Technical Note
Construction of Neuroanatomical Volumetric Models Using 3-Dimensional Scanning
Techniques: Technical Note and Applications
Roberto Rodriguez Rubio1-3, Joseph Shehata1,2, Ioannis Kournoutas1,2, Ricky Chae1,2, Vera Vigo1,2, Minghao Wang1,2,4,
Ivan El-Sayed2,3, Adib A. Abla1,2
- BACKGROUND: Visuospatial features of neuroanatomy
are likely the most difficult concepts to learn in anatomy.
Three-dimensional (3D) modalities have gradually begun to
supplement traditional 2-dimensionanl representations of
dissections and illustrations. We have introduced and
described the workflow of 2 innovative methods—photo-
grammetry (PGM) and structured light scanning (SLS)—
which have typically been used for reverse-engineering
applications. In the present study, we have described a
novel application of SLS and PGM that could enhance
medical education and operative planning in neurosurgery.
- METHODS: We have described the workflow of SLS and
PGM for creating volumetric models (VMs) of neuroana-
tomical dissections, including the requisite equipment and
software. We have also provided step-by-step procedures
on how users can postprocess and refine these images
according to their specifications. Finally, we applied both
methods to 3 dissected hemispheres to demonstrate the
quality of the VMs and their applications.
- RESULTS: Both methods yielded VMs with suitable
clarity and structural integrity for anatomical education,
surgical illustration, and procedural simulation.
- CONCLUSIONS: The application of 3D computer
graphics to neurosurgical applications has shown great
promise. SLS and PGM can facilitate the construction of
VMs with high accuracy and quality that can be used and
Key words
- 3D animation
- 3D scanning
- Extended reality
- Photogrammetry
- Structured light scanning
- Surgical neuroanatomy
Abbreviations and Acronyms
2D: 2-Dimensional
3D: 3-Dimensional
PGM: Photogrammetry
SLS: Structured light scanning
SS: Stereoscopic
VM: Volumetric model
WORLD NEUROSURGERY 126: 359-368, JUNE 2019
shared in a variety of 3D platforms. Similarly, the technical
demands are not high; thus, it is plausible that neurosur-
geons could become quickly proficient and enlist their use
in education and surgical planning. Although SLS is pref-
erable in settings in which high accuracy is required, PGM
is a viable alternative with a short learning curve.
INTRODUCTION
N euroanatomy is one of the most challenging concepts
to understand within anatomy, primarily owing to the
difficulty in attaining a comprehensive visuospatial un-
derstanding of the many neurovascular structures.1 Teaching
neurosurgical anatomy has traditionally involved dissecting
cadaveric specimens and reviewing 2-dimensional (2D)
anatomic representations. A number of recent studies have
suggested that incorporating stereoscopic (SS) images in medical
education will lead to improved spatial reasoning abilities
compared with traditional methods.2,3 The fundamental principle
behind SS is stereopsis—the perception of depth that arises from
binocular vision—a feature that can be reproduced using a variety
of technologies.4 Because performing surgery itself requires the
simultaneous application of anatomical knowledge and spatial
reasoning, the use of SS modalities in resident education
remains a promising frontier.
On the cutting edge of SS imaging are volumetric models (VMs),
which are often built from DICOM (digital imaging and commu-
nications in medicine) files—a modality that is apt at capturing the
From the 1Department of Neurological Surgery, 2Skull Base and Cerebrovascular Laboratory,
and 3Department of OtolaryngologyeHead and Neck Surgery, University of California, San
Francisco, California, USA; and 4Department of Neurological Surgery, First Hospital of China
Medical University, Shenyang, China
To whom correspondence should be addressed: Roberto Rodriguez Rubio, M.D.
[E-mail: luis.rodriguezrubio@ucsf.edu]
Supplementary digital content available online.
