Original Article

International Journal of Computer Assisted Radiology and Surgery

, Volume 6, Issue 5, pp 565-572

First online:

Neurosurgical craniotomy localization using a virtual reality planning system versus intraoperative image–guided navigation

  • Axel T. StadieAffiliated withNeurochirurgische Klinik und Poliklinik, Universitätsmedizin Mainz Email author 
  • , Ralf A. KockroAffiliated withNeurochirurgische Klinik, Universitätsspital Zürich
  • , Luis SerraAffiliated withNational Neuroscience Institute
  • , Gerrit FischerAffiliated withNeurochirurgische Klinik und Poliklinik, Universitätsmedizin Mainz
  • , Eike SchwandtAffiliated withNeurochirurgische Klinik und Poliklinik, Universitätsmedizin Mainz
  • , Peter GrunertAffiliated withNeurochirurgische Klinik und Poliklinik, Universitätsmedizin Mainz
  • , Robert ReischAffiliated withZentrum für endoskopische und minimalinvasive Neurochirurgie

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Accurate craniotomy placement is essential for frameless neuronavigation in minimally invasive neurosurgery. A craniotomy using virtual reality (VR) can be as accurate as neuronavigation.


We prospectively enrolled 48 patients that underwent minimally invasive cranial procedures planned using VR, followed by neuronavigation. First, craniotomies were planned using VR derived measurements. Second, frameless neuronavigation was applied to define the craniotomy. The locations of these paired craniotomies were compared. A correctly placed craniotomy was defined as one that enabled the surgeon to totally remove the pathology without need to enlarge the craniotomy intraoperatively.


Using VR, the size and the position of the craniotomy were measured correctly in 47 of 48 cases (98%). In 44 of 48 cases (92%), neuronavigation identified the craniotomy site correctly. In cases where neuronavigation failed, minimally invasive surgery was successfully completed using preoperative VR surgery planning. No statistically significant difference was found between craniotomy localization using VR surgery planning or standard frameless neuronavigation (p = 0.36).


The craniotomy for minimally invasive neurosurgical procedures can be identified accurately using VR surgery planning or neuronavigation. In cases of neuronavigation failure, VR surgery planning serves as an effective backup system to perform a minimally invasive operation.


Craniotomy Surgical procedures Minimally invasive Neuronavigation Neurosurgical procedures Virtual reality Approach planning