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Higa J, Nkatha S, Ramirez Herrera R, Marcus H, Yoo S, Blandford A, Opie J. Augmented reality for endoscopic transsphenoidal surgery: evaluating design factors with neurosurgeons. Int J Comput Assist Radiol Surg 2024:10.1007/s11548-024-03225-9. [PMID: 39060888 DOI: 10.1007/s11548-024-03225-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024]
Abstract
PURPOSE This study investigates the potential utility of augmented reality (AR) in the endoscopic transsphenoidal approach (TSA). While previous research has addressed technical challenges in AR for TSA, this paper explores how design factors can improve AR for neurosurgeons from a human-centred design perspective. METHODS Preliminary qualitative research involved observations of TSA procedures ( n = 2 ) and semi-structured interviews with neurosurgeons ( n = 4 ). These informed the design of an AR mockup, which was evaluated with neurosurgeons ( n = 3 ). An interactive low-fidelity prototype-the "AR-assisted Navigation for the TransSphenoidal Approach (ANTSA)"-was then developed in Unity 3D. A user study ( n = 4 ) evaluated the low-fidelity prototype of ANTSA through contextual interviews, providing feedback on design factors. RESULTS AR visualisations may be beneficial in streamlining the sellar phase and reducing intraoperative errors such as excessive or inadequate exposure. Key design recommendations include a lean mesh rendering, an intuitive colour palette, and optional structure highlighting. CONCLUSION This research presents user-centred design guidelines to improve sensemaking and surgical workflow in the sellar phase of TSA, with the goal of improving clinical outcomes. The specific improvements that AR could bring to the workflow are discussed along with surgeons' reservations and its possible application towards training less experienced physicians.
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Affiliation(s)
- Jennifer Higa
- UCLIC, University College London, London, WC1E 6BT, UK
| | - Sonia Nkatha
- UCLIC, University College London, London, WC1E 6BT, UK
| | - Roxana Ramirez Herrera
- UCLIC, University College London, London, WC1E 6BT, UK.
- WEISS, University College London, London, W1W 7TY, UK.
| | - Hani Marcus
- WEISS, University College London, London, W1W 7TY, UK
| | - Soojeong Yoo
- UCLIC, University College London, London, WC1E 6BT, UK
- WEISS, University College London, London, W1W 7TY, UK
| | - Ann Blandford
- UCLIC, University College London, London, WC1E 6BT, UK
- WEISS, University College London, London, W1W 7TY, UK
| | - Jeremy Opie
- UCLIC, University College London, London, WC1E 6BT, UK
- WEISS, University College London, London, W1W 7TY, UK
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Isikay I, Cekic E, Baylarov B, Tunc O, Hanalioglu S. Narrative review of patient-specific 3D visualization and reality technologies in skull base neurosurgery: enhancements in surgical training, planning, and navigation. Front Surg 2024; 11:1427844. [PMID: 39081485 PMCID: PMC11287220 DOI: 10.3389/fsurg.2024.1427844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/02/2024] [Indexed: 08/02/2024] Open
Abstract
Recent advances in medical imaging, computer vision, 3-dimensional (3D) modeling, and artificial intelligence (AI) integrated technologies paved the way for generating patient-specific, realistic 3D visualization of pathological anatomy in neurosurgical conditions. Immersive surgical simulations through augmented reality (AR), virtual reality (VR), mixed reality (MxR), extended reality (XR), and 3D printing applications further increased their utilization in current surgical practice and training. This narrative review investigates state-of-the-art studies, the limitations of these technologies, and future directions for them in the field of skull base surgery. We begin with a methodology summary to create accurate 3D models customized for each patient by combining several imaging modalities. Then, we explore how these models are employed in surgical planning simulations and real-time navigation systems in surgical procedures involving the anterior, middle, and posterior cranial skull bases, including endoscopic and open microsurgical operations. We also evaluate their influence on surgical decision-making, performance, and education. Accumulating evidence demonstrates that these technologies can enhance the visibility of the neuroanatomical structures situated at the cranial base and assist surgeons in preoperative planning and intraoperative navigation, thus showing great potential to improve surgical results and reduce complications. Maximum effectiveness can be achieved in approach selection, patient positioning, craniotomy placement, anti-target avoidance, and comprehension of spatial interrelationships of neurovascular structures. Finally, we present the obstacles and possible future paths for the broader implementation of these groundbreaking methods in neurosurgery, highlighting the importance of ongoing technological advancements and interdisciplinary collaboration to improve the accuracy and usefulness of 3D visualization and reality technologies in skull base surgeries.
