Multimodal Surgical Management of Cerebral Lesions in Motor-Eloquent Areas Combining Intraoperative 3D Ultrasound with Neurophysiological Mapping

Abstract

Background Resection of tumors adjacent to motor pathways carries risks of both postoperative motor deficit and incomplete resection. Our aim was to assess usefulness and limitations of a multimodal strategy that combines intraoperative ultrasound (iUS) guided resection with intraoperative neurophysiology. Methodology This is a prospective study of 25 patients with brain lesions adjacent to motor areas who underwent intracranial surgery with assistance of the iUS guidance system and intraoperative neurophysiological monitoring and mapping. Pathologies treated included 19 gliomas, 3 metastases, 1 anaplastic meningioma, 1 arteriovenous malformation (AVM), and 1 ependymoma. The iUS-guided lesion removal accuracy and the extent of resection were estimated and compared with a 30-day postoperative brain MRI. The results were assessed considering the extent of resection related to 6-month motor function outcome. Results iUS was accurate in checking the extent of resection in 17 patients, whereas in 8 cases the decline of the iUS images quality did not allow a valuable assessment. Positive mapping was obtained in 16 patients. Gross total resection was achieved in 16 patients. In five of nine cases with subtotal resection, surgery was stopped because a functional area was reached. In four patients, tumor removal was limited due to the difficulty of identifying neoplastic tissue. Motor function worsening was transient in six patients and permanent in two. Conclusions The integrated use of intraoperative neuromonitoring to identify motor areas and iUS to identify tumor–tissue interface could help increase the rate of radical resection respecting the eloquent areas.

Atypical and aggressive diffuse leptomeningeal glioneuronal tumor in a young adult: A case report and review of the literature

“…The tumor was then approached with intraoperative ultrasound and functional mapping with direct electrical stimulation with a monopolar probe. [ 22 , 23 ] The procedure was interrupted due to sudden deterioration of the motor evoked potentials; then, to decompress the spinal cord, a duraplasty was completed using a dural patch and a pedicled multifidus muscle flap was performed to decrease the risk of CSF leakage. [ 21 , 29 ]…”

Single thalamic localization of brain toxoplasmosis mimicking brain tumors: Radiological and clinical findings

“…Preoperative planning was conducted using three-dimensional reconstruction to simulate the surgical trajectory and avoid functional areas and tracts (StealthStation S8; Medtronic, Minneapolis, Minnesota, USA) [ Figure 4 ]. [ 3 , 5 - 7 ]…”

“…Preoperative planning was conducted using threedimensional reconstruction to simulate the surgical trajectory and avoid functional areas and tracts (StealthStation S8; Medtronic, Minneapolis, Minnesota, USA) [Figure 4]. [3,[5][6][7] A coronal trajectory was used passing lateral to the lateral ventricle wall. Histopathology revealed extensive areas of necrosis, vascular thrombosis phenomena and aspects of vasculitis with lymphohistiocytic and granulocytic infiltrate at the level of the vascular walls.…”

Intraoperative MR Imaging during Glioma Resection

“…Gliomata appear hypoechoic on ioUS, and this characteristic can be a reliable method to navigate toward glioma during surgical procedure. 5,11,157,[171][172][173][174][175][176][177][178][179][180][181][182][183] The use of ioUS is gaining popularity due to accuracy in localizing glioma, evaluating the extent of resection and cost-effectiveness. 12 In particular, ioUS may be used to provide information on brain shift.…”