A MiXed-Reality automatic system for enhanced precision in craniotomy procedure for meningioma resection: A...

Craniotomy is the standard surgical approach in neuro-oncology for accessing and removing brain tumors. Despite being the clinical gold standard, conventional image-guided systems such as neuronavigation platforms suffer from high costs, limited ergonomics, and 2D visual constraints that can hinder surgical precision and usability. This study presents and validates a standalone mixed reality system for automatic craniotomy planning and intra-operative guidance, designed to provide an ergonomic, cost-effective, and intuitive alternative to traditional neuronavigation.

The system, composed of a laptop and a HoloLens 2 headset, integrates automatic craniotomy planning, hologram-to-patient registration, and real-time 3D visualization. A multicentric in vitro study was conducted with ten neurosurgeons performing craniotomies on a custom 3D-printed phantom with four tumor models, using both the mixed reality system and a commercial neuronavigation platform. Performance metrics included craniotomy extension, percentage of tumor exposure, craniotomy centering, and procedural time.

The mixed reality system achieved craniotomy extension, tumor exposure and craniotomy centering comparable or superior to conventional neuronavigation, with improved inter-operator consistency and no significant increase in procedural time. Hologram-to-patient registration achieved a root mean squared error of 1.31 ± 0.17 mm and a target registration error of 2.3 ± 0.6 mm. User acceptance of the proposed system was high, as confirmed by four standardized questionnaires.

The proposed mixed reality system demonstrates the potential to serve as a viable, ergonomic, and lower-cost alternative to traditional neuronavigation platforms, supporting accurate and intuitive craniotomy planning and execution.