Effects of anodal stimulation and motor practice on limb-kinetic apraxia in Parkinson's disease.

Limb-kinetic apraxia, the loss of the ability to make precise, independent but coordinated finger and hand movements affects quality of life in patients with Parkinson's disease. We aimed to examine the effects of anodal transcranial direct current stimulation of the left posterior parietal cortex and upper extremity motor practice on limb-kinetic apraxia in Parkinson's disease. This study was conducted in a randomized, double-blind, sham-controlled fashion. Patients confirmed to have Parkinson's disease were recruited. Twenty-eight participants completed the study and were randomized to two groups: anodal or sham stimulation. For participants assigned to active stimulation, anodal stimulation of the left posterior parietal cortex was performed using 2 mA current for 20 min. Patients received anodal or sham stimulation, followed by motor practice in both groups. The primary outcome measure was time-performing sequential buttoning and unbuttoning, and several secondary outcome measures were obtained. A statistically significant interaction between stimulation type and timepoint on time taken to perform buttoning and unbuttoning was found. Patients who received anodal stimulation were found to have a significant decrease in sequential buttoning and unbuttoning time immediately following stimulation and at 24 h in the medication-ON state, compared to the medication-OFF state (31% and 29% decrease, respectively). Anodal stimulation of the left posterior parietal cortex prior to motor practice appears to be effective for limb-kinetic apraxia in Parkinson's disease. Future long-term, multi-session studies looking at the long-term effects of anodal stimulation and motor practice on limb-kinetic apraxia in Parkinson's disease may be worthwhile.

Dose-Dependent Cytotoxicity of Gold Nanoparticles on Human Neural Progenitor Cells and Rat Brain.

Gold nanoparticles (GNPs) are utilized as diagnostic and therapeutic tools to detect and treat human disease. Researchers in the field of nanotoxicity are working to determine the physicochemical properties of nanoparticles that lead to toxicity in an effort to establish safe design rules. In this study, we performed the MTT and terminal transferase dUTP nick end labeling (TUNEL) assays to verify the cytotoxicity of GNPs on rat brain tissue and human neural progenitor cells (NPCs). As results, we observed that GNPs induced apoptosis in NPCs. NPCs were markedly damaged following the administration of 200 µM and 2 mM GNPs, whereas 2 µM GNPs showed slightly increased damage relative to that of the control. In addition, TUNEL-positive cells were densely distributed at regions surrounding the GNP injection site in the brain 7 days after the GNPs injection. During long-term GNPs exposure, TUNEL-positive cells were rarely observed in the cerebral cortex. In this study, we observed that apoptosis increased in proportion to GNP concentrations in the brain and in cultivated NPCs. These result suggest that large GNPs (<100 nm) are toxic and that the cytotoxicity increased as the concentration of GNPs increased in NPCs or in the brain.

Concordance Rate between Clinicians and Watson for Oncology among Patients with Advanced Gastric Cancer: Early, Real-World Experience in Korea.

Backgrounds/Aims: Watson for Oncology (WFO) is a cognitive technology that processes medical information by analyzing the latest evidence and guidelines. However, studies of the concordance rate between WFO and clinicians for advanced gastric cancer (AGC) are lacking. Methods: We retrospectively reviewed 65 patients with AGC who consulted WFO and the Gachon Gil Medical Center multidisciplinary team (GMDT) in 2016 and 2017. The recommendations of WFO were compared with the opinions of the GMDT. WFO provided three treatment options: recommended (first treatment option), for consideration (second treatment option), and not recommended. Results: In total, 65 patients (mean age 61.0 years; 44 males and 21 females) were included in the study. The concordance rate between WFO and the GMDT was 41.5% (27/65) at the recommended level and 87.7% (57/65) at the for consideration level. The main causes of discordance between WFO and the GMDT were as follows. First, WFO did not consider the medical history. Second, WFO recommended the use of agents that are considered outdated in Korea. Third, some patients wanted to be involved in a clinical trial. Fourth, some patients refused to use the biologic agents recommended by WFO for financial reasons as they were not covered by medical insurance. Conclusions: The concordance rate at the recommended level was relatively low but was higher at the for consideration level. Discordances arose mainly from the different medical circumstances at the Gachon Gil Medical Center (GMC) and the Memorial Sloan Kettering Cancer Center (MSKCC), the main WFO consulting center. The utility of WFO as a tool for supporting clinical decision making could be further improved by incorporating regional guidelines.

