See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/338567379

Virtual and augmented reality: potential applications in radiology

Article in Acta Radiologica · January 2020

DOI: 10.1177/0284185119897362

CITATIONS READS

42 1,940

11 authors, including:

Mohammad Elsayed Nadja Kadom

Memorial Sloan Kettering Cancer Center Emory University
33 PUBLICATIONS 313 CITATIONS 177 PUBLICATIONS 3,236 CITATIONS

SEE PROFILE SEE PROFILE

Comeron Ghobadi Omran Al Dandan

The University of Chicago Medical Center Imam Abdul Rahman bin Faisal University
21 PUBLICATIONS 570 CITATIONS 43 PUBLICATIONS 465 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Mohammad Elsayed on 21 April 2021.

The user has requested enhancement of the downloaded file.

Review Article
Virtual and augmented reality:
potential applications in radiology
Mohammad Elsayed1 , Nadja Kadom1, Comeron Ghobadi2,
Benjamin Strauss2, Omran Al Dandan3 ,
Abhimanyu Aggarwal4, Yoshimi Anzai5, Brent Griffith6,
Frances Lazarow4, Christopher M Straus2 and Nabile M Safdar1
Abstract
The modern-day radiologist must be adept at image interpretation, and the one who most successfully leverages new
technologies may provide the highest value to patients, clinicians, and trainees. Applications of virtual reality (VR) and
augmented reality (AR) have the potential to revolutionize how imaging information is applied in clinical practice and
how radiologists practice. This review provides an overview of VR and AR, highlights current applications, future
developments, and limitations hindering adoption.
Keywords
Computer applications, virtual imaging, image manipulation/reconstruction, interventional, education
Date received: 7 October 2019; accepted: 2 December 2019
Introduction
Applications of virtual reality (VR) and augmented
reality (AR) have the potential to revolutionize how
imaging information is applied in clinical practice and
how radiologists practice (1,2). In this review, we per-
formed a targeted literature search (PubMed, Google
Scholar) related to use of AR and VR in medicine,
medical education, and radiology. References within
manuscripts including other manuscripts and news
media are included. Articles containing specific inter-
ventions were prioritized by study quality and publica-
tion date. This review provides an overview of VR and
AR, highlights current applications, future develop-
ments, and limitations hindering adoption.
Definition of VR and AR
Both VR and AR, although distinct from each other,
refer to simulations in which virtual elements are used
to replace or supplement native sensory input. VR is an
immersive simulation which creates the perception of
being present within a non-physical virtual world.
This is typically accomplished with a head-mounted
display (HMD) in which a user receives sensory input
from the display rather than their native surroundings
Acta Radiologica
0(0) 1–8
! The Foundation Acta Radiologica
2020
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0284185119897362
journals.sagepub.com/home/acr
(3). AR differs from VR in that the real world is not
eliminated from the user’s view. Instead, virtual objects
are superimposed onto the real world through a HMD
or other display system, so that the user is able to inter-
act simultaneously with the real world as well as with
virtual objects (3–5). Users may interact with graphics
and virtual objects through the use of voice commands,
hand gestures, or with a controller (3,6).
1
Department of Radiology and Imaging Sciences, Emory University
School of Medicine, Atlanta, GA, USA
2
Department of Radiology, The University of Chicago Pritzker School of
Medicine, IL, USA
3
Department of Radiology, Imam Abdulrahman Bin Faisal University
College of Medicine, Dammam, Eastern Province, Saudi Arabia
4
Department of Radiology, Eastern Virginia Medical School, Norfolk, VA,
USA
5
Department of Radiology and Imaging Sciences, University of Utah
School of Medicine, Salt Lake City, Utah, USA
6
Department of Radiology, Henry Ford Health System, Detroit, MI, USA
Corresponding author:
Mohammad Elsayed, Department of Radiology and Imaging Sciences,
Emory University School of Medicine, 1364 Clifton Road NE, Suite BG03,
Atlanta, GA 303022, USA.
Email: mohammad.elsayed@emory.edu
2 Acta Radiologica 0(0)
Technology development
VR and AR concepts have existed for several decades.
Perhaps the earliest application of virtual reality was
pioneered by cinematographer Morton Heilig, who in
1962 designed and patented a “sensorama,” a wide-
angled video booth in which viewers were able to
watch a film while having their sensory systems
engaged through the use of fans, odor-emitters, stereo-
scopic sound, and motional chairs (7). An early version
of the HMD, attached to large sensors and a mechan-
ical arm suspended from the ceiling, was later devel-
oped by Ivan Sutherland in 1968 (8).
VR and AR applications were initially costly and
had limited capabilities (9). However, advances in tech-
nology, such as decreased costs of smartphone display
technology, graphics processing, and motion tracking
(3), have led to a boom of VR and AR gaming appli-
cations and a renewed interest in medical imaging
applications. The “miniaturization” of technology has
resulted in the development of high-performance wire-
less HMDs (10). Immersive reality has been further pop-
ularized by increased web connectivity and open source
software, which has facilitated exploration, collabora-
tion, and development of VR and AR applications.
