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Weld A, Dixon L, Anichini G, Patel N, Nimer A, Dyck M, O'Neill K, Lim A, Giannarou S, Camp S. Challenges with segmenting intraoperative ultrasound for brain tumours. Acta Neurochir (Wien) 2024; 166:317. [PMID: 39090435 PMCID: PMC11294268 DOI: 10.1007/s00701-024-06179-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 06/22/2024] [Indexed: 08/04/2024]
Abstract
Objective - Addressing the challenges that come with identifying and delineating brain tumours in intraoperative ultrasound. Our goal is to both qualitatively and quantitatively assess the interobserver variation, amongst experienced neuro-oncological intraoperative ultrasound users (neurosurgeons and neuroradiologists), in detecting and segmenting brain tumours on ultrasound. We then propose that, due to the inherent challenges of this task, annotation by localisation of the entire tumour mass with a bounding box could serve as an ancillary solution to segmentation for clinical training, encompassing margin uncertainty and the curation of large datasets. Methods - 30 ultrasound images of brain lesions in 30 patients were annotated by 4 annotators - 1 neuroradiologist and 3 neurosurgeons. The annotation variation of the 3 neurosurgeons was first measured, and then the annotations of each neurosurgeon were individually compared to the neuroradiologist's, which served as a reference standard as their segmentations were further refined by cross-reference to the preoperative magnetic resonance imaging (MRI). The following statistical metrics were used: Intersection Over Union (IoU), Sørensen-Dice Similarity Coefficient (DSC) and Hausdorff Distance (HD). These annotations were then converted into bounding boxes for the same evaluation. Results - There was a moderate level of interobserver variance between the neurosurgeons [ I o U : 0.789 , D S C : 0.876 , H D : 103.227 ] and a larger level of variance when compared against the MRI-informed reference standard annotations by the neuroradiologist, mean across annotators [ I o U : 0.723 , D S C : 0.813 , H D : 115.675 ] . After converting the segments to bounding boxes, all metrics improve, most significantly, the interquartile range drops by [ I o U : 37 % , D S C : 41 % , H D : 54 % ] . Conclusion - This study highlights the current challenges with detecting and defining tumour boundaries in neuro-oncological intraoperative brain ultrasound. We then show that bounding box annotation could serve as a useful complementary approach for both clinical and technical reasons.
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Affiliation(s)
- Alistair Weld
- Hamlyn Centre, Imperial College London, Exhibition Rd, London, SW7 2AZ, UK.
| | - Luke Dixon
- Department of Imaging, Charing Cross Hospital, Fulham Palace Rd, London, W6 8RF, UK
| | - Giulio Anichini
- Department of Neurosurgery, Charing Cross Hospital, Fulham Palace Rd, W6 8RF, London, UK
| | - Neekhil Patel
- Department of Neurosurgery, Charing Cross Hospital, Fulham Palace Rd, W6 8RF, London, UK
| | - Amr Nimer
- Department of Neurosurgery, Charing Cross Hospital, Fulham Palace Rd, W6 8RF, London, UK
| | - Michael Dyck
- School of Computation, Information and Technology, Technical University of Munich, Boltzmannstr. 3, Garching, 85748, Germany
| | - Kevin O'Neill
- Department of Neurosurgery, Charing Cross Hospital, Fulham Palace Rd, W6 8RF, London, UK
| | - Adrian Lim
- Department of Imaging, Charing Cross Hospital, Fulham Palace Rd, London, W6 8RF, UK
| | - Stamatia Giannarou
- Hamlyn Centre, Imperial College London, Exhibition Rd, London, SW7 2AZ, UK
| | - Sophie Camp
- Department of Neurosurgery, Charing Cross Hospital, Fulham Palace Rd, W6 8RF, London, UK
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West TR, Mazurek MH, Perez NA, Razak SS, Gal ZT, McHugh JM, Choi BD, Nahed BV. Navigated Intraoperative Ultrasound Offers Effective and Efficient Real-Time Analysis of Intracranial Tumor Resection and Brain Shift. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01250. [PMID: 38995025 DOI: 10.1227/ons.0000000000001250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/01/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Neuronavigation is a fundamental tool in the resection of intracranial tumors. However, it is limited by its calibration to preoperative neuroimaging, which loses accuracy intraoperatively after brain shift. Therefore, surgeons rely on anatomic landmarks or tools like intraoperative MRI to assess the extent of tumor resection (EOR) and update neuronavigation. Recent studies demonstrate that intraoperative ultrasound (iUS) provides point-of-care imaging without the cost or resource utilization of an intraoperative MRI, and advances in neuronavigation-guided iUS provide an opportunity for real-time imaging overlaid with neuronavigation to account for brain shift. We assessed the feasibility, efficacy, and benefits of navigated iUS to assess the EOR and restore stereotactic accuracy in neuronavigation after brain shift. METHODS This prospective single-center study included patients presenting with intracranial tumors (gliomas, metastasis) to an academic medical center. Navigated iUS images were acquired preresection, midresection, and postresection. The EOR was determined by the surgeon intraoperatively and compared with the postoperative MRI report by an independent neuroradiologist. Outcome measures included time to perform the iUS sweep, time to process ultrasound images, and EOR predicted by the surgeon intraoperatively compared with the postoperative MRI. RESULTS This study included 40 patients consisting of gliomas (n = 18 high-grade gliomas, n = 4 low-grade gliomas, n = 4 recurrent) and metastasis (n = 18). Navigated ultrasound sweeps were performed in all patients (n = 83) with a median time to perform of 5.5 seconds and a median image processing time of 29.9 seconds. There was 95% concordance between the surgeon's and neuroradiologist's determination of EOR using navigated iUS and postoperative MRI, respectively. The sensitivity was 100%, and the specificity was 94%. CONCLUSION Navigated iUS was successfully used for EOR determination in glioma and metastasis resection. Incorporating navigated iUS into the surgical workflow is safe and efficient and provides a real-time assessment of EOR while accounting for brain shift in intracranial tumor surgeries.
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Affiliation(s)
- Timothy R West
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | | | | | - Jeffrey M McHugh
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bryan D Choi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Sadahiro H, Fujitsuku S, Sugimoto K, Kawano A, Fujii N, Nomura S, Takahashi M, Ishihara H. Bony Surface-Matching Registration of Neuronavigation with Sectioned 3-Dimensional Skull in Prone Position. World Neurosurg 2024; 187:236-242.e1. [PMID: 38750893 DOI: 10.1016/j.wneu.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Neuronavigation has become an essential system for brain tumor resections. It is sometimes difficult to obtain accurate registration of the neuronavigation with the patient in the prone position. Bony surface-matching registration should be more precise than skin surface-matching registration; however, it is difficult to establish bony registration with limited exposed bone. We created a new bony surface-matching method to a sectioned 3-dimensional (3D) virtual skull in a neuronavigation system and registered with a sectioned 3D skull. In this study, the bony surface-matching with sectioned 3D registration is applied to provide precise registration for brain tumor resection in the prone position. METHODS From May 2023 to April 2024, 17 patients who underwent brain tumor resection in the prone position were enrolled. The navigation system StealthStation S8 (Medtronic, Dublin, Ireland) was used. Bony surface-matching registration with a whole 3D skull in a neuronavigation system was performed. Next, a sectioned 3D skull was made according to the surgical location to compare with the whole 3D skull registration. A phantom model was also used to validate the whole and sectioned 3D skull registration. RESULTS Whole 3D skull registration was successful for only 2 patients (11.8%). However, sectioned 3D skull registration was successful for 16 patients (94.1%). The examinations with a phantom skull model also showed superiority of sectioned 3D skull registration to whole 3D skull registration. CONCLUSIONS Sectioned 3D skull registration was superior to whole 3D skull registration. The sectioned 3D skull method could provide accurate registration with limited exposed bone.
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Affiliation(s)
- Hirokazu Sadahiro
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan.
| | - Shunsuke Fujitsuku
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Kazutaka Sugimoto
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Akiko Kawano
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Natsumi Fujii
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Sadahiro Nomura
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Masakazu Takahashi
- Graduate School of Innovation of Technology Management, Yamaguchi University, Yamaguchi, Japan
| | - Hideyuki Ishihara
- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Yamaguchi, Japan
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Cai S, Xing H, Wang Y, Wang Y, Ma W, Jiang Y, Li J, Wang H. Clinical application of intraoperative ultrasound superb microvascular imaging in brain tumors resections: contributing to the achievement of total tumoral resection. BMC Med Imaging 2024; 24:142. [PMID: 38862900 PMCID: PMC11165841 DOI: 10.1186/s12880-024-01321-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 06/04/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND To investigate whether the intraoperative superb microvascular imaging(SMI) technique helps evaluate lesion boundaries compared with conventional grayscale ultrasound in brain tumor surgery and to explore factors that may be associated with complete radiographic resection. METHODS This study enrolled 57 consecutive brain tumor patients undergoing surgery. During the operation, B-mode and SMI ultrasound evaluated the boundaries of brain tumors. MRI before and within 48h after surgery was used as the gold standard to evaluate gross-total resection(GTR). The ultrasound findings and GTR results were analyzed to determine the imaging factors related to GTR. RESULTS A total of 57 patients were enrolled in the study, including 32 males and 25 females, with an average age of 53.4 ± 14.1 years old(range 19 ~ 80). According to the assessment criteria of MRI, before and within 48 h after the operation, 37(63.9%) cases were classified as GTR, and 20(35.1%) cases were classified as GTR. In comparing tumor interface definition between B-mode and SMI mode, SMI improved HGG boundary recognition in 5 cases(P = 0.033). The results showed that the tumor size ≥ 5 cm and unclear ultrasonic boundary were independent risk factors for nGTR (OR>1, P<0.05). CONCLUSIONS As an innovative intraoperative doppler technique in neurosurgery, SMI can effectively demarcate the tumor's boundary and help achieve GTR as much as possible.
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Affiliation(s)
- Siman Cai
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Hao Xing
- Department of the Neurosurgery Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yuekun Wang
- Department of the Neurosurgery Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yu Wang
- Department of the Neurosurgery Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Wenbin Ma
- Department of the Neurosurgery Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yuxin Jiang
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Jianchu Li
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Hongyan Wang
- Department of Medical Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
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Bopp MHA, Grote A, Gjorgjevski M, Pojskic M, Saß B, Nimsky C. Enabling Navigation and Augmented Reality in the Sitting Position in Posterior Fossa Surgery Using Intraoperative Ultrasound. Cancers (Basel) 2024; 16:1985. [PMID: 38893106 PMCID: PMC11171013 DOI: 10.3390/cancers16111985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/09/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Despite its broad use in cranial and spinal surgery, navigation support and microscope-based augmented reality (AR) have not yet found their way into posterior fossa surgery in the sitting position. While this position offers surgical benefits, navigation accuracy and thereof the use of navigation itself seems limited. Intraoperative ultrasound (iUS) can be applied at any time during surgery, delivering real-time images that can be used for accuracy verification and navigation updates. Within this study, its applicability in the sitting position was assessed. Data from 15 patients with lesions within the posterior fossa who underwent magnetic resonance imaging (MRI)-based navigation-supported surgery in the sitting position were retrospectively analyzed using the standard reference array and new rigid image-based MRI-iUS co-registration. The navigation accuracy was evaluated based on the spatial overlap of the outlined lesions and the distance between the corresponding landmarks in both data sets, respectively. Image-based co-registration significantly improved (p < 0.001) the spatial overlap of the outlined lesion (0.42 ± 0.30 vs. 0.65 ± 0.23) and significantly reduced (p < 0.001) the distance between the corresponding landmarks (8.69 ± 6.23 mm vs. 3.19 ± 2.73 mm), allowing for the sufficient use of navigation and AR support. Navigated iUS can therefore serve as an easy-to-use tool to enable navigation support for posterior fossa surgery in the sitting position.
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Affiliation(s)
- Miriam H. A. Bopp
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
- Center for Mind, Brain and Behavior (CMBB), 35043 Marburg, Germany
| | - Alexander Grote
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
| | - Marko Gjorgjevski
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
| | - Mirza Pojskic
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
- Center for Mind, Brain and Behavior (CMBB), 35043 Marburg, Germany
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Dong Z, Li S, Duan X, Lowerison MR, Huang C, You Q, Chen S, Zou J, Song P. High-Volume-Rate 3-D Ultrasound Imaging Using Fast-Tilting and Redirecting Reflectors. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2023; 70:799-809. [PMID: 37276113 PMCID: PMC10440128 DOI: 10.1109/tuffc.2023.3282949] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Three-dimensional ultrasound imaging has many advantages over 2-D imaging such as more comprehensive tissue evaluation and less operator dependence. However, developing a low-cost and accessible 3-D ultrasound solution with high volume rate and imaging quality remains a challenging task. Recently, we proposed a 3-D ultrasound imaging technique: fast acoustic steering via tilting electromechanical reflectors (FASTER), which uses a fast-tilting acoustic reflector to steer ultrafast plane waves elevationally to achieve high-volume-rate 3-D imaging with conventional 1-D transducers. However, the initial FASTER implementation requires a water tank for acoustic wave conduction and cannot be conveniently used for regular handheld scanning. To address these limitations, here, we developed a novel ultrasound probe clip-on device that encloses a fast-tilting reflector, a redirecting reflector, and an acoustic wave conduction medium. The new FASTER 3-D imaging device can be easily attached to or removed from clinical ultrasound transducers, allowing rapid transformation from 2-D to 3-D imaging. In vitro B-mode studies demonstrated that the proposed method provided comparable imaging quality to conventional, mechanical-translation-based 3-D imaging while offering a much faster volume rate (e.g., 300 versus ∼ 10 Hz). We also demonstrated 3-D power Doppler (PD) and 3-D super-resolution ultrasound localization microscopy (ULM) with the FASTER device. An in vivo imaging study showed that the FASTER device could clearly visualize the 3-D anatomy of the basilic vein. These results suggest that the newly developed redirecting reflector and the clip-on device could overcome key hurdles for future clinical translation of the FASTER 3-D imaging technology.
