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Skambath I, Kren J, Kuppler P, Buschschlueter S, Bonsanto MM. An attempt to identify brain tumour tissue in neurosurgery by mechanical indentation measurements. Acta Neurochir (Wien) 2024; 166:343. [PMID: 39167233 PMCID: PMC11339078 DOI: 10.1007/s00701-024-06218-4] [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: 05/21/2024] [Accepted: 07/24/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND The intraoperative differentiation between tumour tissue, healthy brain tissue, and any sensitive structure of the central nervous system is carried out in modern neurosurgery using various multimodal technologies such as neuronavigation, fluorescent dyes, intraoperative ultrasound or the use of intraoperative MRI, but also the haptic experience of the neurosurgeon. Supporting the surgeon by developing instruments with integrated haptics could provide a further objective dimension in the intraoperative recognition of healthy and diseased tissue. METHODS In this study, we describe intraoperative mechanical indentation measurements of human brain tissue samples of different tumours taken during neurosurgical operation and measured directly in the operating theatre, in a time frame of maximum five minutes. We present an overview of the Young's modulus for the different brain tumour entities and potentially differentiation between them. RESULTS We examined 238 samples of 75 tumour removals. Neither a clear distinction of tumour tissue against healthy brain tissue, nor differentiation of different tumour entities was possible on solely the Young's modulus. Correlation between the stiffness grading of the surgeon and our measurements could be found. CONCLUSION The mechanical behaviour of brain tumours given by the measured Young's modulus corresponds well to the stiffness assessment of the neurosurgeon and can be a great tool for further information on mechanical characteristics of brain tumour tissue. Nevertheless, our findings imply that the information gained through indentation is limited.
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Affiliation(s)
- Isabelle Skambath
- Department of Neurosurgery, UKSH, University of Luebeck, Luebeck, Germany.
| | - Jessica Kren
- Department of Neurosurgery, UKSH, University of Luebeck, Luebeck, Germany
| | - Patrick Kuppler
- Department of Neurosurgery, UKSH, University of Luebeck, Luebeck, Germany
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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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Behboodi B, Carton FX, Chabanas M, de Ribaupierre S, Solheim O, Munkvold BKR, Rivaz H, Xiao Y, Reinertsen I. Open access segmentations of intraoperative brain tumor ultrasound images. Med Phys 2024. [PMID: 39047165 DOI: 10.1002/mp.17317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 04/04/2024] [Accepted: 06/04/2024] [Indexed: 07/27/2024] Open
Abstract
PURPOSE Registration and segmentation of magnetic resonance (MR) and ultrasound (US) images could play an essential role in surgical planning and resectioning brain tumors. However, validating these techniques is challenging due to the scarcity of publicly accessible sources with high-quality ground truth information. To this end, we propose a unique set of segmentations (RESECT-SEG) of cerebral structures from the previously published RESECT dataset to encourage a more rigorous development and assessment of image-processing techniques for neurosurgery. ACQUISITION AND VALIDATION METHODS The RESECT database consists of MR and intraoperative US (iUS) images of 23 patients who underwent brain tumor resection surgeries. The proposed RESECT-SEG dataset contains segmentations of tumor tissues, sulci, falx cerebri, and resection cavity of the RESECT iUS images. Two highly experienced neurosurgeons validated the quality of the segmentations. DATA FORMAT AND USAGE NOTES Segmentations are provided in 3D NIFTI format in the OSF open-science platform: https://osf.io/jv8bk. POTENTIAL APPLICATIONS The proposed RESECT-SEG dataset includes segmentations of real-world clinical US brain images that could be used to develop and evaluate segmentation and registration methods. Eventually, this dataset could further improve the quality of image guidance in neurosurgery.
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Affiliation(s)
- Bahareh Behboodi
- Department of Electrical and Computer Engineering, Concordia University, Montreal, Canada
- School of Health, Concordia University, Montreal, Canada
| | | | - Matthieu Chabanas
- Université Grenoble Alpes, CNRS, Grenoble INP, TIMC, Grenoble, France
| | - Sandrine de Ribaupierre
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ole Solheim
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Bodil K R Munkvold
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Hassan Rivaz
- Department of Electrical and Computer Engineering, Concordia University, Montreal, Canada
- School of Health, Concordia University, Montreal, Canada
| | - Yiming Xiao
- School of Health, Concordia University, Montreal, Canada
- Department of Computer Science and Software Engineering, Concordia University, Montreal, Canada
| | - Ingerid Reinertsen
- Department of Health Research, SINTEF Digital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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4
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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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5
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Bhanja D, James JG, McNutt S, Kray K, Rizk E. Awake craniotomy in pediatric low-grade glioma: barriers and future directions. Childs Nerv Syst 2024:10.1007/s00381-024-06457-x. [PMID: 38985318 DOI: 10.1007/s00381-024-06457-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION The goal of surgical management in pediatric low-grade gliomas (pLGGs) is gross total resection (GTR), as it is considered curative with favorable long-term outcomes. Achieving GTR can be challenging in the setting of eloquent-region gliomas, in which resection may increase risk of neurological deficits. Awake craniotomy (AC) with intraoperative neurofunctional mapping (IONM) offers a promising approach to achieve maximal resection while preserving neurological function. However, its adoption in pediatric cases has been hindered, and barriers to its adoption have not previously been elucidated. FINDINGS This review includes two complementary investigations. First, a survey study was conducted querying pediatric neurosurgeons on their perceived barriers to the procedure in children with pLGG. Next, these critical barriers were analyzed in the context of existing literature. These barriers included the lack of standardized IONM techniques for children, inadequate surgical and anesthesia experience, concerns regarding increased complication risks, doubts about children's ability to tolerate the procedure, and perceived non-indications due to alternative monitoring tools. CONCLUSION Efforts to overcome these barriers include standardizing IONM protocols, refining anesthesia management, enhancing patient preparation strategies, and challenging entrenched beliefs about pediatric AC. Collaborative interdisciplinary efforts and further studies are needed to establish safety guidelines and broaden the application of AC, ultimately improving outcomes for children with pLGG.
