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Park H, Kim JH, Lee CH, Kim S, Kim YR, Kim KT, Kim JH, Rhee JM, Jo WY, Oh H, Park HP, Kim CH. The utility of intraoperative ultrasonography for spinal cord surgery. PLoS One 2024; 19:e0305694. [PMID: 38985701 PMCID: PMC11236127 DOI: 10.1371/journal.pone.0305694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/04/2024] [Indexed: 07/12/2024] Open
Abstract
OBJECTIVES Intraoperative ultrasonography (IOUS) offers the advantage of providing real-time imaging features, yet it is not generally used. This study aims to discuss the benefits of utilizing IOUS in spinal cord surgery and review related literature. MATERIALS AND METHODS Patients who underwent spinal cord surgery utilizing IOUS at a single institution were retrospectively collected and analyzed to evaluate the benefits derived from the use of IOUS. RESULTS A total of 43 consecutive patients were analyzed. Schwannoma was the most common tumor (35%), followed by cavernous angioma (23%) and ependymoma (16%). IOUS confirmed tumor extent and location before dura opening in 42 patients (97.7%). It was particularly helpful for myelotomy in deep-seated intramedullary lesions to minimize neural injury in 13 patients (31.0% of 42 patients). IOUS also detected residual or hidden lesions in 3 patients (7.0%) and verified the absence of hematoma post-tumor removal in 23 patients (53.5%). In 3 patients (7.0%), confirming no intradural lesions after removing extradural tumors avoided additional dural incisions. IOUS identified surrounding blood vessels and detected dural defects in one patient (2.3%) respectively. CONCLUSIONS The IOUS can be a valuable tool for spinal cord surgery in identifying the exact location of the pathologic lesions, confirming the completeness of surgery, and minimizing the risk of neural and vascular injury in a real-time fashion.
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Affiliation(s)
- Hangeul Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jun-Hoe Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang-Hyun Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sum Kim
- Department of Neurosurgery, Kandong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young-Rak Kim
- Department of Neurosurgery, Armed Forces Yangju Hospital, Yangu, Republic of Korea
| | - Kyung-Tae Kim
- Department of Neurosurgery, School of Medicine, Kyungpook National University Chilgok Hospital, Kyungpook National University, Daegu, Republic of Korea
| | - Ji-hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - John M. Rhee
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Woo-Young Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyongmin Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee-Pyoung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Medical Device Development, Seoul National University College of Medicine, Seoul, Republic of Korea
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Soloukey S, Verhoef L, Generowicz BS, De Zeeuw CI, Koekkoek SKE, Vincent AJPE, Dirven CMF, Harhangi BS, Kruizinga P. Case report: High-resolution, intra-operative µDoppler-imaging of spinal cord hemangioblastoma. Front Surg 2023; 10:1153605. [PMID: 37342792 PMCID: PMC10277559 DOI: 10.3389/fsurg.2023.1153605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/19/2023] [Indexed: 06/23/2023] Open
Abstract
Surgical resection of spinal cord hemangioblastomas remains a challenging endeavor: the neurosurgeon's aim to reach total tumor resections directly endangers their aim to minimize post-operative neurological deficits. The currently available tools to guide the neurosurgeon's intra-operative decision-making consist mostly of pre-operative imaging techniques such as MRI or MRA, which cannot cater to intra-operative changes in field of view. For a while now, spinal cord surgeons have adopted ultrasound and its submodalities such as Doppler and CEUS as intra-operative techniques, given their many benefits such as real-time feedback, mobility and ease of use. However, for highly vascularized lesions such as hemangioblastomas, which contain up to capillary-level microvasculature, having access to higher-resolution intra-operative vascular imaging could potentially be highly beneficial. µDoppler-imaging is a new imaging modality especially fit for high-resolution hemodynamic imaging. Over the last decade, µDoppler-imaging has emerged as a high-resolution, contrast-free sonography-based technique which relies on High-Frame-Rate (HFR)-ultrasound and subsequent Doppler processing. In contrast to conventional millimeter-scale (Doppler) ultrasound, the µDoppler technique has a higher sensitivity to detect slow flow in the entire field-of-view which allows for unprecedented visualization of blood flow down to sub-millimeter resolution. In contrast to CEUS, µDoppler is able to image high-resolution details continuously, without being contrast bolus-dependent. Previously, our team has demonstrated the use of this technique in the context of functional brain mapping during awake brain tumor resections and surgical resections of cerebral arteriovenous malformations (AVM). However, the application of µDoppler-imaging in the context of the spinal cord has remained restricted to a handful of mostly pre-clinical animal studies. Here we describe the first application of µDoppler-imaging in the case of a patient with two thoracic spinal hemangioblastomas. We demonstrate how µDoppler is able to identify intra-operatively and with high-resolution, hemodynamic features of the lesion. In contrast to pre-operative MRA, µDoppler could identify intralesional vascular details, in real-time during the surgical procedure. Additionally, we show highly detailed post-resection images of physiological human spinal cord anatomy. Finally, we discuss the necessary future steps to push µDoppler to reach actual clinical maturity.
