GA3-77
Cutting-edge advancement in pediatric neurosurgery and anesthetic implications: Robotic Stereotactic Assistance (ROSA®)
1Brackett S, 2Reddy S, 2Oluigbo C, 2Nelson J
1The George Washington University Hospital, Washington, DC, USA; 2Children's National Health System, Washington, DC, USA
INTRODUCTION
Robotic assisted neurosurgical procedures have become increasingly utilized due to their high degree of precision and minimally invasive approach. The recently developed Robotic Stereotactic Assistance (ROSA®) system uses image guidance to assist neurosurgeons with a variety of minimally invasive procedures, including lead placement for deep brain stimulation, laser ablation of epileptogenic foci, and depth electrode placement for seizure monitoring. However, the use of robotic assistance for neurosurgery has been infrequently reported in the pediatric population. Furthermore, the anesthetic implications and intraoperative considerations for pediatric ROSA® procedures remain to be discussed.
CASE PRESENTATION
A 16-year old 74.3 kg male with intractable epilepsy presented for right-sided depth electrode placement with ROSA®.
After induction of anesthesia and placement of two large bore IVs the patient was endotracheally intubated. General anesthesia was maintained with 2% sevoflurane and a continuous remifentanil infusion ranging from 0.1 to 0.2 mcg/kg/min. The operating room bed was rotated 90º clockwise and the head was placed in Mayfield pins. The ROSA® mechanical arm was extended and locked to the Mayfield frame. Once optimal head positioning was confirmed, the ROSA® laser attachment then scanned the patient’s facial landmarks for surface registration in order to plan trajectory entry sites based on uploaded CT and MR images. After this process was complete, the ROSA® robotic arm directed the neurosurgery team to twelve stereo-electroencephalography (SEEG) implantation sites on the right frontal, temporal, and insular lobes.
Following successful implantation of the SEEG electrodes, the patient was unlocked from the ROSA® system and removed from Mayfield pins. The patient received a total of 1.4 mcg/kg of fentanyl titrated through the case, and an awake extubation was performed at the end of the surgery to facilitate postoperative neurological assessment. The patient was transported to the pediatric ICU in stable condition after an uneventful surgery, where he was monitored for epileptic activity to localize seizure foci.
DISCUSSION
ROSA® allows for a safe, efficient, minimally invasive, and highly accurate image-guided approach to depth electrode placement for seizure monitoring. The combination of image guidance, as well as the stability and precision of the robotic arm, offers advantages over traditional approaches. In addition, compared to invasive monitoring such as subdural grids, SEEG allows for a more precise identification of epileptogenic foci. Due to the need for accurate intracerebral recording of electrical activity, it is imperative that the planned trajectory of the depth electrodes correlates with their actual trajectory. Therefore, patient movement during laser surface recognition or depth electrode placement could lead to highly inaccurate and potentially dangerous trajectory planning. Choosing anesthetic agents that maintain a depth of anesthesia that inhibits patient movement and does not also interfere with recording of electrical activity can be a considerable challenge but is necessary for a successful outcome.
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