Citation: World Neurosurg. (2019) 126:359-368.
https://doi.org/10.1016/j.wneu.2019.03.099
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter Published by Elsevier Inc.
www.journals.elsevier.com/world-neurosurgery 359
TECHNICAL NOTE
Figure 1. Standard photogrammetry setup. After
dissection, the specimen is placed on a rotating surface
and covered with black cloth to avoid the detection of
undesired surface and facial characteristics. The
camera (D810 SLR [Nikon, Tokyo, Japan]) is fixed on a
tripod to maintain the same distance and focus. With
intricate minutiae of neuroanatomical topography. Anatomical
VMs acquired from DICOM were initially introduced for diag-
nostic and therapeutic planning and have now been routinely
used in both neuroanatomical research and teaching.5 Moreover,
interacting with the models using virtual reality could partially
simulate training in a cadaveric laboratory.6 Although the
Figure 2. A screenshot of the photogrammetry
postprocessing software, depicting the reconstruction
process where images are overlapped. The undesired
360 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.03.099
the specimen rotating slowly, the operator takes
photographs ensuring that the light and focus point do
not change during each 360 turn. Next, the process is
repeated at different elevations and angles to attain
high-quality alignment later in the process.
superiority of VM compared with traditional pedagogical
methods has questioned in various fields,7-16 studies of neuro-
anatomical applications and neurosurgical education have
demonstrated their role in improving performance.17-19 This can
be explained by the spatial complexity and density of surgical
neuroanatomy. Thus, it is plausible that volumetric depiction of
portion of the model (e.g., excess black sheet or
external outliers) can be easily erased before the
construction of the cloud to expedite the workflow.

Figure 3. A textured volumetric model created via
photogrammetry before additional postprocessing
highlights. The principle structures are easily
recognized, such as the pre- and postcentral gyrus and
professional surgical dissections will facilitate faster acquisition
and longer retention of the relevant concepts.
Fundamentally, 3-dimensional (3D) scanning describes the process
by which a detector traverses an object or specimen and collects data
on its shape, texture, and color before digitizing it.20 Two popular
techniques for acquiring this initial 3D blueprint of a target object
are photogrammetry (PGM) and structured light scanning (SLS).
PGM is a process by which the metrics of common surface points
are taken from photographs to create clouds of colorized
coordinates that will subsequently be triangulated to construct the
VM. Although methods for obtaining 3D data from 2D photographs
have been available for half a century,21 3D PGM applications have
appeared only sporadically in neurosurgery.22,23 However, recent
advances in 3D PGM software have made it a potentially practical
alternative to dedicated surface scanners.24 Its principal advantages
are portability, less required equipment, and rapid data collection, all
of which can reduce the overall research costs. Notable
applications of PGM include producing film and video games,
preparing topographic maps, and planning architectural designs.25,26
In contrast, 3D scanning techniques such as SLS represent a
portable method to rapidly obtain 3D anatomical data using
structured light or lasers to capture surface topography.24 The
scanner will typically be connected to a computer that
automatically registers and reconstructs the coordinated
frames.27 Subsequently, this rough image can be fine-tuned
and postprocessed to prepare it for export to a 3D modeling
server or 3D printing modality. Popular applications of such mo-
dalities include Microsoft Kinect (Microsoft Corp., Redmond,
Washington, USA), biometric identification software (e.g., face,
retinal scans), and reverse-engineering industrial tasks.28
METHODS
After performing microdissections of embalmed cadaveric
specimens, our laboratory followed a standardized workflow
to record the relevant neurosurgical anatomy. The major
WORLD NEUROSURGERY 126: 359-368, JUNE 2019
TECHNICAL NOTE
the central sulcus. The same model is further dissected
in model 5 after postprocessing—where it is possible
to appreciate the greater image quality and the deep
white matter tracts.
steps consisted of capturing 2D/SS media and subsequently
setting up specimens in a diffuse-light studio for scanning.
The fundamental process underlying both SLS and PGM
techniques was as follows: a series of images of the target
specimen’s surface were acquired from multiple viewpoints
using 360 rotation of an arbitrary vertical axis—at the supe-
rior, medium, and inferior elevations of the camera with
respect to the specimen. Postprocessing software can then
superimpose the acquired images and measure the inter-
secting tie points to triangulate their location in 3D space,
thereby creating a 3D model. Finally, lighting is an essential
consideration, because surface detection is the fundamental
mechanism by which these techniques operate. The object
should remain static, and the lighting should, ideally, be
diffuse. Objects that are glossy, metallic, or transparent
should be covered with talcum powder or scanning spray to
avoid reflections. Round target stickers can also be applied to
the background of objects with a homogenous surface and/or
texture to help the scanner detect the surface. After securing
the specimens on a turntable (Foldio360 [OrangeMonkie, San
Diego, California, USA), the scanning process was initiated.
