Atormac
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 1750  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (2,365 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 » Conclusion
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    Viewed2737    
    Printed48    
    Emailed0    
    PDF Downloaded45    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
NI FEATURE: THE QUEST - COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 2  |  Page : 439-443

Standardization of the technique of silicon injection of human cadaveric heads for opacification of cerebral vasculature in Indian conditions


1 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
3 Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication15-Mar-2018

Correspondence Address:
Dr. Shashwat Mishra
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.227303

Rights and Permissions

 » Abstract 


A surgeon's understanding of the surgical anatomy can be greatly enhanced by the dissection of preserved cadaveric specimens. A reliable and inexpensive biological model for testing and standardization of dye injection concentrations is proposed utilizing the goat's head as a biological model. The first phase was concerned with standardization of the dye by titrating its concentration and injecting various amounts into cerebral vessels of a goat's head until an optimal concentration had been ascertained. In the second phase, this optimum concentration of the dye was injected into four human cadaveric heads following the same technique standardized using the goat's head. Upon dissecting the four cadaveric human heads which were injected with silicon dyes and preserved in 10% formalin, the vessels were all well-opacified and the brain was of near normal consistency and good for dissection, without showing any features of putrefaction. The goat model, having similar color, texture, and the handling as the cadaveric head, offers an opportunity to test indigenously manufactured polymerizing dyes in the future. This biological model, therefore, has the potential to considerably reduce the cost of cadaver preparation.


Keywords: Anatomical dissection of brain, anatomy, cerebral blood vessels, silicon injection
Key Message: Silicon injection for the opacification of cranial vasculature enhances the visual impression and appreciation of the anatomical relationships during dissection of human cadaver heads. The technique of preparing these cadaver specimens can be mastered on the heads of freshly sacrificed goats, as these are easily sourced, possess similar tissue characteristics, and are sufficiently inexpensive to permit repeated trial and error.


How to cite this article:
Soubam P, Mishra S, Suri A, Dhingra R, Mochan S, Lalwani S, Roy T S, Mahapatra AK. Standardization of the technique of silicon injection of human cadaveric heads for opacification of cerebral vasculature in Indian conditions. Neurol India 2018;66:439-43

How to cite this URL:
Soubam P, Mishra S, Suri A, Dhingra R, Mochan S, Lalwani S, Roy T S, Mahapatra AK. Standardization of the technique of silicon injection of human cadaveric heads for opacification of cerebral vasculature in Indian conditions. Neurol India [serial online] 2018 [cited 2019 Aug 19];66:439-43. Available from: http://www.neurologyindia.com/text.asp?2018/66/2/439/227303




Anatomical studies on cadaveric heads have become one of the most useful methods for educating neurosurgeons regarding the surgical anatomy of the brain and skull base.[1] The relevance of such studies is universal, and cadaveric dissection is still considered to be the gold standard for ex-vivo simulation among all the models employed for neurosurgical training.[2] Dye injection of the cranial vascular tree that permits the opacification of the arterial and venous system in different colors has dramatically transformed the visual impression formed upon the trainee by anatomical dissections.

The technique of silicon injection in the cranial vasculature of cadaveric heads has been well described in the literature,[3],[4],[5] but the results have been significantly influenced by the method of cadaver preparation, the operator's experience, and the ambient conditions in which the specimens are preserved. Despite continuing efforts, till now, the technique and materials for the injection of blood vessels of the cadaveric human heads in Indian conditions have not been standardized. Due to the socio-religious constraints and poor acceptance of postmortem donation of bodies, human cadavers are precious and quite difficult to procure in India. They, therefore, cannot possibly be utilized for repeated experimentation, which is an inevitable step in the standardization of any dye injection technique.

Accordingly, in this study, we have attempted to establish a reliable and inexpensive biological model for testing the dye injection techniques and their concentrations. We also describe the application of these techniques to human cadaveric heads.

Technique

The testing protocol was reviewed and approved by the institutional ethics committee. The study was conducted in two phases described below.

