The purpose of the article is to provide a practical guide for manual and semi-automated image segmentation of common neurosurgical cranial lesions, namely meningioma, glioblastoma multiforme (GBM) and subarachnoid haemorrhage (SAH), for neurosurgical trainees and researchers. Materials and Methods: The medical images used were sourced from the Medical Image Computing and Computer Assisted Interventions Society (MICCAI) Multimodal Brain Tumour Segmentation Challenge (BRATS) image database and from the local Picture Archival and Communication System (PACS) record with consent. Image pre-processing was carried out using MRIcron software (v1.0.20190902). ITK-SNAP (v3.8.0) was used in this guideline due to its availability and powerful built-in segmentation tools, although others (Seg3D, Freesurfer and 3D Slicer) are available. Quality control was achieved by employing expert segmenters to review. Results: A pipeline was developed to demonstrate the pre-processing and manual and semi-automated segmentation of patient images for each cranial lesion, accompanied by image guidance and video recordings. Three sample segmentations were generated to illustrate potential challenges. Advice and solutions were provided within both text and video. Conclusions: Semi-automated segmentation methods enhance efficiency, increase reproducibility, and are suitable to be incorporated into future clinical practise. However, manual segmentation remains a highly effective technique in specific circumstances and provides initial training sets for the development of more advanced semi- and fully automated segmentation algorithms.

In the deep inferior epigastric perforator (DIEP) flap breast reconstruction, fat necrosis is a common and distressing complication for patients. While venous outflow augmentation using the superficial inferior epigastric vein (SIEV) has been suggested to improve some perfusion-related outcomes, its effect on fat necrosis remains insufficiently substantiated. A retrospective review was conducted of unilateral, unipedicled DIEP flap breast reconstructions performed between 2012 and 2023 at a tertiary centre in London, United Kingdom. Patients were categorised based on SIEV venous augmentation status, and the incidence of postoperative clinical fat necrosis was recorded. Univariable and multivariable logistic regression models assessed the relationship between fat necrosis and SIEV augmentation, as well as patient, surgical and perfusion-related factors. The total cohort included 119 patients (119 flaps). Of the total flaps, 58.8% received venous augmentation with the SIEV. Fat necrosis occurred in 16.8% of the total cases. Patients in the SIEV-augmented group experienced significantly lower fat necrosis rates compared to controls (10.0% vs. 26.5%, respectively; P = 0.025). Multivariable analysis further demonstrated a protective effect from SIEV augmentation against fat necrosis (adjusted odds ratio 0.33, 95% confidence interval 0.12-0.95; P = 0.039). In the present cohort of DIEP flap breast reconstructions, venous augmentation using SIEV was a significant independent protective factor against fat necrosis. While prospective studies are necessary to validate this relationship, this technique may be considered as part of routine surgical practice in eligible cases.

Indocyanine green (ICG) fluorescence angiography has emerged as an intraoperative method to accurately assess real-time tissue vascularity, perfusion and anastomotic patency in flap surgery. We illustrate a complex case of elbow reconstruction in an elderly patient with a free anterolateral thigh flap, which relied on intraoperative ICG to evaluate the flap pedicle and map the site of arterial occlusion. Supermicrosurgical instrumentation was employed to perform complex perforator-to-perforator anastomosis following resection of the vascular site of the lesion. These unique applications in a patient of known surgical risk enabled immediate flap salvage, and after 6 months postoperatively, the flap remained healthy with adequate wound healing.