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Dong Z, Li S, Duan X, Lowerison MR, Huang C, You Q, Chen S, Zou J, Song P. High Volume Rate 3-D Ultrasound Imaging Using Fast-Tilting and Redirecting Reflectors. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.03.07.531439. [PMID: 36945643 PMCID: PMC10028918 DOI: 10.1101/2023.03.07.531439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
3-D ultrasound imaging has many advantages over 2-D imaging such as more comprehensive tissue evaluation and less operator dependence. Although many 3-D ultrasound imaging techniques have been developed in the last several decades, a low-cost and accessible solution with high imaging volume rate and imaging quality remains elusive. Recently we proposed a new, high volume rate 3-D ultrasound imaging technique: Fast Acoustic Steering via Tilting Electromechanical Reflectors (FASTER), which uses a water-immersible and fast-tilting acoustic reflector to steer ultrafast plane waves in the elevational direction to achieve high volume rate 3-D ultrasound imaging with conventional 1-D array transducers. However, the initial implementation of FASTER imaging only involves a single fast-tilting acoustic reflector, which is inconvenient to use because the probe cannot be held in the regular upright position. Also, conventional FASTER imaging can only be performed inside a water tank because of the necessity of using water for acoustic conduction. To address these limitations of conventional FASTER, here we developed a novel ultrasound probe clip-on device that encloses a fast-tilting reflector, a redirecting reflector, and an acoustic wave conduction medium. The new FASTER 3-D imaging device can be easily attached to or removed from clinical ultrasound transducers, allowing rapid transformation from 2-D to 3-D ultrasound imaging. In vitro B-mode imaging studies demonstrated that the proposed method provided comparable imaging quality (e.g., spatial resolution and contrast-to-noise ratio) to conventional, mechanical-translation-based 3-D imaging while providing a much faster 3-D volume rate (e.g., 300 Hz vs ∼10 Hz). In addition to B-mode imaging, we also demonstrated 3-D power Doppler imaging and 3-D super-resolution ultrasound localization microscopy with the newly developed FASTER device. An in vivo imaging study showed that the FASTER device could clearly visualize the 3-D anatomy of the basilic vein of a healthy volunteer, and customized beamforming was implemented to accommodate the speed of sound difference between the acoustic medium and the imaging object (e.g., soft tissue). These results suggest that the newly developed redirecting reflector and the clip-on device could overcome key hurdles for future clinical translation of the FASTER 3-D imaging technology.
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Frassanito P, Stifano V, Bianchi F, Tamburrini G, Massimi L. Enhancing the Reliability of Intraoperative Ultrasound in Pediatric Space-Occupying Brain Lesions. Diagnostics (Basel) 2023; 13:diagnostics13050971. [PMID: 36900115 PMCID: PMC10000977 DOI: 10.3390/diagnostics13050971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Intraoperative ultrasound (IOUS) may aid the resection of space-occupying brain lesions, though technical limits may hinder its reliability. METHODS IOUS (MyLabTwice®, Esaote, Italy) with a microconvex probe was utilized in 45 consecutive cases of children with supratentorial space-occupying lesions aiming to localize the lesion (pre-IOUS) and evaluate the extent of resection (EOR, post-IOUS). Technical limits were carefully assessed, and strategies to enhance the reliability of real-time imaging were accordingly proposed. RESULTS Pre-IOUS allowed us to localize the lesion accurately in all of the cases (16 low-grade gliomas, 12 high-grade gliomas, eight gangliogliomas, seven dysembryoplastic neuroepithelial tumors, five cavernomas, and five other lesions, namely two focal cortical dysplasias, one meningioma, one subependymal giant cell astrocytoma, and one histiocytosis). In 10 deeply located lesions, IOUS with hyperechoic marker, eventually coupled with neuronavigation, was useful to plan the surgical route. In seven cases, the administration of contrast ensured a better definition of the vascular pattern of the tumor. Post-IOUS allowed the evaluation of EOR reliably in small lesions (<2 cm). In large lesions (>2 cm) assessing EOR is hindered by the collapsed surgical cavity, especially when the ventricular system is opened, and by artifacts that may simulate or hide residual tumors. The main strategies to overcome the former limit are inflation of the surgical cavity through pressure irrigation while insonating, and closure of the ventricular opening with Gelfoam before insonating. The strategies to overcome the latter are avoiding the use of hemostatic agents before IOUS and insonating through normal adjacent brain instead of corticotomy. These technical nuances enhanced the reliability of post-IOUS, with a total concordance to postoperative MRI. Indeed, the surgical plan was changed in about 30% of cases, as IOUS showed a residual tumor that was left behind. CONCLUSION IOUS ensures reliable real-time imaging in the surgery of space-occupying brain lesions. Limits may be overcome with technical nuances and proper training.
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Affiliation(s)
- Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Vito Stifano
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Neurosurgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-0630154587
| | - Federico Bianchi
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Neurosurgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gianpiero Tamburrini
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Neurosurgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Luca Massimi
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Institute of Neurosurgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Plaha P, Camp S, Cook J, McCulloch P, Voets N, Ma R, Taphoorn MJB, Dirven L, Grech-Sollars M, Watts C, Bulbeck H, Jenkinson MD, Williams M, Lim A, Dixon L, Price SJ, Ashkan K, Apostolopoulos V, Barber VS, Taylor A, Nandi D. FUTURE-GB: functional and ultrasound-guided resection of glioblastoma - a two-stage randomised control trial. BMJ Open 2022; 12:e064823. [PMID: 36379652 PMCID: PMC9668053 DOI: 10.1136/bmjopen-2022-064823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Surgery remains the mainstay for treatment of primary glioblastoma, followed by radiotherapy and chemotherapy. Current standard of care during surgery involves the intraoperative use of image-guidance and 5-aminolevulinic acid (5-ALA). There are multiple other surgical adjuncts available to the neuro-oncology surgeon. However, access to, and usage of these varies widely in UK practice, with limited evidence of their use. The aim of this trial is to investigate whether the addition of diffusion tensor imaging (DTI) and intraoperative ultrasound (iUS) to the standard of care surgery (intraoperative neuronavigation and 5-ALA) impacts on deterioration free survival (DFS). METHODS AND ANALYSIS This is a two-stage, randomised control trial (RCT) consisting of an initial non-randomised cohort study based on the principles of the IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up) stage-IIb format, followed by a statistically powered randomised trial comparing the addition of DTI and iUS to the standard of care surgery. A total of 357 patients will be recruited for the RCT. The primary outcome is DFS, defined as the time to either 10-point deterioration in health-related quality of life scores from baseline, without subsequent reversal, progressive disease or death. ETHICS AND DISSEMINATION The trial was registered in the Integrated Research Application System (Ref: 264482) and approved by a UK research and ethics committee (Ref: 20/LO/0840). Results will be published in a peer-reviewed journal. Further dissemination to participants, patient groups and the wider medical community will use a range of approaches to maximise impact. TRIAL REGISTRATION NUMBER ISRCTN38834571.
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Affiliation(s)
- Puneet Plaha
- Department of Neursurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Sophie Camp
- Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan Cook
- Oxford Clinical Trials Research Unit & Surgical Intervention Trials Unit, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, Oxfordshire, UK
| | - Peter McCulloch
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Natalie Voets
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, Oxfordshire, UK
| | - Ruichong Ma
- Department of Neursurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Neurology, Haaglanden Medical Center Bronovo, Den Haag, Zuid-Holland, The Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Matthew Grech-Sollars
- Department of Computer Sciences, UCL, London, UK
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Colin Watts
- Institute of Cancer and Genomic Studies, University of Birmingham, Birmingham, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Michael D Jenkinson
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, Merseyside, UK
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Matthew Williams
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK
| | - Adrian Lim
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - Luke Dixon
- Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen John Price
- Neurosurgery Division, Department of Clinical Neurosciences, Cambridge University, Cambridge, UK
| | | | | | - Vicki S Barber
- Oxford Clinical Trials Research Unit & Surgical Intervention Trials Unit, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, Oxfordshire, UK
| | - Amy Taylor
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Dipankar Nandi
- Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Habib A, Jovanovich N, Hoppe M, Hameed NF, Edwards L, Zinn P. Navigated 3D ultrasound-guided resection of high-grade gliomas: A case series and review. Surg Neurol Int 2022; 13:356. [PMID: 36128115 PMCID: PMC9479605 DOI: 10.25259/sni_469_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background: The crux in high-grade glioma surgery remains maximizing resection without affecting eloquent brain areas. Toward this, a myriad of adjunct tools and techniques has been employed to enhance surgical safety and efficacy. Despite intraoperative MRI and advanced neuronavigational techniques, as well as augmented reality, to date, the only true real-time visualization tool remains the ultrasound (US). Neuroultrasonography is a cost-efficient imaging modality that offers instant, real-time information about the changing anatomical landscape intraoperatively. Recent advances in technology now allow for the integration of intraoperative US with neuronavigation. Case Description: In this report, we present the resection technique for three cases of high-grade gliomas (two glioblastomas and one anaplastic astrocytoma). The patient presented with a variable clinical spectrum. All three cases have been performed using the Brainlab® neuronavigation system (BrainLAB, Munich, Germany) and the bk5000 US Machine® (BK Medical, Analogic Corporation, Peabody, Massachusetts, USA). Conclusion: Gross total resection was achieved in all three cases. The use of 3D navigated US was a reliable adjunct surgical tool in achieving favorable resection outcomes in these patients.
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11
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Novel rapid intraoperative qualitative tumor detection by a residual convolutional neural network using label-free stimulated Raman scattering microscopy. Acta Neuropathol Commun 2022; 10:109. [PMID: 35933416 PMCID: PMC9356422 DOI: 10.1186/s40478-022-01411-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/17/2022] [Indexed: 12/03/2022] Open
Abstract
Determining the presence of tumor in biopsies and the decision-making during resections is often dependent on intraoperative rapid frozen-section histopathology. Recently, stimulated Raman scattering microscopy has been introduced to rapidly generate digital hematoxylin-and-eosin-stained-like images (stimulated Raman histology) for intraoperative analysis. To enable intraoperative prediction of tumor presence, we aimed to develop a new deep residual convolutional neural network in an automated pipeline and tested its validity. In a monocentric prospective clinical study with 94 patients undergoing biopsy, brain or spinal tumor resection, Stimulated Raman histology images of intraoperative tissue samples were obtained using a fiber-laser-based stimulated Raman scattering microscope. A residual network was established and trained in ResNetV50 to predict three classes for each image: (1) tumor, (2) non-tumor, and (3) low-quality. The residual network was validated on images obtained in three small random areas within the tissue samples and were blindly independently reviewed by a neuropathologist as ground truth. 402 images derived from 132 tissue samples were analyzed representing the entire spectrum of neurooncological surgery. The automated workflow took in a mean of 240 s per case, and the residual network correctly classified tumor (305/326), non-tumorous tissue (49/67), and low-quality (6/9) images with an inter-rater agreement of 89.6% (κ = 0.671). An excellent internal consistency was found among the random areas with 90.2% (Cα = 0.942) accuracy. In conclusion, the novel stimulated Raman histology-based residual network can reliably detect the microscopic presence of tumor and differentiate from non-tumorous brain tissue in resection and biopsy samples within 4 min and may pave a promising way for an alternative rapid intraoperative histopathological decision-making tool.
