Pterional vs Lateral Supraorbital Approach in the Management of Middle Cerebral Artery Aneurysms: Insights from a Phantom Model Study

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Erol Sandalcioglu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3986785/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Jul, 2024 Read the published version in Neurosurgical Review → Version 1 posted 13 You are reading this latest preprint version Abstract Background The pterional approach has traditionally been employed for managing middle cerebral artery (MCA) aneurysms. With potential benefits like reduced surgical morbidity and improved postoperative recovery, the lateral supraorbital approach (LSO) should be considered individually based on aneurysm morphology, location and patient-specific variations of the MCA anatomy, which requires considerable technical expertise traditionally acquired through years of experience. Objective Development and evaluation of a novel Phantom simulator in the context of clinical decision-making in the managmement of MCA aneurysm. Materials and Methods High-fidelity Phantom simulators inclusive of MCA models with identical M1- and bifurcation aneurysms were manufactured employing 3D reconstruction techniques, additive manufacturing and rheological testings. Medical students, neurosurgical residents, and seasoned neurosurgeons (n = 22) tested and evaluated both approaches. Clipping quality, participants’ performances and progress over time were assessed based on objective metrics. Results The simulator received positive ratings in face and content validity, with mean scores of 4.9 out of 5, respectively. Objective evaluation demonstrated the model’s efficacy as a training and assessment tool. While requiring more technical expertise, results of the comparative analysis suggest that the LSO approach can improve clipping precision and outcome particularly in patients with shorter than average M1-segments. Conclusion The employed methodology allowed a direct comparison of the pterional and LSO approaches, revealing comparable success rates via the LSO while reducing operation time and complication rate. The Phantom proved to be an effective training, particularly among inexperienced participants. Future research should aim to establish simulators in the context of clinical decision making. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Introduction The pterional approach 1 has been the standard technique employed for the management of middle cerebral artery (MCA) aneurysms for decades, providing wide exposure of the anterior and middle cranial fossae, sellar and parasellar regions, superior orbital fissure, and cavernous sinus. 23 , 4 However, the risk of temporalis muscle atrophy, damage to the frontal branch of the facial nerve, and cosmetic issues has limited this extremely versatile approach. 5 Modifications of the standard pterional approach have become popularized over the last 20 years, including mini-pterional 3 , 6 , 7 and lateral supraorbital (LSO) craniotomies. 8 , 9 The LSO offers several potential benefits over the pterional approach for the surgical treatment of unruptured MCA-bifurcation aneurysms. First, it offers comparable surgical exposure despite a smaller skin incision and craniotomy. This may result in less surgical morbidity and improved postoperative recovery, which is a significant advantage in patient-centered care. Second, the improved ergonomics offered by the LSO approach may reduce surgical time and improve the precision of aneurysm clipping. The choice of surgical approach should be tailored to the individual patient and the specific characteristics of the aneurysm. Each case requires specific microsurgical skills and techniques for a safe and effective dissection. Mastering this crucial technique requires considerable expertise and technical skills that were traditionally acquired through years of experience and rigorous training. As traditional teaching methods 10 , 11 cannot provide adequate opportunities for deliberate practice and skill development, alternative training opportunities are needed to accelerate the surgical learning curve. 12 – 14 Simulators can provide a safe, controlled, and risk-free environment for training, skill development, and mastery of intricate surgical techniques. 13 – 15 Moreover, if implemented correctly, high quality Phantom simulators have the potential to explore new techniques and approaches in a safe environment, allowing a shift towards a more pathology and patient-specific surgical treatment. However, the effectiveness of simulation training heavily relies on the quality and realism of the simulation techniques employed. This study aims to develop and evaluate a high-fidelity simulator for the microsurgical management of middle cerebral artery aneurysms in the context of clinical decision making. For this purpose, meticulously reconstructed models of the skull, brain, and meninges inclusive of MCA models with identical M1- and MCA-bifurcation aneurysms were manufactured employing 3D reconstruction techniques, additive manufacturing and rheological measurements. The simulator facilitates an unprecedented direct comparative analysis of two distinct surgical approaches in the management of identical middle cerebral artery aneurysms, a comparison previously unachievable due to the unique nature of each clinical scenario. To meet the requirements for an effective training and decision-making tool, the simulator was assessed by medical students, neurosurgical residents, and experienced neurosurgeons based on subjective and objective evaluation criteria. Materials and Methods This study protocol adheres to the SQUIRE 2.0 guidelines. Ethics approval: The study protocol was conducted in compliance with the Declaration of Helsinki and approved by the ethics committee of the Otto-von-Guericke University Magdeburg. (Ethics vote number: RENOVA 94/20) Statement of Human and Animal Rights: This article does not contain any studies with human or animal subjects. Statement of Informed Consent: Written informed consent was obtained from the patient for their anonymized information to be published in this article. Data Acquisition After obtaining the approval of the local ethics committee, imaging datasets (computed tomography angiography [CTA], and magnetic resonance imaging [MRI]) of a 52-year-old male with an incidental aneurysm of the left middle cerebral artery (MCA) were used for thresholding-based segmentation and reconstruction of the skull, brain and the circulus arteriosus willisi (CAW). Construction of the Phantom The creation of the Phantom combined digital reconstructions and post-processing with additive manufacturing, material research and handcrafting. The skull was reconstructed from the patient’s CT-angiography data by greysclae boundaries using the freely available 3D reoncstruction software InVesalius3 (Centro de Tecnologia da Informação Renato Archer (CTI)) and subsequently refined with the open-source graphics software tools MeshMixer (Autodesk, Inc.), and Blender (Blender Foundation - Nonprofit organization) to reduce production costs and time expenditure by incorporating reusable and detachable parts via slide and plug-in mechanisms. (Fig. 1 A ) The CAW was segmented from the patient’s contrast-enhanced T1 MRI dataset on the free cross-plattform application MeVisLab (MeVis Medical Solutions AG, Bremen, Germany) employing threshold-based techniques. Subsequent mesh smoothing and adjustments were permormed with MeshMixer and Sculptris 1.02 (Pixologic, Inc., www.sculpteo.com ). The CAW was designed to remainin in the centrale console of the skull with magnetic connectors integrated into the proximal M1-segments to facilitate a swift attachment and detachment of the aneurysm models. (Fig. 1 B ) The reconstruction of the brain from the patient’s MRI datatset was executed with the open-source software Fressurfer (Harvard University, Cambridge, Massachusetts, USA). Additional manual