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Affiliation(s)
- Sadaf Soloukey
- Department of Neuroscience, Erasmus MC, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC, Rotterdam, Netherlands
| | - Luuk Verhoef
- Department of Neuroscience, Erasmus MC, Rotterdam, Netherlands
| | | | - Chris I. De Zeeuw
- Department of Neuroscience, Erasmus MC, Rotterdam, Netherlands
- Royal Dutch Academy for Arts and Sciences, Netherlands Institute for Neuroscience, Amsterdam, Netherlands
| | | | | | | | - Biswadjiet S. Harhangi
- Department of Neurosurgery, Erasmus MC, Rotterdam, Netherlands
- Department of Neurosurgery, Park MC, Rotterdam, Netherlands
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Vetrano IG, Gioppo A, Faragò G, Pinzi V, Pollo B, Broggi M, Schiariti M, Ferroli P, Acerbi F. Hemangioblastomas and Other Vascular Origating Tumors of Brain or Spinal Cord. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1405:377-403. [PMID: 37452946 DOI: 10.1007/978-3-031-23705-8_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Hemangioblastomas (HBs) are highly vascularized, slow-growing, rare benign tumors (WHO grade I). They account for about 2% of intracranial neoplasms; however, they are the most common primary cerebellar tumors in adults. Another frequent seat is the spinal cord (2-10% of primary spinal cord tumors). HBs are constituted by stromal and capillary vascular cells; macroscopically, HBs appear as nodular tumors, with or without cystic components. Although most of the HBs are sporadic (57-75%), they represent a particular component of von Hippel-Lindau disease (VHL), an autosomal dominant syndrome with high penetrance, due to a germline pathogenic mutation in the VHL gene, which is a tumor suppressor with chromosomal location on the short arm of chromosome three. VHL disease determines a variety of malignant and benign tumors, most frequently HBs, renal cell carcinomas, pheochromocytomas/paragangliomas, pancreatic neuroendocrine tumors, and endolymphatic sac tumors. Up to 20% of cases are due to de novo pathogenic variants without a family history. Many epidemiologic details of these tumors, especially the sporadic forms, are not well known. The median age of patients with sporadic HBS is about 40 years. More than two-third of VHL patients develop one or more central nervous system HBs during their lifetime; in case of VHL, patients at first diagnosis are usually younger than the patients with sporadic tumors. The most common presenting signs and symptoms are related to increased intracranial pressure, cerebellar signs, or spinal cord alterations in case of spinal involvement. Magnetic resonance imaging is the gold standard for the diagnosis, assessment, and follow-up of HBs, both sporadic and syndrome-related; angiography is rarely performed because the diagnosis is easily obtained with magnetic resonance. However, the diagnosis of an asymptomatic lesion does not automatically result in therapeutic actions, as the risks of treatment and the onset of possible neurological deficit need to be balanced, considering that HBs may remain asymptomatic and have a static or slow-growing behavior. In such cases, regular follow-up can represent a valid therapeutic option until the patients remain asymptomatic. There are no actual pharmacological therapies that are demonstrated to be effective for HBs. Surgery represents the primary therapeutic approach for these tumors. Observation or radiotherapy also plays a role in the long-term management of patients harboring HBs, especially in VHL; in few selected cases, endovascular treatment has been suggested before surgical removal. This chapter presents a systematic overview of epidemiology, clinical appearance, histopathological and neuroradiological characteristics of central nervous system HBs. Moreover, the genetic and molecular biology of sporadic and VHL HBS deserves special attention. Furthermore, we will describe all the available therapeutic options, along with the follow-up management. Finally, we will briefly report other vascular originating tumors as hemangioendotheliomas, hemangiomas, or angiosarcomas.
