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Article ; Online: Feasibility of exoscopic keyhole surgery: case series.

Sáez-Alegre, Miguel / Ríos-Vicil, Christian / Piper, Keaton / Najera, Edinson / Jean, Walter C

Neurosurgical focus: Video

2024 Volume 10, Issue 1, Page(s) V3

Abstract: Keyhole approaches, performed with the endoscope, microscope, or exoscope, aim to minimize tissue traumatization while maximizing surgical view. The exoscope can provide better ergonomics than the microscope without restricting the space inside of the ... ...

Abstract	Keyhole approaches, performed with the endoscope, microscope, or exoscope, aim to minimize tissue traumatization while maximizing surgical view. The exoscope can provide better ergonomics than the microscope without restricting the space inside of the keyhole, as when using the endoscope. However, a frequently quoted reason for intraoperative exoscope-to-microscope conversion is the absence of sufficient light. In this video, the authors present 4 patients who underwent posterior fossa keyhole surgery without intraoperative conversion. The surgical objective was achieved in all patients without associated morbidity. After adequate adaptation, the exoscope allows sufficient light in the surgical field to perform safe keyhole surgery. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23116.
Language	English
Publishing date	2024-01-01
Publishing country	United States
Document type	Journal Article
ISSN	2643-5217
ISSN (online)	2643-5217
DOI	10.3171/2023.10.FOCVID23116
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Article ; Online: The Inaugural "Century" of Mixed Reality in Cranial Surgery: Virtual Reality Rehearsal/Augmented Reality Guidance and Its Learning Curve in the First 100-Case, Single-Surgeon Series.

Jean, Walter C / Piper, Keaton / Felbaum, Daniel R / Saez-Alegre, Miguel

Operative neurosurgery (Hagerstown, Md.)

2023 Volume 26, Issue 1, Page(s) 28–37

Abstract: Background and objective: Virtual reality (VR) refers to a computer-generated three-dimensional space in which a surgeon can interact with patient-specific anatomic models for surgical planning. Augmented reality (AR) is the technology that places ... ...

Abstract	Background and objective: Virtual reality (VR) refers to a computer-generated three-dimensional space in which a surgeon can interact with patient-specific anatomic models for surgical planning. Augmented reality (AR) is the technology that places computer-generated objects, including those made in VR, into the surgeon's visual space. Together, VR and AR are called mixed reality (MxR), and it is gaining importance in neurosurgery. MxR is helpful for selecting and creating templates for an optimal surgical approach and identifying key anatomic landmarks intraoperatively. By reporting our experience with the first 100 consecutive cases planned with VR and executed with AR, our objective is to detail the learning curve and encountered obstacles while adopting the new technology. Methods: This series includes the first 100 consecutive complex cranial cases of a single surgeon for which MxR was intended for use. Effectiveness of the VR rehearsal and AR guidance was analyzed for four specific contributions: (1) opening size, (2) precise craniotomy placement, (3) guidance toward anatomic landmarks or target, and (4) antitarget avoidance. Seventeen cases in the study cohort were matched with historical non-MxR cases for comparison of outcome parameters. The cases in which MxR failed were plotted over time to determine the nature of the "learning curve." Results: AR guidance was abandoned in eight operations because of technical problems, but problem-free application of MxR increased between the 44th and 63rd cases. This provides some evidence of proficiency acquisition in between. Comparing the 17 pairs of matched MxR and non-MxR cases, no statistically significant differences exist in the groups regarding blood loss, length of stay nor duration of surgery. Cases where MxR had above-expectation performances are highlighted. Conclusion: MxR is a powerful tool that can help tailor operations to patient-specific anatomy and provide efficient intraoperative guidance without additional time for surgery or hospitalization.
MeSH term(s)	Humans ; Augmented Reality ; Learning Curve ; Surgery, Computer-Assisted/methods ; Surgeons ; Virtual Reality
Language	English
Publishing date	2023-09-25
Publishing country	United States
Document type	Journal Article
ZDB-ID	2767575-0
ISSN	2332-4260 ; 2332-4252
ISSN (online)	2332-4260
ISSN	2332-4252
DOI	10.1227/ons.0000000000000908
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Article ; Online: Transorbital Approach for Clipping of Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Jean, Walter C / Piper, Keaton / Wojcik, Randolph / Saez-Alegre, Miguel

Operative neurosurgery (Hagerstown, Md.)

