Intelligent Systems with Applications 18 (2023) 200205

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Intelligent Systems with Applications

journal homepage: www.journals.elsevier.com/intelligent-systems-with-applications

VP shunt entry area recommender (VPSEAR): A computer-assisted system

for VP shunt operation
Kritsanavis Chongsrid a, Leon Wirz a, Sasikan Sukhor b, Anusorn Mungmee b, Vich Yindeedej b,
Pakinee Aimmanee a, *
a
Department of Information, Computer, and Communication Technology (ICT), Sirindhorn International Institute of Technology (SIIT), Thammasat University, Meung,
Pathum Thani, Thailand
b
Department of Neurosurgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Klong Luang, Pathum Thani, Thailand

A R T I C L E I N F O A B S T R A C T

Keywords: Hydrocephalus is a condition with an abnormal cerebrospinal fluid (CSF) accumulation in the brain’s ventricles
Ventriculoperitoneal shunt (VP shunt) resulting in ventricular enlargement. One of the most common surgical treatments for hydrocephalus is the
Hydrocephalus ventriculoperitoneal (VP) Shunt operation. A freehand technique using surface anatomy ventricular catheter
Cerebral ventricle
placement has been widely used in VP Shunt operations because of its simplicity and low cost. However, this
Preoperative surgical planning
technique trades off with moderate accuracy. To improve accuracy, most existing freehand techniques involved
Computer-assisted system
Brain CT-guided software using tools or software to manually measure distances and/or drilling angles from CT or MRI slides. In this work,
we developed the first fully automated system VP shunt entry area recommender (VPSEAR) for a pre-planned
freehand placement. The program with a user- interface took the patient’s CT slides, calculated a circular
entry site on a skull, and reported a unique circular entry region. The program integrated several mathematical
knowledge and 3-D data processing techniques to ensure high accuracy and acceptable running time. We tested
the invented programs on a collection of CT slices of 15 patients with 30 head sides and evaluated the system’s
accuracy against the traditional Keen’s method using 3D Slicer software. We achieved an average accuracy of
95.33% using five internal points evaluation, with accuracy improvement over Keen’s method up to 40.33%. The
program running time was less than 15 min per head side.

1. Introduction and literature reviews
Hydrocephalus is a neurological disorder commonly found in the
elderly, pediatrics with congenital abnormalities, and adults with cere­
bral hemorrhage, meningitis, or a traumatic brain injury. Hydrocepha­
lus involves an abnormal accumulation of the cerebrospinal fluid (CSF)
in the brain’s cavities known as cerebral ventricles. This CSF accumu­
lation induces ventricle enlargement, which not only pressures on and
damages brain tissues but also causes several brain malfunctions
(Lowery & Sive, 2009).
There are several causes of the mentioned CSF accumulation, such as
abnormally high CSF production rate in the cerebral ventricles and low
CSF absorption rate back into the arachnoid granulation. In addition, the
obstacles to CSF circulation in the cerebral ventricles, such as a tumor or
an intracerebral hemorrhage, can also cause hydrocephalus. Patients
with hydrocephalus have the potential to present alteration of con­
sciousness and develop acute symptoms such as severe headaches.
Moreover, patients with chronic hydrocephalus may have gait disorders.
In some cases, the patient has urinary incontinence and urinary fre­
quency, is unable to go to the toilet in time, and also has dementia.
Hydrocephalus is a common condition in neurosurgery around the
world. According to global statistics, there are approximately 400,000
hydrocephalus cases per year (Isaacs et al., 2018). The average incidence
rate is 175 in the elderly, 88 in pediatrics, and 11 in adults, with an
average incidence rate of 85 for all types per 100,000 population. The
prevalence tends to be higher in low-to-mid-income countries (Dewan
et al., 2019).
Generally, a neurosurgeon gives treatment according to the cause of
hydrocephalus. When there is an unbalanced rate of production and
absorption of cerebrospinal fluid (CSF), one common treatment is ven­
triculoperitoneal (VP) shunting. In the VP Shunt operation, a perforator
is used to drill a small hole at the entry point on the skull, a ventricular
catheter (VC) is placed toward the lateral ventricles to drain down the
CSF to the abdominal cavity via the subcutaneous tract, as shown in

* Corresponding author.
E-mail address: pakinee@siit.tu.ac.th (P. Aimmanee).

