Early aggressive constriction resection for hourglass-like constriction of peripheral nerve in the upper extremity: a retrospective study.

OBJECTIVES: The hourglass like constriction (HGC) of peripheral nerves is a characteristic pathological manifestation of Neuralgic Amyotrophy. Once identified, early surgical intervention is essential. However, the method of surgery is controversial, particularly regarding whether HGC needs to be excised. This study aims to explore the efficacy of early aggressive resection of HGC in the upper limb nerves. MATERIALS AND METHODS: This retrospective study focuses on 13 nerves of spontaneous upper limb paralysis treated at our hospital from June 2019 to July 2023, in which HGC was identified during surgery. During surgery, epineurectomy and interfascicular neurolysis were performed on the constricted areas. Post-neurolysis, constriction excision was carried out if any of the following conditions were met: (1) A single constriction with constriction ≥75%. (2) Constriction combined with torsion. (3) The presence of ≥2 constrictions. Regular face-to-face follow-ups were conducted postoperatively. RESULTS: Four cases with a single constriction of less than 75% underwent epineurotomy and interfascicular neurolysis; eight underwent constriction excision, of which four cases with a single constriction and associated torsion had direct end-to-end suturing after excision, and four had more than two constrictions treated with autologous sural nerve grafts. Postoperative follow-ups showed good recovery in all but one case, which had unique pathological features and had underwent only epineurectomy, showing moderate recovery. CONCLUSIONS: For early surgical treatment of HGCs in peripheral nerves of the upper limbs, if severe constriction, constriction combined with torsion, or the presence of more than two constrictions are identified during surgery, aggressive constriction resection may be a better option.

Enhancing precision in hysteroscopic surgery: The role of intraoperative ultrasound.

Hysteroscopy stands as the gold-standard approach for managing intrauterine pathology. However, in complex clinical cases, hysteroscopic evaluation alone may prove insufficient for the safest and successful patient management. Intraoperative ultrasound (IOUS) has emerged as a valuable adjunct to hysteroscopic surgery, offering real-time visualization of endometrial cavity, uterine walls and instruments within the uterine cavity, enabling precise delineation of anatomical structures, and helping to assess the extent of pathology during intricate interventions. This review aims to comprehensively assess the applications, efficacy and utility of IOUS in hysteroscopic surgery. Available evidence indicates that in hysteroscopic myomectomy, IOUS significantly reduces the risk of uterine perforation, particularly in submucosal FIGO 2 myomas, and enhances the likelihood of a single-step procedure. During hysteroscopic metroplasty, ultrasound guidance decreases the chance of incomplete uterine septum resection. In the hysteroscopic management of severe Asherman syndrome, IOUS reduces the risk of uterine perforation or false passage. For cesarean scar pregnancy (CSP), ultrasound is crucial in defining the most appropriate surgical approach and is effective in guiding the hysteroscopic treatment of endogenic CSP. The use of IOUS in hysteroscopy proves valuable in complex cases where the risk of uterine perforation or incomplete procedure is increased.

3D ultrasound-augmented image guidance for surgery of high-grade gliomas - A quantitative analysis focused on the extent of resection.

Background: We have retrospectively reviewed our series of brain tumor patients operated on using 3D IntraOperative UltraSound (IOUS) to report technical advantages and areas of improvement. Methods: Clinical and radiological data of patients with a diagnosis of high-grade glioma IV operated with and without IOUS were retrieved and analyzed. Results: We have found 391 patients operated using IOUS coupled with neuronavigation and 257 using neuronavigation standalone. We have selected a pool of 60 patients with a diagnosis of GlioBlastoma (GB), comparing two equally sized groups operated with and without IOUS, respectively. The average extent of resection (EOR) in the IOUS group was 93%, while in the control group, it was 80%. IOUS was significantly associated with improved EOR (P < 0.0004), even when accounting for other factors affecting EOR. The average overall survival (OS) was 13.4 months, and the average progression-free survival (PFS) was 7.4 months. The Cox proportional hazard model showed an advantage in OS on patients operated using the IOUS. No statistically significant effect was observed on PFS. Conclusion: Intraoperative ultrasound coupled with image guidance is associated with an improved EOR and possibly an improved OS. While we are aware of several limitations related to the present analysis, these data support the routine use of IOUS as a safe and reliable technology. Larger, prospective series with updated IOUS technology are desirable to verify the accuracy of these results.