segmentation was required to accurately replicate the lateral sulcus and generate an anatomically precise negative mold and facilitate the subsequent casting of the Sylvian fissure (SF) models. To achieve this, the SF mesh was manually divided into two segments in Blender, determined by hand-selected points demarcating the pial surfaces of the temporal and frontal lobes within the sulcus. (Fig. 1 C ) Additive manufacturing of the skull, CAW and SF models were executed on a desktop 3D Printer ( Raise3D Pro2 dual extrusion by Raise 3D Technologies, Inc.) using standard 1,75 mm PLA filaments. The rigidity disparities between compact and cancellous bone druing the drilling process were ensured by adjusting the infill density of the skull at 15%. Mimicking the tactile properties of the living brain was a challenging process based on previous studies and involving a substudy with subjective and objective material research and evaluations. Candle gel, identified by six experienced neurosurgeons for its similar tactile properties to the brain tissue as encountered during surgery, circumvents the limitations associated with previous gelatin-based models while offering a more sustainable and ethically sound option. The result was an anatomically and tactilly accurate, reusable replication of the SF. ( Fig. 2 A ) The subjective evaluation was further validated through rheological assessments. (Fig. 2 B ) MCA models with identical aneurysms located at M1 and MCA-birfucarrtion were handcrafted using paraffin wax and coated with two thin layers of liquid latex. After a detaliled shaping process, the models were then bathed in water with temperatures between 65°-70° C to wash out the paraffin wax. (Fig. 3 A - C) The simulation of the meninges involved applying a latex layer to mimic the dura mater, enhanced with a coalescing agent for better adhesion. ( Fig. 4 A ) The web-like texture of the arachnoid mater was recreated using a blend of synthetic resin adhesive, latex, and glycerin, meticulously applied to the SF to achieve a natural, wet look. (Fig. 4 B ) Simulator assembly: The initial step of the assembly involves attaching the dura mater to the interchangeable lateral skull base models. Concurrently, the middle cerebral artery aneurysm models, and optionally cerebral veins, are carefully placed within the SF models. After applying the arachnoid membrane, the SF models are positioned in the lateral skull bases which are then connected to the central console via clip mechanisms. During this process, the aneurysm model establishes a magnetic connection with the CAW model placed on the central console. In the final assembly stage, the skull base and central console are securely attached to the rest of the Phantom via integrated rail-slide systems. The assembly process is depicted in Fig. 5 . Study design Three groups of participants (n = 22) with varying levels of neurosurgical experience were recruited for this study. ( Table 1 ) Novice Group (n = 12): 4th - and 5th -year medical students (MS) Advanced Group (n = 6): 4th - and 5th -year neurosurgical residents (NR) Expert Group (n = 4): neurosurgeons (NS) specialized in vascular neurosurgery Simulation setting: The simulation took place at the microneurosurgical laboratories of the department of neurosurgery, where a training environment with a full-functioning operating theatre is provided. Simulations were executed using a ZEISS OPMI Neuro NC-4. ( Fig. 6 ) A full set of neurosurgical instruments including drills, scalpels, forceps, scissors, bone punches, aneurysm clips, and clip appliers were organized on a surgical tray within a hand’s reach. To allow a direct comparison between the two approaches, identical MCA models fitted with two aneurysms placed in the M1- and MCA-bifurcation segments, were used in this study. The length of the M1-segment was set at 14 mm 20 where the MCA-bifurcation aneurysm was placed. A second aneurysm was placed at 8 mm length, representing an MCA-bifurcation aneurysm with a shorter M1-segment. ( Fig. 7 ) Simulation Process: The simulation was preceded by an introduction explaining the principles and key steps of MCA aneurysm clipping. The surgical approach was predefined to the standard pterional and the lateral supraorbital approaches. All medical students received additional instruction on the operating microscope and microsurgical instruments. The participants started the simulation with the positioning of the head in a 3-pin immobilization device. Craniotomy and dural incision were performed. After visualizing the aneurysm a clip was chosen and placed on the neck of the aneurysm. Each participant performed the procedure twice, with either approach on one side of the Phantom. Both approaches were repeated after a period of three to five days. Per attempt, each participant was given one chance to clip each aneurysm with either one or two clips of choice. ( Fig. 8 ) Simulation assessment: The simulations were directly followed by a questionnaire for the assessment of face and content validity derived on 5-point Likert scales. All participants (n = 22) were asked to gauge their attitude towards the simulator. Neurosurgical residents and neurosurgeons rated the simulators’ usefulness in developing technical skills. Experienced neurosurgeons rated the simulators’ realism and accuracy. The expert group further compared both approaches regarding the surgical exposure of key anatomical structures, accessibility of MCA-bifurcation aneurysms, the ease of surgical manipulation, and overall surgical experience. All participants were observed during the simulations and assessed by two independent neurosurgeons based on the Objective Structured Assessment of Aneurysm Clipping Skills (OSAACS) 15 , 19 (Table 2) OSAACS rates surgical clipping skills based on user performance during simulation to evaluate progress in training and differentiate between novice and advanced surgeons (construct validity). The tool was modified to include specific assessment criteria for correct head positioning and craniotomy placement. Results Subjective Evaluation: Face and content validities: The simulator was rated favorably by neurosurgical residents, and neurosurgeons with a mean score of 4.9 out of 5 regarding its educational usefulness in conveying and training key steps of the procedure and developing surgical skills. (Fig. 9 ) Experienced neurosurgeons perceived the simulator as highly accurate regarding tactile and anatomical realism (Fig. 10 ). The results of the subjective evaluation of the LSO and pterional approach by experienced neurosurgeons regarding surgical exposure levels are shown in Fig. 11 . In terms of accessibility, the LSO approach offered comparable exposure of the M1-segment and the bifurcation of the MCA as the pterional approach. This was particularly the case for aneurysms of the short M1-segments. However, while the LSO can provide access to the optic nerve and anterior clinoid process, its trajectory may limit exposure to structures that are more lateral or posterior without additional bone removal. Objective Evaluation: Construct validity: The average results in clipping quality by approach and participant for MCA bifurcation-aneurysm with an average length of the M1-segment (14 mm) and a short M1-segment (8 mm) are presented in Fig. 12 A and B. The placement of clips via the pterional approach was often easier for novice medical students and neurosurgical residents as it offerered superior ergonomics, resulting in higher clipping success rates, particularly for MCA -bifurcation aneurysms with an average M1-lenght. However, among experienced neurosurgeons, the LSO approach offered comparable clipping success in MCA-bifurcation aneurysms with an average M1 lengths and even slightly higher clipping quality success in MCA variations with a short M1-segment, (Fig. 13 ) while on average offering lower complication rates and a shorter procedure time than the standard pterional approach (Fig. 14 A, B) The initial differences between