https://doi.org/10.1016/j.iswa.2023.200205
Received 4 September 2022; Received in revised form 30 November 2022; Accepted 16 February 2023
Available online 20 February 2023
2667-3053/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
K. Chongsrid et al.
Fig. 1. Illustration of the VP Shunt surgery (Children’s Health Queens­
land, 2016).
Fig. 1.
Finding the entry point and trajectory to reach the lateral ventricles
is one of the most critical steps in VP Shunt in freehand operation. The
VC can fail to get into the ventricles, damaging the brain’s tissues and
possibly resulting in a brain hemorrhage when the entry point and tra­
jectory are operated at the wrong location and angle. Consequently,
more than one attempt to find the new entry point may be required
(Lecker & Chang, 2021).
Nowadays determining the entry point can be done in real-time or in
pre-planned. In the first approach, modern and very accurate tools are
used to see the brain’s components in real-time. Advanced tools are used
to digitally scan the head and show 3-D visualization of the brain
internally. It can be used not only to determine an appropriate entry
point, but also for the orientations of the driller, and the depth of the
shunt conveniently. Different kinds of machines have been built and
used for these purposes. Endoscopy (Kestle et al., 2003), stereotaxy
(Roberts et al., 1986), neuronavigation (Azeem & Origitano, 2007),
ultrasound (Whitehead et al., 2008), electromagnetic (Hayhurst et al.,
2010; Mahan, Spetzler and Nakaji, 2013), and robotic navigation (Jerbić
et al., 2020; Raguž et al., 2022), are examples of the tools used in this
approach. Generally, these machines help substantially improve VC
accuracy. However, the accuracy is paid with a high price. In addition, it
is not generally available in resource-limited public hospitals or in
emergencies.
Augmented reality (AR) has also been explored for real-time VP
Shunt operations in the past few years. A few studies attempt to use AR
to help in VC operations (Hooten et al., 2014; Schneider et al., 2021;
Yudkowsky et al., 2013). However, the accuracy of AR is not as good as
neuro-navigator for VP shunting because the technology is not fully
developed to be used in the medical sector.
For the pre-planned approach, the entry point and trajectory are pre-
calculated before the operation. Traditional entry points are pre-
approximated based on neuroanatomy, guided by superficial anatom­
ical landmarks. This technique is so-called freehand placement, which is
considered to be simple and widely used. Several entries have been
proposed and used for nearly a century, but one of their drawbacks was
that this technique uses the same measurement in all patients. There­
fore, their accuracies are not so high due to patients’ individual
2
Intelligent Systems with Applications 18 (2023) 200205
differences. After the CT and MRI scanners were invented in 1971 and
1977, several works tried to find appropriate entry points and corre­
sponding trajectories from the patient’s scanned slides. Most works
(Eisenring et al., 2019; Lollis et al., 2008; Thomale et al., 2012, 2017)
picked non-specific entry points and used software or an application as a
measuring device, to manually find the appropriate angles. Their at­
tempts are rather inconvenient as it still requires human efforts. In
addition, measuring angles from a curvy skull is time-consuming.
The VPSEAR software proposed in this work overcomes the expen­
sive cost of the tools or equipment used in the real-time approach and
moderate accuracy from the non-automatic existing pre-planned
methods. The program requires a computer to operate it, and CT-
scanned slides for inputs, so it is economical and easy to use. It is fully
automatic and comes with a graphic user interface, so it is convenient.
At a fixed 90-degree drilling angle to the skull surface, the program
recommends a circular area on a side skull, of which any of its internal
points can be used as entry points. The recommended circular region
allows a neurosurgeon to select the entry points flexibly. In addition, the
90-degree angle is considered the easiest degree to approximate by hand
compared to other angles.
The 90-degree drilling angle is also used with a famous traditional
Keen’s entry point (Keen, 1890). However, several works (Anantha­
nandorn, 2017; Woo et al., 2021; Yamada et al., 2022) reported that the
precision of the accepted location is only moderate (around 62%). When
slices are manually read, the accuracy of VP shunt operation also de­
pends on the experience of each neurosurgeon. The Keen’s point is
commonly measured from the top of the ear’s helix 3 cm backward and
3 cm vertically upward. As the entry point is approximated universally
regardless of the individual patient’s anatomy, consequently, surgeons
often need to consider CT data information to adjust the entry point
differently from the traditional Keen’s (Yamada et al., 2022). As the
VPSEAR program takes the CT data of a patient into the calculation to
recommend an entry area, theoretically it is more accurate than the
traditional Keen’s entry point.
Our system integrates several 3-D data processing techniques and
advanced mathematical knowledge to produce highly accurate results
for the conventional VP operation. Moreover, the proposed system al­
lows the neurosurgeon to select his preferences to view a 2-D and a 3-D
model through a user interface. The 2-D model shows the side view of
the involved components and the recommended circular region,
whereas the 3-D model shows these in the three-dimensional aspect for
detailed visualization. The system is experimentally proven to be more
accurate than the traditional Keen’s method and can produce outputs at
an acceptable speed, the program can practically be used clinically. It is
very impactful for neurosurgeons to get a fast, low-cost, and accurate
aided surgery planer for free-hand conventional VP operation. Patients
benefit directly from this system because they can save surgery costs. To
the best of our knowledge, our work is the first fully automatic
computer-aided system to recommend an entry area for the pre-planned
approach.
2. Methodology
The VPSEAR system was implemented as a stand-alone offline
application based on the MATLAB platform, version R2021b, and
MATLAB’s App Designer (MathWorks Inc., 2022). The system was
designed with efficient algorithms based on needed anatomical struc­
tures to minimize the computer memory to ensure acceptable compu­
tational time in an average computer specification. Brief information on
essential parts and their unique ranges of CT values measured in the
Hounsfield unit, which are to be mentioned in the later sections, are
provided in Section 2.1. The system is composed of front-end and
back-end parts. Their details of implementations are provided in Section
2.2 and Section 2.3, respectively.
K. Chongsrid et al. Intelligent Systems with Applications 18 (2023) 200205

Table 1
Ranges of CT number (Hounsfield unit) of essential tissues/substances.
Tissue/Substance Hounsfield Unit Tissue/Substance Hounsfield Unit

Skull > 100 Calcification > 100

Fat − 120 to − 90 Cartilage +80 to +130
Ventricle +1 to +15 Skin − 100 to 200
Falx cerebri +40 to +50 Air < − 800