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Affiliation(s)
- Ignazio G Vetrano
- Neurovascular Surgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Andrea Gioppo
- Interventional Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giuseppe Faragò
- Interventional Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Valentina Pinzi
- Radiotherapy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Bianca Pollo
- Neuropathology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Morgan Broggi
- Neurovascular Surgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco Schiariti
- Neurovascular Surgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Neurovascular Surgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Acerbi
- Neurovascular Surgery Unit and Experimental Microsurgical Laboratory, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via G. Celoria 11, 20133, Milan, Italy.
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4
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Mazzapicchi E, Restelli F, Falco J, Broggi M, Gatti L, Alongi P, Valentini L, Ferroli P, Vetrano IG, DiMeco F, Acerbi F. Sporadic and von Hippel-Lindau Related Hemangioblastomas of Brain and Spinal Cord: Multimodal Imaging for Intraoperative Strategy. Cancers (Basel) 2022; 14:cancers14225492. [PMID: 36428588 PMCID: PMC9688688 DOI: 10.3390/cancers14225492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 11/12/2022] Open
Abstract
Hemangioblastomas (HBs) are rare, benign tumors often related to von Hippel-Lindau disease. They represent the most frequent primary cerebellar tumors in adults. Neurosurgical procedures aim to obtain a gross-total resection of tumor nodules, avoiding intra-postoperative hemorrhage. The introduction of new intraoperative imaging techniques has considerably changed surgical strategies in neuro-oncology. We present an overview of clinical and radiological data of a mono-institutional retrospective cohort, focusing on the role of intraoperative multimodal imaging in surgical strategy. From 2015 to 2021, we identified 64 (81%) cranial (42 cerebellar, 8 supratentorial, and 14 of the brainstem) HBs and 15 (19%) spinal (4 cervical and 11 dorsal) HBs in 79 patients. Intraoperatively, indocyanine green videoangiography with FLOW800 was used in 62 cases (52 cranial and 10 spinal), intraoperative ultrasound and contrast-enhanced ultrasounds in 22 cases (18 cranial and 4 spinal HBs), and fluorescein in 10 cases (in 6 cranial and 2 spinal cases used as SF-VA). Gross total resection was achieved in 100% of the cases (53 mural nodule removal and 26 complete resections of the solid tumor). No side effects were reported following the combination of these tools. Multimodal intraoperative techniques provide valuable and reliable information to identify the tumor and its vasculature, guiding a more precise and safer resection and reducing the risk of recurrence.
