Clinical evaluation and follow-up outcome of presurgical plan by Dextroscope: a prospective controlled study in patients with skull base tumors

Applications of Augmented Reality in Neuro-Oncology: A Case Series

Augmented reality (AR) is a technological tool that superimposes two-dimensional virtual images onto three-dimensional real-world scenarios through the integration of neuronavigation and a surgical microscope. The aim of this study was to demonstrate our initial experience with AR and to assess its application in oncological neurosurgery. This is a case series with 31 patients who underwent surgery at Santa Casa BH for the treatment of intracranial tumors in the period from March 4, 2022, to July 14, 2023. The application of AR was evaluated in each case through three parameters: whether the virtual images auxiliated in the incision and craniotomy and whether the virtual images aided in intraoperative microsurgery decisions. Of the 31 patients, 5 patients developed new neurological deficits postoperatively. One patient died, with a mortality rate of 3.0%. Complete tumor resection was achieved in 22 patients, and partial resection was achieved in 6 patients. In all patients, AR was used to guide the incision and craniotomy in each case, leading to improved and precise surgical approaches. As intraoperative microsurgery guidance, it proved to be useful in 29 cases. The application of AR seems to enhance surgical safety for both the patient and the surgeon. It allows a more refined immediate operative planning, from head positioning to skin incision and craniotomy. Additionally, it helps decision-making in the intraoperative microsurgery phase with a potentially positive impact on surgical outcomes.

Virtual Reality and Augmented Reality in Plastic and Craniomaxillofacial Surgery: A Scoping Review

Virtual reality (VR) and augmented reality (AR) have evolved since their introduction to medicine in the 1990s. More powerful software, the miniaturization of hardware, and greater accessibility and affordability enabled novel applications of such virtual tools in surgical practice. This scoping review aims to conduct a comprehensive analysis of the literature by including all articles between 2018 and 2021 pertaining to VR and AR and their use by plastic and craniofacial surgeons in a clinician-as-user, patient-specific manner. From the initial 1637 articles, 10 were eligible for final review. These discussed a variety of clinical applications: perforator flaps reconstruction, mastectomy reconstruction, lymphovenous anastomosis, metopic craniosynostosis, dermal filler injection, auricular reconstruction, facial vascularized composite allotransplantation, and facial artery mapping. More than half (60%) involved VR/AR use intraoperatively with the remainder (40%) examining preoperative use. The hardware used predominantly comprised HoloLens (40%) and smartphones (40%). In total, 9/10 Studies utilized an AR platform. This review found consensus that VR/AR in plastic and craniomaxillofacial surgery has been used to enhance surgeons' knowledge of patient-specific anatomy and potentially facilitated decreased intraoperative time via preoperative planning. However, further outcome-focused research is required to better establish the usability of this technology in everyday practice.

A data-centric artificial intelligent and extended reality technology in smart healthcare systems

Extended reality (XR) solutions are quietly maturing, and their novel use cases are already being investigated, particularly in the healthcare industry. By 2022, the extended reality market is anticipated to be worth $209 billion. Certain diseases, such as Alzheimer's, Schizophrenia, Stroke rehabilitation stimulating specific areas of the patient's brain, healing brain injuries, surgeon training, realistic 3D visualization, touch-free interfaces, and teaching social skills to children with autism, have shown promising results with XR-assisted treatments. Similar effects have been used in video game therapies like Akili Interactive's EndeavorRx, which has previously been approved by the Food and Drug Administration (FDA) as a treatment regimen for children with attention deficit hyperactivity disorder (ADHD). However, while these improvements have received positive feedback, the field of XR-assisted patient treatment is in its infancy. The growth of XR in the healthcare sphere has the potential to transform the delivery of medical services. Imagine an elderly patient in a remote setting having a consultation with a world-renowned expert without ever having to leave their house. Rather than operating on cadavers in a medical facility, a surgical resident does surgery in a virtual setting at home. On the first try, a nurse uses a vein finder to implant an IV. Through cognitive treatment in a virtual world, a war veteran recovers from post-traumatic stress disorder (PTSD). The paper discusses the potential impact of XR in transforming the healthcare industry, as well as its use cases, challenges, XR tools and techniques for intelligent health care, recent developments of XR in intelligent healthcare services, and the potential benefits and future aspects of XR techniques in the medical domain.

