Hamed Azarnoush

Assessing bimanual performance in brain tumor resection with NeuroTouch, a virtual reality simulator.

BACKGROUND: Validated procedures to objectively measure neurosurgical bimanual psychomotor skills are unavailable. The NeuroTouch simulator provides metrics to determine bimanual performance, but validation is essential before implementation of this platform into neurosurgical training, assessment, and curriculum development. OBJECTIVE: To develop, evaluate, and validate neurosurgical bimanual performance metrics for resection of simulated brain tumors with NeuroTouch. METHODS: Bimanual resection of 8 simulated brain tumors with differing color, stiffness, and border complexity was evaluated. Metrics assessed included blood loss, tumor percentage resected, total simulated normal brain volume removed, total tip path lengths, maximum and sum of forces used by instruments, efficiency index, ultrasonic aspirator path length index, coordination index, and ultrasonic aspirator bimanual forces ratio. Six neurosurgeons and 12 residents (6 senior and 6 junior) were evaluated. RESULTS: Increasing tumor complexity impaired resident bimanual performance significantly more than neurosurgeons. Operating on black vs glioma-colored tumors resulted in significantly higher blood loss and lower tumor percentage, whereas altering tactile cues from hard to soft decreased resident tumor resection. Regardless of tumor complexity, significant differences were found between neurosurgeons, senior residents, and junior residents in efficiency index and ultrasonic aspirator path length index. Ultrasonic aspirator bimanual force ratio outlined significant differences between senior and junior residents, whereas coordination index demonstrated significant differences between junior residents and neurosurgeons. CONCLUSION: The NeuroTouch platform incorporating the simulated scenarios and metrics used differentiates novice from expert neurosurgical performance, demonstrating NeuroTouch face, content, and construct validity and the possibility of developing brain tumor resection proficiency performance benchmarks.

Neurosurgical Assessment of Metrics Including Judgment and Dexterity Using the Virtual Reality Simulator NeuroTouch (NAJD Metrics)

Advances in computer-based technology has created a significant opportunity for implementing new training paradigms in neurosurgery focused on improving skill acquisition, enhancing procedural outcome, and surgical skills assessment. NeuroTouch is a computer-based virtual reality system that can generate output data known as metrics from operator performance during simulated brain tumor resection. These measures of quantitative assessment are used to track and compare psychomotor performance during simulated operative procedures. Data output from the NeuroTouch system is recorded in a comma-separated values file. Data mining from this file and subsequent metrics development requires the use of sophisticated software and engineering expertise. In this article, we introduce a system to extract a series of new metrics using the same data file using Excel software. Based on the data contained in the NeuroTouch comma-separated values file, 13 novel NeuroTouch metrics were developed and classified. Tier 1 metrics include blood loss, tumor percentage resected, and total simulated normal brain volume removed. Tier 2 metrics include total instrument tip path length, maximum force applied, sum of forces utilized, and average forces utilized by the simulated ultrasonic aspirator and suction instrument along with pedal activation frequency of the ultrasonic aspirator. Advanced tier 2 metrics include instrument tips average separation distance, efficiency index, ultrasonic aspirator path length index, coordination index, and ultrasonic aspirator bimanual forces ratio. This system of data extraction provides researchers expedited access for analyzing the data files available for NeuroTouch platform to assess the multiple psychomotor and cognitive neurosurgical skills involved in complex surgical procedures.

Bimanual Psychomotor Performance in Neurosurgical Resident Applicants Assessed Using NeuroTouch, a Virtual Reality Simulator.