Such advances have enabled innumerable applications
within medicine, including in medical education, proce-
dural planning, and therapeutic intervention. Total
spending in VR and AR is expected to rise dramatically,
from $11.4 billion in 2017 to nearly $215 billion in 2021,
with spending in healthcare applications projected to
reach $5.1 billion in 2025 (11,12).
Current and future applications
Alternative to 3D printing
In the last decade, physicians have increasingly utilized
3D-printing technology, in which reconstructions are
Table 1. Comparison between 3D printing to VR and AR.*
Interactivity
Render customizability (e.g. resizing,
coloring, morphing)
Associated costs
Turnaround time
Ease of use for end-user
Potential side effects for end-user
*Table based on the authors’ experience.
AR, augmented reality; HMD, head-mounted display; VR, virtual reality.
printed into models that can be interactively explored
(13,14). Use of 3D-printed models has improved pro-
cedural planning (15–32), medical research, and medi-
cal education (26,33–37). Despite the benefits of 3D
printing, there are several limitations which hinder its
widespread adoption, including cost, turnaround time,
and size constraints of printed models (14). VR and AR
technologies provide several advantages over 3D print-
ing (Table 1). Reconstructions can be generated at
comparatively low costs and turnaround times.
Specialized software allows models to be viewed at dif-
ferent sizes and manipulated in dynamic ways that
may improve an understanding of complex anatomy
(Fig. 1). The ease of use, lower cost, shorter turnaround
time, and customizability are appealing features of VR
and AR that can supplement or substitute 3D printing
in specific applications (38). While controlled data com-
paring the two modalities are limited, some studies
report advantages over 3D printing. For example,
when evaluating cerebrovascular anatomy for neurosur-
gical training, users reported greater resolution and edu-
cational potential with VR over 3D printing (39).
Diagnosis and surgical planning
VR and AR can aid in the understanding of complex
anatomical relationships. For example, AR models of
kidneys have been generated for surgical planning and
decision-making before robotic-assisted partial nephrec-
tomy (40). In the setting of camera-assisted surgery in
which the operator is limited by the endoscope’s internal
field of view, AR applications can transpose the endo-
scopic view onto the patient, aiding the surgeon’s ability
to navigate (41). Successful use of this technology has
been described for nephrectomy, nephrolithotomy, adre-
nalectomy, brain tumor resection, cerebral aneurysm
clipping, splenectomy, and abdominal tumor resection
(42–53). In mammography, viewing images of the breast
3D printing VR and AR
Haptic experience Visual simulation
Before printing Before and in real time
Software Software
Access to 3D printer HMD
Printing material
Hours to weeks (depending on how Minutes to hours
models are printed)
Easy Easy to difficult, depending on
complexity of the platform
None Cyber sickness
Elsayed et al.
Fig. 1. 3D-printed model and virtual reconstruction of conjoined twins for surgical planning.
in AR allows for stereoscopic depth perception, 3D
cursor use, and joystick navigation (54,55). Joystick nav-
igation involves the use of a handheld controller, which
can be used to “fly” throughout an image to better visu-
alize target areas. These tools may ultimately improve
detection and localization of abnormal microcalcifica-
tions and tumors (54,55). VR reconstructions of the
breast have also been introduced for the assessment of
tumor response after neoadjuvant chemotherapy and for
aiding in surgical planning (55,56).
Interventional radiology
VR and AR have the potential to revolutionize image-
guided interventions and improve patient outcomes.
Real-time AR reconstructions superimposed onto
patients for percutaneous and endovascular interven-
tions may provide benefits over conventional localiza-
tion techniques. A pilot study showed that viewing VR
reconstructions of splenic artery aneurysms before
endovascular embolization improved operator confi-
dence (57). In one model, AR reconstructions of the
aorta and its major branches were transposed onto a
phantom and, with the use of electromagnetic markers,
an endovascular catheter was tracked within the virtu-
ally generated vascular tree (58). This type of applica-
tion could theoretically reduce procedure time and
radiation exposure (58). AR also has growing promise
in percutaneous interventions, such as biopsies and
ablations (59). Although there are challenges associated
with patient movement and image mismatch when
using AR, advances in image reconstruction have sig-
nificantly improved accurate lesion localization with
AR, achieving a difference of <5 mm between virtual
and real distances (60). Currently, however, studies
evaluating objective benefits of AR over conventional
localization techniques in interventional radiology
3
(such as “road-mapping with fluoroscopy”) are limited
and will require more robust research than “proof-
of-concept” demonstrations to validate clinical utility.