Intraoperative Ultrasound in Brain Surgery.

This study describes the essential components and the technique of intraoperative ultrasound (IOUS), including probe selection and techniques used to produce quality images. Case examples are given to illustrate the value and the accuracy of IOUS in intracranial surgery of companion animals. IOUS has proven an invaluable addition to intracranial surgery, especially in real-time localization of the mass, identifying borders between mass and normal cerebral tissue, and identifying vascular supply to the mass.

Could intraoperative ultrasound improve clinical and radiological outcomes during arthroscopic calcification evacuation of rotator cuff?

Background: Martinel et al described an intraoperative ultrasound technique to easier identify calcification (CA) under arthroscopy. Our hypothesis was that intraoperative ultrasound monitoring allowed better evacuation of calcific tendinopathy. Our aim was to determine whether ultrasound monitoring improved the short-term clinical and radiological outcomes of calcific tendinopathy. Methods: A prospective, single-center, single-operator, consecutive study conducted between February 2020 and June 2023. The inclusion criterion was surgical treatment for evacuation of symptomatic macro-centimetric CA type A or B. The first 20 patients were operated on using the standard surgical technique and the next 20 under ultrasound control. The mean age at surgery was 49.8 years (minimum: 28 years; maximum: 64 years). Patients were reviewed at 6 weeks and 3 months. The evacuation of the CA was checked at 6 weeks by X-ray. Results: In the standard technique group, the mean preoperative Constant score was 41.4/100 (±15.07). Postoperatively, the Constant score was 58.88/100 (±15.28) at 6 weeks and 69.16/100 (±13.86) at 3 months. The mean preoperative Subjective Shoulder Value (SSV) was 39.0% (±18.61). Postoperatively, the SSV was 64.0% (±17.21) at 6 weeks and 79.47% (±16.06) at 3 months. In the ultrasound control group, the preoperative Constant score was 44.48/100 (±14.28) and 58.18/100 (±15.64) at 6 weeks and 66.87/100 (±18.45) at 3 months postoperatively. The mean preoperative SSV was 40.0% (±16.54) and 61.75% (±18.59) at 6 weeks and 76.05% (±19.62) at 3 months postoperatively. There was no significant postoperative difference in Constant score (P = .732) or SSV (P = .566) between the 2 groups. There was a significant difference (P = .004) between the 2 groups in terms of complete evacuation of the CA with the standard technique in 65% of cases (13 patients out of 20) and with intraoperative ultrasound monitoring in 95% of cases (19 patients out of 20). Conclusion: There was no significant postoperative difference in Constant score and SSV between the 2 groups in the short term. Evacuation of calcification was significantly better with ultrasound monitoring.

Contrast-Enhanced Intraoperative Ultrasound Shows Excellent Performance in Improving Intraoperative Decision-Making.

