Image-guided ultrasonography for recurrent cystic gliomas

Approach to a cerebral hernia caused by an intratumoral hemorrhage of a cystic oligodendroglioma: a case report

The incidence of cerebral herniation caused by intratumoral hemorrhage (ITH) in cystic oligodendroglioma (COD) is exceedingly rare. This study presents a case of cerebral herniation subsequent to cystic oligodendroglioma (COD) and sudden intratumoral hemorrhage. Following initial emergency treatment and evaluation, we successfully circumvented the solid component of the tumor and proceeded with cystic puncture and external drainage to prevent the incidence of brain herniation and mitigate the severity of associated symptoms. Based on preoperative examination results, the cystic glioma was successfully resected, and the patient experienced an uneventful recovery. According to the pathological findings, the oligodendroglioma was classified as World Health Organization (WHO) grade III. The treatment efficacy was comparable to cases of the same pathological grade, in which neither intratumoral hemorrhage nor cerebral hernia was observed.

Intra-operative ultrasound (IOUS) value in cases of AVM and cavernoma excision: single-center experience

Objective

The aim of the study is to use ultrasound to get maximal lesion resection without doing harm to the brain tissue in the absence of neuronavigation system in neurovascular cases as AVM and cavernoma.

Methods

The study is held in Mansoura University Hospitals, Department of Neurosurgery. Two different cases (AVM and cavernoma) were operated, and IOUS was used to assess its value during the surgery. Postoperatively the patients are followed up clinically and radiologically.

Results

In 2 different parenchymal lesions: AVM and cavernoma, IOUS was valuable in accurate localization of the lesions and the related vascularity specially in AVM case. It also helped to evaluate the extent of resection and confirm total excision. It also helped to determine the site of cortical incision and so to minimize brain tissue manipulation to prevent development of postoperative neurological deficit.

Conclusion

IOUS can be very helpful in cases of parenchymal neurovascular lesions such as AVM and cavernoma.

Intraoperative Ultrasound-Guided Resection of Gliomas: A Meta-Analysis and Review of the Literature

BACKGROUND

Image-guided surgery has become standard practice during surgical resection, using preoperative magnetic resonance imaging. Intraoperative ultrasound (IoUS) has attracted interest because of its perceived safety, portability, and real-time imaging. This report is a meta-analysis of intraoperative ultrasound in gliomas.

METHODS

Critical literature review and meta-analyses, using the MEDLINE/PubMed service. The list of references in each article was double-checked for any missing references. We included all studies that reported the use of ultrasound to guide glioma-surgery. The meta-analyses were conducted according to statistical heterogeneity between the studies using Open MetaAnalyst Software. If there was no heterogeneity, fixed effects model was used for meta-analysis; otherwise, a random effect model was used. Statistical heterogeneity was explored by χ(2) and inconsistency (I(2)) statistics; an I(2) value of 50% or more represented substantial heterogeneity.

RESULTS

A wide search yielded 19,109 studies that might be relevant, of which 4819 were ultrasound in neurosurgery; 756 studies used ultrasound in cranial surgery, of which 24 studies used intraoperative ultrasound to guide surgical resection and 74 studies used it to guide biopsy. Fifteen studies fulfilled our stringent inclusion criteria, giving a total of 739 patients. The estimated average gross total resection rate was 77%. Furthermore, the relationship between extent of surgical resection and study population was not linear. Gross total resection was more likely under IoUS when the lesion was solitary and subcortical, with no history of surgery or radiotherapy. IoUS image quality, sensitivity, specificity, and positive and negative predictive values deteriorated as surgical resection proceeded.

CONCLUSION

IoUS-guided surgical resection of gliomas is a useful tool for guiding the resection and for improving the extent of resection. IoUS can be used in conjunction with other complementary technologies that can improve anatomic orientation during surgery. Real-time imaging, improved image quality, small probe sizes, repeatability, portability, and relatively low cost make IoUS a realistic, cost-effective tool that complements any existing tools in any neurosurgical operating environment.

The influence of intraoperative resection control modalities on survival following gross total resection of glioblastoma

The purpose of the present study is to analyze the impact of intraoperative resection control modalities on overall survival (OS) and progression-free survival (PFS) following gross total resection (GTR) of glioblastoma. We analyzed data of 76 glioblastoma patients (30f, mean age 57.4 ± 11.6 years) operated at our institution between 2009 and 2012. Patients were only included if GTR was achieved as judged by early postoperative high-field MRI. Intraoperative technical resection control modalities comprised intraoperative ultrasound (ioUS, n = 48), intraoperative low-field MRI (ioMRI, n = 22), and a control group without either modality (n = 11). The primary endpoint of our study was OS, and the secondary endpoint was PFS-both analyzed in Kaplan-Meier plots and Cox proportional hazards models. Median OS in all 76 glioblastoma patients after GTR was 20.4 months (95 % confidence interval (CI) 18.5-29.0)-median OS in patients where GTR was achieved using ioUS was prolonged (21.9 months) compared to those without ioUS usage (18.8 months). A multiple Cox model adjusting for age, preop Karnofsky performance status, tumor volume, and the use of 5-aminolevulinic acid showed a beneficial effect of ioUS use, and the estimated hazard ratio was 0.63 (95 % CI 0.31-1.2, p = 0.18) in favor of ioUS, however not reaching statistical significance. A similar effect was found for PFS (hazard ratio 0.59, p = 0.072). GTR of glioblastoma performed with ioUS guidance was associated with prolonged OS and PFS. IoUS should be compared to other resection control devices in larger patient cohorts.