OBJECTIVE Current selection methods for neurosurgical residents fail to include objective measurements of bimanual psychomotor performance. Advancements in computer-based simulation provide opportunities to assess cognitive and psychomotor skills in surgically naive populations during complex simulated neurosurgical tasks in risk-free environments. This pilot study was designed to answer 3 questions: (1) What are the differences in bimanual psychomotor performance among neurosurgical residency applicants using NeuroTouch? (2) Are there exceptionally skilled medical students in the applicant cohort? and (3) Is there an influence of previous surgical exposure on surgical performance? DESIGN Participants were instructed to remove 3 simulated brain tumors with identical visual appearance, stiffness, and random bleeding points. Validated tier 1, tier 2, and advanced tier 2 metrics were used to assess bimanual psychomotor performance. Demographic data included weeks of neurosurgical elective and prior operative exposure. SETTING This pilot study was carried out at the McGill Neurosurgical Simulation Research and Training Center immediately following neurosurgical residency interviews at McGill University, Montreal, Canada. PARTICIPANTS All 17 medical students interviewed were asked to participate, of which 16 agreed. RESULTS Performances were clustered in definable top, middle, and bottom groups with significant differences for all metrics. Increased time spent playing music, increased applicant self-evaluated technical skills, high self-ratings of confidence, and increased skin closures statistically influenced performance on univariate analysis. A trend for both self-rated increased operating room confidence and increased weeks of neurosurgical exposure to increased blood loss was seen in multivariate analysis. CONCLUSIONS Simulation technology identifies neurosurgical residency applicants with differing levels of technical ability. These results provide information for studies being developed for longitudinal studies on the acquisition, development, and maintenance of psychomotor skills. Technical abilities customized training programs that maximize individual resident bimanual psychomotor training dependant on continuously updated and validated metrics from virtual reality simulation studies should be explored.

Real-Time Control of Angioplasty Balloon Inflation Based on Feedback From Intravascular Optical Coherence Tomography: Preliminary Study on an Artery Phantom

A method is proposed to achieve computerized control of angioplasty balloon inflation, based on feedback from intravascular optical coherence tomography (IVOCT). Controlled balloon inflation could benefit clinical applications, cardiovascular research, and medical device industry. The proposed method was experimentally tested for balloon inflation within an artery phantom. During balloon inflation, luminal contour of the phantom was extracted from IVOCT images in real time. Luminal diameter was estimated from the obtained contour and was used in a feedback loop. Based on the estimated actual diameter and a target diameter, a computer controlled a programmable syringe pump to deliver or withdraw liquid in order to achieve the target diameter. The performance of the control method was investigated under different conditions, e.g., various flow rates and various target diameters. The results were satisfactory, as the control method provided convergence to the target diameters in various experiments.

Optical coherence tomography monitoring of angioplasty balloon inflation in a deployment tester

We present an innovative integration of an intravascular optical coherence tomography probe into a computerized balloon deployment system to monitor the balloon inflation process. The high-resolution intraluminal imaging of the balloon provides a detailed assessment of the balloon quality and, consequently, a technique to improve the balloon manufacturing process. A custom-built swept-source optical coherence tomography system is used for real-time imaging. A semicompliant balloon with a nominal diameter of 4 mm is fabricated for the experiments. Imaging results correspond to balloon deployment in air and inside an artery phantom. A characterization of the balloon diameter, wall thickness, compliance, and elastic modulus is provided, based on image segmentation. Using the images obtained from the probe pullback, a three-dimensional visualization of the inflated balloon is presented.

Intravascular optical coherence tomography to characterize tissue deformation during angioplasty: preliminary experiments with artery phantoms.

Abstract. We explored the potential of intravascular optical coherence tomography (IVOCT) to assess deformation during angioplasty balloon inflation. Using a semi-compliant balloon and artery phantoms, we considered two experimental scenarios. The goal for the first scenario was to investigate if variation in the elasticity of the structure surrounding the balloon could be sensed by IVOCT monitoring. In this scenario, we used three single-layer phantoms with various mechanical properties. Image analysis was performed to extract the inner and outer diameters of the phantoms at various pressures. The goal for the second scenario was twofold. First, we investigated the IVOCT capability to monitor a more complex balloon inflation process. The balloon was in a folded state prior to inflation. This allowed studying two stages of deformation: during balloon unfolding and during balloon expansion. Second, we investigated IVOCT capability to monitor the deformation in a three-layer phantom used to better mimic a true artery. So, not only were the IVOCT images processed to provide the inner and outer diameters of the phantom, but the layer thicknesses were also determined. In both scenarios, IVOCT monitoring revealed to be very efficient in providing relevant information about the phantom deformation during balloon inflation.