PGM and Image Postprocessing
The PGM workflow consists of 3 steps: 1) image capture, 2)
preprocessing (optional), and 3) postprocessing. Because the
image was taken in 2 dimensions, the surface area that can
be captured was limited by the camera’s field of view. To
obtain additional surface angles, the assembly must be
moved relative to the surface, similar to the method used in
the scanning workflow.
Image capture can proceed using 3 methods: 1) taking multiple
photographs with a handheld camera moving relative to the
specimen between photographs; 2) rotating the specimen on a
turntable with the camera fixed on a tripod; and 3) extracting
www.journals.elsevier.com/world-neurosurgery 361
TECHNICAL NOTE
Figure 4. A standard structured light scanning setup, with the scanner
positioned at an optimal distance from the rotating specimen. Using
structured light scanning, the operator must be more accurate and give
more attention to the distance to capture all the desire surface. A rough
of the upcoming model will be created almost instantaneously.
frames from a video, again with the camera moving relative to
the specimen. The camera used will typically be a digital,
single-lens reflex, charged couple device, mirrorless camera,
or a smartphone camera. The selected camera should ideally
have a high megapixel count (>12 megapixels), with lens that
can provide a clear and static view of the entire surface.
Changes in distance or focus during photographic cycles will be
deleterious to the image quality and surface recognition. In the
videography option, auto-focus features should be disabled.
In our experience, we believe that the first 2 methods
involving the handheld camera and tripod will be the most
efficient for image capture (step 1). First, the specimen is
362 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.03.099
placed on a black cloth and secured on a turntable (a green
screen can also be used to facilitate masking). Next, the
operator takes a video or a series of photographs from the
superior, middle, and inferior aspects of the specimen,
rotating the object 360 on the turntable for each view of the
specimen (w45 photographs should be acquired about the
axis from each aspect; Figure 1). In the video option, capturing
a 45e90-second video at a frame rate of 24 frames/second
will yield w1000e2000 frames. Therefore, setting a frame
step of w10e25 should yield w80 images.
Although an optional step, preprocessing (step 2) the raw im-
age data set will yield a superior final result by increasing the
visibility of the details in the shaded and lit areas and increasing
the microcontrast. To achieve a visually aesthetic final image,
the exposure should be fixed such that the parts in shade are
lightened and the lit areas darkened. Chromatic aberrations
and noise will then be removed, and the image will be sharp-
ened. All processes are run in 16-bit and exported in 16-bit tag
image file format (.tiff), 16-bit portable network graphic format
(.png), or 100% quality 8-bit joint photographic experts group
format (.jpeg) using image processing software (DxO Optic-
sPro 11 [DxO Labs, Paris, France]).
Postprocessing (step 3) describes generating the mesh and
texture data from the images. The images are uploaded to a
reconstruction application and put through a sequence of
processing steps. A cache location is set to a dedicated large
solid-state drive (512 Gb) or on a hard disk drive. The images
are first subjected to automated masking, followed by manual
correction of the automatically generated masks. This step
excludes the background during model construction. Image
grouping with low overlap should be enabled to help avoid
incorrect camera and lens estimations. To construct the dig-
ital model, the masked photographs are then run through
alignment, geometric reconstruction, and texturing steps in
PGM software (Reality Capture Beta 1.0 [Capturing Reality,
Bratislava, Slovakia]). These processes will usually be run in a
semimanual mode (Figure 2). The reconstruction application
will compare the shapes in the photograph (alignment step)
to generate a high-resolution 3D mesh. During geometric
reconstruction, sharp reconstruction should be used to pre-
vent the software from filling holes in the 3D polygon. Af-
terward, texturing will superimpose a precisely shaded and
colored representation of the specimen over the geometric
reconstruction (i.e., the color contained in the photographs is
transferred to the textures used on the surface of the mesh).
The mesh can then be decimated to yield a simpler mesh
with fewer polygons (500,000e1,000,000), smoothed, and
exported in a wavefront data format (.obj) file with the
accompanying material files (.mtl format) and texture files
(.png format). The steps for postprocessing the image data
sets obtained from videos or photographs are identical.
