Vitor Pereira and Nicole Cancelliere (St Michael’s Hospital, Toronto, Canada) outline recent breakthroughs in the deployment of robotics for neurointerventional procedures and discuss future use indications for these technologies within stroke treatment.
Although use of robotics in surgery is not a new concept, its application in neurointerventional surgery is very recent. On 1 November 2019, our team (Pereira et al) performed the first robotic-assisted neurosurgical procedure in the world, and we have since built the largest case series globally. The one-year follow-up imaging and clinical results from the initial case series was recently published in the Journal of NeuroInterventional Surgery—demonstrating the safety and efficacy of the system for intracranial aneurysm treatment.
Regarding the benefits of the current system, it is incredibly precise, and the operator can comfortably perform the procedure from a seated position without the need for a heavy X-ray protective suit and with a close-up view of the screens enhancing visualisation of the anatomy. The team is using a robotic system called the CorPath GRX (Corindus/Siemens Healthineers), which is currently the only robotic system clinically approved for neurovascular interventions.
The operator controls the robot from a controller in a lead-shielded cockpit or from the angio control room, while the bedside team—with a specialised robotic technologist—exchange devices into the robot and manage the patient. The system allows for millimetric control of one microcatheter and one microwire. Although this is sufficient to perform most of the intracranial steps of an aneurysm repair, such as a stent-assisted coiling or flow diverter placement, the system will need to be developed further before it can be used in acute ischaemic stroke.
Endovascular treatments for acute ischaemic stroke
In 2015, the results of five randomised controlled trials showed that a mechanical thrombectomy, or endovascular therapy (EVT), is the most effective treatment for large vessel occlusions causing acute ischaemic stroke. Across all trials, the single-most important indicator for good patient outcomes was time between symptom onset to reperfusion. The faster a patient receives EVT to remove the blood clot in the brain, the better the chance of survival and good neurological outcomes—hence “Time is Brain”.
Comprehensive stroke centres, which provide this life-saving procedure, are typically located in urban centres as highly specialised expertise is available. It is virtually impossible to have a fully trained neurointerventionist team in all remote hospitals. For this reason, there is a large inequity in access to stroke care for patients living in rural communities. More than half of the people living in North America do not have timely access to EVT, and thus are at a significantly higher risk of neurological impairment or death if they have a stroke.
Remote robotics and equal stroke care access for rural communities
Our team is working towards building a future where the operator in an urban city like Toronto will be able to perform an EVT procedure for stroke in a rural Canadian city using telerobotics. There will certainly be challenges, but that is what makes the work we do so exciting. As part of the robotic research programme at the RADIS Lab, we have led over 200 experiments to develop the techniques and approaches used for robotic intracranial aneurysm procedures performed today.
Various themes will need to be addressed to make the leap from the current system to remote robotic stroke treatment. Although the CorPath GRX system has been used to perform long distance telerobotic-assisted percutaneous coronary interventions, a newer generation of the robot—which gives the operator complete control from the access site to the brain—will need to be developed to make this goal of remote stroke treatment a success.
There has previously been some uncertainty expressed towards remote stroke treatment but, to allay these concerns, we are preparing the landscape well in advance. From system hardware, software, and connectivity, to legal and ethical concerns, we are considering it all. We believe it is not a matter of ‘if’ but rather ‘when’ it will happen. The problem is huge, and the benefits are massive. We will have to do the same as we did with stroke EVT treatment— show the benefit, and that will drive the change.
References:
- Cancelliere N M, Lynch J, Nicholson P et al. Robotic-assisted intracranial aneurysm treatment: 1 year follow-up imaging and clinical outcomes. J Neurointerv Surg. 2021. DOI: 10.1136/neurintsurg-2021-017865.
- Pereira V M, Cancelliere N M, Nicholson P et al. First-in-human, robotic-assisted neuroendovascular intervention. J Neurointerv Surg. 2020; 12(4): 338–40. DOI: 10.1136/neurintsurg-2019-015671.rep.
- Pereira V M, Nicholson P, Cancelliere N M et al. Feasibility of robot-assisted neuroendovascular procedures. J Neurosurg. 2020. DOI: 10.3171/2021.1.JNS203617.
- Patel T M, Shah S C, Pancholy S B. Long Distance Tele-Robotic-Assisted Percutaneous Coronary Intervention: A Report of First-in-Human Experience. EClinicalMedicine. 2019; 14: 53–8. DOI: 10.1016/j.eclinm.2019.07.017.
Vitor Pereira is a neurosurgeon and professor of Medical Imaging and Surgery at the University of Toronto in Toronto, Canada. He is specialised in endovascular neurosurgery, and treating complex neurovascular diseases of the head and spine. His research group, the RADIS Lab, at St Michael’s Hospital, is working to create innovative approaches in the field of neurointervention.
Nicole Cancelliere is the neurovascular research programme manager at St Michael’s Hospital in Toronto, Canada, and works as a medical radiation technologist specialised in neurointerventional and robotic-assisted procedures. She is also co-lead of the RADIS Lab, together with Pereira, at the St Michael’s Li Ka Shing Knowledge Institute.
DISCLOSURES: The authors declared no relevant disclosures.
