Interactive virtual simulation using a 3D computer graphics model for microvascular decompression surgery

Clinical article

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Object

The purpose of this paper is to report on the authors' advanced presurgical interactive virtual simulation technique using a 3D computer graphics model for microvascular decompression (MVD) surgery.

Methods

The authors performed interactive virtual simulation prior to surgery in 26 patients with trigeminal neuralgia or hemifacial spasm. The 3D computer graphics models for interactive virtual simulation were composed of the brainstem, cerebellum, cranial nerves, vessels, and skull individually created by the image analysis, including segmentation, surface rendering, and data fusion for data collected by 3-T MRI and 64-row multidetector CT systems. Interactive virtual simulation was performed by employing novel computer-aided design software with manipulation of a haptic device to imitate the surgical procedures of bone drilling and retraction of the cerebellum. The findings were compared with intraoperative findings.

Results

In all patients, interactive virtual simulation provided detailed and realistic surgical perspectives, of sufficient quality, representing the lateral suboccipital route. The causes of trigeminal neuralgia or hemifacial spasm determined by observing 3D computer graphics models were concordant with those identified intraoperatively in 25 (96%) of 26 patients, which was a significantly higher rate than the 73% concordance rate (concordance in 19 of 26 patients) obtained by review of 2D images only (p < 0.05). Surgeons evaluated interactive virtual simulation as having “prominent” utility for carrying out the entire surgical procedure in 50% of cases. It was evaluated as moderately useful or “supportive” in the other 50% of cases. There were no cases in which it was evaluated as having no utility. The utilities of interactive virtual simulation were associated with atypical or complex forms of neurovascular compression and structural restrictions in the surgical window. Finally, MVD procedures were performed as simulated in 23 (88%) of the 26 patients .

Conclusions

Our interactive virtual simulation using a 3D computer graphics model provided a realistic environment for performing virtual simulations prior to MVD surgery and enabled us to ascertain complex microsurgical anatomy.

Abbreviations used in this paper:AICA = anterior inferior cerebellar artery; CAD = computer-aided design; CISS = constructive interference in steady state; CPA = cerebellopontine angle; CTA = CT angiography; MRA = MR angiography; MVD = microvascular decompression; PICA = posterior inferior cerebellar artery; SCA = superior cerebellar artery; STL = standard triangulated language; VA = vertebral artery.

Article Information

Address correspondence to: Makoto Oishi, M.D., Department of Neurosurgery, Brain Research Institute, Niigata University, 1-757 Asahimachidori, Chuo-Ku, Niigata 951-8585, Japan. email: mac.oishi@mac.com.

Please include this information when citing this paper: published online June 29, 2012; DOI: 10.3171/2012.5.JNS112334.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: FreeForm modeling system (Sensable Technologies, Inc.) characterized by unique 3D design software and a haptic device (PHANTOM, Sensable Technologies, Inc.). B: In combination with a 3D display, interactive virtual simulation is performed under 3D visualization through the 3D glasses.

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    Case 8: right trigeminal neuralgia. A–F: Original CISS (A) and TOF (B) MR images showing the SCA (yellow arrows) to be the offending vessel compressing the trigeminal nerve and the 3D computer graphics model (C) directly visualizing the neurovascular compression with indentation by the SCA on the trigeminal nerve (black arrow). Skull (D) and veins (E), especially petrosal veins (white arrow)—extracted from CT data—are integrated, and then the 3D computer graphics model for the simulation is completed (F). G–I: Performing interactive virtual simulation with surgical positioning (the right side is the top in each photo). The craniotomy location is determined on the translucent skull image (G) and the virtual craniotomy is performed on the 3D computer graphics model with a drilling tool (H). To view the CPA region, the cerebellum is retracted by a virtual retractor (translucent orange ball) (I). J and K: The operative perspective predicted by interactive virtual simulation (J) shows detailed microsurgical anatomy, including the form of the trigeminal nerve compression by the SCA and also petrosal veins passing through the surgical field and is completely concordant with the intraoperative microscopic view (K). cbll = cerebellum; PV = petrosal vein; pyr = pyramis; tent = tentorium; V = CN V (trigeminal nerve); VIII = CN VIII (acoustic nerve).

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    Case 26: left hemifacial spasm. A: Sequential CISS (upper) and TOF (lower) MR images do not clarify the relationship of the elongated VA and AICA at the root exit zone of the facial nerve (VII) (yellow arrows). B: The 3D computer graphics model directly visualizes the AICA as running along the VA, which is shown as partially translucent, and compressing the root exit zone of the facial nerve. C and D: The predicted perspective on interactive virtual simulation (C), in which the cerebellum is retracted to imitate the infrafloccular approach, shows that the AICA compresses the root exit zone of the facial nerve (black arrow) with a contribution from the VA in the microsurgical window, and is confirmed to be concordant with the intraoperative microscopic view (D). Flo = cerebellar flocculus; VI = CN VI (abducens nerve); VII = CN VII (facial nerve); IX-X = CN IX and CN X (glossopharyngeal and vagus nerves).

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    Case 4: trigeminal neuralgia with atypical pattern of neurovascular compression. A: Sequential CISS MR images showing multiple vessels (arrows) around the trigeminal nerve with no marked findings of compression. B: The 3D computer graphics model created from the MRI data shows no direct compression of the SCA, but there are findings suggestive of veins adhering to the nerve. C and D: The predicted perspective on interactive virtual simulation (C) shows that the trigeminal nerve may adhere to the petrosal vein (PV2) and the transverse pontine vein (TPV) and is confirmed to be concordant with the intraoperative microscopic view (D). E: Removal of arachnoid tissues around the nerve, transposition of the SCA and PV2, and coagulation of the transverse pontine vein are performed, and postoperative pain relief is thereby obtained.

  • View in gallery

    Case 7 (A–F) and Case 17 (G–K): representative interactive virtual simulations demonstrating restricted surgical windows. A–F: Case 7—left trigeminal neuralgia. The CISS images (A and B) show arterial compression (yellow arrow) of the trigeminal nerve and multiple large bridging veins in the surgical field (white arrow). On the 3D computer graphics model (C), anatomical relationships are directly determined. Interactive virtual simulation predicts the restricted operative window surrounded by the large transverse pontine vein and petrosal vein, suprameatal process (SMP), tentorium, and cerebellum (D), and during the actual operation it was necessary to manipulate structures in this predicted restricted surgical window (E and F). The SCA behind the nerve in the window (D) is identified based on interactive virtual simulation knowledge (F). G–K: Case 17—left hemifacial spasm. The CISS image (G) identifies a vessel passing by the root exit zone (yellow arrow) and the CT image (H) shows protrusion of the jugular tubercle (JT, white arrow). The 3D computer graphics model shows neurovascular compression at the root exit zone by the AICA from the common trunk (I), and interactive virtual simulation predicts a restricted operative window due to marked protrusion of the jugular tubercle (J). Manipulation within this restricted window was necessary during the actual operation (K). REZ = root exit zone.

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