The reading room
Attempts are underway to redesign the conventional
reading room with virtual reality. Typical reading
rooms require highly specialized equipment and specific
lighting conditions to ensure accurate image interpre-
tation. A novel virtual reality reading room has been
introduced, where images can be interpreted using a
commercially available HMD (61). Optimal image con-
ditions can be reconstructed in a virtual environment,
precluding the need for controlled external lighting
conditions and specialized monitors (61). In this spe-
cific application, image navigation is performed with
the use of hand gestures, which allows for dynamic
visualization, such as real-time object rotation and
tilting. Users found the platform to have sufficient
ease of use and interpretability without reporting any
discomfort (61). Use of VR reading rooms could cut
equipment and maintenance costs, and by eliminating
effects of ambient lighting conditions could potentially
improve diagnostic accuracy.
Relaxation/Distraction therapy
Distraction or relaxation therapies aim to reduce
patient pain and anxiety by using sensory stimuli in
lieu of pharmacological substances. Common distrac-
tion methods include listening to music or viewing
scenes on a standard digital screen (62–64). A distinct
benefit of using VR for distraction/relaxation therapy
is due to its completely immersive nature. Multiple
studies have shown that VR can help reduce the use
of sedation during MR imaging (65–67). VR has also
4 Acta Radiologica 0(0)
benefited pediatric patients aged 4–6 years by decreas-
ing pain and anxiety during dental procedures (68),
intravenous line placement (69), and other procedural
interventions (70). In adult burn victims, the use of VR
distraction therapy during dressing changes reduced
pain, anxiety, and length of hospitalization (71).
Reductions in pain were more notable with higher
quality headsets that covered a wider field of view,
suggesting that more immersive VR experiences are
more effective (72). In a separate pilot study, VR relax-
ation therapy was safely used during orthopedic sur-
gery under regional anesthesia (73). Distraction
therapy also decreased intravenous sedation and pro-
cedure related pain during preoperative adductor canal
catheter placement before total knee arthroplasty (74).
The efficacy of VR relaxation therapy has been validat-
ed by functional magnetic resonance imaging (fMRI)
(75). Users exposed to painful thermal stimuli during
fMRI scans reported less subjective pain and had sta-
tistically significant reductions in pain-related brain
activity while using VR relaxation therapy (75). The
reported successes of using VR for distraction therapy,
during invasive surgical procedures warrants adoption
in interventional radiology as well. Patients prone to
anxiety, claustrophobia, or high analgesic requirements
during interventional radiology procedures may find
this therapy especially beneficial.
Informed consent process
Informed consent, generally speaking, is a process of
communicating the purposes, risks, and benefits of pro-
cedures between a patient and provider (76). There has
been a shift toward a more patient-centered model in
which visual aids are used in an effort to overcome
lower levels of patient health literacy and ultimately
achieve a greater sense of autonomy in patients (77).
Improving the informed consent process can result in
decreased anxiety, higher patient satisfaction, and an
improved understanding of procedures (78–80). Part of
the consent process is an explanation of the procedure,
which could be accomplished by using VR. For exam-
ple, patients who were primed with what to experience
during the recovery process also experienced lower
postoperative pain, a shorter length of stay, and less
negative affect (81,82). Based on such positive effects,
the use of VR to enhance patient education and
consent for radiology procedures should be further
explored.
Education and training
Advances in diagnostic and interventional radiology
have increased the scope of procedures performed by
radiologists. Despite the growing breadth of radiology
procedures, time constraints in busy clinical services
have made it challenging to provide standardized
teaching for trainees. Trainees and faculty would
favor implementation of standardized procedural train-
ing during radiology residency (83), and VR lends itself
to creating such curricula. Current simulations based
on phantoms do not provide an experience that accu-
rately portrays a live situation, while VR simulations,
such as for cardiopulmonary resuscitation, can provide
an extremely high fidelity and customizable experience
(84). VR and AR simulations may also be used to more
accurately assess trainee performance, such as knowl-
edge and skill levels in neurosurgery (1).
Patients may also prefer that trainees undergo pro-
cedural training in a simulated environment before per-
forming procedures on patients. By using VR, trainees
can be transported into a procedure room where they
may observe and even participate in virtual procedures
before performing them on patients. This allows edu-
cators to provide standardized and curated educational
training material to all trainees. In a pilot program
implemented by McCarthy et al. (10), radiology faculty
and trainees were able to watch interventional radiolo-
gy tutorials in VR. This program allowed trainees to
experience the process of learning with an instructor in
a procedure room. The majority of pilot participants
reported that the module they watched was excellent or
good and had the potential to contribute to the future
of interventional radiology training (10). VR can also
fill gaps in procedural experience by providing simula-
tions of procedures that a trainee rarely encounters
during their graduate medical training (85,86).
Teaching challenging anatomical concepts can be
made simpler with VR and AR. 3D reconstructions
of images and post-processing software can be used
to generate high quality interactive VR and AR simu-
lations. Such simulations will enable the user to manip-
ulate and edit objects in ways that are not possible
using other modalities, such as 3D printing (3). For
example, virtual reality has been used to teach anatomy
to medical students with “virtual dissections” (87).