2.2.1. Design
Fig. 2. Head anatomy of the essential components. Temporalis muscle and
Components such as figures, buttons, and text fields could be drag­
Eyeball of the images taken from © Kenhub (Kenhub 2012, 2022) (Muscles of
ged and dropped independently. This functionality of App Designer
mastication, 2022) and Neurovasculature of the orbit, 2022.
allowed us to directly design the front-end’s arrangement of UI com­
ponents without using any third-party software. The design was shown
2.1. Involving components and CT values
in Fig. 3. The interface comprised the main display area on the left and
the options panel on the right. The main display illustrated the output
In this section, we provide brief information about the brain’s parts
figures selected by the user via the options panel. There were seven sub-
that will be mentioned in the later sections. Fig. 2 depicts the brain parts
panels in the options panel arranged from top to bottom. The layout and
involved in this work.
functionality of the options panel were illustrated in Fig. 3(B).
The skull is a skeletal framework of the head. It is the outer entry
The first sub-panel was for browsing the input CT images. The second
component of VP Shunting. Thus, the surface of the skull is an essential
one was for selecting kinds of displaying outputs. The choices were the
component that needs to be obtained in VPSEAR. The outer ear com­
2-D model, the 3-D model, and the depth map. The third sub-panel was
prises the ear canal and the pinna. The pinna’s outer rim is called a helix.
for the user’s choice of the side (either left or right) of the head. The
The helix is essential in this work as it has points used as references for
fourth sub-panel was for the ear’s reference-point selection. The fifth
the traditional Keen’s method and for our circular recommended area.
sub-panel was for selecting how the lateral ventricles should be dis­
The helix can be divided into three parts: the ascending helix (light
played: whole, only atrium, or only ventricle on the selected side. The
blue), the posterior helix (brown), and the superior helix (purple), as
sixth sub-panelwas for other additional settings.
illustrated in Fig. 2. The root of the helix is the middle of the ear as a
The last sub-panel held three buttons for communicating with the
raised ridge. The following points are used as references in our work: the
back end. First was the Display button. When it is clicked, the program
backmost point of the posterior helix, the top of the superior helix, and
showed images according to user-selected choices. The Save 2-D Model
the frontmost of the ascending helix, which is the helix’s root. The user
can select an option of a reference point the person prefers to use in the
UI.
The ventricular system is a series of four interconnected cavities
within the brain. It composes of a pair of lateral ventricles, the third
ventricle, and the fourth ventricle, as shown in Fig. 2. The left and right
lateral ventricles are the largest cavities among them. The atrium, also
known as the trigone of the lateral ventricle, is a junction with the
temporal and occipital horns. It is mostly used for the internal entry site
of VP Shunting with Keen’s point. The lateral ventricle is connected to
the third ventricle by a channel called the foramen of Monro (inter­
ventricular foramina). Similarly, the third ventricle and the fourth
ventricle are connected by the cerebral aqueduct. These cavities and
channels are filled with the CSF, produced by choroid plexuses. Physi­
ologically, there may be some calcification at the choroid plexus within
the lateral ventricle.
The falx cerebri is a large, crescent-shaped fold of dura mater (brain
meninges) that descends vertically into the longitudinal fissure between
the cerebral hemispheres of the human brain. The falx cerebri can be
used to identify the mid-sagittal plane that separates the two hemi­
spheres (Qian et al., 2017). Fig. 2 shows the falx cerebri in light yellow
color. The porion and orbitale are used as landmarks to identify the
Frankfurt plane (Cheng et al., 2012). The porions are located at the roof
of each external bony ear hole. The orbitales are the inferior margins of
each eye socket. These two components can be observed in Fig. 2.
The range of CT numbers (the Hounsfield values) of each tissue/
substance is provided in Table 1 (Ali et al., 2013; Karjodkar et al., 2009;
Lepor, 2000; Qian et al., 2017; Wu et al., 2009)

2.2. Frontend

As the system was designed for neurosurgeons conveniently

regardless of their computer programming background, it provided a
user-friendly interface to communicate with the back-end module,
where the complicated codes were written.
Fig. 3. Layout of VPSEAR’s UI comprising the main display area and the op­
tions panel (A), and the Options Panel with sub-panels functionality (B).

3
K. Chongsrid et al. Intelligent Systems with Applications 18 (2023) 200205

Fig. 4. VPSEAR’s UI with main display (center) and options panels (right).

Fig. 6. Illustration of data representation of the point cloud.

where all options were pulled from checkboxes, radio buttons, and
sliders. These options chose the workflow branches to go hand-in-hand
with the user’s preferences.

2.3. Back‑end module

Fig. 5. Framework depicting overall processes of the back-end module.
Fig. 5 illustrates the overall processes within the back-end module.
Details of each step are provided in the following subsections.
and Save Text Report buttons allowed the user to save the 2-D model
(with .jpeg or .png extension) or the text report (with .txt extension) of
2.3.1. Conversion of 2-D CT images to a point cloud
the output. During the running, the state text showed at the bottom left
The input DICOM images of CT slices kept multiple cross-sectional
under the main display. The program showed the current state, along
information of anatomical structures inside a patient’s head. However,
with the total current running time and the estimated finish time. Fig. 4
viewing the data slice by slice could not help us see useful features, such
depicts the user interface of VPSEAR.
as 3-D shape and connectivity. To obtain these features, we first trans­
formed the series of CT images into a point cloud (pc), using three
2.2.2. Front-End implementation
DICOM tags: instance number, slice spacing, and pixel spacing. In the
The implementation of the front-end module was accomplished by
series of CT images, one can always convert the position in the image to
building multiple functions based on the back-end module. Further­
a point (x, y, z) in space.
more, each function had an additional app argument used in the current
The x, y, and z coordinates at the row number R, column number C,
application’s context, enabling it to be called in the App designer. Each
and slice number I, were calculated using the following formulas.
interactable UI component had some event controller tied to itself,
affecting the process and output. x = (R − 1) × PS (1)
The user had to select a path to the folder of Digital Imaging and
Communications in Medicine (DICOM) files via the first sub-panel. The y = (C − 1) × PS (2)
main function which started our program was tied to the Display button.
After the user clicked the Display button, the main algorithm started, z = (I − 1) × SS (3)

