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Pitfalls of intraoperative ultrasound - what can be done better?
EANS Academy. Steno A. Sep 27, 2019; 276103; EP12064
Andrej Steno
Andrej Steno

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Abstract
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Background: While benefits of intraoperative ultrasound (iUS) have been frequently described, data on iUS limitations are sparse. Optimal ultrasound imaging is challenging predominantly during: A. surgeries where horizontal craniotomy placement and complete filling of resection cavity with saline is impossible - such as some awake procedures requiring comfortable patient positioning; B. transsphenoidal pituitary surgery - an optimal probe depicting the entire sellar region is not available. We aim to explore significant limitations of iUS and present potential solutions.
Methods: The study group consists of 33 consecutive surgeries - 28 awake resections of eloquent gliomas guided by navigated 3D-ultrasound, and five transsphenoidal resections (four macroadenomas, one craniopharyngeoma) performed using 2D-ultrasound flexible mini-probe.
The extent of resection and the tumor-residua location were evaluated using postoperative MRI.
Results: Three eloquent glioma resections were gross-total. During all 25 incomplete awake resections, a non-resectable residuum was visualized by 3D-iUS; however, in four patients another resectable residuum was found only on postoperative MRI. During two procedures performed in semi-sitting position, the resection cavity could not be sufficiently filled with saline due non-horizontal craniotomy, what resulted in a suboptimal iUS image and incomplete anterior tumor portion removal. In two other gliomas, ultrasound artifacts precluded distinct depiction of the resection cavity bottom, resulting in incomplete deep tumor portion removal. Later in the series, we successfully solved aforementioned pitfalls using (I) mini-barriers made from bone-wax used to keep saline within resection cavities, and (II) a miniature iUS probe inserted into resection cavity - what minimized ultrasound artifacts.
Four complete and one subtotal transsphenoidal resections were achieved - only suprasellar but not parasellar structures were distinctly visualized by iUS.
Conclusions: Significant limitations of iUS-guided glioma resections may be reduced by proper scanning techniques; however, development of probes capable of adequate sellar region imaging continues to be a challenge.
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