Advances in HMDs and decreasing costs have
enabled the “VR classroom.” For example, teaching
modules recorded with specialized 360 cameras can
be viewed in VR, which may provide more engagement
than conventional teaching methods. Certain applica-
tions also enable users to convene in a virtual location
(88). This technology can be used to enhance radiology
collaboration and education, including in underserved
locations. As commercial medical virtual reality appli-
cations continue to emerge, new interactive methods to
teach radiology will be developed (3).
Overall, the advent of VR simulations in medical
education can increase opportunities for providing
high-quality standardized educational simulations and
Elsayed et al.
assessments at scale, while minimizing the need for ded-
icated physical space, costly simulation manikins, or
need for human cadavers.
Limitations and ethical considerations in
VR and AR
One of the most notable side effects of immersive real-
ity is “cyber sickness.” In essence, this describes sensa-
tions of discomfort including nausea, headache, and
dizziness when using VR and AR applications (89–
91). It is posited that cyber sickness is due to vestibular
mismatch, in which there is the visual perception of
motion in a simulation without matching input from
the vestibular system (3). Multiple strategies aimed at
reducing cyber sickness have been explored, such as
developing VR simulations which only shows move-
ment when there is actual movement of the user’s
head (3). Advanced VR HMDs can track nuanced
head movements to reduce vestibular mismatch (3).
Eye strain may also contribute to discomfort with
VR, which can be caused by low frame-rates and
HMDs which do not properly accommodate the
user’s eyes (3,91). Developers must anticipate potential
discomfort with VR and find ways to mitigate
unwanted side effects when creating applications.
AR must overcome several limitations to become
useful during image-guided procedures. For example,
when virtually reconstructed anatomy is transposed
over a patient in real time with AR HMDs, the
image location must be accurate. Inaccurate localiza-
tion may result in a less efficient procedure or unnec-
essary patient harm. Techniques are being developed to
optimize AR image reconstruction, including overcom-
ing respiratory motion and organ deformation
(60,92–94). In addition to accurate image localization,
the device must feel like a “natural extension” of the
operator’s senses (95). The image must move smoothly
and accurately while the operator’s head position
changes. The HMD must also be light, comfortable,
and mobile enough for the operator to use during
potentially long image-guided interventions (95).
VR and AR technology are still limited with regards
to accurately portraying reality. Creating a realistic vir-
tual experience, while feasible using current technolo-
gy, can require significant time, financial resources, and
expertise. Therefore, developing simulations that do
not require high levels of accuracy, such as those sim-
ulating the performance of simple tasks may provide
the highest initial value (86). In addition, more high-
quality research is necessary to understand whether VR
and AR educational and training applications in radi-
ology provide a significant advantage over convention-
al methods to justify costs.
5
Caution should be taken when implementing this
technology in medicine. Numerous VR and AR appli-
cations have already been cleared by the FDA using the
510(k) pathway, where safety and effectiveness are
demonstrated by showing “substantial equivalence”
to pre-existing 3D modeling software (96,97).
However, more research is required to ensure that the
introduction of this technology in specific use-cases
confers a benefit to the radiologist workflow and
patient care.
Ethical concerns have been raised regarding any
unintended consequences when VR and AR supple-
ment or replace existing methods (98). For example,
inaccuracies in simulations may contribute to improper
training. An analogy to this is flight training of military
pilots, where a virtual simulation may not accurately
replicate certain scenarios, leading to a distorted per-
ception of real-time flight (98). In addition, trainees
may not receive the same level of scrutiny as they
would during live interventions, potentially fostering
the development of flawed techniques.
As VR and AR technology evolves, thorough con-
sideration should be given on how it is introduced into
medicine. Special attention should be placed on major
participants and their motivations in this arena.
Oversight from a combination of professions including
radiologist and non-radiologist physicians, informatics
specialists, developers, artists, and other industry pro-
fessionals are required to adequately test, facilitate, and
record changes in this field. Cautious introduction of
VR and AR will ensure that it is incorporated in a safe
and effective manner.
Conclusion
Advances in VR and AR have enabled novel
applications in education, training, and patient care
in radiology. We are currently exploring the utility of
VR for visualization of complex anatomy and proce-
dural training in interventional radiology. We believe
that further exploration and thorough research is war-
ranted to better understand how to best utilize this
technology to optimize radiology training and improve
patient care.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
6 Acta Radiologica 0(0)
ORCID iDs
Mohammad Elsayed https://orcid.org/0000-0002-2353-
5409
Omran Al Dandan https://orcid.org/0000-0002-2472-8261
References
1. Pelargos PE, Nagasawa DT, Lagman C, et al. Utilizing
virtual and augmented reality for educational and
clinical enhancements in neurosurgery. J Clin Neurosci
2017;35:1–4.
2. Committee on Diagnostic Error in Health C, Board on
Health Care S, Medicine Io, et al. Technology and Tools
in the Diagnostic Process. In: Balogh EP, Miller BT, Ball
JR (eds) Improving Diagnosis in Health Care. Washington,
DC: National Academies Press, 2015, pp.217–262.
