Creating a Comprehensive Research Platform for Surgical Technique and Operative Outcome in Primary Brain Tumor Neurosurgery

World Neurosurg. 2020 Dec;144:e62-e71. doi: 10.1016/j.wneu.2020.07.209. Epub 2020 Aug 3.

Abstract

Background: The operative environment poses many challenges to studying the relationship between surgical acts and patient outcomes in intracranial oncological neurosurgery. We sought to develop a framework in which neurosurgical performance and extent of resection could be precisely quantified in a controlled setting.

Methods: The stiffness of an alginate hydrogel-based tumor was modified with differing concentrations of the cross-linking agent calcium sulfate until biomechanical properties similar to those of human primary brain tumors measured at resection were achieved. The artificial tumor was subsequently incorporated into an ex-vivo animal brain as a final model. Magnetic resonance imaging enhancement and ultraviolet fluorescence was achieved by incorporating gadolinium and fluorescein solution, respectively. Video recordings from the operative microscope, ceiling cameras, and instrument-mounted fiducial markers within a surgical suite environment captured operative performance.

Results: A total of 24 rheometer measurements were conducted on alginate hydrogels containing 10-, 11-, and 12-mM concentrations of calcium sulfate. Sixty-eight stiffness measurements were conducted on eight patient tumor samples. No differences were found between the alginate and brain tumor stiffness values [Kruskal-Wallis χ2(4) = 9.187; P = 0.057]. Tumor was identified using ultraviolet fluorescence and ultrasonography. The volume and location of the resected white and gray matter and residual tumor could be quantified in 0.003-mm3 increments using a 7T magnetic resonance imaging coil. Ultrasonic aspirator and bipolar electrocautery movement data were successfully transformed into performance metrics.

Conclusion: The developed framework can offer clinicians, learners, and researchers the ability to perform operative rehearsal, teaching, and studies involving brain tumor surgery in a controlled laboratory environment and represents a crucial step in the understanding and training of expertise in neurosurgery.

Keywords: Alginate; Assessment; Brain neoplasm; Hydrogel; Imaging; Simulation.

MeSH terms

  • Alginates
  • Animals
  • Biomechanical Phenomena
  • Brain Neoplasms / diagnostic imaging
  • Brain Neoplasms / surgery*
  • Calcium Sulfate
  • Cattle
  • Computer Simulation
  • Cross-Linking Reagents
  • Fluorescence
  • Humans
  • Hydrogels
  • Magnetic Resonance Imaging
  • Models, Anatomic
  • Neurosurgical Procedures / methods*
  • Research Design*
  • Treatment Outcome
  • Ultrasonography
  • Video Recording

Substances

  • Alginates
  • Cross-Linking Reagents
  • Hydrogels
  • Calcium Sulfate