Yoshihiro Otani, Kazuhiko Kurozumi, Joji Ishida, Masafumi Hiramatsu, Masahiro Kameda, Tomotsugu Ichikawa, Isao Date

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1 SNI: Generl Neurosurgery OPEN ACCESS For entire Editoril Bord visit : Editor: Eric Nussum, M.D. Ntionl Brin Aneurysm nd Tumor Center, Twin Cities, MN, USA Technicl Note Comintion of the tuulr retrctor nd rin sptuls provides n dequte opertive field in surgery for deep seted lesions: Cse series nd technicl note Yoshihiro Otni, Kzuhiko Kurozumi, Joji Ishid, Msfumi Hirmtsu, Mshiro Kmed, Tomotsugu Ichikw, Iso Dte Deprtment of Neurologicl Surgery, Okym University Grdute School of Medicine, Dentistry, nd Phrmceuticl Sciences, Shikt, Kit ku, Okym , Jpn E mil: Yoshihiro Otni yoshihiro00tni@gmil.com; *Kzuhiko Kurozumi kkuro@md.okym u.c.jp; Joji Ishid georgeorge1422@gmil.com; MsfumiHirmtsu mhirmtsu@okym u.c.jp; Mshiro Kmed mrkmed@gmil.com; Tomotsugu Ichikw tomoichi@cc.okym u.c.jp; Iso Dte idte333@md.okym u.c.jp *Corresponding uthor Received: 02 Mrch 18 Accepted: 17 Septemer 18 Pulished: 01 Novemer 18 Astrct Bckground: Surgeries for deep seted lesions re chllenging ecuse mking corridor nd oserving the interfce etween lesions nd norml rin tissue re difficult. The ViewSite Brin Access System, which is cler plstic tuulr retrctor system, is used for resection of deep seted lesions. However, the tpered shpe of this system my result in limittion of the surgicl field nd cuse rin injury to oserve the interfce etween lesions nd norml tissue. In this study, we evluted the usefulness of the comintion of ViewSite nd rin sptuls. Methods: Nine ptients were retrospectively identified who underwent resection of deep seted lesions with the comintion of Viewsite nd rin sptuls. We ssessed the extent of resection, prognosis, nd quntittive rin injury from postopertive diffusion weighed imging (DWI). Results: There were four totl rdiogrphiclly confirmed resections. Sutotl resection in four ptients nd prtil resection in one with centrl neurocytom were chieved ecuse these tumors were strongly dherent to the choroid plexus nd ependyml veins. Only one cse of metsttic tumor relpsed 6 months fter surgery. The men postopertive high signl on DWI ws 3.68 ± 0.80 cm 3. Conclusions: The comintion of ViewSite nd rin sptuls provides wide nd dequte opertive fields to oserve the interfce etween lesions nd norml tissue, nd to prevent rin injury from excessive retrction pressure on the rin derived from repositioning of the ViewSite. Postopertive 3D volumetric nlysis Access this rticle online Wesite: DOI: /sni.sni_62_18 Quick Response Code: This is n open ccess journl, nd rticles re distriuted under the terms of the Cretive Commons Attriution-NonCommercil-ShreAlike 4.0 License, which llows others to remix, twek, nd uild upon the work non-commercilly, s long s pproprite credit is given nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com How to cite this rticle: Otni Y, Kurozumi K, Ishid J, Hirmtsu M, Kmed M, Ichikw T, et l. Comintion of the tuulr retrctor nd rin sptuls provides n dequte opertive field in surgery for deep-seted lesions: Cse series nd technicl note. Surg Neurol Int 2018;9: seted-lesions:-cse-seriesnd-technicl-note/ 2018 Surgicl Neurology Interntionl Pulished y Wolters Kluwer - Medknow

2 shows miniml dmge to norml rin tissue. This report my provide new insight into the use of the ViewSite tuulr retrctor. Key Words: Brin sptul, deep seted lesion, tuulr retrctor, ViewSite INTRODUCTION Surgeries for intrcrnil deep seted lesions re chllenging, despite dvncement nd improvement of surgicl pproches nd techniques. Cretion nd mintennce of sfe corridor into the tumor is criticl, s well s the ility to visulize the tumor nd surrounding structures during the opertion. [11] These lesions hve een resected using visuliztion y microscopy with rin sptuls for decdes. Since the introduction of the first self retining retrctor y Greenerg in 1981, mny retrctor systems hve een used in clinicl