Reliability of intraoperative high-resolution 2D ultrasound as an alternative to high–field strength MR imaging for tumor resection control: a prospective comparative study

Clinical article

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Ultrasound may be a reliable but simpler alternative to intraoperative MR imaging (iMR imaging) for tumor resection control. However, its reliability in the detection of tumor remnants has not been definitely proven. The aim of the study was to compare high-field iMR imaging (1.5 T) and high-resolution 2D ultrasound in terms of tumor resection control.


A prospective comparative study of 26 consecutive patients was performed. The following parameters were compared: the existence of tumor remnants after presumed radical removal and the quality of the images. Tumor remnants were categorized as: detectable with both imaging modalities or visible only with 1 modality.


Tumor remnants were detected in 21 cases (80.8%) with iMR imaging. All large remnants were demonstrated with both modalities, and their image quality was good. Two-dimensional ultrasound was not as effective in detecting remnants < 1 cm. Two remnants detected with iMR imaging were missed by ultrasound. In 2 cases suspicious signals visible only on ultrasound images were misinterpreted as remnants but turned out to be a blood clot and peritumoral parenchyma. The average time for acquisition of an ultrasound image was 2 minutes, whereas that for an iMR image was ~ 10 minutes. Neither modality resulted in any procedure-related complications or morbidity.


Intraoperative MR imaging is more precise in detecting small tumor remnants than 2D ultrasound. Nevertheless, the latter may be used as a less expensive and less time-consuming alternative that provides almost real-time feedback information. Its accuracy is highest in case of more confined, deeply located remnants. In cases of more superficially located remnants, its role is more limited.

Abbreviation used in this paper: iMR = intraoperative MR.

Article Information

Address correspondence to: Venelin M. Gerganov, M.D., Ph.D., International Neuroscience Institute–Hannover, Rudolf Pichlmayr Strasse 4, Hannover 30625, Germany. email:

Please include this information when citing this paper: published online March 27, 2009; DOI: 10.3171/2009.2.JNS08535.

© AANS, except where prohibited by US copyright law.



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    A–C: Images providing an initial perspective of a recurrent glioblastoma multiforme: native T1-weighted images (a); diffusion tensor fiber-tracking image (b). The patient had partial hemianopsia and our goal was to resect the tumor as radically as possible without causing additional visual field deficit. A 2D ultrasound image (c) shows the tumor intraoperatively. Asterisk indicates the tumor, V the ventricle, arrowheads the optic tracts. D and E: Axial T1-weighted MR and ultrasound images obtained after further tumor removal. Some tumor remains between the resection cavity (R) and the ventricle. F and G: Axial T1-weighted MR and ultrasound images obtained after further tumor removal where arrows show the tumor remnant. H and I: Axial T1-weighted MR and ultrasound images acquired at the end of surgery. The tumor remnant (arrow) is demonstrated posterior to the ventricle. To avoid injury to the optic tract and complete hemianopsia, however, we decided not to proceed with further resection.

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    Images obtained in a patient with a low-grade glioma. A and B: Axial T1-weighted MR images of a left temporal low-grade glioma. C: Ultrasound image clearly demonstrating both the tumor boundary and its internal structure, where the asterisk indicates the tumor and d the middle cranial fossa dura mater. D: Intraoperative T2-weighted MR image showing complete tumor removal. E: Intraoperative ultrasound image exhibiting complete correspondence to the MR imaging findings. The temporal horn of the lateral ventricle is slightly enlarged.

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    Imaging studies. A and B: Axial T1-weighted MR and ultrasound images of the tumor (asterisk) prior to dural incision. F indicates the falx. C and D: Intraoperative control T1-weighted MR and ultrasound images. On the ultrasound image only the deeply located tumor remnants (asterisk) can be clearly delineated. The area in the upper part of the resection cavity (R) was misinterpreted as rim zone on ultrasound due to the suboptimal image quality, but it turned out to be tumor remnant (arrow) according to MR imaging and histopathological findings.


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