the participating groups in clipping quality and other performance metrics based on OSAACS showcases a high construct validity of the simulator. Objective assessments of surgical clipping skills of the participating groups over a period of four attempts in four key metrics are presented in Fig. 15 . The novice group experienced a rapid and considerable increase in accuracy, timing, and quality, underlining the efficacy of the simulator to convey microsurgical understanding and techniques. Discussion In this study, we investigated the utility of a state-of-the-art Phantom model in juxtaposing the lateral supraorbital (LSO) and pterional approaches for treating unruptured middle cerebral artery (MCA) bifurcation aneurysms. By facilitating a direct comparison between the LSO and pterional approaches, the presented model provided insights into the potential benefits of the LSO approach, such as comparable surgical exposure and clipping success and the potential for reduced surgical morbidity and improved postoperative recovery. The LSO approach, however, requires more technical expertise and precise surgical manipulation in a limited operative field. Traditionally, these skills are acquired through rigorous training and repetition. Simulation training has the potential to accelerate the learning curve by allowing surgeons to gain familiarity with these requirements and build confidence in performing the technique, thereby potentially improving patient outcomes. The fundamental assumption of simulation-based training, however, is that skills acquired in simulated settings are transferable to the operative setting 22 – 24 . The more realistic the simulation, the more likely that it will help improve surgical skills such as dexterity and spatial awareness. At the same time, a lack of realism can lead to a negative learning effect and ultimately endanger patients’ lives. The presented Phantom model, designed to encompass varying lengths of the M1-segment and bifurcation aneurysms, allowed the participants to simulate the surgical experience closely, thereby offering a safe and controlled environment for learning and skill refinement. The incorporation of accurate tactile and rheological properties enables trainees to develop a keen sense of touch, dexterity, and instrument handling that can be transferred to any neurosurgical procedures involving the use of microsurgical instruments and a microscope. Limitations: While the sequential improvement in skills observed among inexperienced participants indicates high efficacy, post-training performances in real-life scenarios would need to be evaluated to see if improvements on the simulator translate to real-world skill enhancements. Conclusion The choice of surgical approach should be tailored to the individual patient and the specific characteristics of the aneurysm. The results of this study highlight the benefits of the LSO over the standard pterional approach such as reduced operation time and complication rates but also the challenges that a smaller approach entails. The results of the objective and subjective assessments of the presented Phantom showcase the invaluable role of Phantom simulators in overcoming these challenges and, ultimately, advancing patient-specific treatment strategies. Future studies should continue to leverage Phantoms simulators to explore and compare other surgical approaches, with the ultimate aim of accelerating the surgical learning curve and improving patient care. Declarations Ethical Approval The study protocol was conducted in compliance with the Declaration of Helsinki and approved by the ethics committee of the Otto-von-Guericke University Magdeburg. (Ethics vote number: RENOVA 94/20) Complete written informed consent was obtained from the patient for the publication of this study and accompanying images. Availability of data and materials The authors confirm that the data supporting the findings of this study are available within the article. Conflicts of interest/Competing interests The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Patient consent for participation and publication was obtained. Sources of funding This study did not receive any funding or financial support. Acknowledgments and authors’ contributions AA and BN designed and organized the simulations, derived the models, and analyzed the data. AA, VMS, KPS contributed to the digital reconstructions of the models and sample preparation. AA, BN, and took the lead in writing the manuscript. BN, VMS, AR, and IES contributed to the interpretation of the results. AR, BN, KPS, and IES supervised and assessed the simulations. All authors provided critical feedback and helped shape the research, analysis, and manuscript. All authors discussed the results and contributed to the final manuscript. References Wen HT, Oliveira E de, Tedeschi H, Andrade FC, Rhoton AL. 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Simulation for skills training in neurosurgery: a systematic review, meta-analysis, and analysis of progressive scholarly acceptance. Neurosurg Rev . Published online September 18, 2020. doi:10.1007/s10143-020-01378-0 Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables1and2.docx Cite Share Download PDF Status: Published Journal Publication published 22 Jul, 2024 Read the published version in Neurosurgical Review → Version 1 posted Editorial decision: Revision requested 24 May, 2024 Reviews received at journal 22 May, 2024 Reviews received at journal 19 May, 2024 Reviewers agreed at journal 19 May, 2024 Reviewers agreed at journal 07 May, 2024 Reviews received at journal 07 Mar, 2024 Reviewers agreed at journal 07 Mar, 2024 Reviewers agreed at journal 05 Mar, 2024 Reviewers agreed at journal 05 Mar, 2024 Reviewers invited by journal 05 Mar, 2024 Editor assigned by journal 05 Mar, 2024 Submission checks completed at journal 26 Feb, 2024 First submitted to journal 24 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3986785","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275095151,"identity":"4da62911-ad3e-4f4d-a5c7-6f1ef90b5a50","order_by":0,"name":"Amir Amini","email":"","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":false,"prefix":"","firstName":"Amir","middleName":"","lastName":"Amini","suffix":""},{"id":275095152,"identity":"ee062a37-c8b4-4331-b68e-bc1fa3cb2a98","order_by":1,"name":"Vanessa Swiatek","email":"","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":false,"prefix":"","firstName":"Vanessa","middleName":"","lastName":"Swiatek","suffix":""},{"id":275095153,"identity":"36f6b265-0e13-4c85-bf0b-294e27e2fd00","order_by":2,"name":"Klaus-Peter Stein","email":"","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":false,"prefix":"","firstName":"Klaus-Peter","middleName":"","lastName":"Stein","suffix":""},{"id":275095154,"identity":"ad0e8cb2-c054-4f0a-bf3b-c4c98ea2e3e4","order_by":3,"name":"Ali Rashidi","email":"","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Rashidi","suffix":""},{"id":275095155,"identity":"7d1a89a0-86b6-4944-825d-38e8b0bf47f3","order_by":4,"name":"I. Erol Sandalcioglu","email":"","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":false,"prefix":"","firstName":"I.","middleName":"Erol","lastName":"Sandalcioglu","suffix":""},{"id":275095156,"identity":"5c571f16-e3bd-4176-9513-de6b79949cc1","order_by":5,"name":"Belal Neyazi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIie2PMUvDQBTHXwiY5XDu0saPcOXAWqJ+lguBZNG9Wy8EMlVcFfwQnW6+8MAuha43CBoKXXS4Uad6xSAup3UTvB83vP/jfrz3ADyePwiFUMBTF5QBCMRHHX6j2D+8C83Nr5WQ7KOMorI0HB4GdLFo8ezitC+iGXsmkAxcynjWVD0OG0aXnOOlzJkgy+OEQMGci+lUWAXTueLKKmhjnjNiO8KlPLbVq1Wm81UrcCy3n8rUqeig3k3hVGeAgVRWyXBtFe4w7C1pfcIpDm/1BpormbGa4H1wR4uha8ooQtRmgvHhqlibN3nev47KyrxMktg1pVsP4Eh19YF9vV3nR+Ive4RmD8Hj8Xj+D+8rEmCKIMtW2QAAAABJRU5ErkJggg==","orcid":"","institution":"Otto-von-Guericke University Magdeburg","correspondingAuthor":true,"prefix":"","firstName":"Belal","middleName":"","lastName":"Neyazi","suffix":""}],"badges":[],"createdAt":"2024-02-25 