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12
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Saß B, Zivkovic D, Pojskic M, Nimsky C, Bopp MHA. Navigated Intraoperative 3D Ultrasound in Glioblastoma Surgery: Analysis of Imaging Features and Impact on Extent of Resection. Front Neurosci 2022; 16:883584. [PMID: 35615280 PMCID: PMC9124826 DOI: 10.3389/fnins.2022.883584] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/08/2022] [Indexed: 12/12/2022] Open
Abstract
Background Neuronavigation is routinely used in glioblastoma surgery, but its accuracy decreases during the operative procedure due to brain shift, which can be addressed utilizing intraoperative imaging. Intraoperative ultrasound (iUS) is widely available, offers excellent live imaging, and can be fully integrated into modern navigational systems. Here, we analyze the imaging features of navigated i3D US and its impact on the extent of resection (EOR) in glioblastoma surgery. Methods Datasets of 31 glioblastoma resection procedures were evaluated. Patient registration was established using intraoperative computed tomography (iCT). Pre-operative MRI (pre-MRI) and pre-resectional ultrasound (pre-US) datasets were compared regarding segmented tumor volume, spatial overlap (Dice coefficient), the Euclidean distance of the geometric center of gravity (CoG), and the Hausdorff distance. Post-resectional ultrasound (post-US) and post-operative MRI (post-MRI) tumor volumes were analyzed and categorized into subtotal resection (STR) or gross total resection (GTR) cases. Results The mean patient age was 59.3 ± 11.9 years. There was no significant difference in pre-resectional segmented tumor volumes (pre-MRI: 24.2 ± 22.3 cm3; pre-US: 24.0 ± 21.8 cm3). The Dice coefficient was 0.71 ± 0.21, the Euclidean distance of the CoG was 3.9 ± 3.0 mm, and the Hausdorff distance was 12.2 ± 6.9 mm. A total of 18 cases were categorized as GTR, 10 cases were concordantly classified as STR on MRI and ultrasound, and 3 cases had to be excluded from post-resectional analysis. In four cases, i3D US triggered further resection. Conclusion Navigated i3D US is reliably adjunct in a multimodal navigational setup for glioblastoma resection. Tumor segmentations revealed similar results in i3D US and MRI, demonstrating the capability of i3D US to delineate tumor boundaries. Additionally, i3D US has a positive influence on the EOR, allows live imaging, and depicts brain shift.
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Affiliation(s)
- Benjamin Saß
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- *Correspondence: Benjamin Saß,
| | - Darko Zivkovic
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Mirza Pojskic
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- Center for Mind, Brain and Behavior (CMBB), Marburg, Germany
| | - Miriam H. A. Bopp
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- Center for Mind, Brain and Behavior (CMBB), Marburg, Germany
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13
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Giammalva GR, Ferini G, Musso S, Salvaggio G, Pino MA, Gerardi RM, Brunasso L, Costanzo R, Paolini F, Di Bonaventura R, Umana GE, Graziano F, Palmisciano P, Scalia G, Tumbiolo S, Midiri M, Iacopino DG, Maugeri R. Intraoperative Ultrasound: Emerging Technology and Novel Applications in Brain Tumor Surgery. Front Oncol 2022; 12:818446. [PMID: 35178348 PMCID: PMC8844995 DOI: 10.3389/fonc.2022.818446] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/04/2022] [Indexed: 01/22/2023] Open
Abstract
Intraoperative ultrasound (IOUS) is becoming progressively more common during brain tumor surgery. We present data from our case series of brain tumor surgery performed with the aid of IOUS in order to identify IOUS advantages and crucial aspects that may improve the management of neurosurgical procedures for brain tumors. From January 2021 to September 2021, 17 patients with different brain tumors underwent brain tumor surgery aided by the use of IOUS. During surgery, the procedure was supported by the use of multiples ultrasonographic modalities in addition to standard B-mode: Doppler, color Doppler, elastosonography, and contrast-enhanced intraoperative ultrasound (CEUS). In selected cases, the use of IOUS during surgical procedure was combined with neuronavigation and the use of intraoperative fluorescence by the use of 5-aminolevulinic acid (5-ALA). In one patient, a preoperative ultrasound evaluation was performed through a former iatrogenic skull defect. This study confirms the role of IOUS in maximizing the EOR, which is strictly associated with postoperative outcome, overall survival (OS), and patient’s quality of life (QoL). The combination of ultrasound advanced techniques such as Doppler, color Doppler, elastosonography, and contrast-enhanced intraoperative ultrasound (CEUS) is crucial to improve surgical effectiveness and patient’s safety while expanding surgeon’s view.
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Affiliation(s)
- Giuseppe Roberto Giammalva
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Gianluca Ferini
- Department of Radiation Oncology, REM Radioterapia srl, Catania, Italy
| | - Sofia Musso
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Giuseppe Salvaggio
- Section of Radiology, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Maria Angela Pino
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosa Maria Gerardi
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Lara Brunasso
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Roberta Costanzo
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Federica Paolini
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Rina Di Bonaventura
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Emmanuele Umana
- Department of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Catania, Italy
| | - Francesca Graziano
- Department of Neurosurgery Highly Specialized Hospital and of National Importance "Garibaldi", Catania, Italy
| | - Paolo Palmisciano
- Department of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Catania, Italy
| | - Gianluca Scalia
- Department of Neurosurgery Highly Specialized Hospital and of National Importance "Garibaldi", Catania, Italy
| | | | - Massimo Midiri
- Section of Radiology, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
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14
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Giammalva GR, Musso S, Salvaggio G, Pino MA, Gerardi RM, Umana GE, Midiri M, Iacopino DG, Maugeri R. Coplanar Indirect-Navigated Intraoperative Ultrasound: Matching Un-navigated Probes With Neuronavigation During Neurosurgical Procedures. How We Do It. Oper Neurosurg (Hagerstown) 2021; 21:485-490. [PMID: 34498674 DOI: 10.1093/ons/opab316] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/08/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Intraoperative ultrasound (IOUS) is becoming more and more adopted in neurosurgery, since it has been associated to greater extent of resection (EOR) and to gross total resection (GTR) during brain tumor surgery. IOUS main limitations are spatial resolution, width and orientation of the field of view and scan quality, which are operator-dependent. Furthermore, most neurosurgeons are not confident with this technique, which needs a long learning curve in order to identify and interpret anatomic structures. OBJECTIVE To describe an effective procedure to take advantages of both IOUS and neuronavigation in case of lack of a navigated ultrasound system. METHODS We propose a reliable "indirect-navigated" technique which is based on the optical tracking of un-navigated IOUS probe by the use of a multipurpose passive tracker and a proper configuration of common neuronavigation system. RESULTS Navigated IOUS is not available in all neurosurgical operating rooms but ultrasound systems are common tools in many hospital facilities and neuronavigation systems are common in almost all the neurosurgical operating rooms. The proposed indirect-navigated technique shows some paramount advantages: since almost all the neurosurgical operating rooms are provided with a neuronavigation system, the only tool needed is the ultrasonography. Therefore, this procedure is largely accessible and costless, reliable, and may improve the neurosurgeon's ability in ultrasonographic anatomy. CONCLUSION This technique is based on the coplanar and coupled use of both un-navigated IOUS probe and standard optical neuronavigation, in order to allow the intraoperative navigation of IOUS images when a navigated ultrasound system is not available.
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Affiliation(s)
- Giuseppe Roberto Giammalva
- Unit of Neurosurgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Sofia Musso
- Unit of Neurosurgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Giuseppe Salvaggio
- Section of Radiology, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Maria Angela Pino
- Unit of Neurosurgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosa Maria Gerardi
- Unit of Neurosurgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Giuseppe Emmanuele Umana
- Department of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Catania, Italy
| | - Massimo Midiri
- Section of Radiology, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Domenico Gerardo Iacopino
- Unit of Neurosurgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosario Maugeri
- Unit of Neurosurgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
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Abstract
As the epidemiological and clinical burden of brain metastases continues to grow, advances in neurosurgical care are imperative. From standard magnetic resonance imaging (MRI) sequences to functional neuroimaging, preoperative workups for metastatic disease allow high-resolution detection of lesions and at-risk structures, facilitating safe and effective surgical planning. Minimally invasive neurosurgical approaches, including keyhole craniotomies and tubular retractors, optimize the preservation of normal parenchyma without compromising extent of resection. Supramarginal surgery has pushed the boundaries of achieving complete removal of metastases without recurrence, especially in eloquent regions when paired with intraoperative neuromonitoring. Brachytherapy has highlighted the potential of locally delivering therapeutic agents to the resection cavity with high rates of local control. Neuronavigation has become a cornerstone of operative workflow, while intraoperative ultrasound (iUS) and intraoperative brain mapping generate real-time renderings of the brain unaffected by brain shift. Endoscopes, exoscopes, and fluorescent-guided surgery enable increasingly high-definition visualizations of metastatic lesions that were previously difficult to achieve. Pushed forward by these multidisciplinary innovations, neurosurgery has never been a safer, more effective treatment for patients with brain metastases.
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Affiliation(s)
- Patrick R Ng
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bryan D Choi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Manish K Aghi
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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de Quintana-Schmidt C, Salgado-Lopez L, Aibar-Duran JA, Alvarez Holzapfel MJ, Cortes CA, Alvarado JDP, Rodriguez RR, Teixidó JM. Neuronavigated Ultrasound in Neuro-Oncology: A True Real-Time Intraoperative Image. World Neurosurg 2021; 157:e316-e326. [PMID: 34655818 DOI: 10.1016/j.wneu.2021.10.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Ultrasound is considered a real-time imaging method in neuro-oncology because of its highly rapid image acquisition time. However, to our knowledge, there are no studies that analyze the additional surgical time that it requires. METHODS A prospective study of 100 patients who underwent intra-axial brain tumor resection with navigated intraoperative ultrasound. The primary outcomes were lesion visibility grade on ultrasound and concordance with preoperative magnetic resonance imaging (MRI) scan, intraoperative ultrasound usage time, and percentage of tumor resection on ultrasound and comparison with postoperative MRI scan. RESULTS The breakdown of patients included the following: 53 high-grade gliomas, 26 metastases, 14 low-grade gliomas, and 7 others. Ninety-six percent of lesions were clearly visualized. The tumor border was clearly delimited in 71%. Concordance with preoperative MRI scan was 78% (P < 0.001). The mean time ± SD for sterile covering of the probe was 2.16 ± 0.5 minutes, and the mean image acquisition time was 2.49 ± 1.26 minutes. Insular tumor location, low-grade glioma, awake surgery, and recurrent tumor were statistically associated with an increased ultrasound usage time. Ultrasound had a sensitivity of 94.4% and a specificity of 100% for residual tumor detection. CONCLUSIONS Neuronavigated ultrasound can be considered a truly real-time intraoperative imaging method because it does not increase surgical time significantly and provides optimal visualization of intra-axial brain lesions and residual tumor.
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Affiliation(s)
| | - Laura Salgado-Lopez
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA; Universitat Autònoma de Barcelona (Doctorat), Barcelona, Spain
| | | | | | | | | | | | - Joan Molet Teixidó
- Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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17
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Saß B, Pojskic M, Zivkovic D, Carl B, Nimsky C, Bopp MHA. Utilizing Intraoperative Navigated 3D Color Doppler Ultrasound in Glioma Surgery. Front Oncol 2021; 11:656020. [PMID: 34490080 PMCID: PMC8416533 DOI: 10.3389/fonc.2021.656020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 07/23/2021] [Indexed: 01/23/2023] Open
Abstract
Background In glioma surgery, the patient’s outcome is dramatically influenced by the extent of resection and residual tumor volume. To facilitate safe resection, neuronavigational systems are routinely used. However, due to brain shift, accuracy decreases with the course of the surgery. Intraoperative ultrasound has proved to provide excellent live imaging, which may be integrated into the navigational procedure. Here we describe the visualization of vascular landmarks and their shift during tumor resection using intraoperative navigated 3D color Doppler ultrasound (3D iUS color Doppler). Methods Six patients suffering from glial tumors located in the temporal lobe were included in this study. Intraoperative computed tomography was used for registration. Datasets of 3D iUS color Doppler were generated before dural opening and after tumor resection, and the vascular tree was segmented manually. In each dataset, one to four landmarks were identified, compared to the preoperative MRI, and the Euclidean distance was calculated. Results Pre-resectional mean Euclidean distance of the marked points was 4.1 ± 1.3 mm (mean ± SD), ranging from 2.6 to 6.0 mm. Post-resectional mean Euclidean distance was 4.7. ± 1.0 mm, ranging from 2.9 to 6.0 mm. Conclusion 3D iUS color Doppler allows estimation of brain shift intraoperatively, thus increasing patient safety. Future implementation of the reconstructed vessel tree into the navigational setup might allow navigational updating with further consecutive increasement of accuracy.