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Affiliation(s)
- Debarati Bhanja
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | - Justin G James
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | - Sarah McNutt
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | - Kimberly Kray
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | - Elias Rizk
- Department of Neurosurgery, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA.
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Wu H, Cheng Y, Gao W, Chen P, Wei Y, Zhao H, Wang F. Progress in the application of ultrasound in glioma surgery. Front Med (Lausanne) 2024; 11:1388728. [PMID: 38957299 PMCID: PMC11218567 DOI: 10.3389/fmed.2024.1388728] [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: 02/20/2024] [Accepted: 06/06/2024] [Indexed: 07/04/2024] Open
Abstract
Brain glioma, which is highly invasive and has a poor prognosis, is the most common primary intracranial tumor. Several studies have verified that the extent of resection is a considerable prognostic factor for achieving the best results in neurosurgical oncology. To obtain gross total resection (GTR), neurosurgery relies heavily on generating continuous, real-time, intraoperative glioma descriptions based on image guidance. Given the limitations of existing devices, it is imperative to develop a real-time image-guided resection technique to offer reliable functional and anatomical information during surgery. At present, the application of intraoperative ultrasound (IOUS) has been indicated to enhance resection rates and maximize brain function preservation. IOUS, which is promising due to its lower cost, minimal operational flow interruptions, and lack of radiation exposure, can enable real-time localization and precise tumor size and form descriptions while assisting in discriminating residual tumors and solving brain tissue shifts. Moreover, the application of new advancements in ultrasound technology, such as contrast-enhanced ultrasound (CEUS), three-dimensional ultrasound (3DUS), noninvasive ultrasound (NUS), and ultrasound elastography (UE), could assist in achieving GTR in glioma surgery. This article reviews the advantages and disadvantages of IOUS in glioma surgery.
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Affiliation(s)
| | | | | | | | | | | | - Fenglu Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Xi’an Medical University, Xi’an, China
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7
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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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Juvekar P, Dorent R, Kögl F, Torio E, Barr C, Rigolo L, Galvin C, Jowkar N, Kazi A, Haouchine N, Cheema H, Navab N, Pieper S, Wells WM, Bi WL, Golby A, Frisken S, Kapur T. ReMIND: The Brain Resection Multimodal Imaging Database. Sci Data 2024; 11:494. [PMID: 38744868 PMCID: PMC11093985 DOI: 10.1038/s41597-024-03295-z] [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: 09/28/2023] [Accepted: 04/23/2024] [Indexed: 05/16/2024] Open
Abstract
The standard of care for brain tumors is maximal safe surgical resection. Neuronavigation augments the surgeon's ability to achieve this but loses validity as surgery progresses due to brain shift. Moreover, gliomas are often indistinguishable from surrounding healthy brain tissue. Intraoperative magnetic resonance imaging (iMRI) and ultrasound (iUS) help visualize the tumor and brain shift. iUS is faster and easier to incorporate into surgical workflows but offers a lower contrast between tumorous and healthy tissues than iMRI. With the success of data-hungry Artificial Intelligence algorithms in medical image analysis, the benefits of sharing well-curated data cannot be overstated. To this end, we provide the largest publicly available MRI and iUS database of surgically treated brain tumors, including gliomas (n = 92), metastases (n = 11), and others (n = 11). This collection contains 369 preoperative MRI series, 320 3D iUS series, 301 iMRI series, and 356 segmentations collected from 114 consecutive patients at a single institution. This database is expected to help brain shift and image analysis research and neurosurgical training in interpreting iUS and iMRI.