fields. Surgeons hve ttempted to resect deep seted lesions using these novel modlities with either or oth the microscope nd endoscope. Recently, the ViewSite Brin Access System (Vycor Medicl, Inc., Boc Rton, FL, USA) hs een used for resection of deep seted lesions. The usefulness of this tuulr retrctor system for rin tumors hs een documented in dult [9] nd peditric series. [16] The ViewSite tuulr retrctor is trnsprent plstic tuulr retrctor system tht consists of n introducer inside of working chnnel port nd is ville in three lengths (3, 5, nd 7 cm) nd four widths (12, 17, 21, nd 28 mm). This retrctor is designed s tpered forwrd edge to minimize disruption of the rin during insertion [Figure 1]. Recinos et l. reported postopertive imging following use of the ViewSite tuulr retrctor. They showed miniml T2/fluid ttenuted inversion recovery (FLAIR) chnges long the surgicl pth. [16] This result indictes miniml tissue dmge nd ischemi. In contrst, ecuse of the tpered shpe of this retrctor, the width of the forwrd edge is smller thn tht of the reverse edge, nd it leds to limittion in the working spce [Figure 1]. Moreover, in mny deep seted lesions, the interfce etween norml tissue nd the lesion is not lwys cler, nd lesions frequently hve n irregulr order. [12] Moving Figure 1: The ViewSite rin retrctor. The ViewSite rin retrctor is designed s tpered shpe to minimlize disruption to the rin during insertion (). The width of the forwrd edge (solid line) is smller thn tht of the reverse edge (dshed line) nd it leds to limittion in the working spce () the ViewSite tuulr retrctor then ecomes necessry to oserve the order etween the lesion nd surrounding norml rin tissue. Whether moving the ViewSite tuulr retrctor cuses excessive rin retrction pressure nd leds to moridity is uncler. In this study, we report nine cses of deep seted lesions, which were resected using the ViewSite tuulr retrctor nd rin sptuls. We nlyzed postopertive 3D volumetric chnges in diffusion weighted imging (DWI). MATERIALS AND METHODS Ptients Ptients with intrcrnil deep seted lesions who were treted using oth the ViewSite tuulr retrctor nd rin sptuls were identified from the medicl records of Okym University Hospitl from Mrch 2013 to Octoer Medicl chrts were reviewed for ge t presenttion, sex, clinicl presenttion, rdiogrphic imging, opertion record, pthologicl findings, tretment, nd outcome. This study (no ) ws pproved y the ethicl committee of the Okym University Grdute School of Medicine, Dentistry nd Phrmceuticl Sciences, Okym, Jpn. Surgicl techniques Preopertively, for the neuronvigtion system, computed tomogrphy (CT) imging nd contrst enhnced mgnetic resonnce imging (MRI) were performed. When the lesion ws djcent to the eloquent re, functionl MRI nd diffusion tensor imging (DTI) were lso chieved. Using these imges, either Curve TM Imge Guided Surgery (BrinL, Munich, Germny), StelthSttion S7 (Medtronic Inc., Louisville, CO, USA), or StelthSttion Treon (Medtronic Inc.) ws registered, nd the surgicl trjectory ws plnned to void the eloquent re nd criticl vsculture. After corticotomy ws performed over non eloquent gyrus, the ViewSite tuulr retrctor ws gently inserted long the previously plnned surgicl trct. As mentioned ove, there re severl sizes of the ViewSite tuulr retrctor. Therefore, the distnce from the entry point of prenchym to the lesion ws mesured on imges to decide which retrctor ws suitle. We usully selected 17 nd 21 mm wide retrctors in the 7 cm lengths. After setting the ViewSite tuulr retrctor in the proper position, the retrctor ws fixed with self retining Leyl rm (Aesculp, Tuttlingen, Germny), nd the introducer ws removed. We then resected lesions through the ViewSite tuulr

