Use of Augmented Reality Navigation in Pediatric Deep Cerebellar Tumor Resection: An Illustrative Case

Use of Augmented Reality Navigation in Pediatric Deep Cerebellar Tumor Resection: An Illustrative Case | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Use of Augmented Reality Navigation in Pediatric Deep Cerebellar Tumor Resection: An Illustrative Case Gabriel Urreola, Venina Kalistratova, Paolo Palmisciano, Cameron Sadegh, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7716418/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Pediatric central nervous system tumors, such as medulloblastomas, are rare but represent the second most common childhood malignancy. Despite advancements in technology, resecting deep-seated tumors within the posterior fossa remains challenging due to critical surrounding structures, such as the straight sinus, and potential complications, including neurological deficits and posterior fossa syndrome. Augmented reality (AR) technology has emerged as a promising tool, providing real-time visualization of critical anatomy to enhance precision and safety during surgery. This case represents the first reported application of AR-assisted navigation for the resection of a pediatric deep cerebellar tumor. Observations We present the case of a 14-year-old female with recurrent medulloblastoma who underwent surgical resection aided by AR navigation. The AR technology was a hands-free headset (Microsoft HoloLens) with integrated navigation software (Xironetics) which allowed surgeons to overlay critical anatomy while orienting themselves in 3D space. The tumor was successfully resected without complications, and AR navigation demonstrated significant utility in preoperative planning, incision guidance, and real-time depth perception. Lessons This case highlights the potential of AR navigation to improve patient safety, enhance surgical accuracy, and optimize outcomes in complex neurosurgical cases. The use of AR-navigation technology offered distinct advantages, such as accurate cranial surface mapping, hands-free navigation, and real-time deep anatomical visualization. Our report highlights a new generation of AR technologies with positive outcomes, which motivates the need for further research, including prospective, multi-center studies, to validate the broader application of AR in neurosurgery. Augmented Reality Augmented Reality Navigation Virtual Reality Mixed Reality Medulloblastoma Neuro Oncology Neurooncological surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Pediatric CNS tumors are rare but account for the second most common childhood malignancy 1 . The incidence rate of pediatric CNS tumors is 5.76 per 100,000 annually, with Medulloblastoma being the most common malignant pediatric brain tumor. Gold-standard treatment for Medulloblastoma consists of surgical resection followed by radiation and chemotherapy, with an overall survival rate of 70–80%. In Pediatric Neurosurgery precision and accuracy are paramount in avoiding damage to delicate vasculature and brain parenchyma in patients with medulloblastoma. Medulloblastoma resection is performed through a posterior fossa approach. Common postoperative complications include new neurological deficits, cerebellar ataxia, cerebellar mutism, cerebrospinal fluid leak, and posterior fossa syndrome 2 . Advances in surgical technology have continuously evolved to improve outcomes for pediatric patients undergoing brain tumor resection. These innovations include stereotactic surgery, microscopic assistance, pre- and intraoperative imaging modalities (CT, MRI, and ultrasound), and intraoperative navigation systems, all of which enhance surgical accuracy, safety, and efficiency 3 . Augmented reality (AR) has emerged as a new frontier in advancing neurosurgery due to its ability to enhance pre-operative planning, but also intra-operative accuracy 4 . AR enables real-time visualization of critical anatomical structures whose preservation is essential for optimal patient outcomes 5 . Furthermore, AR and its use intra-operatively have distinct advantages that allow for hand-free navigation and the opportunity for surgeons to augment their anatomical knowledge with visual feedback, all the while keeping their hands and eyes on the surgical field 4 – 6 . The case presented is the first case to our knowledge that utilizes augmented reality for intra-operative navigation for resection of deep cerebellar tumors with a posterior fossa approach. The novel AR technology allowed for surgeons to traverse the straight sinus and other key structures. The goal of this illustrative case is twofold. One, to demonstrate a novel application of AR to pediatric neurosurgery. Secondly, to contribute to the literature that AR can be safely and accurately utilized in Neurosurgery to enhance patient outcomes, safety and surgical effectiveness. Illustrative Case Patient History Our case included a 14-year-old girl, with a history of recurrent medulloblastoma who was being managed with Avastin and Temozolomide (TMZ)/ Irinotecan. She was initially diagnosed in 2018 and 1.5 years ago had a biopsy with Laser interstitial thermal therapy (LITT) to the region of the recurrent vermis enhancement. Repeat MRI post LITT, demonstrated enlargement of signal abnormality with mass effect plus enhancement on DWI in the area immediately adjacent to the site. Given progression despite therapy, the pediatric neuro-oncology board recommended surgical revision due to concerns of recurrence (Fig. 1 ). The goal was for maximal tumor resection with the aid of AR pre-operative planning and AR guided navigation followed by adjuvant salvage