04:15:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3986785/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3986785/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10143-024-02518-6","type":"published","date":"2024-07-22T16:15:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51834569,"identity":"92473646-0d48-4cc5-9e13-f6c9cdaace4f","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":290726,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e) Digital reconstruction, postprocessing and additive manufacturing of the Skull with modifications to the filler density of the skull model to simulate the tabula externa and interna (blue arrows). Plug-in (red arrows) and slide mechanism (white arrows) incorporated in the skull allowing swift de- and reattachment of the replaceable parts \u003cstrong\u003eB)\u003c/strong\u003e Reconstruction and digital modelling of the CAW in MeshMixer and Blender designed to remain in the phantom’s central console \u003cstrong\u003eC) \u003c/strong\u003eMeticulous segmentation and reconstruction of the SF in frontal and temporal lobe parts for anatomical accuracy and to facilitate to casting process\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/7cb5ef213d2e08dc65388c07.jpg"},{"id":51834581,"identity":"9ada8ad6-09ee-4391-8689-b2e1f2b629da","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":244853,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA) \u003c/strong\u003eAnatomically and tactilly accurate replication of Sylvian fissure model is durable, portable, and reusable for weeks without losing its haptic properties. \u003cstrong\u003eB\u003c/strong\u003e) Graph of stretch vs. stress derived by implementing compression stress of (a) 0.2 kPa, (b) 0.6) kPa, and (c) 1.2 kPa on candle gel samples with comparable rheological results as previously as life-like established findings involving 260 Bloom gelatin samples in 17.5% concentrations.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/b22832c4b75bcf2e7901ef8a.jpg"},{"id":51834570,"identity":"1f090f8c-92a2-4e08-85c1-0bf3907c80b2","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":149609,"visible":true,"origin":"","legend":"\u003cp\u003eModelling process of the middle celebral arteries with bifurcationaneurysms located at 8 mm and 14 mm representing short and average M1 lenghts. Left: paraffin wax model. Middel: Coating of the model with thin layers of liquid Latex. Right: Finished left-sided MCA-model with aneurysms\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/d1dd94bb86f94ef2d5c91e9f.jpg"},{"id":51834571,"identity":"dfd5638c-93f0-475b-9727-8dbd48e1e76c","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":461833,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA)\u003c/strong\u003eApplication of latex-based dura to the lateral skull base and B) Simulation of craniotomy and dural opening \u003cstrong\u003eC)\u003c/strong\u003e finished arachnoid membrane applied to the SF with \u003cstrong\u003eD)\u003c/strong\u003e anatomically accurate incorporation of arteries and aneurysms within the lateral sulcus\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/fcbf60f5474ab2c52eee1eee.jpg"},{"id":51835131,"identity":"8c3b3e73-c18e-4adc-9f11-cb0fd3e7b403","added_by":"auto","created_at":"2024-02-29 20:29:47","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":202667,"visible":true,"origin":"","legend":"\u003cp\u003eModel Assembly (depicted aneurysm models not included in this study).\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/bd665117b421244ad1546c1f.jpg"},{"id":51834577,"identity":"4d184b3f-4fe2-4ec8-a5ac-f47642ad0ab2","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":437755,"visible":true,"origin":"","legend":"\u003cp\u003eSimulation setup\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/75ad42b7466bb9dd3806a603.jpg"},{"id":51834706,"identity":"f33644e4-1ccc-4ac2-8ed4-b4439ac41444","added_by":"auto","created_at":"2024-02-29 20:21:47","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":396013,"visible":true,"origin":"","legend":"\u003cp\u003ePhantom model with identical MCA-aneurysm models and locations on both sides facilitating the comparative evaluation of the pterional and LSO approaches.\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/b4149011935706137f3816e0.jpg"},{"id":51834573,"identity":"1fbd4438-32a8-4b62-907b-177cfef1d419","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":323567,"visible":true,"origin":"","legend":"\u003cp\u003eSimulation Process: head positioning, craniotomy planning via standard pterional and the LSO approach, burr hole placements and craniotomy, dural opening, microsurgical dissection of the SF, visualization of key anatomical landmarks, target exposure, proximal control and clipping of both aneurysms.\u003c/p\u003e","description":"","filename":"8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/5a27e438007312db6d134a0e.jpg"},{"id":51834582,"identity":"a3cb60fc-2cb1-45b5-8212-66345e70c230","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":325366,"visible":true,"origin":"","legend":"\u003cp\u003eAverage responses of participating residents and neurosurgeons (n = 10) on the simulator’s educational usefulness and efficacy derived from a 5-point Likert scale\u003c/p\u003e","description":"","filename":"9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/ca9cbf402dbdb40235b0f395.jpg"},{"id":51834576,"identity":"8a57baee-ee4c-4b12-9511-4e99f412d723","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":208183,"visible":true,"origin":"","legend":"\u003cp\u003eAverage responses on realism and accuracy of the Phantom as perceived by experienced neurosurgeons (n = 4) derived from a 5-point Likert scale.\u003c/p\u003e","description":"","filename":"10.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/5071b0dcc6b299b867e5980b.jpg"},{"id":51834584,"identity":"abb19f62-35ab-4c15-9423-0ab276f42d44","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":210381,"visible":true,"origin":"","legend":"\u003cp\u003eComparative subjective grading of surgical exposure level of relevant anatomical structures via LSO and pterional approach by experienced neurosurgeons \u0026nbsp;(n = 4)\u003c/p\u003e","description":"","filename":"11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/64b7ac2f08bfe8ef2196afbf.jpg"},{"id":51834583,"identity":"8e102de9-35b8-4447-82da-747a367de2d2","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":378484,"visible":true,"origin":"","legend":"\u003cp\u003eResults in clipping quality by approach for MCA bifurcation-aneurysm with an average lengths of the M1-segment (14 mm) and a short M1-segment (8 mm).\u003c/p\u003e","description":"","filename":"12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/d2f17b14d9092e855077ba08.jpg"},{"id":51834579,"identity":"8cab1d2a-13fd-43f5-a6dc-5bc47c11b2c2","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":395270,"visible":true,"origin":"","legend":"\u003cp\u003ePost-simulation assessment of clipping quality of participating neurosurgeons based on OSAACS criteria revealing only a slight variation in clipping success between the two approaches.\u003c/p\u003e","description":"","filename":"13.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/9d393b9e4f31ff9cabb1ebb4.jpg"},{"id":51834585,"identity":"081a7e8a-f42d-44a3-99d1-6e162715e628","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":398682,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA)\u003c/strong\u003e Average complication rate by approach \u003cstrong\u003eB) \u003c/strong\u003eAverage procedure time by approach starting from head positioning to clipping of both aneurysms\u003c/p\u003e","description":"","filename":"14.