Heads-up Display in Complex Cranial Surgery: Pilot Study on Surgical Integration and Accuracy

Introduction: The use of intraoperative navigation is limited in microsurgical surgery when attention needs to be focused on the operative field. A Heads-Up Display (HUD) option may allow for the direct application of navigation into surgery work flow and resection. This study details our pilot study in the use of HUD in complex surgery.

Methods: We retrospectively reviewed all patients who underwent HUD surgery from April 2016 to present. We analyzed pre-operative imaging, stereotactic navigational sequencing and determined intra-operative accuracy in all cases.

Results: A total of 26 patients with 29 pathologies were included. Vascular pathologies included aneurysms (n = 6; Ophthalmic, ICA, MCA, ACA perforator, Acomm, PICA), AVMs (n = 3; temporal, parietal, lateral ventricular), and cavernous malformations (n = 2; cerebellar, 4th ventricular). Oncologic pathologies included meningiomas (n = 7; convexity (4), sphenoid wing, optic, foramen magnum), metastatic tumors (n = 3, parietal, temporal bone, hypoglossal canal), sellar/parasellar tumors (n = 3; pituitary adenoma (2), hemangioblastoma), schwannomas (n = 2; vestibular, trigeminal), CPA epidermoid (n = 1), frontal glioma (n = 1), and temporal osteoblastoma (n = 1). 19 of the lesions were deep and 10 were superficial. Structures identified included the lesion (n = 29), vessels (n = 10), and nerves/brainstem (n = 9). HUD accuracy was deemed accurate (n = 21), near-accurate (n = 3), and inaccurate (n = 5). Loss of HUD accuracy was always secondary to loss of navigation accuracy.

Conclusions: HUD can be integrated into surgical planning and operative resection. HUD may be useful for deep lesions for which an early visualization and accurate trajectory is beneficial. It is important to maintain navigation accuracy throughout the procedure. Further study is necessary to demonstrate utility and outcome benefit.