Cadmore media player playing video Intraoperative use of heads-up display in skull base surgery
Video Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the video. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Language
1x
Play Speed
Adjust Volume
Transcript
Search
Result Count
of
Click to jump to result
Search
Re-center
Segments
Result Count
of
Click to jump to result
Search
Name:
Intraoperative use of heads-up display in skull base surgery
Description:
Intraoperative use of heads-up display in skull base surgery
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/87962c61-281d-403a-b50a-8599b8a0d4a6/videoscrubberimages/Scrubber_181.jpg
Duration:
T00H09M37S
Embed URL:
https://stream.cadmore.media/player/87962c61-281d-403a-b50a-8599b8a0d4a6
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/87962c61-281d-403a-b50a-8599b8a0d4a6/21-177.mp4?sv=2019-02-02&sr=c&sig=T8%2B1L%2FRH6OucRTp7YFfgXO%2B9jXJYr5yqoEckH0zIqKM%3D&st=2025-01-22T04%3A06%3A53Z&se=2025-01-22T06%3A11%3A53Z&sp=r
Upload Date:
2021-11-19T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: We present the case of a 45-year-old woman with a right glenoid meningioma diagnosed incidentally after a head trauma. Her neurological exam was normal at the time of presentation. The tumor was extending from the parasellar and sellar regions to the middle and posterior fossa. A CTA was obtained to further characterize the intracranial arteries encased and displaced by the tumor. A preoperative angiogram was conducted 2 days before surgery to devascularize the lesion and reduce intraoperative blood loss.
SPEAKER: The inferolateral and meningohypophyseal trunks were coiled, resulting in a reduction of tumor blush. Note the fetal origin of the right posterior cerebral artery. After the procedure, the patient experienced a right partial third nerve palsy. Three-dimensional simulation allows neurosurgeons in training to explore the different operative angles as well as to plan the bone opening while using the virtual reality goggles.
SPEAKER: Here, we can see in close detail how the tumor was encasing the internal carotid artery terminus, the origin of the anterior and middle cerebral arteries, as well as the posterior communicating and anterior choroidal arteries. The basilar and superior cerebellar arteries were in close contact with the posterior medial aspect of the tumor and laterally displaced. This 3D virtual model of the patient's specific anatomy can also be integrated with the navigation information intraoperatively to assist during a surgical resection.
SPEAKER: The images of the CT angiography and MRI DICOM series were fused to coregister scans for preoperative planning and intraoperative navigation. Preoperative planning software allows for segmentation and 3D reconstruction of the tumor and critical neurovascular structures using the Smartbrush tool on the MRI or CT imaging. The segmented neurovascular objects can be highlighted in specific colors.
SPEAKER: Here, among others, we have segmented the tumor in purple, the internal carotid and the middle cerebral arteries in pink, the posterior communicating artery in blue, optic nerves in yellow, and the brainstem in green. This information can then be registered via navigation and displayed in the eyepiece of the microscope in an augmented reality fashion to optimize surgery workflow and avoid having to redirect attention to the navigation screen.
SPEAKER: The objects can be turned on and off during surgery to draw attention to specific structures intraoperatively and also limit attention blindness. The heads-up display has potential value during multiple stages of surgery from as early as planning the skin incision to craniotomy design or dural opening. The microscope can be brought to the field to superimpose the tumor object over the patient's anatomy and confirm appropriate size of the pterional craniotomy.
SPEAKER: The dura was opened in a C- shape and reflected anteriorly. When opening the basal cisterns, special care must be taken to identify and preserve the superomedially displaced optic nerve, which can be seen outlined in yellow in the heads-up display before it becomes visible. While we continue to split the sylvian fissure and advance in the subarachnoid dissection to access the tumor, we have changed the heads-up display visualization from 3D to 2D.
SPEAKER: The augmented reality can be seen as distracting and interferes with a visualization of the surgical field. However, over time and with practice, the optimized number of segmented structures can easily be integrated with anatomic visual information. Here, we have specifically outlined the optic nerves, the internal carotid arteries, the middle cerebral artery branches, and the tumor.