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Affiliation(s)
- Elio Mazzapicchi
- Neurosurgical Unit 2, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Francesco Restelli
- Neurosurgical Unit 2, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Jacopo Falco
- Neurosurgical Unit 2, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Morgan Broggi
- Neurosurgical Unit 2, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Laura Gatti
- Neurobiology Laboratory, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Pierpaolo Alongi
- Nuclear Medicine Unit, ARNAS Ospedali Civico, Di Cristina e Benfratelli, 90127 Palermo, Italy
| | - Laura Valentini
- Neurosurgical Unit 1, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Paolo Ferroli
- Neurosurgical Unit 2, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Ignazio G. Vetrano
- Neurosurgical Unit 1, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
- Department of Biomedical Sciences for Health, Università di Milano, 20122 Milan, Italy
- Correspondence:
| | - Francesco DiMeco
- Neurosurgical Unit 1, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
- Department of Oncology and Hemato-Oncology, Università di Milano, 20122 Milan, Italy
- Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, MD 21205, USA
| | - Francesco Acerbi
- Neurosurgical Unit 2, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
- Experimental Microsurgical Laboratory, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
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5
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Hwang M, Barnewolt CE, Jüngert J, Prada F, Sridharan A, Didier RA. Contrast-enhanced ultrasound of the pediatric brain. Pediatr Radiol 2021; 51:2270-2283. [PMID: 33599780 DOI: 10.1007/s00247-021-04974-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/10/2020] [Accepted: 01/14/2021] [Indexed: 12/16/2022]
Abstract
Brain contrast-enhanced ultrasound (CEUS) is an emerging application that can complement gray-scale US and yield additional insights into cerebral flow dynamics. CEUS uses intravenous injection of ultrasound contrast agents (UCAs) to highlight tissue perfusion and thus more clearly delineate cerebral pathologies including stroke, hypoxic-ischemic injury and focal lesions such as tumors and vascular malformations. It can be applied not only in infants with open fontanelles but also in older children and adults via a transtemporal window or surgically created acoustic window. Advancements in CEUS technology and post-processing methods for quantitative analysis of UCA kinetics further elucidate cerebral microcirculation. In this review article we discuss the CEUS examination protocol for brain imaging in children, current clinical applications and future directions for research and clinical uses of brain CEUS.
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Affiliation(s)
- Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Carol E Barnewolt
- Department of Radiology, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Jörg Jüngert
- Department of Pediatrics, Friedrich-Alexander University Erlangen - Nürnberg, Erlangen, Germany
| | - Francesco Prada
- Acoustic Neuroimaging and Therapy Laboratory, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA.,Focused Ultrasound Foundation, Charlottesville, VA, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Ryne A Didier
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Chryssikos T, Wessell A, Pratt N, Cannarsa G, Sharma A, Olexa J, Han N, Schwartzbauer G, Sansur C, Crandall K. Enhanced Safety of Pedicle Subtraction Osteotomy Using Intraoperative Ultrasound. World Neurosurg 2021; 152:e523-e531. [PMID: 34098140 DOI: 10.1016/j.wneu.2021.05.120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Pedicle subtraction osteotomy (PSO) can improve sagittal alignment but carries risks, including iatrogenic spinal cord and nerve root injury. Critically, during the reduction phase of the technique, medullary kinking or neural element compression can lead to neurologic deficits. METHODS We describe 3 cases of thoracic PSO and evaluate the feasibility, findings, and utility of intraoperative ultrasound in this setting. RESULTS Intraoperative ultrasound can provide a visual assessment of spinal cord morphology before and after PSO reduction and influences surgical decision making with regard to the final amount of sagittal plane correction. This modality is particularly useful for confirming ventral decompression of disc-osteophyte complex before reduction and also after reduction maneuvers when there is kinking of the thecal sac but uncertainty about the underlying status of the spinal cord. Intraoperative ultrasound is a reliable modality that fits well into the technical sequence of PSO, adds a minimal amount of operative time, and has few limitations. CONCLUSIONS We propose that intraoperative ultrasound is a useful supplement to standard neuromonitoring modalities for ensuring safe PSO reduction and decompression of neural elements.
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Affiliation(s)
- Timothy Chryssikos
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA.
| | - Aaron Wessell
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Nathan Pratt
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Gregory Cannarsa
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Ashish Sharma
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Nathan Han
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Charles Sansur
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Kenneth Crandall
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
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7
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Vetrano IG, Gennari AG, Erbetta A, Acerbi F, Nazzi V, DiMeco F, Prada F. Contrast-Enhanced Ultrasound Assisted Surgery of Intramedullary Spinal Cord Tumors: Analysis of Technical Benefits and Intra-operative Microbubble Distribution Characteristics. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:398-407. [PMID: 33349517 DOI: 10.1016/j.ultrasmedbio.2020.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 06/12/2023]
Abstract
Intra-operative contrast-enhanced ultrasound (CEUS) is a relatively standardized procedure in brain neurosurgery, but it is still underused in spinal cord and intramedullary tumor evaluation. We reviewed and analyzed the intra-operative data from a surgical series of patients harboring intramedullary spinal cord tumors who underwent surgery under CEUS guidance. CEUS was performed in 12 patients (age range: 13-55 y); all lesions had ill-defined boundaries or peritumoral cysts at preliminary intra-operative B-mode ultrasound. CEUS highlighted the tumors in all cases. The contrast agent's spinal distribution revealed different phases (arterial, peak, washout), as observed in the brain, but these appeared to be slower and less intense. In our experience, intra-operative CEUS allows surgeons to assess spinal cord perfusion and highlight intramedullary tumors in real time. As for other imaging modalities, ultrasound contrast agents add valuable information over baseline imaging, and their use should be fostered to better understand microbubble distribution dynamics.