3. Sutherland J, Belec J, Sheikh A, et al. Applying modern
virtual and augmented reality technologies to medical
images and models. J Digit Imaging 2019;32:38–53.
4. Moro C, Stromberga Z, Raikos A. The effectiveness of
virtual and augmented reality in health sciences and med-
ical anatomy. 2017;10:549–559.
5. Plasencia DM. One step beyond virtual reality: connect-
ing past and future developments. XRDS 2015;22:18–23.
6. Pratt P, Ives M, Lawton G, et al. Through the HoloLens
looking glass: augmented reality for extremity recon-
struction surgery using 3D vascular models with perfo-
rating vessels. Eur Radiol Exp 2018;2:2.
7. Drummond K, Hamburger E, Houston T, et al. The Rise
and Fall and Rise of Virtual Reality. Available at: http://
theverge.com/a/virtual-reality
8. Sutherland IE. A head-mounted three dimensional dis-
play. In: Proceedings of the December 9–11, 1968, fall
joint computer conference, part I. New York, NY:
ACM, 1968:757–764.
9. Schnipper M. Seeing is believing: The state of virtual
reality, https://www.theverge.com/a/virtual-reality (2017,
accessed November 2019).
10. McCarthy CJ, Yu AYC, Do S, et al. Interventional
Radiology Training Using a Dynamic Medical
Immersive Training Environment (DynaMITE). J Am
Coll Radiol 2018; 15: 789–793.
11. Worldwide Spending on Augmented and Virtual
Reality. Available At: https://www.idc.com/getdoc.jsp?
containerId=prUS42959717 (last accessed Oct 2018).
12. Healthcare Augmented & Virtual Reality Market Worth
$5.1 Billion By 2025. 2017. Available at: https://www.grand
viewresearch.com/press-release/global-augmented-reality-
ar-virtual-reality-vr-in-healthcare-market (last accessed
Oct 2018).
13. Rengier F, Mehndiratta A, von Tengg-Kobligk H, et al. 3D
printing based on imaging data: review of medical applica-
tions. Int J Comput Assist Radiol Surg 2010;5:335–341.
14. McGurk M, Amis AA, Potamianos P, et al. Rapid pro-
totyping techniques for anatomical modelling in medi-
cine. Ann R Coll Surg Engl 1997;79:169–174.
15. Nekooei S, Sardabi M, Razavi ME, et al. Implantation of
Customized, Preshaped Implant for Orbital Fractures
with the Aid of Three-dimensional Printing. Middle
East Afr J Ophthalmol 2018;25:56–58.
16. D’Urso PS, Earwaker WJ, Barker TM, et al. Custom
cranioplasty using stereolithography and acrylic. Br J
Plast Surg 2000;53:200–204.
17. Faber J, Berto PM, Quaresma M. Rapid prototyping as a
tool for diagnosis and treatment planning for maxillary
canine impaction. Am J Orthod Dentofacial Orthop
2006;129:583–589.
18. Mavili ME, Canter HI, Saglam-Aydinatay B, et al. Use
of three-dimensional medical modeling methods for pre-
cise planning of orthognathic surgery. J Craniofac Surg
2007;18:740–747.
19. Muller A, Krishnan KG, Uhl E, et al. The application of
rapid prototyping techniques in cranial reconstruction
and preoperative planning in neurosurgery. J Craniofac
Surg 2003;14:899–914.
20. Poukens J, Haex J, Riediger D. The use of rapid proto-
typing in the preoperative planning of distraction osteo-
genesis of the cranio-maxillofacial skeleton. Comput
Aided Surg 2003;8:146–154.
21. Guarino J, Tennyson S, McCain G, et al. Rapid proto-
typing technology for surgeries of the pediatric spine
and pelvis: benefits analysis. J Pediatr Orthop
2007;27:955–960.
22. Hurson C, Tansey A, O’Donnchadha B, et al.
Rapid prototyping in the assessment, classification and
preoperative planning of acetabular fractures. Injury
2007;38:1158–1162.
23. Wurm G, Tomancok B, Pogady P, et al. Cerebrovascular
stereolithographic biomodeling for aneurysm surgery.
Technical note. J Neurosurg 2004;100:139–145.
24. Giesel FL, Hart AR, Hahn HK, et al. 3D reconstructions
of the cerebral ventricles and volume quantification
in children with brain malformations. Acad Radiol
2009;16:610–617.
25. Armillotta A, Bonhoeffer P, Dubini G, et al. Use of rapid
prototyping models in the planning of percutaneous pul-
monary valved stent implantation. Proc Inst Mech Eng H
2007;221:407–416.
26. Kim MS, Hansgen AR, Wink O, et al. Rapid prototyp-
ing: a new tool in understanding and treating structural
heart disease. Circulation 2008;117:2388–2394.
