BACKGROUND The advent of the operating microscope (OM) revolutionized the field of neurosurgery. It allowed surgeons to operate on and effectively treat diseases previously inaccessible with conventional eyesight because of magnification and illumination. Improvements in the essential methods of visualization and the quality of the optics have plateaued. Another main limitation of the OM remains its ergonomics because of the need of the surgeon and assistant to directly interface with the OM objective. Recently, exoscopes have been introduced to overcome some shortcomings of the conventional OM. OBJECTIVE To subjectively review the individual authors experience with the current exoscope platforms in an attempt to provide a resource to the neurosurgeon when considering imaging options. METHODS Experts with previous use of each individual platform were contacted and asked to contribute their experiences. RESULTS In total, 4 systems are discussed. They include the VITOM (Karl Storz, Tuttlingen, Germany), the Olympus ORBEYE (Olympus, Tokyo, Japan), the Synaptive Modus V (Synaptive Medical, Toronto, Canada), and the Zeiss KINEVO (Carl Zeiss AG, Oberkochen, Germany). CONCLUSION The advent of exoscopes has the potential to begin to allow surgeons to move beyond solely the microscope for intraoperative visualization while improving upon its ergonomic disadvantages.

BACKGROUND During its development and preclinical assessment, a novel, 3-dimensional (3D), high-definition (4K-HD) exoscope system was formerly shown to provide an immersive surgical experience, while maintaining a portable, low-profile design. OBJECTIVE To assess the clinical applicability of this 3D 4K-HD exoscope via first-in-man surgical use. METHODS The operative workflow, functionality, and visual haptics of the 3D 4K-HD exoscope were assessed in a variety of microneurosurgical cases at 2 US centers. RESULTS Nineteen microneurosurgical procedures in 18 patients were performed exclusively using the 3D 4K-HD exoscope. Pathologies treated included 4 aneurysms, 3 cavernous malformations (1 with intraoperative electrocorticography), 2 arteriovenous malformations, 1 foramen magnum meningioma, 1 convexity meningioma, 1 glioma, 1 occipital cyst, 1 chiari malformation, 1 carotid endarterectomy, 1 subdural hematoma, 1 anterior cervical discectomy and fusion, and 2 lumbar laminectomies. All patients experienced good surgical and clinical outcomes. Similar to preclinical assessments, the 3D 4K-HD exoscope provided an immersive 3D surgical experience for the primary surgeon, assistants, and trainees. The small exoscope frame, large depth of field, and hand/foot pedal controls improved exoscope mobility, decreased need to re-focus, and provided unobstructed operative corridors. Flexible positioning of the camera allows the surgeon's posture to be kept in a neutral position with uncompromised viewing angles. CONCLUSION The first-in-man clinical experience with the 3D 4K-HD exoscope confirms its excellent optics and ergonomics for the entire operative team, with high workflow adaptability for a variety of microneurosurgical cases. Expanded clinical use of the 3D 4K-HD exoscope is justified.

Background The use of liquid embolic agents in the endovascular treatment of dural arteriovenous (dAVFs) fistulas and brain arteriovenous malformations (AVMs) has become common practice. The use of dual lumen balloon microcatheters has greatly improved the efficacy of liquid embolization. The purpose of this series is to discuss our early experience with the Scepter Mini dual lumen balloon microcatheter. Methods A retrospective chart review was performed of all patients who underwent embolization with the Scepter Mini dual lumen balloon at a single institution. Technical details and procedural complications were recorded for each case. Results In total, 10 Scepter Mini dual lumen balloon microcatheters were used in nine patients. All patients except two were treated for AVMs. Technical success was achieved in all but one case where one balloon had to be discarded due to precipitation of the tantalum powder. Average vessel diameter where the balloon was inflated was 1.1 mm (0.8–2.4 mm). It provided flow arrest in 100% of cases with no cases of reflux of embolic material. Balloon “jump back” was found to occur in 44.4% (4/9) of cases. Seven out of nine cases used Onyx, and two cases used n-butyl cyanoacrylate. Conclusions The Scepter Mini is a new dual lumen balloon ideal for distal access and can be used for embolization with liquid embolic agents with a high degree of technical success. Its great benefit is the immediate and safe flow arrest of distal vasculature upon balloon inflation. One important consideration for effective embolization is early identification of balloon jump back.

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Background Even in the modern endovascular era, the treatment of Vein of Galen Malformations (VOGM) is extremely challenging. While their natural history is very poor, endovascular embolization has emerged as the standard of care. These lesions often require multiple treatment sessions to decrease shunting, with each treatment including multiple pedicles. Here we present the first reported use of the Scepter Mini (Microvention, Aliso Viejo, CA) in the treatment of vein of Galen malformations. Clinical presentation A 7 month old female presented with an enlarging VOGM that was initially identified on prenatal ultrasound. Given the enlarging size of the lesion and failure to meet developmental milestones, the patient underwent planned endovascular embolization of the VOGM. The novel Scepter Mini balloon catheter was used for treatment of this lesion affording easy access to the target pedicle and immediate flow arrest which allowed for immediate cure of the lesion. Conclusion The novel Scepter Mini Balloon (Microvention, Aliso Viejo, CA) afforded excellent distal access with subsequent immediate flow arrest therefore facilitating endovascular cure. Initially, a staged approach was favored for the treatment of the lesion, but the flow arrest achieved by the Scepter mini facilitated immediate occlusion from a single pedicle.

Background: Surgery on patients with lesions in the dominant hemisphere for language is best done with awake language mapping. Intraoperative MRI (iMRI) has also been proposed as an ideal method for tumor resection control in patients with primary brain tumors. Objectives: This study examines the feasibility of low-field iMRI during awake craniotomy and tumor resection. Methods: 36 patients underwent awake resection with a compact iMRI for guidance. Outcomes were grouped using an A–D classification. Outcome A was defined as gross total resection (GTR) without iMRI, B as GTR achieved secondary to iMRI findings, C as resection stopped due to mapping but prior to iMRI, and, finally, D as resection stopped after iMRI had showed residual tumor but subsequent mapping limited further resection. Results: Diagnoses included primary brain tumors in all but 2 patients: 1 had mesial temporal sclerosis and 1 cysticercosis. Overall, outcomes A and D were the most common with 12 patients each, outcome C was the least common occurring in only 3 patients, and outcome B occurred in 9 patients. Hence, in 12 patients, iMRI led to increased tumor resection while in another 12 brain mapping limited the extent of resection. Conclusions: Combined awake language and motor mapping and iMRI guidance is feasible for resection of brain lesions. A compact iMRI has unique advantages for this approach.

The surgical management of deep brain tumors is often challenging due to the limitations of stereotactic needle biopsies and the morbidity associated with transcortical approaches. We present a novel microscopic navigational technique utilizing the Viewsite Brain Access System (VBAS) (Vycor Medical, Boca Raton, FL, USA) for resection of a deep parietal periventricular high-grade glioma as well as another glioma and a cavernoma with no related morbidity. The approach utilized a navigational tracker mounted on a microscope, which was set to the desired trajectory and depth. It allowed gentle continuous insertion of the VBAS directly to a deep lesion under continuous microscopic visualization, increasing safety by obviating the need to look up from the microscope and thus avoiding loss of trajectory. This technique has broad value for the resection of a variety of deep brain lesions.