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/2e882c1c334ed9c0c16ef535.jpg"},{"id":51834574,"identity":"45d27a97-d504-4448-9706-ae8cfdeb5a38","added_by":"auto","created_at":"2024-02-29 20:13:47","extension":"jpg","order_by":15,"title":"Figure 15","display":"","copyAsset":false,"role":"figure","size":361549,"visible":true,"origin":"","legend":"\u003cp\u003eObjective assessment of performances of participating medicals students (MS), neurosurgical residents (NR) and neurosurgeons (NS) over time (attempts 1 – 4). Initial differences in surgical skills reflecting users’ abilities showcase a high construct validity of the model. Significant increase in surgical skills, particularly among novice students and resident neurosurgeons, demonstrate high efficacy of the Phantom\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"15.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/1905bc1e2e75fd82a7a22513.jpg"},{"id":61596123,"identity":"e6c6e93e-022b-480d-bac9-889e38e2909a","added_by":"auto","created_at":"2024-08-01 17:24:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5262908,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/16632a86-13ae-41ae-b98c-8512119e2103.pdf"},{"id":51834705,"identity":"8474a008-a353-4035-a2d5-f63f1634984c","added_by":"auto","created_at":"2024-02-29 20:21:47","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":528301,"visible":true,"origin":"","legend":"","description":"","filename":"Tables1and2.docx","url":"https://assets-eu.researchsquare.com/files/rs-3986785/v1/0fca85307eb2492473879063.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pterional vs Lateral Supraorbital Approach in the Management of Middle Cerebral Artery Aneurysms: Insights from a Phantom Model Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe pterional approach\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e has been the standard technique employed for the management of middle cerebral artery (MCA) aneurysms for decades, providing wide exposure of the anterior and middle cranial fossae, sellar and parasellar regions, superior orbital fissure, and cavernous sinus. \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, the risk of temporalis muscle atrophy, damage to the frontal branch of the facial nerve, and cosmetic issues has limited this extremely versatile approach.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eModifications of the standard pterional approach have become popularized over the last 20 years, including mini-pterional \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e and lateral supraorbital (LSO) craniotomies.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The LSO offers several potential benefits over the pterional approach for the surgical treatment of unruptured MCA-bifurcation aneurysms. First, it offers comparable surgical exposure despite a smaller skin incision and craniotomy. This may result in less surgical morbidity and improved postoperative recovery, which is a significant advantage in patient-centered care. Second, the improved ergonomics offered by the LSO approach may reduce surgical time and improve the precision of aneurysm clipping.\u003c/p\u003e \u003cp\u003eThe choice of surgical approach should be tailored to the individual patient and the specific characteristics of the aneurysm. Each case requires specific microsurgical skills and techniques for a safe and effective dissection. Mastering this crucial technique requires considerable expertise and technical skills that were traditionally acquired through years of experience and rigorous training. As traditional teaching methods \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e cannot provide adequate opportunities for deliberate practice and skill development, alternative training opportunities are needed to accelerate the surgical learning curve. \u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSimulators can provide a safe, controlled, and risk-free environment for training, skill development, and mastery of intricate surgical techniques.\u003csup\u003e\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Moreover, if implemented correctly, high quality Phantom simulators have the potential to explore new techniques and approaches in a safe environment, allowing a shift towards a more pathology and patient-specific surgical treatment. However, the effectiveness of simulation training heavily relies on the quality and realism of the simulation techniques employed.\u003c/p\u003e \u003cp\u003eThis study aims to develop and evaluate a high-fidelity simulator for the microsurgical management of middle cerebral artery aneurysms in the context of clinical decision making. For this purpose, meticulously reconstructed models of the skull, brain, and meninges inclusive of MCA models with identical M1- and MCA-bifurcation aneurysms were manufactured employing 3D reconstruction techniques, additive manufacturing and rheological measurements. The simulator facilitates an unprecedented direct comparative analysis of two distinct surgical approaches in the management of identical middle cerebral artery aneurysms, a comparison previously unachievable due to the unique nature of each clinical scenario. To meet the requirements for an effective training and decision-making tool, the simulator was assessed by medical students, neurosurgical residents, and experienced neurosurgeons based on subjective and objective evaluation criteria.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study protocol adheres to the SQUIRE 2.0 guidelines.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eEthics approval:\u003c/h2\u003e\n\u003cp\u003eThe study protocol was conducted in compliance with the Declaration of Helsinki and approved by the ethics committee of the Otto-von-Guericke University Magdeburg. (Ethics vote number: RENOVA 94/20)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eStatement of Human and Animal Rights:\u003c/h2\u003e\n\u003cp\u003eThis article does not contain any studies with human or animal subjects.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eStatement of Informed Consent:\u003c/h2\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for their anonymized information to be published in this article.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eData Acquisition\u003c/h2\u003e\n\u003cp\u003eAfter obtaining the approval of the local ethics committee, imaging datasets (computed tomography angiography [CTA], and magnetic resonance imaging [MRI]) of a 52-year-old male with an incidental aneurysm of the left middle cerebral artery (MCA) were used for thresholding-based segmentation and reconstruction of the skull, brain and the circulus arteriosus willisi (CAW).\u003c/p\u003e\n\u003cp\u003eConstruction of the Phantom\u003c/p\u003e\n\u003cp\u003eThe creation of the Phantom combined digital reconstructions and post-processing with additive manufacturing, material research and handcrafting.\u003c/p\u003e\n\u003cp\u003eThe skull was reconstructed from the patient\u0026rsquo;s CT-angiography data by greysclae boundaries using the freely available 3D reoncstruction software \u003cem\u003eInVesalius3\u003c/em\u003e (Centro de Tecnologia da Informa\u0026ccedil;\u0026atilde;o Renato Archer (CTI)) and subsequently refined with the open-source graphics software tools \u003cem\u003eMeshMixer\u003c/em\u003e (Autodesk, Inc.), and \u003cem\u003eBlender\u003c/em\u003e (Blender Foundation - Nonprofit organization) to reduce production costs and time expenditure by incorporating reusable and detachable parts via slide and plug-in mechanisms. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe CAW was segmented from the patient\u0026rsquo;s contrast-enhanced T1 MRI dataset on the free cross-plattform application \u003cem\u003eMeVisLab\u003c/em\u003e (MeVis Medical Solutions AG, Bremen, Germany) employing threshold-based techniques. Subsequent mesh smoothing and adjustments were permormed with \u003cem\u003eMeshMixer\u003c/em\u003e and \u003cem\u003eSculptris 1.02\u003c/em\u003e (Pixologic, Inc., \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.sculpteo.com\" target=\"_blank\"\u003ewww.sculpteo.com\u003c/a\u003e\u003c/span\u003e\u003c/span\u003e). The CAW was designed to remainin in the centrale console of the skull with magnetic connectors integrated into the proximal M1-segments to facilitate a swift attachment and detachment of the aneurysm models. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eB\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe reconstruction of the brain from the patient\u0026rsquo;s MRI datatset was executed with the open-source software \u003cem\u003eFressurfer\u003c/em\u003e (Harvard University, Cambridge, Massachusetts, USA). Additional manual segmentation was required to accurately replicate the lateral sulcus and generate an anatomically precise negative mold and facilitate the subsequent casting of the Sylvian fissure (SF) models. To achieve this, the SF mesh was manually divided into two segments in Blender, determined by hand-selected points demarcating the pial surfaces of the temporal and frontal lobes within the sulcus. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eC\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditive manufacturing of the skull, CAW and SF models were executed on a desktop 3D Printer (\u003cem\u003eRaise3D Pro2 dual extrusion\u003c/em\u003e by Raise 3D Technologies, Inc.) using standard 1,75 mm PLA filaments. The rigidity disparities between compact and cancellous bone druing the drilling process were ensured by adjusting the infill density of the skull at 15%.\u003c/p\u003e\n\u003cp\u003eMimicking the tactile properties of the living brain was a challenging process based on previous studies and involving a substudy with subjective and objective material research and evaluations. Candle gel, identified by six experienced neurosurgeons for its similar tactile properties to the brain tissue as encountered during surgery, circumvents the limitations associated with previous gelatin-based models while offering a more sustainable and ethically sound option. The result was an anatomically and tactilly accurate, reusable replication of the SF. \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA\u003cstrong\u003e)\u003c/strong\u003e The subjective evaluation was further validated through rheological assessments. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMCA models with identical aneurysms located at M1 and MCA-birfucarrtion were handcrafted using paraffin wax and coated with two thin layers of liquid latex. After a detaliled shaping process, the models were then bathed in water with temperatures between 65\u0026deg;-70\u0026deg; C to wash out the paraffin wax. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eA \u003cstrong\u003e- C)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe simulation of the meninges involved applying a latex layer to mimic the dura mater, enhanced with a coalescing agent for better adhesion. \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003eA\u003cstrong\u003e)\u003c/strong\u003e The web-like texture of the arachnoid mater was recreated using a blend of synthetic resin adhesive, latex, and glycerin, meticulously applied to the SF to achieve a natural, wet look. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003eB\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eSimulator assembly:\u003c/h2\u003e\n\u003cp\u003eThe initial step of the assembly involves attaching the dura mater to the interchangeable lateral skull base models. Concurrently, the middle cerebral artery aneurysm models, and optionally cerebral veins, are carefully placed within the SF models. After applying the arachnoid membrane, the SF models are positioned in the lateral skull bases which are then connected to the central console via clip mechanisms. During this process, the aneurysm model establishes a magnetic connection with the CAW model placed on the central console. In the final assembly stage, the skull base and central console are securely attached to the rest of the Phantom via integrated rail-slide systems. The assembly process is depicted in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eThree groups of participants (n\u0026thinsp;=\u0026thinsp;22) with varying levels of neurosurgical experience were recruited for this study. \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eNovice Group (n\u0026thinsp;=\u0026thinsp;12): 4th - and 5th -year medical students (MS)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eAdvanced Group (n\u0026thinsp;=\u0026thinsp;6): 4th - and 5th -year neurosurgical residents (NR)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eExpert Group (n\u0026thinsp;=\u0026thinsp;4): neurosurgeons (NS) specialized in vascular neurosurgery\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSimulation setting:\u003c/p\u003e\n\u003cp\u003eThe simulation took place at the microneurosurgical laboratories of the department of neurosurgery, where a training environment with a full-functioning operating theatre is provided. Simulations were executed using a ZEISS OPMI Neuro NC-4. \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e A full set of neurosurgical instruments including drills, scalpels, forceps, scissors, bone punches, aneurysm clips, and clip appliers were organized on a surgical tray within a hand\u0026rsquo;s reach.\u003c/p\u003e\n\u003cp\u003eTo allow a direct comparison between the two approaches, identical MCA models fitted with two aneurysms placed in the M1- and MCA-bifurcation segments, were used in this study. The length of the M1-segment was set at 14 mm\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e where the MCA-bifurcation aneurysm was placed. A second aneurysm was placed at 8 mm length, representing an MCA-bifurcation aneurysm with a shorter M1-segment. \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSimulation Process:\u003c/p\u003e\n\u003cp\u003eThe simulation was preceded by an introduction explaining the principles and key steps of MCA aneurysm clipping. The surgical approach was predefined to the standard pterional and the lateral supraorbital approaches. All medical students received additional instruction on the operating microscope and microsurgical instruments. The participants started the simulation with the positioning of the head in a 3-pin immobilization device. Craniotomy and dural incision were performed. After visualizing the aneurysm a clip was chosen and placed on the neck of the aneurysm. Each participant performed the procedure twice, with either approach on one side of the Phantom. Both approaches were repeated after a period of three to five days. Per attempt, each participant was given one chance to clip each aneurysm with either one or two clips of choice. \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e8\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSimulation assessment:\u003c/p\u003e\n\u003cp\u003eThe simulations were directly followed by a questionnaire for the assessment of face and content validity derived on 5-point Likert scales. All participants (n\u0026thinsp;=\u0026thinsp;22) were asked to gauge their attitude towards the simulator. Neurosurgical residents and neurosurgeons rated the simulators\u0026rsquo; usefulness in developing technical skills. Experienced neurosurgeons rated the simulators\u0026rsquo; realism and accuracy.\u003c/p\u003e\n\u003cp\u003eThe expert group further compared both approaches regarding the surgical exposure of key anatomical structures, accessibility of MCA-bifurcation aneurysms, the ease of surgical manipulation, and overall surgical experience.\u003c/p\u003e\n\u003cp\u003eAll participants were observed during the simulations and assessed by two independent neurosurgeons based on the Objective Structured Assessment of Aneurysm Clipping Skills (OSAACS)\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e \u003cstrong\u003e(Table\u0026nbsp;2)\u003c/strong\u003e OSAACS rates surgical clipping skills based on user performance during simulation to evaluate progress in training and differentiate between novice and advanced surgeons (construct validity). The tool was modified to include specific assessment criteria for correct head positioning and craniotomy placement.