2023 Volume 25, Issue 4, Page(s) e237

MeSH term(s)	Humans ; Intracranial Aneurysm/diagnostic imaging ; Intracranial Aneurysm/surgery ; Neurosurgical Procedures/methods ; Microsurgery/methods
Language	English
Publishing date	2023-07-25
Publishing country	United States
Document type	Video-Audio Media ; Journal Article
ZDB-ID	2767575-0
ISSN	2332-4260 ; 2332-4252
ISSN (online)	2332-4260
ISSN	2332-4252
DOI	10.1227/ons.0000000000000816
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Article ; Online: Transorbital Surgical Corridor: An Anatomic Analysis of Ocular Globe Retraction and the Associated Exposure for the Transpalpebral Orbital Rim Preserving Endoscopic Orbitotomy (TORPEDO) Approach.

Piper, Keaton / Saez-Alegre, Miguel / George, Zeegan / Srivastava, Aneil / Felbaum, Daniel R / Jean, Walter C

Operative neurosurgery (Hagerstown, Md.)

2023 Volume 26, Issue 2, Page(s) 196–202

Abstract: Background and objectives: The transorbital approach varies by the extent of bony removal and the target. Orbital rim-sparing transorbital approach with removal of only the orbit's posterior wall provides optimal cosmetic results, without the need for ... ...

Abstract	Background and objectives: The transorbital approach varies by the extent of bony removal and the target. Orbital rim-sparing transorbital approach with removal of only the orbit's posterior wall provides optimal cosmetic results, without the need for reconstruction. The size of this corridor, limited by the medial globe retraction, has not yet been defined and is difficult to determine in cadavers because of postmortem tissue desiccation. By using patient-specific models in virtual reality, precise areas and degrees of surgical freedom (AOF and DOF, respectively) provided by globe retraction were calculated. These measurements define a potential maximum safe AOF and DOF, as well as the globe retraction, needed to achieve a sufficient surgical corridor. Methods: Using a virtual reality system, transorbital rim-preserving craniectomies were performed. The axial and sagittal DOF as well as AOF were calculated lateral to the globe, limited by the orbital rim and globe, with an anterior clinoid target. The DOFs and AOFs were calculated for each degree of medial globe retraction and analyzed using paired t tests. Results: With only 5 mm of retraction, the AOF was 886 mm 2 , while at 10 mm, the AOF was 1546 mm 2 . This increase between 5 and 10 mm allowed for the largest increase in surgical working corridor ( P = .02). At 15 mm of retraction (previously studied point at which intraocular pressure raises), the AOF averaged 2189 mm 2 and axial DOF averaged 23.1°. Eighteen DOF (a previously studied point needed to achieve sufficient working space for 2 instruments) was achieved at 11 mm on average, generating 1675 mm 2 AOF. Conclusion: Globe retraction of 11 mm is needed to achieve sufficient DOF for 2 surgical instruments, and 15 mm of retraction is a conservative limit that provides comparable AOFs with similar cranial approaches.
MeSH term(s)	Humans ; Orbit/surgery ; Neurosurgical Procedures/methods ; Face
Language	English
Publishing date	2023-10-09
Publishing country	United States
Document type	Journal Article
ZDB-ID	2767575-0
ISSN	2332-4260 ; 2332-4252
ISSN (online)	2332-4260
ISSN	2332-4252
DOI	10.1227/ons.0000000000000934
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Article ; Online: Mixed reality in neurosurgery: redefining the paradigm for arteriovenous malformation planning and navigation to improve patient outcomes.

Najera, Edinson / Lockard, Gavin / Saez-Alegre, Miguel / Piper, Keaton / Jean, Walter C

Neurosurgical focus

2023 Volume 56, Issue 1, Page(s) E5

Abstract: Objective: Brain arteriovenous malformations (AVMs) present significant challenges in neurosurgery, requiring detailed planning and execution. In this study, the authors aimed to evaluate the efficacy of mixed reality (MxR), a synergistic application of ...