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Affiliation(s)
| | - Reuben Dorent
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Fryderyk Kögl
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
- Computer Aided Medical Procedures, Technische Universität München, Munich, Germany
| | - Erickson Torio
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Colton Barr
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Laura Rigolo
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Colin Galvin
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Nick Jowkar
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Anees Kazi
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Nazim Haouchine
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Harneet Cheema
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
- Department of Health Science, University of Ottawa, Ottawa, Canada
| | - Nassir Navab
- Computer Aided Medical Procedures, Technische Universität München, Munich, Germany
| | - Steve Pieper
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - William M Wells
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Wenya Linda Bi
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Alexandra Golby
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Sarah Frisken
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Tina Kapur
- Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
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Wagner A, Brielmaier MC, Kampf C, Baumgart L, Aftahy AK, Meyer HS, Kehl V, Höhne J, Schebesch KM, Schmidt NO, Zoubaa S, Riemenschneider MJ, Ratliff M, Enders F, von Deimling A, Liesche-Starnecker F, Delbridge C, Schlegel J, Meyer B, Gempt J. Fluorescein-stained confocal laser endomicroscopy versus conventional frozen section for intraoperative histopathological assessment of intracranial tumors. Neuro Oncol 2024; 26:922-932. [PMID: 38243410 PMCID: PMC11066924 DOI: 10.1093/neuonc/noae006] [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: 10/10/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The aim of this clinical trial was to compare Fluorescein-stained intraoperative confocal laser endomicroscopy (CLE) of intracranial lesions and evaluation by a neuropathologist with routine intraoperative frozen section (FS) assessment by neuropathology. METHODS In this phase II noninferiority, prospective, multicenter, nonrandomized, off-label clinical trial (EudraCT: 2019-004512-58), patients above the age of 18 years with any intracranial lesion scheduled for elective resection were included. The diagnostic accuracies of both CLE and FS referenced with the final histopathological diagnosis were statistically compared in a noninferiority analysis, representing the primary endpoint. Secondary endpoints included the safety of the technique and time expedited for CLE and FS. RESULTS A total of 210 patients were included by 3 participating sites between November 2020 and June 2022. Most common entities were high-grade gliomas (37.9%), metastases (24.1%), and meningiomas (22.7%). A total of 6 serious adverse events in 4 (2%) patients were recorded. For the primary endpoint, the diagnostic accuracy for CLE was inferior with 0.87 versus 0.91 for FS, resulting in a difference of 0.04 (95% confidence interval -0.10; 0.02; P = .367). The median time expedited until intraoperative diagnosis was 3 minutes for CLE and 27 minutes for FS, with a mean difference of 27.5 minutes (standard deviation 14.5; P < .001). CONCLUSIONS CLE allowed for a safe and time-effective intraoperative histological diagnosis with a diagnostic accuracy of 87% across all intracranial entities included. The technique achieved histological assessments in real time with a 10-fold reduction of processing time compared to FS, which may invariably impact surgical strategy on the fly.
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Affiliation(s)
- Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Maria Charlotte Brielmaier
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Charlotte Kampf
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Lea Baumgart
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Amir Kaywan Aftahy
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Hanno S Meyer
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Victoria Kehl
- Institute for AI and Informatics in Medicine & Muenchner Studienzentrum (MSZ), Technical University Munich School of Medicine, Munich, Germany
| | - Julius Höhne
- Department of Neurosurgery, Regensburg University Hospital, Regensburg, Germany
- Department of Neurosurgery, Paracelsus Medical University, Nürnberg, Germany
| | - Karl-Michael Schebesch
- Department of Neurosurgery, Regensburg University Hospital, Regensburg, Germany
- Department of Neurosurgery, Paracelsus Medical University, Nürnberg, Germany
| | - Nils O Schmidt
- Department of Neurosurgery, Regensburg University Hospital, Regensburg, Germany
| | - Saida Zoubaa
- Department of Neuropathology, Regensburg University Hospital, Regensburg, Germany
| | | | - Miriam Ratliff
- Department of Neurosurgery, University Hospital Mannheim, Mannheim, Germany
| | - Frederik Enders
- Department of Neurosurgery, University Hospital Mannheim, Mannheim, Germany
| | - Andreas von Deimling
- Department of Neuropathology, University Hospital Heidelberg and CCU Neuropathology, German Cancer Center (DKFZ), Heidelberg, Germany
| | | | - Claire Delbridge
- Department of Neuropathology, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Juergen Schlegel
- Department of Neuropathology, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar Technical University Munich School of Medicine, Munich, Germany
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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10
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Dong Y, Zhang H, Jin K, Li H. Three-dimensional transvaginal ultrasound diagnosis of interstitial ectopic pregnancy in a unicornuate uterus: A case report. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:473-477. [PMID: 38288546 DOI: 10.1002/jcu.23641] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 05/08/2024]
Abstract
A rare case of unicornuate uterus with interstitial ectopic pregnancy was diagnosed using three-dimensional transvaginal ultrasound (3D-TVUS). The ultrasound revealed a "lancet-shaped" endometrial corona, a gestational sac near the uterus base extending toward the uterine serosa, and visible interstitial lines. The patient underwent laparoscopic surgery for a lesion in the right fallopian tube. 3D-TVUS was crucial in precisely locating the gestational sac, aiding in effective treatment. Interstitial ectopic pregnancies risk severe hemorrhaging upon rupture. Rapid, accurate diagnosis is vital for lifesaving treatment and preventing critical complications.