First phase

The first phase was concerned with the standardization of the dye injection and the cadaveric preservation technique. For this phase, eight fresh goat heads sectioned at the neck were procured from butchers as they are inexpensive, widely available, and their use for experimentation is ethically permissible. Bilateral internal carotid arteries and internal jugular veins were dissected and copiously irrigated with tap water till the return was clear and free of blood clots. Once there was free flow of water from the corresponding vessels on the opposite side, bilateral internal carotid arteries and internal jugular veins were cannulated with different sizes of commonly available tubings based on the size of the vessels. The tubes were firmly secured inside the vessels with the help of sutures. This step was important as considerable pressure has been required to inject the viscous dye into the blood vessels, and during this process, the tubes tend to back out of the vessel lumen. Distension of the vascular tree with tap water injected through the carotid arteries helps to distend the great veins, which are otherwise floppy and difficult to isolate from the surrounding soft tissue. The vascular tree was then irrigated with the preservation and fixation solution and clamped for 30 minutes. Blue and red-colored silicone rubber dyes (Biodur ® GmBh, Germany) were then prepared as per the specifications described in [Table 1].
Table 1: Recipe for silicone dye preparation, 50 ml vol. (Biodur ® GmBh, Germany)

Click here to view


Red dye was injected into the carotid vessels to opacify the arterial vasculature, and blue dye was injected into the internal jugular vein to delineate the venous vasculature [Figure 1]. A 50-cc syringe was used to inject the colored silicone till the dye egressed from the contralateral corresponding vessel. The ipsilateral vessel was then clamped, and the dye was injected from the contralateral vessel under considerable pressure to ensure that the dye penetrated up to the smaller ramifications of the vascular tree. The injected specimens were immersed in a solution of formalin, absolute alcohol, and distilled water for a fortnight. Initially, we started with 15% formalin solution. We, then, titrated the solution concentration to ensure a proper concentration of the constituent chemicals, based upon our observations following dissection of the specimens. A small craniotomy was then performed around the vertex of the cranium. The condition of the brain and quality of the injection in the dural as well as cortical vessels were observed.
Figure 1: (a) Cannulation of both the carotid vessels (red arrows) and the jugular veins (blue arrows); (b) Red dye was injected into the carotid vessels till it exuded from the contralateral carotid artery; (c) Blue dye was injected into the veins; (d) the final result showing the expected exudation of the dye from the epidural venous plexus (white arrows) and external carotid branches (black arrow)

Click here to view


Second phase

In the second phase, we injected dyes into four human cadaveric heads following the same technique standardized in the goat's head. All the injections were performed in bodies donated to the Anatomy Department of the institute. The regulations pertaining to these donations did not permit decapitation of the bodies immediately after donations.

Dissection, cannulation, and preparation of the vascular tree in the human head

The carotid arteries and the internal jugular veins were dissected in a fairly straightforward manner after isolating the carotid sheath through a standard vertical incision along the medial border of the sternocleidomastoid (SCM) muscle. These vessels were then cannulated with appropriate sized tubes. The tubes were secured inside the vessel lumen with silk threads for up to a length of 4 cm along the course of the vessels.

The exposure of the vertebral arteries in the neck was more challenging.[6] The lower part of the vertical incision in the neck was extended to the suprasternal notch. The sternal head of the SCM was divided close to its origin to enlarge the exposure. The dissection was carried out between the reflected part of SCM laterally and the internal jugular vein medially. The vertebral artery was identified as it entered the transverse foramen of the C6 vertebra (just medial to the Chassaignac's tubercle) in the triangle between the anterior scalene muscle and the longus colli muscle [Figure 2]. It was carefully cannulated with appropriate sized tubings.
Figure 2: (a) Exposure of the neck vessels in the human cadaver before dye injection. The V1 segment of the vertebral artery is exposed deep to the internal jugular vein between the anterior scalene muscle laterally and the longus colli muscle medially (not seen); (b) cannulation of the major vessels in the neck

Click here to view


The carotid arteries and veins were then liberally irrigated with normal saline till the returning fluid was free of clots. The irrigation fluid had a tendency to ooze out from small tributaries of the jugular veins, which might have been inadvertently divided during dissection of the internal jugular vein. These tributaries were then carefully ligated to seal off the venous system before the dye injection.