Abstract	Objective: Brain arteriovenous malformations (AVMs) present significant challenges in neurosurgery, requiring detailed planning and execution. In this study, the authors aimed to evaluate the efficacy of mixed reality (MxR), a synergistic application of virtual reality (VR) and augmented reality (AR), in the surgical management of AVMs. Methods: A retrospective review was conducted on 10 patients who underwent AVM resection between 2021 and 2023. Preoperative planning used patient-specific 360° VR models, while intraoperative guidance used AR markers for targeted disconnection of arterial feeders. Data were analyzed for surgical duration, blood loss, and postoperative outcomes, stratified by Spetzler-Martin (SM) and supplemented Spetzler-Martin (Supp-SM) grades. Results: In 10 patients with cerebral AVMs, MxR significantly facilitated the identification of 21 arterial feeders, including challenging deep feeders. MxR-assisted surgeries demonstrated efficient identification and disconnection of arterial feeders, contributing to precise AVM resection. The mean surgical duration was approximately 5 hours 11 minutes, with a mean intraoperative blood loss of 507.5 ml. Statistically significant variations in surgical duration and blood loss were observed based on SM and supplemented Supp-SM grades. Two patients experienced worsened postoperative neurological deficits, underscoring the inherent risks of AVM surgeries. The marked difference in hospital stays between patients with ruptured and those with unruptured AVMs, particularly for SM grade III, highlights the significant impact of rupture status on postoperative recovery. Conclusions: In this study, the authors delineated a novel paradigm using MxR for the surgical intervention of AVMs. Using 3D VR for preoperative planning and AR for intraoperative guidance, they achieved unparalleled precision and efficiency in targeting deep arterial feeders. While the results are promising, larger studies are needed to further validate this approach.
MeSH term(s)	Humans ; Augmented Reality ; Treatment Outcome ; Neurosurgery ; Intracranial Arteriovenous Malformations/diagnostic imaging ; Intracranial Arteriovenous Malformations/surgery ; Retrospective Studies
Language	English
Publishing date	2023-12-15
Publishing country	United States
Document type	Journal Article
ZDB-ID	2026589-X
ISSN	1092-0684 ; 1092-0684
ISSN (online)	1092-0684
ISSN	1092-0684
DOI	10.3171/2023.10.FOCUS23637
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Article ; Online: Does Head Positioning After Percutaneous Glycerol Rhizotomy for Trigeminal Neuralgia Matter?

Piper, Keaton / Smith, Teagen / Saez-Alegre, Miguel / Jean, Walter / Bezchlibnyk, Yarema / Van Loveren, Harry

World neurosurgery

2023 Volume 181, Page(s) e447–e452

Abstract: Background: Percutaneous glycerol rhizotomy (PGR) is a minimally invasive procedure for patients with trigeminal neuralgia who are not candidates for microvascular decompression. PGR has widely varying success rates. It has been postulated that ... ...

Abstract	Background: Percutaneous glycerol rhizotomy (PGR) is a minimally invasive procedure for patients with trigeminal neuralgia who are not candidates for microvascular decompression. PGR has widely varying success rates. It has been postulated that differences in post-injection head positioning might account for the various success rates. Methods: By comparing glycerol dispersion after injection at various head positions, we provide the first evidence supporting post-injection head flexion positioning. Furthermore, we study the clival-Meckel cave (CMC) angle as a predictor of beneficial glycerol flow, measured on computed tomography images. Twenty-two dissected cadaveric specimens were injected with dyed glycerol through the Hartel approach. The glycerol dispersion was measured at prespecified intervals for 1 hour. The Mann-Whitney U and χ Results: We found that 30° of anterior head flexion provided optimal trigeminal nerve glycerol submersion (81.82%) in comparison to neutral (27.27%) and 15° (68.18%), P < 0.001. There was minimal unfavorable dispersion beyond 30 minutes at all angles. More obtuse CMC angles were associated with higher rates of unfavorable BC dispersion (U = 6.0; P = 0.001). For specimens with CMC angles >75°, unfavorable BC dispersion was prevented by head flexion (U = 4.5; P = 0.021). We show that 30° of lateral head tilt achieves V1 submersion in all specimens by 30 minutes [X Conclusions: We found that 30° anterior head flexion for >30 minutes provides ideal conditions for PGR to avoid BC dispersion and ensure V1-V3 branches achieve glycerol submersion. For patients with V1 symptoms, contralateral head flexion might help optimize treatment effects.
MeSH term(s)	Humans ; Trigeminal Neuralgia/surgery ; Rhizotomy/methods ; Glycerol ; Treatment Outcome ; Trigeminal Nerve/surgery
Chemical Substances	Glycerol (PDC6A3C0OX)
Language	English
Publishing date	2023-10-20
Publishing country	United States
Document type	Journal Article
ZDB-ID	2534351-8
ISSN	1878-8769 ; 1878-8750
ISSN (online)	1878-8769
ISSN	1878-8750
DOI	10.1016/j.wneu.2023.10.078
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Article ; Conference proceedings: Utilization of Mixed Reality in the Surgical Management of Dural Arteriovenous Fistulas with Cortical Venous Reflux: A Case Series

Najera, Edinson / Alayli, Adam / Patrick, Hayes / Saez-Alegre, Miguel / Piper, Keaton / Jean, Walter C.