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eSubjective Evaluation:\u003c/h2\u003e\n\u003cp\u003eFace and content validities: The simulator was rated favorably by neurosurgical residents, and neurosurgeons with a mean score of 4.9 out of 5 regarding its educational usefulness in conveying and training key steps of the procedure and developing surgical skills. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e9\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e Experienced neurosurgeons perceived the simulator as highly accurate regarding tactile and anatomical realism (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe results of the subjective evaluation of the LSO and pterional approach by experienced neurosurgeons regarding surgical exposure levels are shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e11\u003c/span\u003e. In terms of accessibility, the LSO approach offered comparable exposure of the M1-segment and the bifurcation of the MCA as the pterional approach. This was particularly the case for aneurysms of the short M1-segments. However, while the LSO can provide access to the optic nerve and anterior clinoid process, its trajectory may limit exposure to structures that are more lateral or posterior without additional bone removal.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eObjective Evaluation:\u003c/h2\u003e\n\u003cp\u003eConstruct validity: The average results in clipping quality by approach and participant for MCA bifurcation-aneurysm with an average length of the M1-segment (14 mm) and a short M1-segment (8 mm) are presented in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e12\u003c/span\u003eA and B. The placement of clips via the pterional approach was often easier for novice medical students and neurosurgical residents as it offerered superior ergonomics, resulting in higher clipping success rates, particularly for MCA -bifurcation aneurysms with an average M1-lenght.\u003c/p\u003e\n\u003cp\u003eHowever, among experienced neurosurgeons, the LSO approach offered comparable clipping success in MCA-bifurcation aneurysms with an average M1 lengths and even slightly higher clipping quality success in MCA variations with a short M1-segment, (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e13\u003c/span\u003e) while on average offering lower complication rates and a shorter procedure time than the standard pterional approach (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e14\u003c/span\u003eA, B)\u003c/p\u003e\n\u003cp\u003eThe initial differences between the participating groups in clipping quality and other performance metrics based on OSAACS showcases a high construct validity of the simulator. Objective assessments of surgical clipping skills of the participating groups over a period of four attempts in four key metrics are presented in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e15\u003c/span\u003e. The novice group experienced a rapid and considerable increase in accuracy, timing, and quality, underlining the efficacy of the simulator to convey microsurgical understanding and techniques.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we investigated the utility of a state-of-the-art Phantom model in juxtaposing the lateral supraorbital (LSO) and pterional approaches for treating unruptured middle cerebral artery (MCA) bifurcation aneurysms.\u003c/p\u003e \u003cp\u003eBy facilitating a direct comparison between the LSO and pterional approaches, the presented model provided insights into the potential benefits of the LSO approach, such as comparable surgical exposure and clipping success and the potential for reduced surgical morbidity and improved postoperative recovery. The LSO approach, however, requires more technical expertise and precise surgical manipulation in a limited operative field. Traditionally, these skills are acquired through rigorous training and repetition. Simulation training has the potential to accelerate the learning curve by allowing surgeons to gain familiarity with these requirements and build confidence in performing the technique, thereby potentially improving patient outcomes.\u003c/p\u003e \u003cp\u003eThe fundamental assumption of simulation-based training, however, is that skills acquired in simulated settings are transferable to the operative setting \u003csup\u003e\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. The more realistic the simulation, the more likely that it will help improve surgical skills such as dexterity and spatial awareness. At the same time, a lack of realism can lead to a negative learning effect and ultimately endanger patients\u0026rsquo; lives.\u003c/p\u003e \u003cp\u003eThe presented Phantom model, designed to encompass varying lengths of the M1-segment and bifurcation aneurysms, allowed the participants to simulate the surgical experience closely, thereby offering a safe and controlled environment for learning and skill refinement. The incorporation of accurate tactile and rheological properties enables trainees to develop a keen sense of touch, dexterity, and instrument handling that can be transferred to any neurosurgical procedures involving the use of microsurgical instruments and a microscope.\u003c/p\u003e \u003cp\u003eLimitations:\u003c/p\u003e \u003cp\u003eWhile the sequential improvement in skills observed among inexperienced participants indicates high efficacy, post-training performances in real-life scenarios would need to be evaluated to see if improvements on the simulator translate to real-world skill enhancements.\u003c/p\u003e"},{"header":"Conclusion","content":" \u003cp\u003eThe choice of surgical approach should be tailored to the individual patient and the specific characteristics of the aneurysm. The results of this study highlight the benefits of the LSO over the standard pterional approach such as reduced operation time and complication rates but also the challenges that a smaller approach entails. The results of the objective and subjective assessments of the presented Phantom showcase the invaluable role of Phantom simulators in overcoming these challenges and, ultimately, advancing patient-specific treatment strategies. Future studies should continue to leverage Phantoms simulators to explore and compare other surgical approaches, with the ultimate aim of accelerating the surgical learning curve and improving patient care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was conducted in compliance with the Declaration of Helsinki and approved by the ethics committee of the Otto-von-Guericke University Magdeburg. (Ethics vote number: RENOVA 94/20)\u003c/p\u003e\n\u003cp\u003eComplete written informed consent was obtained from the patient for the publication of this study and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Patient consent for participation and publication was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding or financial support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments and authors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAA and BN designed and organized the simulations, derived the models, and analyzed the data.\u003c/p\u003e\n\u003cp\u003eAA, VMS, KPS contributed to the digital reconstructions of the models and sample preparation.\u003c/p\u003e\n\u003cp\u003eAA, BN, and took the lead in writing the manuscript.\u003c/p\u003e\n\u003cp\u003eBN, VMS, AR, and IES contributed to the interpretation of the results.\u003c/p\u003e\n\u003cp\u003eAR, BN, KPS, and IES supervised and assessed the simulations.\u003c/p\u003e\n\u003cp\u003eAll authors provided critical feedback and helped shape the research, analysis, and manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors discussed the results and contributed to the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWen HT, Oliveira E de, Tedeschi H, Andrade FC, Rhoton AL. The pterional approach: Surgical anatomy, operative technique, and rationale. \u003cem\u003eOperative Techniques in Neurosurgery\u003c/em\u003e. 2001;4(2):60-72. doi:10.1053/otns.2001.25567\u003c/li\u003e\n\u003cli\u003e1. Yasargil MG, Antic J, Laciga R, Jain KK, Hodosh RM, Smith RD. Microsurgical pterional approach to aneurysms of the basilar bifurcation. Surg Neurol. 