4
K. Chongsrid et al.
Fig. 7. An example of segmentation processes.
where PS is pixel spacing, SS is slice spacing. A point cloud is a set of
these data points represented in 3-D cartesian coordinates. Each point
has a value of a CT number in the Hounsfield unit (HU). We thus can
view each point as 4-D.
Fig. 6 illustrates a point cloud comprising 18 data shown as red dots.
The point cloud was constructed from two adjacent slices at different
gray-scale pixels. The blue and pink lines show pixel spacing and slice
spacing, respectively.
2.3.2. Segmentation of essential components
Generally, three essential parts: the skull, lateral ventricles, and the
ear’s helix were segmented from the point cloud using a thresholding
method because each component had a unique range of CT numbers (see
Table 1). After thresholding, we used morphological processing and
connected component labeling (CCL) (Aissou & Aissa, 2020; Balado
et al., 2020) to eliminate irrelevant components. The detailed proced­
ures to segment each component are as follows.
As the skull was assumed to be the largest connected component after
thresholding, we used only CCL to find the skull point cloud and neglect
other irrelevant islands, such as the calcification, which were smaller.
For the lateral ventricles, the outlier components are the regions
containing CSF, such as the third and fourth ventricles, or sharing
similar HU with the lateral ventricles, such as brain lesions. Unlike the
skull, CCL did not well separate the mentioned components because
these outlier components connected with the lateral ventricles. The third
ventricle connected to the lateral ventricles via the narrow canal so-
called interventricular foramen (see Fig. 2). We applied morphological
erosion with a sphere-shaped structuring element to eliminate the
interventricular foramen. As some of the regions of the lateral ventricles
were also eroded, we applied morphological dilation to compensate for
the missing parts. Last, we removed holes appearing in the lateral
ventricle by filling them with a 3-D morphological closing operation.
The morphological process could also help smoothen the ventricle
edges.
Some of the initial point clouds of the helices might include parts of
the skin and the temporal fat pad. Thus, the non-helix point cloud cor­
responding to these irrelevant parts was calculated by applying a
morphological opening to the initial point cloud with the sphere-shaped
structuring element. The final helix point cloud was obtained by elimi­
nating the non-helix point cloud from the original 3-D. Fig. 7 illustrates
the 3-D segmentation processes of the skull, ventricle, and helix.
The pseudo-code of the segmentation algorithm is provided in Al­
gorithm 1.
It requires these three functions.
Threshold(pc, t) takes a 4-D point cloud pc and a constant value t. It
returns a 3-D point cloud in which the Hounsfield value in pc is greater
than t.
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Intelligent Systems with Applications 18 (2023) 200205
Algorithm 1
A pseudocode of the segmentation processes of essential parts.
Input: pc = The 4-D point cloud of the input DICOM
tskull = The threshold value of the skull
thelix = The threshold value of the helix
tventricle, low = The lower bound of the threshold value of the ventricle
tventricle, high = The upper bound of the threshold value of the ventricle
ND = Neighborhood distance
% Skull Segmentation
temp = Threshold(pc, tskull)
pcskull = LargestConnectedComponent(temp, ND)
% Lateral Ventricle Segmentation
temp = Threshold(pc, tventricle, low) − Threshold(pc, tventricle, high)
temp = Erosion(temp)
pcventricle = LargestConnectedComponent(temp, ND)
temp = Dilation(temp)
temp = Closing(temp)
% Helix Segmentation
temp = Threshold(pc, thelix)
temp = temp − Opening(temp)
pchelix = LargestConnectedComponent(temp, ND)
Output: pcskull = the 3-D point cloud of the skull
pcLV = the 3-D point cloud of ventricle
pchelix = the 3-D point cloud of ear’s helix
LargestConnectedComponent(pc, ND) takes a 3-D point cloud pc. It
returns another 3-D point cloud, which is the largest connected cluster of
the data points in pc, where the maximum neighborhood distance within
the same cluster is ND.
Erosion(pc), Dilation(pc), Closing(pc), and Opening(pc) are functions
that take a 3-D point cloud pc as an input and return a point cloud
resulting from applying the corresponding morphological operator:
erosion, dilation, closing, and opening, with sphere-shaped structuring
elements to pc respectively.
The thresholding parameters for the skull, helix, and ventricle tskull,
thelix, tventricle, low, and tventricle, high are selected based on CT numbers
provided in Table 1. That is tskull =100, thelix=− 200, tventricle, low = 1, and
tventricle, high =15, respectively. The neighborhood distance ND for
determining connectivity is set to 0.87.
2.3.3. Head alignment adjustment
As the images of a patient could be in an inclination angle as shown
in Fig. 8 (left), thus, it was essential to adjust alignments for both mid-
sagittal and Frankfurt planes for the correct coordinates used in shunt
surgery planning as illustrated in Fig. 8 (middle). To achieve mid-
sagittal plane alignment, we identified the orientation using falx cere­
bri. We calculated the volume of interest (VOI) by excluding the skull
part obtained in the prior step from the brain. Then we identified the
minimum bounding cuboid that fit with the entire brain volume. After
that, we trimmed a quarter of the volume from each of the two sagittal
sides. The remaining half-width of the cuboid was used as the VOI. To
detect the falx cerebri, we applied the Hounsfield-based threshold in the
range of 40 to 50 HU to the point cloud. Then, we selected the largest
connected component within the VOI to get the falx cerebri. Let (xi, yi, zi)
for i = 1, 2, …, p be the coordinates of data points of the falx cerebri,
Fig. 8. Before (left) and after (right) applying midsagittal plane alignment (red)
and the Frankfurt plane alignment (blue); view from 20◦ elevation.