27. Hiramatsu H, Yamaguchi H, Nimi S, et al. [Rapid pro-
totyping of the larynx for laryngeal frame work surgery].
Nihon Jibiinkoka Gakkai Kaiho 2004;107:949–955.
28. D’Urso PS, Barker TM, Earwaker WJ, et al.
Stereolithographic biomodelling in cranio-maxillofacial
surgery: a prospective trial. J Craniomaxillofac Surg
1999;27:30–37.
29. Kalet IJ, Wu J, Lease M, et al. Anatomical information
in radiation treatment planning. Proc AMIA Symp
1999:291–295.
30. Sun SP, Wu CJ. Using the full scale 3D solid anthropo-
metric model in radiation oncology positioning and
verification. Conf Proc IEEE Eng Med Biol Soc
2004;5:3432–3435.
31. Zemnick C, Woodhouse SA, Gewanter RM, et al. Rapid
prototyping technique for creating a radiation shield.
J Prosthet Dent 2007;97:236–241.
32. Sulaiman A, Boussel L, Taconnet F, et al. In vitro
non-rigid life-size model of aortic arch aneurysm for
Elsayed et al.
endovascular prosthesis assessment. Eur J Cardiothorac
Surg 2008;33:53–57.
33. Suzuki M, Ogawa Y, Kawano A, et al. Rapid prototyp-
ing of temporal bone for surgical training and medical
education. Acta Otolaryngol 2004;124:400–402.
34. Knox K, Kerber CW, Singel SA, et al. Rapid prototyping
to create vascular replicas from CT scan data: making
tools to teach, rehearse, and choose treatment strategies.
Catheter Cardiovasc Interv 2005;65:47–53.
35. Bruyere F, Leroux C, Brunereau L, et al. Rapid proto-
typing model for percutaneous nephrolithotomy training.
J Endourol 2008;22:91–96.
36. Canstein C, Cachot P, Faust A, et al. 3D MR flow anal-
ysis in realistic rapid-prototyping model systems of the
thoracic aorta: comparison with in vivo data and compu-
tational fluid dynamics in identical vessel geometries.
Magn Reson Med 2008;59:535–546.
37. Sodian R, Schmauss D, Schmitz C, et al. 3-dimensional
printing of models to create custom-made devices
for coil embolization of an anastomotic leak after aortic
arch replacement. Ann Thorac Surg 2009; 88:974–978.
38. Radhika Dhuru AS. 3 Ways Virtual Reality Can
Supplement Your Medical 3D Printing Activities (And
3 Ways It Won’t). Available at: https://www.material
ise.com/en/blog/3-ways-virtual-reality-supplements-medi
cal-3d-printing (last accessed Nov 2019).
39. Bairamian D, Liu S, Eftekhar B. Virtual reality angiogram
vs 3-dimensional printed angiogram as an educational tool-
A comparative study. Neurosurgery 2019;85:E343–e349.
40. Wake N, Bjurlin MA, Rostami P, et al. Three-dimension-
al printing and augmented reality: enhanced precision for
robotic assisted partial nephrectomy. Urology
2018;116:227–228.
41. Nicolau S, Soler L, Mutter D, et al. Augmented reality
in laparoscopic surgical oncology. Surg Oncol
2011;20:189–201.
42. Simpfendorfer T, Gasch C, Hatiboglu G, et al.
Intraoperative computed tomography imaging for navi-
gated laparoscopic renal surgery: first clinical experience.
J Endourol 2016;30:1105–1111.
43. Teber D, Guven S, Simpfendorfer T, et al. Augmented
reality: a new tool to improve surgical accuracy during
laparoscopic partial nephrectomy? Preliminary in vitro
and in vivo results. Eur Urol 2009;56:332–338.
44. Su L-M, Vagvolgyi BP, Agarwal R, et al. Augmented
reality during robot-assisted laparoscopic partial
nephrectomy: toward real-time 3D-CT to stereoscopic
video registration. Urology 2009;73:896–900.
45. Ukimura O, Gill IS. Imaging-Assisted Endoscopic Surgery:
Cleveland Clinic Experience. J Endourol 2008;22:803–810.
46. Marescaux J, Rubino F, Arenas M, et al. Augmented-
reality-assisted laparoscopic adrenalectomy. JAMA
2004;292:2214–2215.
47. Baumhauer M, Feuerstein M, Meinzer H-P, et al.
Navigation in endoscopic soft tissue surgery: perspectives
and limitations. J Endourol 2008;22:751–766.
48. Besharati Tabrizi L, Mahvash M. Augmented reality-
guided neurosurgery: accuracy and intraoperative appli-
cation of an image projection technique. J Neurosurg
2015;123:206–211.
7
49. Mahvash M, Besharati Tabrizi L. A novel augmented
reality system of image projection for image-guided neu-
rosurgery. Acta Neurochir (Wien) 2013;155:943–947.
50. Stadie AT, Kockro RA. Mono-stereo-autostereo: the
evolution of 3-dimensional neurosurgical planning.
