Rationale:
Surgical approaches used in the treatment of epilepsy often involve complex anatomy and the integration of multiple imaging modalities for surgical plan optimization and safe surgical execution. Augmented Reality (AR) has been shown to improve understanding of complex 3D neuroanatomy, but few reports exist detailing the integration of AR into routine epilepsy surgical care, including pre-operative planning, patient education, and intraoperative navigation. Herein, we describe our early experience applying AR to epilepsy surgery, including the first known report of AR navigation for lesionectomy following stereotactic electroencephalography (SEEG).
Methods:
Epilepsy cases where AR was used were identified from the primary author’s prospectively maintained epilepsy surgery database. Preoperative MRI/CT data was segmented into 3D mesh files using 3D Slicer and BrainLab Elements. AR software was collaboratively developed with Xironetic and deployed onto the Microsoft HoloLens 2, a commercially available head-mounted display. AR data was registered intraoperatively to the patient using a stylus and anatomic landmarks. Surveys were conducted to assess patient understanding and confidence in the proposed surgical plan.
Results:
Between June and September 2024, AR was used in a total of 6 surgical epilepsy cases. AR was integrated across the continuum of epilepsy surgical care (Figure 1). In 2 cases, AR was used for intraoperative navigation during posterior frontal lesionectomies (1 arteriovenous malformation [AVM] resection, and 1 resection of a seizure onset zone identified by SEEG) (Figure 2). AR was used to visualize the resection area and key surrounding structures (e.g., superior sagittal sinus, tractography, and cortical vessels) (Figure 2b,c). In 5 cases, AR was used for collaborative pre-surgical planning, including surgical approach planning (i.e., open craniotomy vs. laser interstitial thermal therapy [LITT]), resection/ablation margin visualization, and LITT trajectory planning. For example, the AR visualization of one patient’s seizure onset zone pre-operatively helped the primary surgeon decide to limit the ablation volume due to close proximity of the corticospinal tract (Figure 1a). In 4 cases, AR was used to enhance patient and family education during discussions about definitive epilepsy surgery. Following AR visualization, patients were more confident in the surgical plan, and found AR to be especially useful for the visualization of SEEG electrode placement and their proximity to relevant anatomical structures.
Conclusions:
AR has provided significant value toward the continuum of epilepsy surgical care at our institution. It has helped patients feel more confident about the surgical plan. It has helped surgeons better plan their surgical approach. Intraoperatively, it has provided an improved method of cortical surface neuronavigation and is comparable to traditional neuronavigation for deeper structures.
Funding: None