The egress of the irrigating fluid from the vertebral arteries upon flushing the carotids was reassuring as it ensured the complete coverage of the circle of Willis and the possibility of a satisfactory arterial injection. Once the vascular tree was free from clots, it was irrigated with 10% formalin solution. The tubes within the vessels were then identified, labelled, and clamped and the heads were left for 3–4 days for the formalin solution to act.

The dyes were then prepared and injected in a manner described above for the goat's head. A small amount of dye was retained in the chamber of the injecting syringe to observe its polymerization.

Following the dye injection, the bodies were immersed in a formalin tank for at least 21 days. After due permission was sought from the interested parties for decapitation of the body, the neck was sectioned near its root, and the head was used for dissection.

Our experience

To determine the appropriate concentration of formalin required for best results to be achieved following dye injection, we experimented with several compositions of the preserving fluid into which the goat heads were immersed following dye injection. Our observations are summarized in [Table 2]. [Figure 3] shows our observations upon dissection of a well-preserved specimen of the injected goat's head.
Table 2: Composition of the preservation solution and findings in the goat specimens

Click here to view
Figure 3: (a) Injected goat's head showing dye opacification of the arteries and veins on the base of the brain; (b) interhemispheric approach through the goat's brain

Click here to view


Upon dissecting the four cadaveric human heads which were injected with silicon dyes and preserved in 10% formalin, the vessels were all well-opacified and the brain was of near normal consistency and good for dissection [Figure 4].
Figure 4: (a) Pterional craniotomy in an injected cadaveric head showing well-opacified dural arteries and veins; (b) exposure of the cortical surface showing adequately opacified cortical blood vessels; (c) right retrosigmoid craniotomy showing the exposure of the Vth, VII–VIIIth cranial nerve complex and petrosal vein (PV); (d) transcavernous anterior petrosectomy showing the exposure of Gasserian ganglion and cisternal segment of Vth cranial nerve

Click here to view


Pros and cons of the technique

A surgeon's understanding of the surgical anatomy can be greatly enhanced by the dissection of preserved cadaveric specimens. Among neurosurgeons, the realization of the importance of cadaveric dissection is evidenced by the fact that cadaver courses are increasingly being organized around the globe and are seeing an enthusiastic attendance. They have almost become a necessary prelude to all national and international conferences. However, cadaveric dissection is often an unpleasant task even for the most determined anatomist, chiefly because of the pungency of the embalming solutions used in cadaver preparation. In an earlier publication, we have described the usual process of cadaver procurement and processing for laboratory dissection.[7] Formaldehyde has been adapted as the standard embalming solution for cadavers since the late 19th century. Its advantages include its low cost, excellent preservation properties especially for the brain tissue, antimicrobial activity, and easy availability.

On the other hand, formaldehyde solutions are associated with a disagreeable odor, produce troublesome tissue rigidity, and there are potential risks for the operator who may develop a malignancy from the long term exposure to formaldehyde. To avoid the undesirable effects of formalin preservation, several alternative liquids have been experimented with. Ethyl alcohol offered excellent tissue preservation, but the fixation of the brain was unsatisfactory. The most agreeable alternative, therefore, was low formalin embalming which could reduce the carcinogenic potential of formalin but retain its antimicrobial activity. Some workers have experimented with formalin concentrations as low as 2.3%,[8] but in our case, very low formalin concentrations rendered the preservation of brain unpredictable.

We obtained a favorable consistency of the brain without features of putrefaction on preserving sheep head with 10% formalin. The above concentration of formaldehyde and alcohol was also applicable for preserving human cadaver head for silicon dye injection. Specimens preserved in 10% formalin were also devoid of any disagreeable odor and prolonged dissection sessions were possible without any inconvenience. Between the dissection sessions, the formalin-treated specimens were preserved in freezers maintaining an ambient temperature of −20°C. The tissues of these cadaveric specimens were quite rigid immediately upon bringing them out of the freezer because of the formation of ice crystals inside them. Immersion of the specimens in warm water for a few hours considerably softened them and facilitated the subsequent dissection considerably.

Obtaining a satisfactory vascular injection in a human cadaver head during the initial attempts may be usually troublesome and sometimes annoying. The method of preparation and dye injection for decapitated human heads is well described in the literature.[3],[5],[9] The best injections are obtained when the heads are processed as early after death as possible. However, under Indian conditions, early decapitation of the donated bodies is often not permissible. Hence, the technique should be modified for heads not sectioned at the neck, which we have described in this paper.