SPEAKER: We start by carefully dissecting the tumor away from the branches of the middle cerebral artery. There is a superior and posterior offset of the heads-up display relatively to the patient's anatomy. The current software allows us to update the heads-up display information intraoperatively. But given that, in this case, there is just 1 or 2 mm of difference, it is not necessary to adjust it.
SPEAKER: Note that the solid lines represent the portions of the middle cerebral artery with the current focal depth of the microscope, whereas the portions in the deeper plane are outlined in dots. By confirming that the objects displayed correspond with the patient's anatomy, we have confidence that the information provided by the heads-up display is accurate.
SPEAKER: After careful retraction of the frontal lobe, we visualize the lenticulostriate arteries, which limit access to the medial aspect of the tumor. Therefore, attention is taken to approach the tumor in its most anterolateral aspect. At this point, a cortical grid was placed over the motor cortex to obtain continuous monitoring from the left side of the body. Transcranial motor and somatosensory evoked potentials were also monitored bilaterally since the beginning of the surgery.
SPEAKER: After gaining inferior access to the most anterolateral aspect of the tumor, we dissect the tumor away from the middle cranial fossa floor. Here again, the solid line represent the portion of the tumor with the same focal depth of the microscope, whereas the tumor that is deeper to the plane of dissection is outlined in dots, providing constant awareness on how much further we have to go, continue this part of the dissection.
SPEAKER: The SONOPET is combined here with a bipolar to facilitate tumor debulking. We can see how this part of the tumor is relatively avascular thanks to the preoperative embolization. The anterolateral aspect of the tumor has been debulked. And now we're progressing the dissection toward the superior posterior aspect and delivering it anteriorly into the expanded sylvian fissure.
SPEAKER: Again, we use our bipolar to dissect the tumor capsule and ultimately the SONOPET to debulk the tumor. Here we take advantage of the heads-up display to early identify the internal carotid artery on the left side of the surgical field. In addition, given that the lateral aspect of the tumor is underneath the temporal lobe, the heads-up display is also helpful to provide awareness of the lateral border of the tumor.
SPEAKER: Here we see the origin of the posterior communicating artery entering into the tumor. Just distal to the posterior communicating artery, it is the origin of the anterior choroidal artery medial to the suction tip. Those arteries are protected with a cottonoid, and further work is done on the tumor lateral to them. At this point, it is necessary to identify the posterior communicating and the interior choroidal arteries as they exit the tumor posteriorly.
SPEAKER: The heads-up display, here outlined in blue, is critical in order to provide situational awareness for the surgeon to identify these structures before seeing them with the microscope. This moment is one of the most important of the case, since it is essential to preserve these arteries given the crucial anatomical brain areas they supply and the fetal origin of the right posterior cerebral artery.
SPEAKER: We confirm the patency of the vessels using the Doppler. After confirming the vessels, just as we did anteriorly, we'll now focus the remainder of the resection lateral to those vessels. Here, we identify the superior cerebellar artery in the perimesencephalic cistern medial and beneath the tentorium. This demonstrates, again, the efficacy of the preoperative embolization in creating relatively avascular tumor tissue.
SPEAKER: The consistency of this portion of the tumor is, however, more fibrotic than its most anterior aspect, and the use of the bipolar is needed to coagulate and detach tumor pieces. Here, we can see the fourth nerve in the ambient cistern just beneath the free edge of the tentorium. With the superior cerebellar artery now protected underneath a cottonoid, we can see here branches of the anterior inferior cerebellar artery.
SPEAKER: Over the left, we can see how the posterior cerebral artery correlates with the integrated navigation screen with the microscope trajectory in blue. By following the dissection medially and inferiorly to the posterior cerebral artery, we identify the basilar artery and dissect it from the tumor. In this final stage of the surgery, we're decompressing the brainstem by removing the last portion of the tumor in the posterior fossa accessible through this approach.
