Download PDF
J Neurol Surg A Cent Eur Neurosurg 2023; 84(06): 562-569
DOI: 10.1055/s-0042-1759827
Original Article

Augmented Reality–Assisted versus Freehand Ventriculostomy in a Head Model

Max Schneider
1   Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
,
Christian Kunz
2   Institute for Anthropomatics and Robotics - Health Robotics and Automation (HERA), KIT, Karlsruhe, Germany
,
Christian Rainer Wirtz
1   Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
,
Franziska Mathis-Ullrich
2   Institute for Anthropomatics and Robotics - Health Robotics and Automation (HERA), KIT, Karlsruhe, Germany
,
Andrej Pala
1   Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
,
Michal Hlavac
1   Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
› Author Affiliations Funding This work was supported by the German Federal Ministry of Education and Research under the grant 01IS17005 (“Holomed—Context sensitive support of the surgeon in the operating room through augmented reality”).
› Further Information
    Permissions and Reprints

Abstract

Background Ventriculostomy (VST) is a frequent neurosurgical procedure. Freehand catheter placement represents the standard current practice. However, multiple attempts are often required. We present augmented reality (AR) headset guided VST with in-house developed head models. We conducted a proof of concept study in which we tested AR-guided as well as freehand VST. Repeated AR punctures were conducted to investigate if a learning curve can be derived.

Methods Five custom-made 3D-printed head models, each holding an anatomically different ventricular system, were filled with agarose gel. Eleven surgeons placed two AR-guided as well as two freehand ventricular drains per head. A subgroup of four surgeons did a total of three series of AR-guided punctures each to test for a learning curve. A Microsoft HoloLens served as the hardware platform. The marker-based tracking did not require rigid head fixation. Catheter tip position was evaluated in computed tomography scans.

Results Marker-tracking, image segmentation, and holographic display worked satisfactorily. In freehand VST, a success rate of 72.7% was achieved, which was higher than under AR guidance (68.2%, difference not statistically significant). Repeated AR-guided punctures increased the success rate from 65 to 95%. We assume a steep learning curve as repeated AR-guided punctures led to an increase in successful attempts. Overall user experience showed positive feedback.

Conclusions We achieved promising results that encourage the continued development and technical improvement. However, several more developmental steps have to be taken before an application in humans can be considered. In the future, AR headset–based holograms have the potential to serve as a compact navigational help inside and outside the operating room.

Keywords

augmented reality - freehand ventriculostomy - ventricular puncture - ventricular drain - holomed


