Mixed Reality Holography-Assisted Neuroendovascular Coil Embolization of Intracranial Aneurysms: Feasibility and a Novel Benefit Scoring System in 123 Consecutive Cases.

Abstract

Endovascular coil embolization is an established treatment for intracranial aneurysms; however, it is limited by its reliance on two-dimensional (2D) fluoroscopic imaging. Mixed Reality Holography (MRH) offers real-time three-dimensional (3D) visualization, potentially improving procedural accuracy and patient outcomes. This study evaluated the feasibility and clinical utility of MRH for neuroendovascular procedures. To assess the feasibility, benefits, and outcomes of MRH-assisted endovascular coil embolization for treating intracranial aneurysms. Object Loader, an existing mixed reality application built on the Unity platform, was deployed on HoloLens 2. Between September 2021 and August 2024, 115 consecutive patients with 123 intracranial saccular aneurysms underwent MRH-assisted embolization. Preoperative 3D vascular models were created using rotational angiography and were integrated into the MRH system. The benefits of MRH were assessed using a novel scoring system, developed by the authors, that quantified its impact on anatomical visualization, spatial awareness, and catheter navigation. Procedural success, aneurysm occlusion rates, and complications were analyzed. MRH significantly improved spatial perception and anatomical discrimination with a mean benefit score of 6.0. The most frequent benefits were enhanced visualization of the overlapping anatomy (89%) and improved spatial awareness (64%). Immediate postoperative angiography revealed a complete occlusion rate of 92% (modified Raymond-Roy classification I). No hemorrhagic complications occurred, and two cases of in-stent thrombosis were successfully managed intraoperatively. No new neurological deficits were observed in any of the patients. MRH enhanced intraoperative spatial awareness and anatomical discrimination in neuroendovascular aneurysm embolization. The MRH Benefit Scoring system provides a reproducible framework for evaluating visualization technologies in this field. MRH may serve as a valuable adjunct that could help reduce cognitive load and enhance spatial awareness; however, its effect on procedural outcomes remains to be established through prospective, controlled studies.