3 retrctor under surgicl microscope (OPMI Pentero or NC4; Crl Zeiss Co., Oerkochen, Germny) nd/or n endoscope (Krl Storz Endoscopy, Tuttlingen, Germny) [Figure 2 nd ]. The mjority of lesions were resected. The ViewSite tuulr retrctor ws then removed, nd we used mllele rin sptul (Fujit Medicl Instruments Co., Ltd., Tokyo, Jpn) to oserve the interfce etween norml tissue nd lesions nd to remove residul lesions [Figure 2c nd d]. At the end of resection, ventriculostomy ctheter ws plced t the intrventriculr spce in ventriculr tumor surgery. Finlly, the dur mter, the one flp, nd skin were closed in stndrd fshion. Volumetric nlysis Resercher who ws not involved in the surgicl procedure of the ptients in this study conducted the volumetric nlysis descried elow. Postopertive rdiogrphic MRI ws imported into BrinL softwre for volumetric nlysis. c Figure 2: Illustrtion depicting surgicl pproches to deep seted lesions with the ViewSite tuulr retrctor or rin sptuls. When only using the ViewSite tuulr retrctor, the surgicl field is limited ecuse of its tpered shpe ( nd ). However, using rin sptuls fter mking corridor to the lesion with the ViewSite tuulr retrctor provides n dequte surgicl field (c nd d) d DWI ( vlue; 1000) ws used ecuse restricted diffusion on DWI is mrker for rin cytotoxic edem nd ischemic or cell dmge. [3] Using ipln 3.0 Crnil (BrinL), ojects were drwn to mesure 3D volumes. The extent of resection (EOR) ws lso clculted. Gross totl resection (GTR) ws considered EOR >99%, sutotl resection (STR) 95% 99%, nd prtil resection (PR) <95%. RESULTS A comprehensive list of the ptients is shown in Tle 1. Among the nine cses, the men ge ws 57 ± 5.5 yers, nd five ptients were men (55.6%). Histologiclly, five ptients were dignosed with centrl neurocytom in which ll of the tumors were locted in the lterl ventricle, two ptients hd metsttic rin tumor, one ptient hd gliolstom multiforme, nd one ptient hd cvernous ngiom in the third ventricle. There were four totl rdiogrphiclly confirmed resections (44.4%). STR nd PR were chieved in four (44.4%) ptients nd in one (11.1%) ptient with centrl neurocytom, respectively, ecuse these tumors were strongly dherent to the choroid plexus nd ependyml veins. Postopertively, there ws no moridity, including cererospinl fluid lekge, worsened neurologicl symptoms, nd postopertive hemtom for this procedure. There ws no periopertive deth. Only one cse of metsttic tumor relpsed fter 6 months fter the ptient s first surgery (cse 5).This ptient hd second surgery nd CyerKnife tretment. Postopertive DWI ws tken in five ptients. The men postopertive DWI high signl ws 3.68 ± 0.80 cm 3. Illustrtive cse A 56 yer old womn ws trnsferred to our hospitl with sensory disturnce in her left rm nd leg. MRI of the hed showed 29 mm tumor in the right frontl nd prietl loes. The tumor hd necrotic re in the center of the tumor. After dministrtion Tle 1: Chrcteristics of the ptients Cse Age, Gender Dignosis Tumor loction Resection Permnent moridity Recurrence 1 34, M Centrl neurocytom Rt. LV STR None None 2 41, M Centrl neurocytom Lt. LV STR None None 3 65, F Cvernous ngiom 3 rd V GTR None None 4 41, M Centrl neurocytom Lt. LV STR None None 5 76, M Metsttic rin Rt. Prietl GTR None Recurrence tumor 6 56, F GBM Rt. GTR None None Frontoprietl 7 73, F Centrl neurocytom Lt. LV STR None None 8 50, F Centrl neurocytom Rt. LV PR None None 9 77, M Metsttic rin tumor Rt. Prietl GTR None None GBM=gliolstom multiforme, LV=lterl ventricle, GTR=gross totl resection, PR=prtil resection, STR=sutotl resection

4 c f d e Figure 3: Preopertive imging of n illustrtive cse. Preopertive contrst enhnced xil () nd sgittl () MRI shows 29 mm tumor in the right frontl nd prietl loes. 11 C methionine positron emission tomogrphy shows high uptke (c), nd DTI shows tht the corticospinl trct is present in the front of nd djcent to the tumor itself (d). Digitl sutrction ngiogrm shows tumor stining (e, rrow). Contrst enhnced cone em CT shows tht min feeding rteries (yellow rrowhed) from the right middle cererl rtery re locted in the lterl prt of the tumor, nd drining veins (white rrowhed) re in the medil portion of the tumor (f) of contrst enhncement, the tumor showed ring enhncement [Figure 3 nd ]. 