Five-year outcomes and predictive factors of transforaminal full-endoscopic lumbar discectomy.

Although several studies have reported the effectiveness of transforaminal full-endoscopic lumbar discectomy (TELD), no cohort study on the long-term outcomes of TELD has been conducted. Thus, this study aimed to evaluate the long-term clinical outcomes of TELD and to determine the factors predicting favorable outcome.Five-year longitudinal data of 204 consecutive patients who underwent TELD were collected. Outcomes were assessed using the visual analog scale (VAS) pain score, Oswestry disability index (ODI), patient satisfaction rating, and the modified Macnab criteria.The mean VAS score for leg pain improved from 7.64 at the baseline to 1.71, 0.81, 0.90, and 0.99 at postoperative 6 weeks, 1 year, 2 years, and 5 years, respectively (P <.001). The mean ODI improved from 67.2% at the baseline to 15.7%, 8.5%, 9.4%, and 10.1% at postoperative 6 weeks, 1 year, 2 years, and 5 years, respectively (P <.001). The overall patient satisfaction rate was 94.1%. Based on the modified Macnab criteria, 83.8% of patients had excellent or good results. In this study, younger patients with intracanal disc herniation tended to have better outcomes than elderly patients with foraminal/far-lateral disc herniation (P <.05).Transforaminal endoscopic lumbar discectomy offers favorable long-term outcomes with minimal tissue damage. Postoperative pain and functional status may change over time. Proper patient selection remains essential for the success of this minimally invasive procedure.

Laser-Assisted Microdiscectomy for Far Lateral Lumbar Disc Herniation at the L5-S1 Level.

OBJECTIVE: Laser-assisted paraspinal microdiscectomy for far lateral lumbar disc herniation (LDH) enables direct access to the foraminal or far lateral zone with minimal tissue injury and preserves facet joints, thereby preventing postoperative segmental instability. We demonstrated the clinical outcomes of this technique and discussed the pros and cons of laser use in lumbar disc surgery. BACKGROUND: The microdiscectomy technique for L5-S1 far lateral zone may be difficult due to the limited surgical field with narrowed disc space, hypertrophied facet, and sacral ala. Thus, we used carbon dioxide (CO2) laser for sophisticated decompression. METHODS: Eighty-four patients who were treated with microdiscectomy for far lateral LDH at the L5-S1 level were evaluated. Among them, 40 patients were treated using CO2 laser-assisted microdiscectomy, and the remaining 44 patients using conventional microdiscectomy. Perioperative and postoperative data were compared between the two groups with 2 years of follow-up. Clinical outcomes were assessed using the visual analog scale (VAS), Oswestry disability index (ODI), and modified Macnab criteria. RESULTS: VAS and ODI significantly improved in both groups. An excellent or good outcome was rated in 80% and 77.3% of the laser and conventional group, respectively. There was no significant difference in global outcomes. However, hospital stay and time to return to work were significantly shorter in the laser group (p < 0.05). CONCLUSIONS: CO2 laser-assisted paraspinal microdiscectomy is effective for treating far lateral LDH. The pinpoint laser scalpel enables delicate and complete decompression in a limited surgical field with minimal tissue trauma.

Use of lasers in minimally invasive spine surgery.

INTRODUCTION: Currently, minimally invasive spine surgery (MISS) has become a new gold-standard spine technique because it may reduce morbidity and recovery times. Technical developments based on light amplification by stimulated emission of radiation (laser) have been applied extensively in the field of MISS. The objective of this review is to describe the surgical applications of laser technology in MISS and to discuss the pros and cons of laser spine surgery. AREAS COVERED: We reviewed the medical literature to identify how lasers are being used in the current MISS techniques. We also described a variety of laser spine surgery according to the laser employed and surgical approach. There are three categories of laser surgery in MISS: (1) open microscopic laser surgery; (2) percutaneous endoscopic laser surgery; and (3) laser tissue modulation for spinal pain. Even though numerous laser procedures and related case series have demonstrated clinical efficacy in selected cases, there continues to be a paucity of randomized clinical trials. EXPERT COMMENTARY: Although there have been controversies on the effect of treatment, laser spine surgery shows promising results and has potentials for further investigations. Technical advancement and high-quality researches are needed to increase the practicality of laser spine surgery.

Assessing Concordance With Watson for Oncology, a Cognitive Computing Decision Support System for Colon Cancer Treatment in Korea.

