Neurological Surgery最新文献

Moyamoya disease is characterized by stenosis of the terminal region of the internal carotid artery and the development of collateral blood vessels with a smoke-like appearance. It causes cerebral infarction and hemorrhage. However, the occurrence of cognitive impairment in patients with moyamoya disease has been insufficiently addressed. Many patients with moyamoya disease experience difficulties in social life, such as schooling and employment, due to cognitive impairment. This article describes the current cognitive impairment status in patients with moyamoya disease, focusing on the COSMO-Japan Study, a multicenter study on patients with moyamoya disease.

Three-dimensional multi-fusion image (3DMFI) is a preoperative 3D model that depicts the detailed anatomical structure, such as vascular, tumor, bone and brain surface, using 3D rotation angiography, 3 Tesla magnetic resonance imaging, and computed tomography. Interactive virtual simulation (IVS) with a pen-type haptic device using 3DMFI is a useful tool to predict intraoperative structures and understand surgical strategies. Precise and safe intraoperative decision could be supported by 3DMFI and multiple surgical instruments. Besides 3DMFI, integrated operation image system provides the chronological information peri- and postoperatively in detail. Here, we introduce the practical method and illustrative cases in our institution.

Augmented reality (AR) and virtual reality (VR) technologies have been rapidly developing and are widely used. They have also been applied in the field of neurosurgery through the use of various devices. Integration with microsurgery, initially introduced as an extension of surgical navigation, may be the most widespread AR technology at present. Tablet devices, smart glasses, and 3D printers can all be used for surgical assistance or training. Although these devices still have some issues associated with imaging, registration error, brain shift, costs, and human resources, they are expected to improve the accuracy and safety of neurosurgery.

The exoscope, proposed by Gildenberg et al. in 1994, was developed as a new surgical assistive technology that differed from conventional microscopic surgeries. However, no significant progress has been made in this regard over the past decade. In 2008, a high-definition exoscope (HDXO-SCOPE) system developed by Mamelak et al. achieved a focal length of approximately 200 mm with an accuracy comparable to that of an operating microscope. This camera, commercialized as VITOM^® (Karl Storz) was smaller than an operating microscope but had a wider field of view. Furthermore, the VITOM^® was later adapted to three-dimensional imaging, providing an experience similar to microsurgery. The ORBEYE^® (Olympus), on the other hand, was developed as an alternative to the operating microscope and provided a three-dimensional field of view with a focal length of 220 to 550 mm. The most significant advantage of the exoscope is the increased freedom of surgical positioning. Conventional microscopes restrict the surgical approach and surgeons' physical position when conducting surgery, which can be problematic. On the other hand, the exoscope reduces burden on the arms and body and allows for more precise surgery. The exoscope is especially useful in surgeries of posterior cranial fossa, and surgeries on elderly patients. The use of an exoscope also allows greater flexibility when conducting surgery of midbrain lesions. In general, exoscopes are good alternatives to microscopes for brain tumor surgery; however, the current technology should be further improved. Exoscopes are expected to ultimately surpass surgical microscopes in the future leading to their adoption in an increasing number of surgeries.

In neuroendovascular surgery, operators must manipulate devices, such as microcatheters and guidewires, with millimeter precision while simultaneously monitoring multiple areas across up to four radiography monitors. Although both operators and assistants maintain careful observation, any oversight can lead to serious complications. To address this challenge, we have developed a real-time assistance system using artificial intelligence (AI). This paper discusses the practical experience, current challenges, and future prospects of the intraoperative real-time AI assistance system implemented in Japan.

In recent years, advancements in intraoperative imaging technology, surgical visualization systems, Artificial Intelligence (AI), and robotic-assisted technologies have significantly improved the precision, safety, and postoperative outcomes of neurosurgical procedures. Surgical simulation contributes to optimizing preoperative planning and enhancing the skills of young surgeons, while navigation technologies, utilizing optical or magnetic systems, enhance the accuracy of tumor resection. Intraoperative MRI and CT provide real-time assessment of residual tumors and vascular structures, and the integration of AI allows high-resolution imaging even with low-field MRI systems. Neuroendoscopes and exoscopes equipped with 4K resolution or 3D technology have improved visual precision, while AI aids in tumor boundary identification and postoperative outcome prediction. The integration of robotic technology further enhances surgical accuracy. However, challenges remain, including high implementation costs, inadequate reimbursement systems, insufficient evidence, and a lack of standardized operational guidelines. Integrating and standardizing these technologies will enhance surgical safety, precision, and efficiency, improve patient outcomes, and optimize healthcare workflows, necessitating policy reforms and robust evidence-based frameworks.