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Affiliation(s)
- Yanhua Dong
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbin Zhang
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Jin
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hezhou Li
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Juvekar P, Dorent R, Kögl F, Torio E, Barr C, Rigolo L, Galvin C, Jowkar N, Kazi A, Haouchine N, Cheema H, Navab N, Pieper S, Wells WM, Bi WL, Golby A, Frisken S, Kapur T. ReMIND: The Brain Resection Multimodal Imaging Database. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.09.14.23295596. [PMID: 37745329 PMCID: PMC10516086 DOI: 10.1101/2023.09.14.23295596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
The standard of care for brain tumors is maximal safe surgical resection. Neuronavigation augments the surgeon's ability to achieve this but loses validity as surgery progresses due to brain shift. Moreover, gliomas are often indistinguishable from surrounding healthy brain tissue. Intraoperative magnetic resonance imaging (iMRI) and ultrasound (iUS) help visualize the tumor and brain shift. iUS is faster and easier to incorporate into surgical workflows but offers a lower contrast between tumorous and healthy tissues than iMRI. With the success of data-hungry Artificial Intelligence algorithms in medical image analysis, the benefits of sharing well-curated data cannot be overstated. To this end, we provide the largest publicly available MRI and iUS database of surgically treated brain tumors, including gliomas (n=92), metastases (n=11), and others (n=11). This collection contains 369 preoperative MRI series, 320 3D iUS series, 301 iMRI series, and 356 segmentations collected from 114 consecutive patients at a single institution. This database is expected to help brain shift and image analysis research and neurosurgical training in interpreting iUS and iMRI.
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Affiliation(s)
- Parikshit Juvekar
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Reuben Dorent
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Fryderyk Kögl
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Computer Aided Medical Procedures, Technische Universität München, Munich, Germany
| | - Erickson Torio
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Colton Barr
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura Rigolo
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Colin Galvin
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nick Jowkar
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Anees Kazi
- Computer Aided Medical Procedures, Technische Universität München, Munich, Germany
| | - Nazim Haouchine
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Harneet Cheema
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Health Science, University of Ottawa, Ottawa, Canada
| | - Nassir Navab
- Computer Aided Medical Procedures, Technische Universität München, Munich, Germany
| | - Steve Pieper
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - William M. Wells
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Boston, USA
| | - Wenya Linda Bi
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra Golby
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Frisken
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Tina Kapur
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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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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Han B, Zhang L, Jia W. Contrast-Enhanced Ultrasound in Resection of Spinal Cord Gliomas. World Neurosurg 2023; 171:e83-e92. [PMID: 36427693 DOI: 10.1016/j.wneu.2022.11.087] [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: 10/12/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intraoperative contrast-enhanced ultrasound (iCEUS) is a relatively new technique for visualizing brain gliomas and can help achieve maximum resection, but its potential in evaluation of spinal cord gliomas has not been well defined. The aim of this study was to describe the iCEUS characterization of and evaluate its role in visualizing intramedullary gliomas. METHODS A retrospective review of patients who underwent intramedullary glioma resection with iCEUS guidance from 2019 to 2021 was conducted. An offline analysis was performed to compare and characterize the perfusion features of each glioma. RESULTS This study included 36 patients who underwent iCEUS for spinal cord gliomas. iCEUS was performed successfully, and all gliomas were clearly identified. The distribution of contrast agent showed different dynamic phases (arterial, peak, and washout) from those observed in brain gliomas, generally appearing slower and less intense in spinal cord gliomas. iCEUS helped highlight intramedullary gliomas, each of which demonstrated specific iCEUS features depending on the grade. Gross total resection was achieved in 20 patients (55.6%), subtotal resection was achieved in 11 patients (30.6%), and partial resection was achieved in 5 patients (13.8%). CONCLUSIONS ICEUS adds valuable information in highlighting spinal cord gliomas in real time. It allows the neurosurgeon to assess the anatomical location of the glioma and delineate the tumor margins. iCEUS could play a potentially important role in guiding spinal cord glioma resection. Further study with more cases is needed to better understand the microbubble distribution dynamics in intramedullary gliomas.
