Versatile Use of Intraoperative Ultrasound Guidance for Brain Puncture

The Application of Intraoperative Ultrasound with Burr Hole Probe in Minimally Invasive Diagnosis and Treatment in Neurosurgery

OBJECTIVE

To summarize the preliminary application experience of intraoperative ultrasound with burr hole probe in minimally invasive neurosurgery and to explore its application value.

METHODS

Thirty-one patients who underwent intraoperative ultrasound guided puncture with burr hole probe in our center from August 2018 to May 2024 were collected, including 16 cases of ventriculoperitoneal shunt operation, 6 cases of assisted stereotactic needle biopsy, 3 cases of intracranial pressure probe implantation in lateral ventricle, 3 cases of brain abscess puncture for external drainage, and 3 cases of intracranial cyst puncture and peritoneal drainage. During the procedures, the burr hole probe was used to locate the intracranial targets and guide the puncture. The postoperative computed tomography (CT) scans or combined postoperative pathological results could verify the accuracy of puncture. In addition, the intervention effect and recovery status of patients were also recorded.

RESULTS

The intraoperative ultrasound with burr hole probe could clearly display all the purposed targets and accurately guide the puncture procedures in all cases. All patients achieved satisfactory diagnostic and therapeutic results without new neurological dysfunction and serious complications.

CONCLUSIONS

The intraoperative ultrasound with burr hole probe is an effective device for demonstrating intracranial structures. It not only enables minimally invasive and precise diagnosis or treatment of many neurosurgical diseases, but also is simple and safe to operate, which has important promotional value in the neurosurgery.

Intraoperative ultrasonography in microsurgical resection of vestibular schwannomas via retrosigmoid approach: surgical technique and proof-of-concept illustrative case series

PURPOSE

Intraoperative ultrasonography (ioUS) is an established tool for the real-time intraoperative orientation and resection control in intra-axial oncological neurosurgery. Conversely, reports about its implementation in the resection of vestibular schwannomas (VS) are scarce. The aim of this study is to describe the role of ioUS in microsurgical resection of VS.

METHODS

ioUS (Craniotomy Transducer N13C5, BK5000, B Freq 8 MHz, BK Medical, Burlington, MA, USA) is integrated into the surgical workflow according to a 4-step protocol (transdural preresection, intradural debulking control, intradural resection control, transdural postclosure). Illustrative cases of patients undergoing VS resection through a retrosigmoid approach with the use of ioUS are showed to illustrate advantages and pitfalls of the technique.

RESULTS

ioUS allows clear transdural identification of the VS and its relationships with surgically relevant structures of the posterior fossa and of the cerebellopontine cistern prior to dural opening. Intradural ioUS reliably estimates the extent of tumor debulking, thereby helping in the choice of the right moment to start peripheral preparation and in the optimization of the extent of resection in those cases where subtotal resection is the ultimate goal of surgery. Transdural postclosure ioUS accurately depicts surgical situs.

CONCLUSION

ioUS is a cost-effective, safe, and easy-to-use intraoperative adjunctive tool that can provide a significant assistance during VS surgery. It can potentially improve patient safety and reduce complication rates. Its efficacy on clinical outcomes, operative time, and complication rate should be validated in further studies.

Precise angle estimation of capsule robot in ultrasound using heatmap guided two-stage network

PURPOSE

A capsule robot can be controlled inside gastrointestinal (GI) tract by an external permanent magnet outside of human body for finishing non-invasive diagnosis and treatment. Locomotion control of capsule robot relies on the precise angle feedback that can be achieved by ultrasound imaging. However, ultrasound-based angle estimation of capsule robot is interfered by gastric wall tissue and the mixture of air, water, and digestive matter existing in the stomach.

METHODS

To tackle these issues, we introduce a heatmap guided two-stage network to detect the position and estimate the angle of the capsule robot in ultrasound images. Specifically, this network proposes the probability distribution module and skeleton extraction-based angle calculation to obtain accurate capsule robot position and angle estimation.

RESULTS

Extensive experiments were finished on the ultrasound image dataset of capsule robot within porcine stomach. Empirical results showed that our method obtained small position center error of 0.48 mm and high angle estimation accuracy of 96.32%.

CONCLUSION

Our method can provide precise angle feedback for locomotion control of capsule robot.

Intraoperative ultrasound-guided ventricular cannulation in patients with normal-sized ventricles

INTRODUCTION

Many pathologies require normal-sized ventricle cannulation, which may be technically challenging even with neuronavigation guidance. This study presents a series of ventricular cannulation of normal-sized ventricles using intraoperative ultrasound (iUS) guidance and the outcomes of patients treated by this technique, for the first time.

METHODS

The study included patients who underwent ultrasound-guided ventricular cannulation of normal-sized ventricles (either ventriculoperitoneal (VP) shunting or Ommaya reservoir) between January 2020 and June 2022. All patients underwent iUS-guided ventricular cannulation from the right Kocher's point. The inclusion criteria for normal-sized ventricles were as follows: (1) Evans index <30%, and (2) widest third ventricle diameter <6mm. Medical records and pre-, intra- and post-operative imaging were retrospectively analyzed.