Additional images of the most geometrically complex sur-
faces, including partially or entirely hidden surfaces and sur-
faces with fine detail, can be acquired to improve the
completeness and accuracy of the final volumetric model
(Figure 3). The image sharpness and depth of field should be
maximized.
 TECHNICAL NOTE

Figure 5. An image depicting 3 preliminary scans before alignment.

3D SLS The SLS scanner (Artec Space Spider [Artec, Luxembourg City,
The 3D scanning workflow for SLS involves 1) scanning and 2) Luxembourg]) should be held at an optimized distance (9e18
postprocessing. The specimen is first placed on a black cloth on cm) from the surface of the specimen, as determined by the
top of a turntable (if unstable, a wax support should be used). preview screen shown by the scanning software (Artec Studio

Figure 6. Postalignment model depicting the synthesis of the 3 scans obtained via structured light scanning.

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TECHNICAL NOTE
Figure 7. The volumetric model after the mesh has been decimated and smoothed. At this point, the model can be exported and texture added to complete
the final processing steps (e.g., texture touchups, smoothing).
12 [Artec]). The turntable should be smoothly rotated such that
the specimen rotates relative to the scanner. Multiple scans are
then acquired (Figure 4). For surface capture, 3 scans are
conventionally acquired (Figure 5). For capturing specimen
surfaces that cannot be fully scanned in a single orientation on
the turntable, 6e12 scans should be acquired by adjusting the
orientation of the specimen. The scanner can also be moved
over the surface of the static object. Regardless of the
method used, the scans should be taken with 360 rotation of
the specimen about an arbitrary vertical axis passing through
the center of the surface from the superior, middle, and
inferior aspects. The software will capture both geometrical
features and the color texture of the object. Overlap on the
scans will be achieved with the approximate aim that each
element is present in 3 images.
Each frame should be registered during postprocessing. For
rigid specimens, rigid alignment will be conducted (Figure 6).
For nonrigid specimens, the specimen should be frozen and
semithawed to facilitate the use of the nonrigid alignment
tool. The color texture should permit robust autoalignment
of the scans. Registration between the scans should be
performed and the outliers. The scan views should be
merged with sharp fusion to create a watertight polygon
mesh file. This semiautomatic process can be performed
using the 3D scanner’s proprietary software. The mesh is
then decimated to 500,000e1,000,000 polygons and
smoothed, if necessary (Figure 7). Finally, the mesh is
exported using the same file and formatting as described
for PGM (Figure 8).
364 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.03.099
Additional Postprocessing
Common problems that arise in the raw mesh are the holes
and nonmanifold edges or vertices (intersections) from the
decimation step. Standard semiautomated postprocessing,
including noise reduction hole filling, can be applied to fix raw
mesh topology errors for both PGM and SLS. The quality of
the clean mesh can then be checked for the same errors.
After repairing the mesh with 3D modeling software (Mesh-
Mixer, version 3.5 [AutoDesk, Inc., San Rafael, California,
USA]), a clean mesh can be textured and exported. If the
cameras were correctly aligned and the shots well taken, the
texture should be accurate and only require further editing in
areas at which the surface capture proceeded from a high
camera angle or hidden surfaces were reconstructed. Healing
brush tools from various software packages (Photoshop CC
2018 “19.00” [Adobe Systems, San Jose, California, USA])
allow for cloning and fusing textures from adjacent regions to
the part under restoration or re-creation.
We recorded and scanned a stepwise dissection of 3 hemi-
spheres that had been prepared via the Klinger method.29
One of the specimens was latex injected to depict the
relevant neurovascular anatomy of the medial and basal
surfaces.
After VMs had been obtained using the reported workflows
(Table 1), the models were uploaded to a 3D viewing platform
(Sketchfab [Sketchfab Inc., New York, New York, USA]) to
facilitate its interaction in 2 dimensions and extended reality
(i.e., virtual reality, mixed reality, augmented reality).