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Affiliation(s)
- Ignazio G Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Antonio G Gennari
- Department of Radiology, Cattinara Hospital, University of Trieste, Trieste, Italy; Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Erbetta
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Vittoria Nazzi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy; Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Francesco Prada
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA; Focused Ultrasound Foundation, Charlottesville, Virginia, USA.
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8
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Barkley A, McGrath LB, Hofstetter CP. Intraoperative contrast-enhanced ultrasound for intramedullary spinal neoplasms: patient series. JOURNAL OF NEUROSURGERY. CASE LESSONS 2021; 1:CASE2083. [PMID: 36046770 PMCID: PMC9394227 DOI: 10.3171/case2083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Primary intramedullary spinal tumors cause significant morbidity and death.
Intraoperative ultrasound as an adjunct for localization and monitoring the
extent of resection has not been systematically evaluated in these patients;
the effectiveness of intraoperative contrast-enhanced ultrasound (CEUS)
remains almost completely unexplored. OBSERVATIONS A retrospective case series of patients at a single institution who had
consented to the off-label use of intraoperative CEUS was identified. Seven
patients with a mean age of 52.8 ± 15.8 years underwent resection of
intramedullary tumors assisted by CEUS performed by a single attending
neurosurgeon. Histopathological evaluation revealed 3 cases of
hemangioblastoma, 1 case of pilocytic astrocytoma, 2 cases of ependymoma,
and 1 case of subependymoma. Contrast enhancement correlated with gadolinium
enhancement on preoperative magnetic resonance imaging. Intraoperative CEUS
facilitated precise lesion localization and myelotomy planning. Dynamic CEUS
studies were useful in demonstrating the blood supply to lesions with a
dominant vascular pedicle. Regardless of contrast uptake, the differential
enhancement between spinal cord tissue and neoplasm assisted in determining
interface boundaries. LESSONS Intraoperative CEUS constitutes a useful adjunct for the intraoperative
delineation of contrast-enhancing intramedullary tumors and in vivo
confirmation of gross-total resection. Systematic investigation is needed to
establish the role of CEUS for resection of intramedullary spinal tumors of
various pathologies.
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Affiliation(s)
- Ariana Barkley
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Lynn B McGrath
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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9
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Contrast enhanced ultrasound (CEUS) applications in neurosurgical and neurological settings – New scenarios for brain and spinal cord ultrasonography. A systematic review. Clin Neurol Neurosurg 2020; 198:106105. [DOI: 10.1016/j.clineuro.2020.106105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/19/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
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10
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Han B, Wu D, Jia W, Lin S, Xu Y. Intraoperative Ultrasound and Contrast-Enhanced Ultrasound in Surgical Treatment of Intramedullary Spinal Tumors. World Neurosurg 2020; 137:e570-e576. [DOI: 10.1016/j.wneu.2020.02.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/07/2020] [Accepted: 02/08/2020] [Indexed: 11/30/2022]
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11
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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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12
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Prada F, Vetrano IG, DelBene M, Mauri G, Sconfienza LM, DiMeco F. Letter to the Editor Regarding "The Diagnostic Properties of Intraoperative Ultrasound in Glioma Surgery and Factors Associated with Gross Total Tumor Resection". World Neurosurg 2019; 125:553-554. [PMID: 31500084 DOI: 10.1016/j.wneu.2018.12.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Francesco Prada
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA.