PURPOSE: IBM Watson for Oncology (WFO) is a clinical decision-support computing system that provides oncologists with evidence-based treatment recommendations for a variety of cancer diagnoses. The evidence-based supported treatment recommendations are presented in three categories: Recommended, representing the Memorial Sloan Kettering Cancer Center (MSKCC) preferred approach; For Consideration, evidence-based alternative treatments; and Not Recommended, alternative therapies that may be unacceptable. We examined the absolute concordance of treatment options with that of the recommendations of a multidisciplinary team of oncologists from Gachon University, Gil Medical Centre, Incheon, South Korea. METHODS: We enrolled 656 patients with stage II, III, and IV colon cancer between 2009 and 2016. Cases were processed using WFO and, using retrospective clinical data, outputs were compared with the actual treatment the patient received. Absolute concordance was defined as an alignment of recommendation in the Recommended MSKCC preferred-approach category. Treatment recommendations that were represented in the For Consideration category were not the focus of this study. RESULTS: The absolute concordance between the WFO-derived MSKCC preferred approach and Gil Medical Centre treatment recommendations was 48.9%. The percentage of cases found to be acceptable was 65.8% (432 of 656) and the stage-specific concordance rate was 32.5% for patients with stage II disease who had risk factors and 58.8% for patients with stage III disease. Patients 70 years of age and older had a concordance rate of only 20.2%, whereas younger patients had a concordance rate of 63.8% ( P = .0001). CONCLUSION: The main reasons attributed to the low concordance rate were age, reimbursement plan, omitting chemotherapy after liver resection, and not recommending biologic agents (ie, cetuximab and bevacizumab).

Miniaturized and Wireless Optical Neurotransmitter Sensor for Real-Time Monitoring of Dopamine in the Brain.

Real-time monitoring of extracellular neurotransmitter concentration offers great benefits for diagnosis and treatment of neurological disorders and diseases. This paper presents the study design and results of a miniaturized and wireless optical neurotransmitter sensor (MWONS) for real-time monitoring of brain dopamine concentration. MWONS is based on fluorescent sensing principles and comprises a microspectrometer unit, a microcontroller for data acquisition, and a Bluetooth wireless network for real-time monitoring. MWONS has a custom-designed application software that controls the operation parameters for excitation light sources, data acquisition, and signal processing. MWONS successfully demonstrated a measurement capability with a limit of detection down to a 100 nanomole dopamine concentration, and high selectivity to ascorbic acid (90:1) and uric acid (36:1).

Cytotoxicity of gold nanoparticles in human neural precursor cells and rat cerebral cortex.

Nanoparticles are promising tools for the advancement of drug delivery, medical imaging, and as diagnostic sensor. Medical nanodevices should develop miniaturization, because it would be injected into a human body. Gold nanoparticles (GNPs) with different sizes and shapes have therapeutic potential as a result of their small size, robust nature, excellent biocompatibility and optical properties. However, the application of GNPs as medical nanodevices it is necessary to know the biodegradation, biocompatibility, and development of surface coating which avoid the accumulation of nanoparticles. In this study, we carry out an in vitro toxicity and in vivo gene expression study using two kinds of GNPs. We found that GNPs toxicity is dependent on the dose or size administrated after the injected GNPs into the brain, and small particle size GNPs appeared more nestin expression compared to large particle size at short term implantation. These findings of toxicity of GNPs may play an important role in development of in vivo tools for the safety of GNPs.

Cytotoxicity of Gold Nanorods and Nanowires on Cultivated Neural Precursor Cells.

Given the emergence of nanotherapeutics and nanodiagnostics as key tools in today's medicine, it has become of critical importance to define the interactions of nanomaterials with biological systems. The biomedical applications of nanoparticles (NPs) in chemical sensing, biological imaging, drug delivery, photothermal therapy and cancer treatment have been demonstrated. Gold NPs as new biomedical tools are the focus of research due to their ease of synthesis, chemical stability and unique optical properties. Therefore, there is a need to establish the toxicity, side effects and safety of gold NPs for human applications. To study the in vitro cytotoxicity of gold NPs, we performed MTT assay using two types of gold NPs such as gold nanorods (GNRs) and gold nanowires (GNWs). The percentage cytotoxicity of damaged neural precursor cells (NPCs) that were treated with 100 mg GNRs was 97.5±3.9%; and proportion of damaged NPCs following the administration of the same dose of GNWs was 98.8±0.3%. The cytotoxicity of 10 mg GNRs in NPCs was 54.4±8.3%, whereas it was 98.7±0.6% for the same dose of GNWs. Then, to verify that gold NPs induced apoptotic cell death in NPCs, the LIVE/DEAD Viability/Cytotoxicity assay was performed. We observed that cell death of NPCs increased with an increase in quantity of both types of gold NPs. Cell viability assessed the overall dose-dependent toxicity of NPs in cultured cells. As the results suggest, this study demonstrated that treatment with gold NPs resulted in cellular toxicity in a dose-dependent manner in cultured NPCs.