 TECHNICAL NOTE

Figure 8. A textured volumetric model created via structured light scanning before export. The details of the structured light scanning model are well-visible,
with the nerves and arteries easily visualized. After rendering, the model can be exported and can be used as an interactive model in 2 dimensions or 3
dimensions—or used to perform a cinematic rendering (Videos 3 and 4).

Annotations were added to the relevant anatomical landmarks
on the models. Two cinematic videos depicting the VM in
different stages of microdissection were rendered using 3D
modeling software (Blender 2.79 [Blender Foundation,
Amsterdam, Netherlands]) to provide a stylized view of the
corresponding neuroanatomy.
RESULTS
Both 3D scanning methods yielded models that upheld suitable
clarity and structural integrity for anatomical education, surgical
illustration, and, potentially, procedural simulation. Eight models of
the brain obtained via PGM (models 1e5) and SLS
(models 6e8) are depicted in Videos 1 and 2,
respectively. Model 5 (available at: https://sketchfab.
com/models/c8bd14b4d3374658a42a95a37e341511)
and model 8 (available at: https://sketchfab.com/
models/b9e3d39d2d8a4acc875873888c101233) are Video available at
www.sciencedirect.com
available on Sketchfab for a fully interactive
experience. In addition, rendered animations of the
VM were produced using Blender software (Blender
Foundation) to demonstrate a clip using a professional render
engine (Videos 3 and 4). The workflow and characteristics of each
technique are briefly summarized in Tables 1 and 2.
DISCUSSION
Computer graphics is a rapidly developing field with applications in
science, engineering, architecture, entertainment, and
medicine.30-32 Because most neurosurgical procedures and corre-
sponding pathologic entities involve intricate, minute anatomical
structures that cannot be easily perceived, neuroimaging has
become an integral component of clinical practice.5 Although
neuroimaging has enabled visualization of structures for both
diagnosis and surgical treatment, radiographs, computed
tomography scans, and magnetic resonance imaging have
typically been limited to 2 dimensions or a 3D volume in 2D
slices.33 Some studies have suggested that incorporating 3D
imaging of relevant anatomical structures can help medical
students and residents learn and retain the information, which has
supported the proliferation of anatomic volumetric models.34
Both SLS and PGM have specific advantages and
limitations. The best commercial 3D scanners have a
reported accuracy of 30 mm, a nominal resolution of
100 mm, and a rate point accuracy of 50 mm.35-38
Thus, these scanners will be most effective when
digitizing small-size objects with intricate details,
sharp edges, and thin ribs, such as certain neuroan-
atomical specimens. These scanners can generate
3D models with an accuracy of up to w100 mm.24 Although SLS
setups have typically been more expensive compared with PGM,
the physical sensors on SLS scanners allow for reconstruction of
meatus, foramina, canals, and other anatomical corridors. In
contrast, PGM lacks the reflection of visible light from the
deeper structures that results in constructing black meshes.
PGM-textured models seem to have improved texture quality
and, thus, greater cosmetic precision compared with those

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TECHNICAL NOTE
Table 1. Brief Summary of General Workflow for
Photogrammetry and Structured Light Scanning
Variable Photogrammetry
Imaging capture Surface of the object is
captured from the
superior, middle, and
inferior aspects; if
videography is chosen,
one must complete
frame extraction to
obtain the image data
set
Preprocessing Photographs can be
optimized and exported
in.tiff, .png, or .jpeg
format
Postprocessing Using postprocessing
software, images are
automatically masked,
aligned, reconstructed,
and textured; mesh is
decimated (500,000
e1,000,000 polygons),
smoothed, and exported
generated by SLS, which might improve anatomical fidelity. In
judging whether PGM is an appropriate tool for generating 3D
neuroanatomical reconstructions for a given project, several
practical considerations must be considered (Table 2). The
primary benefits of PGM technology include faster raw data
collection, portability, greater texture quality, and lower costs.
