First Experience With Postoperative Transcranial Ultrasound Through Sonolucent Burr Hole Covers in Adult Hydrocephalus Patients

Neurosurgery 92:382–390, 2023

Managing patients with hydrocephalus and cerebrospinal fluid (CSF) disorders requires repeated head imaging. In adults, it is typically computed tomography (CT) or less commonly magnetic resonance imaging (MRI). However, CT poses cumulative radiation risks and MRI is costly. Ultrasound is a radiation-free, relatively inexpensive, and optionally point-of-care alternative, but is prohibited by very limited windows through an intact skull.

OBJECTIVE: To describe our initial experience with transcutaneous transcranial ultrasound through sonolucent burr hole covers in postoperative hydrocephalus and CSF disorder patients.

METHODS: Using cohort study design, infection and revision rates were compared between patients who underwent sonolucent burr hole cover placement during new ventriculoperitoneal shunt placement and endoscopic third ventriculostomy over the 1-year study time period and controls from the period 1 year before. Postoperatively, trans-burr hole ultrasound was performed in the clinic, at bedside inpatient, and in the radiology suite to assess ventricular anatomy.

RESULTS: Thirty-seven patients with sonolucent burr hole cover were compared with 57 historical control patients. There was no statistically significant difference in infection rates between the sonolucent burr hole cover group (1/37, 2.7%) and the control group (0/57, P = .394). Revision rates were 13.5% vs 15.8% (P = 1.000), but no revisions were related to the burr hole or cranial hardware.

CONCLUSION: Trans-burr hole ultrasound is feasible for gross evaluation of ventricular caliber postoperatively in patients with sonolucent burr hole covers. There was no increase in infection rate or revision rate. This imaging technique may serve as an alternative to CT and MRI in the management of select patients with hydrocephalus and CSF disorders.

Ultrasonic spine surgery for every thoracic disc herniation

J Neurosurg Spine 36:800–808, 2022

Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. This series elucidates the versatility, efficacy, and safety of the partial transpedicular approach with the use of intraoperative ultrasound and ultrasonic aspiration for resection of TDHs of various sizes, locations, and consistencies. This technique can be deployed to safely remove all TDHs.

METHODS A retrospective review was performed of patients who underwent a thoracic discectomy via the partial transpedicular approach between January 2014 and December 2020 by a single surgeon. Variables reviewed included demographics, perioperative imaging, and functional outcome scores.

RESULTS A total of 43 patients (53.5% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 10.4 ± 11.6 months. A total of 21 (38.9%) discs were fully calcified on imaging and 15 (27.8%) were partially calcified. A total of 36 (66.7%) were giant TDHs (> 40% canal compromise). The average operative time was 197.2 ± 77.1 minutes with an average blood loss of 238.8 ± 250 ml. Six patients required ICU stays. Hospital length of stay was 4.40 ± 3.4 days. Of patients with follow-up MRI, 38 of 40 (95%) disc levels demonstrated < 20% residual disc. Postoperative Frankel scores (> 3 months) were maintained or improved for all patients, with 28 (65.1%) patients having an increase of 1 grade or more on their Frankel score. Six (14%) patients required repeat surgery, 2 of which were due to reherniation, 2 were from adjacent-level herniation, and 2 others were from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intraoperative neuromonitoring was associated with a greater improvement in Frankel grade.

CONCLUSIONS The authors demonstrate a minimally disruptive, posterior approach that uses intraoperative ultrasound and ultrasonic aspiration with excellent outcomes and a complication profile similar to or better than other reported case series. This posterior approach is a valuable complement to the spine surgeon’s arsenal for the confident tackling of all TDHs.

3D ultrasound–guided resection of low-grade gliomas: principles and clinical examples

Neurosurg Focus 47 (6):E9, 2019

3D ultrasound (US) is a convenient tool for guiding the resection of low-grade gliomas, seemingly without deterioration in patients’ quality of life.

This article offers an update of the intraoperative workflow and the general principles behind the 3D US acquisition of high-quality images.

The authors also provide case examples illustrating the technique in two small mesial temporal lobe lesions and in one insular glioma. Due to the ease of acquiring new images for navigation, the operations can be guided by updated image volumes throughout the entire course of surgery.

The high accuracy offered by 3D US systems, based on nearly realtime images, allows for precise and safe resections. This is especially useful when an operation is performed through very narrow transcortical corridors.

Ultrasound-guided brain surgery: echographic visibility of different pathologies and surgical applications in neurosurgical routine

Acta Neurochirurgica (2018) 160:1175–1185

The use of intraoperative ultrasound (iUS) has increased in the last 15 years becoming a standard tool in many neurosurgical centers. Our aim was to assess the utility of routine use of iUS during various types of intracranial surgery. We reviewed our series to assess ultrasound visibility of different pathologies and iUS applications during the course of surgery.

