Journal of Clinical Neuroscience 62 (2019) 14–20

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Journal of Clinical Neuroscience

journal homepage: www.elsevier.com/locate/jocn

Review article

Virtual reality and augmented reality in the management of intracranial

tumors: A review
Chester Lee, George Kwok Chu Wong ⇑
Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong Special Administrative Region

a r t i c l e i n f o a b s t r a c t

Article history: Neurosurgeons are faced with the challenge of planning, performing, and learning complex surgical pro-
Received 28 November 2018 cedures. With improvements in computational power and advances in visual and haptic display tech-
Accepted 22 December 2018 nologies, augmented and virtual surgical environments can offer potential benefits for tests in a safe
and simulated setting, as well as improve management of real-life procedures. This systematic literature
review is conducted in order to investigate the roles of such advanced computing technology in neuro-
Keywords: surgery subspecialization of intracranial tumor removal. The study would focus on an in-depth discussion
Virtual reality
on the role of virtual reality and augmented reality in the management of intracranial tumors: the current
Mixed reality
Augmented reality
status, foreseeable challenges, and future developments.
Brain tumor Ó 2018 Elsevier Ltd. All rights reserved.
Intracranial tumor
Neurosurgery

1. Introduction filled with neuroanatomical models as well as with critical clin-

Visualizing the anatomical structures beneath the human skin
has always been a problematic issue for surgeons, especially if try-
ing to avoid the skin incision. When it comes to brain tumors, the
skull is particularly difficult to penetrate, which makes their visu-
alization and the following excision a great challenge. The first
solution came with the discovery of X-rays, and have since contin-
ually improved. Thanks to the technological progress in neuro-
surgery and beyond, augmented and virtual reality appeared: the
first augmented monoscopic operating microscope in 1985 [1],
the first augmented external display for cranial surgery in 1994
[2,3], the first augmented stereo-operating microscope in 1995
[4], the first augmented fluoroscopy display for neurosurgical
endovascular surgery in 1998 [5], and the first augmented neuro-
surgical endoscope for endonasal transsphenoidal surgery in
2002 [6,7].
It is important distinguish between augmented reality (AR)
and virtual reality (VR). The idea behind AR is overlaying real-
life structures with artificial elements. The double-layered image
can be displayed on many surfaces: monitors, optics like micro-
scopes or head-mounted oculars or semi-transparent surface, as
well as directly on the patient. The augmented view can be
⇑ Corresponding author at: 4/F Lui Che Wo Clinical Sciences Building, Department
of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, Hong Kong
Special Administrative Region.
E-mail address: georgewong@surgery.cuhk.edu.hk (G.K.C. Wong).
ical data [7,8]. On the other hand, VR is a full immersion of the
person into a crafted, virtual world. The VR set is usually com-
posed of a virtual patient on a physical model, a model of the
pathology, surgical instruments and connector of all VR reality
interface [7,8]. Both AR/VR visualization have their advantages
and disadvantages, and have a role in different stages of sur-
gery. The operator should be able to switch with ease between
them [9]. This man-machine symbiotic relationship can intro-
duce a new scope of possibilities for neurosurgery of intracra-
nial tumors.
2. Methods
2 reviewers (CL, GW) performed a systematic literature review
of 3 databases (PubMed/MEDLINE, Google Scholar and Cochrane)
was performed on August 20, 2018 with the use of search term:
(‘‘virtual reality” OR ‘‘augmented reality”) AND (‘‘intracranial
tumor” OR ‘‘brain tumor” OR ‘‘glioma” OR ‘‘meningioma”)”. After
the search 2315 articles were screened by title and abstract. The
remaining 76 articles underwent a detailed review of relevance
for full-text (Fig. 1).
During the research we identified 15 articles on VR/AR in neu-
rosurgery [10–21]. There has been no study focused on both
modalities in the usage for intracranial tumor surgery planning,
performance and post-surgical assessment. 15 trials and device
protocols were included into the final analysis (Table 1) Our review
follows the guidelines set by the PRISMA statement [22].

