Abstract
BACKGROUNDPrimary intramedullary spinal tumors cause significant morbidity and death. Intraoperative ultrasound as an adjunct for localization and monitoring the extent of resection has not been systematically evaluated in these patients; the effectiveness of intraoperative contrast-enhanced ultrasound (CEUS) remains almost completely unexplored.OBSERVATIONSA retrospective case series of patients at a single institution who had consented to the off-label use of intraoperative CEUS was identified. Seven patients with a mean age of 52.8 ± 15.8 years underwent resection of intramedullary tumors assisted by CEUS performed by a single attending neurosurgeon. Histopathological evaluation revealed 3 cases of hemangioblastoma, 1 case of pilocytic astrocytoma, 2 cases of ependymoma, and 1 case of subependymoma. Contrast enhancement correlated with gadolinium enhancement on preoperative magnetic resonance imaging. Intraoperative CEUS facilitated precise lesion localization and myelotomy planning. Dynamic CEUS studies were useful in demonstrating the blood supply to lesions with a dominant vascular pedicle. Regardless of contrast uptake, the differential enhancement between spinal cord tissue and neoplasm assisted in determining interface boundaries.LESSONSIntraoperative CEUS constitutes a useful adjunct for the intraoperative delineation of contrast-enhancing intramedullary tumors and in vivo confirmation of gross-total resection. Systematic investigation is needed to establish the role of CEUS for resection of intramedullary spinal tumors of various pathologies.
Highlights
Primary intramedullary spinal tumors cause significant morbidity and death
Observations Seven patients with a mean age of 52.8 ± 15.8 years consented to undergo intraoperative contrast-enhanced ultrasound (CEUS) to assist with tumor resection
Four cases (3 hemangioblastomas and 1 ependymoma) displayed vivid contrast enhancement on preoperative magnetic resonance imaging (MRI), which was mirrored on intraoperative CEUS
Summary
Primary intramedullary spinal tumors cause significant morbidity and death. Intraoperative ultrasound as an adjunct for localization and monitoring the extent of resection has not been systematically evaluated in these patients; the effectiveness of intraoperative contrast-enhanced ultrasound (CEUS) remains almost completely unexplored. Techniques to augment visualization of the brain–tumor tissue interface have been developed to facilitate GTR of primary brain tumors, including intraoperative magnetic resonance imaging (MRI), 5-aminolevulinic acid (5-ALA), fluorescein, and intraoperative ultrasound These tools have demonstrated benefit in certain situations, obstacles continue to prevent their widespread adoption.[3,4,5,6,7,8,9] Intraoperative MRI requires a large capital investment and prolongs operative time while subjecting the patient to serial undraping and redraping.[10] MRI remains vulnerable to anatomical error secondary to physical perturbations such as cerebrospinal fluid drainage or resection that are not accounted for without new image acquisition.[11,12] Fluorescence-guided resection agents such as 5-ALA and fluorescein demarcate tumor tissue only on the surface of the resection cavity and are associated with potential phototoxicity, and efficacy studies have largely been restricted to high-grade gliomas, limiting applicability to broader histopathology.[11,13]. An additional 10-μl/kg intravenous bolus of Definity was administered and intraoperative CEUS was repeated to assess for possible residual tumor
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