Anatomical localization and resection of a refractory epileptic focus in the right supplementary motor area/presupplementary motor area using augmented reality: illustrative case

BACKGROUND: Medically refractory seizures occur in up to 30% of patients with epilepsy. Treatments may include neuromodulation, ablative procedures, and stereotactic surgery. Cutting-edge technology, such as neuroimaging, anatomical mapping, electroencephalography, and augmented reality (AR), assist in localization and safer treatment planning. OBSERVATIONS: A 26-year-old male with focal onset epilepsy underwent phase II monitoring with stereo-electroencephalography (sEEG) that localized his seizure focus to the right supplementary motor area (SMA)/pre-SMA. A combination of traditional navigation, phase-reversal electrocorticography, and AR was used to perform anatomical localization and verification to assist with craniotomy and resection. He is now seizure free with no significant neurological deficit 9 months after surgery. LESSONS: AR has multiple applications in neurosurgery, including preoperative planning, anatomical verification, and intraoperative guidance. In this case, AR navigation provided real-time 3D overlays of MRI- and CT-derived patient anatomy onto the surgical field, allowing visualization of segmented cortical surface anatomy, vascular structures, white matter tracts, and electrodes via voice commands. This enabled precise mapping of deep-seated anatomy and electrode trajectories without increasing operative time or complication risk. Given the early stage of the technology, AR was used adjunctively with neuronavigation during SMA/pre-SMA resection and demonstrated localization concordant with traditional mapping techniques. https://thejns.org/doi/10.3171/CASE25611.