Japan's healthcare system is undergoing significant transformations, driven by demographic shifts, with critical challenges anticipated in 2025 and 2040. The Ministry of Health, Labor, and Welfare is promoting regional medical care vision plans to restructure healthcare delivery across different administrative levels, addressing evolving medical demands and population changes. However, the implementation of these plans has been uneven, with many regions focusing primarily on reducing hospital beds rather than on effectively redistributing medical roles and functions. Time constraints have hindered meaningful discussions regarding comprehensive healthcare restructuring. The text illustrates these challenges through two case studies in the Fukuoka Prefecture: Fukuoka-Itoshima and Keichiku areas. These regions demonstrate contrasting demographic trajectories with significantly aging and declining working-age populations. Notably, the Fukuoka-Itoshima area anticipates a substantial increase in cerebrovascular disease hospitalizations, whereas Keichiku expects moderate changes. This analysis suggests that future neurosurgeons must be adaptable professionals capable of navigating clinical, management, and policy domains. By 2040, they should proactively develop strategies to address demographic changes and involve current medical trainees and students in strategic planning of the healthcare landscape.

Subdural electrode (SDE) implantation and stereotactic electroencephalography (SEEG) represent two primary invasive monitoring techniques employed in epilepsy surgery. In North America, the advent of commercially available surgical robotic systems has initiated a paradigm shift from SDE to SEEG implantation. Advances in robotic technology have enabled the precise and efficient placement of depth electrodes for SEEG. In Japan, robot-assisted stereotactic electrode placement has been covered by National Health Insurance since 2020, further promoting its adoption. SEEG relies exclusively on intracerebral depth electrodes, which are stereographically inserted through twist drill holes or burr holes, eliminating the need for craniotomy-a requirement for SDE implantation. The planning of electrode trajectories is critical and must be meticulously performed using three-dimensional gadolinium-enhanced magnetic resonance imaging datasets to avoid vascular structures. Unlike SDE, SEEG allows for accurate sampling of cortical areas at the surface of hemispheres and bottom of sulci and deep-seated structures, such as the insular cortex, cingulate gyrus, and medial temporal lobes. This section provides a comprehensive overview of the indications for SEEG, the method of electrode implantation using robotic systems, the advantages of SEEG over other monitoring techniques, and its associated risks.

Future operating rooms (ORs) should integrate cutting-edge technologies to address the limitations of traditional surgical environments. Leveraging intraoperative imaging, the Internet of Things, and artificial intelligence enables real-time data integration, precise decision-making, and improved surgical outcomes. This approach transforms implicit knowledge into structured and actionable insights, thereby enhancing efficiency. Technologies, such as intraoperative magnetic resonance imaging, hybrid ORs, and surgical robots offer advanced capabilities, reduce complications, and standardize surgical performance. Remote surgery and telemonitoring extend expert care to underserved regions, addressing geographical disparities. However, challenges such as high implementation costs, data security, and standardization, persist. International efforts, such as OPeLiNK, aim to standardize data protocols and interoperability. Future ORs are envisioned as dynamic and intelligent environments that can adapt to complex needs, ensuring enhanced patient safety, clinical outcomes, and equitable healthcare delivery.

The implementation of standardized prehospital stroke assessments, transport decision-making, and treatment is crucial for optimizing acute stroke care. This includes the efficient utilization of intravenous thrombolysis for acute ischemic stroke and mechanical thrombectomy for acute large-vessel occlusion (LVO). In the existing acute stroke care system, it is imperative to promptly recognize a stroke, gather essential information, select an appropriate hospital with the necessary capabilities, and establish a rapid transport pathway. The Japan Stroke Association has designated primary stroke centers for intravenous thrombolysis and mechanical thrombectomy, making this information accessible to both the general public and healthcare professionals. Additionally, the JSS/JAAM standard LVO Scale, comprising six items, could be the preferred scale for predicting LVO in Japan, with efforts underway to address various challenges associated with its clinical application.