Intraoperative ultrasound imaging of the entire brain through unilateral exploratory burr holes after severe head injury: technical note

Demonstrative study of brain anatomical landmarks by intraoperative ultrasound imaging

Objectives

Intraoperative use of ultrasound in brain surgery needs good understanding of the brain anatomy in ultrasound images. This study aims to compare ultrasound imaging of brain anatomical landmarks during surgery to perioperative computed tomography (CT), and perioperative magnetic resonance imaging (MRI) as demonstration for encouraging usage as low cost, available and hazardless device.

Methods

In total; 350 patients were subjected to brain surgeries under ultrasound guidance using 2.5–8 megahertz (MHZ) transducers, at neurosurgery department Zagazig university hospital from January 2012 to January 2019. Brain anatomical landmarks were compared between ultrasound images, and perioperative images for safe, and confident surgeries.

Results

Various intracranial anatomical landmarks could be well-demonstrated by ultrasound through the open fontanel, or once the skull was opened, and during surgical work in real time fashion, facilitating surgical procedures, and avoiding complications.

Conclusion

Real-time ultrasound is of great help during brain surgeries in delineating brain anatomical landmarks as well as MRI, and CT brain. The growing learning standard of intraoperative ultrasound (IOUS) use makes brain surgery more simple with avoiding brain shift problems, radiation exposure, and high cost of other intraoperative modalities.

Diagnostic usefulness of intraoperative ultrasonography for unexpected severe brain swelling in ultra-early surgery for ruptured intracranial aneurysms

BACKGROUND

In ultra-early aneurysm surgery, the few hours from admission to aneurysm clipping present the greatest risk for an in-hospital recurrent hemorrhage, the development of acute hydrocephalus, and severe brain edema. Thus, severe brain swelling encountered after dural opening in a craniotomy can sometimes not be explained by a preoperative computed tomography (CT) scan. Therefore, neurosurgeons need a diagnostic tool to determine the exact cause of the brain swelling to apply appropriate intraoperative management. Accordingly, the authors propose a designated optimal ultrasound window for evaluating brain swelling during a pterional craniotomy, and assess its diagnostic usefulness and clinical impact.

METHODS

Intraoperative ultrasonography was performed during pterional craniotomies to identify the causes of severe brain swelling in 23 out of 185 patients treated using a policy of ultra-early treatment after a subarachnoid hemorrhage. Paine's point was used as the sonographic window to provide axial images showing the anterior interhemispheric fissure, lentiform nucleus, insular cortex, sylvian fissure, and ventricular system.

RESULTS

The intraoperative ultrasonography revealed significant changes from the preoperative CT findings in 9 (39.1 %) of the 23 patients. These changes included the occurrence of an intracerebral hemorrhage (ICH, n = 2) related to aneurysm rebleeding with aggravated hydrocephalus and the development (n = 5) or aggravation (n = 2) of acute hydrocephalus without rebleeding. Meanwhile, for 14 (60.9 %) of the 23 patients, the ultrasonography showed no intracranial changes. For the total 23 patients with severe brain swelling, the intraoperative management included aspiration of an ICH (n = 3), a ventriculostomy (n = 16), and medical management (n = 8) with additional mannitol and/or mild hyperventilation.

CONCLUSIONS

When severe brain swelling is encountered during a pterional craniotomy for clipping a ruptured aneurysm, an intraoperative ultrasonography technique using Paine's point as a sonographic window provides useful and reliable diagnostic information on the causes of the brain swelling, enabling the neurosurgeon to select appropriate intraoperative management.

Morphological and hemodynamic evaluations by means of transcranial power Doppler imaging in patients with severe head injury

The following conditions of 17 patients with severe head injury (ages 9-76; mean 37:12 focal and 5 diffuse injuries) were evaluated during acute phase (1-14 days after injury, mean 5) by transcranial power Doppler imaging (PDI), a new color Doppler ultrasound technique: a) morphological changes via temporal window, b) hemodynamic changes in major intracranial/cervical arteries based on measured angle-corrected time-averaged mean (TAM)/ peak velocities and vessel diameter (Va), and calculated pulsatility indices (PI), vessel area (Va), and flow volume (Vf = TAM x Va). a) 1) Major trunks of intracranial vessels and circle of Willis and pathological changes in frontal/temporal lobes and midbrain were finely visualized. 2) Contusional hemorrhage and cerebral contusion demonstrated irregular hyper- and hypo-echoic lesions, respectively. 3) Delayed epidural hematoma showed a hyper-echoic band. b) 1) Decreased velocities, significant PI increase, and Va increase tendency were observed in intracranial arteries. 2) Increased velocities with Vf increase but no Va decrease indicated hyperemia rather than vasospasm. 3) Va in the intracranial vessels, however, tended to increase PDI appears useful in evaluating real-time and simultaneous morphological and hemodynamic information in pathogenesis and neurointensive care of patients with severe head injury.

Patients who talk and deteriorate

Patients who "talk and deteriorate" are defined as those who utter recognizable words at some time after head injury and then deteriorate to a severe head-injured condition (Glasgow Coma Scale score of 8 or less) within 48 hours of injury. They represent a very small but important subgroup of patients with brain injury. In approximately 75% of these patients, the cause of this deterioration is intracranial hematoma. Despite the fact that talking indicates nonlethal impact brain injury, deterioration is a marker of poor prognosis. Outcome depends on early recognition of deterioration and rapid removal of mass lesions. The challenge for emergency physicians is to distinguish patients at risk for deterioration from the many patients evaluated after head injury.