Perspectives in Intraoperative Diagnostics of Human Gliomas

Amongst large a variety of oncological diseases, malignant gliomas represent one of the most severe types of tumors. They are also the most common type of the brain tumors and account for over half of the astrocytic tumors. According to different sources, the average life expectancy of patients with various glioblastomas varies between 10 and 12 months and that of patients with anaplastic astrocytic tumors between 20 and 24 months. Therefore, studies of the physiology of transformed glial cells are critical for the development of treatment methods. Modern medical approaches offer complex procedures, including the microsurgical tumor removal, radiotherapy, and chemotherapy, supplemented with photodynamic therapy and immunotherapy. The most radical of them is surgical resection, which allows removing the largest part of the tumor, reduces the intracranial hypertension, and minimizes the degree of neurological deficit. However, complete removal of the tumor remains impossible. The main limitations are insufficient visualization of glioma boundaries, due to its infiltrative growth, and the necessity to preserve healthy tissue. This review is devoted to the description of advantages and disadvantages of modern intraoperative diagnostics of human gliomas and highlights potential perspectives for development of their treatment.

Role of surgical resection in low- and high-grade gliomas

OPINION STATEMENT

Central nervous system tumors are a major cause of morbidity and mortality in the United States. Outside of brain metastasis, low- and high-grade gliomas are the most common intrinsic brain tumors. Low-grade gliomas have a 5- and 10-year survival rate of 97 % and 91 %, respectively, when extent of resection is greater than 90 %. High-grade gliomas are extremely aggressive with the vast majority of patients experiencing recurrence and a median survival of 1 to 3 years. Survival of patients with both low- and high-grade gliomas is enhanced with maximal tumor resection. The pursuit of more aggressive extent of resection must be balanced with preservation of functional pathways. Several innovations in neurosurgical oncology have expanded our understanding of individualized patient neuroanatomy, physiology, and function. Emerging imaging technologies as well as intraoperative techniques have expanded our ability to resect maximal amounts of tumor while preserving essential function. Stimulation mapping of language and motor pathways is well-established for the safe resection of intrinsic brain lesions. Additional techniques including neuro-navigation, fluorescence-guided microsurgery using 5-aminolevulinic acid, intraoperative magnetic resonance imaging, and high-frequency ultrasonography can all be used to improve extent of resection in glioma patients.

Neuronavigational neuroendoscopy--to be or not to be? An international pilot questionnaire-based study

OBJECTIVE

The almost age-old neuroendoscopy (NE) and neuronavigation (NN) in its twenties independently and indisputably have proved their high value as neurosurgical armamentarium and became even indispensable in some pathologies. However, nowadays the effectiveness of their simultaneous and combined application still is a matter of debate. The purpose of our pilot international, questionnaire-based survey was to assess the position of the opinion leaders in the field of neuroendoscopy worldwide toward the neuronavigational neuroendoscopy (NNNE).

METHODS

Within 3 months, a questionnaire with 17 questions was emailed repeatedly to 55 leading academic neuroendoscopic neurosurgeons from 50 institutions in 24 countries. The questionnaire covered aspects of personal and institutional experience in NE, NN, and NNNE, the most frequently treated pathologies by NNNE as well as inquiring the neurosurgeons' opinion for the importance and future of NNNE.

RESULTS

Forty-one questionnaires were returned (response rate = 74.6%). Six questionnaires were excluded because of incomplete or incorrect answers, leaving in the survey 35 respondents from 35 institutions in 18 countries. The less experienced neurosurgeons rely in higher degree on NNNE. Most frequently, NNNE is performed for hydrocephalus (procedures other than third ventriculostomy), transsphenoidal surgery, tumor biopsy, and cyst fenestration. Regardless their neurosurgical and NE experience, more than 75% of the respondents state that NNNE extends the range of neuroendoscopic procedures in their neurosurgical departments.

CONCLUSION

NNNE represents a valuable operative technique with excellent future prospects. NNNE extends the range of neuroendoscopic procedures, transforming some number of patients from "nonoperable" neuroendoscopically to suitable for neuroendoscopy.