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Affiliation(s)
- Bo Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liang Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Hebei Cancer Hospital, Chinese Academy of Medical Sciences, Langfang, China; National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenqing Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Juvekar P, Torio E, Bi WL, Bastos DCDA, Golby AJ, Frisken SF. Mapping Resection Progress by Tool-Tip Tracking during Brain Tumor Surgery for Real-Time Estimation of Residual Tumor. Cancers (Basel) 2023; 15:cancers15030825. [PMID: 36765783 PMCID: PMC9913508 DOI: 10.3390/cancers15030825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
Surgical resection continues to be the primary initial therapeutic strategy in the treatment of patients with brain tumors. Computerized cranial neuronavigation based on preoperative imaging offers precision guidance during craniotomy and early tumor resection but progressively loses validity with brain shift. Intraoperative MRI (iMRI) and intraoperative ultrasound (iUS) can update the imaging used for guidance and navigation but are limited in terms of temporal and spatial resolution, respectively. We present a system that uses time-stamped tool-tip positions of surgical instruments to generate a map of resection progress with high spatial and temporal accuracy. We evaluate this system and present results from 80 cranial tumor resections. Regions of the preoperative tumor segmentation that are covered by the resection map (True Positive Tracking) and regions of the preoperative tumor segmentation not covered by the resection map (True Negative Tracking) are determined for each case. We compare True Negative Tracking, which estimates the residual tumor, with the actual residual tumor identified using iMRI. We discuss factors that can cause False Positive Tracking and False Negative Tracking, which underestimate and overestimate the residual tumor, respectively. Our method provides good estimates of the residual tumor when there is minimal brain shift, and line-of-sight is maintained. When these conditions are not met, surgeons report that it is still useful for identifying regions of potential residual.
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Affiliation(s)
- Parikshit Juvekar
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
- Correspondence: or (P.J.); (S.F.F.)
| | - Erickson Torio
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Dhiego Chaves De Almeida Bastos
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Alexandra J. Golby
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Sarah F. Frisken
- Harvard Medical School, Boston, MA 02115, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Correspondence: or (P.J.); (S.F.F.)
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16
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[Robotics and computer-assisted procedures in cranial neurosurgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:299-306. [PMID: 36629923 DOI: 10.1007/s00104-022-01783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The medical technical innovations over the last decade have made operations in the highly sensitive regions of the brain much safer. OBJECTIVE Presentation of how far computer assistance and robotics have become incorporated into clinical neurosurgery. MATERIAL AND METHOD Evaluation of the scientific literature and analysis of the certification status of the corresponding medical devices. RESULTS The rapid development of computer technology and the switch to digital imaging has led to the widespread introduction of neurosurgical planning software and intraoperative neuronavigation. In the field of robotics, the penetration into clinical neurosurgery is currently still largely limited to the automatic setting of trajectories. CONCLUSION The digitalization of imaging has fundamentally transformed neurosurgery. In the field of cranial neurosurgery, computer-assisted procedures can now be distinguished from noncomputer-assisted procedures only in a handful of cases. In the coming years important innovations for the clinical implementation can be expected in the field of robotics.
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Wang M, Yu J, Zhang J, Pan Z, Chen J. Intraoperative ultrasound in recurrent gliomas surgery: Impact on residual tumor volume and patient outcomes. Front Oncol 2023; 13:1161496. [PMID: 37035181 PMCID: PMC10076842 DOI: 10.3389/fonc.2023.1161496] [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: 02/08/2023] [Accepted: 03/10/2023] [Indexed: 04/11/2023] Open
Abstract
Background Reoperation may be beneficial for patients with recurrent gliomas. Minimizing the residual tumor volume (RTV) while ensuring the functionality of relevant structures is the goal of the reoperation of recurrent gliomas. Intraoperative ultrasound (IoUS) may be helpful for intraoperative tumor localization, intraoperative real-time imaging to guide surgical resection, and postoperative evaluation of the RTV in the reoperation for recurrent gliomas. Objective To assess the effect of real-time ioUS on minimizing RTV in recurrent glioma surgery compared to Non-ioUS. Methods We retrospectively analyzed the data from 92 patients who had recurrent glioma surgical resection: 45 were resected with ioUS guidance and 47 were resected without ioUS guidance. RTV, Karnofsky Performance Status (KPS) at 6 months after the operation, the number of recurrent patients, and the time to recurrence were evaluated. Results The average RTV in the ioUS group was significantly less than the Non-ioUS group (0.27 cm3 vs. 1.33 cm3, p = 0.0004). Patients in the ioUS group tended to have higher KPS scores at 6 months of follow-up after the operation than those in the Non-ioUS group (70.00 vs. 60.00, p = 0.0185). More patients in the Non-ioUS group experienced a recurrence than in the ioUS group (43 (91.49%) vs. 32 (71.11%), p = 0.0118). The ioUS group had a longer mean time to recurrence than the Non-ioUS group (7.9 vs. 6.3 months, p = 0.0013). Conclusion The use of ioUS-based real-time for resection of recurrent gliomas has been beneficial in terms of both RTV and postoperative outcomes, compared to the Non-ioUS group.