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Affiliation(s)
- Benjamin Saß
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Mirza Pojskic
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Darko Zivkovic
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, Marburg, Germany.,Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Marburg, Germany.,Center for Mind, Brain and Behavior (CMBB), Marburg, Germany
| | - Miriam H A Bopp
- Department of Neurosurgery, University of Marburg, Marburg, Germany.,Center for Mind, Brain and Behavior (CMBB), Marburg, Germany
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18
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Moiraghi A, Prada F, Delaidelli A, Guatta R, May A, Bartoli A, Saini M, Perin A, Wälchli T, Momjian S, Bijlenga P, Schaller K, DiMeco F. Navigated Intraoperative 2-Dimensional Ultrasound in High-Grade Glioma Surgery: Impact on Extent of Resection and Patient Outcome. Oper Neurosurg (Hagerstown) 2021; 18:363-373. [PMID: 31435672 DOI: 10.1093/ons/opz203] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 04/16/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Maximizing extent of resection (EOR) and reducing residual tumor volume (RTV) while preserving neurological functions is the main goal in the surgical treatment of gliomas. Navigated intraoperative ultrasound (N-ioUS) combining the advantages of ultrasound and conventional neuronavigation (NN) allows for overcoming the limitations of the latter. OBJECTIVE To evaluate the impact of real-time NN combining ioUS and preoperative magnetic resonance imaging (MRI) on maximizing EOR in glioma surgery compared to standard NN. METHODS We retrospectively reviewed a series of 60 cases operated on for supratentorial gliomas: 31 operated under the guidance of N-ioUS and 29 resected with standard NN. Age, location of the tumor, pre- and postoperative Karnofsky Performance Status (KPS), EOR, RTV, and, if any, postoperative complications were evaluated. RESULTS The rate of gross total resection (GTR) in NN group was 44.8% vs 61.2% in N-ioUS group. The rate of RTV > 1 cm3 for glioblastomas was significantly lower for the N-ioUS group (P < .01). In 13/31 (42%), RTV was detected at the end of surgery with N-ioUS. In 8 of 13 cases, (25.8% of the cohort) surgeons continued with the operation until complete resection. Specificity was greater in N-ioUS (42% vs 31%) and negative predictive value (73% vs 54%). At discharge, the difference between pre- and postoperative KPS was significantly higher for the N-ioUS (P < .01). CONCLUSION The use of an N-ioUS-based real-time has been beneficial for resection in noneloquent high-grade glioma in terms of both EOR and neurological outcome, compared to standard NN. N-ioUS has proven usefulness in detecting RTV > 1 cm3.
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Affiliation(s)
- Alessandro Moiraghi
- Division of Neurosurgery, University of Geneva Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Francesco Prada
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "C. Besta," Milan, Italy.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia.,Focused Ultrasound Foundation, Charlottesville, Virginia
| | - Alberto Delaidelli
- Department of Molecular Oncology, British Columbia Cancer Research Centre, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Ramona Guatta
- Division of Neurosurgery, University of Geneva Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Adrien May
- Division of Neurosurgery, University of Geneva Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Andrea Bartoli
- Division of Neurosurgery, University of Geneva Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Marco Saini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "C. Besta," Milan, Italy
| | - Alessandro Perin
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "C. Besta," Milan, Italy
| | - Thomas Wälchli
- Division of Neurosurgery, University of Geneva Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland.,Group of CNS Angiogenesis and Neurovascular Link, Physician-Scientist Program, Institute for Regenerative Medicine, Neuroscience Center Zurich, University Hospital Zurich, Zurich, Switzerland.,Division of Neurosurgery, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH), University Hospital Zurich, Zurich, Switzerland.,Department of Fundamental Neurobiology, Krembil Research Institute, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Canada
| | - Shahan Momjian
- Division of Neurosurgery, University of Geneva Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Bijlenga
- Division of Neurosurgery, University of Geneva Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Karl Schaller
- Division of Neurosurgery, University of Geneva Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "C. Besta," Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, Maryland
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19
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Incekara F, Smits M, Dirven L, Bos EM, Balvers RK, Haitsma IK, Schouten JW, Vincent AJPE. Intraoperative B-Mode Ultrasound Guided Surgery and the Extent of Glioblastoma Resection: A Randomized Controlled Trial. Front Oncol 2021; 11:649797. [PMID: 34094939 PMCID: PMC8170308 DOI: 10.3389/fonc.2021.649797] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/09/2021] [Indexed: 12/17/2022] Open
Abstract
Background Intraoperative MRI and 5-aminolaevulinic acid guided surgery are useful to maximize the extent of glioblastoma resection. Intraoperative ultrasound is used as a time-and cost-effective alternative, but its value has never been assessed in a trial. The goal of this randomized controlled trial was to assess the value of intraoperative B-mode ultrasound guided surgery on the extent of glioblastoma resection. Materials and Methods In this randomized controlled trial, patients of 18 years or older with a newly diagnosed presumed glioblastoma, deemed totally resectable, presenting at the Erasmus MC (Rotterdam, The Netherlands) were enrolled and randomized (1:1) into intraoperative B-mode ultrasound guided surgery or resection under standard neuronavigation. The primary outcome of this study was complete contrast-enhancing tumor resection, assessed quantitatively by a blinded neuroradiologist on pre- and post-operative MRI scans. This trial was registered with ClinicalTrials.gov (NCT03531333). Results We enrolled 50 patients between November 1, 2016 and October 30, 2019. Analysis was done in 23 of 25 (92%) patients in the intraoperative B-mode ultrasound group and 24 of 25 (96%) patients in the standard surgery group. Eight (35%) of 23 patients in the intraoperative B-mode ultrasound group and two (8%) of 24 patients in the standard surgery group underwent complete resection (p=0.036). Baseline characteristics, neurological outcome, functional performance, quality of life, complication rates, overall survival and progression-free survival did not differ between treatment groups (p>0.05). Conclusions Intraoperative B-mode ultrasound enables complete resection more often than standard surgery without harming patients and can be considered to maximize the extent of glioblastoma resection during surgery.
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Affiliation(s)
- Fatih Incekara
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marion Smits
- Department of Radiology and Nuclear Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, Netherlands
| | - Eelke M Bos
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Rutger K Balvers
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Iain K Haitsma
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Joost W Schouten
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Arnaud J P E Vincent
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands
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Shapey J, Dowrick T, Delaunay R, Mackle EC, Thompson S, Janatka M, Guichard R, Georgoulas A, Pérez-Suárez D, Bradford R, Saeed SR, Ourselin S, Clarkson MJ, Vercauteren T. Integrated multi-modality image-guided navigation for neurosurgery: open-source software platform using state-of-the-art clinical hardware. Int J Comput Assist Radiol Surg 2021; 16:1347-1356. [PMID: 33937966 PMCID: PMC8295168 DOI: 10.1007/s11548-021-02374-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/08/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Image-guided surgery (IGS) is an integral part of modern neuro-oncology surgery. Navigated ultrasound provides the surgeon with reconstructed views of ultrasound data, but no commercial system presently permits its integration with other essential non-imaging-based intraoperative monitoring modalities such as intraoperative neuromonitoring. Such a system would be particularly useful in skull base neurosurgery. METHODS We established functional and technical requirements of an integrated multi-modality IGS system tailored for skull base surgery with the ability to incorporate: (1) preoperative MRI data and associated 3D volume reconstructions, (2) real-time intraoperative neurophysiological data and (3) live reconstructed 3D ultrasound. We created an open-source software platform to integrate with readily available commercial hardware. We tested the accuracy of the system's ultrasound navigation and reconstruction using a polyvinyl alcohol phantom model and simulated the use of the complete navigation system in a clinical operating room using a patient-specific phantom model. RESULTS Experimental validation of the system's navigated ultrasound component demonstrated accuracy of [Formula: see text] and a frame rate of 25 frames per second. Clinical simulation confirmed that system assembly was straightforward, could be achieved in a clinically acceptable time of [Formula: see text] and performed with a clinically acceptable level of accuracy. CONCLUSION We present an integrated open-source research platform for multi-modality IGS. The present prototype system was tailored for neurosurgery and met all minimum design requirements focused on skull base surgery. Future work aims to optimise the system further by addressing the remaining target requirements.
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Affiliation(s)
- Jonathan Shapey
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK. .,Wellcome/EPSRC Centre for Interventional and Surgical Sciences, UCL, London, UK. .,Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
| | - Thomas Dowrick
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, UCL, London, UK.,Centre for Medical Image Computing, UCL, London, UK.,Department of Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Rémi Delaunay
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, UCL, London, UK
| | - Eleanor C Mackle
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, UCL, London, UK
| | - Stephen Thompson
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, UCL, London, UK.,Centre for Medical Image Computing, UCL, London, UK.,Department of Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Mirek Janatka
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, UCL, London, UK.,Centre for Medical Image Computing, UCL, London, UK.,Department of Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Roland Guichard
- Research Software Development Group, Research IT Services, UCL, London, UK
| | | | - David Pérez-Suárez
- Research Software Development Group, Research IT Services, UCL, London, UK
| | - Robert Bradford
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Shakeel R Saeed
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.,The Ear Institute, UCL, London, UK.,The Royal National Throat, Nose and Ear Hospital, London, UK
| | - Sébastien Ourselin
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Matthew J Clarkson
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, UCL, London, UK.,Centre for Medical Image Computing, UCL, London, UK.,Department of Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Tom Vercauteren
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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21
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Bastos DCDA, Juvekar P, Tie Y, Jowkar N, Pieper S, Wells WM, Bi WL, Golby A, Frisken S, Kapur T. Challenges and Opportunities of Intraoperative 3D Ultrasound With Neuronavigation in Relation to Intraoperative MRI. Front Oncol 2021; 11:656519. [PMID: 34026631 PMCID: PMC8139191 DOI: 10.3389/fonc.2021.656519] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/09/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Neuronavigation greatly improves the surgeons ability to approach, assess and operate on brain tumors, but tends to lose its accuracy as the surgery progresses and substantial brain shift and deformation occurs. Intraoperative MRI (iMRI) can partially address this problem but is resource intensive and workflow disruptive. Intraoperative ultrasound (iUS) provides real-time information that can be used to update neuronavigation and provide real-time information regarding the resection progress. We describe the intraoperative use of 3D iUS in relation to iMRI, and discuss the challenges and opportunities in its use in neurosurgical practice. Methods We performed a retrospective evaluation of patients who underwent image-guided brain tumor resection in which both 3D iUS and iMRI were used. The study was conducted between June 2020 and December 2020 when an extension of a commercially available navigation software was introduced in our practice enabling 3D iUS volumes to be reconstructed from tracked 2D iUS images. For each patient, three or more 3D iUS images were acquired during the procedure, and one iMRI was acquired towards the end. The iUS images included an extradural ultrasound sweep acquired before dural incision (iUS-1), a post-dural opening iUS (iUS-2), and a third iUS acquired immediately before the iMRI acquisition (iUS-3). iUS-1 and preoperative MRI were compared to evaluate the ability of iUS to visualize tumor boundaries and critical anatomic landmarks; iUS-3 and iMRI were compared to evaluate the ability of iUS for predicting residual tumor. Results Twenty-three patients were included in this study. Fifteen patients had tumors located in eloquent or near eloquent brain regions, the majority of patients had low grade gliomas (11), gross total resection was achieved in 12 patients, postoperative temporary deficits were observed in five patients. In twenty-two iUS was able to define tumor location, tumor margins, and was able to indicate relevant landmarks for orientation and guidance. In sixteen cases, white matter fiber tracts computed from preoperative dMRI were overlaid on the iUS images. In nineteen patients, the EOR (GTR or STR) was predicted by iUS and confirmed by iMRI. The remaining four patients where iUS was not able to evaluate the presence or absence of residual tumor were recurrent cases with a previous surgical cavity that hindered good contact between the US probe and the brainsurface. Conclusion This recent experience at our institution illustrates the practical benefits, challenges, and opportunities of 3D iUS in relation to iMRI.
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Affiliation(s)
| | - Parikshit Juvekar
- Department of Neurosurgery, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, United States
| | - Yanmei Tie
- Department of Neurosurgery, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, United States
| | - Nick Jowkar
- Department of Neurosurgery, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, United States
| | - Steve Pieper
- Department of Neurosurgery, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, United States
| | - Willam M Wells
- Department of Neurosurgery, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, United States
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, United States
| | - Alexandra Golby
- Department of Neurosurgery, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, United States
| | - Sarah Frisken
- Department of Neurosurgery, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, United States
| | - Tina Kapur
- Department of Neurosurgery, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, United States
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22
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Šteňo A, Buvala J, Babková V, Kiss A, Toma D, Lysak A. Current Limitations of Intraoperative Ultrasound in Brain Tumor Surgery. Front Oncol 2021; 11:659048. [PMID: 33828994 PMCID: PMC8019922 DOI: 10.3389/fonc.2021.659048] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/03/2021] [Indexed: 12/11/2022] Open
Abstract
While benefits of intraoperative ultrasound (IOUS) have been frequently described, data on IOUS limitations are relatively sparse. Suboptimal ultrasound imaging of some pathologies, various types of ultrasound artifacts, challenging patient positioning during some IOUS-guided surgeries, and absence of an optimal IOUS probe depicting the entire sellar region during transsphenoidal pituitary surgery are some of the most important pitfalls. This review aims to summarize prominent limitations of current IOUS systems, and to present possibilities to reduce them by using ultrasound technology suitable for a specific procedure and by proper scanning techniques. In addition, future trends of IOUS imaging optimization are described in this article.
