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Intra-operative high frequency ultrasound improves surgery of intramedullary cavernous malformations

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Abstract

Intra-operative ultrasound (ioUS) is a very useful tool in surgery of spinal lesions. Here we focus on modern ioUS to analyze its use for localisation, visualisation and resection control in intramedullary cavernous malformations (IMCM). A series of 35 consecutive intradural lesions were operated in our hospital in a time period of 24 months using modern ioUS with a high frequency 7–15 MHz transducer and a true real time 3D transducer (both Phillips iU 22 ultrasound system). Six of those cases were treated with the admitting diagnosis of a deep IMCM (two cervical, four thoracic lesions). IoUS images were performed before and after the IMCM resection. Pre-operative and early postoperative MRI images were performed in all patients. In all six IMCM cases a complete removal of the lesion was achieved microsurgically resulting in an improved neurological status of all patients. High frequency ioUS emerged to be a very useful tool during surgery for localization and visualization. Excellent resection control by ultrasound was possible in three cases. Minor resolution of true real time 3D ioUS decreases the actual advantage of simultaneous reconstruction in two planes. High frequency ioUS is the best choice for intra-operative imaging in deep IMCM to localize and to visualize the lesion and to plan the perfect surgical approach. Additionally, high frequency ioUS is suitable for intra-operative resection control of the lesion in selected IMCM cases.

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Disclosure

The true real-time 3D transducer (X7-2) has been provided by the company (Philips) for research proposes. This is not the case for the US system (IU22) or the high frequency 2D transducer (L15-7io), which were bought by the department. No financial collaborations, consulting contracts or other conflicts of interest exist for all authors.

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland

    Oliver Bozinov, Jan-Karl Burkhardt, Christoph M. Woernle, Vincent Hagel, Nils H. Ulrich, Niklaus Krayenbühl & Helmut Bertalanffy

  2. Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA

    Jan-Karl Burkhardt

  3. Center for Vascular Neurosurgery, International Neuroscience Institute, Hannover, Germany

    Helmut Bertalanffy

Authors
  1. Oliver Bozinov
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  2. Jan-Karl Burkhardt
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  3. Christoph M. Woernle
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  4. Vincent Hagel
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  5. Nils H. Ulrich
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  6. Niklaus Krayenbühl
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  7. Helmut Bertalanffy
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Correspondence to Oliver Bozinov.

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Comments

Yavor Enchev, Varna, Bulgaria

Bozinov et al. reported six cases of deep intramedullary cavernous malformations surgically treated by the assistance of intra-operative ultrasound. The lesions were completely removed, and the patients improved neurologically. High frequency intra-operative ultrasound was evaluated as an efficient and reliable tool for localization, visualization, surgical planning and resection control of the targeted cavernomas. However, a drawback of the technique was the limited resolution of true real time 3D intra-operative ultrasound.

In conclusion, this is an excellent paper with a potentially high impact on the neurosurgical practice focused on the benefits of the intra-operative high frequency US for the surgery of intramedullary cavernous malformations.

Louis J. Kim, Seattle, USA

Bozinov et al. assessed intra-operative ultrasound (ioUS) for pre-resection visualization and post-resection control imaging for intramedullary spinal cord cavernous malformations (IMCM). The authors demonstrated that high frequency ultrasound was superior to the 3D type due to the bulkier size of the 3D probe and the superior image quality of the high frequency probe. All cases achieved correct localization and minimal myelotomy using ioUS guidance. In acutely ruptured lesions, significant perilesional edema or hemosiderin limited the precision of post-resection ioUS. As a result, ioUS was more accurate in subacute lesions.

I agree with the authors’ conclusions that for IMCM invisible at the pial surface, ioUS can minimize surgical entry points and provide useful post-resection information. In my experience, often it is difficult to predict pre-operatively whether a lesion will present to a pial surface, even with high quality MR imaging. Therefore, optimal intra-operative imaging can be crucial for the surgeon. This paper provides an excellent argument for high frequency ioUS over alternative probes. Hence, along with intra-operative electrophysiological monitoring, ioUS should be a standard part of IMCM intra-operative surgical management.

Jan Regelsberger, Hamburg, Germany

Bozinov et al. report on a series of six intramedullary cavernomas which were resected with the aid of intra-operative ultrasound (IOUS). Even though this technique is not new, impressive figures document the exact localisation found utilizing ioUS, which defines the adequate surgical approach or which may lead to a wider exposure more caudally or cranially minimizing the extent of dural opening and, most importantly, minimizing medullary trauma. A new generation of small and high resolution transducers was used in this small series which not only may convince us to adopt IOUS as a very helpful tool in neurosurgical procedures, but furthermore may encourage us to review the option of an intra-operative resection control with this present technique, especially in cases with intramedullary tumors.

In times in which cost-efficiency is a priority, intra-operative MRI (IOMR) is being assessed by hospital management and its benefits are being honestly reevaluated by clinicians. Moreover, IOMR has not been confirmed to be relevant in spinal cases. While other imaging techniques are not yet available, the work of Bozinov et al. adds at least a second point. IOUS has survived the hype of IOMR, has been further developed technically in the past decade and serves as the only intra-operative technique at present, which is associated with low costs, is easy to handle and provides for a high resolution comparable to that of MRI. Therefore, IOUS should be noticed as the essential tool in spinal vascular and tumor cases without overlooking the necessary support of neurophysiological monitoring techniques.

Oliver Bozinov and Jan-Karl Burkhardt contributed equally.

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Bozinov, O., Burkhardt, JK., Woernle, C.M. et al. Intra-operative high frequency ultrasound improves surgery of intramedullary cavernous malformations. Neurosurg Rev 35, 269–275 (2012). https://doi.org/10.1007/s10143-011-0364-z

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  • DOI: https://doi.org/10.1007/s10143-011-0364-z

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