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Affiliation(s)
- Meiyao Wang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Jin Yu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jibo Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhiyong Pan
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- *Correspondence: Jincao Chen,
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Mosteiro A, Di Somma A, Ramos PR, Ferrés A, De Rosa A, González-Ortiz S, Enseñat J, González JJ. Is intraoperative ultrasound more efficient than magnetic resonance in neurosurgical oncology? An exploratory cost-effectiveness analysis. Front Oncol 2022; 12:1016264. [PMID: 36387079 PMCID: PMC9650059 DOI: 10.3389/fonc.2022.1016264] [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: 08/11/2022] [Accepted: 10/05/2022] [Indexed: 11/22/2022] Open
Abstract
Objective Intraoperative imaging is a chief asset in neurosurgical oncology, it improves the extent of resection and postoperative outcomes. Imaging devices have evolved considerably, in particular ultrasound (iUS) and magnetic resonance (iMR). Although iUS is regarded as a more economically convenient and yet effective asset, no formal comparison between the efficiency of iUS and iMR in neurosurgical oncology has been performed. Methods A cost-effectiveness analysis comparing two single-center prospectively collected surgical cohorts, classified according to the intraoperative imaging used. iMR (2013-2016) and iUS (2021-2022) groups comprised low- and high-grade gliomas, with a maximal safe resection intention. Units of health gain were gross total resection and equal or increased Karnofsky performance status. Surgical and health costs were considered for analysis. The incremental cost-effectiveness ratio (ICER) was calculated for the two intervention alternatives. The cost-utility graphic and the evolution of surgical duration with the gained experience were also analyzed. Results 50 patients followed an iMR-assisted operation, while 17 underwent an iUS-guided surgery. Gross total resection was achieved in 70% with iMR and in 60% with iUS. Median postoperative Karnofsky was similar in both group (KPS 90). Health costs were € 3,220 higher with iMR, and so were surgical-related costs (€ 1,976 higher). The ICER was € 322 per complete resection obtained with iMR, and € 644 per KPS gained or maintained with iMR. When only surgical-related costs were analyzed, ICER was € 198 per complete resection with iMR and € 395 per KPS gained or maintained. Conclusion This is an unprecedented but preliminary cost-effectiveness analysis of the two most common intraoperative imaging devices in neurosurgical oncology. iMR, although being costlier and time-consuming, seems cost-effective in terms of complete resection rates and postoperative performance status. However, the differences between both techniques are small. Possibly, iMR and iUS are complementary aids during the resection: iUS real-time images assist while advancing towards the tumor limits, informing about the distance to relevant landmarks and correcting neuronavigation inaccuracy due to brain shift. Yet, at the end of resection, it is the iMR that reliably corroborates whether residual tumor remains.
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Affiliation(s)
- Alejandra Mosteiro
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
- Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain
- *Correspondence: Alejandra Mosteiro,
| | - Alberto Di Somma
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
- Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Pedro Roldán Ramos
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
- Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Abel Ferrés
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Andrea De Rosa
- Division of Neurosurgery, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Sofía González-Ortiz
- Division of Neurosurgery, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
- Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Jose Juan González
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
- Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain
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Evaluation of a Navigated 3D Ultrasound Integration for Brain Tumor Surgery: First Results of an Ongoing Prospective Study. Curr Oncol 2022; 29:6594-6609. [PMID: 36135087 PMCID: PMC9498154 DOI: 10.3390/curroncol29090518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 11/17/2022] Open
Abstract
The aim of the study was to assess the quality, accuracy and benefit of navigated 2D and 3D ultrasound for intra-axial tumor surgery in a prospective study. Patients intended for gross total resection were consecutively enrolled. Intraoperatively, a 2D and 3D iUS-based resection was performed. During surgery, the image quality, clinical benefit and navigation accuracy were recorded based on a standardized protocol using Likert’s scales. A total of 16 consecutive patients were included. Mean ratings of image quality in 2D iUS were significantly higher than in 3D iUS (p < 0.001). There was no relevant decrease in rating during the surgery in 2D and 3D iUS (p > 0.46). The benefit was rated 2.2 in 2D iUS and 2.6 in 3D iUS (p = 0.08). The benefit remained stable in 2D, while there was a slight decrease in the benefit in 3D after complete tumor resection (p = 0.09). The accuracy was similar in both (mean 2.2 p = 0.88). Seven patients had a small tumor remnant in intraoperative MRT (mean 0.98 cm3) that was not appreciated with iUS. Crucially, 3D iUS allows for an accurate intraoperative update of imaging with slightly lower image quality than 2D iUS. Our preliminary data suggest that the benefit and accuracy of 2D and 3D iUS navigation do not undergo significant variations during tumor resection.