Real-time Control of Angioplasty Balloon Inflation Based on Feedback from Intravascular Optical Coherence Tomography: Experimental Validation on an Excised Heart and a Beating Heart Model

We report on real-time control of balloon inflation inside porcine arteries. In the first step, experiments were done in a coronary artery of an excised heart. In the second step, experiments were done in a beating heart setup providing conditions very close to in vivo conditions without the complications. A programmable syringe pump was used to inflate a compliant balloon in arteries, while intravascular optical coherence tomography (IVOCT) monitoring was performed. In a feedback loop, IVOCT images were processed to provide the balloon diameter values in real time to control the pump action in order to achieve a target diameter. In different experiments, various flow rates and target diameters were used. In the excised heart experiment, there was good convergence to target diameters resulting in a satisfactory balloon inflation control. In the beating heart experiment, there were oscillations in the diameter values due to cyclic arterial contractions. In these experiments, the control system maintained diameter averages satisfactorily close to predetermined target values. Real-time control of balloon inflation could not only provide a safer outcome for angioplasty procedures, but could also provide additional information for diagnostics since it implicitly provides information about the artery response to the inflation process.

Evaluation of a technique to estimate the compliance of atherosclerotic intima

We report evaluation of a technique that may be applied to estimate the compliance of atherosclerotic intima. This estimation can help in identification of the type of plaque. It can also be applied in our finite element software, developed to simulate coronary angioplasty. The software accepts segmented intravascular ultrasound images together with each segments material characteristics. It then simulates the response of the diseased artery, to help choose optimal balloons or stents and also to improve the pressurization strategy. The technique is based on formulating the compliance of two materials in series. A two-layer and two single-layer phantoms were produced to verify the validity of this formulation in practice. The outer layer of the two-layer phantom is chosen with characteristics similar to a real artery. The harder inner layer imitates the intimal thickening. A balloon deployment testing machine, non-compliant balloons and a laser measurement unit were used in experiments.

Drift-diffusion explains response variability and capacity for tracking objects

Being able to track objects that surround us is key for planning actions in dynamic environments. However, rigorous cognitive models for tracking of one or more objects are currently lacking. In this study, we asked human subjects to judge the time to contact (TTC) a finish line for one or two objects that became invisible shortly after moving. We showed that the pattern of subject responses had an error variance best explained by an inverse Gaussian distribution and consistent with the output of a biased drift-diffusion model. Furthermore, we demonstrated that the pattern of errors made when tracking two objects showed a level of dependence that was consistent with subjects using a single decision variable for reporting the TTC for two objects. This finding reveals a serious limitation in the capacity for tracking multiple objects resulting in error propagation between objects. Apart from explaining our own data, our approach helps interpret previous findings such as asymmetric interference when tracking multiple objects.

Nonstationary chimeras in a neuronal network

Chimeras are special states that are composed of coexisting spatial domains of coherent and incoherent dynamics, which typically emerge in identically coupled oscillators. In this paper, we study a network of nonlocally coupled Hindmarsh-Rose neurons that are subject to an alternating current. We show that chimera states emerge when the neurons are connected through electrical synapses. The considered model has two coexisting attractors, namely a limit cycle and a chaotic attractor, to which the dynamics converges in dependence on the initial conditions. While earlier research reported the existence of chimeras in Hindmarsh-Rose neuronal networks mainly through chemical synapses, here we show that an alternating current in an electrically coupled network can also evoke chimeras, whereby the spatial positions of coherent and incoherent domains vary with time. Remarkably, we also observe chimera states in locally coupled neurons through electrical synapses, which reduce the relaxation of nonlocallity in the coupling configuration. The existence of nonstationary chimeras is confirmed by means of a local order parameter.