Objective To evaluate the health economics differences of 3 minimally invasive surgical techniques about neuroendoscopic surgery, frameless stereotactic catheter drainage guided by imaging navigation (puncture drainage), and small bone window craniotomy over a 6-month follow-up period. Methods Total 651 patients with hypertensive intracerebral hemorrhage treated between July 2016 and June 2022 at 16 medical centers in China were included: neuroendoscopic surgery (n=219), puncture drainage (n=220), and small bone window craniotomy (n=212). Neurological outcomes at 6 months were assessed using the modified Rankin Scale (mRS), which was then mapped to health utility values to calculate quality adjusted life year (QALY). Cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) models were constructed to calculate the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR), with one-way and probabilistic sensitivity analyses (PSA) performed to assess result robustness. Results Puncture drainage achieved the lowest hospitalization cost (77351 CNY) and favorable health utility (QALY=0.204 years), resulting in the most favorable CUA (379110 CNY/QALY), making the optimal surgical approach with the greatest health economics advantage. Although neuroendoscopic surgery yielded slightly higher QALY (0.218 years), its high consumable and equipment costs led to an ICUR of approximately 1059630 CNY/QALY, far exceeding China's willingness-to-pay threshold, limiting its broad application. Small bone window craniotomy showed the lowest benefit, with the lowest QALY (0.189 years) and the highest cost (100947 CNY), and was therefore deemed an economically inferior strategy. One-way and PSA showed that puncture drainage had the greatest health economics advantage and was the only surgical procedure that maintained its economics advantage across different parameter assumptions and willingness-to-pay thresholds. Conclusions Under the current healthcare cost structure and willingness-to-pay context, puncture drainage demonstrates the best performance in terms of cost, clinical effectiveness and health economics advantage, making it the preferred minimally invasive surgical approach for the treatment of hypertensive intracerebral hemorrhage. Neuroendoscopic surgery, despite higher health utility value, is better suited for individualized use in specific patient populations due to cost constraints. Small bone window craniotomy, with high cost and low benefit, is not recommended as a routine surgery option. This study provides systematic and quantitative evidence to support clinical decision, making regarding surgical pathway selection and the optimization of health insurance reimbursement policies.

BACKGROUND:Intracerebral hemorrhage (ICH) is a common stroke subtype with high morbidity and mortality. The optimal surgical approach remains unclear. This study compared the efficacy and cost-effectiveness of three minimally invasive surgeries-endoscopic surgery, frameless navigated aspiration, and small-bone flap craniotomy-in patients with hypertensive basal ganglia ICH. METHODS:In this parallel-group, multicenter randomized trial at 16 centers (July 2016 to June 2022), 515 patients were randomly assigned to endoscopic surgery (n=169), navigated aspiration (n=177), or craniotomy (n=169). The primary outcome was favorable functional outcome (modified Rankin Scale 0-2) at 6 months. Economic evaluation included hospitalization costs and quality-adjusted life years (QALYs). RESULTS:Among the 515 enrolled patients, 468 completed the 6-month follow-up. Favorable outcomes occurred in 29.7% (46/155) of the endoscopy group, 28.1% (45/160) of the aspiration group, and 15.7% (24/153) of the craniotomy group (P=0.007). Mean hospitalization costs were ¥91 517 ($12 853), ¥77 786 ($10 925), and ¥101 208 ($14 214), respectively (P<0.001). Endoscopy produced an incremental QALY gain of 0.0665 with cost savings of ¥13 660 ($1919) versus craniotomy, while aspiration achieved a QALY gain of 0.0545 and cost savings of ¥29 423 ($4132), indicating dominance for both minimally invasive strategies. CONCLUSIONS:For patients with hypertensive basal ganglia ICH, both endoscopic surgery and frameless navigated aspiration can improve long-term outcomes compared with small-bone flap craniotomy, while also reducing medical costs. Among the three treatments, aspiration provided the most favorable incremental cost-effectiveness profile. TRIAL REGISTRATION NUMBER:NCT02811614.