therapy. Augmented Reality Technology The AR navigation system was collaboratively developed with Xironetic (Oklahoma City, OK). Xironetics technology integrates high-resolution imaging modalities such as CT and MRI to generate patient-specific anatomical models/plans that can be overlayed into the surgical field. These plans/models were transferred to HoloLens 2 (Microsoft, Redmond, WA) utilizing Xironetic’s IntraOpVSP software (Xironetic, Oklahoma City, OK) (Fig. 2 ). IntraOpVSP is self-contained within the HoloLens 2 hardware and requires no external computing equipment. Through voice and gesture interactions, surgeons can navigate critical structures such as nerves, vasculature, and pathology while maintaining a hands-free approach and continuous visual focus on the surgical field (Fig. 3 ). Voice commands specifically enable surgeons to selectively overlay desired anatomical structures while concealing others as needed. Augmented Reality Navigation Workflow We obtained institutional review board (IRB) approval (University of California, 197 Davis IRB# 2236607-1) and review of this case was performed. Thin cuts of MR Brain with and without contrast and MR angio were obtained. Virtual planning was performed utilizing Elements (Brainlab, Munich Germany) and 3D Slicer ( http://www.slicer.org ) and relevant patient anatomy was segmented. Registration landmarks were identified on the patient’s scan, which included the nasion, inion, bilateral tragal notches and subnasale. The virtual plan and segmentation were transferred to HoloLens 2 and registered to the patient by utilizing the anatomical landmarks (Fig. 2 D). Accuracy was verified using anatomical landmarks. The patient was brought into the OR and prepped and draped as per standard hospital protocol. The AR registration process was coordinated via four physical items: 1.) The anchored reference array (Fig. 2 A/B), 2.) AR HoloLens headset, 3.) the optic code array stylist and 4.) the patient's anatomical landmarks (Fig. 2 D). The reference array was fixed to the surgical table, adjacent to the patient’s skull (Fig. 1 C). An optical code array (ArUco marker library – similar to a “QR code”) was tracked by the HoloLens 2 optical cameras (Fig. 2 D) and used as a registration anchor. The headset was then donned on the surgeon, to confirm the placement of both the reference array and optic code stylist. Once the headset properly confirmed the reference array and optic code stylist, it then was registered to standard anatomical landmarks such as the tragus, nasion, and subnasale (Fig. 2 D). Lastly, after confirmation by the surgeon that the registration was accurate, visual overlay of anatomical structures could be seen through the headset directly on the surgical field (Fig. 3 ) and used to plan an optimal surgical trajectory. Of note, gold-standard navigation by BrainLab supplemented the surgery to ensure proper surgical accuracy (Fig. 4 ). Operative and Post-Operative Course The patient was placed under anesthesia and intubated. Pre-Operative Antibiotics and anti-seizure medications were given for prophylaxis, and mannitol was administered for brain relaxation. The patient was rotated 180 degrees and then secured in the lateral position (right side down) with an axillary roll and pinned in a Mayfield frame with her head turned 30 degrees to the right, neutral flexion, and tilted upward. Brain lab navigation was registered and the trajectory to the lesion was verified. Xironetic navigation was also registered and used to visualize the trajectory (Fig. 3 ). After prepping and draping, the 3D AR overlay and navigation guided surface mapping of anatomical structures onto the skin with a pen (Fig. 3 ). The transverse and straight sinus were overlayed on the visual field and compared to traditional navigation (Fig. 4 ). The AR navigation allowed the surgeon to accurately orient himself around the venous sinuses and guide the incision. Following the incision, the mapping of the venous sinuses could now be seen on the bone and guided mapping and planning of the burr holes. (Fig. 5 ). An occipital craniotomy was followed by removal of a bone flap, exposing sagittal and transverse sinuses. Using the navigating stylet, an EVD was placed in the occipital horn of the right lateral ventricle for brain relaxation. The occipital lobe was visualized, and Adaptec was placed on its surface for protection. Dynamic retraction was employed to gradually expose the falco-tentorial junction and the length of the straight sinus. AR navigation was utilized throughout the entire tumor approach. The operative microscope was then introduced into the surgical field. The ultrasound with a flexible "hockey stick" handpiece was used to visualize the straight sinus and the nearby anatomy to validate our Brainlab and Xironetic-visualized deep sinus anatomy. The pial surface of the right paramedian vermis was opaque and thickened and transitioned to normal pial more laterally. This area was bipolar cauterized, and cut with micro scissors, and the tumor nodule dissected and sampled with tumor forceps. The tumor was pale and avascular and suctioned easily. We transitioned to the Nico Myriad handheld device with an additional light piece. This was used primarily to aspirate the soft tumor gradually, until the depth of the nodule at 1-1.5cm was encountered, and normal folia pia was visualized. From this deep boundary, the 8 Rhoton was used to dissect the boundaries of the nodule and to pull the tumor into the area of central debulking. The tumor was resected piecemeal. After the medial/lateral, and deep anterior/posterior margins were inspected, we used the