BACKGROUND: The aim of this study was to evaluate the performance and the impact of contrast-enhanced intraoperative ultrasound (CE-IOUS) on intraoperative decision-making, as there is still no standardized protocol for its use. Therefore, we retrospectively analyzed multiple CE-IOUS performed in hepato-pancreatic-biliary surgery with respect to pre- and postoperative imaging and histopathological findings. METHODS: Data of 50 patients who underwent hepato-pancreatic-biliary surgery between 03/2022 and 03/2024 were retrospectively collected. CE-IOUS was performed with a linear 6-9 MHz multifrequency probe connected to a high-resolution device. The ultrasound contrast agent used was a stabilized aqueous suspension of sulphur hexafluoride microbubbles. RESULTS: In total, all 50 lesions indicated for surgery were correctly identified. In 30 cases, CE-IOUS was used to localize the primary lesion and to define the resection margins. In the remaining 20 cases, CE-IOUS identified an additional lesion. Fifteen of these findings were identified as malignant. In eight of these cases, the additional malignant lesion was subsequently resected. In the remaining seven cases, CE-IOUS again revealed an inoperable situation. In summary, CE-IOUS diagnostics resulted in a high correct classification rate of 95.7%, with positive and negative predictive values of 95.2% and 100.0%, respectively. CONCLUSIONS: CE-IOUS shows excellent performance in describing intraoperative findings in hepato-pancreatic-biliary surgery, leading to a substantial impact on intraoperative decision-making.

Neuronavigation Combined With Intraoperative Ultrasound and Intraoperative Magnetic Resonance Imaging Versus Neuronavigation Alone in Diffuse Glioma Surgery.

OBJECTIVE: This study aimed to integrate intraoperative ultrasound and magnetic resonance imaging (IMRI) with neuronavigation (NN) to create a multimodal surgical protocol for diffuse gliomas. Clinical outcomes were compared to the standard NN-guided protocol. METHODS: Adult patients with diffuse gliomas scheduled for gross total resection (GTR) were consecutively enrolled to undergo either NN-guided surgery (80 patients, July 2019-January 2022) or multimodal-integrated surgery (80 patients, February 2022-August 2023). The primary outcomes were the extent of resection (EOR) and GTR. Additional outcomes included operative time, blood loss, length of hospital stay, and patient survival. RESULTS: GTR was achieved in 69% of patients who underwent multimodal-integrated surgery, compared to 43% of those who received NN-guided surgery (P = 0.002). Residual tumor was detected by IMRI in 53 patients (66%), and further GTR was achieved in 28 of these cases. The median EOR was 100% for the multimodal group and 95% for the NN-guided group (P = 0.001), while the median operative time was 8 hours versus 5 hours (P < 0.001). Neurological deficits, blood loss, and hospital stay durations were comparable between 2 groups. Multimodal-integrated surgery resulted in greater EOR and higher GTR rates in contrast-enhancing gliomas, gliomas in eloquent regions, and large gliomas (≥50 mm). GTR in glioblastomas and other contrast-enhancing gliomas contributed to improved overall survival. CONCLUSIONS: Compared to standard NN-guided surgery, multimodal-integrated surgery using NN, IMRI, and intraoperative ultrasound significantly increased the EOR and GTR rates for diffuse gliomas.

Contrast-enhanced intraoperative ultrasound improved hepatic recurrence-free survival in initially unresectable colorectal cancer liver metastases.

BACKGROUND: We aimed to evaluate the role of Contrast-enhanced intraoperative ultrasound (CE-IOUS) with perfluorobutane microbubbles (Sonazoid) in improving the prognosis of patients with unresectable colorectal cancer liver metastases (CRLM). METHODS: A total of 130 Patients with unresectable CRLM who underwent curative hepatic resection at our institute were retrospectively analyzed. Of these 130 enrolled patients, 67 underwent intraoperative ultrasound alone (IOUS group); 63 underwent additional CE-IOUS and IOUS (CE-IOUS group). Normalized inverse probability treatment weighting (IPTW) was employed to balance baseline characteristics between groups. Hepatic recurrence-free survival (HRFS) and overall survival (OS) were compared. RESULTS: The treatment strategy was altered in 25 patients (25/63, 39.9%) due to the additional use of CE-IOUS. After applying IPTW, the CE-IOUS group exhibited a significantly lower rate of hepatic recurrence (hazard ratio [HR], 0.55; 95% confidence interval [CI] 0.32-0.95; P = 0.032). Subgroup analysis showed that CE-IOUS provided a significant benefit over IOUS in patients with bilobar liver metastases (P = 0.007), or with a number of live tumors < 3 (P = 0.021), or without DLM (P = 0.018), or with extrahepatic metastasis (P = 0.034), or with a minimum of 6 cycles of systemic therapy (P = 0.03). CONCLUSIONS: CE-IOUS is necessary for unresectable CRLM after preoperative chemotherapy, as it enhances detection accuracy and improves the prognosis of unresectable CRLM patients.