To capture the nuances of the technique, it should be practiced and perfected over a biological model, which is inexpensive, easily available, and ethically permissible. A goat's head sourced from the butcher fulfills all the requirements for such a model. We have also shown that observations from this model could be directly translated to dye injection methods in human heads. Though the dyes that we used for this study were custom made by a foreign manufacturer and were expensive, the goat model offers an opportunity to test indigenously manufactured polymerizing dyes in the future, which has the potential to considerably reduce the cost of cadaver preparation.

The anatomy of the goat's brain is considerably different from the human brain and will not probably contribute to further understanding of the human anatomy. However, the color, texture, and the handling of the goat's brain is similar and can offer useful lessons in microsurgical dissection skills for residents and trainees.[10],[11]


 » Conclusion Top


Goat heads can provide a convenient and suitable model for developing and refining vascular injection techniques required for preparing cadaveric human heads for microsurgical dissection.

Acknowledgement

The facilities for cadaver dissection, photography and archiving was provided by the Department of Biotechnology, Department of Science and Technology and Department of Health Research funded state-of-the-art Neurosurgery Education and Skills Training School at AIIMS, New Delhi. The human cadaveric specimens were procured through the Department of Anatomy, AIIMS, New Delhi.

Financial support and sponsorship

Intramural research grant from AIIMS for the financial year 2015–2016.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Rutka JT. Editorial: The Rhoton Collection and the Journal of Neurosurgery: Expanding the reach of neuroanatomy in the digital print world. J Neurosurg 2016;125:4-6.  Back to cited text no. 1
    
2.
Suri A, Patra DP, Meena RK. Simulation in neurosurgery: Past, present, and future. Neurol India 2016;64:387-95.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Alvernia JE, Pradilla G, Mertens P, Lanzino G, Tamargo RJ. Latex injection of cadaver heads: Technical note. Neurosurgery 2010;67:362-7.  Back to cited text no. 3
    
4.
Limpastan K, Vaniyapong T, Watcharasaksilp W, Norasetthada T. Silicone injected cadaveric head for neurosurgical dissection: Prepared from defrosted cadaver. Asian J Neurosurg 2013;8:90-2.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Sanan A, Abdel Aziz KM, Janjua RM, van Loveren HR, Keller JT. Colored silicone injection for use in neurosurgical dissections: Anatomic technical note. Neurosurgery 1999;45:1267-74.  Back to cited text no. 5
    
6.
Bruneau M, Cornelius JF, George B. Anterolateral approach to the V1 segment of the vertebral artery. Neurosurgery 2006;58:ONS-215-9.  Back to cited text no. 6
    
7.
Suri A, Roy TS, Lalwani S, Deo RC, Tripathi M, Dhingra R, et al. Practical guidelines for setting up neurosurgery skills training cadaver laboratory in India. Neurol India 2014;62:249-56.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Benet A, Rincon-Torroella J, Lawton MT, González Sánchez JJ. Novel embalming solution for neurosurgical simulation in cadavers: Laboratory investigation. J Neurosurg 2014;120:1229-37.  Back to cited text no. 8
    
9.
Urgun K, Toktas ZO, Akakin A, Yilmaz B, Sahin S, Kilic T. A very quickly prepared, colored silicone material for injecting into cerebral vasculature for anatomical dissection: A novel and suitable material for both fresh and non-fresh cadavers. Turk Neurosurg 2016;26:568-73.  Back to cited text no. 9
    
10.
Hamamcioglu MK, Hicdonmez T, Tiryaki M, Cobanoglu S. A laboratory training model in fresh cadaveric sheep brain for microneurosurgical dissection of cranial nerves in posterior fossa. Br J Neurosurg 2008;22:769-71.  Back to cited text no. 10
    
11.
Hicdonmez T, Hamamcioglu MK, Parsak T, Cukur Z, Cobanoglu S. A laboratory training model for interhemispheric-transcallosal approach to the lateral ventricle. Neurosurg Rev 2006;29:159-62.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow