Introduction: CAS has become standard practice in neurosurgery as imagining quality and computing power have improved. There is evidence that CAS navigation offers high-accuracy, reduced cost and morbidity for cranial procedures.1,2,3 Despite this, mainstream neurosurgical practice has been slow to adopt recent advances in imaging technology. Surgeons now have the ability to create detailed, patient specific 3-dimensional(3D) image reconstructions to assist in case preparation and surgical execution. We share our experience using VR for resecting a meningioma encapsulating the right MCA and ICA.
Methods: A volumetric T1-contrasted MRI and 3D-cerebral angiogram were obtained and fused in the Surgical Theater SNAP to create a 3D VR reconstruction. The Chief Resident and attending reviewed the case and performed a VR fly-through using an Oculus-VR headset before surgery. By adjusting segmentation and tissue transparency, it is possible to see through tissue, tumor and vessels, thus improving our understanding of the surgical anatomy and pathology. We used real-time VR navigation and microscope co-registration intra-operatively.
Results: We obtained a gross total resection of the supratentorial GSWM, preserving the enveloped ICA and MCA branches, without neuro-vascular injury.
Conclusions: We have recently published the positive impact of VR case preparation in aneurysm surgery, demonstrating decreased clip attempt time4. Additional surgical studies established that VR preparation groups made six times fewer intraoperative errors than the standard training group and decreased operative times and errors when a VR warmup is performed.5,6
We used VR preparation for a patient with GSWM. MRI and 3D-angiogram fusion provided us with a highly detailed reconstruction, revealing the ICA and MCA coursing centrally within the mass. During the procedure we navigated in VR concurrently with conventional CAS, quickly identifying the MCA and ICA, affording us improved situational awareness.
VR preparation and navigation has great promise to impact neurosurgery. Further trials are indicated to elucidate the clinical and educational impact of VR technology.
Patient Care: Improvement in preoperative planning and rehearsal have been demonstrated to improve surgical performance. Using similar virtual reality imaging technology, there is potential to improve surgical performance.
Learning Objectives: Identify new, enhanced imaging technology for neurosurgery
· Understand how visualization of anatomy and pathology in 3D virtual reality enhances spatial awareness
· Understand how enhanced visualization is used both pre-operatively for rehearsal and intra-operatively for navigation
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2. Barnett GH1, McKenzie RL, Ramos L, Palmer J. Nonvolumetric stereotaxy-assisted craniotomy. Results in 50 consecutive cases. Stereotact Funct Neurosurg. 1993;61(2):80-95.
3. Kelly PJ1, Kall BA, Goerss SJ.Results of computed tomography-based computer-assisted stereotactic resection of metastatic intracranial tumors. Neurosurgery. 1988 Jan;22(1 Pt 1):7-17
4. Chugh AJ, Pace JR, Singer J, Tatsuoka C, Hoffer A, Selman WR, Bambakidis NC. Use of a surgical rehearsal platform and improvement in aneurysm clipping measures: results of a prospective, randomized trial. J Neurosurg. 2016 May 13:1
5. Gallagher A. Importance of validation in simulation. Presentation. Telemedicine and Advanced Technology Research Center (TATRC), US Army Medical Research and Material Command, July 30 2004
6. Kahol K, Satava RM, Ferrara J, et al. J Am Coll Surg 2009;208(2):255–68