Augmented Reality Navigation for External Ventricular Drain Insertion – A Systematic Review and Meta-analysis

Introduction: The freehand technique is currently the standard method for external ventricular drain (EVD) insertion. However, it is associated with misplacements leading to unfavorable outcomes. Neuro-navigation has been shown to improve accuracy and minimize misplacement. Augmented Reality (AR) is increasingly used as a complement to conventional navigation. The accuracy of AR guided EVD insertion has been investigated in several studies, on anthropomorphic phantoms, cadavers and patients. This review aimed to assess the current knowledge and discuss potential benefits and challenges associated with AR guidance in EVD insertion.

Methods: MEDLINE, Embase, and Web of Science were searched from inception to August 2023 for studies evaluating the accuracy of AR guidance for EVD insertion. Studies were screened for eligibility and accuracy data was extracted. The risk of bias was assessed using the Cochrane Risk of Bias Tool and the quality of evidence was assessed using the Newcastle-Ottawa-Scale. Accuracy was reported either as the average deviation from target or according to the Kakarla grading system.

Results: Of the 497 studies retrieved, 14 were included for analysis. All included studies were prospectively designed. Insertions were performed by neurosurgeons on anthropomorphic phantoms, cadavers, or patients, using several different AR devices and interfaces. Deviation from target ranged between 0.7 mm to 11.9 mm. Accuracy according to the Kakarla grading scale ranged between 82 and 96%. Surgical expertise was the most significant factor dictating accuracy. Accuracy was higher for AR compared to the freehand technique in all studies that had control groups.

Conclusion : Current evidence demonstrates that AR is more accurate than free-hand technique for EVD insertion. However, studies are few, the technology developing and there is a need for further studies on patients in relevant clinical settings.