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Affiliation(s)
- Andrej Šteňo
- Department of Neurosurgery, Comenius University, Faculty of Medicine, University Hospital Bratislava, Bratislava, Slovakia
| | - Ján Buvala
- Department of Neurosurgery, Comenius University, Faculty of Medicine, University Hospital Bratislava, Bratislava, Slovakia
| | - Veronika Babková
- Department of Neurosurgery, Comenius University, Faculty of Medicine, University Hospital Bratislava, Bratislava, Slovakia
| | - Adrián Kiss
- Department of Neurosurgery, Comenius University, Faculty of Medicine, University Hospital Bratislava, Bratislava, Slovakia
| | - David Toma
- Department of Neurosurgery, Comenius University, Faculty of Medicine, University Hospital Bratislava, Bratislava, Slovakia
| | - Alexander Lysak
- Department of Neurosurgery, Comenius University, Faculty of Medicine, University Hospital Bratislava, Bratislava, Slovakia
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23
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Cepeda S, García-García S, Arrese I, Velasco-Casares M, Sarabia R. Relationship between the overall survival in glioblastomas and the radiomic features of intraoperative ultrasound: a feasibility study. J Ultrasound 2021; 25:121-128. [PMID: 33594589 PMCID: PMC8964917 DOI: 10.1007/s40477-021-00569-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/04/2021] [Indexed: 02/02/2023] Open
Abstract
PURPOSE Predicting the survival of patients diagnosed with glioblastoma (GBM) is essential to guide surgical strategy and subsequent adjuvant therapies. Intraoperative ultrasound (IOUS) can contain biological information that could be correlated with overall survival (OS). We propose a simple extraction method and radiomic feature analysis based on IOUS imaging to estimate OS in GBM patients. METHODS A retrospective study of surgically treated glioblastomas between March 2018 and November 2019 was performed. Patients with IOUS B-mode and strain elastography were included. After preprocessing, segmentation and extraction of radiomic features were performed with LIFEx software. An evaluation of semantic segmentation was carried out using the Dice similarity coefficient (DSC). Using univariate correlations, radiomic features associated with OS were selected. Subsequently, survival analysis was conducted using Cox univariate regression and Kaplan-Meier curves. RESULTS Sixteen patients were available for analysis. The DSC revealed excellent agreement for the segmentation of the tumour region. Of the 52 radiomic features, two texture features from B-mode (conventional mean and the grey-level zone length matrix/short-zone low grey-level emphasis [GLZLM_SZLGE]) and one texture feature from strain elastography (grey-level zone length matrix/long-zone high grey-level emphasis [GLZLM_LZHGE]) were significantly associated with OS. After establishing a cut-off point of the statistically significant radiomic features, we allocated patients in high- and low-risk groups. Kaplan-Meier curves revealed significant differences in OS. CONCLUSION IOUS-based quantitative texture analysis in glioblastomas is feasible. Radiomic tumour region characteristics in B-mode and elastography appear to be significantly associated with OS.
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Affiliation(s)
- Santiago Cepeda
- Department of Neurosurgery, University Hospital Río Hortega, Calle Dulzaina, 2, 47012, Valladolid, Spain.
| | - Sergio García-García
- Department of Neurosurgery, University Hospital Río Hortega, Calle Dulzaina, 2, 47012 Valladolid, Spain
| | - Ignacio Arrese
- Department of Neurosurgery, University Hospital Río Hortega, Calle Dulzaina, 2, 47012 Valladolid, Spain
| | - María Velasco-Casares
- Department of Radiology, University Hospital Río Hortega, Calle Dulzaina, 2, 47012 Valladolid, Spain
| | - Rosario Sarabia
- Department of Neurosurgery, University Hospital Río Hortega, Calle Dulzaina, 2, 47012 Valladolid, Spain
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24
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Kaale AJ, Rutabasibwa N, Mchome LL, Lillehei KO, Honce JM, Kahamba J, Ormond DR. The use of intraoperative neurosurgical ultrasound for surgical navigation in low- and middle-income countries: the initial experience in Tanzania. J Neurosurg 2021; 134:630-637. [PMID: 32109864 DOI: 10.3171/2019.12.jns192851] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neuronavigation has become a crucial tool in the surgical management of CNS pathology in higher-income countries, but has yet to be implemented in most low- and middle-income countries (LMICs) due to cost constraints. In these resource-limited settings, neurosurgeons typically rely on their understanding of neuroanatomy and preoperative imaging to help guide them through a particular operation, making surgery more challenging for the surgeon and a higher risk for the patient. Alternatives to assist the surgeon improve the safety and efficacy of neurosurgery are important for the expansion of subspecialty neurosurgery in LMICs. A low-cost and efficacious alternative may be the use of intraoperative neurosurgical ultrasound. The authors analyze the preliminary results of the introduction of intraoperative ultrasound in an LMIC setting. METHODS After a training program in intraoperative ultrasound including courses conducted in Dar es Salaam, Tanzania, and Aurora, Colorado, neurosurgeons at the Muhimbili Orthopaedic and Neurosurgical Institute began its independent use. The initial experience is reported from the first 24 prospective cases in which intraoperative ultrasound was used. When possible, ultrasound findings were recorded and compared with postoperative imaging findings in order to establish accuracy of intraoperative interpretation. RESULTS Of 24 cases of intraoperative ultrasound that were reported, 29.2% were spine surgeries and 70.8% were cranial. The majority were tumor cases (95.8%). Lesions were identified through the dura mater in all 24 cases, with 20.8% requiring extension of craniotomy or laminectomy due to inadequate exposure. Postoperative imaging (typically CT) was only performed in 11 cases, but all 11 matched the findings on post-dural closure ultrasound. CONCLUSIONS The use of intraoperative ultrasound, which is affordable and available locally, is changing neurosurgical care in Tanzania. Ultimately, expanding the use of intraoperative B-mode ultrasound in Tanzania and other LMICs may help improve neurosurgical care in these countries in an affordable manner.
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Affiliation(s)
- Aingaya J Kaale
- 1Division of Neurosurgery, Muhimbili Orthopaedic and Neurosurgical Institute, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; and
| | - Nicephorus Rutabasibwa
- 1Division of Neurosurgery, Muhimbili Orthopaedic and Neurosurgical Institute, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; and
| | - Laurent Lemeri Mchome
- 1Division of Neurosurgery, Muhimbili Orthopaedic and Neurosurgical Institute, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; and
| | | | - Justin M Honce
- 3Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joseph Kahamba
- 1Division of Neurosurgery, Muhimbili Orthopaedic and Neurosurgical Institute, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; and
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25
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Navigated 3D Ultrasound in Brain Metastasis Surgery: Analyzing the Differences in Object Appearances in Ultrasound and Magnetic Resonance Imaging. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10217798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Implementation of intraoperative 3D ultrasound (i3D US) into modern neuronavigational systems offers the possibility of live imaging and subsequent imaging updates. However, different modalities, image acquisition strategies, and timing of imaging influence object appearances. We analyzed the differences in object appearances in ultrasound (US) and magnetic resonance imaging (MRI) in 35 cases of brain metastasis, which were operated in a multimodal navigational setup after intraoperative computed tomography based (iCT) registration. Method: Registration accuracy was determined using the target registration error (TRE). Lesions segmented in preoperative magnetic resonance imaging (preMRI) and i3D US were compared focusing on object size, location, and similarity. Results: The mean and standard deviation (SD) of the TRE was 0.84 ± 0.36 mm. Objects were similar in size (mean ± SD in preMRI: 13.6 ± 16.0 cm3 vs. i3D US: 13.5 ± 16.0 cm3). The Dice coefficient was 0.68 ± 0.22 (mean ± SD), the Hausdorff distance 8.1 ± 2.9 mm (mean ± SD), and the Euclidean distance of the centers of gravity 3.7 ± 2.5 mm (mean ± SD). Conclusion: i3D US clearly delineates tumor boundaries and allows live updating of imaging for compensation of brain shift, which can already be identified to a significant amount before dural opening.
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Canalini L, Klein J, Miller D, Kikinis R. Enhanced registration of ultrasound volumes by segmentation of resection cavity in neurosurgical procedures. Int J Comput Assist Radiol Surg 2020; 15:1963-1974. [PMID: 33029677 PMCID: PMC7671994 DOI: 10.1007/s11548-020-02273-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 09/25/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Neurosurgeons can have a better understanding of surgical procedures by comparing ultrasound images obtained at different phases of the tumor resection. However, establishing a direct mapping between subsequent acquisitions is challenging due to the anatomical changes happening during surgery. We propose here a method to improve the registration of ultrasound volumes, by excluding the resection cavity from the registration process. METHODS The first step of our approach includes the automatic segmentation of the resection cavities in ultrasound volumes, acquired during and after resection. We used a convolution neural network inspired by the 3D U-Net. Then, subsequent ultrasound volumes are registered by excluding the contribution of resection cavity. RESULTS Regarding the segmentation of the resection cavity, the proposed method achieved a mean DICE index of 0.84 on 27 volumes. Concerning the registration of the subsequent ultrasound acquisitions, we reduced the mTRE of the volumes acquired before and during resection from 3.49 to 1.22 mm. For the set of volumes acquired before and after removal, the mTRE improved from 3.55 to 1.21 mm. CONCLUSIONS We proposed an innovative registration algorithm to compensate the brain shift affecting ultrasound volumes obtained at subsequent phases of neurosurgical procedures. To the best of our knowledge, our method is the first to exclude automatically segmented resection cavities in the registration of ultrasound volumes in neurosurgery.
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Affiliation(s)
- Luca Canalini
- Fraunhofer MEVIS, Institute for Digital Medicine, Bremen, Germany.
- Medical Imaging Computing, University of Bremen, Bremen, Germany.
| | - Jan Klein
- Fraunhofer MEVIS, Institute for Digital Medicine, Bremen, Germany
| | - Dorothea Miller
- Department of Neurosurgery, University Hospital Knappschaftskrankenhaus, Bochum, Germany
| | - Ron Kikinis
- Surgical Planning Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Farnia P, Mohammadi M, Najafzadeh E, Alimohamadi M, Makkiabadi B, Ahmadian A. High-quality photoacoustic image reconstruction based on deep convolutional neural network: towards intra-operative photoacoustic imaging. Biomed Phys Eng Express 2020; 6:045019. [PMID: 33444279 DOI: 10.1088/2057-1976/ab9a10] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The use of intra-operative imaging system as an intervention solution to provide more accurate localization of complicated structures has become a necessity during the neurosurgery. However, due to the limitations of conventional imaging systems, high-quality real-time intra-operative imaging remains as a challenging problem. Meanwhile, photoacoustic imaging has appeared so promising to provide images of crucial structures such as blood vessels and microvasculature of tumors. To achieve high-quality photoacoustic images of vessels regarding the artifacts caused by the incomplete data, we proposed an approach based on the combination of time-reversal (TR) and deep learning methods. The proposed method applies a TR method in the first layer of the network which is followed by the convolutional neural network with weights adjusted to a set of simulated training data for the other layers to estimate artifact-free photoacoustic images. It was evaluated using a generated synthetic database of vessels. The mean of signal to noise ratio (SNR), peak SNR, structural similarity index, and edge preservation index for the test data were reached 14.6 dB, 35.3 dB, 0.97 and 0.90, respectively. As our results proved, by using the lower number of detectors and consequently the lower data acquisition time, our approach outperforms the TR algorithm in all criteria in a computational time compatible with clinical use.
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Affiliation(s)
- Parastoo Farnia
- Medical Physics and Biomedical Engineering Department, Faculty of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran. Research Centre of Biomedical Technology and Robotics (RCBTR), Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Chicoine MR, Sylvester P, Yahanda AT, Shah A. Image Guidance in Cranial Neurosurgery: How a Six-Ton Magnet and Fluorescent Colors Make Brain Tumor Surgery Better. MISSOURI MEDICINE 2020; 117:39-44. [PMID: 32158048 PMCID: PMC7023946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Maximal safe resection can improve patient outcomes for a variety of brain tumor types including low- and high-grade gliomas, pituitary adenomas, and other pathologies. Numerous intraoperative adjuncts exist to guide surgeons with maximizing extent of resection. Three distinct strategies exist including: 1) surgical navigation; 2) intraoperative imaging; and 3) tumor fluorescence. Surgical navigation involves registration of high-resolution three-dimensional imaging to the patient's cranial surface anatomy, allowing real-time localization of tumor and brain structures. Intraoperative imaging devices like intraoperative magnetic resonance imaging (iMRI), intraoperative computed tomography (iCT), 3-D fluoroscopy, and intraoperative ultrasonography (iUS) allow near real time visualization to assess the extent of resection. Intraoperative fluorescence via intravenous fluorescein or oral 5-aminolevulinic acid (5-ALA) causes brain tumors to "light up", which can be viewed through surgical optics using selective filters and specific wavelength light sources. A general overview, as well as implementation and utilization of some of these image guidance strategies at Washington University and by Siteman Cancer Center neurosurgeons at Barnes Jewish Hospital, is discussed in this review.