Resection of pediatric intracerebral tumors with the aid of intraoperative real-time 3-D ultrasound

PURPOSE

Intraoperative ultrasound (IOUS) has become a useful tool employed daily in neurosurgical procedures. In pediatric patients, IOUS offers a radiation-free and safe imaging method. This study aimed to evaluate the use of a new real-time 3-D IOUS technique (RT-3-D IOUS) in our pediatric patient cohort.

MATERIAL AND METHODS

Over 24 months, RT-3-D IOUS was performed in 22 pediatric patients (8 girls and 14 boys) with various brain tumors. These lesions were localized by a standard navigation system followed by analyses before, intermittently during, and after neurosurgical resection using the iU22 ultrasound system (Philips, Bothell, USA) connected to the RT-3-D probe (X7-2).

RESULTS

In all 22 patients, real-time 3-D ultrasound images of the lesions could be obtained during neurosurgical resection. Based on this imaging method, rapid orientation in the surgical field and the approach for the resection could be planned for all patients. In 18 patients (82%), RT-3-D IOUS revealed a gross total resection with a favorable neurological outcome.

CONCLUSION

RT-3-D IOUS provides the surgeon with advanced orientation at the tumor site via immediate live two-plane imaging. However, navigation systems have yet to be combined with RT-3-D IOUS. This combination would further improve intraoperative localization.

New developments in surgery of malignant gliomas

Background

Malignant gliomas account for a high proportion of brain tumours. With new advances in neurooncology, the recurrence-free survival of patients with malignant gliomas has been substantially prolonged. It, however, remains dependent on the thoroughness of the surgical resection. The maximal tumour resection without additional postoperative deficit is the goal of surgery on patients with malignant gliomas. In order to minimize postoperative deficit, several pre- and intraoperative techniques have been developed.

Conclusions

Several techniques used in malignant glioma surgery have been developed, including microsurgery, neuroendoscopy, stereotactic biopsy and brachytherapy. Imaging and functional techniques allowing for safer tumour resection have a special value. Imaging techniques allow for better preoperative visualization and choice of the approach, while functional techniques help us locate eloquent regions of the brain.

Advantages and limitations of intraoperative 3D ultrasound in neurosurgery. Technical note

Three-dimensional ultrasound (US) technology is supposed to help combat some of the orientation difficulties inherent to two-dimensional US. Contemporary navigation solutions combine reconstructed 3D US images with common navigation images and support orientation. New real-time 3D US (without neuronavigation) is more time effective, but whether it further assists in orientation remains to be determined. An integrated US system (IGSonic, VectorVision, BrainLAB, Munich Germany) and a non-integrated system with real-time 3D US (iU22, Philips, Bothell, USA) were recently compared in neurosurgical procedures in our group. The reconstructed navigation view was time-consuming, but images were displayed in familiar planes (e.g., axial, sagittal, coronal). Further potential applications of US angiography and pure US navigation are possible. Real-time 3D images were displayed without the need for an additional acquisition and reconstruction process, but spatial orientation remained challenging in this preliminary testing phase. Reconstructed 3D US navigation appears to be superior with respect to spatial orientation, and the technique can be combined with other imaging data. However, the potential of real-time 3D US imaging is promising.

Neuronavigation: geneology, reality, and prospects

Currently, neuronavigation is an indivisible and indispensable part of the neurosurgical reality with a significant potential impact in each neurosurgical procedure. The history of neuronavigation is quite short (< 3 decades), but full of highly promising achievements. The advent of neuronavigation would be unimaginable without the development of imaging technology, electronics, robotics, and space technology. The history of neuroradiology is reviewed briefly parallel with the detailed evolution of frame-based stereotaxy and its successor—neuronavigation. The historic milestones and the state of the art of neuronavigation are discussed in a genealogical manner. The future trends of neuronavigation as integrated with intraoperative CT, MR, and ultrasonography, as well as with robotic systems are outlined.

Neuroendoscopic foraminal plasty of foramen of Monro

OBJECTIVES

The aims of this study were to describe and analyze the technique of neuroendoscopic foraminal plasty of foramen of Monro (NEFPFMO) in the treatment of isolated unilateral hydrocephalus (IUH) due to membranous occlusion, to evaluate its efficacy and safety, and to define the benefits of neuronavigational guidance of the procedure.

MATERIALS AND METHODS

Two symptomatic neonates with IUH, as a result of congenital atresia of foramen of Monro, underwent NEFPFMO plus neuroendoscopic septostomy in the first case and neuronavigational guidance in the second one. Clinical results were excellent in both neonates. The postoperative ventricular size decreased and the progressive IUH changed to the state of arrested hydrocephalus. The neuronavigation was precise.

CONCLUSION

NEFPFMO should be the primary treatment option in patients with IUH due to membranous occlusion of foramen of Monro. It reestablishes natural anatomical communication and provides real physiological cerebrospinal fluid flow. Neuronavigation is a useful adjunct of NEFPFMO.