Threshold field painting saves the time for segmentation of minute arteries

PURPOSE

It is often time-consuming to segment fine structures, such as the cerebral arteries from magnetic resonance imaging (MRI). Moreover, extracting anatomically abnormal structures is generally difficult. The segmentation workflow called threshold field painting was tested for its feasibility in morbid minute artery segmentation with special emphasis on time efficiency.

METHODS

Seven patients with meningioma with ten-sided feeding arteries (n = 10) originating from middle meningeal arteries (MMA) were investigated by three experts of the conventional method for segmentation. The MRI time-of-flight sequence was utilized for the segmentation of each procedure. The tasks were accomplished using both the conventional method and the proposed method in random order. The task completion time and usability score were analyzed using the Wilcoxon signed-rank test.

RESULTS

Except for one examinee (P = 0.06), the completion time significantly decreased (both P < 0.01) with the use of the proposed method. The average task completion time among the three examinees for the conventional method was 2.8 times longer than that for the proposed method. The usability score was generally in favor of the proposed method.

CONCLUSION

The normally nonexistent minute arteries, such as the MMA feeders, were deemed more efficiently segmented with the proposed method than with the conventional method. While automatic segmentation might be the ultimate solution, our semiautomatic method incorporating expert knowledge is expected to work as the practical solution.

Examining the benefits of extended reality in neurosurgery: A systematic review

While well-established in other surgical subspecialties, the benefits of extended reality, consisting of virtual reality (VR), augmented reality (AR), and mixed reality (MR) technologies, remains underexplored in neurosurgery despite its increasing utilization. To address this gap, we conducted a systematic review of the effects of extended reality (XR) in neurosurgery with an emphasis on the perioperative period, to provide a guide for future clinical optimization. Seven primary electronic databases were screened following guidelines outlined by PRISMA and the Institute of Medicine. Reported data related to outcomes in the perioperative period and resident training were all examined, and a focused analysis of studies reporting controlled, clinical outcomes was completed. After removal of duplicates, 2548 studies were screened with 116 studies reporting measurable effects of XR in neurosurgery. The majority (82%) included cranial based applications related to tumor surgery with 34% showing improved resection rates and functional outcomes. A rise in high-quality studies was identified from 2017 to 2020 compared to all previous years (p = 0.004). Primary users of the technology were: 56% neurosurgeon (n = 65), 28% residents (n = 33) and 5% patients (n = 6). A final synthesis was conducted on 10 controlled studies reporting patient outcomes. XR technologies have demonstrated benefits in preoperative planning and multimodal neuronavigation especially for tumor surgery. However, few studies have reported patient outcomes in a controlled design demonstrating a need for higher quality data. XR platforms offer several advantages to improve patient outcomes and specifically, the patient experience for neurosurgery.

Optimization of skull base exposure using navigation-integrated, virtual reality templates

In many skull base procedures, arriving at the optimal bone exposure is important. Whereas insufficient exposure can jeopardize the operation itself, over-doing the exposure might lead to complications. We developed a new technique, harnessing the strength of Virtual Reality (VR) technology in planning, rehearsal and navigation, to achieve the optimal skull base exposure for resection of tumors. VR models of patient-specific anatomy were used to rehearse the surgical exposure. From the altered models, the one with the ideal exposure was chosen, integrated with the navigation system in the operating suite, and used as a template to achieve the optimal exposure in surgery. The use of these VR templates is demonstrated in two cases involving skull base tumors. In both cases, over-zealous bone removal could have increased the risk of complications, and inadequate exposure would jeopardize the tumor resection. Navigation guided by the VR templates aided the creation of the "ideal" surgical exposure to reach the surgical goals. Complete resections were achieved and neither patient suffered any approach-related complications. In conclusion, virtual reality is a powerful tool to improve the safety and efficacy of neurosurgical procedures. With preoperatively-altered VR templates, the surgeon is no longer navigating just to find bearings, but to duplicate an opening designed to simultaneously provide sufficient exposure while limiting postoperative complications. Intuitively useful and successful in early application, there has been no identifiable disadvantages to date.