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Affiliation(s)
- Michael R Chicoine
- Michael R. Chicoine, MD, is the August A. Busch, Jr. Professor of Neurological Surgery; Peter Sylvester, MD, Neurosurgery Resident PGY6; Alexander T. Yahanda, BS; and Amar Shah, MD, are all in the Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Peter Sylvester
- Michael R. Chicoine, MD, is the August A. Busch, Jr. Professor of Neurological Surgery; Peter Sylvester, MD, Neurosurgery Resident PGY6; Alexander T. Yahanda, BS; and Amar Shah, MD, are all in the Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander T Yahanda
- Michael R. Chicoine, MD, is the August A. Busch, Jr. Professor of Neurological Surgery; Peter Sylvester, MD, Neurosurgery Resident PGY6; Alexander T. Yahanda, BS; and Amar Shah, MD, are all in the Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Amar Shah
- Michael R. Chicoine, MD, is the August A. Busch, Jr. Professor of Neurological Surgery; Peter Sylvester, MD, Neurosurgery Resident PGY6; Alexander T. Yahanda, BS; and Amar Shah, MD, are all in the Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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Ultrasound-based real-time neuronavigated fluorescence-guided surgery for high-grade gliomas: technical note and preliminary experience. Acta Neurochir (Wien) 2019; 161:2595-2605. [PMID: 31656986 DOI: 10.1007/s00701-019-04094-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The extent of resection (EOR) plays a fundamental role in the prognosis of patients with high-grade gliomas (HGG). One of the main challenges in achieving a complete resection is the distinction between tumor and normal brain. Nowadays, several technologies are employed to obtain a higher tumor removal rate and respect the normal tissue in glioma surgery and in the last decades, fluorescein sodium (FS) and intraoperative ultrasound (IOUS) have been widely used. The aim of our technical note is to demonstrate how combining these two tools offers an ultrasound-based real-time neuronavigated fluorescence-guided surgery in order to optimize HGG removal. METHODS Five patients (3 males, 2 females; mean age 55.2 years, range 36-68 years) undergoing craniotomies for removal of intraaxial lesions suggestive of high-grade gliomas on preoperative MRI were included in the study. Intraoperative navigated B-mode and CEUS associated with sodium fluorescein were used in all cases; white light appearance, IOUS, and fluorescence findings were recorded immediately after each surgery. Also, extent of resection was evaluated on postoperative Gd-enhanced MRI performed within 72 h. RESULTS All tumors effectively stained yellow with fluorescein sodium during the surgical procedure and four were well delineated by IOUS. IOUS was repeated frequently (average 2.6 time) to obtain an orientation of the gross residual tumor with respect to anatomical landmarks as the surgery proceeded. Tumor removal was completed under Yellow 560 filter. CONCLUSIONS In our technical report, we demonstrate that combining intraoperatively fluorescein sodium and IOUS improves the information and facilitates making decisions during the HGG surgery. Further experience gained in larger studies will help confirm these findings.
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Elmesallamy WAEA. The role of intraoperative ultrasound in gross total resection of brain mass lesions and outcome. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0117-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Surgical resection of brain mass lesion mandates safety and the best outcome for the patient.
Objectives
The aim of this study was the evaluation of intraoperative ultrasound (IOUS) in gross total resection of brain mass lesions and patients’ safety in comparison to conventional surgery.
Materials and methods
In total, 632 patients were operated for brain mass lesion resection at Neurosurgery Department, Zagazig University Hospitals, during the period from January 2011 to October 2018 and divided randomly into two groups, IOUS group and conventional group, for the detection value of IOUS in resection, safety, and outcome after 3 months follow-up.
Results
The IOUS group showed statistically significant gross total resection regardless to pathology, location, size, age, and sex in favor of IOUS use, and also, there were significantly less complications and better outcome after 3 months follow-up with the IOUS group. Significantly better outcome was found with gross total resection in total surgeries.
Conclusions
The use of IOUS during brain mass lesion surgery is safe and can assist the surgeon in gross total resection with better outcome.
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Elmesallamy WAEA. Demonstrative study of brain anatomical landmarks by intraoperative ultrasound imaging. EGYPTIAN JOURNAL OF NEUROSURGERY 2019. [DOI: 10.1186/s41984-019-0056-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Wang J, Yang Y, Liu X, Duan Y. Intraoperative contrast-enhanced ultrasound for cerebral glioma resection and the relationship between microvascular perfusion and microvessel density. Clin Neurol Neurosurg 2019; 186:105512. [PMID: 31585336 DOI: 10.1016/j.clineuro.2019.105512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 02/02/2023]
Abstract
We analyzed the relationship between quantitative CEUS parameters and microvessel density (MVD) of different pathologic grades of cerebral gliomas. ICEUS was performed in 49 patients with cerebral gliomas. The enhancement characteristics of cerebral gliomas were observed before and after tumor resection. The number of microvessels was counted by immunostaining with anti-CD34. Differences in these quantitative parameters in cerebral gliomas were compared and subjected to a correlation analysis with MVD. The assessment of iCEUS parameters and tumor MVD showed that cerebral gliomas of different pathological grades had different characteristics. The time-to-peak (Tmax) was significantly shorter, the peak intensity (PI) and MVD were significantly higher in high-grade cerebral gliomas than in low-grade cerebral gliomas (p < 0.05). According to the immunostaining, PI was positively (r = 0.637) correlated with MVD and Tmax was negatively (r = -0.845) correlated with MVD. ICEUS could provid dynamic and continuous real-time imaging and quantitative data analysis of different pathological grades of cerebral gliomas, the quantitiative CEUS parameters were closely related to the MVD, and be helpful in understanding the cerebral gliomas grade and refining surgical strategy.
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Affiliation(s)
- Jia Wang
- Department of Ultrasound, Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, China.
| | - Yilin Yang
- Department of Ultrasound, Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, China.
| | - Xi Liu
- Department of Ultrasound, Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, China.
| | - Yunyou Duan
- Department of Ultrasound, Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, China.
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Segmentation-based registration of ultrasound volumes for glioma resection in image-guided neurosurgery. Int J Comput Assist Radiol Surg 2019; 14:1697-1713. [PMID: 31392670 PMCID: PMC6797669 DOI: 10.1007/s11548-019-02045-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE In image-guided surgery for glioma removal, neurosurgeons usually plan the resection on images acquired before surgery and use them for guidance during the subsequent intervention. However, after the surgical procedure has begun, the preplanning images become unreliable due to the brain shift phenomenon, caused by modifications of anatomical structures and imprecisions in the neuronavigation system. To obtain an updated view of the resection cavity, a solution is to collect intraoperative data, which can be additionally acquired at different stages of the procedure in order to provide a better understanding of the resection. A spatial mapping between structures identified in subsequent acquisitions would be beneficial. We propose here a fully automated segmentation-based registration method to register ultrasound (US) volumes acquired at multiple stages of neurosurgery. METHODS We chose to segment sulci and falx cerebri in US volumes, which remain visible during resection. To automatically segment these elements, first we trained a convolutional neural network on manually annotated structures in volumes acquired before the opening of the dura mater and then we applied it to segment corresponding structures in different surgical phases. Finally, the obtained masks are used to register US volumes acquired at multiple resection stages. RESULTS Our method reduces the mean target registration error (mTRE) between volumes acquired before the opening of the dura mater and during resection from 3.49 mm (± 1.55 mm) to 1.36 mm (± 0.61 mm). Moreover, the mTRE between volumes acquired before opening the dura mater and at the end of the resection is reduced from 3.54 mm (± 1.75 mm) to 2.05 mm (± 1.12 mm). CONCLUSION The segmented structures demonstrated to be good candidates to register US volumes acquired at different neurosurgical phases. Therefore, our solution can compensate brain shift in neurosurgical procedures involving intraoperative US data.
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Shabaev AR, Kazantsev AN, Mironov AV, Ruban EV. [Surgical treatment of protoplasmic astrocytoma of sylvian aqueduct involving posterior part of the third ventricle]. Khirurgiia (Mosk) 2019:82-88. [PMID: 30855596 DOI: 10.17116/hirurgia201902182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It is presented case report of extremely rare pathology - protoplasmic astrocytoma of sylvian aqueduct involving posterior section of the third ventricle. The main principles of treatment were considered. Dynamics of neurological status was demonstrated. An effectiveness of treatment strategy was assessed.
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Affiliation(s)
- A R Shabaev
- Barbarash Kemerovo Regional Clinical Cardiology Clinic, Kemerovo, Russia
| | - A N Kazantsev
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - A V Mironov
- Barbarash Kemerovo Regional Clinical Cardiology Clinic, Kemerovo, Russia
| | - E V Ruban
- Barbarash Kemerovo Regional Clinical Cardiology Clinic, Kemerovo, Russia
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Ganau M, Ligarotti GK, Apostolopoulos V. Real-time intraoperative ultrasound in brain surgery: neuronavigation and use of contrast-enhanced image fusion. Quant Imaging Med Surg 2019; 9:350-358. [PMID: 31032183 DOI: 10.21037/qims.2019.03.06] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Mario Ganau
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gianfranco K Ligarotti
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Göker B, Kırış T. Sodium fluorescein-guided brain tumor surgery under the YELLOW-560-nm surgical microscope filter in pediatric age group: feasibility and preliminary results. Childs Nerv Syst 2019; 35:429-435. [PMID: 30610485 DOI: 10.1007/s00381-018-04037-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 12/17/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the feasibility and safety of sodium fluorescein (Na-Fl)-guided surgery with the use of the PENTERO 900 surgical microscope (Carl Zeiss, Meditec, Oberkochen, Germany) equipped with the YELLOW-560-nm filter and low-dose Na-Fl (2 mg/kg) in pediatric brain tumor surgery. METHODS The study included 23 pediatric patients with various intracranial pathologies, who underwent Na-Fl-guided surgery between April 2015 and February 2018. Clinical features, surgical observations, extent of resection, and tumor histopathology were retrospectively analyzed. The use of YELLOW-560-nm filter was found "helpful" if the discrimination of the pinkish brain tissue and bright yellow stained tumor tissue was clear. Otherwise, it was described as "not helpful." RESULTS There were 11 female and 12 male patients with a mean age of 9.4 years. There were 7 brain stem/tectal plate gliomas, 6 supratentorial tumors, 4 intraventricular tumors, 2 pineal tumors, 2 infratentorial tumors, 1 clivus tumor, and 1 tumor with supra- and infratentorial extensions in the current series. Na-Fl was found helpful by means of the tumor demarcation in 20 instances (87%). In 11 of these 20 operations (55%), a total resection was achieved regardless of the tumor pathology. A subtotal resection was achieved in the remaining 9 patients (45%). No adverse events or side effects were encountered with regard to Na-Fl use. CONCLUSION Na-Fl guidance with the use of the YELLOW-560 filter is safe and effective during brain tumor surgery in pediatric age group.
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Affiliation(s)
- Burcu Göker
- Department of Neurosurgery, Liv Hospital Ulus, Istanbul, Turkey. .,Department of Neurosurgery, Istinye University Medical Faculty, Istanbul, Turkey.
| | - Talat Kırış
- Department of Neurosurgery, Liv Hospital Ulus, Istanbul, Turkey.,Department of Neurosurgery, Istinye University Medical Faculty, Istanbul, Turkey
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Policicchio D, Doda A, Sgaramella E, Ticca S, Veneziani Santonio F, Boccaletti R. Ultrasound-guided brain surgery: echographic visibility of different pathologies and surgical applications in neurosurgical routine. Acta Neurochir (Wien) 2018; 160:1175-1185. [PMID: 29675718 DOI: 10.1007/s00701-018-3532-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/04/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of intraoperative ultrasound (iUS) has increased in the last 15 years becoming a standard tool in many neurosurgical centers. Our aim was to assess the utility of routine use of iUS during various types of intracranial surgery. We reviewed our series to assess ultrasound visibility of different pathologies and iUS applications during the course of surgery. MATERIALS AND METHODS This is a retrospective review of 162 patients who underwent intracranial surgery with assistance of the iUS guidance system (SonoWand). Pathologic categories were neoplastic (135), vascular (20), infectious (2), and CSF related (5). Ultrasound visibility was assessed using the Mair classification, a four-tiered grading system that considers the echogenicity of the lesion and its border visibility (from 0 to 3; grade 0, pathology not visible; grade 3, visible with clear border with normal tissue). iUS applications included lesion localization, approach planning to deep-seated lesions, and lesion removal. RESULTS All pathologies were visible on iUS except one aneurysm. On average, extra-axial tumors were identified more easily and had clearer limits compared to intra-axial tumors (extra-axial 17% grade 2, 83% grade 3; intra-axial 5.5% grade 1, 46.5% grade 2, 48% grade 3). iUS provided precise and safe transcortical trajectories to deep-seated lesions (71 patients; tumors, hemangiomas, ICHs); iUS was judged to be less useful to approach skull base tumors and aneurysms. iUS was used to judge extent of resection in 152 cases; surgical artifacts reduced sonographic visibility in 25 cases: extent of resection was correctly checked in 127 patients (53 gliomas, 15 metastases, 39 meningiomas, 4 schwannomas, 4 sellar region tumors, 6 hemangiomas, 3 AVMs, 2 abscesses). CONCLUSIONS iUS was highly sensitive in detecting all types of pathology, was safe and precise in planning trajectories to intraparenchymal lesions (including minimally mini-invasive approaches), and was accurate in checking extent of resection in more than 80% of cases. iUS is a versatile and feasible tool; it could improve safety and its use may be considered in routine intracranial surgery.
