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Comparing augmented reality-assisted and freehand external ventricular drain placement: a multicenter randomized

Jesse A M van Doormaal1, Elisa Colombo2, Jasper M van der Zee3

  • 1Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands. jessevandoormaal@gmail.com.

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|December 24, 2025
PubMed
Summary
This summary is machine-generated.

Augmented reality (AR) significantly improves external ventricular drain (EVD) placement accuracy compared to freehand techniques. While AR increases procedural time, its enhanced accuracy and favorable usability are expected to improve clinical outcomes.

Keywords:
Augmented realityExternal ventricular drainImage-guided neurosurgery

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Area of Science:

  • Neurosurgery
  • Medical Technology
  • Augmented Reality Applications

Background:

  • External ventricular drain (EVD) placement is a common neurosurgical procedure with notable misplacement rates using the freehand technique.
  • Augmented reality (AR) offers potential improvements by providing 3-D visual guidance for optimal trajectory during EVD placement.
  • This study evaluates an AR application designed for EVD placement, featuring trajectory planning, image-to-patient registration, and 3-D stereoscopic projection.

Purpose of the Study:

  • To assess the efficacy and usability of an AR application in assisting neurosurgical residents with EVD placements.
  • To compare the accuracy of AR-assisted EVD placement against the traditional freehand technique.
  • To evaluate user experience and procedural time associated with AR-assisted EVD placement.

Main Methods:

  • A randomized controlled crossover trial was conducted with 15 neurosurgical residents and one neurosurgeon.
  • A total of 236 EVD procedures were performed on biomimetic phantoms, with 118 AR-assisted and 118 freehand.
  • Accuracy was measured using the Kakarla scale, distance-to-target, angular, and depth inaccuracy, alongside procedural time and user experience questionnaires (NASA-TLX, USE).

Main Results:

  • AR-assisted placement demonstrated significantly higher optimal placement rates (57.6% vs 37.3%) and lower erroneous placement rates (21.2% vs 40.7%).
  • AR resulted in reduced distance-to-target (7.2 mm vs 11.4 mm) and angular inaccuracy (5.58° vs 7.60°).
  • Procedural time increased with AR (7 min 30 s vs 1 min 11 s), but usability was rated favorably, with similar perceived workloads.

Conclusions:

  • Augmented reality (AR) significantly enhances the accuracy of external ventricular drain (EVD) placement compared to the freehand method.
  • The increased procedural time associated with AR is within clinically acceptable limits and is offset by improved accuracy.
  • The AR system demonstrated favorable usability, suggesting its potential to improve clinical efficacy in EVD procedures.