RESULTS

Nine of the 18 included patients underwent VP shunt placement; 6 had idiopathic intracranial hypertension (IIH), 2 had resistant cerebrospinal fluid fistula following posterior fossa surgery, and 1 had iatrogenic intracranial pressure elevation following foramen magnum decompression. Nine patients underwent Ommaya reservoir implantation, 6 of whom had breast carcinoma and leptomeningeal metastases and 3 hematologic disease and leptomeningeal infiltration. All catheter tip positions were achieved in a single attempt, and none were placed suboptimally. Mean follow-up was 10 months. One IIH patient (5.5%) had early shunt infection which necessitated shunt removal.

CONCLUSION

iUS is a simple and safe method for accurate cannulation of normal-sized ventricles. It provides an effective real-time guidance option for challenging punctures.

The accuracy and safety of intraoperative ultrasound-guided external ventricular drainage in intraventricular hemorrhage

Severe IVH often results in a poor outcome. Currently, EVD is a standard treatment for IVH, but there is little research to show whether using ultrasound to guide the catheter placement improves outcome. Patients with severe IVH who had iUS-guided EVD (the iUS-guided group) were enrolled retrospectively and compared with a group who had EVD performed without ultrasound guidance (the control group) from January 2016 to July 2022. Data were collected on accuracy of the catheter placement, complications and outcome at 3 months assessed by mRS. The accuracy of the EVD placement was classified as optimal placement, sub-optimal placement and misplacement according to the position of the catheter tip. The complications reported are catheter-related hemorrhage, intracranial infection and hydrocephalus. There were 105 cases enrolled, with 72 patients in the iUS-guided group having 131 catheters inserted and 33 patients in the group where ultrasound was not used with a total of 59 catheters. 116 (88.55%) were optimally placed, 12 (9.16%) sub-optimal and 3 (2.29%) misplaced in the iUS-guided group, while 25 (42.37%) were in optimally placed, 30 (50.85%) sub-optimal and 4(6.78%) misplaced in the control group. Accuracy of placement was highly significantly improved using ultrasound (P < 0.001). The operation time and the average catheterized time were longer in the iUS-guided group (P < 0.05), but the complication rates were no different between the groups. The mRS at three months was not significantly different between the two groups. Using iUS to place EVD catheters in patients with severe IVH is a safe technique delivering more accurate catheter placement without increasing the complication rate compared with freehand placement.

Full-endoscopic removal of third ventricular colloid cysts: technique, results, and limitations

Introduction

Colloid cysts (CCs) are rare benign lesions that usually arise from the roof of the third ventricle. They may present with obstructive hydrocephalus and cause sudden death. Treatment options include ventriculoperitoneal shunting, cyst aspiration, and cyst resection microscopically or endoscopically. This study aims to report and discuss the full-endoscopic technique for removing colloid cysts.

Materials and methods

A 25°-angled neuroendoscope with an internal working channel diameter of 3.1 mm and a length of 122 mm is used. The authors described the technique of resecting a colloid cyst by a full-endoscopic procedure and evaluated the surgical, clinical, and radiological results.

Results

Twenty-one consecutive patients underwent an operation with a transfrontal full-endoscopic approach. The swiveling technique (grasping the cyst wall and rotational movements) was used for CC resection. Of these patients, 11 were female, and ten were male (mean age, 41 years). The most frequent initial symptom was a headache. The mean cyst diameter was 13.9 mm. Thirteen patients had hydrocephalus at admission, and one needed shunting after cyst resection. Seventeen patients (81%) underwent total resection; 3 (14%), subtotal resection; and 1 (5%), partial resection. There was no mortality; one patient had permanent hemiplegia, and one had meningitis. The mean follow-up period was 14 months.

Conclusion

Even though microscopic resection of cysts has been widely used as a gold standard, successful endoscopic removal has been described recently with lower complication rates. Applying angled endoscopy with different techniques is essential for total resection. Our study is the first case series to show the outcomes of the swiveling technique with low recurrence and complication rates.

Cottonoid-guided intraoperative ultrasonography in neurosurgery: a proof-of-concept single surgeon case series

Ultrasonography was introduced into neurosurgery in the 1950s, but its successful utilization as an intraoperative tool dates from the early 1980s. However, it was not used widely because of limited technology, a lack of specific training, and, most importantly, the concurrent evolution of computerized tomography and magnetic resonance imaging. The intraoperative use of cottonoid patties as acoustical markers was first described in 1984, but the practice did not gain acceptance, and no articles have been published since. Herein, we reconsider the echogenic properties of the surgical cottonoid patty and demonstrate its usefulness with intraoperative ultrasonography (ioUS) in neurosurgical practice as a truly real-time neuronavigation tool. We also discuss its advantages and compare it with other intraoperative image guidance tools. The echogenic properties of the handmade cottonoid patties in various sizes used with ioUS are described. Details of our cottonoid-guided ioUS technique and its advantages with illustrated cases are also described. As an echogenic marker, cottonoid patties can be easily recognized with ioUS. Their usage with ultrasonography provides truly real-time anatomical orientation throughout the surgery, allowing easy access to intraparenchymal pathologies, and precise and safer resection. Cottonoid-guided ioUS helps not only to localize intraparenchymal pathologies but also to delineate the exact surgical trajectory for each type of lesion. Furthermore, it is not affected by brain shift and distortion. Thus, it is a truly real-time, dynamic, cost-effective, and easy-to-use image guidance tool. This technique can be used safely for every intraparenchymal pathology and increases the accuracy and safety of the surgeries.