K. Chongsrid et al.
Fig. 9. Illustrations of the skull’s area of interest shown in gray (A), the zoomed triangulated meshes of the skull shown in dark blue and a ventricle shown in light
blue, and base transformation (B), and a hit point Si projecting from a skull’s ROI to a ventricle (C).
where p is a total number of points. Let Pms be the middle sagittal plane
governed by the following equation
Pms : αx + βy + γ − z
So, the mid-sagittal plane Pms is fitted optimally by the least-squares
fitting approach as
∑p
(5)
′ ′ ′
(α , β , γ ) = argmin(α,β,γ) i=1
(αxi + βyi + γ − zi )2
The red plane shown in Fig. 8 (middle) demonstrates the mid-sagittal
plane Pms. The mid-vertical plane Pmv is defined with the following
equation
Pmv : y − (Cmax − 1) ∗ PS/2
where Cmax is the index of the last column of the CT image and PS is the
pixel spacing. Finally, we use the 3-D affine transformation to align the
mid-sagittal plane Pms to the mid-vertical plane Pmv.
The Frankfurt plane is a plane lying nearly parallel to the surface of
the earth. It passes through three landmark points: left orbitale and left
and right porions (see images of these parts in Fig. 2). We constructed a
plane passing these points to identify such a plane automatically. To
obtain the orbitale, we projected the center of the eyeball on the skull.
Since the eyeball is a spherical structure filled with a gel-like fluid, it was
easy to be segmented based on the circularity feature and the
Hounsfield-based thresholding method in a similar fashion as in the
segmentation of the lateral ventricles.
Next, we detected the ear holes by thresholding at − 800 HU (see
Table 1). We utilized the convex hull of the point cloud to determine the
boundary of the ear’s helix in the sagittal view. The air space nearest to
the mid-sagittal plane was identified as the end of the internal ear canal.
Then we projected the air space region onward the skull to identify the
porions. Similar to the approach used in the mid-sagittal alignment, we
then aligned the Frankfurt plane with the axial plane to get the final, as
shown in Fig. 8 (right).
2.3.4. Area recommendation
Finding area of interest. To obtain the surfaces of the skull, we applied 3-
D convex hulling to the skull’s point cloud to create a convex manifold
(water-tight) polytope (Brassey et al., 2014). The convex hulling oper­
ation fit the smallest convex polytope around the point cloud, resulting
in a tight-fitting hull around the skull and a minimum value for the
convex wrapping volume.
To minimize the required computer memory and computational
time, we focused only on the targeted skull region. Since the skull in
front of the posterior helix was covered by a thick layer of the temporalis
muscle (see Fig. 2), only from the helix’s posterior toward the backside
Intelligent Systems with Applications 18 (2023) 200205
of the head until the backend of the same side was considered. More­
over, only the area above the superior of the helix was focused as it
allowed the catheter to direct to the atrium of the lateral ventricles.
(4)
Lastly, shunting with the occipital approach on the skull below the
lateral ventricles could not propagate to the atrium. Thus, only the skull
that was above the helix’s tip but not beyond the highest of lateral
ventricles was used. Fig. 9(A) shows a region of interest (ROI) according
to the mentioned anatomy and surgical restrictions.
Calculating a hit point cloud. As depicted in Fig. 9(B), we used the point
cloud of the skull surface (i.e. the yellow dot) within the ROI to create a
triangulated mesh (dark blue surface) comprising a set of connected
(6) triangles. The triangular mesh was chosen over a quadrilateral mesh
because of the lower computation complexity to ensure fast running
time. Each triangle consisted of one face and three vertices selected from
the point cloud of the skull. In addition, we applied 2-D Delaunay
triangulation (Shewchuk, 2008) to ensure that the corresponding 2-D
circumcircle of each triangle contains no other point cloud inside it.
For the lateral ventricles, we used the crust triangulation method
(Giaccari, 2022) to construct a hollow volume triangulated mesh (light
blue surface) from the point cloud. The processes of defining a hit point
cloud are as follows.
Defining a hit point. We defined a hit point cloud to be a set of vertices of
the skull triangulated mesh of which their corresponding normal vectors
hit the targeted surface of the lateral ventricle’s triangulated mesh. We
used these hit points to define an entry site. The processes of how the hit
points and their corresponding depths were calculated are as follows.
Suppose S = {S1, S2, …, Si, …, Sn} be a set of vertices in the skull’s
triangulated mesh, n is the size of S. Let N = {N1, N2, …, Ni, …, Nn}be a
set of corresponding normal vectors of S, L = {L1, L2, …, Lj, …, Lm} be a
set of vertices in the lateral ventricle’s triangulated mesh, m is the size of
L. For each Si in S, we calculate a ray originating from Si having the same
direction as Ni. We say Si is a hit point if its ray meets at least a face in the
lateral-ventricle triangulated mesh. A collection of hit points constitutes
a hit point cloud.
Calculating distances from a hit point to a ventricle. We calculated dis­
tances by using Möller–Trumbore ray-triangle intersection algorithm
(Möller, 1997). The algorithm was chosen because it is the most efficient
algorithm for finding the intersection of a vector (a ray) to a triangular
plane. It is time and memory-saving as no pre-calculated equations were
needed. It was experimentally proven to be fast for triangle meshes
(Möller, 1997). The method is described as follows.
Suppose a ray from Si meets the ventricle at k places, the intersection
points are Pi = {Pi,1, Pi,2, …, Pi, j, …, Pi,k}, and the corresponding dis­
tances to the intersection points is di = {di,1, di,2, …, di, j, …, di,k}. For
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K. Chongsrid et al. Intelligent Systems with Applications 18 (2023) 200205