SPEAKER: We can see in the heads-up display how the posterior communicating artery delineates the medial limit of our tumor resection. Endoscope-assisted microsurgery complements traditional microsurgery in the management of complex skull base tumors. The ability to attach the endoscope to the microscope makes easier to combine both techniques.
SPEAKER: In this endoscopic view of the posterior fossa, we can see the preserved fourth nerve underneath the tentorium with some expected residual tumor. The postoperative MRI demonstrated decompression of the brainstem with expected residual tumor medial to the posterior communicating and lenticulostriate arteries. No new neurological deficits were noted after the surgical procedure.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: We present the case of a 45-year-old woman with a right glenoid meningioma diagnosed incidentally after a head trauma. Her neurological exam was normal at the time of presentation. The tumor was extending from the parasellar and sellar regions to the middle and posterior fossa. A CTA was obtained to further characterize the intracranial arteries encased and displaced by the tumor. A preoperative angiogram was conducted 2 days before surgery to devascularize the lesion and reduce intraoperative blood loss.
SPEAKER: The inferolateral and meningohypophyseal trunks were coiled, resulting in a reduction of tumor blush. Note the fetal origin of the right posterior cerebral artery. After the procedure, the patient experienced a right partial third nerve palsy. Three-dimensional simulation allows neurosurgeons in training to explore the different operative angles as well as to plan the bone opening while using the virtual reality goggles.
SPEAKER: Here, we can see in close detail how the tumor was encasing the internal carotid artery terminus, the origin of the anterior and middle cerebral arteries, as well as the posterior communicating and anterior choroidal arteries. The basilar and superior cerebellar arteries were in close contact with the posterior medial aspect of the tumor and laterally displaced. This 3D virtual model of the patient's specific anatomy can also be integrated with the navigation information intraoperatively to assist during a surgical resection.
SPEAKER: The images of the CT angiography and MRI DICOM series were fused to coregister scans for preoperative planning and intraoperative navigation. Preoperative planning software allows for segmentation and 3D reconstruction of the tumor and critical neurovascular structures using the Smartbrush tool on the MRI or CT imaging. The segmented neurovascular objects can be highlighted in specific colors.
SPEAKER: Here, among others, we have segmented the tumor in purple, the internal carotid and the middle cerebral arteries in pink, the posterior communicating artery in blue, optic nerves in yellow, and the brainstem in green. This information can then be registered via navigation and displayed in the eyepiece of the microscope in an augmented reality fashion to optimize surgery workflow and avoid having to redirect attention to the navigation screen.
SPEAKER: The objects can be turned on and off during surgery to draw attention to specific structures intraoperatively and also limit attention blindness. The heads-up display has potential value during multiple stages of surgery from as early as planning the skin incision to craniotomy design or dural opening. The microscope can be brought to the field to superimpose the tumor object over the patient's anatomy and confirm appropriate size of the pterional craniotomy.
SPEAKER: The dura was opened in a C- shape and reflected anteriorly. When opening the basal cisterns, special care must be taken to identify and preserve the superomedially displaced optic nerve, which can be seen outlined in yellow in the heads-up display before it becomes visible. While we continue to split the sylvian fissure and advance in the subarachnoid dissection to access the tumor, we have changed the heads-up display visualization from 3D to 2D.
SPEAKER: The augmented reality can be seen as distracting and interferes with a visualization of the surgical field. However, over time and with practice, the optimized number of segmented structures can easily be integrated with anatomic visual information. Here, we have specifically outlined the optic nerves, the internal carotid arteries, the middle cerebral artery branches, and the tumor.
SPEAKER: We start by carefully dissecting the tumor away from the branches of the middle cerebral artery. There is a superior and posterior offset of the heads-up display relatively to the patient's anatomy. The current software allows us to update the heads-up display information intraoperatively. But given that, in this case, there is just 1 or 2 mm of difference, it is not necessary to adjust it.
SPEAKER: Note that the solid lines represent the portions of the middle cerebral artery with the current focal depth of the microscope, whereas the portions in the deeper plane are outlined in dots. By confirming that the objects displayed correspond with the patient's anatomy, we have confidence that the information provided by the heads-up display is accurate.
