基于简易虚拟现实和增强现实定位的内镜辅助下清除幕上自发性脑内血肿

Endoscopic surgery of spontaneous supratentorial intracerebral hematoma assisted by virtual reality and augmented reality

目的探讨基于简易虚拟现实和增强现实的内镜辅助下清除幕上自发性脑内血肿的可行性及临床效果。方法回顾性分析解放军总医院神经外科2014年9月至2015年10月收治的36例幕上自发性脑出血患者的临床资料。术前患者均行颅脑cT检查，以医院综合式影像存档及传输系统（PACS）实现血肿和患者的颅脑外形轮廓的三维可视化。术中以基于安卓手机的图像融合软件，将三维可视化的血肿和颅脑外形通过手机摄像头与患者的头像实现匹配，可以辅助精准定位血肿的位置，制定优化的穿刺路径。血肿穿刺器穿刺至预设的位置，引导透明的导引器到位，内镜下清除血肿。术后次日复查颅脑CT，以3D—Slicer软件计算血肿的体积以及残留血肿的体积。记录血肿清除率、手术时间、手术失血量、术前和术后1周的格拉斯哥昏迷评分（GCS）。结果通过虚拟现实联合增强现实帮助血肿定位及穿刺路径设计后，穿刺器及工作鞘组均达到预设的位置，手术时间为（54．0±9．6）min，内镜实际操作时间为（33．0±7．2）min，术中出血量为（80．0±21．5）ml。无术后再出血的病例。术前血肿量为（60．1±22．3）ml，术后残留血肿量为（4．3±2．4）ml，平均血肿清除率为95．4％。术前GCS评分为（6．7±1．6）分，术后1周为（12．6±1．9）分，均明显改善（P〈0．01）。结论对于自发性幕上脑内出血，基于虚拟现实和增强现实的方法有助于定位血肿和设计优化的穿刺路径和穿刺靶点，联合神经内镜能有效清除血肿，改善患者的预后。

Objective To study the feasibility and clinical effectiveness of endoscopic removal of spontaneous supratentorial hematoma assisted by virtual reality （VR） and augmented reality （AR）. Methods A retrospective analysis was conducted with 36 patients with spontaneous supratentorial hematoma who were admitted to the neurosurgery department of PLA General Hospital from September 2014 to October 2015. Based on the hospital picture archiving and communication （PACS） system, three-dimensional visualization of the patients＇ hematomas and head outlines were achieved assisted by VR. The technology of AR, used together with imaging fusion application （APP） on android-system cell phones, helped physicians design trajectory to of hematomas. A perforator and transparent sheath were used to set up a working channel for removal of hematomas with endoscopes. Post-operative CT was conducted one day after surgery and volumes of hematomas were calculated with the software of 3D-slicer. The parameters were documented including hematoma evacuation rate, operation time, intraoperative blood loss, preoperative and postoperative （1 week post surgery） scores based on the Glasgow Coma Scale （GCS）. Results Successful punctures to reach hematomas were achieved with the assistance of VR and AR in call cases. The mean operation time and actual endoscopic operation time were 54.0 ± 9.6 min and 33.0 ± 7.2 rain, respectively. The mean amount of blood loss during operation was 80. 0 ± 21.5 ml. None of the cases developed postoperative rebleeding. The average evacuation rate was 95.4%. The mean preoperative GCS score was 6.7 ± 1.6, which was significantly increased to 12.6 ± 1.9 （P 〈 0.01 ） graded 1 week post surgery. Conclusions The technologies of VR based on hospital PACS systems and AR based on cell phone APP could help precisely localize the intracerebral hematomas and select appropriate puncture trajectory. With a working channel established by transparent sheath, the endoscope could help achieve satisfactory removal of hematomas and improve the outcome.