BACKGROUND Endoscopic approaches are being increasingly used for the management of intraventricular lesions. These techniques, however, have important limitations and can result in significant postoperative complications. Here, the authors describe the novel use of a nontraditional neurosurgical device to aid in the resection of an intraventricular tumor. OBSERVATIONS A 13-year-old male presented with obstructive hydrocephalus and a small intraventricular meningioma. Given the lesion’s round shape, the authors expected it would be difficult to resect with conventional ventriculoscopic instruments. Hence, a basket retriever, designed for the removal of urological stones, was used in an endoscopic third ventriculostomy for obstructive hydrocephalus to capture and retract the tumor. Subsequently, the lesion was successfully resected and retrieved. LESSONS The use of a flexible helical basket retriever as both an ETV perforator and a stabilizing “cage” for a mobile, pedunculated angioblast meningioma enabled gross-total resection and long-term stability. The small size and maneuverability of this device were well suited to endoscopic use and may be useful for similar resections of small, mobile intraventricular lesions. https://thejns.org/doi/10.3171/CASE26283

BackgroundMaximal safe resection of intraventricular lesions remains challenging. This study evaluated the feasibility, technical workflow, and clinical outcomes of single burr-hole pure ventriculoscopic resection for small solid intraventricular lesions.MethodsWe retrospectively reviewed patients who underwent single burr-hole pure ventriculoscopic resection of solid intraventricular lesions. Clinical, radiological, operative, and postoperative data were collected. All patients received high-resolution 3D-SPACE MRI, and virtual ventriculoscopic reconstruction using 3D Slicer software for individualized trajectory planning. Lesions were resected using a 6-mm rigid ventriculoscope. Postoperative MRI was performed to evaluate the extent of resection, and patients were followed for neurological outcomes and complications.ResultsThirty-eight patients (median lesion diameter: 17 mm) underwent surgery. Gross-total resection was achieved in 92.1% (35/38) of cases. No seizures, cerebrospinal fluid leakage, permanent neurological deficits, or mortality occurred. Complications included transient diplopia in 2 patients (5.3%) and one intracranial infection (2.6%). Pathological diagnoses included cavernous malformations in 14 patients, subependymomas in 10, meningiomas in 8, low-grade gliomas in 3, and neurofibroma, pseudoaneurysm, and inflammatory granuloma in 1 patient each. During a mean follow-up of 60 months, no definite lesion recurrence was observed, and one patient developed delayed hydrocephalus that was successfully treated endoscopically. The planned surgical trajectories showed good concordance with intraoperative findings, supporting the accuracy of preoperative virtual planning.ConclusionSingle burr-hole pure ventriculoscopic resection is a safe and feasible minimally invasive approach for selected small intraventricular lesions, enabling high rates of complete resection with low morbidity and favorable long-term outcomes.

Intracerebral hemorrhage (ICH) remains one of the most severe forms of stroke and is associated with high mortality, poor functional outcomes, and substantial healthcare burden worldwide. Despite advances in neurocritical care and minimally invasive surgical techniques, the management of ICH remains challenging because of disease heterogeneity, rapid neurological deterioration, and the lack of effective individualized treatment strategies. In recent years, artificial intelligence (AI) has emerged as a promising tool for improving the diagnosis, prognostic evaluation, and precision management of ICH. A systematic literature search was performed in PubMed, Web of Science, and Embase to identify studies on AI applications in ICH, with predefined inclusion criteria focusing on imaging analysis, prognostic prediction, clinical decision support, and minimally invasive surgery. This review summarizes the major clinical applications, limitations, and future directions of AI in ICH, including multimodal foundation models, intelligent surgical assistance, and personalized precision care. Recent studies have demonstrated that AI-based models can significantly improve the accuracy of hematoma segmentation, hematoma expansion prediction, and functional outcome prognostication compared with conventional approaches. Despite encouraging progress, several important barriers continue to limit clinical translation, including data heterogeneity, limited external validation, insufficient interpretability, ethical and regulatory concerns, and challenges in workflow integration. Overall, AI has the potential to transform ICH management from conventional experience-based practice to data-driven, personalized, and precision neurosurgical care.

