharges (IEDs) and HFOs were localized with source imaging at concordant locations. For one patient, intracranial EEG (iEEG) data were also available. For this patient, we found that the HFOs localization was concordant between noninvasive and invasive methods. The comparison of iEEG with the results from scalp recordings served to validate these findings. To our best knowledge, this is the first study that presents the source localization of scalp HFOs from simultaneous EEG and MEG recordings comparing the results with invasive recordings. These findings suggest that HFOs can be reliably detected and localized noninvasively with scalp EEG and MEG. We conclude that the noninvasive localization of interictal HFOs could significantly improve the presurgical evaluation for pediatric patients with epilepsy.

High Frequency Oscillations (HFOs) have emerged as presurgical biomarkers for the identification of the epileptogenic zone in pediatric patients with medically refractory epilepsy. A methodology for the noninvasive recording, detection, and localization of HFOs with simultaneous scalp electroencephalography (EEG) and magnetoencephalography (MEG) is presented.

小児てんかんのバイオマーカーとして同時磁図と脳波を用いて検出発作間高周波発振

Crucial to the success of epilepsy surgery is the availability of a robust biomarker that identifies the Epileptogenic Zone (EZ). High Frequency ...

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

ロボット手術の緊急ドッキング解除: シミュレーション カリキュラム

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

Assessment of Static Graviceptive Perception in the Roll-Plane using the Subjective Visual Vertical Paradigm

Vestibular disorders are among the most common syndromes in medicine. In recent years, new vestibular diagnostic systems have been introduced that allow the examination of all semicircular canals in the clinical setting. Assessment methods of the otolithic system, which is responsible for the perception of linear acceleration and perception of gravity, are far less in clinical use. There are several experimental approaches for measuring the perception of gravity. The most frequently used method is the determination of the subjective visual vertical. This is usually measured with the head in an upright position. We present here an assessment method for testing otolith function in the roll plane. The subjective visual vertical is measured in the head upright position as well as with head inclination of &#177; 15&#176; and &#177; 30&#176; in the roll plane. This extended functional paradigm is an easy-to-perform clinical test of otolith function and ensures increased information content for the detection of impaired graviceptive perception.

The perception of gravity is commonly determined by the subjective visual vertical in the head upright position. The additional assessment at head tilts of &#177; 15&#176; and &#177; 30&#176; in the roll plane ensures increased information content for the detection of impaired graviceptive perception.

主観的視覚的垂直パラダイムを用いたロールプレーンにおける静的なグラビゼーション知覚の評価

Vestibular disorders are among the most common syndromes in medicine. In recent years, new vestibular diagnostic systems have been introduced that allow ...

Evaluation of Cerebral Blood Flow Autoregulation in the Rat Using Laser Doppler Flowmetry

When investigating the body&#39;s mechanisms for regulating cerebral blood flow, a relative measurement of microcirculatory blood flow can be obtained using laser Doppler flowmetry (LDF). This paper demonstrates a closed skull preparation that allows cerebral blood flow to be assessed without penetrating the skull or installing a chamber or cerebral window. To evaluate autoregulatory mechanisms, a model of controlled blood pressure reduction via graded hemorrhage can be utilized while simultaneously employing LDF. This enables the real time tracking of the relative changes in the blood flow in response to reductions in arterial blood pressure produced by the withdrawal of circulating blood volume. This paradigm is a valuable approach to study cerebral blood flow autoregulation during reductions in arterial blood pressure and, with minor modifications in the protocol, is also valuable as an experimental model of hemorrhagic shock. In addition to evaluating autoregulatory responses, LDF can be used to monitor the cortical blood flow when investigating metabolic, myogenic, endothelial, humoral, or neural mechanisms that regulate cerebral blood flow and the impact of various experimental interventions and pathological conditions on cerebral blood flow.

This article demonstrates the use of laser Doppler flowmetry to evaluate the ability of the cerebral circulation to autoregulate its blood flow during reductions in arterial blood pressure.

レーザードップラー流量測定を用いたラットにおける脳血流自動調節の評価

When investigating the body&#39;s mechanisms for regulating cerebral blood flow, a relative measurement of microcirculatory blood flow can be obtained ...