Resorption of Autogenous Bone Graft in Cranioplasty: Resorption and Reintegration Failure.

OBJECTIVE: Re-implantation of autologous skull bone has been known to be difficult because of its propensity for resorption. Moreover, the structural characteristics of the area of the defect cannot tolerate physiologic loading, which is an important factor for graft healing. This paper describes our experiences and results with cranioplasty following decompressive craniectomy using autologous bone flaps. METHODS: In an institutional review, the authors identified 18 patients (11 male and 7 female) in whom autologous cranioplasty was performed after decompressive craniectomy from January 2008 to December 2011. We examined the age, reasons for craniectomy, size of the skull defect, presence of bony resorption, and postoperative complications. RESULTS: Postoperative bone resorption occurred in eight cases (44.4%). Among them, two experienced symptomatic breakdown of the autologous bone graft that required a second operation to reconstruct the skull contour using porous polyethylene implant (Medpor®). The incidence of bone resorption was more common in the pediatric group and in those with large cranial defects (>120 cm(2)). No significant correlation was found with sex, reasons for craniectomy, and cryopreservation period. CONCLUSION: The use of autologous bone flap for reconstruction of a skull defect after decompressive craniectomy is a quick and cost-effective method. But, the resorption rate was greater in children and in patients with large skull defects. As a result, we suggest compressive force of the tightened scalp, young age, large skull defect, the gap between bone flap and bone edge and heat sterilization of autologous bone as risk factors for bone resorption.

An Evaluation of the Government's Current Guideline on the Hospitalization of Minor Head Trauma Patients.

OBJECTIVE: In June 28, 2012, a 'Hospitalization guideline for car accident patients' was announced to mediate the clash of opinions about the hospitalization of minor head trauma patients among doctors, patients and insurance companies. The guideline was issued to describe the patients' symptoms and emotions in detail after the injury. In this paper, evaluation for the guideline and suggestions for modifications was done. METHODS: Thirty-two doctors, 96 patients and 60 employees were each given surveys about the hospitalization guidelines, related personnels' attitude and evaluation of patients' emotional problems. The frequency, ratio and chi-square test were performed. RESULTS: Sixty-eight point eight percent of doctors, 79.8% patients and 91.6% insurance company employees agreed to the need for a guideline. Among the 68.8% doctors that supported the need for a guideline, 18.8% knew that the guideline actually existed. Sixty-nine point two percent of doctors said that they would apply the guideline once they were introduced to it. Among the announced guideline provisions, 'Glasgow coma score less than 15' and 'socially not suitable for discharge' required reevaluation since 40.6% all surveyors consented that these two criteria were not suitable. The consensus supporting the need for emotional evaluation came out to be 78.1%, 58.5%, 50.9% in doctors, patients and insurance employees respectively. CONCLUSION: Although a guideline for hospitalization of minor head injury patients is necessary, some part of it seems to be reevaluated and improved, especially for clauses related to the patient's emotional problems. These changes and revisions to the guideline require further speculation and research.

Mitochondrial DNA in patients with essential tremor.

Essential tremor (ET) is one of the most common of the movement disorders. However, there has been little agreement in the neurological literature regarding diagnostic criteria for ET. It is not clear to what extent ET is associated with defects of mitochondrial DNA. In this study, we analyzed mitochondrial DNA (mtDNA) from the blood cells of the normal and ET patients using the long and accurate polymerase chain reaction (LA-PCR) and PCR. The large deletions were detected within several regions of mtDNA, but were not detected in the D-loop or CO I regions in ET patients. From our study, it is suggested that ET is a disorder showing a deficiency of mtDNA multicomplexes, and it also appears that mitochondrial dysfunction could be one of the causative factors of ET.