Three-Dimensional Modeling of Complex Pediatric Intracranial Aneurysmal Malformations With a Virtual Reality System

INTRODUCTION

Surgical simulation is valuable in neurovascular surgery given the progressive rarity of these cases and their technical complexity, but its use has not been well described for pediatric vascular pathologies. We herein review the use of surgical simulation at our institution for complex pediatric aneurysmal malformations.

METHODS

A retrospective review of patients treated for middle cerebral artery aneurysmal malformations with surgical simulation assistance (SuRgical Planner [SRP]; Surgical Theater, Mayfield Village, OH) during a 2-year period at Rady Children's Hospital of San Diego was performed.

RESULTS

In 5 pediatric patients with complex MCA aneurysmal malformations (mean age = 33.2 ± 49.9 months), preoperative 3-dimensional (3D) interactive modeling informed treatment planning and enhanced surgeon understanding of the vascular pathology. Availability of intraoperative simulation also aided real-time anatomical understanding during surgery. Specific benefits of simulation for these cases included characterization of involved perforating vessels, as well as an enhanced understanding of flow patterns within associated complex arteriovenous fistulas and feeding vessel/daughter branch anatomy. Despite the complexity of the lesions treated, use of simulation qualitatively enhanced surgeon confidence. There were no perioperative complications for patients treated with open surgery.

CONCLUSIONS

Surgical simulation may aid in the treatment of complex pediatric aneurysmal malformations.

Presurgical and Intraoperative Augmented Reality in Neuro-Oncologic Surgery: Clinical Experiences and Limitations

Virtual reality (VR) and augmented reality (AR) represent novel adjuncts for neurosurgical planning in neuro-oncology. In addition to established use in surgical and medical training, VR/AR are gaining traction for clinical use preoperatively and intraoperatively. To understand the utility of VR/AR in the clinical setting, we conducted a literature search in Ovid MEDLINE and EMBASE with various search terms designed to capture the use of VR/AR in neurosurgical procedures for resection of cranial tumors. The search retrieved 302 articles, of which 35 were subjected to full-text review; 19 full-text articles were included in the review. Key findings highlighted by the individual authors were extracted and summarized into themes to present the value of VR/AR in the clinical setting. These studies included various VR/AR systems applied to surgeries involving heterogeneous pathologies and outcome measures. Overall, VR/AR were found to be qualitatively advantageous due to enhanced visualization of complex anatomy and improved intraoperative lesion localization. When these technologies were compared with existing neuronavigation systems, quantitative clinical benefits were also reported. The capacity to visualize three-dimensional images superimposed on patient anatomy is a potentially valuable tool in complex neurosurgical environments. Surgical limitations may be addressed through future advances in image registration and tracking as well as intraoperatively acquired imaging with the ability to yield real-time virtual models.

Virtual reality and augmented reality in the management of intracranial tumors: A review

Neurosurgeons are faced with the challenge of planning, performing, and learning complex surgical procedures. With improvements in computational power and advances in visual and haptic display technologies, augmented and virtual surgical environments can offer potential benefits for tests in a safe and simulated setting, as well as improve management of real-life procedures. This systematic literature review is conducted in order to investigate the roles of such advanced computing technology in neurosurgery subspecialization of intracranial tumor removal. The study would focus on an in-depth discussion on the role of virtual reality and augmented reality in the management of intracranial tumors: the current status, foreseeable challenges, and future developments.

Three-dimensional multimodality fusion imaging as an educational and planning tool for deep-seated meningiomas

INTRODUCTION

The utility of surgical simulation with three-dimensional multimodality fusion imaging (3D-MFI) has been demonstrated. However, its potential in deep-seated brain lesions remains unknown. The aim of this study was to investigate the impact of 3D-MFI in deep-seated meningioma operations.