| | - Ignazio G Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Massimiliano DelBene
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giovanni Mauri
- Department of Interventional Radiology, European Institute of Oncology, Milan, Italy
| | - Luca M Sconfienza
- Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Saß B, Bopp M, Nimsky C, Carl B. Navigated 3-Dimensional Intraoperative Ultrasound for Spine Surgery. World Neurosurg 2019; 131:e155-e169. [DOI: 10.1016/j.wneu.2019.07.188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 12/18/2022]
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Acerbi F, Prada F, Vetrano IG, Falco J, Faragò G, Ferroli P, DiMeco F. Indocyanine Green and Contrast-Enhanced Ultrasound Videoangiography: A Synergistic Approach for Real-Time Verification of Distal Revascularization and Aneurysm Occlusion in a Complex Distal Middle Cerebral Artery Aneurysm. World Neurosurg 2019; 125:277-284. [DOI: 10.1016/j.wneu.2019.01.241] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
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Del Bene M, Perin A, Casali C, Legnani F, Saladino A, Mattei L, Vetrano IG, Saini M, DiMeco F, Prada F. Advanced Ultrasound Imaging in Glioma Surgery: Beyond Gray-Scale B-mode. Front Oncol 2018; 8:576. [PMID: 30560090 PMCID: PMC6287020 DOI: 10.3389/fonc.2018.00576] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 11/16/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction: Glioma surgery is aimed at obtaining maximal safe tumor resection while preserving or improving patient's neurological status. For this reason, there is growing interest for intra-operative imaging in neuro-oncological surgery. Intra-operative ultrasound (ioUS) provides the surgeon with real-time, anatomical and functional information. Despite this, in neurosurgery ioUS mainly relies only on gray-scale brightness mode (B-mode). Many other ultrasound imaging modalities, such as Fusion Imaging with pre-operative acquired magnetic resonance imaging (MRI), Doppler modes, Contrast Enhanced Ultrasound (CEUS), and elastosonography have been developed and have been extensively used in other organs. Although these modalities offer valuable real-time intra-operative information, so far their usage during neurosurgical procedures is still limited. Purpose: To present an US-based multimodal approach for image-guidance in glioma surgery, highlighting the different features of advanced US modalities: fusion imaging with pre-operative acquired MRI for Virtual Navigation, B-mode, Doppler (power-, color-, spectral-), CEUS, and elastosonography. Methods: We describe, in a step-by-step fashion, the applications of the most relevant advanced US modalities during different stages of surgery and their implications for surgical decision-making. Each US modality is illustrated from a technical standpoint and its application during glioma surgery is discussed. Results: B-mode offers dynamic morphological information, which can be further implemented with fusion imaging to improve image understanding and orientation. Doppler imaging permits to evaluate anatomy and function of the vascular tree. CEUS allows to perform a real-time angiosonography, providing valuable information in regards of parenchyma and tumor vascularization and perfusion. This facilitates tumor detection and surgical strategy, also allowing to characterize tumor grade and to identify residual tumor. Elastosonography is a promising tool able to better define tumor margins, parenchymal infiltration, tumor consistency and permitting differentiation of high grade and low grade lesions. Conclusions: Multimodal ioUS represents a valuable tool for glioma surgery being highly informative, rapid, repeatable, and real-time. It is able to differentiate low grade from high grade tumors and to provide the surgeon with relevant information for surgical decision-making. ioUS could be integrated with other intra-operative imaging and functional approaches in a synergistic manner to offer the best image guidance for each patient.
