Intra-operative applications of augmented reality in glioma surgery: a systematic review

Anya Ragnhildstveit; Chao Li; Mackenzie H Zimmerman; Michail Mamalakis; Victoria N Curry; Willis Holle; Noor Baig; Ahmet K Uğuralp; Layth Alkhani; Zeliha Oğuz-Uğuralp; Rafael Romero-Garcia; John Suckling

doi:10.3389/fsurg.2023.1245851

Intra-operative applications of augmented reality in glioma surgery: a systematic review

Front Surg. 2023 Aug 21:10:1245851. doi: 10.3389/fsurg.2023.1245851. eCollection 2023.

Authors

Anya Ragnhildstveit^{1

2}, Chao Li^{3

4}, Mackenzie H Zimmerman¹, Michail Mamalakis², Victoria N Curry^{1

5}, Willis Holle^{1

6}, Noor Baig^{1

7}, Ahmet K Uğuralp¹, Layth Alkhani^{1

8}, Zeliha Oğuz-Uğuralp¹, Rafael Romero-Garcia^{2

9}, John Suckling²

Affiliations

¹ Integrated Research Literacy Group, Draper, UT, United States.
² Department of Psychiatry, University of Cambridge, Cambridge, England.
³ Department of Clinical Neurosciences, University of Cambridge, Cambridge, England.
⁴ Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, England.
⁵ Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, United States.
⁶ Department of Physics and Astronomy, The University of Utah, Salt Lake City, UT, United States.
⁷ Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, United States.
⁸ Department of Biology, Stanford University, Stanford, CA, United States.
⁹ Instituto de Biomedicina de Sevilla (IBiS) HUVR/CSIC/Universidad de Sevilla/CIBERSAM, ISCIII, Dpto. de Fisiología Médica y Biofísica.

Abstract

Background: Augmented reality (AR) is increasingly being explored in neurosurgical practice. By visualizing patient-specific, three-dimensional (3D) models in real time, surgeons can improve their spatial understanding of complex anatomy and pathology, thereby optimizing intra-operative navigation, localization, and resection. Here, we aimed to capture applications of AR in glioma surgery, their current status and future potential.

Methods: A systematic review of the literature was conducted. This adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. PubMed, Embase, and Scopus electronic databases were queried from inception to October 10, 2022. Leveraging the Population, Intervention, Comparison, Outcomes, and Study design (PICOS) framework, study eligibility was evaluated in the qualitative synthesis. Data regarding AR workflow, surgical application, and associated outcomes were then extracted. The quality of evidence was additionally examined, using hierarchical classes of evidence in neurosurgery.

Results: The search returned 77 articles. Forty were subject to title and abstract screening, while 25 proceeded to full text screening. Of these, 22 articles met eligibility criteria and were included in the final review. During abstraction, studies were classified as "development" or "intervention" based on primary aims. Overall, AR was qualitatively advantageous, due to enhanced visualization of gliomas and critical structures, frequently aiding in maximal safe resection. Non-rigid applications were also useful in disclosing and compensating for intra-operative brain shift. Irrespective, there was high variance in registration methods and measurements, which considerably impacted projection accuracy. Most studies were of low-level evidence, yielding heterogeneous results.

Conclusions: AR has increasing potential for glioma surgery, with capacity to positively influence the onco-functional balance. However, technical and design limitations are readily apparent. The field must consider the importance of consistency and replicability, as well as the level of evidence, to effectively converge on standard approaches that maximize patient benefit.

Keywords: augmented reality; brain tumor; glioma; mixed reality; neuronavigation; neurosurgery; systematic review; virtual reality.

Publication types

Review

Grants and funding

All research at the Department of Psychiatry in the University of Cambridge was supported by the NIHR Cambridge Biomedical Research Centre (NIHR203312) and the NIHR Applied Research Collaboration East of England. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.