11 C methionine positron emission tomogrphy showed high uptke [Figure 3c], nd DTI showed the presence of corticospinl trct in the front of nd djcent to the tumor itself [Figure 3d]. A digitl sutrction ngiogrm showed tumor stining through the right middle cererl rtery [Figure 3e]. Contrst enhnced cone em CT nd fusion imge of contrst enhnced cone em CT nd gdolinium enhnced T1 weighted imge showed tht the min feeding rteries were locted in the lterl prt of the tumor, nd drining veins were in the medil portion of the tumor [Figure 3f nd Supplementry Figure 1]. To void injury of the corticospinl trct, direct pth ws plnned from the cortex of the prietl loe. The ViewSite tuulr retrctor ws gently inserted nd plced using neuronvigtion. The tumor ws oserved nd resected through the ViewSite tuulr retrctor under microscope nd endoscope. The nture of the tumor ws soft nd hypervsculr. Susequently, we switched the ViewSite tuulr retrctor into rin sptuls to identify nd scrifice the feeding rtery, which ws present in the interfce etween the norml rin nd lesion. We scrificed the feeding rtery nd removed the residul tumor under microscope. Finlly, crmustine (ischloroethylnitrosoure [BCNU]) implnts (Glidel Wfer; Eisi Inc., Woodcliff Lke, NJ, USA) were plced on the surfce of the resected tumor eds. Postopertive MRI showed GTR [Figure 4 nd ], nd the ptient ws neurologiclly intct with no moridity. Three dimensionl volumetric nlysis Figure 4: Postopertive imging of the illustrtive cse. Preopertive contrst enhnced xil () nd sgittl () MRI shows gross totl resection. Three dimensionl volumetric nlysis of restricted diffusion on DWI ws performed (c) of restricted diffusion on DWI showed 6.03 cm 3 [Figure 4c]. Hemtoxylin eosin stining showed highly cellulrity, prominent microvsculr prolifertion, nd pseudoplisding necrosis. She ws dignosed with gliolstom, nd she then received stndrd rdiotherpy (60 Gy). Twelve months fter the opertion, MRI showed no recurrence of the tumor. DISCUSSION c Surgeries for deep seted lesions re chllenging ecuse creting corridor nd oserving the interfce etween lesions nd norml rin tissue re difficult. To solve these prolems, mny rin retrction systems comined with microscope or endoscope hve een introduced. First, the self retining retrction system y Greenerg ws introduced in [6] However, the dnger of rin infrction nd rin dmge due to excessive rin retrction pressure hs een deted. Rosenorn et l. reported reduction in regionl cererl lood flow in the rin cortex lying under the retrctor with 20 mmhg of rin retrctor pressure using rt models. [17] In the humn rin, the threshold for ischemi nd contusion re estimted to e less thn 30mmHg. [8] Additionlly, systemic intropertive fctors, such s lood loss, cidosis, hypotension, nd metolic normlities, cn increse the risk of cererl ischemi resulting from rin retrctor. [1,2,16] Since these studies, mny neurosurgeons hve suggested the dvntge of tuulr retrctor system. This system cn distriute the forces of retrction evenly nd reduce rin retrction pressure to norml surrounding tissue compred with trditionl retrctors. [3,5,7,9,16,20] Ogur et l. invented cylinder with 0.1 mm trnsprent polyester film to crete cylindricl surgicl route. [15] Of prticulr importnce, they evluted rin retrctor pressure on surrounding tissue, nd it

5 ws less thn 10 mmhg, which is lower thn the criticl threshold for cererl ischemi suggested y Rosenorn. [17] The ViewSite tuulr retrctor is specilly tilored tuulr retrctor for neurosurgery nd pplied for removl of intrprenchyml or intrventriculr tumors, hemorrhge, nd foreign odies. [9,14,16,18] The ViewSite tuulr retrctor is not only used for the trnscorticl pproch ut lso for the interhemispheric trnscllosl pproch for the third ventricle, [19] or middle foss pproch for intrcnliculr tumors. [4] This retrctor hs mny dvntges. First, the ViewSite tuulr retrctor my decrese dmge to norml rin tissue. As mentioned ove, Recinos et l. reported postopertive imging following