A MiXed-Reality automatic system for enhanced precision in craniotomy procedure for meningioma resection: A multicentric study

Background and Objective: Craniotomy is the standard surgical approach in neuro-oncology for accessing and removing brain tumors. Despite being the clinical gold standard, conventional image-guided systems such as neuronavigation platforms suffer from high costs, limited ergonomics, and 2D visual constraints that can hinder surgical precision and usability. This study presents and validates a standalone mixed reality system for automatic craniotomy planning and intra-operative guidance, designed to provide an ergonomic, cost-effective, and intuitive alternative to traditional neuronavigation. Methods: The system, composed of a laptop and a HoloLens 2 headset, integrates automatic craniotomy planning, hologram-to-patient registration, and real-time 3D visualization. A multicentric in vitro study was conducted with ten neurosurgeons performing craniotomies on a custom 3D-printed phantom with four tumor models, using both the mixed reality system and a commercial neuronavigation platform. Performance metrics included craniotomy extension, percentage of tumor exposure, craniotomy centering, and procedural time. Results: The mixed reality system achieved craniotomy extension, tumor exposure and craniotomy centering comparable or superior to conventional neuronavigation, with improved inter-operator consistency and no significant increase in procedural time. Hologram-to-patient registration achieved a root mean squared error of 1.31 ± 0.17 mm and a target registration error of 2.3 ± 0.6 mm. User acceptance of the proposed system was high, as confirmed by four standardized questionnaires. Conclusion: The proposed mixed reality system demonstrates the potential to serve as a viable, ergonomic, and lower-cost alternative to traditional neuronavigation platforms, supporting accurate and intuitive craniotomy planning and execution.