ultrasound to confirm the correct location of resection with respect to the fourth ventricle. Brainlab and Xironetics AR also confirmed the margins. Final pathology confirmed Grade IV Medulloblastoma. The surgical time from incision to closure was 5 hours, with an estimated blood loss of 100 ml. There were no intra-operative or post-operative complications. Discussion Observations Since the inception of neurosurgery, there has been continued evolution of technology to improve patient outcomes and surgical safety, efficiency and accuracy 3 . Some of these technologies include the operative microscope, high resolution imaging, intra-operative navigation and more recently robotics and augmented reality 7 . Just as intra-operative navigation has now become standard practice, we believe Augmented Reality has the potential to follow-suit. This case report is important because it is the first to describe the use of AR to perform a pediatric tumor resection in the posterior fossa. It demonstrates the feasibility of AR in this case and motivates further studies to be conducted. In our case, we resected a cerebellar tumor which was surrounded by the straight sinus, in which damage could result in significant mortality and morbidity. Although anecdotally, with very sparse literature to support these claims, surgeons find posterior fossa surgeries to have higher rates of complications 8 . Our approach was non-conventional in that we underwent an occipital trans tentorial instead of the more commonly used suboccipital craniotomy. Posterior fossa tumor resections, like the one presented above have case series estimating complications between 30% and 62% 8 . One study found some of the most common complications to be CSF leaks (13%), infection (7%), cranial nerve palsy (4.8%), hematoma (3%) and death (2%) 9 . We found the use of AR navigation to be extremely helpful in planning of the incision and burr holes and particularly in navigating around the straight sinus. Specifically, AR was helpful in planning the surgical corridor to the tumor involved lining up surface anatomy (sagittal and transverse sinuses) with deeper anatomy (opening of falx next to straight sinus) to get to the tumor. The technology allowed for improved depth perception and proximity to the lesion. Although we present only one case, we demonstrate a significant benefit of visualizing critical anatomy in real time via AR and its potential to improve patient safety. One of the challenges in neurosurgery is being able to safely accomplish gross total resection of a tumor. Many of these challenges are due to difficulty visualizing the lesion/mass in 3D space but also navigating around critical anatomy. One of the benefits of AR technology intra-operatively is distinct borders around the lesion can be made and then overlayed on the surgical field. A recent study demonstrated that AR guided navigation had more complete tumor resection margins than traditional navigation 9 . With the use of AR, there may be increased confidence that the entirety of the mass is removed because it can be confirmed by visualization. We found pre-operative modeling of patient specific AR overlays to be accurate in comparison to intra-operative use (Fig. 6 ). The time to complete a surgical procedure is one of the limiting factors in neurosurgery. Due to the need for meticulous dissection, procedures can be long and taxing on the surgeon. AR technology may improve accuracy and safety, allowing surgeons to be more time efficient. Improved surgical efficiency diminishes the risks of anesthesia, especially in pediatric populations that are more vulnerable. Improved efficiency can also diminish workload burden on surgeons and improve feelings of burnout. Limitations Although AR is promising in the field of neurosurgery there are a few limitations to note. Although AR-navigation systems, like Xironetics are FDA approved, traditional neuro-navigation is standard of care. Until more research can be done, validating its benefits, we believe AR cases should be done using traditional neuro-navigation to verify accuracy. Joint use of these technologies increases surgical time and makes it difficult to evaluate the true efficacy of AR technology. Another limitation is that the workflow for AR is not standardized. The intraoperative use of this technology may vary and there is currently no unified way to conduct many of these surgeries. Also, the technology itself is not unified. For example, neuro-navigation is mainly done by two systems (Brain lab and Medtronic Stealth). Currently there is no gold-standard for AR technology, in which current systems function slightly differently. Lessons AR technology is an emerging technology, which is promising in the field of neurosurgery. New applications are being utilized in spine surgery, as well as cranial surgery. Our case demonstrates, from our knowledge, the first application of AR to pediatric neurosurgical approach of a posterior fossa tumor. We demonstrated that the technology was useful in improving patient safety, accuracy and efficiency. Specifically, we found the technology useful in craniotomy planning and navigating around venous sinus anatomy. Our results demonstrate the need for prospective multi-center, high volume trials to validate the application of this technology. Declarations Acknowledgements: None Funding Declaration: None References Udaka YT, Packer RJ. Pediatric Brain Tumors. Neurol Clin . 2018;36(3):533-556. doi:10.1016/j.ncl.2018.04.009 Klein O, Boussard N, Guerbouz R, Helleringer M, Joud A, Puget S. Surgical approach to the posterior fossa in children, including anesthetic considerations and complications: The prone and the sitting position. Technical note. Neurochirurgie . 