Neurosurgery 2013;72 Suppl 1:63–77.
51. Konishi K, Hashizume M, Nakamoto M, et al.
Augmented reality navigation system for endoscopic sur-
gery based on three-dimensional ultrasound and comput-
ed tomography: Application to 20 clinical cases.
International Congress Series 2005;1281:537–542.
52. Ieiri S, Uemura M, Konishi K, et al. Augmented reality
navigation system for laparoscopic splenectomy in chil-
dren based on preoperative CT image using optical track-
ing device. Pediatr Surg Int 2012;28:341–346.
53. Souzaki R, Ieiri S, Uemura M, et al. An augmented real-
ity navigation system for pediatric oncologic surgery
based on preoperative CT and MRI images. J Pediatr
Surg 2013;48:2479–2483.
54. Rancati A, Angrigiani C, Nava MB, et al. Augmented
reality for breast imaging. Minerva Chir 2018;73:341–344.
55. Douglas DB, Boone JM, Petricoin E, et al. Augmented
Reality Imaging System: 3D Viewing of a Breast Cancer.
J Nat Sci 2016;2:e215.
56. Douglas DB, Petricoin EF, Liotta L, et al. D3D aug-
mented reality imaging system: proof of concept in mam-
mography. Med Devices (Auckl) 2016;9:277–283.
57. Devcic Z, Idakoji I, Kesselman A, et al. 4:03 PM
Abstract No. 30 Augmented virtual reality assisted treat-
ment planning for splenic artery aneurysms: a pilot study.
J Vasc Intervent Radiol 2018;29:S17.
58. Kuhlemann I, Kleemann M, Jauer P, et al. Towards
X-ray free endovascular interventions - using HoloLens
for on-line holographic visualisation. Healthc Technol
Lett 2017;4:184–187.
59. Nicolau SA, Pennec X, Soler L, et al. An augmented real-
ity system for liver thermal ablation: Design and evalua-
tion on clinical cases. Med Image Anal 2009;13:494–506.
60. Solbiati M, Passera KM, Rotilio A, et al. Augmented
reality for interventional oncology: proof-of-concept
study of a novel high-end guidance system platform.
Eur Radiol Exp 2018;2:18.
61. Sousa M, Mendes D, Paulo S, et al. VRRRRoom:
Virtual Reality for Radiologists in the Reading Room.
In: Proceedings of the 2017 CHI Conference on Human
Factors in Computing Systems, Denver, Colorado, May
6–11, 2017. New York, NY: ACM, 2017:4057–4062.
62. Lechtzin N, Busse AM, Smith MT, et al. A randomized
trial of nature scenery and sounds versus urban scenery
and sounds to reduce pain in adults undergoing bone
marrow aspirate and biopsy. J Altern Complement
Med 2010;16:965–972.
63. Evans D. The effectiveness of music as an intervention
for hospital patients: a systematic review. J Adv Nurs
2002;37:8–18.
64. Tan SY. Cognitive and cognitive-behavioral methods for
pain control: a selective review. Pain 1982;12:201–228.
65. Das DA, Grimmer KA, Sparnon AL, et al. The efficacy
of playing a virtual reality game in modulating pain for
8 Acta Radiologica 0(0)
children with acute burn injuries: a randomized con-
trolled trial [ISRCTN87413556]. BMC Pediatr 2005;5:1.
66. Hoffman HG, Chambers GT, Meyer WJ, 3rd, et al.
Virtual reality as an adjunctive non-pharmacologic anal-
gesic for acute burn pain during medical procedures. Ann
Behav Med 2011;41:183–191.
67. Khan J, Donnelly L, Koch BL, et al. A program to
decrease the need for pediatric sedation for CT and
MRI. Applied Radiology 2007;36:30.
68. Asl Aminabadi N, Erfanparast L, Sohrabi A, et al. The
impact of virtual reality distraction on pain and anxiety
during dental treatment in 4-6 year-old children: a ran-
domized controlled clinical trial. J Dent Res Dent Clin
Dent Prospects 2012;6:117–124.
69. Gold JI, Kim SH, Kant AJ, et al. Effectiveness of virtual
reality for pediatric pain distraction during i.v. place-
ment. Cyberpsychol Behav 2006;9:207–212.
70. Won AS, Bailey J, Bailenson J, et al. Immersive virtual
reality for pediatric pain. Children (Basel) 2017;4:E52.
71. Scapin S, Echevarria-Guanilo ME, Boeira Fuculo Junior
PR, et al. Virtual Reality in the treatment of burn
patients: A systematic review. Burns 2018;44:1403–1416.
72. Hoffman HG, Seibel EJ, Richards TL, et al. Virtual real-
ity helmet display quality influences the magnitude of
virtual reality analgesia. J Pain 2006;7:843–850.
73. Chan PY, Scharf S. Virtual reality as an adjunctive non-
pharmacological sedative during orthopedic surgery
under regional anesthesia: a pilot and feasibility study.