Neuroprotection of adenoviral-vector-mediated GDNF expression against kainic-acid-induced excitotoxicity in the rat hippocampus.

Glial-cell-line-derived neurotrophic factor (GDNF) is a potent survival factor for several types of neurons. In the present study, we examined the protective roles of adenoviral-vector-delivered GDNF (Ad-GDNF) in the hippocampus damaged by kainic-acid (KA)-induced excitotoxicity using GAD-67 immunoreactivity, immunoblot analysis, behavioral test, 5-bromo-2-deoxyuridine (BrdU) and TUNEL assay. Ad-GDNF was pre-inoculated into the KA-treated rat hippocampus 7 days before KA injection. Ad-GDNF resulted in the suppression of KA-induced tonic-clonic convulsions. In situ apoptosis assay demonstrated a significant reduction in apoptotic cells in the CA3 and dentate hilus regions of the Ad-GDNF-pre-inoculated rats (Ad-GDNF-KA), compared to the KA rats. Striking reductions in the density of GAD-67 neurons were also observed in the CA3 and dentate hilus regions of the KA rats. On the other hand, the number of GAD-67-positive cells was recovered to the control levels in the Ad-GDNF-KA rats. Immunoblot analysis further confirmed that GAD-67 and Bcl-2 expression increased in the Ad-GDNF-KA rats compared to KA rats. Taken together, these results suggest that Ad-GDNF may serve to control KA-induced hippocampal cell loss and behavioral seizure.

The change of the neuron-glia differentiation rate in human neural precursor cells (HPCs) and Ad-BDNF-/-GDNF-infected HPCs following the administration of a neurotoxin.

Neurotrophic factors promote the survival of various neurons, including peripheral autonomic and sensory neurons, as well as central motor and dopamine neurons, and it is expected that they could function as therapeutic agents for neurodegenerative disease. We examined the changes in the neuron-glia differentiation rate in normal human neural precursor cells (HPCs), Ad-BDNF- and Ad-GDNF-infected HPCs following their treatment with 6-OHDA. We isolated the precursor cells from the human fetal midbrain. To investigate the expression of differentiated cell markers within neurons and glia after 6-OHDA-induced toxicity in HPCs, immunocytochemistry was performed. Our results showed that the treatment with 6-OHDA (100, 200, 300, 400 and 500 microM) for 24 h decreased the viability of the HPCs in vitro. Among the growth factors tested, BDNF and GDNF protected the HPCs against 6-OHDA-induced toxicity. Approximately, 5.8+/-2.2% and 0.5+/-0.1% of the HPCs treated with 6-OHDA were positive for the neuron marker, MAP2, and the oligodendrocyte marker, GalC, respectively, while 13.8+/-3.2% and 1.1+/-0.36% of the Ad-BDNF- or Ad-GDNF-infected HPCs treated with 6-OHDA stained positive for MAP2 and GalC, respectively. These results suggest that cocktail therapy using human precursor cells (HPCs) and certain neurotrophic factors (BDNF, GDNF) provide direct protection against 6-OHDA-induced toxicity and has an effect on the differentiation rate.

Apoptosis and nestin expression in the cortex and cultured astrocytes following 6-OHDA administration.

We used the dopaminergic neurotoxicant, 6-hydroxydopamine (6-OHDA), as a tool to characterize the origins of the astrocytic response to injury. Reactive astrocytes were examined by immunocyto- and histo-chemical visualization of nestin protein in the brain and cultivated cells. Following 6-OHDA (dose-dependent) treatment, the expression of nestin-like immunoreactive cells in the corpus callosum and cerebral cortex was increased compared with that of the control animals, indicating that a significant up-regulation of nestin protein occurred in these regions. In the corpus callosum and cerebral cortex, the majority of the nestin-like immunoreactive cells showed a distribution and pattern similar to those of the glial fibrillary acid protein (GFAP)-immunoreactive cells. Double immunofluorescence measurements showed that 100% of the nestin-like immunoreactive cells expressed GFAP-immunoreactive cells, indicating that these nestin-like immunoreactive cells belong to a reactive population of the astrocytes. In this study, we observed the morphological changes in the astrocytes following 6-OHDA administration, demonstrating that 6-OHDA induced injury leads to a rapid and transient up-regulation of nestin-like immunoreactivity in activated astrocytes.

Tamoxifen-induced cell death and expression of neurotrophic factors in cultured C6 glioma cells.