2021;67(1):46-51. doi:10.1016/j.neuchi.2020.04.128 Johnson RD, Stacey RJ. The impact of new imaging technologies in neurosurgery. The Surgeon . 2008;6(6):344-349. doi:10.1016/S1479-666X(08)80006-6 Ragnhildstveit A, Li C, Zimmerman MH, et al. Intra-operative applications of augmented reality in glioma surgery: a systematic review. Front Surg . 2023;10. doi:10.3389/fsurg.2023.1245851 Patel N, Hofmann K, Keating RF. Current Applications of VR/AR (Virtual Reality/Augmented Reality) in Pediatric Neurosurgery. In: Di Rocco C, ed. Advances and Technical Standards in Neurosurgery: Volume 49 . Springer International Publishing; 2024:19-34. doi:10.1007/978-3-031-42398-7_2 Hunt R, Scarpace L, Rock JP. Intraoperative Augmented Reality for Complex Glioma Resection: A Case Report. Cureus . 16(4):e57717. doi:10.7759/cureus.57717 Vadhavekar NH, Sabzvari T, Laguardia S, et al. Advancements in Imaging and Neurosurgical Techniques for Brain Tumor Resection: A Comprehensive Review. Cureus . 16(10):e72745. doi:10.7759/cureus.72745 Anetsberger S, Mellal A, Garvayo M, et al. Predictive Factors for the Occurrence of Perioperative Complications in Pediatric Posterior Fossa Tumors. World Neurosurg . 2023;172:e508-e516. doi:10.1016/j.wneu.2023.01.063 Dubey A, Sung WS, Shaya M, et al. Complications of posterior cranial fossa surgery—an institutional experience of 500 patients. Surg Neurol . 2009;72(4):369-375. doi:10.1016/j.surneu.2009.04.001 Luzzi S, Giotta Lucifero A, Martinelli A, et al. Supratentorial high-grade gliomas: maximal safe anatomical resection guided by augmented reality high-definition fiber tractography and fluorescein. Neurosurg Focus . 2021;51(2):E5. doi:10.3171/2021.5.FOCUS21185 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 14 Nov, 2025 Reviews received at journal 10 Nov, 2025 Reviewers agreed at journal 09 Nov, 2025 Reviewers invited by journal 09 Nov, 2025 Editor assigned by journal 06 Oct, 2025 Submission checks completed at journal 06 Oct, 2025 First submitted to journal 25 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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11:50:36","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":48930,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7716418/v1/845ffe51437db8c5bc66486f.html"},{"id":96283787,"identity":"4ee4660b-6491-4b8d-bc70-5cf0f8ba7905","added_by":"auto","created_at":"2025-11-19 11:50:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":232112,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Axial T2-weighted MRI demonstrating a well-circumscribed lesion in the cerebellum measuring approximately 9.3 × 10.2 mm at its largest dimensions. (B) Sagittal post-contrast T1-weighted MRI showing the same lesion with contrast enhancement, highlighting its relationship to the posterior fossa structures.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7716418/v1/5e1d07a958d519c5258803d6.png"},{"id":96363651,"identity":"c99276c5-e589-49a4-a957-dd22e1acb03b","added_by":"auto","created_at":"2025-11-20 10:07:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":779556,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRegistration process: \u003c/strong\u003eA.) Demonstrates surgeon pre-operative planning with the AR anatomical overlay B.) The arUco array anchor C.) Patient in pins with adjacent anchored arUco array D.) Surgeon with AR headset and arUco stylist, setting anatomical landmarks relative to arUco array anchor\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7716418/v1/241797cb04bafe4addc7d307.png"},{"id":96363787,"identity":"643eb8f9-564f-40d1-a688-df2cc0dfeccf","added_by":"auto","created_at":"2025-11-20 10:08:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":196953,"visible":true,"origin":"","legend":"\u003cp\u003eLeveraging AR to overlay the patient’s major anatomical structures and tumor- These structures include the venous sinuses, lateral ventricles, and falx tentorium\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7716418/v1/3cd59f7c6ea6a7755ed314f2.png"},{"id":96363612,"identity":"70845e85-afda-4488-ab05-b18973dad698","added_by":"auto","created_at":"2025-11-20 10:07:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":638009,"visible":true,"origin":"","legend":"\u003cp\u003eSurface tracing accuracy comparing traditional navigation to AR navigation and mapping of venous sinus on the skin\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7716418/v1/f660c9b41e9dde68fe1282de.png"},{"id":96283796,"identity":"158f9ab0-26a2-410a-ac55-71380fdc2b1d","added_by":"auto","created_at":"2025-11-19 11:50:35","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":652398,"visible":true,"origin":"","legend":"\u003cp\u003eA.) Pre-craniotomy planning and visualization of sinus anatomy B.) Drawing on skull surface to mark out burr hole locations C.) Bone flap post-craniotomy\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7716418/v1/e917ffd1e68f4eccc3d9f620.png"},{"id":96283798,"identity":"bfd24075-e8d2-4d65-a593-c327de35889e","added_by":"auto","created_at":"2025-11-19 11:50:35","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":519374,"visible":true,"origin":"","legend":"\u003cp\u003eVisualization post-craniotomy compared to pre-operative planning model\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7716418/v1/5b22876bb3e88b8bfb7dd1f3.png"},{"id":96708948,"identity":"e930479e-13c1-426d-a837-23d6397ef79c","added_by":"auto","created_at":"2025-11-25 10:06:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4027953,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7716418/v1/3e88efbd-eb06-4852-bdc5-39e8cc621d65.