Defining the entry area and depth. We projected a hit point cloud in the
sagittal plane before applying the convex hull to define a closed region
from them. As the entry area was an irregular shape, we selected the
largest inscribed circle with radius r to be the circular recommended
area. The path to the center of the area was determined by two pa­
rameters a and b, as illustrated in Fig. 10. From the selected reference
point, parameter a was measured backward and b was measured verti­
cally upward. Note that the ear’s reference point can be selected by the
user in the front-end module. The parameter d was defined as the depth
at the center of the circular recommended area, as demonstrated in
Fig. 10.
Fig. 10. A model illustrating the circular recommended area of radius r with To construct a contour map within the circular recommended area,
distances a and b and depth d of the center point (left), and a contour map of the
we calculated a polynomial surface function from the discrete depths. A
depths (right).
robust linear least-squares fitting and the bisquare weights method
(NIST, 2022) were applied because they were simple and yielded
each face Lj, there are three corresponding vertices Aj, Bj, and Cj, as adequate accuracy for a rough contour map. The linear least-square
depicted in Fig. 9(C). We used the normalized barycentric coordinates to method was chosen because it was the simplest compared to other
express the position of any point located on the triangle with two scalars, fitting models, which helped keep running time low. As our errors from
ui, j and vi, j. The ui, j and vi, j forms coordinates of a point lying on the outliers follow a normal distribution, a bisquare weighting was suitable
surface of a unit triangle which has the following constraints. First they to remove the extreme outliers and to down-weight proportionally the
cannot be greater than one nor lower than zero. Second, the summation mild outliers.
of ui, j and vi, j cannot be greater than one. This is to ensure that if the
triangle is rotated, scaled, stretched, or translated, the coordinates ui, j 2.3.5. Output models and report
and vi, j defining the position of Pi, j with respect to vertices Aj, Bj, and Cj
will not change. We computed the position of the intersection Pi, j using
2-D model and text report. The 2-D model represents graphically land­
Eq. (7).
marks on the side view of the head, which include the skull, the lateral
( ) ( )
Pi,j = Aj + ui,j Bj − Aj + vi,j Cj − Aj (7) ventricles, the helix’s ear, the entry site, the recommended circular area,
the distances in mm to the center of the circle, the depth at the center,
Pi,j can also be defined using the following ray’s parametric equation: and the Keen’s point.
Pi,j = Si + di,j Ni (8) Fig. 11 depicts the 2-D model. It is designed to help a neurosurgeon
to better visualize the essential components prior to the VP shunt
where di,j is the distance from the ray’s originating from Si to Pi, j. operation. The 2-D model was generated by overlaying essential parts in
Pi,j can be expressed in terms of ui,j, vi,j, and di,j, as demonstrated in the sagittal direction on top of each other. Horizontal grids were used to
Fig. 9(B). Using the Cramer’s rule, ui, j and vi, j can be expressed as in Eqs. allow overlapped regions to be present in the same location. The
(9) and (10) important distances a, b, r, and d were listed first as they define the
( ( ))/( ( )) circular entry area. Note that the d distance is the depth of the VP shunt
ui,j = Pi,j • Si − Aj Pi,j • Bj − Aj (9) from the center of the area.
(( ) ( ))/( ( )) The text report is the minimal format of the 2-D model, comprising
vi,j = Ni • S i − Aj × Bj − Aj Pi,j • Bj − Aj (10) two parts. The first part provides the essential information of the patient
From equations (7) − (10), the distance di, j can be calculated as for verification. The second part contains the reference point, insertion
follows. side, and the information of the circle required to determine the path to
(( ) ( )) ( ) ( ( )) the recommended area. Fig. 12 shows an example of a text report
di,j = Si − Aj × Bj − Aj • Cj − Aj ) / Pi,j • Bj − Aj (11) generated from the program.
For each hit point, the maximum value of di was used as the depth,
Depth map. The depth map was constructed to depict the depth of each
the maximum insertion length of the ventricular catheter.
point in the circular recommended area. We used a contour plot to