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Affiliation(s)
- Ilkay Isikay
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Efecan Cekic
- Neurosurgery Clinic, Polatli Duatepe State Hospital, Ankara, Türkiye
| | - Baylar Baylarov
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Osman Tunc
- Btech Innovation, METU Technopark, Ankara, Türkiye
| | - Sahin Hanalioglu
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
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Edalati S, Slobin J, Harsinay A, Vasan V, Taha MA, Del Signore A, Govindaraj S, Iloreta AM. Augmented and Virtual Reality Applications in Rhinology: A Scoping Review. Laryngoscope 2024. [PMID: 38924127 DOI: 10.1002/lary.31602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/22/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES Virtual reality (VR) and augmented reality (AR) are innovative technologies that have a wide range of potential applications in the health care industry. The aim of this study was to investigate the body of research on AR and VR applications in rhinology by performing a scoping review. DATA SOURCES PubMed, Scopus, and Embase. REVIEW METHODS According to PRISM-ScR guidelines, a scoping review of literature on the application of AR and/or VR in the context of Rhinology was conducted using PubMed, Scopus, and Embase. RESULTS Forty-nine articles from 1996 to 2023 met the criteria for review. Five broad types of AR and/or VR applications were found: preoperative, intraoperative, training/education, feasibility, and technical. The subsequent clinical domains were recognized: craniovertebral surgery, nasal endoscopy, transsphenoidal surgery, skull base surgery, endoscopic sinus surgery, and sinonasal malignancies. CONCLUSION AR and VR have comprehensive applications in Rhinology. AR for surgical navigation may have the most emerging potential in skull base surgery and endoscopic sinus surgery. VR can be utilized as an engaging training tool for surgeons and residents and as a distraction analgesia for patients undergoing office-based procedures. Additional research is essential to further understand the tangible effects of these technologies on measurable clinical results. Laryngoscope, 2024.
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Affiliation(s)
- Shaun Edalati
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jacqueline Slobin
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ariel Harsinay
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vikram Vasan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohamed A Taha
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anthony Del Signore
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alfred Marc Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Mor E, Tejman-Yarden S, Mor-Hadar D, Assaf D, Eifer M, Nagar N, Vazhgovsky O, Duffield J, Henderson MA, Speakman D, Snow H, Gyorki DE. 3D-SARC: A Pilot Study Testing the Use of a 3D Augmented-Reality Model with Conventional Imaging as a Preoperative Assessment Tool for Surgical Resection of Retroperitoneal Sarcoma. Ann Surg Oncol 2024:10.1245/s10434-024-15634-w. [PMID: 38898325 DOI: 10.1245/s10434-024-15634-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Retroperitoneal sarcomas (RPSs) present a surgical challenge, with complex anatomic relationships to organs and vascular structures. This pilot study investigated the role of three-dimensional (3D) augmented reality (3DAR) compared with standard imaging in preoperative planning and resection strategies. METHODS For the study, 13 patients who underwent surgical resection of their RPS were selected based on the location of their tumor (right, left, pelvis). From the patients' preoperative computed tomography (CT) scans, 3DAR models were created using a D2P program and projected by an augmented-reality (AR) glass (Hololens). The 3DAR models were evaluated by three experienced sarcoma surgeons and compared with the baseline two-dimensional (2D) contrast-enhanced CT scans. RESULTS Three members of the surgical team evaluated 13 models of retroperitoneal sarcomas, resulting in a total of 26 responses. When the surgical team was asked to evaluate whether the 3DAR better prepared the surgeon for planned surgical resection, 10 responses favored the 3DAR, 5 favored the 2D CT scans and 11 showed no difference (p = 0.074). According to 15 (57.6 %) of the 26 responses, the 3DAR offered additional value over standard imaging in the preoperative planning (median score of 4; range, 1-5). The median stated likelihood that the surgeons would consult the 3DAR was 5 (range, 2-5) for the preoperative setting and 3 (range, 1-5) for the intraoperative setting. CONCLUSIONS This pilot study suggests that the use of 3DAR may provide additional value over current standard imaging in the preoperative planning for surgical resection of RPS, and the technology merits further study.
