Toward global availability of low-cost, patient-specific cranial implants: creation and validation of automated CranialRebuild freeware application

• Published in: Acta neurochirurgica 2023-08, Vol.165 (8), p.2219-2224
• Main Authors: Xu, Alice, Venugopal, Vysakh, Aryal, Manish Raj, Alfawares, Yara, Matur, Abhijith V., Cheng, Joshua, Kosco, Ethan, McConaha, Matthew, Ghalsasi, Omkar, Lockett, Demiah, Bal, Gabriella, Andaluz, Norberto, Ngwenya, Laura B., Anand, Sam, Forbes, Jonathan
• Format: Article
• Language: English
• Subjects: Algorithms; Automation; Bone Cements; Brain trauma; Cadavers; Computed tomography; Humans; Image processing; Imaging, Three-Dimensional; Interventional Radiology; Medicine; Medicine & Public Health; Minimally Invasive Surgery; Neurology; Neuroradiology; Neurosurgery; Original Article; Polylactic acid; Printing, Three-Dimensional; Prostheses and Implants; Skull; Skull - diagnostic imaging; Skull - surgery; Surgical Orthopedics; Transplants & implants
• ISSN: 0942-0940; 0001-6268; 0942-0940
• DOI: 10.1007/s00701-023-05663-x

Purpose Financial restrictions limit the options for hermetically precise, patient-specific cranial implants (PSCIs) after decompressive hemicraniectomy (DHC) in low-income countries. Use of image segmentation, modeling software, and 3D printers has lowered costs associated with PSCIs. However, requirements of time and technical expertise have prevented widespread utilization. Our objective was to create a fully automated software algorithm that is able to generate a virtual model (.STL) of a negative of an implant using CT imaging following DHC. Methods A freeware algorithm (CranialRebuild) was constructed with the following capabilities: (1) after the upload of digital imaging and communications in medicine files, the normal side is analyzed in reference to the side of DHC, (2) Boolean subtraction is used to obtain a virtual image of the desired implant, and (3) a two-piece virtual model (.STL) of the PSCI mold is generated. In four cadaveric specimens, a standard DHC was performed. Post-DHC CT imaging was used to obtain a .STL of the negative of the implant, which was then printed using poly-lactic acid (PLA). Methylmethacrylate cement was used to generate a PSCI from the mold. The PSCIs were implanted into the index specimens; cosmesis was subjectively evaluated using a 5-point Likert scale. Results Two specimens were graded as 4/5, indicating that minor post-processing modification was needed for optimal cosmesis. Two specimens were graded as 3/5, indicating that optimal cosmesis could be obtained following moderate post-processing modification. Conclusions CranialRebuild can be used to create hermetically precise PSCIs at a fraction of the price of third-party vendors. Validation of this technology has significant implications for the accessibility of customized cranial implants worldwide.