Spontaneous intracerebral hemorrhage (ICH) remains one of the most devastating types of stroke, with high mortality and long-term disability. Minimally invasive hematoma evacuation techniques have been developed to improve outcomes by reducing hematoma volume while minimizing surgical trauma compared with conventional craniotomy or conservative treatment. Artificial intelligence (AI) and neuronavigation enable optimized trajectory planning, real-time intraoperative guidance, and individualized treatment strategies, potentially leading to improved clinical outcomes compared with conservative treatment. This study aims to compare the efficacy and safety of AI-driven navigated hematoma aspiration with conservative therapy. This multicenter, prospective, randomized controlled, open-label trial with blinded outcome assessment will enroll approximately 680 patients with spontaneous supratentorial ICH (20–50 mL) within 24 h of onset and a Glasgow Coma Scale (GCS) score ≥ 8. Eligible patients aged 18–80 years will be randomly assigned in a 1:1 ratio to receive either AI-assisted, navigation-guided hematoma aspiration plus best medical therapy or best medical therapy alone. Randomization will be centralized and stratified by center. The primary outcome is functional status at 6 months, assessed by the modified Rankin Scale, with mRS 0–2 defined as a favorable outcome. Secondary outcomes include mortality, hematoma volume reduction, neurological function, complications, quality of life, length of hospital stay, and cost-effectiveness. This trial is designed to provide robust evidence on the efficacy and safety of AI-guided hematoma aspiration for ICH. If successful, it has the potential to support a precise and minimally invasive treatment strategy and improve clinical outcomes. Clinical Trials NCT07077343. Registered on July 21, 2025.

Mixed Reality Navigation (MRN) has been proposed as a low-cost and intuitive alternative to conventional navigation systems, yet its adoption remains limited by registration inaccuracy and strong user dependence. This work presents a Hybrid Conical-Linear Laser Registration (HCLR) method that combines a conical projection onto five coplanar fiducials with a single linear-laser constraint to recover all six degrees of freedom analytically. A systematic evaluation of 57 marker layouts identified three robust configurations, which were tested in simulated scenarios using clinical CT and MRI datasets from 19 patients. Under realistic noise conditions, HCLR achieved a mean target registration error (TRE) of 1.06 mm compared with 2.57 mm for standard fiducial-based registration, and nearly eliminated rotation errors. These findings demonstrate that HCLR can improve registration accuracy, reduce operator dependence, and provide a compact, hardware-light solution for MRN. With further physical and clinical validation, HCLR has the potential to advance cost-effective neurosurgical navigation.

OBJECTIVE:Intraventricular and subarachnoid neurocysticercosis (IVSN) represents a severe extraparenchymal manifestation of Taenia solium infection, frequently leading to obstructive hydrocephalus and increased intracranial pressure. Despite advances in medical therapy, standardized protocols for endoscopic management remain lacking. The authors aimed to establish a comprehensive diagnostic and surgical workflow for IVSN and evaluate the clinical outcomes of neuroendoscopic management in a large single-center cohort. METHODS:The medical records of 51 patients (mean age 43.4 years, 68.6% male) with IVSN treated via endoscopic surgery from 2009 to 2025 were retrospectively reviewed. Preoperative diagnostics included high-resolution T2-weighted 3D SPACE MRI and lateral view radiographic imaging of the lower legs to enhance the detection of cysts. Endoscopic procedures involved cyst excision, endoscopic third ventriculostomy, and septostomy. Postoperative management included corticosteroids, albendazole, and antiepileptics. Outcomes were assessed via radiological follow-up and clinical monitoring over a mean period of 98.3 months. RESULTS:Complete cyst removal was achieved in 88.2% of patients. Three-dimensional SPACE (sampling perfection with application-optimized contrast using different flip angle evolutions) MRI enabled clear visualization of cyst membranes in all cases, outperforming conventional sequences. Intramuscular calcifications were detected in 94.1% of patients via lateral leg radiographic imaging. The recurrence rate was 2.0%, and only 9.8% of patients required ventriculoperitoneal shunt placement. Postoperative complications were minimal, with intracranial infections in 2 cases (3.9%), both of which were successfully managed. No neurological deficits were observed following surgery. CONCLUSIONS:Neuroendoscopic surgery offers a safe and effective treatment for IVSN when combined with advanced imaging and structured medical therapy. The integration of 3D SPACE MRI and standardized endoscopic protocols facilitates accurate diagnosis, complete cyst removal, and long-term disease control with low complication and recurrence rates.

