Atlas Neurosurgical Navigation System for Low-Resource Settings - Project Summary Traumatic brain injuries (TBI) comprising trauma, subarachnoid hemorrhage, and acute hydrocephalus are neurological emergencies that often require the intervention of a neurosurgeon. Annually, 5.48 million suffer from TBI globally, leading to an economic burden of $37.8 billion annually. Severe TBI occurs more often in low-to- middle income countries (LMIC), leading to increased TBI burden shouldered by these regions of the world. Life- saving treatment for TBI commonly begins with placement of an external ventricular drain (EVD), a catheter that drains fluid from the brain ventricles that has the potential to temporarily stabilize the patient by reducing pressure within the skull. Most LMIC lack critical resources and access to neurosurgeons, making severe TBI a leading cause of trauma-induced death. Developing an EVD placement approach that is accessible for emergency care providers has potential to reduce death from preventable causes, particularly in LMIC. This proposal aims to address a global disparity of access to neurosurgery by constructing a low-cost surgical instrument for real-time surgical navigation and EVD placement that is accessible to LMIC, rural hospitals, and military settings. The instrument will rigidly connect to an injured patient’s skull and act as a coordinate measuring system. The device will register to preoperative imaging and visually guide the operator through the steps of the EVD placement workflow. System accuracy will be tested using novel human ventricular simulators designed specifically for measuring EVD placement. Measurements will be taken with respect to a known target location inside the simulators, allowing for accuracy to be assessed. The research team will then test placement by a variety of care providers in the simulators, with measurements taken using magnetic resonance imaging. The device will be a linear four degrees-of-freedom arm operated with hand-guidance. It will be constructed from aluminum with a stainless steel self-tapping hollow bolt to connect the device to a 10mm skull burr hole. Four encoders will relay their position to a battery-powered Raspberry Pi, communicating wirelessly to a computer’s visualization software. An EVD will attach to the effector of the system with a known offset from the tip, and the operator will guide the drain through the burr hole under visualization into the target ventricle of the brain to achieve adequate drainage. This complete system will be designed to cost less than $5,000 USD at production scale and be capable of guiding an operator through the surgical workflow, allowing for improved access to neurosurgical stabilization treatment even in the absence of a neurosurgeon. The principles of this new type of navigation, named kinematic navigation, will be further explored in additional medical procedures to assess generalizability of its use. The same system used for intracranial pressure relief described above will be used to additionally guide tumor biopsy. Finally, a system with five degrees of freedom will be constructed using five axes to assess the feasibility of using kinematic navigation in image-guided spine surgery.