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Affiliation(s)
- Massimiliano Del Bene
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Alessandro Perin
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Cecilia Casali
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Federico Legnani
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Andrea Saladino
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Luca Mattei
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Marco Saini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, MD, United States
| | - Francesco Prada
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States.,Focused Ultrasound Foundation, Charlottesville, VA, United States
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Comment on the article "Real-time intraoperative contrast-enhanced ultrasound (CEUS) in vascularized spinal tumors: a technical note". Acta Neurochir (Wien) 2018; 160:1873-1874. [PMID: 30046876 DOI: 10.1007/s00701-018-3628-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 07/17/2018] [Indexed: 12/17/2022]
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Contrast-enhanced ultrasound (CEUS) in spinal tumor surgery. Acta Neurochir (Wien) 2018; 160:1869-1871. [PMID: 30054726 DOI: 10.1007/s00701-018-3626-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 07/17/2018] [Indexed: 12/17/2022]
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Integration of Real-Time Intraoperative Contrast-Enhanced Ultrasound and Color Doppler Ultrasound in the Surgical Treatment of Spinal Cord Dural Arteriovenous Fistulas. World Neurosurg 2018; 112:138-142. [DOI: 10.1016/j.wneu.2018.01.101] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 11/17/2022]
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Giammattei L, Messerer M, Prada F, DiMeco F. Intramedullary cavernoma: A surgical resection technique. Neurochirurgie 2017; 63:426-429. [DOI: 10.1016/j.neuchi.2016.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 04/11/2016] [Accepted: 04/16/2016] [Indexed: 10/21/2022]
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Vasudeva VS, Abd-El-Barr M, Pompeu YA, Karhade A, Groff MW, Lu Y. Use of Intraoperative Ultrasound During Spinal Surgery. Global Spine J 2017; 7:648-656. [PMID: 28989844 PMCID: PMC5624373 DOI: 10.1177/2192568217700100] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Review and technical report. OBJECTIVE Intraoperative ultrasound has been used by spine surgeons since the early 1980s. Since that time, more advanced modes of intraoperative imaging and navigation have become widely available. Although the use of ultrasound during spine surgery has fallen out of favor, it remains the only true real-time imaging modality that allows surgeons to visualize soft tissue anatomy instantly and continuously while operating. It is our objective to demonstrate that for this reason, ultrasound is a useful adjunctive technique for spine surgeons, especially when approaching intradural lesions or when addressing pathology in the ventral spinal canal via a posterior approach. METHODS Using PubMed, the existing literature regarding the use of intraoperative ultrasound during spinal surgery was evaluated. Also, surgical case logs were reviewed to identify spinal operations during which intraoperative ultrasound was used. Illustrative cases were selected and reviewed in detail. RESULTS This article provides a brief review of the history of intraoperative ultrasound in spine surgery and describes certain surgical scenarios during which this technique might be useful. Several illustrative cases are provided from our own experience. CONCLUSIONS Surgeons should consider the use of intraoperative ultrasound when approaching intradural lesions or when addressing pathology ventral to the thecal sac via a posterior approach.
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Affiliation(s)
- Viren S. Vasudeva
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Viren S. Vasudeva, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street AB-136, Boston, MA 02115, USA.
| | | | - Yuri A. Pompeu
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Aditya Karhade
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael W. Groff
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Yi Lu
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Costa F, Ortolina A, Cardia A, Riva M, Revay M, Pecchioli G, Anania CD, Asteggiano F, Fornari M. Preoperative Magnetic Resonance and Intraoperative Computed Tomography Fusion for Real-Time Neuronavigation in Intramedullary Lesion Surgery. Oper Neurosurg (Hagerstown) 2017; 13:188-195. [PMID: 28927206 DOI: 10.1093/ons/opw005] [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] [Received: 08/28/2015] [Accepted: 10/18/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Image-guided surgery techniques in spinal surgery are usually based upon fluoroscopy or computed tomography (CT) scan, which allow for a real-time navigation of bony structures, though not of neural structures and soft tissue remains. OBJECTIVE To verify the effectiveness and efficacy of a novel technique of imaging merging between preoperative magnetic resonance imaging (MRI) and intraoperative CT scan during removal of intramedullary lesions. METHODS Ten consecutive patients were treated for intramedullary lesions using a navigation system aid. Preoperative contrast-enhanced MRI was merged in the navigation software, with an intraoperative CT acquisition, performed using the O-arm TM system (Medtronic Sofamor Danek, Minneapolis, Minnesota). Dosimetric and timing data were also acquired for each patient. RESULTS The fusion process was achieved in all cases and was uneventful. The merged imaging information was useful in all cases for defining the exact area of laminectomy, dural opening, and the eventual extension of cordotomy, without requiring exposition corrections. The radiation dose for the patients was 0.78 mSv. Using the authors' protocol, it was possible to merge a preoperative MRI with navigation based on intraoperative CT scanning in all cases. Information gained with this technique was useful during the different surgical steps. However, there were some drawbacks, such as the merging process, which still remains partially manual. CONCLUSION In this initial experience, MRI and CT merging and its feasibility were tested, and we appreciated its safety, precision, and ease.