BACKGROUND AND OBJECTIVE:Electromagnetic navigation technology has demonstrated significant potential in enhancing the accuracy and safety of neurosurgical procedures. However, traditional electromagnetic navigation systems face challenges such as high equipment costs, complex operation, bulky size, and insufficient anti-interference performance. To address these limitations, our study developed and validated a novel portable electromagnetic neuronavigation system designed to improve the precision, accessibility, and clinical applicability of electromagnetic navigation technology in cranial surgery. METHODS:The software and hardware architecture of a portable neural magnetic navigation system was designed. The key technologies of the system were analysed, including electromagnetic positioning algorithms, miniaturized sensor design, optimization of electromagnetic positioning and navigation algorithms, anti-interference signal processing methods, and fast three-dimensional reconstruction algorithms. A prototype was developed, and its accuracy was tested. Finally, a preliminary clinical application evaluation was conducted. RESULTS:This study successfully developed a comprehensive portable electromagnetic neuronavigation system capable of achieving preoperative planning, intraoperative real-time positioning and navigation, and postoperative evaluation of navigation outcomes. Through rigorous collaborative testing of the system's software and hardware, the accuracy of electromagnetic neuronavigation has been validated to meet clinical requirements. CONCLUSIONS:This study developed a portable neuroelectromagnetic navigation system and validated its effectiveness and safety through rigorous model testing and preliminary clinical applications. The system is characterized by its compact size, high precision, excellent portability, and user-friendly operation, making it highly valuable for promoting navigation technology and advancing the precision and minimally invasive nature of neurosurgical procedures.

A single-exposure dual-wavelength digital holographic method is proposed for fast and robust reconstruction using off-axis-optimized conjugate iteration. A dual-wavelength digital holographic structure is constructed to acquire a composite hologram containing both an in-line hologram and an off-axis hologram in a single-exposure. In this context, an off-axis-optimized conjugate iterative method is performed, which uses off-axis phase to provide an initial value for the conjugate iterative process. Then, the in-line holography amplitude constraints are performed on the virtual holographic plane and the conjugate holographic plane until the algorithm converges. The low-frequency phase component of the convergence result is further constrained to achieve high-resolution reconstruction. Compared with existing digital holography techniques, our approach not only improves the reconstruction resolution but also the reconstruction accuracy. More importantly, our approach can realize fast and robust reconstruction of dynamic objects. Both simulations and experiments have demonstrated the superiority of the proposed approach.

OBJECTIVE:Intracerebral hemorrhage (ICH) remains a critical neurosurgical emergency with high mortality and long-term disability. Despite advancements in minimally invasive techniques, procedural precision remains limited by hematoma complexity and resource disparities, particularly in underserved regions where 68% of global ICH cases occur. Therefore, the authors aimed to introduce a deep learning-based decision support and planning system to democratize surgical planning and reduce operator dependence. METHODS:A retrospective cohort of 347 patients (31,024 CT slices) from a single hospital (March 2016-June 2024) was analyzed. The framework integrated nnU-Net-based hematoma and skull segmentation, CT reorientation via ocular landmarks (mean angular correction 20.4° [SD 8.7°]), safety zone delineation with dual anatomical corridors, and trajectory optimization prioritizing maximum hematoma traversal and critical structure avoidance. A validated scoring system was implemented for risk stratification. RESULTS:With the artificial intelligence (AI)-driven system, the automated segmentation accuracy reached clinical-grade performance (Dice similarity coefficient 0.90 [SD 0.14] for hematoma and 0.99 [SD 0.035] for skull), with strong interrater reliability (intraclass correlation coefficient 0.91). For trajectory planning of supratentorial hematomas, the system achieved a low-risk trajectory in 80.8% (252/312) and a moderate-risk trajectory in 15.4% (48/312) of patients, while replanning was required due to high-risk designations in 3.8% of patients (12/312). CONCLUSIONS:This AI-driven system demonstrated robust efficacy for supratentorial ICH, addressing 60% of prevalent hemorrhage subtypes. While limitations remain in infratentorial hematomas, this novel automated hematoma segmentation and surgical planning system could be helpful in assisting less-experienced neurosurgeons with limited resources in primary healthcare settings.