Table 2. Comparison of Efficiency, Quality, and Cost Between
Photogrammetry and Structured Light Scanning
Photogrammetry
Pros Faster raw data
collection (1e10
minutes); portability; low
cost ($50e$300); high
texture quality
Cons Increased
postprocessing time;
postprocessing requires
high RAM (>16 GB);
unable to reconstruct
small cavities and
canals; ambient light
can affect quality
366 www.SCIENCEDIRECT.com
However, the primary drawback of PGM is the postprocessing
time required. Data collection tends to be faster with PGM
than with SLS when video recording is implemented.39 In
Structured Light particular, taking photographs of a single specimen can be
Scanning accomplished in w5e10 minutes and taking a video can
require 1e2 minutes. In contrast, scanning the specimen via
The object is fixed on SLS will require w10e20 minutes. Although SLS requires an
a turntable and independent power source, the PGM hardware is highly
rotated 360 as the portable. Given an adequate light source, the only equipment
scanner is held at an needed to collect photographic data is a digital, single-lens re-
optimized distance (9 flex camera or smartphone, a tripod, and adequate flash card
e18 cm); the storage capacity. Neither a computer nor electrical power is
scanning is completed required on-site unless plug-in lighting is used. Such portability
at the superior, advantages make PGM useful for data collection in the operating
middle, and inferior theater or at a dissection station distant from a main power
aspects of each source or computer because photographs can be taken for future
surface remote digital reconstruction.
Frames are obtained
The tradeoff for the speed and flexibility of data collection with
in.scan format
PGM is that the processing after image capture is time intensive.
For SLS, standard postprocessing requires w15 minutes (inter-
active). For PGM, manual correction of photographic masks av-
Workflow is erages w1 minute per image. The suite of PGM model-building
semiautomatic and operations (alignment, geometry, and texture) is demanding of
includes scan both RAM and video card, commanding >10 GB of memory at
alignment, outlier peak. The time required to complete these operations depends
removal, texture
on the processing capability of the investigator’s computer and
addition, mesh
the number of photographs used to build the model.
decimation/
smoothing, and export Graphics issues in PGM include forming and decimating triangle
meshes, merging multiple range images, and detecting scan ar-
tifacts. One issue with SLS includes self-occlusion (e.g., noses
on faces), which can be readily solved by taking more images of
that region from multiple angles. SLS also has an inability to
reconstruct cavities (not resolvable by taking more images)
owing to the lack of physical sensors, resulting in gaps remaining
in the point cloud. Radial basis function interpolation or Delaunay
triangulation can be used to patch over such holes.40
Furthermore, edge curl will produce artifacts at sharp corners,
permitting discontinuities in the computed mesh to arise. Other
SLS problems are related to surface characteristics such as
surface reflectance and color, the translucence or transparency
of surfaces, and speckle (constructive and destructive
interference of light due to the microstructure of the reflecting
Structured Light
surface, although this will not usually be a problem). Ambient
Scanning
lighting can also be problematic in PGM. The substantial
Accuracy 0.05 mm; flexibility offered to the investigator in photographing a
automated and time- specimen suggests that different protocols could create
efficient variances in model quality.
postprocessing
workflow;
reconstruction of CONCLUSIONS
vessels, nerves, and
foramina The application of 3D computer graphics to neurosurgical edu-
cation has shown great promise and has become increasingly
Slower raw data prevalent in the reported data because development in other
collection (10e20
fields has facilitated its use in medicine. VMs are an innovative
minutes); high cost
and immersive method to experience the intricacies of neuro-
(>$3000); limited
anatomy and will likely continue to proliferate in academia and
portability
popular culture in the future. The present study has described 2
of the most common methods for producing a volumetric
reconstruction of anatomical models: surface capture via PGM
and SLS.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.03.099

Given the straightforward workflow, it is feasible for neurosur-
geons and anatomists to use the necessary hardware and soft-
ware and generate high-quality in situ VMs for neuroanatomical
education, surgical simulation, and surgical planning. SLS is
preferable if high accuracy is desired and the imaging of
anatomical corridors (e.g., foramina, meatus, canals) is required.
PGM yields a viable alternative to dedicated scanners, with the
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https://arxiv.org/pdf/1801.08863.pdf. Accessed Citation: World Neurosurg. (2019) 126:359-368.
August 10, 2018. https://doi.org/10.1016/j.wneu.2019.03.099
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter Published by Elsevier Inc.
Conflict of interest statement: The authors declare that
the article content was composed in the absence of any
commercial or financial relationships that could be
construed as a potential conflict of interest.
Received 6 December 2018; accepted 9 March 2019
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.03.099