use of the ViewSite tuulr retrctor nd showed miniml T2/FLAIR chnges long the surgicl pth. [16] Additionlly, this retrctor is composed of plstic nd hs tpered end, which prevents electricl trnsmission nd llows djcent tissue to e visulized. Additionlly, the ViewSite tuulr retrctor cn e secured onto self retrcting rm, such s the Greenerg or Leyl r systems, to prevent shifting of the opertion field. [16] However, there re two disdvntges of the ViewSite tuulr retrctor. First, the re of the forwrd edge is significntly smller thn tht of the reverse edge ecuse of its unique tpered shpe [13] [Figure 1]. This leds to limittion in working spce [Figure 2 nd ]. In cses, where surgeries re completely performed with the ViewSite tuulr retrctor, n endoscope, nd modified microsurgicl instruments for endoscopic surgery, this disdvntge of the limittion in working spce my e overcome. However, for deep seted hypervsculr tumors, such s gliolstom multiforme, inoculr, nd 3D vision provided y microscope provides more informtion nd leds to sfer resections thn with n endoscope. [10] In these cses, smll working spce restricts the use of microsurgicl instruments. Second, in mny deep seted lesions, the interfce etween norml tissue nd the lesion is not lwys cler, nd lesions frequently hve n irregulr order. [12] Therefore, the order of the lesion should e crefully oserved to chieve gross totl resection. Recinos et l. reported tht the ViewSite tuulr retrctor cn esily e moved nd repositioned for pproching irregulr lesions. [16] However, we speculte whether this retrctor cn cuse excessive rin pressure ecuse its shpe cnnot e chnged freely. In contrst, rin sptuls re fmilir instruments for neurosurgeons nd suitle for overcoming these disdvntges. When rin sptuls re used fter mking corridor y the ViewSite tuulr retrctor, norml rin tissue does not need to e retrcted with excessive pressure ecuse pth to the lesion hs lredy een mde nd retined. Additionlly, rin sptuls enle retrction of the norml rin loclly. Therefore, rin sptuls cn provide lrger opertive fields thn the ViewSite rin retrctor nd dequte opertive fields for oserving the interfce etween lesions nd norml tissue. Brin sptuls cn lso prevent rin injury from excessive rin pressure derived from repositioning of the ViewSite tuulr retrctor. In this study, we evluted restricted diffusion on DWI s mrker for rin cytotoxic edem nd ischemic or cell dmge. To the est our knowledge, only one study quntittively evluted rin dmge resulting from retrctor using postopertive MRI. [3] In this previous study, the uthors used the METRx tuulr retrctor system for deep intrprenchyml lesions. They reported tht postopertive DWI volume (8.35 ± 3.05 cm 3 ) tended to e lower thn tht of the trditionl retrctor (16.51 ± 8.9 cm 3 ). In our series, postopertive DWI volume ws lower thn previously reported. [3] Therefore, the comintion of the ViewSite tuulr retrctor nd rin sptuls my provide less dmge to norml rin tissue. The concept of tuulr retrctor ws proposed more thn 30 yers go, nd their efficcy nd sfety hve een reported numerously compred with trditionl lde retrctors tht my cuse symmetric tension on rin tissue. By contrst, we lso feel the disdvntges of tuulr retrctor, which re the limittion of working spce nd oserving irregulr order of deep seted lesions. The rin sptuls compenste these disdvntges, nd we cn provide minimlly invsive surgery y using the comintion of the ViewSite tuulr retrctor nd rin sptuls technique. CONCLUSION In conclusion, we first introduced the comintion of the ViewSite tuulr retrctor nd rin sptuls to overcome the disdvntge of the ViewSite tuulr retrctor, including the limittion in the re nd view of the opertive field. Our results my provide new insight into the use of the ViewSite tuulr retrctor. Finncil support nd sponsorship Nil. Conflicts of interest All uthors certify tht they hve no ffilitions with or involvement in ny orgniztion or entity with ny finncil interest (such s honorri; eductionl grnts; prticiption in spekers ureus; memership, employment, consultncies, stock ownership, or other equity interest; nd expert testimony or ptent licensing rrngements), or non finncil interest (such s personl or professionl reltionships, ffilitions, knowledge, or eliefs) in the suject mtter or mterils discussed in this mnuscript. Ethicl pprovl All procedures performed in studies involving humn prticipnts were in ccordnce with the ethicl stndrds

