Acta Neurochirurgica

, Volume 161, Issue 3, pp 611–619 | Cite as

Treating cerebrovascular diseases in hybrid operating room equipped with a robotic angiographic fluoroscopy system: level of necessity and 5-year experiences

  • Chih-Hsiang Liao
  • Wen-Hsien Chen
  • Chung-Hsin Lee
  • Shih-Chieh Shen
  • Yuang-Seng TsueiEmail author
Original Article - Vascular Neurosurgery - Other
Part of the following topical collections:
  1. Vascular Neurosurgery – Other



A hybrid operating room (OR) equipped with robotic angiographic fluoroscopy system has become prevalent in neurosurgery. The level of necessity of the hybrid OR in treating cerebrovascular diseases (CVD) is rarely discussed.


The authors proposed a scoring and classification system to evaluate the cerebrovascular procedures according to the level of treatment necessity for CVD in a hybrid OR and shared our 5-year experiences.


From December 2009 to January 2016, the registry of cerebrovascular procedures performed in the hybrid OR was retrieved. A scoring system was used to evaluate the importance of the surgical and interventional components of a cerebrovascular procedure performed in the hybrid OR. The score of either component ranged from 1, 1.5, to 2 (1 = no role, 1.5 = supplementary or informative, 2 = important or therapeutic). The total score of a procedure was by multiplying two individual scores. Levels of necessity were classified into level A (important), level B (beneficial), and level C (replaceable).


A total of 1027 cerebrovascular procedures were performed during this period: diagnostic angiography in 328, carotid artery stenting in 286, aneurysm coiling in 128, intra-operative DSA in 101, aspiration of ICH under image guidance in 79, intra-arterial thrombolysis/thrombectomy in 51, intracranial angioplasty/stenting in 30, hybrid surgery/serial procedures in 19, and rescue surgery during embolization in 5. According to the scoring system, hybrid surgery and serial procedures scored the highest points (2 × 2). The percentages distributed at each level: levels A (2.3%), B (17.5%), and C (80.2%).


This study conveys a concept of what a hybrid OR equipped with robotic angiographic fluoroscopy system is capable of and its potential. For cerebrovascular diseases, hybrid OR exerts its value via hybrid surgery or avoiding patient transportation in serial procedures (level A), via providing real-time high-quality angiography and image guidance (level B), which constituted about 20% of the cases. The subspecialty of the group using the hybrid OR directly reflects on the number of procedures categorized in each level. In a hybrid OR, innovative treatment strategies for difficult-to-treat CVD can be developed.


Cerebrovascular disease Cone-beam computed tomography Digital subtraction angiography Endovascular Hybrid operating room Hybrid surgery Robotic angiographic fluoroscopy system 



We thank Hong-Hsin Lin, Shih-Ruei Huang, and Meng-Ju Lee for their technical assistance in the neurosurgical hybrid operating suite in Taichung Veterans General Hospital.


No funding was received for this research.

Compliance with ethical standards

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (IRB TCVGH No. CE17084A) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this retrospective study, formal consents were not required.

Supplementary material

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Supplementary Figure 1

Rescue EVD surgery for intra-procedural arterial perforation (IPAP) during coiling. (Level A) (A) CTA showed an unruptured aneurysm at the AComA, about 6 mm in dome size. The aneurysm is indicated by the red arrow in this fig. (B) In deploying the first framing coil, aneurysm rupture occurred. Contrast extravasation was noted (yellow arrow). (C) Arrested intracranial blood flow secondary to increased intracranial pressure was detected in the following DSA. (D) Intra-operative photo showed immediate conversion to rescue EVD surgery without moving the patient in the hybrid OR. (E) After EVD insertion, intracranial blood flow restored and allowed completion of aneurysm coiling until there was no further extravasation (F) Final DSA showed adequate aneurysm coiling and patent flow in bilateral anterior cerebral arteries. The blue arrow indicated the ventricular catheter. (PNG 2843 kb)

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High Resolution Image (TIF 3785 kb)
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Supplementary Figure 2

Dyna-CT guided aspiration of ICH in the hybrid OR. (Level B) (A) Pre-operative non-contrast brain CT revealed a left putaminal hemorrhage, about 35 mL. (B) A frontal burr hole was made at the left Kocher’s point, and the ICH location was re-confirmed by Dyna-CT scan. In the workstation, the trajectory of the catheter insertion was a straight line connecting the burr hole and the center of the ICH. The depth of insertion was also calculated. (C) The central region of the ICH was chosen as a target, indicated by the red spot. (D) The direction of fluoroscopic projections of the robotic arm was parallel to the pre-determined trajectory. Under fluoroscopic guidance, the stylet-attached catheter was advanced and projected as a point to confirm correct trajectory. (E) Gentle aspiration of the ICH was performed through the catheter. (F) Intra-operative Dyna-CT showed the ICH volume was immediately reduced to 8 ml (23%). CT scan on post-operative day 3 showed the ICH volume decreased to 1 ml (3%) after direct infusion of urokinase through the catheter. (PNG 2409 kb)

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High Resolution Image (TIF 3248 kb)
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Supplementary Figure 3

A left MCA complex aneurysm treated in the hybrid OR. (Level B) (A and B) CT angiography showed a left MCA complex aneurysm with ICA/ACA junction involvement and distal M1 dilatation. (C) Intra-operative 3D DSA simulated the actual operative view. (D) Intra-operative 3D DSA was performed by a robotic C-arm rotation for data acquisition (E) Post-operative 3D DSA confirmed adequate clip position. (F) Pre- and intra-operative DSA showed no obvious differences in blood flow velocity to the distal MCA territory after clipping surgery. (PNG 3619 kb)

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High Resolution Image (TIF 13906 kb)
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Supplementary Figure 4

A 4-cm AVM at right motor and sensory cortex with hemorrhage treated in the hybrid OR. (Level B) (A) Brain CT scan revealed an unusual location of hemorrhage at eloquent region. (B) 3D CT angiography revealed a MCA-supplied AVM with two large draining veins to the superior sagittal sinus. (C, D, and E) Illustrative fluoroscopic roadmap views assisted in AVM localization before skin incision and before craniotomy. (F) DSA showed multiple MCA branches supplied the AVM. (G) After temporary clipping of two main feeding arteries (red arrows), intra-operative DSA roadmap view assisted in confirming additional feeder (indicated by Rhoton dissector/blue arrow) to the nidus. (H) Intra-operative DSA showed no residual AVM after the excision. (PNG 2172 kb)

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High Resolution Image (TIF 3095 kb)


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  • Chih-Hsiang Liao
    • 1
    • 2
  • Wen-Hsien Chen
    • 3
  • Chung-Hsin Lee
    • 4
  • Shih-Chieh Shen
    • 5
  • Yuang-Seng Tsuei
    • 1
    • 2
    • 6
    Email author
  1. 1.Institute of MedicineChung Shan Medical UniversityTaichungTaiwan
  2. 2.Department of Neurosurgery, Neurological InstituteTaichung Veterans General HospitalTaichungTaiwan
  3. 3.Department of NeuroradiologyTaichung Veterans General HospitalTaichungTaiwan
  4. 4.Department of NeurosurgeryTaichung Tzu Chi HospitalTaichungTaiwan
  5. 5.Department of NeurosurgeryTri-service General Hospital Songshan BranchTaipeiTaiwan
  6. 6.Department of Neurosurgery, National Defense Medical CenterTri-service General HospitalTaipeiTaiwan

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