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Use of Augmented Reality Navigation in Pediatric Deep Cerebellar Tumor Resection: An Illustrative Case","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePediatric CNS tumors are rare but account for the second most common childhood malignancy\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The incidence rate of pediatric CNS tumors is 5.76 per 100,000 annually, with Medulloblastoma being the most common malignant pediatric brain tumor. Gold-standard treatment for Medulloblastoma consists of surgical resection followed by radiation and chemotherapy, with an overall survival rate of 70\u0026ndash;80%. In Pediatric Neurosurgery precision and accuracy are paramount in avoiding damage to delicate vasculature and brain parenchyma in patients with medulloblastoma. Medulloblastoma resection is performed through a posterior fossa approach. Common postoperative complications include new neurological deficits, cerebellar ataxia, cerebellar mutism, cerebrospinal fluid leak, and posterior fossa syndrome \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAdvances in surgical technology have continuously evolved to improve outcomes for pediatric patients undergoing brain tumor resection. These innovations include stereotactic surgery, microscopic assistance, pre- and intraoperative imaging modalities (CT, MRI, and ultrasound), and intraoperative navigation systems, all of which enhance surgical accuracy, safety, and efficiency\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Augmented reality (AR) has emerged as a new frontier in advancing neurosurgery due to its ability to enhance pre-operative planning, but also intra-operative accuracy\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. AR enables real-time visualization of critical anatomical structures whose preservation is essential for optimal patient outcomes\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Furthermore, AR and its use intra-operatively have distinct advantages that allow for hand-free navigation and the opportunity for surgeons to augment their anatomical knowledge with visual feedback, all the while keeping their hands and eyes on the surgical field\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe case presented is the first case to our knowledge that utilizes augmented reality for intra-operative navigation for resection of deep cerebellar tumors with a posterior fossa approach. The novel AR technology allowed for surgeons to traverse the straight sinus and other key structures. The goal of this illustrative case is twofold. One, to demonstrate a novel application of AR to pediatric neurosurgery. Secondly, to contribute to the literature that AR can be safely and accurately utilized in Neurosurgery to enhance patient outcomes, safety and surgical effectiveness.\u003c/p\u003e"},{"header":"Illustrative Case","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatient History\u003c/h2\u003e\u003cp\u003eOur case included a 14-year-old girl, with a history of recurrent medulloblastoma who was being managed with Avastin and Temozolomide (TMZ)/ Irinotecan. She was initially diagnosed in 2018 and 1.5 years ago had a biopsy with Laser interstitial thermal therapy (LITT) to the region of the recurrent vermis enhancement. Repeat MRI post LITT, demonstrated enlargement of signal abnormality with mass effect plus enhancement on DWI in the area immediately adjacent to the site. Given progression despite therapy, the pediatric neuro-oncology board recommended surgical revision due to concerns of recurrence (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The goal was for maximal tumor resection with the aid of AR pre-operative planning and AR guided navigation followed by adjuvant salvage therapy.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAugmented Reality Technology\u003c/h3\u003e\n\u003cp\u003eThe AR navigation system was collaboratively developed with Xironetic (Oklahoma City, OK). Xironetics technology integrates high-resolution imaging modalities such as CT and MRI to generate patient-specific anatomical models/plans that can be overlayed into the surgical field. These plans/models were transferred to HoloLens 2 (Microsoft, Redmond, WA) utilizing Xironetic\u0026rsquo;s IntraOpVSP software (Xironetic, Oklahoma City, OK) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). IntraOpVSP is self-contained within the HoloLens 2 hardware and requires no external computing equipment. Through voice and gesture interactions, surgeons can navigate critical structures such as nerves, vasculature, and pathology while maintaining a hands-free approach and continuous visual focus on the surgical field (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Voice commands specifically enable surgeons to selectively overlay desired anatomical structures while concealing others as needed.\u003c/p\u003e\n\u003ch3\u003eAugmented Reality Navigation Workflow\u003c/h3\u003e\n\u003cp\u003eWe obtained institutional review board (IRB) approval (University of California, 197 Davis IRB# 2236607-1) and review of this case was performed. Thin cuts of MR Brain with and without contrast and MR angio were obtained. Virtual planning was performed utilizing Elements (Brainlab, Munich Germany) and 3D Slicer (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.slicer.org\u003c/span\u003e\u003cspan address=\"http://www.slicer.