Abstract

Background and PurposeOncological neurosurgery relies heavily on making continuous, intra-operative tumor-brain delineations based on image-guidance. Limitations of currently available imaging techniques call for the development of real-time image-guided resection tools, which allow for reliable functional and anatomical information in an intra-operative setting. Functional ultrasound (fUS), is a new mobile neuro-imaging tool with unprecedented spatiotemporal resolution, which allows for the detection of small changes in blood dynamics that reflect changes in metabolic activity of activated neurons through neurovascular coupling. We have applied fUS during conventional awake brain surgery to determine its clinical potential for both intra-operative functional and vascular brain mapping, with the ultimate aim of achieving maximum safe tumor resection.MethodsDuring awake brain surgery, fUS was used to image tumor vasculature and task-evoked brain activation with electrocortical stimulation mapping (ESM) as a gold standard. For functional imaging, patients were presented with motor, language or visual tasks, while the probe was placed over (ESM-defined) functional brain areas. For tumor vascular imaging, tumor tissue (pre-resection) and tumor resection cavity (post-resection) were imaged by moving the hand-held probe along a continuous trajectory over the regions of interest.ResultsA total of 10 patients were included, with predominantly intra-parenchymal frontal and temporal lobe tumors of both low and higher histopathological grades. fUS was able to detect (ESM-defined) functional areas deep inside the brain for a range of functional tasks including language processing. Brain tissue could be imaged at a spatial and temporal resolution of 300 μm and 1.5–2.0 ms respectively, revealing real-time tumor-specific, and healthy vascular characteristics.ConclusionThe current study presents the potential of applying fUS during awake brain surgery. We illustrate the relevance of fUS for awake brain surgery based on its ability to capture both task-evoked functional cortical responses as well as differences in vascular characteristics between tumor and healthy tissue. As current neurosurgical practice is still pre-dominantly leaning on inherently limited pre-operative imaging techniques for tumor resection-guidance, fUS enters the scene as a promising alternative that is both anatomically and physiologically informative.

Highlights

  • Oncological neurosurgery relies heavily on making continuous, intra-operative delineations between tumor and brain tissue

  • Included participants had a mean age of 42 years (31–56 years), with predominantly intra-parenchymal frontal and temporal lobe gliomas of WHO grades II–IV

  • The present study demonstrates the clinical potential of Functional ultrasound (fUS) as a new image-guided resection tool during awake craniotomy surgery. fUS is able to detect the functional areas that were found using Electrocortical Stimulation Mapping (ESM) across a range of functional tasks

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Summary

Introduction

Oncological neurosurgery relies heavily on making continuous, intra-operative delineations between tumor and brain tissue. The ultimate surgical aim is reaching maximum-safe tumor resection, in which most of the tumor is removed, while preserving functional brain areas to prevent post-operative neurological and cognitive deficits (Marko et al, 2014; Li et al, 2015). Conventional clinical practice makes use of several preoperative imaging modalities, including (f)MRI and DTI, which are linked to intra-operative neuro-navigation systems. These imaging modalities allow the surgeon to pre-operatively acquire anatomical and functional data of the tumor and surrounding eloquent areas. Oncological neurosurgery relies heavily on making continuous, intra-operative tumor-brain delineations based on image-guidance. We have applied fUS during conventional awake brain surgery to determine its clinical potential for both intraoperative functional and vascular brain mapping, with the ultimate aim of achieving maximum safe tumor resection

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