Fig. 11. An example of a 2-D model.

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K. Chongsrid et al. Intelligent Systems with Applications 18 (2023) 200205

Fig. 14. An example of a slide with a circle skull, gray matter, and an el­
lipse ventricle.
Fig. 12. An example of a text report.

Fig. 15. Five points evaluation of the circular recommended area (blue circle).
( )
The entry sites (orange dots) are at the center (a, b) and a ± 2r , b and
( r
)
a, b ± 2 .

nearest orthogonal viewing plane instead of all x, y, and z texture planes.

The user could select which models or surfaces to be displayed and
Fig. 13. Examples of the 3-D model illustrating the helix (light blue), posterior
the part of the lateral ventricles to be displayed through the provided UI.
horn and atrium and posterior horn of the chosen-side lateral ventricle (dark
green), body, frontal horn, and inferior horn of the chosen-side lateral ventricle
Ones that were not selected are not rendered to save memory and to
(bright green), entry area (dark red), circular recommended area (light yellow), speed up the process.
unchosen-side lateral ventricle (light green), the insertion direction from the
center (red line). 3. Experiments and evaluation schemes

Table 2 We used retrospective CT scan slices comprising 15 hydrocephalus

Principal semiaxes used in the skull-ventricle models in the test of methods for cases with a mean Evans’ index of 0.37 (SD = 0.067, range 0.30 to 0.58).
surface normal mapping. All the data was collected in DICOM format. The images were taken by
Pattern Model patterns of Principal semiaxes using Philips IQon Elite Spectral and Philips Brilliance iCT 256-slice CT
names Skull-Ventricle Skull Ventricle scanners. The data comprised 3 males and 12 females, ages ranging from
SS Sphere Skull -Sphere Ventricle u = 8, v = 8, w = u= 5, v = 5, w = 5 to 82 years. Each CT slice is 16-bit with dimensions of 512 × 512. The
8 5 number of slices ranged from 327 to 394 per case. The pixel spacing was
EE Ellipsoid Skull – Ellipsoid u = 7, v = 8, w = u= 4, v = 5, w = 0.5 mm, while the slice spacing was 0.39–0.49 mm depending on the
Ventricle 7 3 number of slices.
SE Sphere Skull - Ellipsoid u = 8, v = 8, w = u= 4, v = 5, w =
Ventricle 8 3
It was run on a computer with Windows 10 Home and the 10th
ES Ellipsoid Skull - Sphere u = 7, v = 8, w = u= 5, v = 5, w = generation Intel® Core™ i7 processors with a base frequency of 1.30
Ventricle 7 5 GHz and installed RAM of 16.0 GB. It uses approximately 15 min for the
entire process.
We performed two experiments. The first was to show the perfor­
represent the depth of each location within the circular recommended
mance comparison of our surface normal mapping methods used in
area as a 2-D map, called a depth map. The contour levels representing
VPSEAR against the conventional one. The second was to show the
the depth were separated every 5 mm from 60- 85 mm. An example of
qualitative and quantitative comparisons of VPSEAR against the tradi­
the depth map is shown in Fig. 10 (right).
tional free-hand method for VP operation.

3-D model. The 3-D model showed landmarks in 3-D as shown in Fig. 13.
The orthogonal plane 2-D texture mapping technique was applied for
volume rendering 3-D data. Since the 3-D was rotatable, we used the 2-D
texture render technique instead of the 3-D one to minimize the required
computer memory and the computational time. Thus, we rendered
simultaneously only a few texture planes that were parallel to the
3.1. Tests on the performance of surface normal mapping methods on
simple models
We compared the accuracies of normal mapping from a skull to a
ventricle model using conventional techniques against advanced ones

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K. Chongsrid et al. Intelligent Systems with Applications 18 (2023) 200205

used in the VPSEAR. Ellipsoids and spheres were used to model skulls
and ventricles from the governing equations. The analytical solutions
were computed to be used as ground truths for evaluation. The sphere
and the ellipsoid models were equated generally as in Eq. (12).

x 2 y 2 z2
+ + =1 (12)
u2 v2 w2
Two different sizes and shapes for each of a skull and a ventricle were
used to approximate a typical size of an adult’s skull and ventricle. The
principal semiaxes, u, v, and w, of a skull used for a sphere model were
shown in Table 2.
The skull model of thickness 0.5 was used for the skull’s thickness.
The models were sliced parallel to the x-y plane to make 300 slices. The
colors of the skull, gray matter, and ventricles were set to the corre­
sponding gray values (Hounsfield unit) provided in Table 1. The noise
was added to the gray matter to make its texture similar to the real ones.
Fig. 14 shows an example of a slide from the SE pattern defined in
Table 1. The resultant points calculated by the method were compared
with the exact solution to find the Euclidean distant error rates.
We selected points on the skull’s model and computed corresponding
normal (90-degree) mapped points on the ventricle’s model.
The techniques of conventional methods were as follows.

(1) Skull and ventricle edges were calculated using the thresholding
Fig. 16. Illustration of evaluation of the recommended circular region with method
distances a, b, and d (depth at the center of the circular area) using 3D Slicer. (2) For each skull edge point, a corresponding plane was constructed
from the selected point, an adjacent point on its left in the same
Table 3 slide, and the closest point in the upper adjacent slide.
Performance comparison of the conventional method vs VPSEAR to calculate the (3) A normal vector to the plane from the selected point and the point
mapping points for patterns of 3-D shapes of the skull and theventricle defined in where the normal vector met the surface of the ventricle was
Table 2. computed using calculus knowledge.
Pattern Number Techniques Average Euclidean Time
names of distance (mm) (second) The techniques used in VPSEAR were as follows.
tested
skull
points (1) 3D point cloud thresholding was used to get the 3-D object and
convex hulling was used to get to get the surface point clouds.
Conventional 7.96 209.70
(2) 2-D Delaunay triangulation was used to construct a triangulated
SS 27,739 method mesh.
VPSEAR 0.70 79.45 (3) Möller–Trumbore ray-triangle intersection algorithm was used to
Conventional 21.88 220.58 find the intersection point on a ventricle from a vector normal to
EE 22,093 method
the triangulated mesh
VPSEAR 0.69 64.94
Conventional 16.78 200.11
SE 27,739 method The accuracy was measured by using an average Euclidean distance
VPSEAR 0.97 79.86 between resultant points on the ventricle from a method and the
Conventional 7.20 212.38 analytical solutions.
ES 22,093 method
VPSEAR 0.53 64.49

Fig. 17. The accuracy performance of VPSEAR with 5-point evaluation and Keens at depths 6 and 7 cm.

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K. Chongsrid et al. Intelligent Systems with Applications 18 (2023) 200205

Fig. 18. Comparisons of results of Keen’s (left) and VPSEAR (right) of selected cases.