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Hou Y, Li Y, Li Q, Yu Y, Tang J. Full-course resection control strategy in glioma surgery using both intraoperative ultrasound and intraoperative MRI. Front Oncol 2022; 12:955807. [PMID: 36091111 PMCID: PMC9453394 DOI: 10.3389/fonc.2022.955807] [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: 05/29/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIntraoperative ultrasound(iUS) and intraoperative MRI (iMRI) are effective ways to perform resection control during glioma surgery. However, most published studies employed only one modality. Few studies have used both during surgery. How to combine these two techniques reasonably, and what advantages they could have for glioma surgery are still open questions.MethodsWe retrospectively reviewed a series of consecutive patients who underwent initial surgical treatment of supratentorial gliomas in our center. We utilized a full-course resection control strategy to combine iUS and iMRI: IUS for pre-resection assessment and intermediate resection control; iMRI for final resection control. The basic patient characteristics, surgical results, iMRI/iUS findings, and their impacts on surgical procedures were evaluated and reported.ResultsA total of 40 patients were included. The extent of resection was 95.43 ± 10.37%, and the gross total resection rate was 72.5%. The median residual tumor size was 6.39 cm3 (range 1.06–16.23 cm3). 5% (2/40) of patients had permanent neurological deficits after surgery. 17.5% (7/40) of patients received further resection after the first iMRI scan, resulting in four (10%) more patients achieving gross total resection. The number of iMRI scans per patient was 1.18 ± 0.38. The surgical time was 4.5 ± 3.6 hours. The pre-resection iUS scan revealed that an average of 3.8 borders of the tumor were beside sulci in 75% (30/40) patients. Intermediate resection control was utilized in 67.5% (27/40) of patients. In 37.5% (15/40) of patients, the surgical procedures were changed intraoperatively based on the iUS findings. Compared with iMRI, the sensitivity and specificity of iUS for residual tumors were 46% and 96%, respectively.ConclusionThe full-course resection control strategy by combining iUS and iMRI could be successfully implemented with good surgical results in initial glioma surgeries. This strategy might stabilize resection control quality and provide the surgeon with more intraoperative information to tailor the surgical strategy. Compared with iMRI-assisted glioma surgery, this strategy might improve efficiency by reducing the number of iMRI scans and shortening surgery time.
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Affiliation(s)
- Yuanzheng Hou
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ye Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qiongge Li
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Yu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Tang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Jie Tang,
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Intraoperative MRI versus intraoperative ultrasound in pediatric brain tumor surgery: is expensive better than cheap? A review of the literature. Childs Nerv Syst 2022; 38:1445-1454. [PMID: 35511271 DOI: 10.1007/s00381-022-05545-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The extent of brain tumor resection (EOR) is a fundamental prognostic factor in pediatric neuro-oncology in association with the histology. In general, resection aims at gross total resection (GTR). Intraoperative imaging like intraoperative US (iOUS) and MRI have been developed in order to find any tumoral remnant but with different costs. Aim of our work is to review the current literature in order to better understand the differences between costs and efficacy of MRI and iOUS to evaluate tumor remnants intraoperatively. METHODS We reviewed the existing literature on PubMed until 31st December 2021 including the sequential keywords "intraoperative ultrasound and pediatric brain tumors", "iUS and pediatric brain tumors", "intraoperative magnetic resonance AND pediatric brain tumors", and "intraoperative MRI AND pediatric brain tumors. RESULTS A total of 300 papers were screened through analysis of title and abstract; 254 were excluded. After selection, a total of 23 articles were used for this systematic review. Among the 929 patients described, a total of 349(38%) of the cases required an additional resection after an iMRI scan. GTR was measured on 794 patients (data of 69 patients lost), and it was achieved in 552(70%) patients. In case of iOUS, GTR was estimated in 291 out of 379 (77%) cases. This finding was confirmed at the post-operative MRI in 256(68%) cases. CONCLUSIONS The analysis of the available literature demonstrates that expensive equipment does not always mean better. In fact, for the majority of pediatric brain tumors, iOUS is comparable to iMRI in estimating the EOR.
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22
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Hou Y, Tang J. Advantages of Using 3D Intraoperative Ultrasound and Intraoperative MRI in Glioma Surgery. Front Oncol 2022; 12:925371. [PMID: 35719958 PMCID: PMC9203997 DOI: 10.3389/fonc.2022.925371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yuanzheng Hou
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Tang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Mazzucchi E, La Rocca G, Hiepe P, Pignotti F, Galieri G, Policicchio D, Boccaletti R, Rinaldi P, Gaudino S, Ius T, Sabatino G. Intraoperative integration of multimodal imaging to improve neuronavigation: a technical note. World Neurosurg 2022; 164:330-340. [PMID: 35667553 DOI: 10.1016/j.wneu.2022.05.133] [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: 04/29/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Brain shift may cause significant error in neuronavigation leading the surgeon to possible mistakes. Intraoperative MRI is the most reliable technique in brain tumor surgery. Unfortunately, it is highly expensive and time consuming and, at the moment, it is available only in few neurosurgical centers. METHODS In this case series the surgical workflow for brain tumor surgery is described where neuronavigation of pre-operative MRI, intraoperative CT scan and US as well as rigid and elastic image fusion between preoperative MRI and intraoperative US and CT, respectively, was applied to four brain tumor patients in order to compensate for surgical induced brain shift by using a commercially available software (Elements Image Fusion 4.0 with Virtual iMRI Cranial; Brainlab AG). RESULTS Three exemplificative cases demonstrated successful integration of different components of the described intraoperative surgical workflow. The data indicates that intraoperative navigation update is feasible by applying intraoperative 3D US and CT scanning as well as rigid and elastic image fusion applied depending on the degree of observed brain shift. CONCLUSIONS Integration of multiple intraoperative imaging techniques combined with rigid and elastic image fusion of preoperative MRI may reduce the risk of incorrect neuronavigation during brain tumor resection. Further studies are needed to confirm the present findings in a larger population.