MATERIAL AND METHODS

Fourteen patients with deeply located meningiomas were included in this study. We constructed 3D-MFIs by fusing high-resolution magnetic resonance (MR) and computed tomography (CT) images with a rotational digital subtraction angiogram (DSA) in all patients. The surgical procedure was simulated by 3D-MFI prior to operation. To assess the impact on neurosurgical education, the objective values of surgical simulation by 3D-MFIs/virtual reality (VR) video were evaluated. To validate the quality of 3D-MFIs, intraoperative findings were compared. The identification rate (IR) and positive predictive value (PPV) for the tumor feeding arteries and involved perforating arteries and veins were also assessed for quality assessment of 3D-MFI.

RESULTS

After surgical simulation by 3D-MFIs, near-total resection was achieved in 13 of 14 (92.9%) patients without neurological complications. 3D-MFIs significantly contributed to the understanding of surgical anatomy and optimal surgical view (p < .0001) and learning how to preserve critical vessels (p < .0001) and resect tumors safety and extensively (p < .0001) by neurosurgical residents/fellows. The IR of 3D-MFI for tumor-feeding arteries and perforating arteries and veins was 100% and 92.9%, respectively. The PPV of 3D-MFI for tumor-feeding arteries and perforating arteries and veins was 98.8% and 76.5%, respectively.

CONCLUSIONS

3D-MFI contributed to learn skull base meningioma surgery. Also, 3D-MFI provided high quality to identify critical anatomical structures within or adjacent to deep-seated meningiomas. Thus, 3D-MFI is promising educational and surgical planning tool for meningiomas in deep-seated regions.

Usefulness of high-resolution 3D multifusion medical imaging for preoperative planning in patients with posterior fossa hemangioblastoma: technical note

Successful resection of hemangioblastoma depends on preoperative assessment of the precise locations of feeding arteries and draining veins. Simultaneous 3D visualization of feeding arteries, draining veins, and surrounding structures is needed. The present study evaluated the usefulness of high-resolution 3D multifusion medical imaging (hr-3DMMI) for preoperative planning of hemangioblastoma. The hr-3DMMI combined MRI, MR angiography, thin-slice CT, and 3D rotated angiography. Surface rendering was mainly used for the creation of hr-3DMMI using multiple thresholds to create 3D models, and processing took approximately 3–5 hours. This hr-3DMMI technique was used in 5 patients for preoperative planning and the imaging findings were compared with the operative findings. Hr-3DMMI could simulate the whole 3D tumor as a unique sphere and show the precise penetration points of both feeding arteries and draining veins with the same spatial relationships as the original tumor. All feeding arteries and draining veins were found intraoperatively at the same position as estimated preoperatively, and were occluded as planned preoperatively. This hr-3DMMI technique could demonstrate the precise locations of feeding arteries and draining veins preoperatively and estimate the appropriate route for resection of the tumor. Hr-3DMMI is expected to be a very useful support tool for surgery of hemangioblastoma.

Anatomical study of suboccipital vertebral arteries and surrounding bony structures using virtual reality technology

Background

This work aimed to evaluate the efficacy of virtual reality (VR) technology in neurosurgical anatomy through a comparison of the virtual 3D microanatomy of the suboccipital vertebral arteries and their bony structures as part of the resection of tumors in the craniovertebral junction (CVJ) of 20 patients compared to the actual microanatomy of the vertebral arteries of 15 cadaveric headsets.

Material/Methods

The study was conducted with 2 groups of data: a VR group composed of 20 clinical cases and a physical body group (PB group) composed of 15 cadaveric headsets. In the VR group, the dissection and measurements of the vertebral arteries were simulated on a Dextroscope. In the PB group, the vertebral arteries in the cadaver heads were examined under a microscope and anatomical measurements of VA and bony structures were performed. The length and course of the vertebral arteries and its surrounding bony structures in each group were compared.

