Elsevier

World Neurosurgery

Volume 96, December 2016, Pages 375-382
World Neurosurgery

Original Article
Impact of Virtual and Augmented Reality Based on Intraoperative Magnetic Resonance Imaging and Functional Neuronavigation in Glioma Surgery Involving Eloquent Areas

https://doi.org/10.1016/j.wneu.2016.07.107Get rights and content

Background

The utility of virtual and augmented reality based on functional neuronavigation and intraoperative magnetic resonance imaging (MRI) for glioma surgery has not been previously investigated.

Methods

The study population consisted of 79 glioma patients and 55 control subjects. Preoperatively, the lesion and related eloquent structures were visualized by diffusion tensor tractography and blood oxygen level–dependent functional MRI. Intraoperatively, microscope-based functional neuronavigation was used to integrate the reconstructed eloquent structure and the real head and brain, which enabled safe resection of the lesion. Intraoperative MRI was used to verify brain shift during the surgical process and provided quality control during surgery. The control group underwent surgery guided by anatomic neuronavigation.

Results

Virtual and augmented reality protocols based on functional neuronavigation and intraoperative MRI provided useful information for performing tailored and optimized surgery. Complete resection was achieved in 55 of 79 (69.6%) glioma patients and 20 of 55 (36.4%) control subjects, with average resection rates of 95.2% ± 8.5% and 84.9% ± 15.7%, respectively. Both the complete resection rate and average extent of resection differed significantly between the 2 groups (P < 0.01). Postoperatively, the rate of preservation of neural functions (motor, visual field, and language) was lower in controls than in glioma patients at 2 weeks and 3 months (P < 0.01).

Conclusion

Combining virtual and augmented reality based on functional neuronavigation and intraoperative MRI can facilitate resection of gliomas involving eloquent areas.

Introduction

Virtual reality (VR) can simulate the real world and provide information that may not be otherwise visible to the naked eye, allowing users to visualize objects within a 3-dimensional (3D) space without limits. However, the lack of interaction between VR and the real world limits its widespread application.1, 2

Augmented reality (AR) is a new cross-discipline based on VR that superimposes computer-generated virtual objects in real time and space with auxiliary enhancement such that the user perceives a real-world scene rather than a virtual phenomenon (the so-called enhanced concept). AR technology has been preliminarily applied to neurosurgery.3, 4 In this study, we investigated the utility of combined VR and AR for intraoperative magnetic resonance imaging (iMRI) and neuronavigation in glioma surgery.

Section snippets

Patient Population

A total of 134 consecutive patients with gliomas involving eloquent (motor, language, and vision) areas were prospectively recruited between February 2009 and January 2014. Of these patients, 79 underwent surgery using functional neuronavigation and iMRI and 55 underwent surgery guided by anatomic neuronavigation, comprising the patient and control groups, respectively. The study protocol was approved by our institutional ethics committee, and all patients or their family members provided

General

Glioma patients were diagnosed as LGG [World Health Organization (WHO) grades I and II) or HGG (WHO grades III and IV). The related eloquent area was reconstructed and localized, and their relationship to lesions was demonstrated and recorded in each patient. We defined reconstructed structures related to language (Broca's and Wernicke's areas and arcuate fasciculus), motor (hand and foot cortices and pyramidal tract), and vision (optic radiation and visual cortex) as eloquent areas.

Discussion

In the study, we found that VR based on functional neuronavigation was useful for optimizing surgical planning. Intraoperative 3D visualization of lesions and their associated functional structures (AR) can provide information to neurosurgeons for performing specific manipulations. Moreover, iMRI can detect brain shift during the surgical process and provide quality control during surgery. Most previous studies have focused on a single type of neurologic function, and the relationship between

Conclusion

The VR and AR technique described in our study can help the neurosurgeon design and optimize surgical planning and intraoperatively visualize structures around the lesions. iMRI can confirm brain shift and provide quality control during the surgical process. Thus, the combination of these techniques can significantly enhance resection of gliomas involving eloquent areas.

Acknowledgments

The authors thank the members of the Department of Neurosurgery, PLA General Hospital (Hao Tang, MD; Hai-hao Gao, MD; Xing-hua Xu, MD; and Qun Wang, MD) for their collaboration.

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    Conflict of interest statement: The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article. This study was funded by grants from the Science and Technology Projects of Hainan province (2015SF16); Technological Innovation Foundation of the PLA General Hospital (14KMM37); Medical and Technical Innovation Project, Sanya, Hainan Province (2014YW31); Health Industry Research Project of Hainan Province (14A210218); Natural Science Foundation of Hainan Province (20168362); National Natural Science Foundation of China (81271515); and the Key Research and Development Project of Hainan Province (ZDYF2016118). The sponsors had no role in the design or conduct of this research.

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