Use of Virtual Reality Platforms in the Preoperative Planning and Intraoperative Navigation of Deep-Seated Cavernomas

Abstract

INTRODUCTION: Cavernous malformations in deep-seated eloquent cortex pose significant management challenges. Surgical resection, when indicated, carries a high risk of postoperative neurologic deficit. Obtaining safe surgical access is highly dependent upon location and the patient's clinical status. Three-dimensional (3D) virtual reality platforms, neuronavigation, and advanced neuroimaging can be used as adjuncts to determine and perform the safest surgical approach. METHODS: Five patients who underwent surgical resection of deep seated cavernomas in eloquent cortex were included. 3D images were created from Diffusion Tensor MR Imaging (DTI) using a 360 Virtual Reality planning software (Surgical Theater SRP, Version7.4.0, Cleveland, Ohio). The Surgical Theater system was integrated with the neuronavigation system (Brainlab AG Version 3.0.5, Feldkirchen, Germany) to allow for real time evaluation of the 3D tractography. The 360°VR model was used to assess the location of the cavernoma and relevant anatomy, map multiple trajectories, and compare the advantages and disadvantages of each. SRP and Brainlab projections were used to determine the limits of the cavernoma, guide the placement of the tubular retractor, and confirm the approach vector intraoperatively. RESULTS: Locations of the cavernomas included left caudate head, right superior colliculus, right posteroinferior thalamus, right insula, and left medulla. All patients underwent craniotomy and microsurgical resection. Two patients who presented with a neurologic deficit partially improved after prolonged rehabilitation. Three patients who were neurologically intact on presentation remained so post-op. Grosstotal resection was obtained in all patients. CONCLUSION: Virtual segmentation allows for better understanding of complex anatomic relationships between the lesion and surrounding critical structures. Advanced planning familiarizes surgeons to the patient in the context of the surgical field, increasing spatial and positional orientation. 3D virtual reality planning platforms in conjunction with neuronavigation and DTI can assist in choosing the optimal surgical corridor to achieve gross-total resection of deep-seated cavernomas while minimizing neurologic risk.