Enhancing Pediatric Epilepsy Surgery with Augmented Reality: A New Era in Neurosurgery

A study by the Medical University of Vienna demonstrated that augmented reality (AR) in pediatric epilepsy surgery enhances precision, improves seizure outcomes, and reduces complications by integrating real-time imaging into the surgical field. The results showed an 83.3% favorable seizure outcome with no major surgical complications, highlighting AR's potential in neurosurgery.

The Medical University of Vienna, in collaboration with the Clinic for Pediatrics and Adult Medicine, has conducted a pioneering study on the feasibility of augmented reality (AR) in pediatric epilepsy surgery. Covering procedures performed between October 2020 and October 2023, this retrospective analysis examined 43 pediatric patients undergoing microsurgical resection for focal epilepsy. The study aimed to determine whether AR-enhanced neuronavigation, combined with multimodal imaging, could improve surgical precision and patient outcomes. By integrating real-time imaging overlays into the surgeon’s field of view, the researchers introduced a new level of accuracy in epilepsy surgery, paving the way for future advancements in neurosurgical procedures.

A Breakthrough in Surgical Visualization

Epilepsy surgery, especially in children, poses challenges due to the difficulty in identifying the epileptogenic zone—the area of the brain responsible for seizures. Traditional neuronavigation tools provide preoperative imaging but require constant reference to external screens, forcing surgeons to divide their attention between the navigation display and the surgical field. This can be time-consuming and increases the risk of damaging vital brain regions. Augmented reality overcomes these challenges by seamlessly integrating multimodal imaging data—such as functional MRI (fMRI), positron emission tomography (PET), single-photon emission computed tomography (SPECT), and diffusion tensor imaging (DTI)—directly into the surgical microscope. This innovation allows surgeons to visualize anatomical and functional details in real time, reducing reliance on indirect guidance systems.

The study focused on children aged 0 to 18 years, with an average age of 9 years. Among them, 26 patients (60.5%) had extra-temporal seizure origins, while 17 (39.5%) had temporal lobe epilepsy. The three most common histological findings were focal cortical dysplasia (FCD) in 32.6% of cases, ganglioglioma in 23.3%, and dysembryoplastic neuroepithelial tumors (DNET) in 11.6%. A particularly challenging subset of cases involved patients whose preoperative MRI scans did not reveal clear epileptogenic lesions (MRI-negative cases), representing 25.6% of the study group. These patients required the implantation of depth electrodes for stereo-electroencephalography (sEEG) to identify the precise epileptogenic zone before surgery.

A High-Tech Approach to Epilepsy Surgery

The surgical workflow integrated multimodal imaging from the Brainlab navigation system into a Zeiss Kinevo microscope. This setup enabled the projection of MRI, PET, and other imaging modalities into the microscope’s head-up display (HUD), allowing surgeons to manipulate brain tissue with real-time augmented guidance. In cases where lesions were difficult to define, a navigated suction device equipped with tracking markers was used as an additional tool for enhanced precision. Furthermore, intraoperative MRI was performed in 88.4% of cases, ensuring immediate assessment of resection completeness and, when necessary, a second-look surgery to remove any remaining epileptogenic tissue.

The use of AR provided significant advantages in targeting lesions while avoiding damage to eloquent brain areas responsible for critical functions such as movement and speech. By overlaying imaging data directly onto the surgical field, AR-guided neuronavigation allowed for precise resection, even in cases where visual differentiation between healthy and epileptogenic tissue was difficult. The ability to integrate intraoperative imaging also helped address brain shift, a common issue during surgery that can distort preoperative imaging accuracy.

Impressive Results and Seizure Outcomes

The study reported no adverse events related to AR technology, reinforcing its safety in a neurosurgical setting. A total resection of the lesion was achieved in 83.7% of patients, demonstrating the effectiveness of this advanced surgical approach. Among the 24 patients who had follow-ups exceeding one year, 83.3% displayed favorable seizure outcomes, achieving International League Against Epilepsy (ILAE) Grade 1 status. Notably, 75% of these patients remained entirely seizure-free (ILAE 1a), a remarkable success rate comparable to, if not exceeding, conventional epilepsy surgery outcomes.

Despite the high success rate, some complications were observed. Six patients (14%) developed transient hemiparesis due to the proximity of their lesions to the motor cortex, but all cases resolved within three months. Two patients (4.3%) suffered permanent quadrantanopia due to the involvement of Meyer’s loop during resection. One two-year-old child required a subdural-peritoneal shunt due to postoperative cerebrospinal fluid accumulation. However, no major surgical complications, such as hemorrhage necessitating reoperation, were reported. These results suggest that AR-assisted surgery not only improves precision but may also help reduce surgical risks by enhancing visualization of critical structures.

A Vision for the Future of Neurosurgery

The use of AR in neurosurgery is still a developing field, adapted from advancements in surgical training and other medical disciplines. While previous studies have highlighted AR’s potential for neurosurgical education and planning, its real-time intraoperative application remains underexplored. This study represents one of the first large-scale implementations of AR in pediatric epilepsy surgery, demonstrating its feasibility and effectiveness in a clinical setting. The results align with findings in adult epilepsy surgery, where similar AR-guided techniques have improved accuracy and patient outcomes. By allowing surgeons to visualize epileptogenic zones and functional brain areas simultaneously, AR technology optimizes resections while minimizing the risk of neurological deficits.

One of the study’s limitations is its retrospective design and the absence of a control group for comparison. As AR was integrated into the surgical workflow at the Medical University of Vienna in 2020, all surgeries performed during the study period used this technology, making it difficult to compare outcomes with conventional techniques. Additionally, while AR provided enhanced visualization, its quantitative impact on surgical efficiency and long-term seizure outcomes remains difficult to measure. Future prospective studies with larger patient cohorts and direct comparisons between AR-assisted and traditional neuronavigation surgeries will be needed to validate these findings further.

Despite these limitations, the study indicates that AR-assisted neurosurgery is a promising advancement for pediatric epilepsy treatment. The ability to overlay multimodal imaging onto the surgical field enhances lesion targeting and reduces the likelihood of incomplete resections. Given the complexity of pediatric epilepsy and the need for meticulous surgical planning, AR technology could soon become a standard tool in epilepsy surgery. Moreover, its integration into neurosurgical training programs will prepare future generations of surgeons to work with advanced visualization techniques, ultimately improving patient outcomes. As augmented reality continues to evolve, its role in neurosurgery is expected to expand, paving the way for safer, more effective, and technology-driven surgical interventions.