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) and relevant patient anatomy was segmented. Registration landmarks were identified on the patient\u0026rsquo;s scan, which included the nasion, inion, bilateral tragal notches and subnasale. The virtual plan and segmentation were transferred to HoloLens 2 and registered to the patient by utilizing the anatomical landmarks (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). Accuracy was verified using anatomical landmarks.\u003c/p\u003e\u003cp\u003eThe patient was brought into the OR and prepped and draped as per standard hospital protocol. The AR registration process was coordinated via four physical items: 1.) The anchored reference array (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA/B), 2.) AR HoloLens headset, 3.) the optic code array stylist and 4.) the patient's anatomical landmarks (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD).\u003c/p\u003e\u003cp\u003eThe reference array was fixed to the surgical table, adjacent to the patient\u0026rsquo;s skull (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). An optical code array (ArUco marker library \u0026ndash; similar to a \u0026ldquo;QR code\u0026rdquo;) was tracked by the HoloLens 2 optical cameras (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD) and used as a registration anchor. The headset was then donned on the surgeon, to confirm the placement of both the reference array and optic code stylist. Once the headset properly confirmed the reference array and optic code stylist, it then was registered to standard anatomical landmarks such as the tragus, nasion, and subnasale (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). Lastly, after confirmation by the surgeon that the registration was accurate, visual overlay of anatomical structures could be seen through the headset directly on the surgical field (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) and used to plan an optimal surgical trajectory. Of note, gold-standard navigation by BrainLab supplemented the surgery to ensure proper surgical accuracy (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eOperative and Post-Operative Course\u003c/h3\u003e\n\u003cp\u003eThe patient was placed under anesthesia and intubated. Pre-Operative Antibiotics and anti-seizure medications were given for prophylaxis, and mannitol was administered for brain relaxation. The patient was rotated 180 degrees and then secured in the lateral position (right side down) with an axillary roll and pinned in a Mayfield frame with her head turned 30 degrees to the right, neutral flexion, and tilted upward. Brain lab navigation was registered and the trajectory to the lesion was verified. Xironetic navigation was also registered and used to visualize the trajectory (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAfter prepping and draping, the 3D AR overlay and navigation guided surface mapping of anatomical structures onto the skin with a pen (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The transverse and straight sinus were overlayed on the visual field and compared to traditional navigation (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The AR navigation allowed the surgeon to accurately orient himself around the venous sinuses and guide the incision. Following the incision, the mapping of the venous sinuses could now be seen on the bone and guided mapping and planning of the burr holes. (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). An occipital craniotomy was followed by removal of a bone flap, exposing sagittal and transverse sinuses. Using the navigating stylet, an EVD was placed in the occipital horn of the right lateral ventricle for brain relaxation. The occipital lobe was visualized, and Adaptec was placed on its surface for protection. Dynamic retraction was employed to gradually expose the falco-tentorial junction and the length of the straight sinus. AR navigation was utilized throughout the entire tumor approach. The operative microscope was then introduced into the surgical field. The ultrasound with a flexible \"hockey stick\" handpiece was used to visualize the straight sinus and the nearby anatomy to validate our Brainlab and Xironetic-visualized deep sinus anatomy.\u003c/p\u003e\u003cp\u003eThe pial surface of the right paramedian vermis was opaque and thickened and transitioned to normal pial more laterally. This area was bipolar cauterized, and cut with micro scissors, and the tumor nodule dissected and sampled with tumor forceps. The tumor was pale and avascular and suctioned easily. We transitioned to the Nico Myriad handheld device with an additional light piece. This was used primarily to aspirate the soft tumor gradually, until the depth of the nodule at 1-1.5cm was encountered, and normal folia pia was visualized. From this deep boundary, the 8 Rhoton was used to dissect the boundaries of the nodule and to pull the tumor into the area of central debulking. The tumor was resected piecemeal.\u003c/p\u003e\u003cp\u003eAfter the medial/lateral, and deep anterior/posterior margins were inspected, we used the ultrasound to confirm the correct location of resection with respect to the fourth ventricle. Brainlab and Xironetics AR also confirmed the margins. Final pathology confirmed Grade IV Medulloblastoma. The surgical time from incision to closure was 5 hours, with an estimated blood loss of 100 ml. There were no intra-operative or post-operative complications.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eObservations\u003c/h2\u003e\u003cp\u003eSince the inception of neurosurgery, there has been continued evolution of technology to improve patient outcomes and surgical safety, efficiency and accuracy\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Some of these technologies include the operative microscope, high resolution imaging, intra-operative navigation and more recently robotics and augmented reality\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Just as intra-operative navigation has now become standard practice, we believe Augmented Reality has the potential to follow-suit. This case report is important because it is the first to describe the use of AR to perform a pediatric tumor resection in the posterior fossa. It demonstrates the feasibility of AR in this case and motivates further studies to be conducted.\u003c/p\u003e\u003cp\u003eIn our case, we resected a cerebellar tumor which was surrounded by the straight sinus, in which damage could result in significant mortality and morbidity. Although anecdotally, with very sparse literature to support these claims, surgeons find posterior fossa surgeries to have higher rates of complications\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Our approach was non-conventional in that we underwent an occipital trans tentorial instead of the more commonly used suboccipital craniotomy. Posterior fossa tumor resections, like the one presented above have case series estimating complications between 30% and 62%\u003csup\u003e8\u003c/sup\u003e. One study found some of the most common complications to be CSF leaks (13%), infection (7%), cranial nerve palsy (4.8%), hematoma (3%) and death (2%)\u003csup\u003e9\u003c/sup\u003e. We found the use of AR navigation to be extremely helpful in planning of the incision and burr holes and particularly in navigating around the straight sinus. Specifically, AR was helpful in planning the surgical corridor to the tumor involved lining up surface anatomy (sagittal and transverse sinuses) with deeper anatomy (opening of falx next to straight sinus) to get to the tumor. The technology allowed for improved depth perception and proximity to the lesion. Although we present only one case, we demonstrate a significant benefit of visualizing critical anatomy in real time via AR and its potential to improve patient safety.\u003c/p\u003e\u003cp\u003eOne of the challenges in neurosurgery is being able to safely accomplish gross total resection of a tumor. Many of these challenges are due to difficulty visualizing the lesion/mass in 3D space but also navigating around critical anatomy. One of the benefits of AR technology intra-operatively is distinct borders around the lesion can be made and then overlayed on the surgical field. A recent study demonstrated that AR guided navigation had more complete tumor resection margins than traditional navigation\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. With the use of AR, there may be increased confidence that the entirety of the mass is removed because it can be confirmed by visualization. We found pre-operative modeling of patient specific AR overlays to be accurate in comparison to intra-operative use (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe time to complete a surgical procedure is one of the limiting factors in neurosurgery. Due to the need for meticulous dissection, procedures can be long and taxing on the surgeon. AR technology may improve accuracy and safety, allowing surgeons to be more time efficient. Improved surgical efficiency diminishes the risks of anesthesia, especially in pediatric populations that are more vulnerable. Improved efficiency can also diminish workload burden on surgeons and improve feelings of burnout.\u003c/p\u003e\u003c/div\u003e"},{"header":"Limitations","content":"\u003cp\u003eAlthough AR is promising in the field of neurosurgery there are a few limitations to note. Although AR-navigation systems, like Xironetics are FDA approved, traditional neuro-navigation is standard of care. Until more research can be done, validating its benefits, we believe AR cases should be done using traditional neuro-navigation to verify accuracy. Joint use of these technologies increases surgical time and makes it difficult to evaluate the true efficacy of AR technology. Another limitation is that the workflow for AR is not standardized. The intraoperative use of this technology may vary and there is currently no unified way to conduct many of these surgeries. Also, the technology itself is not unified. For example, neuro-navigation is mainly done by two systems (Brain lab and Medtronic Stealth). Currently there is no gold-standard for AR technology, in which current systems function slightly differently.\u003c/p\u003e\n\u003ch3\u003eLessons\u003c/h3\u003e\n\u003cp\u003eAR technology is an emerging technology, which is promising in the field of neurosurgery. New applications are being utilized in spine surgery, as well as cranial surgery. Our case demonstrates, from our knowledge, the first application of AR to pediatric neurosurgical approach of a posterior fossa tumor. We demonstrated that the technology was useful in improving patient safety, accuracy and efficiency. Specifically, we found the technology useful in craniotomy planning and navigating around venous sinus anatomy. Our results demonstrate the need for prospective multi-center, high volume trials to validate the application of this technology.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements: None\u003c/p\u003e\n\u003cp\u003eFunding Declaration: None\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUdaka YT, Packer RJ. Pediatric Brain Tumors. \u003cem\u003eNeurol Clin\u003c/em\u003e. 2018;36(3):533-556. doi:10.1016/j.ncl.2018.04.009\u003c/li\u003e\n\u003cli\u003eKlein O, Boussard N, Guerbouz R, Helleringer M, Joud A, Puget S. Surgical approach to the posterior fossa in children, including anesthetic considerations and complications: The prone and the sitting position. Technical note. \u003cem\u003eNeurochirurgie\u003c/em\u003e. 2021;67(1):46-51. doi:10.1016/j.neuchi.2020.04.128\u003c/li\u003e\n\u003cli\u003eJohnson RD, Stacey RJ. The impact of new imaging technologies in neurosurgery. \u003cem\u003eThe Surgeon\u003c/em\u003e. 2008;6(6):344-349. doi:10.1016/S1479-666X(08)80006-6\u003c/li\u003e\n\u003cli\u003eRagnhildstveit A, Li C, Zimmerman MH, et al. Intra-operative applications of augmented reality in glioma surgery: a systematic review. \u003cem\u003eFront Surg\u003c/em\u003e. 2023;10. doi:10.3389/fsurg.2023.1245851\u003c/li\u003e\n\u003cli\u003ePatel N, Hofmann K, Keating RF. Current Applications of VR/AR (Virtual Reality/Augmented Reality) in Pediatric Neurosurgery. In: Di Rocco C, ed. \u003cem\u003eAdvances and Technical Standards in Neurosurgery: Volume 49\u003c/em\u003e. Springer International Publishing; 2024:19-34. doi:10.1007/978-3-031-42398-7_2\u003c/li\u003e\n\u003cli\u003eHunt R, Scarpace L, Rock JP. Intraoperative Augmented Reality for Complex Glioma Resection: A Case Report. \u003cem\u003eCureus\u003c/em\u003e. 16(4):e57717. doi:10.7759/cureus.57717\u003c/li\u003e\n\u003cli\u003eVadhavekar NH, Sabzvari T, Laguardia S, et al. Advancements in Imaging and Neurosurgical Techniques for Brain Tumor Resection: A Comprehensive Review. \u003cem\u003eCureus\u003c/em\u003e. 16(10):e72745. doi:10.7759/cureus.72745\u003c/li\u003e\n\u003cli\u003eAnetsberger S, Mellal A, Garvayo M, et al. Predictive Factors for the Occurrence of Perioperative Complications in Pediatric Posterior Fossa Tumors. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2023;172:e508-e516. doi:10.1016/j.wneu.2023.01.063\u003c/li\u003e\n\u003cli\u003eDubey A, Sung WS, Shaya M, et al. Complications of posterior cranial fossa surgery\u0026mdash;an institutional experience of 500 patients. \u003cem\u003eSurg Neurol\u003c/em\u003e. 2009;72(4):369-375. doi:10.1016/j.surneu.2009.04.001\u003c/li\u003e\n\u003cli\u003eLuzzi S, Giotta Lucifero A, Martinelli A, et al. Supratentorial high-grade gliomas: maximal safe anatomical resection guided by augmented reality high-definition fiber tractography and fluorescein. \u003cem\u003eNeurosurg Focus\u003c/em\u003e. 2021;51(2):E5. doi:10.3171/2021.5.FOCUS21185\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Augmented Reality, Augmented Reality Navigation, Virtual Reality, Mixed Reality, Medulloblastoma, Neuro Oncology, Neurooncological surgery","lastPublishedDoi":"10.21203/rs.3.rs-7716418/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7716418/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePediatric central nervous system tumors, such as medulloblastomas, are rare but represent the second most common childhood malignancy. Despite advancements in technology, resecting deep-seated tumors within the posterior fossa remains challenging due to critical surrounding structures, such as the straight sinus, and potential complications, including neurological deficits and posterior fossa syndrome. Augmented reality (AR) technology has emerged as a promising tool, providing real-time visualization of critical anatomy to enhance precision and safety during surgery. This case represents the first reported application of AR-assisted navigation for the resection of a pediatric deep cerebellar tumor.\u003c/p\u003e\u003ch2\u003eObservations\u003c/h2\u003e\u003cp\u003eWe present the case of a 14-year-old female with recurrent medulloblastoma who underwent surgical resection aided by AR navigation. The AR technology was a hands-free headset (Microsoft HoloLens) with integrated navigation software (Xironetics) which allowed surgeons to overlay critical anatomy while orienting themselves in 3D space. The tumor was successfully resected without complications, and AR navigation demonstrated significant utility in preoperative planning, incision guidance, and real-time depth perception.\u003c/p\u003e\u003ch2\u003eLessons\u003c/h2\u003e\u003cp\u003eThis case highlights the potential of AR navigation to improve patient safety, enhance surgical accuracy, and optimize outcomes in complex neurosurgical cases. The use of AR-navigation technology offered distinct advantages, such as accurate cranial surface mapping, hands-free navigation, and real-time deep anatomical visualization. Our report highlights a new generation of AR technologies with positive outcomes, which motivates the need for further research, including prospective, multi-center studies, to validate the broader application of AR in neurosurgery.\u003c/p\u003e","manuscriptTitle":"Use of Augmented Reality Navigation in Pediatric Deep Cerebellar Tumor Resection: An Illustrative Case","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 11:50:31","doi":"10.21203/rs.3.rs-7716418/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-14T10:41:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-10T05:34:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185196915212709731141862031529987265320","date":"2025-11-09T15:12:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-09T15:09:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-06T05:37:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-06T05:35:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2025-09-26T00:02:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"29c1ae1c-8e9d-42ad-9c9f-cdd48655783e","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-10T07:54:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 11:50:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7716418","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7716418","identity":"rs-7716418","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}