Augmented reality (AR) in microsurgical multimodal image guided focal pediatric epilepsy surgery. A technical note

Background: Augmented reality (AR) is increasingly being used to improve surgical planning and assist in real time surgical procedures. A retrospective investigation was conducted to study its role in pediatric epilepsy surgery at a single institution. Methods: Functional neuronavigation using multimodal imaging data (fMRI, DTI-tractography, PET, SPECT, sEEG) were used to augment the surgical navigation by transferring 3D imaging reconstructions as AR maps into the surgical microscope overlaying the surgical field. Results: Altogether, 43 patients (17 female, 0-18 yrs, mean 9 yrs) were operated between 10/2020 and 10/2023 and fulfilled the inclusion criteria. 26 patients (60.5%) had an extra-temporal and 17 (39.5%) a temporal seizure origin. The 3 top histological diagnoses were : FCD (32.6%), ganglioglioma (23.3%) and DNT (11.6%). Preoperative MRI studies showed no epileptogenic lesion in 11 patients (25.6%, MRI negativ group), which necessitated implantation of depth electrodes before resection. Altogether, of 25 patients with a follow up of more than one year, 83% displayed a favorable ILAE grade 1 seizure outcome (75% ILAE 1a). Altogether, 14% experienced a transient hemiparesis, 7% a quadrantanopia and one needed a subdural- peritoneal shunt. Conclusion: AR supported microscope resection facilitated targeting and removal of lesional as well as non-lesional (sEEG defined) epileptogenic lesions in pediatric epilepsy surgery with low morbidity and a remarkably favourable seizure outcome.