RESUMEN
BACKGROUND: Cerebral arteriovenous malformations (AVMs) are complex lesions that can cause hemorrhagic stroke and significant neurological disability. Adenosine induces cardiac standstill and hypotension, which are thought to be useful during cerebral AVM embolization. Herein, we conducted a systematic review and meta-analysis of the technique's safety. METHODS: Following PRISMA guidelines, four databases were queried for studies describing the use of adenosine-assisted embolization of cerebral AVMs. Adenosine-related intraoperative complications, permanent neurological outcomes, morbidity, and mortality assessed the technique's safety. Single proportion analysis under a random-effects model was performed. Heterogeneity was assessed using I² statistics, and publication bias was evaluated through funnel plot analysis and Egger's regression test. RESULTS: Ten studies were included, involving 79 patients (55.7% male) with 79 AVMs (54.4% unruptured and 70.9% Spetzler-Martin grade III-V) who underwent 123 embolizations (80.4% and 5.9% under transarterial and transvenous approaches, respectively) with n-butyl cyanoacrylate (80.4%), ethylene vinyl alcohol (14.4%), or both (5.2%). The incidence of transient adenosine-related intraoperative complications was 0% (95% CI 0% to 3%, I2=24%). Besides, the incidence of adenosine-related morbidity, mortality, and permanent outcomes was 0% (95% CI 0% to 3%, I2=0%). During follow-up, good functional outcomes were reported for 64 patients (81%). CONCLUSIONS: Adenosine's effects on blood flow control can facilitate embolization and mitigate the risk of AVM rupture and embolic agent migration. Although current evidence stems from observational studies, the results of this meta-analysis suggest a safe drug profile due to minimal associated morbidity and mortality. Further research from larger randomized and controlled studies is warranted to attain a higher level of evidence. PROSPERO REGISTRY NUMBER: CRD42023494116.
RESUMEN
OBJECTIVE: Augmented reality (AR) and virtual reality (VR) technologies have been introduced to neurosurgery with the goal of improving the experience of human visualization. In recent years, the application of remote AR and VR has opened new horizons for neurosurgical collaboration across diverse domains of education and patient treatment. Herein, we aimed to systematically review the literature about the feasibility of this technology and discuss the technical aspects, current limitations, and future perspectives. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 4 databases (PubMed, Embase, Scopus, and Cochrane Library) were queried for articles discussing the use of remote AR and VR technologies in neurosurgery. Data were collected in various fields, including surgery type, application type, subspecialty, software and hardware descriptions, haptic device utilization, visualization technology, internet connection, remote site descriptions, technical outcomes, and limitations. Data were summarized as counts and proportions and analyzed using IBM SPSS software. RESULTS: Our search strategy generated 466 records, out of which 9 studies satisfied the inclusion criteria. The majority of AR and VR applications were used in cranial procedures (77.8%), mainly in education (63.6%), followed by telesurgical assistance (18.2%), patient monitoring (9.1%), and surgical planning (9.1%). Local collaborations were established in 55.6% of the studies, while national and international partnerships were formed in 44.4% of the studies. AR was the main visualization technology, and 3G internet connection was predominantly used (27.5%). All studies subjectively reported the utility of remote AR and VR for real-time interaction. The major technical challenges and limitations included audiovisual latency, the requirement for higher-fidelity and resolution image reconstructions, and the level of proficiency of the patient with the software. CONCLUSIONS: The results from this systematic review suggest that AR and VR technologies are dynamically advancing to offer remote collaboration in neurosurgery. Although still incipient in development and with an imperative need for technical improvement, remote AR and VR hold a frontierless potential for patient monitoring, neurosurgical education, and long-distance surgical assistance.