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David D. Yeh, Bernadette Koch and Kerry R. Crone

, neurological injury, and death—tends to increase the more invasive the procedure. 2 , 5 , 9 , 18 Some authors argue that only bone decompression is needed to relieve the pressure at the CCJ. Others support maximal decompression by duraplasty, tonsillar shrinkage, and shunt insertion. Ultimately, the goal of surgery is to restore “normal” CSF dynamics at the CCJ. In this retrospective review, we evaluate a prospective study in which intraoperative ultrasonography was used to determine the need for duraplasty and tonsillar shrinkage in children undergoing posterior fossa

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Jared F. Sweeney, Heather Smith, AmiLyn Taplin, Eric Perloff and Matthew A. Adamo

delineation is also essential to avoid imposing further neurological damage, another essential factor that determines outcomes in this patient population. 6 , 7 , 20 In previous studies, intraoperative ultrasonography (IOUS) has been shown to be a useful intraoperative tool for both tumor localization and evaluating the extent of resection. 2 , 4–7 IOUS provides real-time image guidance, allowing the surgeon to follow and/or plan the progression of tumor excision with accuracy and ease of use. 2 , 4 , 5 , 7 , 15 In comparison with other intraoperative imaging modalities

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Matthew J. McGirt, Frank J. Attenello, Ghazala Datoo, Muraya Gathinji, April Atiba, Jon D. Weingart, Benjamin Carson and George I. Jallo

both increased success with duraplasty 7 and the same outcome regardless of duraplasty. 19 Studies have been limited by smaller sample size, lack of multivariate analysis, outcome prediction based on level of herniation, and a rigid definition of treatment success confined to initial improvement without regard to future symptom recurrence. We set out to determine whether intraoperative ultrasonography can be used to identify patients who can be treated sufficiently without duraplasty. In this series of 256 consecutive pediatric patients, we evaluate whether the

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Yusuke Nishimura, Nova B. Thani, Satoru Tochigi, Henry Ahn and Howard J. Ginsberg

ultrasound imaging of the spinal cord: syringomyelia, cysts, and tumors—a preliminary report . Surg Neurol 18 : 395 – 399 , 1982 10 el-Kalliny M , Tew JM Jr , van Loveren H , Dunsker S : Surgical approaches to thoracic disc herniations . Acta Neurochir (Wien) 111 : 22 – 32 , 1991 11 Epstein FJ , Farmer JP , Schneider SJ : Intraoperative ultrasonography: an important surgical adjunct for intramedullary tumors . J Neurosurg 74 : 729 – 733 , 1991 12 Gambardella G , Gervasio O , Zaccone C : Approaches and surgical results in

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Dimitrios C. Nikas, Alexander Hartov, Karen Lunn, Kyle Rick, Keith Paulsen and David W. Roberts

Object

The authors present their experience with coregistration of preoperative imaging data to intraoperative ultrasonography in the resection of high-grade gliomas, focusing on methodology and clinical observation.

Methods

Images were obtained preoperatively and coregistered to intraoperative hand-held ultrasound images by merging the respective imaging coordinate systems. After patient registration and imaging calibration, the authors computed the location on the magnetic resonance (MR) space of each pixel on an ultrasound image acquired in the operating room. The data were retrospectively reviewed in 11 patients with high-grade gliomas who underwent ultrasonography-assisted resection at our institution between June 2000 and December 2002.

Satisfactory coregistration of intraoperative ultrasound and preoperative MR images was accomplished in all cases. Ultrasound and MR image data were closely congruent. Preoperative setup and intraoperative use of the system were unencumbering.

Conclusions

Based on these preliminary results, intraoperative ultrasonography is an attractive neuronavigational alternative, by which a less expensive and constraining imaging technique is used to acquire updated information. Optimal intraoperative guidance can be provided by the integration of this with other imaging studies.

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Fred J. Epstein, Jean-Pierre Farmer and Steven J. Schneider

T he traditional management of intramedullary spinal cord tumors consisted largely of biopsy and augmentation duraplasty, followed by adjunctive therapy. 9, 12, 14, The major technical reason for this was the surgeon's inability, despite microsurgical techniques, to establish clear anatomical landmarks for guiding the resection. In recent years a more radical approach has been successfully adopted with both ependymomas and astrocytomas. 4, 5, 7, 8, 11, 14, 17, 18 We have found that intraoperative ultrasonography, first described in 1982, 2, 3, 11 provides

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Yi Wang, Yong Wang, Yida Wang, Nobuyuki Taniguchi and Xian-Cheng Chen

to successful AVM surgery is obliteration of the feeding arteries early in the dissection. 4 , 14 , 20 Intraoperative ultrasonography is sometimes useful in locating the AVM nidus, and color Doppler ultrasonography may help identify the vascular anatomy of the lesion. 2 , 7 , 8 , 21 , 23 Because of the unique hemodynamics of this lesion, however, it is sometimes difficult to differentiate between lesion-associated arteries and veins or between feeding arteries and surrounding normal arteries by using a color or pulsed Doppler mode alone. Since the introduction

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Edward H. Oldfield, Karin Muraszko, Thomas H. Shawker and Nicholas J. Patronas

observations unexplained, 3, 5, 67 and few direct observations provide convincing support for either. To examine the mechanism of the progression of syringomyelia associated with Chiari I malformations of the cerebellar tonsils, we used dynamic magnetic resonance (MR) imaging and intraoperative ultrasonography in seven patients to assess the dynamics of the wall of the spinal cord surrounding the syrinx, the cerebellar tonsils, and the syrinx cavity during the cardiac cycle, the positive-pressure respiratory cycles, and Valsalva maneuvers before and after bone and dural

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Matteo Zoli, Giacomo Sollini, Laura Milanese, Emanuele La Corte, Arianna Rustici, Federica Guaraldi, Sofia Asioli, Luigi Cirillo, Ernesto Pasquini and Diego Mazzatenta

( Fig. 1 ). Sharp instruments should not be used to avoid direct muscle or nerve damage; we also avoid detaching the medial rectus muscle. 24 , 40 In particular cases, an external approach may be combined with the EEA to mobilize the tumor and favor its removal through the endonasal approach. To reduce the risk of losing orientation or misinterpreting the pathological tissue, we have adopted intraoperative ultrasonography to localize the tumor, avoiding the limitations of neuronavigation due to the shift of the orbital structures after incising the periorbita. At the

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Noriaki Kawakami, Kentaro Mimatsu, Fumihiko Kato, Yuji Kondo, Hisao Itoh and Toshiyuki Matsunaka

well-enhanced tumor mass with syrinxes located cranially and caudally to the mass in the cervical spinal cord. At surgery, after exposure of the dura mater by lamina-splitting laminoplasty from C-2 to T-5, intraoperative ultrasonography was performed by the saline-immersion method using a routine transducer (7.5 MHz, linear array). The transducer was too large to be introduced into the laminectomy space, and it was almost impossible to confine a pool of saline for scanning at the kyphotic area around the T-3, T-4, and T-5 vertebrae; however, it was possible to