Objective To introduce the application process of a mixed reality(MR)-based multimodal head-mounted intraoperative neurosurgical montioring system and its integration into intraoperative applications,and to evaluate the clinical efficacy of this system for monitoring during neurosurgical intraoperative radiotherapy.Methods A MR-based multimodal head-mounted intraoperative neurosurgical monitoring system was used to assist anesthesiologists in real-time monitoring of patients'vital signs and operation area during radiotherapy in neurosurgical surgery.Before the use of the system,the simulation test was used to record the delay time of video signal streaming.Before the start of radiotherapy in neurosurgery,the system preparation time was recorded.After the operation,an self-designed electronic questionnaire was used to investigate the satisfaction of anesthesiologists with the use of the system.Results The system has been successfully used in 23 cases of neurosurgical intraoperative radiotherapy.No technical failures or related complications occurred.The quantitative delay test showed median time of video signal streaming delay measured by simulation test was 160 ms.The system preparation time decreased from 32 min at the beginning of the study to 4-5 min.A total of 14 anesthesiologists were received the questionnaire survey,and the satisfaction score was 30.43.Conclusions The MR-based multimodal head-mounted intraoperative neurosurgical monitoring system is applied during neurosurgical intraoperative radiotherapy to assist anesthesiologists in real-time monitoring of patients'vital signs and the environment of the operation area,which has a good prospect of popularization and transformation.

Dual-wavelength in-line-and-off-axis hybrid digital holography (iohDH) can achieve high-resolution holographic dynamic imaging. However, it requires the prediction of the diffraction distance and the complex amplitude of the reference beam, which is time consuming and results in complications and accuracy limitations. While telecentric imaging technique can obtain nondiffractive images without predicting the diffraction distance, it also can even eliminate spherical aberration and astigmatic aberration. Therefore, a dual-wavelength telecentric iohDH is proposed to realize non-prior high-resolution reconstruction in a single shot. Employing the dual-wavelength telecentric iohDH, our approach acquires the focused in-line-and-off-axis hologram using a color camera in a single shot. In this case, we perform wavelength conversion on the phase and low-frequency information about the off-axis hologram as constraints for in-line iteration. Then, the in-line amplitude constraints are performed in the spatial and frequency domains until the algorithm converges. Compared to the state-of-the-art dual-wavelength iohDH, our approach can streamline the reconstructed processes without demanding a priori information of the diffraction distance and the complex amplitude of the reference beam. More importantly, our approach enables higher quality and efficient reconstruction under the telecentric system. We verified our approach using simulations and experiments, and the results indicate that our approach can allow the amplitude and phase reconstruction with high resolution in a single shot.

Mixed reality navigation (MRN) technology is emerging as an increasingly significant and interesting topic in neurosurgery. MRN enables neurosurgeons to "see through" the head with an interactive, hybrid visualization environment that merges virtual- and physical-world elements. Offering immersive, intuitive, and reliable guidance for preoperative and intraoperative intervention of intracranial lesions, MRN showcases its potential as an economically efficient and user-friendly alternative to standard neuronavigation systems. However, the clinical research and development of MRN systems present challenges: recruiting a sufficient number of patients within a limited timeframe is difficult, and acquiring low-cost, commercially available, medically significant head phantoms is equally challenging. To accelerate the development of novel MRN systems and surmount these obstacles, the study presents a dataset designed for MRN system development and testing in neurosurgery. It includes CT and MRI data from 19 patients with intracranial lesions and derived 3D models of anatomical structures and validation references. The models are available in Wavefront object (OBJ) and Stereolithography (STL) formats, supporting the creation and assessment of neurosurgical MRN applications.