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Affiliation(s)
- Eyal Mor
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
- The Surgical Oncology Unit - Division of Surgery, Sheba Medical Center, Tel Hashomer, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel.
| | - Shai Tejman-Yarden
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
- The Engineering Medical Research Lab, Sheba Medical Center, Ramat Gan, Israel
| | - Danielle Mor-Hadar
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Dan Assaf
- The Surgical Oncology Unit - Division of Surgery, Sheba Medical Center, Tel Hashomer, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Michal Eifer
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Netanel Nagar
- Industrial Design Department, Shenkar College of Engineering, Design and Art, Ramat-Gan, Israel
| | - Oliana Vazhgovsky
- The Engineering Medical Research Lab, Sheba Medical Center, Ramat Gan, Israel
| | - Jaime Duffield
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michael A Henderson
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - David Speakman
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Hayden Snow
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - David E Gyorki
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
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Chou DW, Annadata V, Willson G, Gray M, Rosenberg J. Augmented and Virtual Reality Applications in Facial Plastic Surgery: A Scoping Review. Laryngoscope 2024; 134:2568-2577. [PMID: 37947302 DOI: 10.1002/lary.31178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/05/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES Augmented reality (AR) and virtual reality (VR) are emerging technologies with wide potential applications in health care. We performed a scoping review of the current literature on the application of augmented and VR in the field of facial plastic and reconstructive surgery (FPRS). DATA SOURCES PubMed and Web of Science. REVIEW METHODS According to PRISMA guidelines, PubMed and Web of Science were used to perform a scoping review of literature regarding the utilization of AR and/or VR relevant to FPRS. RESULTS Fifty-eight articles spanning 1997-2023 met the criteria for review. Five overarching categories of AR and/or VR applications were identified across the articles: preoperative, intraoperative, training/education, feasibility, and technical. The following clinical areas were identified: burn, craniomaxillofacial surgery (CMF), face transplant, face lift, facial analysis, facial palsy, free flaps, head and neck surgery, injectables, locoregional flaps, mandible reconstruction, mandibuloplasty, microtia, skin cancer, oculoplastic surgery, rhinology, rhinoplasty, and trauma. CONCLUSION AR and VR have broad applications in FPRS. AR for surgical navigation may have the most emerging potential in CMF surgery and free flap harvest. VR is useful as distraction analgesia for patients and as an immersive training tool for surgeons. More data on these technologies' direct impact on objective clinical outcomes are still needed. LEVEL OF EVIDENCE N/A Laryngoscope, 134:2568-2577, 2024.
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Affiliation(s)
- David W Chou
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vivek Annadata
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gloria Willson
- Education and Research Services, Levy Library, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mingyang Gray
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Rosenberg
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Begagić E, Bečulić H, Pugonja R, Memić Z, Balogun S, Džidić-Krivić A, Milanović E, Salković N, Nuhović A, Skomorac R, Sefo H, Pojskić M. Augmented Reality Integration in Skull Base Neurosurgery: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:335. [PMID: 38399622 PMCID: PMC10889940 DOI: 10.3390/medicina60020335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: To investigate the role of augmented reality (AR) in skull base (SB) neurosurgery. Materials and Methods: Utilizing PRISMA methodology, PubMed and Scopus databases were explored to extract data related to AR integration in SB surgery. Results: The majority of 19 included studies (42.1%) were conducted in the United States, with a focus on the last five years (77.8%). Categorization included phantom skull models (31.2%, n = 6), human cadavers (15.8%, n = 3), or human patients (52.6%, n = 10). Microscopic surgery was the predominant modality in 10 studies (52.6%). Of the 19 studies, surgical modality was specified in 18, with microscopic surgery being predominant (52.6%). Most studies used only CT as the data source (n = 9; 47.4%), and optical tracking was the prevalent tracking modality (n = 9; 47.3%). The Target Registration Error (TRE) spanned from 0.55 to 10.62 mm. Conclusion: Despite variations in Target Registration Error (TRE) values, the studies highlighted successful outcomes and minimal complications. Challenges, such as device practicality and data security, were acknowledged, but the application of low-cost AR devices suggests broader feasibility.
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Affiliation(s)
- Emir Begagić
- Department of General Medicine, School of Medicine, University of Zenica, Travnička 1, 72000 Zenica, Bosnia and Herzegovina;
| | - Hakija Bečulić
- Department of Neurosurgery, Cantonal Hospital Zenica, Crkvice 67, 72000 Zenica, Bosnia and Herzegovina; (H.B.)
