Simulation-Based Consultations for Patients with Cranial Tumors and Cerebrovascular Pathology

Background Computer-based virtual reality simulations of intracranial pathology are used in clinical practice with increasing frequency. We sought to review our recent experience integrating multiple simulation platforms in the process of preoperative planning, intraoperative navigation, and during outpatient consultations.

Description of Program, Methods Simulation technology was used in 301 patients undergoing evaluation for surgery for cranial tumor or cerebrovascular pathology between August 2015 and July 2017. In the majority of patients, structural image segmentation was based on MRI (253 patients, 18 including MR angiograms), CT scans (278 patients including 162 CT angiograms), and angiogram (49 patients). Surgical Theater, Brainlab, and Synaptive platforms were used for simulation consultation and preoperative planning. Intraoperatively, simulations were integrated into a surgical environment which included Zeiss Pantero, Leica OH6, and BK Ultrasound.

Outcomes/Metrics The distribution of preoperative pathologies in our patient cohort included 65 meningiomas, 32 aneurysms, 24 pituitary adenomas, 27 malignancies, 9 cavernomas, 22 AVMs, 5 microvascular decompression TGN, and a single instance each of endarterectomy and cervical mass. The surgical approach was distributed as 252 craniotomy, 74 endoscopic, 6 cervical, and 10 cases which did not proceed to surgery. Among the total population, 107 patients had simulation-based consultations consisting of an interactive review of patient or pathology-specific 3D reconstructions. These were presented using interactive hardware such as VR headsets, touch screen display, and high-resolution video. Interactive alternatives for the surgical approach and resection or clipping techniques were demonstrated to each patient and family. Skin rendering provided patients with 3D models in which their own facial features were recognizable. Transparency options enhanced their appreciation of the pathology in relation to their normal anatomy providing understanding of possible side effects.

In 18 out of 301 of simulated cases, simulation provided information that leads to a modification of the surgical or treatment plan. Because the integration and fusion of MRI, CT, and angiography studies including 3D angiogram, we were better able to visualize the vascular anatomy and its changes in relation to the pathology which we believe led to the plan modifications.

Conclusion The use of 3D simulation has become an integral component of the patient experience in the neurosurgery department at Mount Sinai Hospital. Patients have reported increased understanding of their own anatomy, pathology, and side effects due to preoperative simulation-based consultation, leading to decreased anxiety for patients and improved confidence in their surgical team. In all cases, surgeons report improved situational awareness during surgery. Frequently, preoperative study of simulations lead to improved surgical approaches.