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Affiliation(s)
- Edoardo Mazzucchi
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy; Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy.
| | - Giuseppe La Rocca
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy; Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | | | - Fabrizio Pignotti
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy; Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Gianluca Galieri
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy; Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | | | | | | | - Simona Gaudino
- Institute of Radiology, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Giovanni Sabatino
- Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy; Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
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Bernstock JD, Gary SE, Klinger N, Valdes PA, Ibn Essayed W, Olsen HE, Chagoya G, Elsayed G, Yamashita D, Schuss P, Gessler FA, Peruzzi PP, Bag A, Friedman GK. Standard clinical approaches and emerging modalities for glioblastoma imaging. Neurooncol Adv 2022; 4:vdac080. [PMID: 35821676 PMCID: PMC9268747 DOI: 10.1093/noajnl/vdac080] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Glioblastoma (GBM) is the most common primary adult intracranial malignancy and carries a dismal prognosis despite an aggressive multimodal treatment regimen that consists of surgical resection, radiation, and adjuvant chemotherapy. Radiographic evaluation, largely informed by magnetic resonance imaging (MRI), is a critical component of initial diagnosis, surgical planning, and post-treatment monitoring. However, conventional MRI does not provide information regarding tumor microvasculature, necrosis, or neoangiogenesis. In addition, traditional MRI imaging can be further confounded by treatment-related effects such as pseudoprogression, radiation necrosis, and/or pseudoresponse(s) that preclude clinicians from making fully informed decisions when structuring a therapeutic approach. A myriad of novel imaging modalities have been developed to address these deficits. Herein, we provide a clinically oriented review of standard techniques for imaging GBM and highlight emerging technologies utilized in disease characterization and therapeutic development.
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Affiliation(s)
- Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Sam E Gary
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Neil Klinger
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Pablo A Valdes
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Hannah E Olsen
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Gustavo Chagoya
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Galal Elsayed
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Daisuke Yamashita
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
| | - Patrick Schuss
- Department of Neurosurgery, Unfallkrankenhaus Berlin , Berlin, Germany
| | | | - Pier Paolo Peruzzi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - Asim Bag
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital , Memphis, TN USA
| | - Gregory K Friedman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , AL, USA
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham , Birmingham, AL, USA
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham , AL, USA
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25
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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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26
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Matsumae M, Nishiyama J, Kuroda K. Intraoperative MR Imaging during Glioma Resection. Magn Reson Med Sci 2022; 21:148-167. [PMID: 34880193 PMCID: PMC9199972 DOI: 10.2463/mrms.rev.2021-0116] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/11/2021] [Indexed: 11/09/2022] Open
Abstract
One of the major issues in the surgical treatment of gliomas is the concern about maximizing the extent of resection while minimizing neurological impairment. Thus, surgical planning by carefully observing the relationship between the glioma infiltration area and eloquent area of the connecting fibers is crucial. Neurosurgeons usually detect an eloquent area by functional MRI and identify a connecting fiber by diffusion tensor imaging. However, during surgery, the accuracy of neuronavigation can be decreased due to brain shift, but the positional information may be updated by intraoperative MRI and the next steps can be planned accordingly. In addition, various intraoperative modalities may be used to guide surgery, including neurophysiological monitoring that provides real-time information (e.g., awake surgery, motor-evoked potentials, and sensory evoked potential); photodynamic diagnosis, which can identify high-grade glioma cells; and other imaging techniques that provide anatomical information during the surgery. In this review, we present the historical and current context of the intraoperative MRI and some related approaches for an audience active in the technical, clinical, and research areas of radiology, as well as mention important aspects regarding safety and types of devices.
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Affiliation(s)
- Mitsunori Matsumae
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Jun Nishiyama
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kagayaki Kuroda
- Department of Human and Information Sciences, School of Information Science and Technology, Tokai University, Hiratsuka, Kanagawa, Japan
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Zoli M, Daniele B, Giovanni R, Teresa S, Cesare Z, Giuseppe Maria DP. Young Neurosurgeons and Technology: Survey of Young Neurosurgeons Section of Italian Society of Neurosurgery (SINch). World Neurosurg 2022; 162:e436-e456. [DOI: 10.1016/j.wneu.2022.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
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