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Affiliation(s)
- Domenico Policicchio
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola 1, 07100, Sassari, SS, Italy.
| | - Artan Doda
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola 1, 07100, Sassari, SS, Italy
| | - Enrico Sgaramella
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola 1, 07100, Sassari, SS, Italy
| | - Stefano Ticca
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola 1, 07100, Sassari, SS, Italy
| | - Filippo Veneziani Santonio
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola 1, 07100, Sassari, SS, Italy
| | - Riccardo Boccaletti
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Sassari, Via Enrico De Nicola 1, 07100, Sassari, SS, Italy
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Sweeney JF, Smith H, Taplin A, Perloff E, Adamo MA. Efficacy of intraoperative ultrasonography in neurosurgical tumor resection. J Neurosurg Pediatr 2018; 21:504-510. [PMID: 29451454 DOI: 10.3171/2017.11.peds17473] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative ultrasonography (IOUS) is a widely accessible imaging modality that provides real-time surgical guidance with minimal identified risk or additional operative time. A recent study by the authors found a strong correlation between IOUS and postoperative MRI findings when evaluating the extent of tumor resection, suggesting that IOUS might have significant clinical implications. The objective of this study was to expand on results from the previous study in order to provide more evidence on the usage of IOUS in the determination of gross-total resection (GTR) in both adult and pediatric patients with brain tumors. METHODS This study consisted of a retrospective review of adult and pediatric neurosurgical patients who were treated at Albany Medical Center between August 2009 and March 2016 for a tumor of the brain. All patients were treated with IOUS and then underwent postoperative MRI (with and without contrast) within 1 week of surgery. RESULTS A total of 260 patients (55% of whom were males) met inclusion criteria for the study (age range 3 months to 84 years). IOUS results showed a strong association with postoperative MRI results (φ = 0.693, p < 0.001) and an 81% intended GTR rate. In cases in which GTR was pursued, 19% had false-negative results. IOUS was able to accurately identify residual tumor in 100% of subtotal resection cases where resection was stopped due to invasion of tumor into eloquent locations. Cases involving gliomas had a 75% intended GTR rate and a 25% false-negative rate. Cases involving metastatic tumors had an 87% intended GTR rate and a 13% false-negative rate. The sensitivity, specificity, negative predictive value, and positive predictive value are reported for IOUS in all included tumor pathologies, glioma cases, and metastatic tumor cases, respectively. CONCLUSIONS The use of IOUS may allow for a reliable imaging modality to achieve a more successful GTR of brain tumors in both adult and pediatric neurosurgical patients. When attempting GTR, the authors demonstrated an 81% GTR rate. The authors also report false-negative IOUS results in 19% of attempted GTR cases. The authors support the use of IOUS in both adult and pediatric CNS tumor surgery to improve surgical outcomes. However, further studies are warranted to address existing limitations with its use to further improve its efficacy and better define its role as an intraoperative imaging tool.
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Affiliation(s)
- Jared F Sweeney
- 2Upstate Medical University College of Medicine, Syracuse, New York
| | - Heather Smith
- 1Department of Neurosurgery, Albany Medical Center, Albany; and
| | - AmiLyn Taplin
- 1Department of Neurosurgery, Albany Medical Center, Albany; and
| | - Eric Perloff
- 1Department of Neurosurgery, Albany Medical Center, Albany; and
| | - Matthew A Adamo
- 1Department of Neurosurgery, Albany Medical Center, Albany; and
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Munkvold BKR, Jakola AS, Reinertsen I, Sagberg LM, Unsgård G, Solheim O. The Diagnostic Properties of Intraoperative Ultrasound in Glioma Surgery and Factors Associated with Gross Total Tumor Resection. World Neurosurg 2018; 115:e129-e136. [PMID: 29631086 DOI: 10.1016/j.wneu.2018.03.208] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE In glioma operations, we sought to analyze sensitivity, specificity, and predictive values of intraoperative 3-dimensional ultrasound (US) for detecting residual tumor compared with early postoperative magnetic resonance imaging (MRI). Factors possibly associated with radiologic complete resection were also explored. METHODS One hundred forty-four operations for diffuse supratentorial gliomas were included prospectively in an unselected, population-based, single-institution series. Operating surgeons answered a questionnaire immediately after surgery, stating whether residual tumor was seen with US at the end of resection and rated US image quality (e.g., good, medium, poor). Extent of surgical resection was estimated from preoperative and postoperative MRI. RESULTS Overall specificity was 85% for "no tumor remnant" seen in US images at the end of resection compared with postoperative MRI findings. Sensitivity was 46%, but tumor remnants seen on MRI were usually small (median, 1.05 mL) in operations with false-negative US findings. Specificity was highest in low-grade glioma operations (94%) and lowest in patients who had undergone prior radiotherapy (50%). Smaller tumor volume and superficial location were factors significantly associated with gross total resection in a multivariable logistic regression analysis, whereas good ultrasound image quality did not reach statistical significance (P = 0.061). CONCLUSIONS The specificity of intraoperative US is good, but sensitivity for detecting the last milliliter is low compared with postoperative MRI. Tumor volume and tumor depth are the predictors of achieving gross total resection, although ultrasound image quality was not.
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Affiliation(s)
| | - Asgeir Store Jakola
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway; Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Ingerid Reinertsen
- Norwegian National Advisory Unit for Ultrasound and Image Guided Therapy, St. Olav's University Hospital, Trondheim, Norway; SINTEF, Department of Medical Technology, Trondheim, Norway
| | - Lisa Millgård Sagberg
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway; Norwegian National Advisory Unit for Ultrasound and Image Guided Therapy, St. Olav's University Hospital, Trondheim, Norway; Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Geirmund Unsgård
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway; Norwegian National Advisory Unit for Ultrasound and Image Guided Therapy, St. Olav's University Hospital, Trondheim, Norway; Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ole Solheim
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway; Norwegian National Advisory Unit for Ultrasound and Image Guided Therapy, St. Olav's University Hospital, Trondheim, Norway; Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
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Automatic intraoperative estimation of blood flow direction during neurosurgical interventions. Int J Comput Assist Radiol Surg 2018. [PMID: 29536326 DOI: 10.1007/s11548-018-1711-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE In neurosurgery, reliable information about blood vessel anatomy and flow direction is important to identify, characterize, and avoid damage to the vasculature. Due to ultrasound Doppler angle dependencies and the complexity of the vascular architecture, clinically valuable 3-D flow direction information is currently not available. In this paper, we aim to clinically validate and demonstrate the intraoperative use of a fully automatic method for estimation of 3-D blood flow direction from freehand 2-D Doppler ultrasound. METHODS A 3-D vessel model is reconstructed from 2-D Doppler ultrasound and used to determine the vessel architecture. The blood flow direction is then estimated automatically using the model in combination with Doppler velocity data. To enable testing and validation during surgery, the method was implemented as part of the open-source navigation system CustusX ( www.custusx.org ). RESULTS Ten patients were included prospectively. Data from four patients were processed postoperatively, and data from six patients were processed intraoperatively. In total, the blood flow direction was estimated for 48 different blood vessels with a success rate of 98%. CONCLUSIONS In this work, we have shown that the proposed method is suitable for fully automatic estimation of the blood flow direction in intracranial vessels during neurosurgical interventions. The method has the potential to make the understanding of the complex vascular anatomy and flow pattern more intuitive for the surgeon. The method is compatible with intraoperative use, and results can be presented within the limited time frame where they still are of clinical interest.
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Suero Molina E, Wölfer J, Ewelt C, Ehrhardt A, Brokinkel B, Stummer W. Dual-labeling with 5-aminolevulinic acid and fluorescein for fluorescence-guided resection of high-grade gliomas: technical note. J Neurosurg 2018; 128:399-405. [PMID: 28338432 DOI: 10.3171/2016.11.jns161072] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fluorescence guidance with 5-aminolevulinic acid (5-ALA) helps improve resections of malignant gliomas. However, one limitation is the low intensity of blue light for background illumination. Fluorescein has recently been reintroduced into neurosurgery, and novel microscope systems are available for visualizing this fluorochrome, which highlights all perfused tissues but has limited selectivity for tumor detection. Here, the authors investigate a combination of both fluorochromes: 5-ALA for distinguishing tumor and fluorescein for providing tissue fluorescence of adjacent brain tissue. METHODS The authors evaluated 6 patients who harbored cerebral lesions suggestive of high-grade glioma. Patients received 5-ALA (20 mg/kg) orally 4 hours before induction of anesthesia. Low-dose fluorescein (3 mg/kg intravenous) was injected immediately after anesthesia induction. Pentero microscopes (equipped either with Yellow 560 or Blue 400 filters) were used to visualize fluorescence. To simultaneously visualize both fluorochromes, the Yellow 560 module was combined with external blue light illumination (D-light C System). RESULTS Fluorescein-induced fluorescence created a useful background for protoporphyrin IX (PPIX) fluorescence, which appeared orange to red, surrounded by greenly fluorescent normal brain and edematous tissue. Green brain-tissue fluorescence was helpful in augmenting background. Levels of blue illumination that were too strong obscured PPIX fluorescence. Unspecific extravasation of fluorescein was noted at resection margins, which did not interfere with PPIX fluorescence detection. CONCLUSIONS Dual labeling with both PPIX and fluorescein fluorescence is feasible and gives superior background information during fluorescence-guided resections. The authors believe that this technique carries potential as a next step in fluorescence-guided resections if it is completely integrated into the surgical microscope.
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Affiliation(s)
| | - Johannes Wölfer
- 1Department of Neurosurgery, University Hospital Münster; and
| | - Christian Ewelt
- 1Department of Neurosurgery, University Hospital Münster; and
| | | | | | - Walter Stummer
- 1Department of Neurosurgery, University Hospital Münster; and
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Experimental study of sector and linear array ultrasound accuracy and the influence of navigated 3D-reconstruction as compared to MRI in a brain tumor model. Int J Comput Assist Radiol Surg 2018; 13:471-478. [PMID: 29368236 DOI: 10.1007/s11548-018-1705-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 01/13/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE Currently, intraoperative ultrasound in brain tumor surgery is a rapidly propagating option in imaging technology. We examined the accuracy and resolution limits of different ultrasound probes and the influence of 3D-reconstruction in a phantom and compared these results to MRI in an intraoperative setting (iMRI). METHODS An agarose gel phantom with predefined gel targets was examined with iMRI, a sector (SUS) and a linear (LUS) array probe with two-dimensional images. Additionally, 3D-reconstructed sweeps in perpendicular directions were made of every target with both probes, resulting in 392 measurements. Statistical calculations were performed, and comparative boxplots were generated. RESULTS Every measurement of iMRI and LUS was more precise than SUS, while there was no apparent difference in height of iMRI and 3D-reconstructed LUS. Measurements with 3D-reconstructed LUS were always more accurate than in 2D-LUS, while 3D-reconstruction of SUS showed nearly no differences to 2D-SUS in some measurements. We found correlations of 3D-reconstructed SUS and LUS length and width measurements with 2D results in the same image orientation. CONCLUSIONS LUS provides an accuracy and resolution comparable to iMRI, while SUS is less exact than LUS and iMRI. 3D-reconstruction showed the potential to distinctly improve accuracy and resolution of ultrasound images, although there is a strong correlation with the sweep direction during data acquisition.
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Sodium Fluorescein-Guided Resection under the YELLOW 560 nm Surgical Microscope Filter in Malignant Gliomas: Our First 38 Cases Experience. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7865747. [PMID: 29124069 PMCID: PMC5662847 DOI: 10.1155/2017/7865747] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/01/2017] [Accepted: 09/10/2017] [Indexed: 11/18/2022]
Abstract
Objective Sodium fluorescein (FL) had been safely used in fluorescence-guided microsurgery for imaging various brain tumors. Under the YELLOW 560 nm surgical microscope filter, low-dose FL as a fluorescent dye helps in visualization. Our study investigated the safety and efficacy of this innovative technique in malignant glioma (MG) patients. Patients and Method 38 patients suffering from MGs confirmed by pathology underwent FL-guided resection under YELLOW 560 nm surgical microscope filter. We retrospectively analyzed the clinical characters, microsurgery procedure, extent of resection, pathology of MGs, progression-free survival (PFS), and overall survival (OS). Results Thirty-eight patients had MGs (10 WHO grade III, 28 WHO grade IV). With YELLOW 560 nm surgical microscope filter combined with neuronavigation, sodium fluorescein-guided gross total resection (GTR) was achieved in 35 (92.1%) patients and subtotal resection in 3 (7.69%). The sensitivity and specificity of FL were 94.4% and 88.6% regardless of radiographic localization. Intraoperatively, 10 biopsies (10/28 FL[+]) showed “low” or “high” fluorescence in non-contrast-enhancement region and are also confirmed by pathology. Our data showed 6-month PFS of 92.3% and median survival of 11 months. Conclusion FL-guided resection of MGs under the YELLOW 560 nm surgical microscope filter combined with neuronavigation was safe and effective, especially in non-contrast-MRI regions. It is feasible for improving the extent of resection in MGs especially during emergency cases.
