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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Object

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.

Methods

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.

Results

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.

Conclusions

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: vgerganov@gmail.com.

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.

Headings

Figures

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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.

References

  • 1

    Albert FKForsting MSartor KAdams HPKunze S: Early postoperative magnetic resonance imaging after resection of malignant glioma: objective evaluation of residual tumour and its influence on regrowth and prognosis. Neurosurgery 34:45611994

  • 2

    Auer LMvan Velthoven V: Intraoperative ultrasound (US) imaging: Comparison of pathomorphological findings in US and CT. Acta Neurochir (Wien) 104:84951990

  • 3

    Berger MSDeliganis AVDobbins JKeles GE: The effect of extent of resection on recurrence in patients with low grade cerebral hemisphere gliomas. Cancer 74:178417911994

  • 4

    Black PMMoriarty TAlexander E IIIStieg PWoodard EJGleason PL: Development and implementation of intra-operative magnetic resonance imaging and its neurosurgical applications. Neurosurgery 41:8318451997

  • 5

    Campbell JWPollack IFMartinez AJShultz B: High-grade astrocytomas in children: radiologically complete resection is associated with an excellent long-term prognosis. Neurosurgery 38:2582641996

  • 6

    Chacko AGKumar NKChacko GAthyal RRajshekhar V: Intraoperative ultrasound in determining the extent of resection of parenchymal brain tumours—a comparative study with computed tomography and histopathology. Acta Neurochir (Wien) 145:7437482003

  • 7

    Chandler WFKnake JEMcGillicuddy JELillehei KOSilver TM: Intraoperative use of real-time ultrasonography in neurosurgery. J Neurosurg 57:1571631982

  • 8

    Fahlbusch RGanslandt OBuchfelder MSchott WNimsky C: Intraoperative magnetic resonance imaging during transsphenoidal surgery. J Neurosurg 95:3813902001

  • 9

    Fahlbusch RSamii A: A review of cranial imaging techniques: potential and limitations. Clin Neurosurg 54:1001042007

  • 10

    Gaab MR: [Intraoperative ultrasound imaging in neurosurgery.]. Ultraschall Med 11:62711990. (Ger)

  • 11

    Gronningsaeter AKleven AOmmedal SAarseth TELie TLindseth F: SonoWand, an ultrasound-based neuronavigation system. Neurosurgery 47:137313802000

  • 12

    Hall WALiu HMaxwell RETruwit CL: Influence of 1.5-Tesla intraoperative MR imaging on surgical decision making. Acta Neurochir Suppl 85:29372003

  • 13

    Hammoud MALigon BLelSouki RShi WMSchomer DFSawaya R: Use of intraoperative ultrasound for localizing tumors and determining the amount of resection: a comparative study with magnetic resonance imaging. J Neurosurg 84:7377411996

  • 14

    Hata NDohi TIseki HTakakura K: Development of a frameless and armless stereotactic neuronavigation system with ultrasonographic registration. Neurosurgery 41:6086141997

  • 15

    Jödicke ADeinsberger WErbe HKriete ABöker DK: Intra-operative three dimensional ultrasonography: an approach to register brain shift using multidimensional image processing. Minim Invasive Neurosurg 41:13191998

  • 16

    Keles GEChang EFLamborn KRTihan TChang CJChang SM: Volumetric extent of resection and residual contrast enhancement on initial surgery as predictors of outcome in adult patients with hemispheric anaplastic astrocytoma. J Neurosurg 105:34402006

  • 17

    Knauth MWirtz CRTronnier VMAras NKunze SSartor K: Intraoperative MR imaging increases the extent of tumor resection in patients with high-grade gliomas. AJNR Am J Neuroradiol 20:164216461999

  • 18

    Kowalczuk AMacdonald RLAmidei CDohrmann G IIIErickson RKHekmatpanah J: Quantitative imaging study of extent of surgical resection and prognosis of malignant astrocytomas. Neurosurgery 41:102810381997

  • 19

    Kunz UGoldmann ABader COldenkott P: Stereotactic and ultrasound guided minimal invasive surgery of subcortical cavernomas. Minim Invasive Neurosurg 37:17201994

  • 20

    Lacroix MAbi-Said DFourney DRGokaslan ZLShi WDeMonte F: A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. J Neurosurg 95:1901982001

  • 21

    LeRoux PDWinter TCBerger MSMack LAWang KElliott JP: A comparison between preoperative magnetic resonance and intraoperative ultrasound tumor volumes and margins. J Clin Ultrasound 22:29361994

