In Reply: The Modern Evolution of Simulations in Endovascular Neurosurgery-A Short Review.

Abstract

To the Editor: We read the letter to the editor by Azzam et al1 titled “Letter: The Modern Evolution of Simulations in Endovascular Neurosurgery—A Short Review” with great interest. The authors have concluded that modern simulation-based training systems are not a luxury but a necessity for neurosurgery trainees for practicing various procedures, especially endovascular procedures. They have also reported how lower- and middle-income countries are lagging because of issues such as lack of cadavers, high cost of cadavers, and legal and ethical problems. They have also mentioned how current ad hoc unpredictable events such as the COVID-19 pandemic have increased this gap and become a barrier to achieving the goals of global neurosurgery. As a solution to provide more hands-on training in endovascular neurosurgery, they have recommended the use of “haptics-based simulators.” These haptics-based simulators come with their drawbacks, where the Simbionix ANGIO Mentor simulator2 comes with a comparatively lower cost and easy user interface but can only be used for cerebral angiography training. The Mentice VIST simulators3 although comes with a wide range of endovascular procedure but need a trainer to learn these because of its difficult user interface, and the ViVitro Endovascular Simulator4 although can be used to learn cerebral angiography and some other simple endovascular procedures, is comparatively costlier, given their limited services. So, these haptics-based simulators cannot solve the problems that neurosurgical trainees of lower- and middle-income countries face. A systematic review published by Rangarajan et al5 has reported that haptic feedback has been shown to improve fidelity and realism, but at present, haptic simulators are expensive and in a nascent stage, so further research and cost-benefit analysis of these tools must be performed before implementing in lower-resource countries. We would like to add that policymakers of these countries must prioritize health and start manufacturing these simulators in their own countries to decrease the cost of these simulators.