- Department of Anatomy, School of Medicine, University of Zenica, Travnička 1, 72000 Zenica, Bosnia and Herzegovina;
| | - Ragib Pugonja
- Department of Anatomy, School of Medicine, University of Zenica, Travnička 1, 72000 Zenica, Bosnia and Herzegovina;
| | - Zlatan Memić
- Department of General Medicine, School of Medicine, University of Zenica, Travnička 1, 72000 Zenica, Bosnia and Herzegovina;
| | - Simon Balogun
- Division of Neurosurgery, Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ilesa Road PMB 5538, Ile-Ife 220282, Nigeria
| | - Amina Džidić-Krivić
- Department of Neurology, Cantonal Hospital Zenica, Crkvice 67, 72000 Zenica, Bosnia and Herzegovina
| | - Elma Milanović
- Neurology Clinic, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
| | - Naida Salković
- Department of General Medicine, School of Medicine, University of Tuzla, Univerzitetska 1, 75000 Tuzla, Bosnia and Herzegovina;
| | - Adem Nuhović
- Department of General Medicine, School of Medicine, University of Sarajevo, Univerzitetska 1, 71000 Sarajevo, Bosnia and Herzegovina;
| | - Rasim Skomorac
- Department of Neurosurgery, Cantonal Hospital Zenica, Crkvice 67, 72000 Zenica, Bosnia and Herzegovina; (H.B.)
- Department of Surgery, School of Medicine, University of Zenica, Travnička 1, 72000 Zenica, Bosnia and Herzegovina
| | - Haso Sefo
- Neurosurgery Clinic, Clinical Center University of Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina
| | - Mirza Pojskić
- Department of Neurosurgery, University Hospital Marburg, Baldingerstr., 35033 Marburg, Germany
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Lin CJY, Ruscoe Z, Lim L, Wei MYK, Yeung JMC. Is it time to adopt 3D modelling for complex fistula-in-ano? ANZ J Surg 2024; 94:17-18. [PMID: 37985646 DOI: 10.1111/ans.18765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Cindy J Y Lin
- Department of Surgery, Western Precinct, University of Melbourne, Melbourne, Victoria, Australia
| | - Zoe Ruscoe
- Department of Surgery, Western Precinct, University of Melbourne, Melbourne, Victoria, Australia
| | - Lincoln Lim
- Department of Radiology, Western Health, Melbourne, Victoria, Australia
| | - Matthew Y K Wei
- Department of Colorectal Surgery, Western Health, Melbourne, Victoria, Australia
| | - Justin M C Yeung
- Department of Surgery, Western Precinct, University of Melbourne, Melbourne, Victoria, Australia
- Department of Colorectal Surgery, Western Health, Melbourne, Victoria, Australia
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Ritter A, Levyn H, Shah J. Recent advances in head and neck surgical oncology. J Surg Oncol 2024; 129:32-39. [PMID: 37990842 PMCID: PMC10842243 DOI: 10.1002/jso.27529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023]
Abstract
In recent years, the field of head and neck oncology has witnessed a remarkable transformation with unprecedented advances that have revolutionized the management of complex tumors in this region. As an intricate subspecialty within oncology, head and neck surgical procedures demand detailed knowledge of the complex anatomy meticulous precision in surgical technique, and expertise to preserve vital functions while ensuring optimal oncological outcomes. With the relentless pursuit of improved patient outcomes, the integration of innovative technologies has significantly enhanced the surgical armamentarium. Robotics, endoscopic platforms, and image-guided navigation have revolutionized the surgical approach, enabling precise tumor resection and sparing healthy tissues. Furthermore, the application of advanced imaging modalities and molecular biomarker profiling has opened new avenues for personalized treatment strategies. From targeted therapies and immunotherapies to adaptive radiation techniques, clinicians are now equipped with an array of tailored options, ushering in a new era of personalized care for patients with head and neck malignancies. This article delves into the unfolding narratives of clinical triumphs, exploring the transformative potential of emerging therapies and the collaborative efforts propelling head and neck surgical oncology toward a future of hope and healing.