The effects of ( Z)-2[ p -(1,2-diphenyl-1-butenyl)phenoxy]-N ,N -dimethylamine citrate (tamoxifen) on cell survival and the expression of neurotrophic factors (NTF) were investigated in rat C6 glioma cells (C6). C6 cells do not express the estrogen receptor. Cytotoxic effect was detected from 24 h after the treatment with 10 microM tamoxifen and increased with time in a dose-dependent manner. C6 cells treated with tamoxifen also displayed various morphological types such as elliptical, round and aggregated form. As the treatment time increased, the proliferation of C6 cells was reduced remarkably and most of them became the round or aggregated form. To examine the relationship of the expression of NTF and the cytotoxicity of tamoxifen, the mRNA level of brain-derived neurotrophic factor (BDNF), glial-derived neurotrophic factor (GDNF), and basic fibroblast growth factor (bFGF) was measured after 24 h treatment with tamoxifen by RT-PCR. The expression of mRNA of BDNF or GDNF in C6 cells treated with various concentrations of tamoxifen was comparable to controls. The expression of bFGF mRNA was significantly reduced in C6 cells treated with 10 or 15 microM tamoxifen. The results suggest that tamoxifen exerts cytotoxic effect on estrogen receptor-negative C6 cells through the inhibition of the transcription of bFGF.

Neurotrophic factor in the treatment of Parkinson disease.

OBJECT: Parkinson disease (PD) is a well-known degenerative disease resulting in the depletion of dopamine-producing neurons in the pars compacta of the substantia nigra. Adenoviral vector delivery of neurotrophic factors may provide a potential therapy for PD. The authors examined whether glial cell line-derived neurotrophic factor (GDNF) delivered via adenoviral vector (Ad-GDNF) could promote functional recovery in a rat model of PD. Additionally, they examined whether neural precursor cells (NPCs) provide the therapeutic potential of cultured neural cells for cell regeneration and replacement in PD. METHODS: All animals underwent stereotactic injection of 6-hydroxydopamine into the right substantia nigra. Eight weeks later, the rats were tested for apomorphine-induced rotational asymmetry and evaluation of explanted grafts infected with the complementary DNA for GDNF containing NPCs and NPCs alone. In the NPC cultures of embryonic rat striata, the authors found that basic fibroblast growth factor induced the proliferation of stem cells, which give rise to spheres of undifferentiated cells that generate neurons and glia. CONCLUSIONS: In this study the authors found that the reduction of apomorphine-induced rotation was more prominent in parkinsonian rats that received Ad-GDNF-treated grafts containing NPCs (61%) than in those that received grafts of NPCs alone (16%).

Utility of multi-modality image guidance in epilepsy surgery / La utilidad de la imagen guiada multimodal en la cirugía de la epilepsia

De abril de 1994 a septiembre de 1996 se utilizó el ISG Viewing Wand, uno de los llamados sistemas de "cirugía estereotáctica sin marco", como una valiosa ayuda en el tratamiento quirúrgico de 120 casos de epilepsia. El sistema consta de una computadora procesadora de imágenes localizada en el quirófano que crea imágenes tridimensionales, triplanares y en línea basadas en imágenes de RM y TC. Incluye además un brazo mecánico de diseño ergonómico sensible a la posición y una sonda de mano. El procedimiento quirúrgico comienza una vez que se calibra el brazo, registra determinados rasgos de la cara y el cuero cabelludo del paciente. Con rapidez y precisión se relaciona un punto en el campo quirúrgico con el punto correspondiente en la pantalla de la computadora. El sistema provee una visualización de la información del paciente permitiendo la elección de la trayectoria óptima o menos invasiva. De esta manera, se puede determinar el abordaje óptimo a determinado blanco anatómico o lesión antes y durante la cirugía. Esta orientación da al cirujano mayor confianza y una mejor comprensión de la anatomía espacial y quirúrgica. Además, el sistema es un excelente instrumento didáctico. Las modalidades de imagenología que se utilizan actualmente son: angiorresonancia, angiografía por sustracción digital (DSA) y tomografía por emisión de positrones (PET), permite al cirujano seleccionar la modalidad imagenológica que proporcione la información anatómica y funcional pertinente para cada procedimiento en particular. Una limitación del sistema actual es su incapacidad para seleccionar y reproducir los cambios morfológicos ocurridos durante el procedimiento en el volumen quirúrgico