https://doi.org/10.1016/j.jocn.2018.12.036
0967-5868/Ó 2018 Elsevier Ltd. All rights reserved.
 C. Lee, G.K.C. Wong / Journal of Clinical Neuroscience 62 (2019) 14–20
Fig. 1. Flow diagram of methodology [22].
3. Discussion/results
3.1. Surgical planning
The role of imaging grows tremendously with the development
of new imaging modalities and improvements in scan quality and
resolution [8]. Currently, surgeons work in cooperation with radi-
ologists and are building tumor models in their minds pre-
surgically. AR/VR gives a unique opportunity to transform 2-D pic-
tures into 3-D models. It provides not only the tumor structure, but
also shows its detailed relationship to anatomical structures. It is
most advantageous when the margin of the tumor is blurred and
the exact plan of removal extent is in preparation [23]. Currently,
multiple softwares for neurosurgical planning have emerged [8].
One of them is NeuroPlanner – system based on 2D and 3D atlases
of human brain. Presurgically the surgeon may plan and simulate
the procedure, naming stereotactic trajectory planning and target-
ing, mensuration, segmentation and labeling of anatomy or inser-
tion of the electrode [24]. NeuroBase is an extension of
NeuroPlanner, which enables on loading multiple dataset, both
anatomical and functional. Its usefulness is way beyond intracra-
nial tumor removal [25].
Moreover, the mixed-reality gives an opportunity to elaborate
on a mathematical model, which quantifies the extent of tumorous
invasion of individual gliomas in three-dimensions to a degree
beyond the limits of present medical imaging. The idea of mathe-
matical modeling off tumor growth was based on a simple obser-
vation of metastatic growth on chest X-rays, which has a
constant rate of doubling [26]. Murray elaborated it to conserva-
tion equation: the rate of change of tumor cell population = the
15
diffusion (motility) of tumor cells + the net proliferation of tumor
cells [27]. Model proposed by Swanson introduced the complex
anatomy of the brain and allowed diffusion to be a part of equation
[28]. As tumor cells invade peripheral to the CT- or MRI-defined
boundaries of the tumor, mathematical modeling of preserved
cancerous cells is useful for planning postsurgical therapy regimes
[29,30].
3.2. Surgical navigation
Localization of intracranial tumors has always been a great
challenge for neurosurgeons. Gleason with Colleagues described
the first enhanced reality usage for neurosurgical guidance in
1994. Their technique is based on the merge of 3D pre-operative
scans with live per-operative video images. The biggest step for-
ward was the ability to see the whole tumor and its surroundings,
not only a particular point in empty space [2]. In fact, the first
microscope with AR for cranial surgery was reported by Dartmouth
in 1985, but it was unable to track tools in real time during oper-
ation. This is a persistent problem for neuronavigation stereotactic
system widely used today [1].
Neurosurgeons are heavily dependent on images during the
operations. Usually, the pre-operative scans are displayed in 3
separate planes (coronal, axial, saggital). During the operation,
the surgeon not only has to constantly switch their mental repre-
sentations between the operation field and radiological images
[19]. The first conceptual description of AR idea of 3-dimensional
stereoscopic overlay of the operating field in an operating micro-
scope appeared in 2003 by Aschke et al. [31]. They built the proto-
type with the source images from pre- and intra-operative MRI or
16
Table 1
Summary of literature. KPF – Karnofsky Performance Score.
Clinical application/surgical domain
Presurgical plan for skull base tumor
VR in the planning of tumor
resection in the sellar region
VR in presurgical planning for
cerebral gliomas and
tractography
VR simulator as an assessment of
performance in brain tumor
resection
VR simulator as an assessment of
bimanual performance in brain
tumor resection
VR simulator as assessment of force
application
AR/VR for functional
neuronavigation
Presurgical planning of feeder
resection
AR system to assist novice surgeons
VR system for training simulation
for a robotic surgery system
VR systems as a base for
mathematical modeling of
glioma tumor growth
AR system with back-facing camera
AR system for neuronavigation
AR system for neuronavigation for
pituitary tumors
AR system for image-guided
neurosurgery
C. Lee, G.K.C. Wong / Journal of Clinical Neuroscience 62 (2019) 14–20
Device PICO (populations, intervention, comparison, outcome) – if applicable
Dextroscope [70] P 48 patients with skull base tumor divided into 2 groups,
I surgery with/without plan provided by Dextroscope
C Tumor’s resection rate, the preoperative evaluation: duration of operation,
total blood loss, the postoperative LOS, cerebrovascular injury,
complications, and postoperative KPS of patients on discharge/6mo follow-
up
O The duration of operation and the postoperative LOS of each patient were
5.25 ± 0.64 h and 8.50 ± 1.10 days in the test group and 7.36 ± 0.87 h and