  • 22

    Lindner DTrantakis CRenner CArnold SSchmitgen ASchneider J: Application of intraoperative 3D ultrasound during navigated tumor resection. Minim Invasive Neurosurg 49:1972022006

  • 23

    Mäurer MBecker GWagner RWoydt MHofmann EPuls I: Early postoperative transcranial sonography (TCS), CT, and MRI after resection of high grade glioma: evaluation of residual tumour and its influence on prognosis. Acta Neurochir (Wien) 142:108910972000

  • 24

    Nimsky CGanslandt OBuchfelder MFahlbusch R: Glioma surgery evaluated by intraoperative low-field magnetic resonance imaging. Acta Neurochir Suppl 85:55632003

  • 25

    Nimsky CGanslandt OBuchfelder MFahlbusch R: Intra-operative visualization for resection of gliomas: The role of functional neuronavigation and intraoperative 1.5 T MRI. Neurol Res 28:4824872006

  • 26

    Nimsky CGanslandt OFahlbusch R: 1.5 Tesla intraoperative imaging beyond standard anatomic imaging. Neurosurg Clin N Am 16:1852002005

  • 27

    Nimsky CGanslandt OKober HBuchfelder MFahlbusch R: Intraoperative magnetic resonance imaging combined with neuronavigation: a new concept. Neurosurgery 48:108210912001

  • 28

    Regelsberger JLohmann FHelmke KWestphal M: Ultrasound guided surgery of deep seated brain lesions. Eur J Ultrasound 12:1151212000

  • 29

    Roth JBiyani NBeni-Adani LConstantini S: Real-time neuronavigation with high-quality 3D ultrasound SonoWand in pediatric neurosurgery. Pediatr Neurosurg 43:1851912007

  • 30

    Rubin JMQuint DJ: Intraoperative US versus intraoperative MR imaging for guidance during intracranial neurosurgery. Radiology 215:9179182000

  • 31

    Rygh OMNagelhus Hernes TALindseth FSelbekk TBrostrup Müller TUnsgaard G: Intraoperative navigated 3-dimensional ultrasound angiography in tumor surgery. Surg Neurol 66:5815922006

  • 32

    Sanai NBerger MS: Glioma extent of resection and its impact on patient outcome. Neurosurgery 62:7537662008

  • 33

    Stadlbauer AMoser EGruber SNimsky CFahlbusch RGanslandt O: Integration of biochemical images of a tumor into frameless stereotaxy achieved using a magnetic resonance imaging/magnetic resonance spectroscopy hybrid data set. J Neurosurg 101:2872942004

  • 34

    Sutherland GRKaibara TLouw DHoult DITomanek BSaunders J: A mobile high-field magnetic resonance system for neurosurgery. J Neurosurg 91:8048131999

  • 35

    Tronnier VMBonsanto MMStaubert AKnauth MKunze SWirtz CR: Comparison of intraoperative MR imaging and 3D-navigated ultrasonography in the detection and resection control of lesions. Neurosurg Focus 10:2E32001

  • 36

    Unsgaard GOmmedal SMuller TGronningsaeter ANagelhus Hernes TA: Neuronavigation by intraoperative three-dimensional ultrasound: Initial experience during brain tumor resection. Neurosurgery 50:8048122002

  • 37

    Unsgaard GRygh OMSelbekk TSelbekk TBrostrup Müller TUnsgaard G: Intra-operative 3D ultrasound in neurosurgery. Acta Neurochir (Wien) 148:2352532006

  • 38

    Unsgaard GSelbekk TBrostrup Muller TOmmedal STorp SHMyhr G: Ability of navigated 3D ultrasound to delineate gliomas and metastases—comparison of image interpretations with histopathology. Acta Neurochir (Wien) 147:125912692005

  • 39

    van Velthoven VAuer LM: Practical application of intraoperative ultrasound imaging. Acta Neurochir (Wien) 105:5131990

  • 40

    Woydt MKrone ABecker GSchmidt KRoggendorf WRoosen K: Correlation of intra-operative ultrasound with histopathologic findings after tumour resection in supratentorial gliomas: a method to improve gross total tumour resection. Acta Neurochir (Wien) 138:139113981996

  • 41

    Woydt MKrone ASoerensen NRoosen K: Ultrasound-guided neuronavigation of deep-seated cavernous haemangiomas: clinical results and navigation techniques. Br J Neurosurg 15:4854952001

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