Intraoperative transvaginal ultrasound to standardize bowel endometriosis shaving.

OBJECTIVE: To study the use of intraoperative transvaginal ultrasound after bowel endometriosis shaving. DESIGN: Stepwise demonstration with a narrated video footage of preoperative and intraoperative ultrasound to evaluate the extent of an endometriotic rectal nodule. SETTING: Lausanne University Hospital and Geneva University Hospital. PATIENT(S): Two women with symptomatic endometriosis rectal lesion. INTERVENTION(S): Preoperative transvaginal ultrasound was performed to measure the rectal nodule. After completing bowel shaving, the surgeon conducted both clinical and sonographic evaluations of the rectal wall. Clinically, this was performed using laparoscopic grasping forceps and sonographically with a transvaginal probe after filling the pelvis with saline solution. MAIN OUTCOME MEASURE(S): Assessment of the rectal wall for residual disease after bowel shaving and evaluation of the necessity for additional bowel resection. RESULT(S): After sonographic evaluation of the rectal wall, the surgeon decided in both patients to perform a discoid resection because of the presence of a residual rectal disease despite thorough bowel shaving. CONCLUSION(S): Intraoperative transvaginal ultrasound after bowel endometriosis shaving is a promising technique that is safe, reproducible, and efficient. It aids surgeons in accurately assessing the extent of excision of deep rectosigmoid infiltrating endometriosis and determining the necessity of additional bowel resection to reduce recurrence risk. Moreover, intraoperative ultrasound provides precise measurements of residual nodules, enabling differentiation between persistent, recurrent, or new lesions during follow-up.

Surgical Management of the Horrible Gallbladder.

Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.

Dorsal arachnoid web of the thoracic spine associated with an arachnoid cyst and a presyrinx state as an unexplained cause of thoracic myelopathy: illustrative case.

BACKGROUND: Dorsal thoracic arachnoid web is a rare diagnosis and is not commonly seen in neurosurgical practice. Patients can present with symptoms and signs of thoracic myelopathy in the setting of an arachnoid cyst and a presyrinx state. OBSERVATIONS: A 57-year-old male with a 10-year history of worsening bilateral leg weakness and chronic back pain re-presented to the neurosurgery clinic after being seen by neurology and orthopedic spine surgery. Initial imaging was concerning for myelomalacia and syringomyelia, and repeat delayed computed tomography myelography findings were consistent with an evolving thoracic arachnoid web, now demonstrating spinal cord compression secondary to arachnoid cyst formation and consistent with the signs of thoracic myelopathy. Intraoperative ultrasound displayed the arachnoid web as the cause of the evolving arachnoid cyst, edematous spinal cord, and a presyrinx-like state. The patient underwent surgical decompression, which restored cerebrospinal fluid (CSF) dynamics, resulting in clinical improvement. LESSONS: Dorsal thoracic arachnoid web is a dynamic condition that can occur in the setting of an arachnoid cyst. There appears to be a relationship between dorsal thoracic arachnoid web formation and the presence of an arachnoid cyst resulting from a ball-valve mechanism leading to the creation of a pressure gradient effect that alters CSF fluid dynamics. https://thejns.org/doi/10.3171/CASE24313.

Intraoperative ultrasound and magnetic resonance comparative analysis in brain tumor surgery: a valuable tool to flatten ultrasound's learning curve.