12.50 ± 1.52 days in the control group (P < 0.05) KPS of patients in the test
group improved from discharge to the 6 month after (P < 0.05), there were
adverse results in the test group (P < 0.05)
Dextroscope [71] P – 60 patients with sellar region tumors
I – VR models of the tumor and simulation of different approaches to its
removal (transmononasal sphenoid sinus, pterional, and other)
C – survey questionnaire filled by 11 neurosurgeons
O – models were helpful for the individualized planning of surgery in the
sellar region
Dextroscope [72] P 45 patients with suspected glioma
I – MRI (tractography, DTI, 3d) simulation
C – amplitude of the number of effective fibers at affected sides, KPS at
6 months
O – optimization of surgical trajectory, maximization of safe tumor removal
NeuroTouch [39] P 71 participants (10 medical students, 18 junior residents, and 44 senior
residents)
I – Participants completed the internal resection of a simulated convexity
meningioma
C – the volume of tissues removed, tool path lengths, duration of excessive
forces applied and efficient use of the aspirator
O – a significant increase in a tumor removed and efficiency of ultrasonic
aspirator use between medical students and residents
NeuroTouch [73] P – 18 (6 neurosurgeons, 6 senior residents, 6 junior residents)
I – Bimanual resection of 8 simulated brain tumors with differing color,
stiffness, and border complexity
C – blood loss, tumor percentage resected, total simulated normal brain
volume removed, total tip path lengths, maximum and sum of forces used
by instruments, efficiency index, ultrasonic aspirator path length index,
coordination index, ultrasonic aspirator bimanual forces ratio
O – metrics differentiate novice from expert neurosurgical performance
NeuroVR [54] P – 16 neurosurgeons, 15 residents, 84 medical students
I – 18 cases on simulator
C – ultrasonic aspirator force application was continually assessed during
resection of simulated brain tumors
O – Handedness, ergonomics, and visual and haptic tumor characteristics
resulted in distinct well-defined 3D force pyramid patterns
Functional Neuronavigation [74] P 79 glioma patients and 55 control subjects.
I – Neuronavigation based on presurgical tractography or anatomical
landmarks
C – resection rate, the average extent of resection, the rate of preservation of
neural functions
O – the complete resection subjects, with average resection rates of
95.2% ± 8.5% and average extent of resection differed between the 2 groups
(P < 0.01)
Virtual operation field (VOF) by high-spatial- P – 8 cases with cerebellopontine angle meningioma
resolution three-dimensional computer graphics I – (1) operation (2) presurgical simulation with VOF
(hs-3DCG) [75] C – the point at which main feeding artery penetrated meningioma
O – By using VOF, the point at which the main feeder penetrated the tumor
was estimated
AR goggles [76] Compared to conventional planning environments, the proposed system
greatly improves the non-clinicians’ performance, independent of the
sensorimotor tasks performed (p < 0.01). The time to perform clinically
relevant tasks is always reduced (p < 0.05).
Robotic Operative Microscope [67] Case study as an assessment of assessed robotic, exoscopic, endoscopic,
fluorescence functionality.
Mathematical model [30] The velocity of expansion is linear with time and varies about 10-fold, from
about 4 mm/year for low-grade gliomas to about 3 mm/month for high-
grade ones.
Tablet-AR [77] The alignment errors in the skull specimen study were 4.6 pixels (1.6 mm)
and clinical experiment 6 pixels (2.1 mm).
AR system based on open-source software 3D The images were overlaid in all 3 cases with the AR error was 2–3 mm for
Slicer, Polaris and web cameras [78] meningioma cases
Endoscopic AR navigation system [6] AR system superimposes 3-d virtual representations of the patient’s tumor
and local anatomy, indicate position and direction of the endoscopic beam,
color changes of wire-frame images with the moving distance between
endoscope tip and tumor. A useful addition to the transsphenoidal surgery.
AR system [79] Technical note and visualization on the model skull with mean projection
error: 0.3 mm
 C. Lee, G.K.C. Wong / Journal of Clinical Neuroscience 62 (2019) 14–20
ultrasound inserted into the microscopic beam during the opera-
tion, which enables the surgeon to focus the sight solely on the
operating field [31].
Head-mounted devices such as smart glasses have been well
studied and their usage was proven in the field of neurosurgery:
for craniotomy, lumbar biopsy, ventriculoperitoneal shunt and
endoscopy – especially useful for visualization of ultrasound image
during nerve blockage, where the surgeon is no longer forced to
move his sight away from the patient. As of today, there is no
assessment of head-mounted devices for the removal of intracra-
nial tumors [14].
The accuracy of presurgical mapping degrades over the course
of the operation. The IBIS platform (Intra-operative Brain Imaging
System) is created in 2012 an open-source image-guided neuro-