3.2. Test the accuracy of recommended circular area on real patients’s

data

We used 3D slicer software (Kikinis et al., 2014) to verify the accu­

racy of the recommended circular area. The CT slides were loaded into
the 3D slicer to get a 3D model of the ear, skull, and ventricle. The
distances a, b, and r returned by the VPSEAR were measured on a
3D-slicer model from the superior helix position to the recommended
area. We tested five entry points, as illustrated in the orange dots in
Fig. 15.
The first point was the center (a, b). The remaining points could be
visualized by their degrees in a polar coordinate system with the arm
length 2r and angles: 0◦ , 90◦ , 180◦ , and 270◦ These four points were
Fig. 19. Examples of unsuccessful cases of VPSEAR- catheter tip exceeding the
equivalent to (a ±2r , b) and (a, b ±2r ). Each point had a corresponding
lateral ventricle (left), the catheter tip slightly exceeding the midline
depth which could be obtained from the depth map. plane (right).
These points and their corresponding depths were tested and

10
K. Chongsrid et al.
compared against the traditional Keen’s point. With Keen’s point, we
tested at depths equal to 6 and 7 cm, according to the literature
(Haeussinger et al., 2011; Junaid et al., 2018).
The score of each entry point was interpreted on a binary grading
system, either 1 (pass) or 0 (fail). The entry site was determined to be a
pass if and only if the ventricular catheter could get inside of the lateral
ventricle and the endpoint stayed in the lateral ventricle without
crossing the midsagittal line. Fig. 16 illustrates the use of the 3D Slicer
for evaluation of the accuracy. Given success be the number of passes and
total be the total number of tests, we used the accuracy formula shown in
Eq. (13) to define the overall performance of the entry model.
success
accuracy = , (13)
total
4. Results and discussion
4.1. Performance of surface normal mapping methods on simple models
The average Euclidean distance and time used were presented in
Table 3. The number of tested points was the number of all possible
points on a skull whose normal vectors meet the ventricle surface, based
on analytical solutions.
VPSEAR significantly outperformed the conventional methods as it
yielded significantly lower error rates compared to the conventional
method. The errors of the conventional method were due to the inflex­
ibility of choosing points in the plane construction. The time usage of
VPSEAR was also considerably shorter (around 2.5 times) than con­
ventional method. The reason that VPSEAR had a fast running speed was
because technically it did not calculate plane equations like the con­
ventional method did.
4.2. Results of accuracy performance of VPSEAR vs traditional Keen’s
point
The numerical results were reported in Fig. 17. At the center of the
circular recommended area, VPSEAR yielded an excellent accuracy of
96.67%. For the other four interior points measured at 0◦ , 90◦ , 180◦ , and
270◦ , the accuracies are 90.00%, 100.00%, 90.00%, and 100.00%,
respectively. This result showed that the accuracy was slightly lower
when the entry site was closer to the left or right side of the recom­
mended area. This could be explained that the vertically thin shape of
the lateral ventricle could increase the chance of the program missing
the targeted ventricle on the sides. On the other hand, at the angles 90◦
and 270◦ , there was more space in the vertical direction so the chance to
get to the ventricle is higher. We achieved 100% perfectly for these
angles. The four neighbor points had an average accuracy of 95.00%,
which was slightly below the accuracy of 96.67% at the center. The
average accuracy of VPSEAR using a 5-point evaluation was 95.33%.
We used five point evaluation described prior in Section 4 to evaluate
the accuracy. In comparison, the accuracies of Keen’s method with the
insertion length of 6 and 7 cm were 73.33 and 36.67%. The average
performance of these two lengths was 55%. We observed that the ac­
curacy of Keen’s point droped considerably when the depth increased.
Remark that in our evaluation we assumed that the catheter was not
flexible. On average our VPSEAR program significantly outperformed
Keen’s method by as much as 40.33%. Fig. 18 depicts four examples of
result comparison of VPSEARs and Keens using 3D Slicer.
The ratio of fail sides for all evaluated degrees of VPSEAR to the total
cases was 9.33%. 71.43% of this number was due to the catheter’s tip
exceeding the lateral ventricle area, and the rest was due to crossing the
midsagittal plane. Fig. 19(left) shows an unsuccessful case where the
catheter tip is not in the lateral ventricle. Our analysis shows that the
cause of the failure comes from imprecisely selecting the reference point
of the evaluator which differs from the VPSEAR’s calculation. In this
case, the incorrect point selection is due to the flat superior area of the
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Intelligent Systems with Applications 18 (2023) 200205
helix of the patient. This area of the helix is not unique so it makes the
evaluator pick a point different from the program.
For the second case, the errors can come from manual head adjust­
ment and the piercing angle done by the evaluator not exactly 90◦ to the
skull surface, this causes the trajectory to deviate from the program,
consequently, it crosses the midsagittal plane as shown in Fig. 19 (right)
The program VPSEAR can be improved as follows. First, we may
consider a new reference point that is fixed such as the ear’s canal.
Second, we can allow a lateral ventricle to be viewed instantly through
AR glasses. These will be our future work.
5. Conclusion
In this work, we developed a user-friendly computer-aided program,
named VPSEAR, to precisely find a circular area on the skull surface that
is suitable for VP Shunting. We evaluated the accuracy of the program
against the traditional Keen’s point. The tests were done on 30 head
sides of 15 patients by using a 3D Slicer program. VPSEAR’s average
accuracy achieved was 95.33% while Keen’s was only 55.00%. The
accuracy improvement is up to 40.33%. The program is fully automatic,
and the run time is less than 15 min per head side.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Data availability
The data that has been used is confidential.
Acknowledgments
We gratefully acknowledge the financial support from the Center of
Excellence in Biomedical Engineering of Thammasat University. We
sincerely thank the department of surgery, faculty of medicine, Tham­
masat University for kindly providing the CT brain datasets. We also
acknowledge Walita Narkbuakaew, D.Eng., National Science and
Technology Development Agency (NSTDA) for kindly providing helpful
discussions related to the CT scanner and CT data processing.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.iswa.2023.200205.
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