Augmented reality navigation (ARN) enhances localization and operation by overlaying virtual guides onto realworld surgical fields. The study introduces a laser path anchor (LPA), a novel tool for ARN in surgery aimed at mitigating depth perception challenges. The LPA anchors the virtual planned path onto the physical laser beam, ensuring accurate puncture from any perspective. The tool consists of a rack, a primary laser emitter, an indicating laser emitter, and an AR marker with intrinsic and extrinsic properties validated through calibration and testing. Intrinsic validation involved measuring the parallelism between the indicating and primary laser using Cartesian graph screens. Extrinsic validation assessed the alignment and shortest distance between the virtual path and primary lasers. Results showed an angle deviation of 0.08° between the indicating and primary laser and 1.44° ± 0.47° between the virtual path and primary lasers, with a shortest distance of 7.60 mm ± 2.50 mm. The usability test demonstrated the LPA’s effectiveness in guiding needle insertions without altering the perspective or distracting the surgeon. Despite some limitations, the LPA enhances the user’s perception of linear objects and eliminates the need for perspective adjustments during puncture, warranting further development.

Abstract Background Intracerebral hemorrhage (ICH) is a common stroke type with high morbidity and mortality. There are mainly three surgical methods for treating ICH. Unfortunately, thus far, no specific surgical method has been proven to be the most effective. We carried out this study to investigate whether minimally invasive surgeries with endoscopic surgery or stereotactic aspiration (frameless navigated aspiration) will improve functional outcomes in patients with supratentorial ICH compared with small-bone flap craniotomy. Methods In this parallel-group multicenter randomized controlled trial conducted at 16 centers, patients with supratentorial hypertensive ICH were randomized to receive endoscopic surgery, stereotactic aspiration, or craniotomy at a 1:1:1 ratio from July 2016 to June 2022. The follow-up duration was 6 months. Patients were randomized to receive endoscopic evacuation, stereotactic aspiration, or small-bone flap craniotomy. The primary outcome was favorable functional outcome, defined as the proportion of patients who achieved a modified Rankin scale (mRS) score of 0–2 at the 6-month follow-up. Results A total of 733 patients were randomly allocated to three groups: 243 to the endoscopy group, 247 to the aspiration group, and 243 to the craniotomy group. Finally, 721 patients (239 in the endoscopy group, 246 in the aspiration group, and 236 in the craniotomy group) received treatment and were included in the intention-to-treat analysis. Primary efficacy analysis revealed that 73 of 219 (33.3%) in the endoscopy group, 72 of 220 (32.7%) in the aspiration group, and 47 of 212 (22.2%) in the craniotomy group achieved favorable functional outcome at the 6-month follow-up (P = .017). We got similar results in subgroup analysis of deep hemorrhages, while in lobar hemorrhages the prognostic outcome was similar among three groups. Old age, deep hematoma location, large hematoma volume, low preoperative GCS score, craniotomy, and intracranial infection were associated with greater odds of unfavorable outcomes. The mean hospitalization expenses were ¥92,420 in the endoscopy group, ¥77,351 in the aspiration group, and ¥100,947 in the craniotomy group (P = .000). Conclusions Compared with small bone flap craniotomy, endoscopic surgery and stereotactic aspiration improved the long-term outcome of hypertensive ICH, especially deep hemorrhages. Trial Registration ClinicalTrials.gov Identifier: NCT02811614.

To date, neuroanatomy education courses are still based on two-dimensional (2D) illustrations combined with cadaver dissections. To gain a more comprehensive understanding of neuroanatomy, we offered mixed reality experience using a head-mounted device (HMD) for medical students during their neuroanatomy course. This pilot study´s purpose was to determine whether or not, from a pragmatic view, the utilization of 3D VR/AR via HMD is viable in neuroanatomy courses and aimed to evaluate the feasibility of using mixed reality in neuroanatomy education and experiences with the mixed reality brain environment. A virtual model including major neuroanatomical structures was generated from a MRI dataset using computer software. Major structures were displayed and annotated in different combinations and scenes using an HMD. Along with the 3D virtual model, the original MRI was presented in a virtual form inside the HMD. Conventional 2D anatomical atlases were also used during the seminar. Thirty medical students (11 male; 19 female; average: 23.2 years) in their second year were recruited from October 2022 to February 2023 for this study via open invitation during neuroanatomy lectures. Participants were asked to wear the HMDs and to take a 2 h neurosurgery-oriented mixed reality seminar given by a neurosurgical teacher in small groups (3 per group). A questionnaire comprising five levels of options was designed and used to evaluate the feasibility/effectiveness of this seminar. The mixed reality environment, comprising virtual 3D models of major brain structures, virtual MRI, and conventional 2D anatomical graphs, was uncomplicated and feasible for neuroanatomy education of the medical students. According to our survey, all participants (30/30) strongly agreed that the 3D visualization of the spatial relationships between anatomical structures was easy to use as a meaningful supplement. Twenty-one of the participants strongly agreed and nine quite agreed that they had more interest in neuroanatomy. Eighty-seven percent of the participants were strongly satisfied with the mixed reality seminar versus conventional neuroanatomy seminars, and the other 13