Journal of Neurological Surgery Part B: Skull Base

2024 Volume 85, Issue S 01

Event/congress	33rd Annual Meeting North American Skull Base Society, Atlanta Marriott Marquis Atlanta, Georgia, United States, 2024-02-16
Language	English
Publishing date	2024-02-01
Publisher	Georg Thieme Verlag KG
Publishing place	Stuttgart ; New York
Document type	Article ; Conference proceedings
ZDB-ID	2654269-9
ISSN	2193-634X ; 2193-6331
ISSN (online)	2193-634X
ISSN	2193-6331
DOI	10.1055/s-0044-1780392
Database	Thieme publisher's database

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Article ; Conference proceedings: Mixed Reality in the Surgical Management of Brain Arteriovenous Malformations

Najera, Edinson / Lockard, Gavin / Saez-Alegre, Miguel / Piper, Keaton / Jean, Walter C

Journal of Neurological Surgery Part B: Skull Base

2024 Volume 85, Issue S 01

Event/congress	33rd Annual Meeting North American Skull Base Society, Atlanta Marriott Marquis Atlanta, Georgia, United States, 2024-02-16
Language	English
Publishing date	2024-02-01
Publisher	Georg Thieme Verlag KG
Publishing place	Stuttgart ; New York
Document type	Article ; Conference proceedings
ZDB-ID	2654269-9
ISSN	2193-634X ; 2193-6331
ISSN (online)	2193-634X
ISSN	2193-6331
DOI	10.1055/s-0044-1779822
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Article ; Online: The TIGR triangle of the pineal region: a virtual reality anatomic study.

Saez-Alegre, Miguel / Rios-Vicil, Christian I / Alvarez, Ana Sofia / Sagrati, John / Piper, Keaton / Jean, Walter C

Acta neurochirurgica

2023 Volume 165, Issue 12, Page(s) 4083–4091

Abstract: Background: In this morphometric study, we describe the anatomy of the TIGR triangle, which is bordered by the tentorial surface of the cerebellum, the internal cerebral vein and vein of Galen complex, and the vein of Rosenthal. These structures define ... ...

Abstract	Background: In this morphometric study, we describe the anatomy of the TIGR triangle, which is bordered by the tentorial surface of the cerebellum, the internal cerebral vein and vein of Galen complex, and the vein of Rosenthal. These structures define the window, or deep keyhole, to access the pineal region in non-midline supracerebellar infratentorial approaches. Methods: The posterior fossa anatomy of 16 patients was studied in virtual reality (VR), and the TIGR triangles were defined and measured with special attention on its angular orientation in the posterior fossa. The angular expanse of the posterior fossa was measured and recorded as the transverse-sigmoid junction (TSJ) angle. Because a perpendicular corridor through an anatomic aperture provides the best exposure, we studied the starting point along the TSJ angle that offers the best exposure of TIGR. Results: In the 31 posterior fossa sides included in the study, the perpendicular trajectory through the TIGR triangle was on average 27.13° CI 95% (range: 5.97°-48.53°) from the midline. When comparing the SCIT variants, both the paramedian and lateral approaches provided near-perpendicular trajectory through the TIGR triangle in a majority of specimens. However, the modified paramedian approach, with starting point defined as TSJ angle/3, provided the most perpendicular path through the TIGR triangle. Conclusion: We studied the size, spatial orientation, and morphology of the TIGR triangle. Our data indicated that the best exposure of TIGR is through a modified paramedian SCIT approach, in which the starting point one third of the way from midline to the TSJ.
MeSH term(s)	Humans ; Craniotomy ; Pineal Gland/surgery ; Cerebellum/surgery ; Cerebellum/anatomy & histology ; Dura Mater
Language	English
Publishing date	2023-11-14
Publishing country	Austria
Document type	Journal Article
ZDB-ID	80010-7
ISSN	0942-0940 ; 0001-6268
ISSN (online)	0942-0940
ISSN	0001-6268
DOI	10.1007/s00701-023-05880-4
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Article ; Conference proceedings: New Approach—Biportal Endoscopic Transfrontal Sinus Approach: A Novel Minimally Invasive Approach to the Anterior Cranial Fossa: Cadaveric Feasibility Study

Saez-Alegre, Miguel / Jean, Walter C. / Neto, Carlos D. Pinheiro / Morshed, Ramin A. / Link, Michael J. / Van Gompel, Jamie J. / Peris-Celda, Maria

Journal of Neurological Surgery Part B: Skull Base

2024 Volume 85, Issue S 01

Event/congress	33rd Annual Meeting North American Skull Base Society, Atlanta Marriott Marquis Atlanta, Georgia, United States, 2024-02-16
Language	English
Publishing date	2024-02-01
Publisher	Georg Thieme Verlag KG
Publishing place	Stuttgart ; New York
Document type	Article ; Conference proceedings
ZDB-ID	2654269-9
ISSN	2193-634X ; 2193-6331
ISSN (online)	2193-634X
ISSN	2193-6331
DOI	10.1055/s-0044-1780189
Database	Thieme publisher's database

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