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Affiliation(s)
- Francesco Costa
- Departments of Neurosurgery, Humani-tas Clinical and Research Center, Rozzano (MI), Italy
| | - Alessandro Ortolina
- Departments of Neurosurgery, Humani-tas Clinical and Research Center, Rozzano (MI), Italy
| | - Andrea Cardia
- Departments of Neurosurgery, Humani-tas Clinical and Research Center, Rozzano (MI), Italy
| | - Marco Riva
- Departments of Neurosurgery, Humani-tas Clinical and Research Center, Rozzano (MI), Italy
| | - Martina Revay
- Departments of Neurosurgery, Humani-tas Clinical and Research Center, Rozzano (MI), Italy
| | - Guido Pecchioli
- Departments of Neurosurgery, Humani-tas Clinical and Research Center, Rozzano (MI), Italy
| | - Carla Daniela Anania
- Departments of Neurosurgery, Humani-tas Clinical and Research Center, Rozzano (MI), Italy
| | - Francesco Asteggiano
- Departments of Radiology, Humanitas Clinical and Research Center, Rozzano (MI), Italy
| | - Maurizio Fornari
- Departments of Neurosurgery, Humani-tas Clinical and Research Center, Rozzano (MI), Italy
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Spinal Dural Arteriovenous Fistula: Is There a Role for Intraoperative Contrast-Enhanced Ultrasound? World Neurosurg 2017; 100:712.e15-712.e18. [DOI: 10.1016/j.wneu.2017.01.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/07/2017] [Accepted: 01/10/2017] [Indexed: 11/20/2022]
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Lekht I, Brauner N, Bakhsheshian J, Chang KE, Gulati M, Shiroishi MS, Grant EG, Christian E, Zada G. Versatile utilization of real-time intraoperative contrast-enhanced ultrasound in cranial neurosurgery: technical note and retrospective case series. Neurosurg Focus 2016; 40:E6. [PMID: 26926064 DOI: 10.3171/2015.11.focus15570] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Intraoperative contrast-enhanced ultrasound (iCEUS) offers dynamic imaging and provides functional data in real time. However, no standardized protocols or validated quantitative data exist to guide its routine use in neurosurgery. The authors aimed to provide further clinical data on the versatile application of iCEUS through a technical note and illustrative case series. METHODS Five patients undergoing craniotomies for suspected tumors were included. iCEUS was performed using a contrast agent composed of lipid shell microspheres enclosing perflutren (octafluoropropane) gas. Perfusion data were acquired through a time-intensity curve analysis protocol obtained using iCEUS prior to biopsy and/or resection of all lesions. RESULTS Three primary tumors (gemistocytic astrocytoma, glioblastoma multiforme, and meningioma), 1 metastatic lesion (melanoma), and 1 tumefactive demyelinating lesion (multiple sclerosis) were assessed using real-time iCEUS. No intraoperative complications occurred following multiple administrations of contrast agent in all cases. In all neoplastic cases, iCEUS replicated enhancement patterns observed on preoperative Gd-enhanced MRI, facilitated safe tumor debulking by differentiating neoplastic tissue from normal brain parenchyma, and helped identify arterial feeders and draining veins in and around the surgical cavity. Intraoperative CEUS was also useful in guiding a successful intraoperative needle biopsy of a cerebellar tumefactive demyelinating lesion obtained during real-time perfusion analysis. CONCLUSIONS Intraoperative CEUS has potential for safe, real-time, dynamic contrast-based imaging for routine use in neurooncological surgery and image-guided biopsy. Intraoperative CEUS eliminates the effect of anatomical distortions associated with standard neuronavigation and provides quantitative perfusion data in real time, which may hold major implications for intraoperative diagnosis, tissue differentiation, and quantification of extent of resection. Further prospective studies will help standardize the role of iCEUS in neurosurgery.
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Affiliation(s)
| | | | - Joshua Bakhsheshian
- Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ki-Eun Chang
- Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | | | - Eisha Christian
- Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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