2005;63(6):491-499.\u003c/li\u003e\n\u003cli\u003eTra H, Huynh T, Nguyen B. Minipterional and Supraorbital Keyhole Craniotomies for Ruptured Anterior Circulation Aneurysms: Experience at Single Center. \u003cem\u003eWorld Neurosurgery\u003c/em\u003e. 2018;109:36-39. doi:10.1016/j.wneu.2017.09.058\u003c/li\u003e\n\u003cli\u003eLan Q, Zhang H, Zhu Q, et al. Keyhole Approach for Clipping Intracranial Aneurysm: Comparison of Supraorbital and Pterional Keyhole Approach. \u003cem\u003eWorld Neurosurgery\u003c/em\u003e. 2017;102:350-359. doi:10.1016/j.wneu.2017.02.025\u003c/li\u003e\n\u003cli\u003eLan Q, Zhu Q, Li G. 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In: Yonekawa Y, Keller E, Sakurai Y, Tsukahara T, eds. \u003cem\u003eNew Trends of Surgery for Stroke and Its Perioperative Management\u003c/em\u003e. Vol 94. Acta Neurochirurgica Supplements. Springer-Verlag; 2005:17-21. doi:10.1007/3-211-27911-3_4\u003c/li\u003e\n\u003cli\u003eChoque-Velasquez J, Hernesniemi J. One burr-hole craniotomy: Lateral supraorbital approach in Helsinki Neurosurgery. \u003cem\u003eSurg Neurol Int\u003c/em\u003e. 2018;9(1):156. doi:10.4103/sni.sni_185_18\u003c/li\u003e\n\u003cli\u003eCameron JL. William Stewart Halsted. Our surgical heritage. \u003cem\u003eAnn Surg\u003c/em\u003e. 1997;225(5):445-458. doi:10.1097/00000658-199705000-00002\u003c/li\u003e\n\u003cli\u003eWright JR, Schachar NS. 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IEEE; 2018:1327-1330. doi:10.1109/EMBC.2018.8512524\u003c/li\u003e\n\u003cli\u003eBudday S, Sommer G, Haybaeck J, Steinmann P, Holzapfel GA, Kuhl E. Rheological characterization of human brain tissue. \u003cem\u003eActa Biomater\u003c/em\u003e. 2017;60:315-329. doi:10.1016/j.actbio.2017.06.024\u003c/li\u003e\n\u003cli\u003eBudday S, Ovaert TC, Holzapfel GA, Steinmann P, Kuhl E. Fifty Shades of Brain: A Review on the Mechanical Testing and Modeling of Brain Tissue. \u003cem\u003eArch Computat Methods Eng\u003c/em\u003e. 2020;27(4):1187-1230. doi:10.1007/s11831-019-09352-w\u003c/li\u003e\n\u003cli\u003eUrvi S, Suman V, Subathra A. Assessment of morphometric parameters of middle cerebral artery using CT angiography in a tertiary care hospital. \u003cem\u003eSurg Radiol Anat\u003c/em\u003e. 2023;45(8):939-945. doi:10.1007/s00276-023-03148-1\u003c/li\u003e\n\u003cli\u003eBelykh E, Miller EJ, Lei T, et al. Face, Content, and Construct Validity of an Aneurysm Clipping Model Using Human Placenta. \u003cem\u003eWorld Neurosurgery\u003c/em\u003e. 2017;105:952-960.e2. doi:10.1016/j.wneu.2017.06.045\u003c/li\u003e\n\u003cli\u003eDawe SR, Pena GN, Windsor JA, et al. Systematic review of skills transfer after surgical simulation-based training. \u003cem\u003eBr J Surg\u003c/em\u003e. 2014;101(9):1063-1076. doi:10.1002/bjs.9482\u003c/li\u003e\n\u003cli\u003eSturm LP, Windsor JA, Cosman PH, Cregan P, Hewett PJ, Maddern GJ. A Systematic Review of Skills Transfer After Surgical Simulation Training. \u003cem\u003eAnnals of Surgery\u003c/em\u003e. 2008;248(2):166-179. doi:10.1097/SLA.0b013e318176bf24\u003c/li\u003e\n\u003cli\u003eDavids J, Manivannan S, Darzi A, Giannarou S, Ashrafian H, Marcus HJ. Simulation for skills training in neurosurgery: a systematic review, meta-analysis, and analysis of progressive scholarly acceptance. \u003cem\u003eNeurosurg Rev\u003c/em\u003e. Published online September 18, 2020. doi:10.1007/s10143-020-01378-0\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3986785/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3986785/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe pterional approach has traditionally been employed for managing middle cerebral artery (MCA) aneurysms. With potential benefits like reduced surgical morbidity and improved postoperative recovery, the lateral supraorbital approach (LSO) should be considered individually based on aneurysm morphology, location and patient-specific variations of the MCA anatomy, which requires considerable technical expertise traditionally acquired through years of experience.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eDevelopment and evaluation of a novel Phantom simulator in the context of clinical decision-making in the managmement of MCA aneurysm.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eHigh-fidelity Phantom simulators inclusive of MCA models with identical M1- and bifurcation aneurysms were manufactured employing 3D reconstruction techniques, additive manufacturing and rheological testings. Medical students, neurosurgical residents, and seasoned neurosurgeons (n\u0026thinsp;=\u0026thinsp;22) tested and evaluated both approaches. Clipping quality, participants\u0026rsquo; performances and progress over time were assessed based on objective metrics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe simulator received positive ratings in face and content validity, with mean scores of 4.9 out of 5, respectively. Objective evaluation demonstrated the model\u0026rsquo;s efficacy as a training and assessment tool. While requiring more technical expertise, results of the comparative analysis suggest that the LSO approach can improve clipping precision and outcome particularly in patients with shorter than average M1-segments.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe employed methodology allowed a direct comparison of the pterional and LSO approaches, revealing comparable success rates via the LSO while reducing operation time and complication rate. The Phantom proved to be an effective training, particularly among inexperienced participants. Future research should aim to establish simulators in the context of clinical decision making.\u003c/p\u003e","manuscriptTitle":"Pterional vs Lateral Supraorbital Approach in the Management of Middle Cerebral Artery Aneurysms: Insights from a Phantom Model Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-29 20:13:42","doi":"10.21203/rs.3.rs-3986785/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-25T01:37:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-22T04:19:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-20T01:57:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87659244915309163749977262969037864569","date":"2024-05-20T01:20:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113880931752942087927012393628826915818","date":"2024-05-07T20:20:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-07T13:43:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6ab35be1-6bf1-4092-934f-d16e5444095c","date":"2024-03-07T11:26:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8964ac04-21f1-4582-80fe-26ee1bab51ef_SNPRID","date":"2024-03-06T02:52:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4cecd8de-a194-40b9-be82-84a7684d012e","date":"2024-03-06T00:32:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-06T00:11:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-06T00:10:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-27T04:16:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2024-02-25T04:08:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bad1af8d-8061-4dfd-b67c-1f0babb14950","owner":[],"postedDate":"February 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-01T17:05:48+00:00","versionOfRecord":{"articleIdentity":"rs-3986785","link":"https://doi.org/10.1007/s10143-024-02518-6","journal":{"identity":"neurosurgical-review","isVorOnly":false,"title":"Neurosurgical Review"},"publishedOn":"2024-07-22 16:15:52","publishedOnDateReadable":"July 22nd, 2024"},"versionCreatedAt":"2024-02-29 20:13:42","video":"","vorDoi":"10.1007/s10143-024-02518-6","vorDoiUrl":"https://doi.org/10.1007/s10143-024-02518-6","workflowStages":[]},"version":"v1","identity":"rs-3986785","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3986785","identity":"rs-3986785","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}