Results

The distances from the inferior part of the transverse process foramen (TPF) of C1 to the inferior part of TPF of C2 were 17.68±2.86 mm and 18.4±1.82 mm in the PB and VR groups, respectively. The distances between the middle point of the posterior arch of the atlas and the medial intersection of VA on the groove were 17.35±2.23 mm in the PB group and 18.13±2.58 mm in the VR group. The distances between the middle line and the entrance of VA to the lower rim of TPF of Atlas were 28.64±2.67 mm in PB group and 29.23±2.89 mm in VR group. The diameters of the vertebral artery (VA) at the end of the groove and foramen of C2 transverse process were 4.02±046 mm and 4.25±0.51 mm, respectively, in the PB group and 3.54±0.44 mm and 4.47±0.62 mm, respectively, in VR group. The distances between the VA lumen center and midline of the foramen magnum at the level of dural penetration was 10.4±1.13 mm in the PB group and 11.5±1.34 mm in the VR group (P>0.05).

Conclusions

VR technology can accurately simulate the anatomical features of the suboccipital vertebral arteries and their bony structures, which facilitates the planning of individual surgeries in the CVJ.

Autostereoscopic 3D visualization and image processing system for neurosurgery

A demonstrator system for planning neurosurgical procedures was developed based on commercial hardware and software. The system combines an easy-to-use environment for surgical planning with high-end visualization and the opportunity to analyze data sets for research purposes. The demonstrator system is based on the software AMIRA. Specific algorithms for segmentation, elastic registration, and visualization have been implemented and adapted to the clinical workflow. Modules from AMIRA and the image processing library Insight Segmentation and Registration Toolkit (ITK) can be combined to solve various image processing tasks. Customized modules tailored to specific clinical problems can easily be implemented using the AMIRA application programming interface and a self-developed framework for ITK filters. Visualization is done via autostereoscopic displays, which provide a 3D impression without viewing aids. A Spaceball device allows a comfortable, intuitive way of navigation in the data sets. Via an interface to a neurosurgical navigation system, the demonstrator system can be used intraoperatively. The precision, applicability, and benefit of the demonstrator system for planning of neurosurgical interventions and for neurosurgical research were successfully evaluated by neurosurgeons using phantom and patient data sets.

Navigation in surgery

INTRODUCTION

"Navigation in surgery" spans a broad area, which, depending on the clinical challenge, can have different meanings. Over the past decade, navigation in surgery has evolved beyond imaging modalities and bulky systems into the rich networking of the cloud or devices that are pocket-sized.

DISCUSSION

This article will review various aspects of navigation in the operating room and beyond. This includes a short history of navigation, the evolution of surgical navigation, as well as technical aspects and clinical benefits with examples from neurosurgery, spinal surgery, and orthopedics.

CONCLUSION

With improved computer technology and a trend towards advanced information processing within hospitals, navigation is quickly becoming an integral part in the surgical routine of clinicians.

Stereoscopic virtual reality models for planning tumor resection in the sellar region

BACKGROUND

It is difficult for neurosurgeons to perceive the complex three-dimensional anatomical relationships in the sellar region.

METHODS

To investigate the value of using a virtual reality system for planning resection of sellar region tumors. The study included 60 patients with sellar tumors. All patients underwent computed tomography angiography, MRI-T1W1, and contrast enhanced MRI-T1W1 image sequence scanning. The CT and MRI scanning data were collected and then imported into a Dextroscope imaging workstation, a virtual reality system that allows structures to be viewed stereoscopically. During preoperative assessment, typical images for each patient were chosen and printed out for use by the surgeons as references during surgery.

RESULTS

All sellar tumor models clearly displayed bone, the internal carotid artery, circle of Willis and its branches, the optic nerve and chiasm, ventricular system, tumor, brain, soft tissue and adjacent structures. Depending on the location of the tumors, we simulated the transmononasal sphenoid sinus approach, transpterional approach, and other approaches. Eleven surgeons who used virtual reality models completed a survey questionnaire. Nine of the participants said that the virtual reality images were superior to other images but that other images needed to be used in combination with the virtual reality images.

CONCLUSIONS

The three-dimensional virtual reality models were helpful for individualized planning of surgery in the sellar region. Virtual reality appears to be promising as a valuable tool for sellar region surgery in the future.