{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T15:16:57Z","timestamp":1788967017409,"version":"build-2803163510"},"reference-count":36,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,1]]},"abstract":"\n OBJECTIVE<\/jats:title>\n Brain arteriovenous malformations (AVMs) present significant challenges in neurosurgery, requiring detailed planning and execution. In this study, the authors aimed to evaluate the efficacy of mixed reality (MxR), a synergistic application of virtual reality (VR) and augmented reality (AR), in the surgical management of AVMs.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n A retrospective review was conducted on 10 patients who underwent AVM resection between 2021 and 2023. Preoperative planning used patient-specific 360\u00b0 VR models, while intraoperative guidance used AR markers for targeted disconnection of arterial feeders. Data were analyzed for surgical duration, blood loss, and postoperative outcomes, stratified by Spetzler-Martin (SM) and supplemented Spetzler-Martin (Supp-SM) grades.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n In 10 patients with cerebral AVMs, MxR significantly facilitated the identification of 21 arterial feeders, including challenging deep feeders. MxR-assisted surgeries demonstrated efficient identification and disconnection of arterial feeders, contributing to precise AVM resection. The mean surgical duration was approximately 5 hours 11 minutes, with a mean intraoperative blood loss of 507.5 ml. Statistically significant variations in surgical duration and blood loss were observed based on SM and supplemented Supp-SM grades. Two patients experienced worsened postoperative neurological deficits, underscoring the inherent risks of AVM surgeries. The marked difference in hospital stays between patients with ruptured and those with unruptured AVMs, particularly for SM grade III, highlights the significant impact of rupture status on postoperative recovery.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n In this study, the authors delineated a novel paradigm using MxR for the surgical intervention of AVMs. Using 3D VR for preoperative planning and AR for intraoperative guidance, they achieved unparalleled precision and efficiency in targeting deep arterial feeders. While the results are promising, larger studies are needed to further validate this approach.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2023.10.focus23637","type":"journal-article","created":{"date-parts":[[2023,12,31]],"date-time":"2023-12-31T23:49:59Z","timestamp":1704066599000},"page":"E5","source":"Crossref","is-referenced-by-count":14,"title":["Mixed reality in neurosurgery: redefining the paradigm for arteriovenous malformation planning and navigation to improve patient outcomes"],"prefix":"10.3171","volume":"56","author":[{"given":"Edinson","family":"Najera","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Lehigh Valley Health Network, Allentown, Pennsylvania; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gavin","family":"Lockard","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lehigh Valley Health Network, Allentown, Pennsylvania; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miguel","family":"Saez-Alegre","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lehigh Valley Health Network, Allentown, Pennsylvania; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Keaton","family":"Piper","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of South Florida, Tampa, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Walter C.","family":"Jean","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lehigh Valley Health Network, Allentown, Pennsylvania; and"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"1","key":"b1","series-title":"J Neurosurg Pediatr","first-page":"71","article-title":"Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children\u2019s Hospital experience","volume":"15","author":"Gross BA","year":"2015","unstructured":"Gross BA, Storey A, Orbach DB, Scott RM, Smith ER. Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children\u2019s Hospital experience. J Neurosurg Pediatr. 2015;15(1):71\u201377."},{"issue":"4","key":"b2","series-title":"J Neurosurg","first-page":"476","article-title":"A proposed grading system for arteriovenous malformations","volume":"65","author":"Spetzler RF","year":"1986","unstructured":"Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986;65(4):476\u2013483."},{"issue":"4","key":"b3","series-title":"Neurosurgery","first-page":"702","article-title":"A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery","volume":"66","author":"Lawton MT","year":"2010","unstructured":"Lawton MT, Kim H, McCulloch CE, Mikhak B, Young WL. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery. 2010;66(4):702\u2013713."},{"issue":"5","key":"b4","series-title":"J Neurosurg","first-page":"1409","article-title":"The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms","volume":"130","author":"Lawton MT","year":"2019","unstructured":"Lawton MT, Lang MJ. The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms. J Neurosurg. 2019;130(5):1409\u20131425."},{"issue":"20","key":"b5","series-title":"Neurology","first-page":"917","article-title":"Brain arteriovenous malformations: a review of natural history, pathobiology, and interventions","volume":"95","author":"Chen CJ","year":"2020","unstructured":"Chen CJ, Ding D, Derdeyn CP, Brain arteriovenous malformations: a review of natural history, pathobiology, and interventions. Neurology. 2020;95(20):917\u2013927."