Intraoperative real-time contrast-enhanced ultrasound angiography: a new adjunct in the surgical treatment of arteriovenous malformations

Restricted access

Object

The goal of this study was to combine the use of ultrasound contrast agents with intraoperative ultrasound techniques to identify intraoperatively a patient's vascular anatomy, including feeding arteries and draining veins of an intracranial arteriovenous malformation (AVM).

Methods

The authors examined 12 consecutive patients with AVMs that had been diagnosed on the basis of preoperative findings on magnetic resonance images and digital subtraction angiograms obtained between September 2003 and December 2005. After each patient had undergone a routine craniotomy, a bolus of contrast agent was injected intravenously, and a real-time microbubble perfusion process was observed to identify the feeding arteries and draining veins of the AVM in a single cross-section. The so-called burst–refill technique was used to sweep the lesion in multiple sections and orientations to obtain information on the surrounding vascular anatomy, after which the findings were compared with those obtained during preoperative imaging.

Results

Intraoperative ultrasonography provided high-quality images in every case. Although plain imaging failed to show an identifiable AVM boundary, color Doppler flow imaging clearly delineated the shape and margin of the AVM. Nevertheless, neither mode of imaging enabled the surgeons to categorically distinguish between feeding and draining vessels.

The real-time perfusion process of microbubbles was first visualized 20 to 30 seconds after the SonoVue bolus injection, and the burst–refill technique made possible identification of the vascular anatomy of malformation lesions in multiple planes.

Conclusions

Using both an ultrasound contrast agent and the burst–refill technique provided a rapid, convenient, and precise way of locating AVM feeding arteries intraoperatively. The combined technique seems warranted in the intraoperative treatment of AVMs.

Abbreviations used in this paper:AVM = arteriovenous malformation; DS = digital subtraction; MR = magnetic resonance; RI = resistance index.
Article Information

Contributor Notes

Address correspondence to: Yong Wang, M.D., Department of Ultrasound, Huashan Hospital, 12 Middle Urumuqi Road, Shanghai 200040, China. email: wyongc@online.sh.cn.

© Copyright 1944-2019 American Association of Neurological Surgeons

Headings
References
  • 1

    Awad IARobinson JR JrMohanty SEstes ML: Mixed vascular malformations of the brain. Neurosurgery 33:1791881993

  • 2

    Dempsey RJMoftakhar RPozniak M: Intraoperative Doppler to measure cerebrovascular resistance as a guide to complete resection of arteriovenous malformations. Neurosurgery 55:1551612004

    • Search Google Scholar
    • Export Citation
  • 3

    Feinstein SB: The powerful microbubble: from bench to bedside, from intravascular indicator to therapeutic delivery system, and beyond. Am J Physiol Heart Circ Physiol 287:H450H4572004

    • Search Google Scholar
    • Export Citation
  • 4

    Fleetwood IGSteinberg GK: Arteriovenous malformations. Lancet 359:8638732002

  • 5

    Fournier DTerBrugge KGWillinsky RLasjaunias PMontanera W: Endovascular treatment of intracerebral arteriovenous malformations: experience in 49 cases. J Neurosurg 75:2282331991

    • Search Google Scholar
    • Export Citation
  • 6

    Fry FJSanghvi NTFoster RSBihrle RHennige C: Ultrasound and microbubbles: their generation, detection and potential utilization in tissue and organ therapy—experimental. Ultrasound Med Biol 21:122712371995

    • Search Google Scholar
    • Export Citation
  • 7

    Goodkin RMcKhann GMHaynor DRMayberg MREskridge JMWinn HR: Persistent feeding arteries to angiographically completely embolized arteriovenous malformation demonstrated by intraoperative color-flow Doppler testing: report of two cases. Surg Neurol 44:3263331995

    • Search Google Scholar
    • Export Citation
  • 8

    Griffith SPozniak MAMitchell CCLedwidge MEDempsey RPeters A: Intraoperative sonography of intracranial arteriovenous malformations: how we do it. J Ultrasound Med 23:106510722004

    • Search Google Scholar
    • Export Citation
  • 9

    Huston J IIIRufenacht DAEhman RLWiebers DO: Intracranial aneurysms and vascular malformations: comparison of time-of-flight and phase-contrast MR angiography. Radiology 181:7217301991

    • Search Google Scholar
    • Export Citation
  • 10

    Kane RA: Intraoperative ultrasonography: history, current state of the art, and future directions. J Ultrasound Med 23:140714202004

    • Search Google Scholar
    • Export Citation
  • 11

    Kucharczyk WLemme-Pleghos LUske ABrant-Zawadzki MDooms GNorman D: Intracranial vascular malformations: MR and CT imaging. Radiology 56:3833891985

    • Search Google Scholar
    • Export Citation
  • 12

    Makuuchi MTorzilli GMachi J: Histroy of intraoperative ultrasound. Ultrasound Med Biol 24:122912421998

  • 13

    McCormick WF: The pathology of vascular (“arteriovenous”) malformations of the brain. J Neurosurg 24:8078161966

  • 14

    Ogilvy CSStieg PEAwad IBrown RDKondziolka DRosen-wasser R: Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Circulation 103:264426572001

    • Search Google Scholar
    • Export Citation
  • 15

    Rubin JMHatfield MKChandler WFBlack KLDiPietro MA: Intracerebral arteriovenous malformations: intraoperative color Doppler flow imaging. Radiology 170:2192221989

    • Search Google Scholar
    • Export Citation
  • 16

    Schlienger MAtlan DLefkopoulos DMerienne LTouboul EMissir O: Linac radiosurgery for cerebral arteriovenous malformations: results in 169 patients. Int J Radiat Oncol Biol Phys 46:113511422000

    • Search Google Scholar
    • Export Citation
  • 17

    Seidel GMeyer K: Impact of ultrasound contrast agents in cere-brovascular diagnostics. Eur J Ultrasound 16:81902002

  • 18

    Sosna JBarth MMKruskal JBKane RA: Intraoperative sonography for neurosurgery. J Ultrasound Med 24:167116822005

  • 19

    Spetzler RFMartin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:4764831986

  • 20

    Steinberg GKStoodley MASurgical management of intracranial arteriovenous malformations. Schmidek HHSweet WH: Schmidek & Sweet Operative Neurosurgical Techniques: Indications Methods and Results ed 4BostonElsevier Science2001. 13631379

    • Search Google Scholar
    • Export Citation
  • 21

    Thien CRosenfeld JVPhelan E: Colour Doppler imaging as an aid to excision of an arteriovenous malformation. J Clin Neurosci 3:3583621996

    • Search Google Scholar
    • Export Citation
  • 22

    Vitali ASalmoiraghi PButti IPompei LSarti ECaverni L: Localization of cerebral arterovenous malformations using digital angiography. Med Phys 27:202420302000

    • Search Google Scholar
    • Export Citation
  • 23

    Woydt MPerez JMeixensberger JKrone ASoerensen NRoosen K: Intraoperative colour-duplex-sonography in the surgical management of cerebral AV-malformations. Acta Neurochir (Wien) 140:6896981998

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 196 195 18
Full Text Views 150 71 0
PDF Downloads 111 41 0
EPUB Downloads 0 0 0
PubMed
Google Scholar