Materials and methods This is a retrospective review of 162 patients who underwent intracranial surgery with assistance of the iUS guidance system (SonoWand). Pathologic categories were neoplastic (135), vascular (20), infectious (2), and CSF related (5). Ultrasound visibility was assessed using the Mair classification, a four-tiered grading system that considers the echogenicity of the lesion and its border visibility (from 0 to 3; grade 0, pathology not visible; grade 3, visible with clear border with normal tissue). iUS applications included lesion localization, approach planning to deep-seated lesions, and lesion removal.

Results All pathologies were visible on iUS except one aneurysm. On average, extra-axial tumors were identified more easily and had clearer limits compared to intra-axial tumors (extra-axial 17%grade 2, 83%grade 3; intra-axial 5.5% grade 1, 46.5%grade 2, 48% grade 3). iUS provided precise and safe transcortical trajectories to deep-seated lesions (71 patients; tumors, hemangiomas, ICHs); iUS was judged to be less useful to approach skull base tumors and aneurysms. iUS was used to judge extent of resection in 152 cases; surgical artifacts reduced sonographic visibility in 25 cases: extent of resection was correctly checked in 127 patients (53 gliomas, 15 metastases, 39 meningiomas, 4 schwannomas, 4 sellar region tumors, 6 hemangiomas, 3 AVMs, 2 abscesses).

Conclusions iUS was highly sensitive in detecting all types of pathology, was safe and precise in planning trajectories to intraparenchymal lesions (including minimally mini-invasive approaches), and was accurate in checking extent of resection in more than 80% of cases. iUS is a versatile and feasible tool; it could improve safety and its use may be considered in routine intracranial surgery.

USim: A New Device and App for Case-Specific, Intraoperative Ultrasound Simulation and Rehearsal in Neurosurgery

Operative Neurosurgery 14:572–578, 2018

Intraoperative ultrasound (iUS) is an excellent aid for neurosurgeons to perform better and safer operations thanks to real time, continuous, and high-quality intraoperative visualization. OBJECTIVE: To develop an innovative training method to teach how to perform iUS in neurosurgery.

METHODS: Patients undergoing surgery for different brain or spine lesions were iUS scanned (before opening the dura) in order to arrange a collection of 3-dimensional, US images; this set of data was matched and paired to preoperatively acquired magnetic resonance images in order to create a library of neurosurgical cases to be studied offline for training and rehearsal purposes. This new iUS training approach was preliminarily tested on 14 European neurosurgery residents, who participated at the 2016 European Association of Neurosurgical Societies Training Course (Sofia, Bulgaria).

RESULTS: USim was developed by Camelot and the Besta NeuroSim Center as a dedicated app that transforms any smartphone into a “virtual US probe,” in order to simulate iUS applied to neurosurgery on a series of anonymized, patient-specific cases of different central nervous system tumors (eg, gliomas, metastases, meningiomas) for education, simulation, and rehearsal purposes. USim proved to be easy to use and allowed residents to quickly learn to handle a US probe and interpret iUS semiotics.

CONCLUSION: USim could help neurosurgeons learn neurosurgical iUS safely. Furthermore, neurosurgeons could simulate many cases, of different brain/spinal cord tumors, that resemble the specific cases they have to operate on. Finally, the library of caseswould be continuously updated, upgraded, and made available to neurosurgeons.

Noninvasive neuromodulation and thalamic mapping with low-intensity focused ultrasound

J Neurosurg 128:875–884, 2018

Ultrasound can be precisely focused through the intact human skull to target deep regions of the brain for stereotactic ablations. Acoustic energy at much lower intensities is capable of both exciting and inhibiting neural tissues without causing tissue heating or damage. The objective of this study was to demonstrate the effects of low-intensity focused ultrasound (LIFU) for neuromodulation and selective mapping in the thalamus of a large-brain animal.

METHODS Ten Yorkshire swine (Sus scrofa domesticus) were used in this study. In the first neuromodulation experiment, the lemniscal sensory thalamus was stereotactically targeted with LIFU, and somatosensory evoked potentials (SSEPs) were monitored. In a second mapping experiment, the ventromedial and ventroposterolateral sensory thalamic nuclei were alternately targeted with LIFU, while both trigeminal and tibial evoked SSEPs were recorded. Temperature at the acoustic focus was assessed using MR thermography. At the end of the experiments, all tissues were assessed histologically for damage.

RESULTS LIFU targeted to the ventroposterolateral thalamic nucleus suppressed SSEP amplitude to 71.6% ± 11.4% (mean ± SD) compared with baseline recordings. Second, we found a similar degree of inhibition with a high spatial resolution (~ 2 mm) since adjacent thalamic nuclei could be selectively inhibited. The ventromedial thalamic nucleus could be inhibited without affecting the ventrolateral nucleus. During MR thermography imaging, there was no observed tissue heating during LIFU sonications and no histological evidence of tissue damage.

CONCLUSIONS These results suggest that LIFU can be safely used to modulate neuronal circuits in the central nervous system and that noninvasive brain mapping with focused ultrasound may be feasible in humans.