Evaluation of a Navigated 3D Ultrasound Integration for Brain Tumor Surgery: First Results of an Ongoing Prospective Study

Danilo Aleo, Ziad Elshaer, Andreas Pfnür, Patrick J Schuler, Marco Maria Fontanella, Christian Rainer Wirtz, Andrej Pala, Jan Coburger, Danilo Aleo, Ziad Elshaer, Andreas Pfnür, Patrick J Schuler, Marco Maria Fontanella, Christian Rainer Wirtz, Andrej Pala, Jan Coburger

Abstract

The aim of the study was to assess the quality, accuracy and benefit of navigated 2D and 3D ultrasound for intra-axial tumor surgery in a prospective study. Patients intended for gross total resection were consecutively enrolled. Intraoperatively, a 2D and 3D iUS-based resection was performed. During surgery, the image quality, clinical benefit and navigation accuracy were recorded based on a standardized protocol using Likert’s scales. A total of 16 consecutive patients were included. Mean ratings of image quality in 2D iUS were significantly higher than in 3D iUS (p < 0.001). There was no relevant decrease in rating during the surgery in 2D and 3D iUS (p > 0.46). The benefit was rated 2.2 in 2D iUS and 2.6 in 3D iUS (p = 0.08). The benefit remained stable in 2D, while there was a slight decrease in the benefit in 3D after complete tumor resection (p = 0.09). The accuracy was similar in both (mean 2.2 p = 0.88). Seven patients had a small tumor remnant in intraoperative MRT (mean 0.98 cm3) that was not appreciated with iUS. Crucially, 3D iUS allows for an accurate intraoperative update of imaging with slightly lower image quality than 2D iUS. Our preliminary data suggest that the benefit and accuracy of 2D and 3D iUS navigation do not undergo significant variations during tumor resection.

Keywords: extent of resection; glioma surgery; image quality; intraoperative 3D ultrasound; navigation.

Conflict of interest statement

A.P. (Andrej Pala) and J.C. are working as Brainlab consultants.

Figures

Figure 1
Figure 1
Flow chart designed for patient enrollment.
Figure 2
Figure 2
Box plot showing the overall values for quality, benefit and accuracy (Likert scale). White circles = low potential outlier (more than 1.5 inter-quartile range at most 3 inter-quartile range.)
Figure 3
Figure 3
Box plot showing 2D and 3D quality variations during the different stages of resection.
Figure 4
Figure 4
Box plot showing 2D and 3D benefit variations during different stages of resection. White circles = low potential outlier (more than 1.5 inter-quartile range at most 3 inter-quartile range.)
Figure 5
Figure 5
Box plot showing 2D and 3D benefit variations for the three main categories of tumors: HGG = high-grade gliomas, LGG = low-grade gliomas, MTX = metastases. White circles = White circles = low potential outlier (more than 1.5 inter-quartile range at most 3 inter-quartile range. * = high potential outliers of more than 3 inter-quartile ranges).
Figure 6
Figure 6
Box plot showing 2D and 3D accuracy variations during different stages of resection.
Figure 7
Figure 7
Axial contrast enhanced T1-weighted MRI (left) and coronal T2 flair (right) sequences showing a frontal left mass.
Figure 8
Figure 8
2D iUS scan after dura opening.
Figure 9
Figure 9
“live” iUS-guided resection before iMRI scan. Note how the cortical spinal bundle highlighted in violet was spared from the resection area.
Figure 10
Figure 10
“live” iUS-guided resection at 50% of tumor removal showing the mismatch between the pointer and the real position on iUS (white arrow).
Figure 11
Figure 11
Preoperative (left) and intraoperative (right) MRI. Note the residual tumor outlined in violet along the edges of the surgical cavity on iMRI.
Figure 12
Figure 12
2D iUS scan performed at the 100% surgical resection stage. No obvious residual disease was found.

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