Clinical accuracy and efficiency of augmented reality head-mounted displays in cranial neurosurgery: a systematic review

Background Augmented Reality (AR) integrates virtual anatomical information into the real-world environment in real time and has emerged as a promising navigation adjunct in cranial neurosurgery. Compared with conventional neuronavigation (CN), AR Head-Mounted Display (HMD) systems project patient-specific anatomy directly into the surgeon’s field of view, potentially improving spatial perception, ergonomics, and surgical workflow. However, their clinical performance remains uncertain because the available evidence is limited and methodologically heterogeneous. This systematic review synthesizes the accuracy and efficiency of AR HMD in cranial neurosurgical procedures. Methods A systematic review was conducted according to PRISMA guidelines. PubMed, Scopus, and ScienceDirect were searched for prospective clinical studies comparing AR HMD with conventional neuronavigation or reporting quantitative accuracy and/or efficiency outcomes in cranial neurosurgery. Results Nine prospective non-randomized studies involving 186 patients were included. Accuracy was assessed using registration error, deviation error, percent overlap, and subjective or objective evaluations. Among the five studies reporting registration accuracy, registration error ranged from 1.86 to 4.4 mm. Deviation errors were approximately 4 mm, and spatial congruence exceeded 65%. Subjective and objective assessments also demonstrated favorable anatomical localization and lesion visualization. Efficiency outcomes included registration, setup, planning, and navigation time. Registration time ranged from 2.6 to 7.95 min. Among five comparative studies, two reported shorter procedural times with AR HMD, one reported comparable time, and two reported longer times than conventional neuronavigation. Conclusion AR HMD technology is a promising adjunct for cranial neurosurgical navigation, providing clinically useful accuracy comparable to conventional neuronavigation in selected applications while improving spatial orientation, ergonomics, and surgical workflow. Current systems should be regarded as complementary rather than replacement technologies and appear most suitable for cranial procedures requiring low to moderate precision navigation. Further prospective multicenter studies with standardized validation protocols and continued technological refinement are needed before widespread clinical adoption.