Objective: The traditional freehand technique for external ventricular drain (EVD) placement is most frequently used, but remains the primary risk factor for inaccurate drain placement. As this procedure could benefit from image guidance, the authors set forth to demonstrate the impact of augmented-reality (AR) assistance on the accuracy and learning curve of EVD placement compared with the freehand technique.
Methods: Sixteen medical students performed a total of 128 EVD placements on a custom-made phantom head, both before and after receiving a standardized training session. They were guided by either the freehand technique or by AR, which provided an anatomical overlay and tailored guidance for EVD placement through inside-out infrared tracking. The outcome was quantified by the metric accuracy of EVD placement as well as by its clinical quality.
Results: The mean target error was significantly impacted by either AR (p = 0.003) or training (p = 0.02) in a direct comparison with the untrained freehand performance. Both untrained (11.9 ± 4.5 mm) and trained (12.2 ± 4.7 mm) AR performances were significantly better than the untrained freehand performance (19.9 ± 4.2 mm), which improved after training (13.5 ± 4.7 mm). The quality of EVD placement as assessed by the modified Kakarla scale (mKS) was significantly impacted by AR guidance (p = 0.005) but not by training (p = 0.07). Both untrained and trained AR performances (59.4% mKS grade 1 for both) were significantly better than the untrained freehand performance (25.0% mKS grade 1). Spatial aptitude testing revealed a correlation between perceptual ability and untrained AR-guided performance (r = 0.63).
Conclusions: Compared with the freehand technique, AR guidance for EVD placement yielded a higher outcome accuracy and quality for procedure novices. With AR, untrained individuals performed as well as trained individuals, which indicates that AR guidance not only improved performance but also positively impacted the learning curve. Future efforts will focus on the translation and evaluation of AR for EVD placement in the clinical setting.
Keywords: HoloLens; augmented reality; freehand; neuronavigation; ventricular drain; ventricular puncture.