A new application of ultrasound-magnetic resonance multimodal fusion virtual navigation in glioma surgery

Abstract

Background: Long-term survival and high-quality life of patients with gliomas depends on the extent of resection (EOR) and the protection of functional white matter fibers. The navigation system provides precise positioning for surgery based on preoperative magnetic resonance imaging (MRI) but the precision decreases when intraoperative brain drift occurs. Ultrasound (US) can support real-time imaging and correct brain shift. The real-time US-MRI multimodal fusion virtual navigation system (UMNS) is a new technique for glioma surgery. In order to obtain a maximum EOR and functional protection, this study aimed to explore the feasibility, efficiency, and safety of real-time UMNS for glioma surgery, and to evaluate the benefit of the new application by UMNS presetting markers between the tumor and functional white matter fiber surgery.Methods: A retrospective analysis included 45 patients who underwent glioma surgery, 19 patients with only intraoperative US, and 26 patients with UMNS. A preoperative plan was made by 3D-slicer software based on preoperative MRI. This was combined with a reconstruction of diffusion tensor imaging (DTI) that designed the important locations as "warning points" between functional white matter fibers and tumor.Following patient registration, markers were injected into preset "warning points" under image-guided UMNS in order to give us a warning during surgery in case of postoperative function deficits. The operating time, volumetric assessment in glioma resection, and postoperative complications were evaluated and used to compared those surgeries using intraoperative US (iUS) with those surgeries using intraoperate MRI (iMRI) navigation.Results: A total of 45 patients underwent glioma surgery. Gross total removal (GTR) of iUS alone was achieved in 6 of 19 cases, while this was achieved in 22 of 26 cases with UMNS alone, demonstrating an improvement in rate of GTR from 31.58% to 84.62%, respectively. This may be attributable to the superior US image quality provided by UMNS. In 13 of 26 cases, there was improved image quality (from poor/ moderate to moderate/good) with the aid of UMNS. In addition, the consistency of EOR of postoperative MRI evaluated by UMNS (92.31%) was higher than when using iUS alone (42.11%). The whole process of intraoperative scanning time and marker injection did not lead to a significant delay of the operating time compared to using iUS alone, and has been reported to be shorter than with iMRI as well. Furthermore, the percentage of postoperative morbidity in the UMNS group was lower than that in the iUS group (motor deficit: 11.54% vs. 42.11%; aphasia: P =3.85% vs. 31.58%, respectively).Conclusions: Real-time UMNS is an effective, timesaving technology that offers high quality intraoperative imaging. Injection markers between functional white matter fibers and tumor by UMNS can help to obtain a maximum EOR of glioma and functional protection postoperatively. The integration of iUS into the neuronavigation system offered quick and helpful intra-operative images....

Brain Shift in Neuronavigation of Brain Tumors: An Updated Review of Intra-Operative Ultrasound Applications

“…Finally, in 2019, Liang et al ( 18 ) published a retrospective case review on a cohort of patients that underwent iUS alone without registration during resection and iUS with pre-operative MRI registration to review the extent of resection (EOR) improvement. Of the 45 total patients reviewed, only 6/19 cases using iUS alone achieved gross total resection (GTR) whereas 22/26 (85%) cases using MRI registered to iUS had GTR.…”

“…Resection metrics, such as EOR and GTR provide valuable clinical information but given their value being relative in nature, it is difficult to compare them with other objective measures not specifically related to the tumor volumes. For example, Steno 2018 ( 27 ) reports a small but statistically significant improvement in EOR (from 76 to 87%), while Liang 2019 ( 18 ) reports an increase of tumor GTR from 32% without ultrasound navigation to 85% with ultrasound-corrected navigation. Both studies demonstrate statistically significant objective and clinical benefits of using iUS-based technology but are near impossible to compare with work that uses registration errors to quantify their results.…”

Effect of 3D Slicer Preoperative Planning and Intraoperative Guidance with Mobile Phone Virtual Reality Technology on Brain Glioma Surgery

“…Brain gliomas are tumors in CNS originating from glial cells, which are classified into low-grade (I and II) gliomas and high-grade (III and IV) gliomas by the WHO based on pathological manifestations [ 14 ]. The survival of patients with early to mid-term brain glioma can be prolonged through surgery, but the surgical effect is affected by the extent of tumor resection.…”

Standard clinical approaches and emerging modalities for glioblastoma imaging

“…One of the more detailed approaches was performed by Liang et al who overlayed contrast-enhanced iUS images with preoperative MRI images, which improved gross total resection rate from 31.58% (6 of 19 cases) to 84.62% (22 of 26 cases) and improved post-operative morbidity. 113 As reviewed by Del Bene et al, 114 numerous other studies have attempted to use contrast-enhanced iUS, Doppler iUS, and multimodal imaging overlays with iUS. No randomized controlled trials have been completed to definitively determine whether any iUS method provides significant benefit for delineating gliomas, detecting residual tumor tissue, or improving overall survival or morbidity compared to other intraoperative imaging techniques, thereby limiting confidence for which iUS can be used clinically.…”