surgery research platform which attempts to fill this gap by valida-
tion of intraoperative ultrasound facilitated through AR. Image-to-
patient registration accuracy is on the order of 3.72 ± 1.27 mm and
can be improved with ultrasound to a median target registration
error of 2.54 mm [32]. An updated patient model can be obtained
within less than 20 s by capturing tracked ultrasound images,
reconstructing a 3D volume and using this volume to automatically
realign preoperative plans. Its clinical application ranges from
brain shift assessment, vascular neurosurgery, tumor surgery,
and spine surgery to DBS/epilepsy electrode implantation [32].
3.3. Surgical training
The current healthcare environment demands the best patient
outcomes with maximal cost efficiency. It heavily restricts the time
of surgical resident spent under supervision of senior colleagues
and disturbs the ideal Halsted’s approach to surgery education
[33]. Moreover, it is very dangerous for an inexperienced operator
to start immediately with a living patient, as any move could be
the last. The overriding importance of patient safety, the complex-
ity of surgical techniques, and the challenges associated with
teaching surgical trainees in the operating room are all the factors
driving the need for mixed reality as a new, exciting solution to
these problems. Simulation provides a unique opportunity for
learners to practice clinical skills in a low stakes setting before
operating room (OR) experience [33].
As it is easy to calculate the number of procedures and compli-
cations, it is much harder to validate their quality. More than 75%
of neurosurgical errors are deemed to be technical in nature and
therefore preventable [34]. Adequate assessment and room for
improvement is necessary – simulation training embrace both of
the tasks. It also enhances learning by implementing mental
rehearsal practice and staged motor learning.
In general surgery, several randomized controlled trials have
shown that virtual reality simulation not only is an efficient use
of learning time, but can decrease initial and subsequent errors
in the operating room [34]. In urology simulation is well integrated
into training curriculum. The 10 attributes of simulation are high-
lighted: (1) Feedback can be provided during the learning experi-
ence, (2) Learners can use repetitive practice, (3) Simulation can
be integrated, (4) Level of difficulty can be varied, (5) Simulation
can be adapted to different learning strategies, (6) Clinical varia-
tion can be incorporated, (7) The environment can be controlled
and changed, (8) The process can safely permit individual learning,
(9) Learning outcomes can be defined and measured, (10) and The
simulation can approximate clinical practice. In the end simulation
assess not only technical skills, but also non-technical communica-
tion skills and ability to deal with complications [35]. Lately the
concept of simulation of not only technical skills, but also team
working was introduced in Crisis Management Simulation study,
where neurosurgery residents were teamed with anesthesia resi-
dent and had to manage intraoperative crisis. No significant
17
difference between learner specialties was observed for situation
awareness, decision making, communications and teamwork, or
leadership evaluations. Learners reported the simulation realistic,
beneficial, and highly instructive [36].
Urology is also the field with one of the earliest robotic surgery
introduction more than 20 years with the daVinci system (Intuitive
Surgical, Sunnyvale, US). It enables for 3D high-definition visual-
ization, precise hand–eye coordination, physiological tremor filter-
ing, and motion-scaling. As of 2016, some 2500 da Vinci systems
have been installed and have performed almost half a million pro-
cedures (radical prostatectomy, radical cystectomy, partial
nephrectomy). The training curricula on virtual reality-robotic sys-
tems with mentorships are already well established to provide
excellence in procedures [35]. For general surgery robotics entered
only around 2010 for procedures like cholecystectomy, bariatric
surgery, hernia repair and other. Virtual reality surgical simulation
has also proved to be a validated method for robotic training. It
improves basic skillsets, demonstrates good content and con-
structs validity for laparoscopic and robotic training as well as
translates into improved skills in the operating room [37].
NeuroTouch is a VR simulator developed by researchers at McGill
University, Montreal, Canada, for neurosurgical procedures training.
It is the work summary of 50 experts out of 20 neurosurgical centers
across Canada. It is composed out of 3 main elements: high-end
computer, stereovision system (binoculars which provide 3-D view)
and bimanual haptic tool manipulators. The simulator components
are mounted on the on a special frame, which enables to adjust the
height and tilt angle to every participant. As for visualization: a
Wheatstone stereoscope was designed with the usage of binocular
pieces and two 17-inch LCS screens (1280  1024 px) and surface