Anesth Analg 2017;125:1200–1202.
74. Pandya PG, Kim TE. Virtual reality distraction decreases
routine intravenous sedation and procedure-related
pain during preoperative adductor canal catheter
insertion: a retrospective study. Korean J Anesthesiol
2017;70:439–445.
75. Hoffman HG, Richards TL, Coda B, et al. Modulation
of thermal pain-related brain activity with virtual reality:
evidence from fMRI. Neuroreport 2004;15:1245–1248.
76. Baheti AD, Thakur MH, Jankharia B. Informed consent
in diagnostic radiology practice: Where do we stand? Ind
J Radiol Imaging 2017;27:517–520.
77. Satyanarayana Rao KH. Informed consent: an ethical
obligation or legal compulsion? J Cutan Aesthet Surg
2008;1:33–35.
78. Coyne CA, Xu R, Raich P, et al. Randomized, controlled
trial of an easy-to-read informed consent statement for clin-
ical trial participation: a study of the Eastern Cooperative
Oncology Group. J Clin Oncol 2003;21:836–842.
79. Pereira SP, Hussaini SH, Wilkinson ML. Informed consent
for upper gastrointestinal endoscopy. Gut 1995;37:151–153.
80. Davis TC, Holcombe RF, Berkel HJ, et al. Informed
consent for clinical trials: a comparative study of stan-
dard versus simplified forms. J Natl Cancer Inst
1998;90:668–674.
81. Powell R, Scott NW, Manyande A, et al. Psychological
preparation and postoperative outcomes for adults
undergoing surgery under general anaesthesia.
Cochrane Database Syst Rev 2016;(5):CD008646.
82. Kruzik N. Benefits of preoperative education for adult
elective surgery patients. AORN J 2009;90:381–387.
View publication stats
83. Prater A, Rostad BS, Ebert EL, et al. Towards consen-
sus: training in procedural skills for diagnostic radiology
residents-current opinions of residents and faculty at a
large academic center. Curr Probl Diagn Radiol
2018;47:387–392.
84. Murphy B. Virtual reality taking the dummies out of med-
ical simulation. Available at: https://www.ama-assn.org/edu
cation/accelerating-change-medical-education/virtual-reali
ty-taking-dummies-out-medical (last accessed 9 Jan 2018).
85. Harrison P, Raison N, Abe T, et al. The validation of a
novel robot-assisted radical prostatectomy virtual reality
module. J Surg Educ 2018;75:758–766.
86. Olasky J, Sankaranarayanan G, Seymour NE, et al.
Identifying opportunities for virtual reality simulation
in surgical education: a review of the Proceedings from
the Innovation, Design, and Emerging Alliances in
Surgery (IDEAS) Conference: VR Surgery. Surg Innov
2015;22:514–521.
87. Mitzi B. How VR is Revolutionizing the Way Future
Doctors are Learning About Our Bodies. Available at:
https://www.ucsf.edu/news/2018/07/411366/musical-
improvisation-brain (last accessed Oct 2018).
88. Nijholt A, Zwiers J, Peciva J. Mixed reality participants in
smart meeting rooms and smart home environments.
Personal and Ubiquitous Computing 2009;13:85–94.
89. Rebenitsch L, Owen C. Review on cybersickness in
applications and visual displays. Virtual Reality
2016;20:101–125.
90. Rebenitsch L. Managing cybersickness in virtual reality.
XRDS 2015;22:46–51.
91. Garzorz IT, MacNeilage PR. Visual-vestibular
conflict detection depends on fixation. Curr Biol
2017;27:2856–2861.e2854.
92. Zygomalas A, Kehagias I. Up-to-date intraoperative
computer assisted solutions for liver surgery. World J
Gastrointest Surg 2019;11:1–10.
93. Cheung TT, Ma KW, She WH, et al. Pure laparoscopic
hepatectomy with augmented reality-assisted indocyanine
green fluorescence versus open hepatectomy for hepatocel-
lular carcinoma with liver cirrhosis: A propensity analysis at
a single center. Asian J Endosc Surg 2018;11:104–111.
94. Kleemann M, Deichmann S, Esnaashari H, et al.
Laparoscopic navigated liver resection: technical aspects
and clinical practice in benign liver tumors. Case Rep
Surg 2012;2012:265918.
95. Khor WS, Baker B, Amin K, et al. Augmented and
virtual reality in surgery-the digital surgical
environment: applications, limitations and legal pitfalls.
Ann Transl Med 2016;4:454–454.
96. Corporation PbN. 510(k) Pemarket Notification for
OpenSight. Silver Spring, MD: U.S Food and Drug
Administration, 2018.
97. LLC PbST. 510 (k) Premarket Notification for SuRgical
Planner (SRP). Silver Spring, MD: U.S Food and Drug
Administration, 2018.
98. Whalley LJ. Ethical issues in the application of virtual
reality to medicine. Comput Biol Med 1995;25:107–114.