Development and Evaluation of 3D-Printed Cardiovascular Phantoms for Interventional Planning and Training

Catheter-based interventions are standard treatment options for cardiovascular pathologies. Therefore, patient-specific models could help training physicians&#39; wire-skills as well as improving planning of interventional procedures. The aim of this study was to develop a manufacturing process of patient-specific 3D-printed models for cardiovascular interventions.
To create a 3D-printed elastic phantom, different 3D-printing materials were compared to porcine biological tissues (i.e., aortic tissue) in terms of mechanical characteristics. A fitting material was selected based on comparative tensile tests and specific material thicknesses were defined. Anonymized contrast-enhanced CT-datasets were collected retrospectively. Patient-specific volumetric models were extracted from these datasets and subsequently 3D-printed. A pulsatile flow loop was constructed to simulate the intraluminal blood flow during interventions. Models&#39; suitability for clinical imaging was assessed by x-ray imaging, CT, 4D-MRI and (Doppler) ultrasonography. Contrast medium was used to enhance visibility in x-ray-based imaging. Different catheterization techniques were applied to evaluate the 3D-printed phantoms in physicians&#39; training as well as for pre-interventional therapy planning.
Printed models showed a high printing resolution (~30 &#181;m) and mechanical properties of the chosen material were comparable to physiological biomechanics. Physical and digital models showed high anatomical accuracy when compared to the underlying radiological dataset. Printed models were suitable for ultrasonic imaging as well as standard x-rays. Doppler ultrasonography and 4D-MRI displayed flow patterns and landmark characteristics (i.e., turbulence, wall shear stress) matching native data. In a catheter-based laboratory setting, patient-specific phantoms were easy to catheterize. Therapy planning and training of interventional procedures on challenging anatomies (e.g., congenital heart disease (CHD)) was possible.
Flexible patient-specific cardiovascular phantoms were 3D-printed, and the application of common clinical imaging techniques was possible. This new process is ideal as a training tool for catheter-based (electrophysiological) interventions and can be used in patient-specific therapy planning.

Here we present development of a mock circulation setup for multimodal therapy evaluation, pre-interventional planning, and physician-training on cardiovascular anatomies. With the application of patient-specific tomographic scans, this setup is ideal for therapeutic approaches, training, and education in individualized medicine.

介入計画と訓練のための3Dプリント心血管ファントムの開発と評価

Catheter-based interventions are standard treatment options for cardiovascular pathologies. Therefore, patient-specific models could help training ...

Repetitive Blood Sampling from the Subclavian Vein of Conscious Rat

Rats are widely used in pharmacokinetics (PK) and toxicokinetic (TK) studies that need to collect a certain amount of blood at specific time points to detect drug exposure. The rat blood sampling method determines the quality of the plasma and further affects the precision of the test results. The subclavian vein blood collection method described in this protocol collects blood samples repeatedly in the conscious state of animals to meet the needs of PK and TK tests. The skills of restraint handling and appropriate procedure of needle incision ensure the success rate of blood collection. It is easy to operate while ensuring the quality of plasma and at the same time catering to animal welfare. However, this method requires skilled operation, and an improper one may cause animal weakness, pain, lameness, and even mortality. The current method has been used in the testing facility for a 4-week oral toxicity study in Sprague Dawley (SD) rats with TK. The maximum amount of blood collected within 24 h did not exceed 20% of the animal's total blood. The animals' body weight was more than 200 g for males and females. The data showed that the animals' bodyweight increased steadily every week, and the clinical observation was normal after repetitive sample collection.

The present protocol describes a simple and efficient method for collecting blood from the subclavian vein in rats. It enables rapid, timely, and easily identifiable sampling without anesthesia and obtains high-quality blood through repetitive sample collection.

意識性ラットの鎖骨下静脈からの反復採血

Rats are widely used in pharmacokinetics (PK) and toxicokinetic (TK) studies that need to collect a certain amount of blood at specific time points to ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

肺門胆管癌に対するロボットタージマハル肝切除術

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...