Recent advances in cerebrovascular simulation and neuronavigation for the optimization of intracranial aneurysm clipping

Abstract

Endovascular treatment of intracranial aneurysms (IAs) has improved to the extent that in some instances such an approach has now become safer than surgery. This has dramatically changed clinical practice by reducing the volume and increasing the complexity of IAs referred for open surgical treatment. We review the simulation techniques and dedicated vascular neuronavigation systems that have been developed to maintain the quality of aneurysm clipping in this context. Simulation of surgical approaches was made possible by the introduction of high-resolution 3D imaging techniques such as three-dimensional CT angiography (3D-CTA) and three-dimensional digital subtraction angiography (3D-DSA), enabling reproduction of the craniotomy and rotation of the vascular tree according to the orientation of the operative microscope. A virtual simulator for compiling such data, the Dextroscope Õ , is now available for this purpose. Simulation of final clipping has been investigated through virtual or physical models, enabling anticipation of aneurysm deformation during clip application and selection of the appropriate clip(s) in terms of number, size, shape and orientation. To improve surgical dissection guidance, specific cerebrovascular neuronavigation procedures have been developed based on 3D-CTA or 3D-DSA. These help make the operation secure by accurately predicting the location and orientation of an aneurysm within its parenchymal and vascular environment. Future simulators dedicated to cerebrovascular procedures will need to integrate representation of the brain surface and biomechanical modeling of brain and aneurysm wall deformation under retraction or during clipping. They should contribute to training and maintenance of surgical skills, thereby optimizing the quality of surgical treatment in this field.

Presurgical selection of the ideal aneurysm clip by the use of a three-dimensional planning system

“…Intraoperative techniques such as ICG videoangiography or catheter angiography aim to immediately assess aneurysm occlusion and allow for clip correction and improvement of occlusion [16,31]. In addition to intraoperative assessment, presurgical planning and simulation could improve aneurysm occlusion, and various approaches are in use [32].…”

Three-Dimensional Modeling of Complex Pediatric Intracranial Aneurysmal Malformations With a Virtual Reality System

“…Although this feature was not used in this series, preoperative surgical simulation for procedural rehearsal (as opposed to enhancing anatomic understanding as used herein) is an ongoing area for future VR improvement. 19…”

Implantation of 3D-Printed Patient-Specific Aneurysm Models into Cadaveric Specimens: A New Training Paradigm to Allow for Improvements in Cerebrovascular Surgery and Research

“…3D virtual reality environments have been created as a tool for neurosurgical trainees to learn surgical approaches to vascular lesions [ 26 ]. Although the advances in virtual reality computerized models and neuronavigation have been presented as potential contributors to training surgical skills [ 27 ], it is widely agreed that human cadaveric models are anatomically the most realistic ones [ 28 ].…”