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Woodall WJ, Chang EH, Toy S, Lee DR, Sherman JH. Does Extended Reality Simulation Improve Surgical/Procedural Learning and Patient Outcomes When Compared With Standard Training Methods?: A Systematic Review. Simul Healthc 2024; 19:S98-S111. [PMID: 38240622 DOI: 10.1097/sih.0000000000000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
INTRODUCTION The use of extended reality (XR) technologies, including virtual, augmented, and mixed reality, has increased within surgical and procedural training programs. Few studies have assessed experiential learning- and patient-based outcomes using XR compared with standard training methods. METHODS As a working group for the Society for Simulation in Healthcare, we used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a PICO strategy to perform a systematic review of 4238 articles to assess the effectiveness of XR technologies compared with standard training methods. Outcomes were grouped into knowledge, time-to-completion, technical proficiency, reactions, and patient outcomes. Because of study heterogeneity, a meta-analysis was not feasible. RESULTS Thirty-two studies met eligibility criteria: 18 randomized controlled trials, 7 comparative studies, and 7 systematic reviews. Outcomes of most studies included Kirkpatrick levels of evidence I-III (reactions, knowledge, and behavior), while few reported level IV outcomes (patient). The overall risk of bias was low. With few exceptions, included studies showed XR technology to be more effective than standard training methods in improving objective skills and performance, shortening procedure time, and receiving more positive learner ratings. However, XR use did not show significant differences in gained knowledge. CONCLUSIONS Surgical or procedural XR training may improve technical skill development among trainees and is generally favored over standard training methods. However, there should be an additional focus on how skill development translates to clinically relevant outcomes. We recommend longitudinal studies to examine retention and transfer of training to clinical settings, methods to improve timely, adaptive feedback for deliberate practice, and cost analyses.
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Affiliation(s)
- William J Woodall
- From the Medical College of Georgia (W.J.W.), Augusta, GA; Department of Otolaryngology (E.H.C.), University of Arizona, Tucson, AZ; Departments of Basic Science Education and Health Systems & Implementation Science (S.T.), Virginia Tech Carilion School of Medicine, Roanoke, VA; University of Michigan School of Nursing (D.R.L.), Ann Arbor, MI; and WVU Rockefeller Neuroscience Institute (J.H.S.), Morgantown, WV
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Campisi BM, Costanzo R, Gulino V, Avallone C, Noto M, Bonosi L, Brunasso L, Scalia G, Iacopino DG, Maugeri R. The Role of Augmented Reality Neuronavigation in Transsphenoidal Surgery: A Systematic Review. Brain Sci 2023; 13:1695. [PMID: 38137143 PMCID: PMC10741598 DOI: 10.3390/brainsci13121695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
In the field of minimally invasive neurosurgery, microscopic transsphenoidal surgery (MTS) and endoscopic transsphenoidal surgery (ETS) have been widely accepted as a safe approach for pituitary lesions and, more recently, their indications have been extended to lesions at various skull base regions. It is mandatory during transsphenoidal surgery (TS) to identify key anatomical landmarks in the sphenoid sinus and distinguish them from the lesion. Over the years, many intraoperative tools have been introduced to improve the neuronavigation systems aiming to achieve safer and more accurate neurosurgical interventions. However, traditional neuronavigation systems may lose the accuracy of real-time location due to the discrepancy between the actual surgical field and the preoperative 2D images. To deal with this, augmented reality (AR)-a new sophisticated 3D technology that superimposes computer-generated virtual objects onto the user's view of the real world-has been considered a promising tool. Particularly, in the field of TS, AR can minimize the anatomic challenges of traditional endoscopic or microscopic surgery, aiding in surgical training, preoperative planning and intra-operative orientation. The aim of this systematic review is to analyze the potential future role of augmented reality, both in endoscopic and microscopic transsphenoidal surgeries.
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Affiliation(s)
- Benedetta Maria Campisi
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (B.M.C.); (V.G.); (C.A.); (M.N.); (L.B.); (L.B.); (D.G.I.); (R.M.)
| | - Roberta Costanzo
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (B.M.C.); (V.G.); (C.A.); (M.N.); (L.B.); (L.B.); (D.G.I.); (R.M.)
| | - Vincenzo Gulino
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (B.M.C.); (V.G.); (C.A.); (M.N.); (L.B.); (L.B.); (D.G.I.); (R.M.)
| | - Chiara Avallone
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (B.M.C.); (V.G.); (C.A.); (M.N.); (L.B.); (L.B.); (D.G.I.); (R.M.)
| | - Manfredi Noto
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (B.M.C.); (V.G.); (C.A.); (M.N.); (L.B.); (L.B.); (D.G.I.); (R.M.)
| | - Lapo Bonosi
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (B.M.C.); (V.G.); (C.A.); (M.N.); (L.B.); (L.B.); (D.G.I.); (R.M.)
| | - Lara Brunasso
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (B.M.C.); (V.G.); (C.A.); (M.N.); (L.B.); (L.B.); (D.G.I.); (R.M.)
| | - Gianluca Scalia
- Neurosurgery Unit, Department of Head and Neck Surgery, Garibaldi Hospital, 95122 Catania, Italy;
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (B.M.C.); (V.G.); (C.A.); (M.N.); (L.B.); (L.B.); (D.G.I.); (R.M.)
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy; (B.M.C.); (V.G.); (C.A.); (M.N.); (L.B.); (L.B.); (D.G.I.); (R.M.)
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11
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Zaccardi S, Frantz T, Beckwée D, Swinnen E, Jansen B. On-Device Execution of Deep Learning Models on HoloLens2 for Real-Time Augmented Reality Medical Applications. SENSORS (BASEL, SWITZERLAND) 2023; 23:8698. [PMID: 37960398 PMCID: PMC10648161 DOI: 10.3390/s23218698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
The integration of Deep Learning (DL) models with the HoloLens2 Augmented Reality (AR) headset has enormous potential for real-time AR medical applications. Currently, most applications execute the models on an external server that communicates with the headset via Wi-Fi. This client-server architecture introduces undesirable delays and lacks reliability for real-time applications. However, due to HoloLens2's limited computation capabilities, running the DL model directly on the device and achieving real-time performances is not trivial. Therefore, this study has two primary objectives: (i) to systematically evaluate two popular frameworks to execute DL models on HoloLens2-Unity Barracuda and Windows Machine Learning (WinML)-using the inference time as the primary evaluation metric; (ii) to provide benchmark values for state-of-the-art DL models that can be integrated in different medical applications (e.g., Yolo and Unet models). In this study, we executed DL models with various complexities and analyzed inference times ranging from a few milliseconds to seconds. Our results show that Unity Barracuda is significantly faster than WinML (p-value < 0.005). With our findings, we sought to provide practical guidance and reference values for future studies aiming to develop single, portable AR systems for real-time medical assistance.
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Affiliation(s)
- Silvia Zaccardi
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel, 1050 Brussel, Belgium; (T.F.); (B.J.)
- Rehabilitation Research Group (RERE), Vrije Universiteit Brussel, 1090 Brussel, Belgium; (D.B.); (E.S.)
- IMEC, 3001 Leuven, Belgium
| | - Taylor Frantz
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel, 1050 Brussel, Belgium; (T.F.); (B.J.)
- IMEC, 3001 Leuven, Belgium
| | - David Beckwée
- Rehabilitation Research Group (RERE), Vrije Universiteit Brussel, 1090 Brussel, Belgium; (D.B.); (E.S.)
| | - Eva Swinnen
- Rehabilitation Research Group (RERE), Vrije Universiteit Brussel, 1090 Brussel, Belgium; (D.B.); (E.S.)
| | - Bart Jansen
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel, 1050 Brussel, Belgium; (T.F.); (B.J.)
- IMEC, 3001 Leuven, Belgium
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12
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Hey G, Guyot M, Carter A, Lucke-Wold B. Augmented Reality in Neurosurgery: A New Paradigm for Training. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1721. [PMID: 37893439 PMCID: PMC10608758 DOI: 10.3390/medicina59101721] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/23/2023] [Accepted: 09/24/2023] [Indexed: 10/29/2023]
Abstract
Augmented reality (AR) involves the overlay of computer-generated images onto the user's real-world visual field to modify or enhance the user's visual experience. With respect to neurosurgery, AR integrates preoperative and intraoperative imaging data to create an enriched surgical experience that has been shown to improve surgical planning, refine neuronavigation, and reduce operation time. In addition, AR has the potential to serve as a valuable training tool for neurosurgeons in a way that minimizes patient risk while facilitating comprehensive training opportunities. The increased use of AR in neurosurgery over the past decade has led to innovative research endeavors aiming to develop novel, more efficient AR systems while also improving and refining present ones. In this review, we provide a concise overview of AR, detail current and emerging uses of AR in neurosurgery and neurosurgical training, discuss the limitations of AR, and provide future research directions. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 386 articles were initially identified. Two independent reviewers (GH and AC) assessed article eligibility for inclusion, and 31 articles are included in this review. The literature search included original (retrospective and prospective) articles and case reports published in English between 2013 and 2023. AR assistance has shown promise within neuro-oncology, spinal neurosurgery, neurovascular surgery, skull-base surgery, and pediatric neurosurgery. Intraoperative use of AR was found to primarily assist with surgical planning and neuronavigation. Similarly, AR assistance for neurosurgical training focused primarily on surgical planning and neuronavigation. However, studies included in this review utilize small sample sizes and remain largely in the preliminary phase. Thus, future research must be conducted to further refine AR systems before widespread intraoperative and educational use.
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Affiliation(s)
- Grace Hey
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Michael Guyot
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Ashley Carter
- Eastern Virginia Medical School, Norfolk, VA 23507, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32610, USA
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13
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Santona G, Madoglio A, Mattavelli D, Rigante M, Ferrari M, Lauretti L, Mattogno P, Parrilla C, De Bonis P, Galli J, Olivi A, Fontanella MM, Fiorentino A, Serpelloni M, Doglietto F. Training models and simulators for endoscopic transsphenoidal surgery: a systematic review. Neurosurg Rev 2023; 46:248. [PMID: 37725193 PMCID: PMC10509294 DOI: 10.1007/s10143-023-02149-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/29/2023] [Accepted: 09/02/2023] [Indexed: 09/21/2023]
Abstract
Endoscopic transsphenoidal surgery is a novel surgical technique requiring specific training. Different models and simulators have been recently suggested for it, but no systematic review is available. To provide a systematic and critical literature review and up-to-date description of the training models or simulators dedicated to endoscopic transsphenoidal surgery. A search was performed on PubMed and Scopus databases for articles published until February 2023; Google was also searched to document commercially available. For each model, the following features were recorded: training performed, tumor/arachnoid reproduction, assessment and validation, and cost. Of the 1199 retrieved articles, 101 were included in the final analysis. The described models can be subdivided into 5 major categories: (1) enhanced cadaveric heads; (2) animal models; (3) training artificial solutions, with increasing complexity (from "box-trainers" to multi-material, ct-based models); (4) training simulators, based on virtual or augmented reality; (5) Pre-operative planning models and simulators. Each available training model has specific advantages and limitations. Costs are high for cadaver-based solutions and vary significantly for the other solutions. Cheaper solutions seem useful only for the first stages of training. Most models do not provide a simulation of the sellar tumor, and a realistic simulation of the suprasellar arachnoid. Most artificial models do not provide a realistic and cost-efficient simulation of the most delicate and relatively common phase of surgery, i.e., tumor removal with arachnoid preservation; current research should optimize this to train future neurosurgical generations efficiently and safely.
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Affiliation(s)
- Giacomo Santona
- Department of Information Engineering, University of Brescia, Brescia, Italy
| | - Alba Madoglio
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy
| | - Davide Mattavelli
- Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Mario Rigante
- Otorhinolaryngology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Ferrari
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua - Azienda Ospedaliera di Padova, Padua, Italy
| | - Liverana Lauretti
- Neurosurgery, Department of Neurosciences, Sensory Organs and Thorax, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pierpaolo Mattogno
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudio Parrilla
- Otorhinolaryngology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pasquale De Bonis
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy
| | - Jacopo Galli
- Otorhinolaryngology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Otorhinolaryngology, Department of Neurosciences, Sensory Organs and Thorax, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Alessandro Olivi
- Neurosurgery, Department of Neurosciences, Sensory Organs and Thorax, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Maria Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia - ASST Spedali Civili di Brescia, Brescia, Italy
| | - Antonio Fiorentino
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Mauro Serpelloni
- Department of Information Engineering, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Neurosurgery, Department of Neurosciences, Sensory Organs and Thorax, Università Cattolica del Sacro Cuore, Rome, Italy.
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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14
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Enkaoua A, Islam M, Ramalhinho J, Dowrick T, Booker J, Khan DZ, Marcus HJ, Clarkson MJ. Image-guidance in endoscopic pituitary surgery: an in-silico study of errors involved in tracker-based techniques. Front Surg 2023; 10:1222859. [PMID: 37780914 PMCID: PMC10540627 DOI: 10.3389/fsurg.2023.1222859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/11/2023] [Indexed: 10/03/2023] Open
Abstract
Background Endoscopic endonasal surgery is an established minimally invasive technique for resecting pituitary adenomas. However, understanding orientation and identifying critical neurovascular structures in this anatomically dense region can be challenging. In clinical practice, commercial navigation systems use a tracked pointer for guidance. Augmented Reality (AR) is an emerging technology used for surgical guidance. It can be tracker based or vision based, but neither is widely used in pituitary surgery. Methods This pre-clinical study aims to assess the accuracy of tracker-based navigation systems, including those that allow for AR. Two setups were used to conduct simulations: (1) the standard pointer setup, tracked by an infrared camera; and (2) the endoscope setup that allows for AR, using reflective markers on the end of the endoscope, tracked by infrared cameras. The error sources were estimated by calculating the Euclidean distance between a point's true location and the point's location after passing it through the noisy system. A phantom study was then conducted to verify the in-silico simulation results and show a working example of image-based navigation errors in current methodologies. Results The errors of the tracked pointer and tracked endoscope simulations were 1.7 and 2.5 mm respectively. The phantom study showed errors of 2.14 and 3.21 mm for the tracked pointer and tracked endoscope setups respectively. Discussion In pituitary surgery, precise neighboring structure identification is crucial for success. However, our simulations reveal that the errors of tracked approaches were too large to meet the fine error margins required for pituitary surgery. In order to achieve the required accuracy, we would need much more accurate tracking, better calibration and improved registration techniques.
