title: Preoperative simulation for the planning of microsurgical clipping of intracranial aneurysms.
abstract: BACKGROUND
  The safety and success of intracranial aneurysm (IA) surgery could be improved through the dedicated application of simulation covering the procedure from the 3-dimensional (3D) description of the surgical scene to the visual representation of the clip application. We aimed in this study to validate the technical feasibility and clinical relevance of such a protocol.
  
  
  METHODS
  All patients preoperatively underwent 3D magnetic resonance imaging and 3D computed tomography angiography to build 3D reconstructions of the brain, cerebral arteries, and surrounding cranial bone. These 3D models were segmented and merged using Osirix, a DICOM image processing application. This provided the surgical scene that was subsequently imported into Blender, a modeling platform for 3D animation. Digitized clips and appliers could then be manipulated in the virtual operative environment, allowing the visual simulation of clipping. This simulation protocol was assessed in a series of 10 IAs by 2 neurosurgeons.
  
  
  RESULTS
  The protocol was feasible in all patients. The visual similarity between the surgical scene and the operative view was excellent in 100% of the cases, and the identification of the vascular structures was accurate in 90% of the cases. The neurosurgeons found the simulation helpful for planning the surgical approach (ie, the bone flap, cisternal opening, and arterial tree exposure) in 100% of the cases. The correct number of final clip(s) needed was predicted from the simulation in 90% of the cases. The preoperatively expected characteristics of the optimal clip(s) (ie, their number, shape, size, and orientation) were validated during surgery in 80% of the cases.
  
  
  CONCLUSIONS
  This study confirmed that visual simulation of IA clipping based on the processing of high-resolution 3D imaging can be effective. This is a new and important step toward the development of a more sophisticated integrated simulation platform dedicated to cerebrovascular surgery.
authors.affiliation: From the Division of Neurosurgery (P.M., P.B., J.-P.L., L.T.), Department of Neurosciences and Locomotive System, Lille University Medical Centre; Université Lille Nord de France (P.M., M.V., J.-P.L., S.M., L.T.); and Unité INSERM U703 (P.M., M.V., J.-P.L., S.M., L.T.), Université Lille Nord de France, CHRU de Lille, Lille, France.
authors.forename: Paulo
authors.initials: P
authors.lastname: Marinho
authors.forename: Maximilien
authors.initials: M
authors.lastname: Vermandel
authors.forename: Philippe
authors.initials: P
authors.lastname: Bourgeois
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Lejeune
authors.forename: Serge
authors.initials: S
authors.lastname: Mordon
authors.forename: Laurent
authors.initials: L
authors.lastname: Thines
mesh_terms: D003198:Computer Simulation; D006801:Humans; D021621:Imaging, Three-Dimensional; D007318:Inservice Training / Q000379:methods*; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000601:surgery*; D008866:Microsurgery / Q000379:methods*; D009493:Neurosurgery; D057234:Preoperative Period; D011859:Radiography