},{"issue":"1","key":"b6","series-title":"Neurosurg Focus","first-page":"E17","article-title":"Evaluation of the precision of operative augmented reality compared to standard neuronavigation using a 3D-printed skull","volume":"50","author":"Haemmerli J","year":"2021","unstructured":"Haemmerli J, Davidovic A, Meling TR, Chavaz L, Schaller K, Bijlenga P. Evaluation of the precision of operative augmented reality compared to standard neuronavigation using a 3D-printed skull. Neurosurg Focus. 2021;50(1):E17."},{"issue":"4","key":"b7","series-title":"Neurosurg Open","first-page":"e00017","article-title":"Utilization of navigation-integrated, mixed reality templates for minimizing invasiveness of neurosurgical procedures: a case series","volume":"3","author":"Jean WC","year":"2022","unstructured":"Jean WC, Sack KD. Utilization of navigation-integrated, mixed reality templates for minimizing invasiveness of neurosurgical procedures: a case series. Neurosurg Open. 2022;3(4):e00017."},{"issue":"9","key":"b8","series-title":"Acta Neurochir (Wien)","first-page":"1769","article-title":"Augmented reality in the surgery of cerebral arteriovenous malformations: technique assessment and considerations","volume":"156","author":"Cabrilo I","year":"2014","unstructured":"Cabrilo I, Bijlenga P, Schaller K. Augmented reality in the surgery of cerebral arteriovenous malformations: technique assessment and considerations. Acta Neurochir (Wien). 2014;156(9):1769\u20131774."},{"issue":"25","key":"b9","series-title":"J Neurosurg Case Lessons","first-page":"CASE21135","article-title":"Augmented reality\u2013assisted microsurgical resection of brain arteriovenous malformations: illustrative case","volume":"3","author":"Scherschinski L","year":"2022","unstructured":"Scherschinski L, McNeill IT, Schlachter L, Augmented reality\u2013assisted microsurgical resection of brain arteriovenous malformations: illustrative case. J Neurosurg Case Lessons. 2022;3(25):CASE21135."},{"issue":"4","key":"b10","series-title":"Oper Neurosurg (Hagerstown)","first-page":"188","article-title":"Early experience with virtual and synchronized augmented reality platform for preoperative planning and intraoperative navigation: a case series","volume":"21","author":"Louis RG","year":"2021","unstructured":"Louis RG, Steinberg GK, Duma C, Early experience with virtual and synchronized augmented reality platform for preoperative planning and intraoperative navigation: a case series. Oper Neurosurg (Hagerstown). 2021;21(4):188\u2013196."},{"issue":"0 2)(suppl 2","key":"b11","series-title":"Neurosurgery","first-page":"52","article-title":"Virtual reality cerebral aneurysm clipping simulation with real-time haptic feedback","volume":"11","author":"Alaraj A","year":"2015","unstructured":"Alaraj A, Luciano CJ, Bailey DP, Virtual reality cerebral aneurysm clipping simulation with real-time haptic feedback. 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Acta Neurochir (Wien). 2017;159(8):1457\u20131478."},{"issue":"1","key":"b18","series-title":"J Neurosurg","first-page":"79","article-title":"A proposed radiosurgery-based grading system for arteriovenous malformations","volume":"96","author":"Pollock BE","year":"2002","unstructured":"Pollock BE, Flickinger JC. A proposed radiosurgery-based grading system for arteriovenous malformations. J Neurosurg. 2002;96(1):79\u201385."},{"issue":"1","key":"b1","series-title":"J Neurosurg Pediatr","first-page":"71","article-title":"Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children\u2019s Hospital experience","volume":"15","author":"Gross BA","year":"2015","unstructured":"Gross BA, Storey A, Orbach DB, Scott RM, Smith ER. Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children\u2019s Hospital experience. 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Neurosurg Open. 2022;3(4):e00017."},{"issue":"9","key":"b8","series-title":"Acta Neurochir (Wien)","first-page":"1769","article-title":"Augmented reality in the surgery of cerebral arteriovenous malformations: technique assessment and considerations","volume":"156","author":"Cabrilo I","year":"2014","unstructured":"Cabrilo I, Bijlenga P, Schaller K. Augmented reality in the surgery of cerebral arteriovenous malformations: technique assessment and considerations. Acta Neurochir (Wien). 2014;156(9):1769\u20131774."},{"issue":"25","key":"b9","series-title":"J Neurosurg Case Lessons","first-page":"CASE21135","article-title":"Augmented reality\u2013assisted microsurgical resection of brain arteriovenous malformations: illustrative case","volume":"3","author":"Scherschinski L","year":"2022","unstructured":"Scherschinski L, McNeill IT, Schlachter L, Augmented reality\u2013assisted microsurgical resection of brain arteriovenous malformations: illustrative case. 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Neurosurgery. 2015;11(0 2)(suppl 2):52\u201358."},{"key":"b12","series-title":"Clin Neurol Neurosurg","first-page":"6","article-title":"Intraoperative clinical application of augmented reality in neurosurgery: a systematic review","volume":"177","author":"Contreras L\u00f3pez WO","year":"2019","unstructured":"Contreras L\u00f3pez WO, Navarro PA, Crispin S. Intraoperative clinical application of augmented reality in neurosurgery: a systematic review. Clin Neurol Neurosurg. 2019;177:6\u201311."},{"issue":"1","key":"b13","series-title":"Oper Neurosurg (Hagerstown)","first-page":"e38","article-title":"Resection of arteriovenous malformation with sonolucent cranioplasty: 2-dimensional operative video with 360\u00b0 virtual reality fly-through","volume":"25","author":"Rossitto CP","year":"2023","unstructured":"Rossitto CP, Yudkoff C, Youssef D, Resection of arteriovenous malformation with sonolucent cranioplasty: 2-dimensional operative video with 360\u00b0 virtual reality fly-through. 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