Paolo Ferroli, MD* Department of Neurosurgery, Fondazione Istituto Neurologico “Carlo Besta,” Milan, Italy Giovanni Tringali, MD* Department of Neurosurgery, Fondazione Istituto Neurologico “Carlo Besta,” Milan, Italy Francesco Acerbi, MD Department of Neurosurgery, Fondazione Istituto Neurologico “Carlo Besta,” Milan, Italy Domenico Aquino, MD Department of Neurosurgery, Fondazione Istituto Neurologico “Carlo Besta,” Milan, Italy Angelo Franzini, MD Department of Neurosurgery, Fondazione Istituto Neurologico “Carlo Besta,” Milan, Italy Giovanni Broggi, MD Department of Neurosurgery, Fondazione Istituto Neurologico “Carlo Besta,” Milan, Italy Reprint requests: Paolo Ferroli, MD, Department of Neurosurgery, Fondazione Istituto Neurologico “Carlo Besta,” Via Celoria 11, Milan 20133, Italy. E-mail: pferroli@istituto-besta.it Received, April 30, 2009. Accepted, February 22, 2010. *These authors contributed to this work equally. Copyright © 2010 by the Congress of Neurological Surgeons A comprehensive understanding of the spa- tial relationships between intracranial ana- tomy and pathological features is a crucial element in neurosurgical planning. The thera- peutic execution of any neurosurgical interven- tion requires a careful study of data that have been generated from numerous preoperative sources such as magnetic resonance imaging (MRI), functional MRI, diffusion tensor imag- ing, magnetic resonance angiography, computed tomography (CT), CT angiography, and digital subtraction angiography, which can then be inte- grated by the surgeon into a highly complex 3- dimensional (3D) anatomic rendering. The complexity of this analytical process is one of the reasons why the clinical learning curve in neu- rosurgery is so long and steep. Despite all of the analytical advances, the experienced neurosur- geon never forgets that the risk of suboptimal exposure of any brain lesion is always present. New technologies, however, particularly in the areas of virtual reality and robotics, can be expected to have a major impact on our discipline and on health care in general in the next decade. 1-3 Currently, virtual reality simulation is already being used in a number of medical disciplines for training purposes in both military and civil- ian clinical arenas. Recently, there have been a number of reports in which simulators have been developed for laparoscopic surgery, endoscopy, and interventional radiology. 3-7 In neurosurgery, an augmented reality workstation (Dextroscope; Volume Interactions Pte Ltd, Singapore) has already been introduced. At present, this partic- ular workstation system is able to process patient- specific coregistered, fused radiological data sets NEUROSURGERY VOLUME 67 | OPERATIVE NEUROSURGERY 1 | SEPTEMBER 2010 | ons79 Brain Surgery in a Stereoscopic Virtual Reality Environment: A Single Institution’s Experience With 100 Cases BACKGROUND: A comprehensive understanding of the spatial relationships between intracra- nial anatomy and pathological features is a crucial element in neurosurgical planning. OBJECT: To assess our clinical experiences using a novel approach, stereoscopic virtual reality environment, to help neurosurgeons with both surgical training and surgical strategic planning purposes. METHODS: Patient-specific digital imaging data obtained from a variety of different diag- nostic sources (computed tomography, computed tomographic angiography, magnetic resonance, functional magnetic resonance, magnetic resonance–diffusion tensor imag- ing) were collected and then transferred to a workstation setting. These clinical data were obtained from 100 patients who were suffering from either brain vascular malformations or tumors that were located in difficult brain sites. A 3-dimensional volume rendering was produced for each of the 100 clinical cases, which were then subjected to data coregistra- tion and fusion. RESULTS: By using different head positioning systems and craniotomy options, we simu- lated microscopic visualizations of the lesion through numerous surgical approaches and from various angles of view. This simulation strategy enabled us to carry out an approach selection and eventually to identify the optimum angle of lesion visualization. CONCLUSION: These virtual craniotomies successfully simulated a sampling of different operative environments that have the potential to play a significant role in neurosurgical training and operative planning worthy of further exploration and development. KEY WORDS: Neuronavigation, Surgical simulation, Surgical training, Virtual reality Neurosurgery 67[ONS Suppl 1]:ons79-ons84, 2010 DOI: 10.1227/01.NEU.0000383133.01993.96 EDUCATION New Technology