Addressing conventional neurosurgical navigation systems’ high costs and complexity, this study explores the feasibility and accuracy of a simplified, cost-effective mixed reality navigation (MRN) system based on a laser crosshair simulator (LCS). A new automatic registration method was developed, featuring coplanar laser emitters and a recognizable target pattern. The workflow was integrated into Microsoft’s HoloLens-2 for practical application. The study assessed the system’s precision by utilizing life-sized 3D-printed head phantoms based on computed tomography (CT) or magnetic resonance imaging (MRI) data from 19 patients (female/male: 7/12, average age: 54.4 ± 18.5 years) with intracranial lesions. Six to seven CT/MRI-visible scalp markers were used as reference points per case. The LCS-MRN’s accuracy was evaluated through landmark-based and lesion-based analyses, using metrics such as target registration error (TRE) and Dice similarity coefficient (DSC). The system demonstrated immersive capabilities for observing intracranial structures across all cases. Analysis of 124 landmarks showed a TRE of 3.0 ± 0.5 mm, consistent across various surgical positions. The DSC of 0.83 ± 0.12 correlated significantly with lesion volume (Spearman rho = 0.813, p < 0.001). Therefore, the LCS-MRN system is a viable tool for neurosurgical planning, highlighting its low user dependency, cost-efficiency, and accuracy, with prospects for future clinical application enhancements.

OBJECTIVE Mixed-reality simulation is an emerging tool for creating anatomical models for preoperative planning. Its use in neurosurgical training (NT) has been limited because of the difficulty in real-time interactive teaching. This study describes the development of a patient-specific, interactive mixed-reality NT system. The authors took cases of intracranial tumor resection or neurovascular compression (NVC) as examples to verify the technical feasibility and efficacy of the mixed-reality NT system for residents’ training and preoperative planning. METHODS This study prospectively enrolled 40 patients who suffered from trigeminal neuralgia, hemifacial spasms, or intracranial tumors. The authors used a series of software programs to process the multimodal imaging data, followed by uploading the holographic models online. They used a HoloLens or a standard iOS device to download and display the holographic models for training. Ten neurosurgical residents with different levels of surgical experience were trained with this mixed-reality NT system. Change in surgical strategy was recorded, and a questionnaire survey was conducted to evaluate the efficacy of the mixed-reality NT system. RESULTS The system allows the trainer and trainee to view the mixed-reality model with either a HoloLens or an iPad/iPhone simultaneously online at different locations. Interactive manipulation and instant updates were able to be achieved during training. A clinical efficacy validation test was conducted. The surgeons changed their exploration strategy in 48.3% of the NVC cases. For residents with limited experience in surgery, the exploration strategy for 75.0% of all patients with NVC was changed after the residents were trained with the mixed-reality NT system. Of the 60 responses for intracranial tumors, the trainee changed the surgical posture in 19 (31.7%) cases. The change of the location (p = 0.0338) and size (p = 0.0056) of craniotomy are significantly related to the experience of the neurosurgeons. CONCLUSIONS The mixed-reality NT system is available for local or real-time remote neurosurgical resident training. It may effectively help neurosurgeons in patient-specific training and planning of surgery for cases of NVC and intracranial tumor. The authors expect the system to have a broader application in neurosurgery in the near future.