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Acerbi F, Broggi M, Schebesch KM, Höhne J, Cavallo C, De Laurentis C, Eoli M, Anghileri E, Servida M, Boffano C, Pollo B, Schiariti M, Visintini S, Montomoli C, Bosio L, La Corte E, Broggi G, Brawanski A, Ferroli P. Fluorescein-Guided Surgery for Resection of High-Grade Gliomas: A Multicentric Prospective Phase II Study (FLUOGLIO). Clin Cancer Res 2017; 24:52-61. [PMID: 29018053 DOI: 10.1158/1078-0432.ccr-17-1184] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/05/2017] [Accepted: 10/05/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Sodium fluorescein is a dye that, intravenously injected, selectively accumulates in high-grade glioma (HGG) tissue through a damaged blood-brain barrier. In this article, the final results of a multicentric prospective phase II trial (FLUOGLIO) on fluorescein-guided HGG resection through a dedicated filter on the surgical microscope were reported.Methods: Patients with suspected HGGs considered suitable for removal were eligible to participate in this trial. Fluorescein was intravenously injected at a dose of 5 to 10 mg/kg. The primary endpoint was the percentage of patients with histologically confirmed HGGs, without contrast-enhancing tumor at the immediate postoperative MRI. Secondary endpoints were PFS, residual tumor on postoperative MRI, overall survival, neurologic deficits, and fluorescein-related toxicity. The sensitivity and specificity of fluorescein in identifying tumor tissue were estimated by fluorescent and nonfluorescent biopsies at the tumor margin. The study was registered on the European Regulatory Authorities website (EudraCT 2011-002527-18).Results: Fifty-seven patients aged 45 to 75 years were screened for participation, and 46 were considered for primary and secondary endpoints. Mean preoperative tumor volume was 28.75 cm3 (range, 1.3-87.8 cm3). Thirty-eight patients (82.6%) underwent a complete tumor removal. Median follow-up was 11 months. PFS-6 and PFS-12 were 56.6% and 15.2%. Median survival was 12 months. No adverse reaction related to SF administration was recorded. The sensitivity and specificity of fluorescein in identifying tumor tissue were respectively 80.8% and 79.1%.Conclusions: Fluorescein-guided technique with a dedicated filter on the surgical microscope is safe and enables a high percentage of contrast-enhancing tumor in patients with HGGs. Clin Cancer Res; 24(1); 52-61. ©2017 AACR.
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Affiliation(s)
- Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy.
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Karl-Michael Schebesch
- Department of Neuropathology and Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Julius Höhne
- Department of Neuropathology and Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Claudio Cavallo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Camilla De Laurentis
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marica Eoli
- Department of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Elena Anghileri
- Department of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Maura Servida
- Department of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Carlo Boffano
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Bianca Pollo
- Department of Neuropathology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Sergio Visintini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Cristina Montomoli
- Department of Public Health, Forensic and Experimental Medicine, Unit of Biostatistic and Clinic Epidemiology, University of Pavia, Pavia, Italy
| | - Lorenzo Bosio
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Emanuele La Corte
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Giovanni Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Alexander Brawanski
- Department of Neuropathology and Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Matrone G, Ramalli A, Savoia AS, Quaglia F, Castellazzi G, Morbini P, Piastra M. An Experimental Protocol for Assessing the Performance of New Ultrasound Probes Based on CMUT Technology in Application to Brain Imaging. J Vis Exp 2017. [PMID: 28994803 DOI: 10.3791/55798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The possibility to perform an early and repeatable assessment of imaging performance is fundamental in the design and development process of new ultrasound (US) probes. Particularly, a more realistic analysis with application-specific imaging targets can be extremely valuable to assess the expected performance of US probes in their potential clinical field of application. The experimental protocol presented in this work was purposely designed to provide an application-specific assessment procedure for newly-developed US probe prototypes based on Capacitive Micromachined Ultrasonic Transducer (CMUT) technology in relation to brain imaging. The protocol combines the use of a bovine brain fixed in formalin as the imaging target, which ensures both realism and repeatability of the described procedures, and of neuronavigation techniques borrowed from neurosurgery. The US probe is in fact connected to a motion tracking system which acquires position data and enables the superposition of US images to reference Magnetic Resonance (MR) images of the brain. This provides a means for human experts to perform a visual qualitative assessment of the US probe imaging performance and to compare acquisitions made with different probes. Moreover, the protocol relies on the use of a complete and open research and development system for US image acquisition, i.e. the Ultrasound Advanced Open Platform (ULA-OP) scanner. The manuscript describes in detail the instruments and procedures involved in the protocol, in particular for the calibration, image acquisition and registration of US and MR images. The obtained results prove the effectiveness of the overall protocol presented, which is entirely open (within the limits of the instrumentation involved), repeatable, and covers the entire set of acquisition and processing activities for US images.
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Affiliation(s)
- Giulia Matrone
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia
| | | | | | | | - Gloria Castellazzi
- Brain Connectivity Center, BCC, Istituto Neurologico Nazionale Fondazione C. Mondino I.R.C.C.S
| | - Patrizia Morbini
- Department of Molecular Medicine - Unit of Pathology, University of Pavia, Foundation IRCCS Policlinico San Matteo
| | - Marco Piastra
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia;
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Fluorescein-Guided Surgery for High-Grade Glioma Resection: An Intraoperative “Contrast-Enhancer”. World Neurosurg 2017; 104:239-247. [DOI: 10.1016/j.wneu.2017.05.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 11/22/2022]
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Bayer S, Maier A, Ostermeier M, Fahrig R. Intraoperative Imaging Modalities and Compensation for Brain Shift in Tumor Resection Surgery. Int J Biomed Imaging 2017; 2017:6028645. [PMID: 28676821 PMCID: PMC5476838 DOI: 10.1155/2017/6028645] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/03/2017] [Indexed: 11/26/2022] Open
Abstract
Intraoperative brain shift during neurosurgical procedures is a well-known phenomenon caused by gravity, tissue manipulation, tumor size, loss of cerebrospinal fluid (CSF), and use of medication. For the use of image-guided systems, this phenomenon greatly affects the accuracy of the guidance. During the last several decades, researchers have investigated how to overcome this problem. The purpose of this paper is to present a review of publications concerning different aspects of intraoperative brain shift especially in a tumor resection surgery such as intraoperative imaging systems, quantification, measurement, modeling, and registration techniques. Clinical experience of using intraoperative imaging modalities, details about registration, and modeling methods in connection with brain shift in tumor resection surgery are the focuses of this review. In total, 126 papers regarding this topic are analyzed in a comprehensive summary and are categorized according to fourteen criteria. The result of the categorization is presented in an interactive web tool. The consequences from the categorization and trends in the future are discussed at the end of this work.
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Affiliation(s)
- Siming Bayer
- Pattern Recognition Lab, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Andreas Maier
- Pattern Recognition Lab, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
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Vasefi F, MacKinnon N, Farkas DL, Kateb B. Review of the potential of optical technologies for cancer diagnosis in neurosurgery: a step toward intraoperative neurophotonics. NEUROPHOTONICS 2017; 4:011010. [PMID: 28042588 PMCID: PMC5184765 DOI: 10.1117/1.nph.4.1.011010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 11/07/2016] [Indexed: 05/06/2023]
Abstract
Advances in image-guided therapy enable physicians to obtain real-time information on neurological disorders such as brain tumors to improve resection accuracy. Image guidance data include the location, size, shape, type, and extent of tumors. Recent technological advances in neurophotonic engineering have enabled the development of techniques for minimally invasive neurosurgery. Incorporation of these methods in intraoperative imaging decreases surgical procedure time and allows neurosurgeons to find remaining or hidden tumor or epileptic lesions. This facilitates more complete resection and improved topology information for postsurgical therapy (i.e., radiation). We review the clinical application of recent advances in neurophotonic technologies including Raman spectroscopy, thermal imaging, optical coherence tomography, and fluorescence spectroscopy, highlighting the importance of these technologies in live intraoperative tissue mapping during neurosurgery. While these technologies need further validation in larger clinical trials, they show remarkable promise in their ability to help surgeons to better visualize the areas of abnormality and enable safe and successful removal of malignancies.
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Affiliation(s)
- Fartash Vasefi
- Spectral Molecular Imaging Inc., 13412 Ventura Boulevard, Suite 250, Sherman Oaks, California 91423, United States
- Brain Mapping Foundation, 8159 Santa Monica Boulevard, Suite 200, West Hollywood, California 90046, United States
- Society for Brain Mapping and Therapeutics (SBMT), 8159 Santa Monica Boulevard, Suite 200, West Hollywood, California 90046, United States
| | - Nicholas MacKinnon
- Spectral Molecular Imaging Inc., 13412 Ventura Boulevard, Suite 250, Sherman Oaks, California 91423, United States
| | - Daniel L. Farkas
- Spectral Molecular Imaging Inc., 13412 Ventura Boulevard, Suite 250, Sherman Oaks, California 91423, United States
- University of Southern California, Department of Biomedical Engineering, 1042 Downey Way, Los Angeles, California 90089, United States
| | - Babak Kateb
- Brain Mapping Foundation, 8159 Santa Monica Boulevard, Suite 200, West Hollywood, California 90046, United States
- Society for Brain Mapping and Therapeutics (SBMT), 8159 Santa Monica Boulevard, Suite 200, West Hollywood, California 90046, United States
- California Neurosurgical Institute, 25751 McBean Pkwy #305, Santa Clarita, California 91355, United States
- National Center for Nano-Bio-Electronics (NCNBE), NASA Research Park, P.O.Box 23, Moffett Field, California 94035, United States
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49
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Smith H, Taplin A, Syed S, Adamo MA. Correlation between intraoperative ultrasound and postoperative MRI in pediatric tumor surgery. J Neurosurg Pediatr 2016; 18:578-584. [PMID: 27472668 DOI: 10.3171/2016.5.peds15739] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Malignant disease of the CNS is the primary etiology for deaths resulting from cancer in the pediatric population. It has been well documented that outcomes of pediatric neurosurgery rely on the extent of tumor resection. Therefore, techniques that improve surgical results have significant clinical implications. Intraoperative ultrasound (IOUS) offers real-time surgical guidance and a more accurate means for detecting residual tumor that is inconspicuous to the naked eye. The objective of this study was to evaluate the correlation of extent of resection between IOUS and postoperative MRI. The authors measured the correlation of extent of resection, negative predictive value, and sensitivity of IOUS and compared them with those of MRI. METHODS This study consisted of a retrospective review of the medical charts of all pediatric patients who underwent neurosurgical treatment of a tumor between August 2009 and July 2015 at Albany Medical Center. Included were patients who were aged ≤ 21 years, who underwent brain or spinal tumor resection, for whom IOUS was used during the tumor resection, and for whom postoperative MRI (with and without contrast) was performed within 1 week of surgery. RESULTS Sixty-two patients met inclusion criteria for the study (33 males, mean age 10.0 years). The IOUS results very significantly correlated with postoperative MRI results (φ = 0.726; p = 0.000000011; negative predictive value 86.3% [95% CI 73.7%-94.3%]). These results exemplify a 71% overall gross-total resection rate and 80% intended gross-total resection rate with the use of IOUS (i.e., excluding cases performed only for debulking purposes). CONCLUSIONS The use of IOUS may play an important role in achieving a greater extent of resection by providing real-time information on tumor volume and location in the setting of brain shift throughout the course of an operation. The authors support the use of IOUS in pediatric CNS tumor surgery to improve clinical outcomes at low cost with minimal additional operating-room time and no identified additional risk.
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Affiliation(s)
- Heather Smith
- Department of Neurosurgery, Albany Medical Center, Albany, New York
| | - AmiLyn Taplin
- Department of Neurosurgery, Albany Medical Center, Albany, New York
| | - Sohail Syed
- Department of Neurosurgery, Albany Medical Center, Albany, New York
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical Center, Albany, New York
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50
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Gerard IJ, Kersten-Oertel M, Petrecca K, Sirhan D, Hall JA, Collins DL. Brain shift in neuronavigation of brain tumors: A review. Med Image Anal 2016; 35:403-420. [PMID: 27585837 DOI: 10.1016/j.media.2016.08.007] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Neuronavigation based on preoperative imaging data is a ubiquitous tool for image guidance in neurosurgery. However, it is rendered unreliable when brain shift invalidates the patient-to-image registration. Many investigators have tried to explain, quantify, and compensate for this phenomenon to allow extended use of neuronavigation systems for the duration of surgery. The purpose of this paper is to present an overview of the work that has been done investigating brain shift. METHODS A review of the literature dealing with the explanation, quantification and compensation of brain shift is presented. The review is based on a systematic search using relevant keywords and phrases in PubMed. The review is organized based on a developed taxonomy that classifies brain shift as occurring due to physical, surgical or biological factors. RESULTS This paper gives an overview of the work investigating, quantifying, and compensating for brain shift in neuronavigation while describing the successes, setbacks, and additional needs in the field. An analysis of the literature demonstrates a high variability in the methods used to quantify brain shift as well as a wide range in the measured magnitude of the brain shift, depending on the specifics of the intervention. The analysis indicates the need for additional research to be done in quantifying independent effects of brain shift in order for some of the state of the art compensation methods to become useful. CONCLUSION This review allows for a thorough understanding of the work investigating brain shift and introduces the needs for future avenues of investigation of the phenomenon.
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Affiliation(s)
- Ian J Gerard
- McConnell Brain Imaging Center, MNI, McGill University, Montreal, Canada.
| | | | - Kevin Petrecca
- Department of Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Denis Sirhan
- Department of Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Jeffery A Hall
- Department of Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - D Louis Collins
- McConnell Brain Imaging Center, MNI, McGill University, Montreal, Canada; Department of Neurosurgery, McGill University, Montreal, Quebec, Canada
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