SPEAKER: After careful retraction of the frontal lobe, we visualize the lenticulostriate arteries, which limit access to the medial aspect of the tumor. Therefore, attention is taken to approach the tumor in its most anterolateral aspect. At this point, a cortical grid was placed over the motor cortex to obtain continuous monitoring from the left side of the body. Transcranial motor and somatosensory evoked potentials were also monitored bilaterally since the beginning of the surgery.
SPEAKER: After gaining inferior access to the most anterolateral aspect of the tumor, we dissect the tumor away from the middle cranial fossa floor. Here again, the solid line represent the portion of the tumor with the same focal depth of the microscope, whereas the tumor that is deeper to the plane of dissection is outlined in dots, providing constant awareness on how much further we have to go, continue this part of the dissection.
SPEAKER: The SONOPET is combined here with a bipolar to facilitate tumor debulking. We can see how this part of the tumor is relatively avascular thanks to the preoperative embolization. The anterolateral aspect of the tumor has been debulked. And now we're progressing the dissection toward the superior posterior aspect and delivering it anteriorly into the expanded sylvian fissure.
SPEAKER: Again, we use our bipolar to dissect the tumor capsule and ultimately the SONOPET to debulk the tumor. Here we take advantage of the heads-up display to early identify the internal carotid artery on the left side of the surgical field. In addition, given that the lateral aspect of the tumor is underneath the temporal lobe, the heads-up display is also helpful to provide awareness of the lateral border of the tumor.
SPEAKER: Here we see the origin of the posterior communicating artery entering into the tumor. Just distal to the posterior communicating artery, it is the origin of the anterior choroidal artery medial to the suction tip. Those arteries are protected with a cottonoid, and further work is done on the tumor lateral to them. At this point, it is necessary to identify the posterior communicating and the interior choroidal arteries as they exit the tumor posteriorly.
SPEAKER: The heads-up display, here outlined in blue, is critical in order to provide situational awareness for the surgeon to identify these structures before seeing them with the microscope. This moment is one of the most important of the case, since it is essential to preserve these arteries given the crucial anatomical brain areas they supply and the fetal origin of the right posterior cerebral artery.
SPEAKER: We confirm the patency of the vessels using the Doppler. After confirming the vessels, just as we did anteriorly, we'll now focus the remainder of the resection lateral to those vessels. Here, we identify the superior cerebellar artery in the perimesencephalic cistern medial and beneath the tentorium. This demonstrates, again, the efficacy of the preoperative embolization in creating relatively avascular tumor tissue.
SPEAKER: The consistency of this portion of the tumor is, however, more fibrotic than its most anterior aspect, and the use of the bipolar is needed to coagulate and detach tumor pieces. Here, we can see the fourth nerve in the ambient cistern just beneath the free edge of the tentorium. With the superior cerebellar artery now protected underneath a cottonoid, we can see here branches of the anterior inferior cerebellar artery.
SPEAKER: Over the left, we can see how the posterior cerebral artery correlates with the integrated navigation screen with the microscope trajectory in blue. By following the dissection medially and inferiorly to the posterior cerebral artery, we identify the basilar artery and dissect it from the tumor. In this final stage of the surgery, we're decompressing the brainstem by removing the last portion of the tumor in the posterior fossa accessible through this approach.
SPEAKER: We can see in the heads-up display how the posterior communicating artery delineates the medial limit of our tumor resection. Endoscope-assisted microsurgery complements traditional microsurgery in the management of complex skull base tumors. The ability to attach the endoscope to the microscope makes easier to combine both techniques.
SPEAKER: In this endoscopic view of the posterior fossa, we can see the preserved fourth nerve underneath the tentorium with some expected residual tumor. The postoperative MRI demonstrated decompression of the brainstem with expected residual tumor medial to the posterior communicating and lenticulostriate arteries. No new neurological deficits were noted after the surgical procedure.
Form Title Download
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode