Augmented Reality Navigation for Superficial Temporal Artery Mapping in Extracranial-Intracranial Bypass: Cadaver Validation and Clinical Translation

Background: Accurate localization of the superficial temporal artery (STA) is critical for extracranial–intracranial (EC–IC) bypass, yet can be challenging in patients with variant anatomy or vascular disease. Conventional approaches rely on Doppler probes or duplex ultrasound, which may occlude small-caliber branches. Augmented reality (AR) navigation, leveraging preoperative imaging and real-time overlays, provides a direct visual map of vasculature on the surgical field. Our group previously developed an AR registration workflow using landmarking and surface-tracing. Objective: To validate the registration accuracy of our AR navigation system in cadavers and assess its clinical utility for STA mapping in EC–IC bypass patients. Methods: Five cadaver heads were procured. Neurosurgical residents and faculty (n=5) registered preoperative CT to cadavers using AR surface-tracing registration and drilled 12 preplanned burr holes per head (n=60) (Fig. 1a). Post-procedural CT was used to measure burr hole accuracy. Participants completed surveys comparing AR and conventional navigation ( Table 1 ). Following validation, the AR system was applied in 4 consecutive patients undergoing EC–IC bypass. Average registration error, mapping times, and intraoperative applications (STA course visualization, graft length estimation, anastomosis planning, and cortical mapping post-dural opening) were documented (Fig. 1b–d). Results: On cadavers, burr hole placement demonstrated a median error of 1.67 mm (IQR 0.99 mm). Likert-scale surveys favored AR for maintaining surgical focus (mean 4.57 vs 2.29, p = 0.0004), while also finding AR navigation to be intuitive to use and easily integrated into the surgical workflow ( Table 1 ). In 4 clinical EC–IC bypass cases, average registration error was 1.75 mm, and STA mapping was completed in an average of 95 s. AR was used intraoperatively for graft length measurement, localization of anastomosis sites, and visualization of motor cortex after dural opening. All patients achieved robust revascularization on postoperative angiography. Table 1 Surgeon feedback on AR vs traditional navigation (Likert 1–5) Conclusion: This AR navigation system provided sub-2 mm registration accuracy comparable to conventional navigation, while enabling rapid (