2-1-2 Stroke microsurgical thrombectomy technique as a tertiary/salvage treatment option.

BACKGROUND: Microsurgical thrombectomy (MST) has been used for many years in few stroke cases without any prospective randomized study, nor detailed systemized technique description. As many centers worldwide are recruited for stroke thrombectomy availability, MST might increase in the near future either as a tertiary or salvage treatment option. A straightforward surgical plan is mandatory empowering a safe, efficient, and rapid neurosurgical operation, so our aim is to describe the 2-1-2 microsurgical technique. METHODS: Three patients presented at emergency department with large stroke not suitable to venous thrombolysis and/or mechanical thrombectomy due to late arrival time and endovascular suite technical problems. They were referred to 2-1-2 MST after imaging showed brain collaterals on head angio-CT scan and ASPECTS greater than 6 points. The procedure comprised 2 insulin needle punctures in the target artery, 1mm micro-scissor transverse arteriotomy, milk thrombus removal and 2 simple sutures micro stitches. Sixty days clinical follow-up and brain imaging control provided data results. RESULTS: All patients treated with 2-1-2 MST technique had complete thrombus removal by precise surgical maneuvers avoiding surgeons unplanned and insecure movements to reduced operation time. Head angio-CT scan evidenced complete cerebrovascular circulation re-flow with clinical improvements in 60 days follow-up without complications or hospital readmissions. CONCLUSIONS: 2-1-2 MST technique can be rapidly and efficaciously performed in a systemized manner offering a tertiary or salvage technique for acute stroke treatment. Specific microsurgical training is mandatory to accomplish this treatment and larger studies are necessary to confirm our hypothesis.

The Fluorescent Patient: An Unusual Effect of Fluorescein Angiography.

Although fluorescein is widely used for intraoperative angiography, some of its side effects remain obscure. In this report, we present the case of a 41-year-old patient with chronic ischemia caused by moyamoya syndrome who underwent bypass revascularization with intraoperative fluorescein angiography (FA). Immediately after the surgery, the patient presented homogeneous fluorescence of the entire skin. We discuss this curious phenomenon as well as other side effects that may arise due to FA.

Superficial Temporal Artery-Middle Cerebral Artery Bypass Ex Vivo Hybrid Simulator: Face, Content, Construct, and Concurrent Validity.

BACKGROUND: Cerebrovascular bypass surgical procedures require highly developed dexterity and refined bimanual technical skills. To attain such a level of prowess, neurosurgeons and residents have traditionally relied on "flat" models (without depth of field), such as chicken wings, live rats, silicone vessels, and other materials that stray far from the reality of the operating room, albeit more accessible. We have explored the use of a hybrid ex vivo simulator that takes advantage of the availability of placenta vessels and retains the complexity of surgery performed on a human skull to create a more realistic method for the development of cerebrovascular bypass surgical skills. METHODS: Twelve ex vivo simulators were constructed using 3 human placentas and 1 synthetic human skull for each. Face, content, construct, and concurrent validity were assessed by 12 neurosurgeons (6 trained vascular surgeons and 6 general neurosurgeons) and compared with those of other bypass models. RESULTS: The fidelity grade was ranked as low (Linkert scale score, 1-2), medium (score, 3), and high (score, 4-5). The face and content validity of the model showed high fidelity to superficial temporal artery-middle cerebral artery bypass surgery. Construct validity showed that cerebrovascular neurosurgeons had better performance, and concurrent validity highlighted that all surgical steps were present. CONCLUSION: The simulator was found to have strong face and content, construct, and concurrent validity for microsurgical cerebrovascular training, allowing for simulation of all surgical steps of the bypass procedure. The hybrid simulator seems to be a promising method for shortening the bypass surgery learning curve. However, more studies are required to evaluate the predictive validity of the model.