Publication History

Received: 20 January 2022

Accepted: 01 September 2022

Article published online:
04 July 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Sekula RF, Cohen DB, Patek PM, Jannetta PJ, Oh MY. Epidemiology of ventriculostomy in the United States from 1997 to 2001. Br J Neurosurg 2008; 22 (02) 213-218
    CrossrefPubMedGoogle Scholar
  • 2 Raabe C, Fichtner J, Beck J, Gralla J, Raabe A. Revisiting the rules for freehand ventriculostomy: a virtual reality analysis. J Neurosurg 2018; 128 (04) 1250-1257
    CrossrefPubMedGoogle Scholar
  • 3 O'Neill BR, Velez DA, Braxton EE, Whiting D, Oh MY. A survey of ventriculostomy and intracranial pressure monitor placement practices. Surg Neurol 2008; 70 (03) 268-273 , discussion 273
    CrossrefPubMedGoogle Scholar
  • 4 Miller C, Tummala RP. Risk factors for hemorrhage associated with external ventricular drain placement and removal. J Neurosurg 2017; 126 (01) 289-297
    CrossrefPubMedGoogle Scholar
  • 5 AlAzri A, Mok K, Chankowsky J, Mullah M, Marcoux J. Placement accuracy of external ventricular drain when comparing freehand insertion to neuronavigation guidance in severe traumatic brain injury. Acta Neurochir (Wien) 2017; 159 (08) 1399-1411
    CrossrefPubMedGoogle Scholar
  • 6 Azeem SS, Origitano TC. Ventricular catheter placement with a frameless neuronavigational system: a 1-year experience. Neurosurgery 2007;60(4, Suppl 2):243–247, discussion 247–248
    PubMedGoogle Scholar
  • 7 Wilson TJ, Stetler Jr WR, Al-Holou WN, Sullivan SE. Comparison of the accuracy of ventricular catheter placement using freehand placement, ultrasonic guidance, and stereotactic neuronavigation. J Neurosurg 2013; 119 (01) 66-70
    CrossrefPubMedGoogle Scholar
  • 8 Thomale UW, Schaumann A, Stockhammer F. et al. GAVCA study: randomized, multicenter trial to evaluate the quality of ventricular catheter placement with a mobile health assisted guidance technique. Neurosurgery 2018; 83 (02) 252-262
    CrossrefPubMedGoogle Scholar
  • 9 Cartucho J, Shapira D, Ashrafian H, Giannarou S. Multimodal mixed reality visualisation for intraoperative surgical guidance. Int J CARS 2020; 15 (05) 819-826
    CrossrefPubMedGoogle Scholar
  • 10 Contreras López WO, Navarro PA, Crispin S. Intraoperative clinical application of augmented reality in neurosurgery: a systematic review. Clin Neurol Neurosurg 2019; 177: 6-11
    CrossrefPubMedGoogle Scholar
  • 11 Karmonik C, Boone TB, Khavari R. Workflow for visualization of neuroimaging data with an augmented reality device. J Digit Imaging 2018; 31 (01) 26-31
    CrossrefPubMedGoogle Scholar
  • 12 Schneider M, Kunz C, Pal'a A, Wirtz CR, Mathis-Ullrich F, Hlaváč M. Augmented reality-assisted ventriculostomy. Neurosurg Focus 2021; 50 (01) E16
    CrossrefPubMedGoogle Scholar
  • 13 Kunz C, Henrich P, Scheikl PM. et al. Fast Volumetric Auto-Segmentation of Head CT Images in Emergency Situations for Ventricular Punctures. CURAC 2019: 18th Annual Meeting of the German Society for Computer and Robot-Assisted Surgery, Reutlingen, September 19–21, 2019
    PubMedGoogle Scholar
  • 14 Rosenbaum BP, Vadera S, Kelly ML, Kshettry VR, Weil RJ. Ventriculostomy: Frequency, length of stay and in-hospital mortality in the United States of America, 1988-2010. J Clin Neurosci 2014; 21 (04) 623-632
    CrossrefPubMedGoogle Scholar
  • 15 Foreman PM, Hendrix P, Griessenauer CJ, Schmalz PGR, Harrigan MR. External ventricular drain placement in the intensive care unit versus operating room: evaluation of complications and accuracy. Clin Neurol Neurosurg 2015; 128: 94-100
    CrossrefPubMedGoogle Scholar
  • 16 Hsieh CT, Chen GJ, Ma HI. et al. The misplacement of external ventricular drain by freehand method in emergent neurosurgery. Acta Neurol Belg 2011; 111 (01) 22-28
    PubMedGoogle Scholar
  • 17 Kakarla UK, Kim LJ, Chang SW, Theodore N, Spetzler RF. Safety and accuracy of bedside external ventricular drain placement. Neurosurgery 2008;63(1, Suppl 1):ONS162–ONS166, discussion ONS166–ONS167
    PubMedGoogle Scholar
  • 18 Mansoor N, Madsbu MA, Mansoor NM. et al. Accuracy and complication rates of external ventricular drain placement with twist drill and bolt system versus standard trephine and tunnelation: a retrospective population-based study. Acta Neurochir (Wien) 2020; 162 (04) 755-761
    CrossrefPubMedGoogle Scholar
  • 19 Huyette DR, Turnbow BJ, Kaufman C, Vaslow DF, Whiting BB, Oh MY. Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. J Neurosurg 2008; 108 (01) 88-91
    CrossrefPubMedGoogle Scholar
  • 20 Patil V, Lacson R, Vosburgh KG. et al. Factors associated with external ventricular drain placement accuracy: data from an electronic health record repository. Acta Neurochir (Wien) 2013; 155 (09) 1773-1779
    CrossrefPubMedGoogle Scholar
  • 21 Van Gestel F, Frantz T, Vannerom C. et al. The effect of augmented reality on the accuracy and learning curve of external ventricular drain placement. Neurosurg Focus 2021; 51 (02) E8
    CrossrefPubMedGoogle Scholar
  • 22 Condino S, Carbone M, Piazza R, Ferrari M, Ferrari V. Perceptual limits of optical see-through visors for augmented reality guidance of manual tasks. IEEE Trans Biomed Eng 2020; 67 (02) 411-419
    CrossrefPubMedGoogle Scholar
  • 23 Grubert J, Itoh Y, Moser K, Swan JE. A survey of calibration methods for optical see-through head-mounted displays. IEEE Trans Vis Comput Graph 2018; 24 (09) 2649-2662
    CrossrefPubMedGoogle Scholar
  • 24 Sun Q, Mai Y, Yang R, Ji T, Jiang X, Chen X. Fast and accurate online calibration of optical see-through head-mounted display for AR-based surgical navigation using Microsoft HoloLens. Int J CARS 2020; 15 (11) 1907-1919
    CrossrefPubMedGoogle Scholar
  • 25 Azimi E, Niu Z, Stiber M. et al. An interactive mixed reality platform for bedside surgical procedures. In: Martel AL, Abolmaesumi P, Stoyanov D. et al., eds. Medical Image Computing and Computer Assisted Intervention – MICCAI 2020. Vol. 12263. Lecture Notes in Computer Science. Berlin: Springer International Publishing; 2020: 65-75
    Google Scholar
  • 26 Li Y, Chen X, Wang N. et al. A wearable mixed-reality holographic computer for guiding external ventricular drain insertion at the bedside. J Neurosurg 2018; 131 (05) 1-8
    CrossrefPubMedGoogle Scholar
  • 27 Eisenring CV, Burn F, Baumann M. et al. sEVD-smartphone-navigated placement of external ventricular drains. Acta Neurochir (Wien) 2020; 162 (03) 513-521
    CrossrefPubMedGoogle Scholar
  • 28 Ivan ME, Eichberg DG, Di L. et al. Augmented reality head-mounted display-based incision planning in cranial neurosurgery: a prospective pilot study. Neurosurg Focus 2021; 51 (02) E3
    CrossrefPubMedGoogle Scholar