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With augmented reality (AR), the accuracy of EVD placement could be improved by providing a 3-D overlay, guiding optimal placement using a virtual trajectory superimposed over the patient. In this study, we aimed to assess the efficacy and usability of an AR application for assisting EVD placements which supported trajectory planning, point-based image-to-patient registration and 3-D stereoscopic projection.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>We conducted a randomized controlled crossover trial involving 15 neurosurgical residents and one neurosurgeon, who performed 236 EVD procedures (118 AR-assisted and 118 freehand) on biomimetic phantoms. EVD placement accuracy was evaluated using the Kakarla scale, distance-to-target, angular inaccuracy, and depth inaccuracy. The total procedural time was recorded. The user experience was evaluated using the NASA Task Load Index (NASA-TLX) and the Usefulness, Satisfaction, and Ease of Use (USE) questionnaire.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>AR-assisted placement achieved significantly higher rates of optimal placement (Kakarla grade 1: 57.6% vs 37.3%; p\u2009&lt;\u2009.001), lower rates of erroneous placement (Kakarla grade 3: 21.2% vs 40.7%; p\u2009&lt;\u2009.001), a lower distance-to-target (median, 7.2\u00a0mm vs 11.4\u00a0mm; p\u2009&lt;\u2009.001) and lower angular inaccuracy (median, 5.58\u00b0 vs 7.60\u00b0; p\u2009&lt;\u2009.001). Procedural time was longer for AR (median, 7\u00a0min 30\u00a0s vs 1\u00a0min 11\u00a0s; p\u2009&lt;\u2009.001). Participants rated the AR system favorably on the USE for ease of learning (mean, 6.09\/7 [SD, 0.94]) and satisfaction (mean, 6.45\/7 [SD, 0.69]), while NASA-TLX scores indicated similar workloads between AR and freehand techniques.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>AR improves the accuracy of EVD placement compared to the freehand technique, which is expected to improve the efficacy in clinical settings. It increases total procedural time but remains within clinically acceptable limits and provides favorable usability.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00701-025-06738-7","type":"journal-article","created":{"date-parts":[[2025,12,24]],"date-time":"2025-12-24T06:16:53Z","timestamp":1766557013000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Comparing augmented reality-assisted and freehand external ventricular drain placement: a multicenter randomized controlled crossover phantom study"],"prefix":"10.1007","volume":"167","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9531-2765","authenticated-orcid":false,"given":"Jesse A. 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Front Surg. https:\/\/doi.org\/10.3389\/fsurg.2024.1513899","journal-title":"Front Surg"}],"container-title":["Acta Neurochirurgica"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00701-025-06738-7","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00701-025-06738-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00701-025-06738-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,26]],"date-time":"2025-12-26T04:57:36Z","timestamp":1766725056000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00701-025-06738-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,24]]},"references-count":46,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["6738"],"URL":"https:\/\/doi.org\/10.1007\/s00701-025-06738-7","relation":{},"ISSN":["0942-0940"],"issn-type":[{"value":"0942-0940","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,24]]},"assertion":[{"value":"4 April 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"7 August 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 December 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was conducted in accordance with the Declaration of Helsinki. The anonymized data from a previous study was partially reused in this study [\n                      \n                      ]. This dataset had undergone the appropriate ethical review and approval process under the ethical review board of the Canton of Zurich, Switzerland (KEK ZH 2021\u201301844).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"Written general consent for the future use of patient-specific data was obtained from all individuals included in this dataset, or from their legal representatives, as part of the original study [\n                      \n                      ].","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate"}},{"value":"No identifiable information is included in this manuscript.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"J.A.M. van Doormaal is an employee at Augmedit B.V., a start-up company specializing in the development of augmented reality tools for surgeons. J.A.M. van Doormaal is a first-degree relative (brother) of T.P.C. van Doormaal. T.P.C. van Doormaal is the founder and CMO at Augmedit BV, a start-up company specializing in the development of mixed reality tools for surgeons.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"336"}}