mirrors instead of lenses. The size and distance of the screens shows
30 degree of visual field and are focused around 40 cm for eye strain
reduction. The haptic system is based on linkages connected by
joints and in NeuroTouch simulator is based on Phantom Desktop
and Freedom 6s system. The data gathered by haptic devices is called
degree of freedom (DOF) and tells about the tool position (up-down,
left-right, forward-backward) and orientation (azimuth, elevation,
roll). Moreover, the foot pedal, tool handle sensors, dial knobs and
push buttons can be incorporated to the haptic system by Arduino
connection. The simulation software was developed in-house and
is based on 3 asynchronous processes updating the multiple tasks
(graphics, haptics and tissue mechanics) [38].
Researchers created the first conceptual framework for stan-
dardized training with NeuroTouch: Five tasks of increasing diffi-
culty were selected as representative of basic and advanced
neurosurgical skill: 1) ventriculostomy, 2) endoscopic nasal navi-
gation, 3) tumor debulking, 4) hemostasis and 5) microdissection.
Cases are under continuous progress, but the proficiency metrics
are already obtained for the basic procedures [39–41]. It is worth
noticing that the simulator may not only judge hard technical skills
but also provide input into psychomotor ability and cognitive input
[42]. Moreover, the simulator provides the opportunity to upload a
particular case and practice it before the real surgery [43].
NeuroTouch is a part of Canadian ‘‘rookie camp” for junior res-
idents available in some residency programs across country –
though only for the limited time of 1–5 days per year. It has poten-
tial to compensate for the limited exposure to certain complex
neurosurgical cases such as aneurysm clipping. Moreover, simula-
tor could provide objective measurement of certain surgical skills
and knowledge. However, its usage nowadays is limited. Due to
nation-wide survey in Canada lack of funding is the biggest prob-
lem due to program directors whereas residents pinpoints lack of
free time as a highest obstacle [44]. The summary of case perfor-
mance may help studies on the acquisition and development as
well as maintenance of psychomotor skills of young and experi-
enced neurosurgeons [45].
18 C. Lee, G.K.C. Wong / Journal of Clinical Neuroscience 62 (2019) 14–20
The simulator enables not only to simulate the brain tumor sur-
gery via craniotomy route, but also lets to practice endoscopic
sinus approach [46]. The McGilll simulator from Canada gathered
high score in both realism (7.97 ± 0.29 out of 10) and usefulness
(8.57 ± 0.69 out of 10). [47] The study from Australia clearly indi-
cated that the opinions of participants group are different based
on specialty level: students and residents were more likely to give
a positive realism feedback for the simulator than specialist [48].
Virtual reality training has been introduced into neurosurgery
training program in USA with the help of ImmersiveTouch – the
firm with more than 20 years of experience in simulation. They
started as a flight simulator in the University of Chicago and cur-
rently they provide the wide range of cases: from the basic,
anatomical concepts to the complex procedures and management
of rare complications. It enables to upload new, patient-specific
cases [34]. Surgeons can practice difficult procedures under com-
puter control without putting a patient at risk. In addition, sur-
geons can practice on these simulators at any time, immune
from case-volume or location limitations [15,49].
Gasco et al. for the first time assessed not only educational ben-
efit of virtual reality simulation, but also its costs. They created
curriculum for neurosurgery simulation that included basic and
advanced skills. 68 core exercises were distributed in individual-
ized sets of 30 for 6 neurosurgery residents and consisted of 79
simulations with physical models, 57 cadaver dissections, and 44
haptic/ computerized sessions. Total of 180 procedures and sur-
veys of self-perceived performance were analyzed. Junior residents
(year 1–3) reported proficiency improvements in 82% of simula-
tions performed, whereas Senior residents (year 4–6) – in 42.5%.
Initial cost of simulation system implementation is $341 978.00,
with $27 876.36 for annual operational expenses [49].
In 2000 the VR system Dextroscope with VIVIAN (Virtual
intracranial Visualization and Navigation) was developed for sim-
ulation of presurgical planning and procedures. It coregisters
MRI, MRA and CT images into a fused 3D visualization as well as
is equipped with simulation tools for VR. The registration accuracy
is 1.0 ± 0.6 mm. It has proved to be useful in both research and clin-
ical settings – especially in cranial base surgery, the simulation
decreased the pre- and intraoperative guesswork and increased
the surgeon’s confidence in carrying out complex procedures
[50]. It proved to be useful in vascular neurosurgery: aneurysm
clipping and arterio-venous malformation excision. Simulation of
procedures enabled to rehearse the microsurgical procedure and
