Abstract:

Background: Neurosurgery developed rapidly with technology advancing. Concept of digit-intelligent neurosurgery becomes mature and augmented reality (AR) technology shows great potential in future neurosurgical operations. The feasibility and applicability of AR assisted technology is currently the most important topic in clinical research. Methods: Four cases engaged from January to December 2024 in Department of Neurosurgery of Beijing Tsinghua Changgung Hospital with vestibular schwannoma (one case), intracranial aneurysm (2 cases) and subclavian artery (SA) occlusion caused vertebral artery steal syndrome (one case) have been conducted tumor resection, internal carotid artery (ICA)-posterior communicating artery (PCoA) aneurysm clipping and common carotid artery (CCA)-SA bypass, respectively. Using presurgical imaging data-based Surgical AR reconstruction on the HoloLens 2 platform, preoperative planning, surgical simulation, and intraoperative display were conducted. These were then compared with surgical practices and postoperative imaging data to qualitatively evaluate their effectiveness in assisting neurosurgery. Results: 1) Vestibular schwannoma resection: compared to the preoperative AR assisted simulation, we fully replicated the procedures of retrosigmoid approach craniotomy, removal of the posterior wall of internal auditory canal, and the exposure and removal of the internal auditory canal tumor during surgical practice. Facial nerve function was preserved intact during the surgery and reached House-Brackmann grade Ⅰ, but effective hearing was not preserved. Postoperative imaging data showed non-significant difference compared to preoperative simulation and surgical practice. The modified Rankin Scale (mRS) assessed postoperatively was 2. 2) ICA-PCoA aneurysm clipping: compared to the presurgical AR assistance, we fully replicate the procedures of lateral supraorbital craniotomy, removal of anterior clinoid process and the exposure and clipping of the neck of aneurysm. Postoperative imaging data showed non-significant difference compared to preoperative simulation. Postoperatively symptoms such as eye pain, ptosis, and double visian were completely relieved and the mRS was 0 after 6 months. 3) Basilar artery apex aneurysm clipping: based on preoperative simulation, we opted for the orbito-zygomatic approach during surgery to provide full exposure of the aneurysm neck and direct visualization of the bilateral P1 segment of posterior cerebral artery (PCA), offering better safety compared to the subtemporal approach. In surgical practice, lateral sulcus was separated, basilar artery and aneurysm was exposed and clipped via carotid spaces. Postoperatively occlomoter nerve was well recovered mRS was 0 after 6 months. 4) CCA- SA bypass: critical muscles and vessels on the neck were located intraoperatively on the body surface with AR assistance. CCA and SA were fully exposed and artificial vessel was anastomosed. Postoperative CTA 3D reconstruction suggested the blood flow was patent. The dizziness did not recur, and the blood pressure in the upper limb on the affected side returned to normal. Postoperative mRS was 0 after 6 months. Conclusions: The application of AR technology in neurosurgical procedures allows for preoperative planning, surgical simulation, and intraoperative display. It aids young surgeons in quickly understanding complex anatomical structures and shortens the learning curve, holding significant clinical value and promising application prospects.

Key words: Augmented reality, Skull base neoplasms, Intracranial aneurysm, Neurosurgical procedures

摘要：

研究背景: 计算机技术和人工智能技术的发展使数智神经外科学日趋成熟, 增强现实技术作为新兴技术已在神经外科手术中展现出巨大潜力, 探讨该项技术辅助神经外科手术的可行性和实用性将是现阶段临床研究的重要议题。方法: 纳入4例2024年1-12月在清华大学附属北京清华长庚医院行神经外科手术的前庭神经鞘瘤（1例）、颅内动脉瘤（2例）和锁骨下动脉闭塞致椎动脉盗血综合征（1例）患者, 分别接受前庭神经鞘瘤切除术、颈内动脉-后交通动脉动脉瘤夹闭术和颈总动脉（CCA）-锁骨下动脉（SA）搭桥术; 将术前常规影像学数据导入Surgical AR软件, 基于HoloLens 2平台进行术前规划、模拟手术和术中实时显示, 并与实际手术操作和术后影像学数据对比, 定性分析增强现实技术辅助神经外科手术的疗效。结果: （1）前庭神经鞘瘤切除术: 与术前增强现实技术模拟手术（模拟手术）对比, 实际手术完全复现经枕下乙状窦后入路开颅、内耳道后壁磨除、内耳道内肿瘤显露和切除的操作过程, 术中面神经保护完好, 术后面神经功能达House-Brackmann分级Ⅰ级, 但未保留有效听力; 术后1周三维重建CT与术前模拟和术中实际所见无明显差异; 术后6个月改良Rankin量表（mRS）评分为2分。（2）颈内动脉-后交通动脉动脉瘤夹闭术: 与术前模拟手术对比, 实际手术完全复现经眶上外侧入路开颅、磨除前床突、显露动脉瘤颈并夹闭的手术过程; 术后三维重建CTA与术前模拟无明显差异; 术后6个月, 眼部胀痛、上睑下垂、复视等症状完全缓解, mRS评分为零。（3）基底动脉尖动脉瘤夹闭术: 根据术前模拟结果, 经眶颧入路对动脉瘤颈的显露更充分且术者可于直视下完全夹闭动脉瘤并保护双侧大脑后动脉P1段, 操作安全性明显优于经颞下入路; 实际手术中选择经眶颧入路, 分离外侧裂经颈内动脉-动眼神经间隙显露基底动脉和动脉瘤、夹闭动脉瘤; 术后6个月mRS评分为零, 动眼神经功能恢复良好。（4）CCA-SA搭桥术: 术中通过增强现实技术辅助颈部重要肌肉、血管体表定位, 充分显露颈总动脉和锁骨下动脉, 人工血管吻合; 术后三维重建CTA显示桥血管通畅; 患者头晕症状未再发作, 患侧上肢血压恢复正常; 术后6个月mRS评分为零。结论: 增强现实技术用于神经外科手术可术前手术规划、手术模拟和术中引导, 有助于青年医师快速理解复杂的解剖结构、缩短学习曲线, 具有重要的临床价值和广阔的应用前景。

关键词: 增强现实, 颅底肿瘤, 颅内动脉瘤, 神经外科手术