Ultrasound is not generally used to guide neurosurgical procedures because of the poor quality of the images and the difficulty in identifying anatomical features. The real-time nature of the technique could prove useful in aligning pre-operative images to the patient, however. Ultrasound has been proposed for use in compensating for brain shift and also in improving rigid registration by finding the bone surface in spinal surgery.

Attention is also being paid to the ergonomics of surgical guidance. The systems have sometimes been seen as a cumbersome addition to an already crowded operating theater, and the interface between the system and the surgeon is often too complicated. Simplicity and ease of use are vital if image-guided neurosurgery is to become standard practice. Visualization of pre-operative images is an important factor in this regard, especially for microscopic procedures. The surgeon often finds that looking away from the operative view is distracting and inconvenient. Visualization of the target lesion and surrounding critical structures directly on the optical view of the patient, sometimes referred to as "augmented reality", is one way of avoiding this problem. In the MAGI (microscope-assisted guided intervention) system [28], this is achieved accurately and in stereo, offering the possibility of 3D perception of structures beneath the viewed surface (Fig. 7.1).

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