select the best approach to head positioning, size of craniotomy
and visualization from different angles [51,52].
Dextroscopic virtual reality stimulation can provide an illus-
trated preoperative planning and training for excision of cerebral
AVM. Dextroscope could help to obtain an anatomical understand-
ing of arterial feeders, nidus, and draining veins in relationship to
surrounding cerebral cortex. It allowed one to see the exposure
with the different angles of visualization, similar to what happened
under the operative microscope [51].
To prepare for complicated procedures of the ruptured intracra-
nial aneurysm clipping patient-specific imaging data from com-
puted tomographic angiography of the intracranial circulation
and cranium were transferred to the workstation (Dextroscope;
Volume Interactions Pte. Ltd., Singapore, Singapore). An aneurysm
clip database was loaded into the patient data set. 3-D volume ren-
dering was followed by data co-registration and fusion. With the
virtual head positioning and craniotomy and angle of application,
it allows for assessment of different degree of obliteration of vari-
ous approaches [52].
Many studies addressed the benefit of VR training system for
surgeons [16,53,54], but there is only one study found on its limi-
tation. According to study performed by Lee and Lee in 2017, which
involved 32 participants proved that pupils who were learning on
VR set under the guidance of mentor achieve better results than
unsupervised colleagues. After the simulation training, self-
learners showed substantially lower simulation task scores
(82.9 ± 6.0) compared with mentored group (93.2 ± 4.8). Both
groups demonstrated improved physical model tasks performance
in comparison with the actual robot. The mentored group exhib-
ited lower global mental workload/distress, higher engagement,
and a better understanding of methods that improve performance
[55].
3.4. Further directions
Current challenges in surgery of brain tumors are: selection of
surgical approach, balance between extent of resection and leaving
parts involved in functional networks [56]. The assessment of neu-
ral pathways is currently achieved by awake surgery or intraoper-
ative electrophysiological monitoring and mapping [57] and
researched with the use of pre-operative fMRI [58], diffusion ten-
sor imaging [59] – for those methods brain shift during surgery
is a problem [60]. Moreover, assessment of post-surgical brain
tumor treatment response by MRI is fraught with pitfalls such as
differentiating progression from treatment-related changes and
pseudoprogression [56].
The most formidable challenge for mixed reality in the neuro-
surgical field is a gap between the theoretical concept in a labora-
tory and the real experience. Kersten-Oertel et al. showed that only
16% of the peer-reviewed articles were evaluated in the operating
room and only 6% measured the impact on clinical outcome of the
patient [61]. The DVV (data, visualization processing view) taxon-
omy has been proposed to support structured discussion in the
future studies to fill this gap [62]. All the major components of
AR environment are highlighted and create an understandable con-
tact route between creators of mixed-reality system and end-users
[62]. Moreover, the visualization of complex brain relationship to
pathologies borders and blood supply is hard to implement, though
it is constantly improving in parallel to changes in real-life brain
imaging advancements (like diffusion tensor imaging) [15].
The data overload is another contemporary problem [63,64]. It
is hard to synthetize all information available for the particular
stage of surgery at once for a one person in the long term. Taking
into consideration an insufficient supply of adequately trained spe-
cialists as compared to the increasing demands and value of their
time, the easiness of mixed-reality devices implementation should
be in the center of attention [65].
The main limitation for a wide implementation of neurosurgical
simulators is the fact that they require physical space, teachers and
large capital – for the primary investment and on-going mainte-
nance [34].
Moreover, mixed reality training poses an opportunity to safely
test and validate the automated surgery robot, like NauroBlate or
PUMA [66], that will support surgeons in their work in the future
[67]. We can envision systems ranging from semiautomated
devices with integrated scanners and surgical arms, to a fully oper-
ational humanoid machine [68]. Additionally, the emerging serious
medical gaming can become a base for future training programs
[69].
4. Conclusions
The technological revolution is a sign of our times. Solutions
provided by the technology are embraced by medicine and gradu-
ally introduced into everyday clinical practice. This article serves as
a contemporary summary of virtual and augmented environment
in the field of brain tumor surgery.
 C. Lee, G.K.C. Wong / Journal of Clinical Neuroscience 62 (2019) 14–20 19

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