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Affiliation(s)
- Aure Enkaoua
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Mobarakol Islam
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - João Ramalhinho
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Thomas Dowrick
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - James Booker
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Danyal Z. Khan
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Hani J. Marcus
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Matthew J. Clarkson
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
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15
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State of the Art and Future Prospects of Virtual and Augmented Reality in Veterinary Medicine: A Systematic Review. Animals (Basel) 2022; 12:ani12243517. [PMID: 36552437 PMCID: PMC9774422 DOI: 10.3390/ani12243517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Virtual reality and augmented reality are new but rapidly expanding topics in medicine. In virtual reality, users are immersed in a three-dimensional environment, whereas in augmented reality, computer-generated images are superimposed on the real world. Despite advances in human medicine, the number of published articles in veterinary medicine is low. These cutting-edge technologies can be used in combination with existing methods in veterinary medicine to achieve diagnostic/therapeutic and educational goals. The purpose of our review was to evaluate studies for their use of virtual reality and augmented reality in veterinary medicine, as well as human medicine with animal trials, to report results and the state of the art. We collected all of the articles we included in our review by screening the Scopus, PubMed, and Web of Science databases. Of the 24 included studies, 11 and 13 articles belonged to virtual reality and augmented reality, respectively. Based on these articles, we determined that using these technologies has a positive impact on the scientific output of students and residents, can reduce training costs, and can be used in training/educational programs. Furthermore, using these tools can promote ethical standards. We reported the absence of standard operation protocols and equipment costs as study limitations.
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16
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Bopp MHA, Saß B, Pojskić M, Corr F, Grimm D, Kemmling A, Nimsky C. Use of Neuronavigation and Augmented Reality in Transsphenoidal Pituitary Adenoma Surgery. J Clin Med 2022; 11:jcm11195590. [PMID: 36233457 PMCID: PMC9571217 DOI: 10.3390/jcm11195590] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/17/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to report on the clinical experience with microscope-based augmented reality (AR) in transsphenoidal surgery compared to the classical microscope-based approach. AR support was established using the head-up displays of the operating microscope, with navigation based on fiducial-/surface- or automatic intraoperative computed tomography (iCT)-based registration. In a consecutive single surgeon series of 165 transsphenoidal procedures, 81 patients underwent surgery without AR support and 84 patients underwent surgery with AR support. AR was integrated straightforwardly within the workflow. ICT-based registration increased AR accuracy significantly (target registration error, TRE, 0.76 ± 0.33 mm) compared to the landmark-based approach (TRE 1.85 ± 1.02 mm). The application of low-dose iCT protocols led to a significant reduction in applied effective dosage being comparable to a single chest radiograph. No major vascular or neurological complications occurred. No difference in surgical time was seen, time to set-up patient registration prolonged intraoperative preparation time on average by twelve minutes (32.33 ± 13.35 vs. 44.13 ± 13.67 min), but seems justifiable by the fact that AR greatly and reliably facilitated surgical orientation and increased surgeon comfort and patient safety, not only in patients who had previous transsphenoidal surgery but also in cases with anatomical variants. Automatic intraoperative imaging-based registration is recommended.
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Affiliation(s)
- Miriam H. A. Bopp
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (CMBB), 35032 Marburg, Germany
- Correspondence:
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
| | - Mirza Pojskić
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
| | - Felix Corr
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
- EDU Institute of Higher Education, Villa Bighi, Chaplain’s House, KKR 1320 Kalkara, Malta
| | - Dustin Grimm
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
- EDU Institute of Higher Education, Villa Bighi, Chaplain’s House, KKR 1320 Kalkara, Malta
| | - André Kemmling
- Department of Neuroradiology, University of Marburg, 35043 Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, 35043 Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (CMBB), 35032 Marburg, Germany
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