Turcotte, Evelyn

Abstract Background and aims A substantial proportion of large vessel strokes remain untreated worldwide due to limited access to specialized neuroendovascular care. Remote robotic neuroendovascular thrombectomy performed by expert interventionalists from a distant hub has been proposed as one solution to address these disparities. In this study, we test the feasibility of remote robotic thrombectomy in a live animal model. Methods Two live porcine experiments were conducted, involving Mayo Clinic Arizona (MCA), University Hospital Zurich (USZ), and Inselspital—Bern University Hospital (USB), Switzerland. Aspiration thrombectomy at USB was performed remotely from USZ (regional hub, 95 km; two experiments) and MCA (international hub, one experiment). Five aspiration thrombectomies were completed using a proprietary robotic magnetic navigation system consisting of a mobile magnetic field generator, a three-axis robotic advancer, controlling an 80 cm 6f sheath, a 6f aspiration catheter and a 0.035″ magnetically trackable guidewire, and a teleoperated console. The primary endpoint was the feasibility of successful clot aspiration using the robotic magnetic navigation system. Results Five out of seven thrombectomy procedures were successfully completed, achieving full clot retrieval. In the remaining two procedures, more distal clots were targeted, which could not be reached due to the limited catheter length. Magnetic navigation was successful in all cases. Image quality was excellent to acceptable. Conclusions Remote robotic thrombectomy using robotic magnetic navigation technology is technically feasible over both regional and transcontinental distances. This first-in-vivo regional and transatlantic study establishes a potential model of stroke intervention that may one day bridge access to endovascular stroke treatment. Conflict of interest Patrick Thurner and Tilman Schubert have consulting agreements with Nanoflex Robotics.

Cavernomas at the posterolateral pontomesencephalic surface can be approached from a lateral infratentorial supracerebellar corridor. In this surgical video, we demonstrate two cases of brainstem cavernomas resected through a lateral supracerebellar infratentorial approach. A supine position with lateral turn of the head was used along with significant reverse Trendelenburg to allow the cerebellum to fall away with gravity from the tentorium. After exposure of the posterior surface of the brainstem between the tentorium and the superior cerebellar surface with aid of neuronavigation, the cavernomas were safely resected. The video can be found here: https://youtu.be/fUDdaprg26Y .

Abstract This is the case of an 86-yr-old gentleman who presented with left facial pain exacerbated by eating, drinking, chewing, and shaving (distribution: V2, V3). The patient was diagnosed with trigeminal neuralgia and was refractory to medications. Imaging showed a superior cerebellar artery (SCA) loop adjacent to the trigeminal nerve root entry zone and a decision to perform a microvascular decompression of the fifth nerve was presented to the patient. After patient informed consent was obtained, a standard 3 cm × 3 cm retrosigmoid craniotomy was performed with the patient in a supine head turned position and in reverse Trendelenburg. The arachnoid bands tethering the SCA to the trigeminal nerve were sharply divided. A slit was then made in the tentorium and a 3 mm fenestrated clip was then used to secure the transposed SCA away from the trigeminal nerve. The SCA proximal to this was slightly patulous in its course so a small amount of a fibrin glue was also used to secure the more proximal SCA to the tentorium. The patient was symptom-free postoperatively and no longer required medical therapy. Additionally, imaging was consistent with adequate separation of the nerve from adjacent vessels. 1-5