How I do it: superficial temporal artery to middle cerebral artery bypass for treatment of giant middle cerebral artery aneurysm

Early Experience of Surgical Planning for STA-MCA Bypass Using Virtual Reality

BACKGROUND

The superficial temporal artery (STA)-to-middle cerebral artery (MCA) bypass requires precise preoperative planning, and 3-dimensional virtual reality (VR) models have recently been used to optimize planning of STA-MCA bypass. In the present report, we have described our experience with VR-based preoperative planning of STA-MCA bypass.

METHODS

Patients from August 2020 to February 2022 were analyzed. For the VR group, using 3-dimensional models from the patients' preoperative computed tomography angiograms, VR was used to locate the donor vessels, potential recipient, and anastomosis sites and plan the craniotomy, which were referenced throughout surgery. Computed tomography angiograms or digital subtraction angiograms were used to plan the craniotomy for the control group. The procedure time, bypass patency, craniotomy size, and postoperative complication rates were assessed.

RESULTS

The VR group included 17 patients (13 women; age, 49 ± 14 years) with Moyamoya disease (76.5%) and/or ischemic stroke (29.4%). The control group included 13 patients (8 women; age, 49 ± 12 years) with Moyamoya disease (92.3%) and/or ischemic stroke (7.3%). For all 30 patients, the preoperatively planned donor and recipient branches were effectively translated intraoperatively. No significant difference were found in the procedure time or craniotomy size between the 2 groups. Bypass patency was 94.1% for the VR group (16 of 17) and 84.6% for the control group (11 of 13). No permanent neurological deficits occurred in either group.

CONCLUSIONS

Our early experience has shown that VR can serve as a useful, interactive preoperative planning tool by enhancing visualization of the spatial relationship between the STA and MCA without compromising the surgical results.

The "Canopy Approach": Case Series Using Immersive Virtual Reality for Bottom-Up Target-Based Preoperative Planning in Pediatric Neurosurgery

BACKGROUND

Virtual reality (VR) is increasingly used for trajectory planning in neurosurgery.

OBJECTIVE

To describe a case series showing the application of immersive VR involving both "top-down" from skull to lesion and "bottom-up" from lesion to skull approaches for trajectory planning in pediatric neurosurgical patients.

METHODS

We detail the preoperative and intraoperative application of VR and clinical courses of 5 children (aged 7-14 years) with anatomically challenging intraparenchymal lesions that posed operative risks to nearby vascular anatomy and fiber tracts. Preoperative planning consisted of standard presurgical evaluation with computed tomography and magnetic resonance imaging used to render 3-dimensional models that could be viewed and manipulated using desktop software and immersive VR headsets and hand controllers by the surgeon and family. Patient satisfaction was evaluated by survey. Surgical outcomes were degree of seizure control or extent of resection.

RESULTS

Three patients underwent lesion resection and 2 laser ablation. Modifications to 2-dimensional and "top-down" VR trajectory plans were made after "bottom-up" navigation in all cases. All families reported that the VR enhanced their understanding of the procedure. There were no complications, and no patients suffered permanent neurological deficits postoperatively. Gross total resection was achieved in all lesional cases, and patients with epilepsy achieved seizure freedom at 2 years postoperatively.

CONCLUSION

Immersive VR allows operative corridors to be virtually traveled and viewed from a "top-down" and "bottom-up" perspective, as if looking up from under a forest canopy of overlying anatomy, for optimal trajectory planning and improvement of family understanding in pediatric neurosurgery.