6 of the institutionl nd/or ntionl reserch committee nd with the 1964 Helsinki declrtion nd its lter mendments or comprle ethicl stndrds. REFERENCES 1. Alin MS, Bunegin L. The insidiousness of rin retrctor pressure: Another Smoking gun? AnesthAnlg 2003;96:306; uthor reply Andrews RJ, Brings JR. A review of rin retrction nd recommendtions for minimizing intropertive rin injury. Neurosurgery 1993;33: ; discussion Bnder ED, Jones SH, Kovnliky I, Schwrtz TH. Utility of tuulr retrctors to minimize surgicl rin injury in the removl of deep intrprenchyml lesions: A quntittive nlysis of FLAIR hyperintensity nd pprent diffusion coefficient mps. JNeurosurg 2016;124: Bernrdo A, Evins AI, Tsiouris AJ, Stieg PE. A Percutneous trnstuulr middle foss pproch for intrcnliculr tumors. World Neurosurg 2015;84: Fhim DK, Relye K, Nyr VV, Fox BD, Whitehed WE, Curry DJ, et l. Trnstuulr microendoscopic pproch for resection of choroidl rteriovenous mlformtion. JNeurosurg Peditr 2009;3: Greenerg I. Self-retining retrctor nd hndrest system for neurosurgery. Neurosurgery 1981;8: Greenfield JP, Co WS, Tsouris AJ, Schwrtz TH. Stereotctic minimlly invsive tuulr retrctor system for deep rin lesions. Neurosurgery 2008;63(Suppl 2):334 9; discussion Hrd S, Nkmur T. Retrction induced rin edem. Act Neurochir Suppl (Wien) 1994;60: Herrer SR, Shin JH, Chn M, Kouloumeris P, Goellner E, Slvin KV. Use of trnsprent plstic tuulr retrctor in surgery for deep rin lesions: A cse series. SurgTechnol Int 2010;19: Ichikw T, Otni Y, Ishid J, Fujii K, Kurozumi K, Ono S, et l. Hyrid microscopic endoscopic surgery for crniophryngiom in neurosurgicl suite: Technicl notes. World Neurosurg 2016;85:340 8.e Kssm AB, Engh JA, Mintz AH, Prevedello DM. Completely endoscopic resection of intrprenchyml rin tumors. JNeurosurg 2009;110: Kelly PJ. Future perspectives in stereotctic neurosurgery: Stereotctic microsurgicl removl of deep rin tumors. JNeurosurg Sci 1989;33: Kishid Y, Sto T, Od K, Ichikw M, Skum J, Sito K. Pure endoscopic resection of deep intrcrnil tumors using the ViewSite Brin Access System. No shinkei gek 2014;42: Mtsumoto Y, Kurozumi K, Shimzu Y, Ichikw T, Dte I. Endoscope ssisted resection of cvernous ngiom t the formen of Monro: A cse report. Springerplus 2016;5: Ogur K, Tchin E, Aoshim C, Sumitomo M. New microsurgicl technique for intrprenchyml lesions of the rin: Trnscylinder pproch. Act Neurochir (Wien) 2006;148:779 85; discussion Recinos PF, Rz SM, Jllo GI, Recinos VR. Use of minimlly invsive tuulr retrction system for deep seted tumors in peditric ptients. JNeurosurg Peditr 2011;7: Rosenorn J, Diemer NH. Reduction of regionl cererl lood flow during rin retrction pressure in the rt. JNeurosurg 1982;56: Rymrczuk GN, Dvidson L, Severson MA, Armond RA. Use of minimlly invsive retrctor system for retrievl of intrcrnil frgments in wrtime trum. World Neurosurg 2015;84: Shokzemi A, Evins AI, Burrell JC, Stieg PE, Bernrdo A. A 3D endoscopic trnstuulr trnscllosl pproch to the third ventricle. JNeurosurg 2015;122: Ydv YR, Ydv S, Sherekr S, Prihr V. A new minimlly invsive tuulr rin retrctor system for surgery of deep intrcererl hemtom. Neurol Indi 2011;59:74 7.

7 Supplementry Figure 1: A fusion imge of contrst enhnced cone em CT nd gdolinium enhnced T1 weighted imge of n illustrtive cse. A fusion imge of contrst enhnced cone em CT nd gdolinium enhnced T1 weighted imge showed tht the min feeding rteries (yellow rrowhed) from the right middle cererl rtery () nd drining veins tht connected to thlmostrite vein (, white rrowhed)