BACKGROUND: Intraoperative ultrasound (IOUS) is a profitable tool for neurosurgical procedures' assistance, especially in neuro-oncology. It is a rapid, ergonomic and reproducible technique. However, its known handicap is a steep learning curve for neurosurgeons. Here, we describe an interesting postoperative analysis that provides extra feedback after surgery, accelerating the learning process. METHOD: We conducted a descriptive retrospective unicenter study including patients operated from intra-axial brain tumors using neuronavigation (Curve, Brainlab) and IOUS (BK-5000, BK medical) guidance. All patients had preoperative Magnetic Resonance Imaging (MRI) prior to tumor resection. During surgery, 3D neuronavigated IOUS studies (n3DUS) were obtained through craniotomy N13C5 transducer's integration to the neuronavigation system. At least two n3DUS studies were obtained: prior to tumor resection and at the resection conclusion. A postoperative MRI was performed within 48 h. MRI and n3DUS studies were posteriorly fused and analyzed with Elements (Brainlab) planning software, permitting two comparative analyses: preoperative MRI compared to pre-resection n3DUS and postoperative MRI to post-resection n3DUS. Cases with incomplete MRI or n3DUS studies were withdrawn from the study. RESULTS: From April 2022 to March 2024, 73 patients were operated assisted by IOUS. From them, 39 were included in the study. Analyses comparing preoperative MRI and pre-resection n3DUS showed great concordance of tumor volume (p < 0,001) between both modalities. Analysis comparing postoperative MRI and post-resection n3DUS also showed good concordance in residual tumor volume (RTV) in cases where gross total resection (GTR) was not achieved (p < 0,001). In two cases, RTV detected on MRI that was not detected intra-operatively with IOUS could be reviewed in detail to recheck its appearance. CONCLUSIONS: Post-operative comparative analyses between IOUS and MRI is a valuable tool for novel ultrasound users, as it enhances the amount of feedback provided by cases and could accelerate the learning process, flattening this technique's learning curve.

A comparative study of learning curves among general surgery residents for intraoperative ultrasound-guided breast-conserving surgery.

Breast-conserving surgery (BCS) followed by radiotherapy is preferred for early-stage breast cancer because its survival rate is equivalent to that of mastectomy. Achieving negative surgical margins in BCS is crucial to minimize the risk of recurrence. Intraoperative ultrasound (IOUS) enhances surgical accuracy, but its efficacy is operator dependent. This study aimed to compare the success of achieving negative margins using IOUS between an experienced breast surgeon and general surgical residents and to evaluate the learning curve for the residents. A prospective study involving 96 patients with BCS who underwent IOUS guidance was conducted. Both the breast surgeon and residents assessed the surgical margins using IOUS, with the breast surgeon making the final margin adequacy decision. Permanent histopathological analysis was used to confirm the status of the margins and was considered the gold standard for comparison. The breast surgeon accurately assessed the margin status in all 96 cases (100% accuracy), with 93 negative and three positive margins. All of these were ductal carcinomas in situ. Initially, the residents demonstrated low accuracy rates in predicting margin positivity using intraoperative ultrasonography. However, the learning curves of the three residents demonstrated that, with an average 12th case onwards, a significant improvement in the cumulative accuracy rates was observed, which reached the level of the breast surgeon. IOUS is an effective tool for accurately predicting the margin status in BCS, with an acceptable learning curve for novice surgeons. Training and experience are pivotal for optimizing surgical outcomes. These findings support the integration of IOUS training into surgical education programs to enhance proficiency and improve patient outcomes.

Challenges with segmenting intraoperative ultrasound for brain tumours.

Objective - Addressing the challenges that come with identifying and delineating brain tumours in intraoperative ultrasound. Our goal is to both qualitatively and quantitatively assess the interobserver variation, amongst experienced neuro-oncological intraoperative ultrasound users (neurosurgeons and neuroradiologists), in detecting and segmenting brain tumours on ultrasound. We then propose that, due to the inherent challenges of this task, annotation by localisation of the entire tumour mass with a bounding box could serve as an ancillary solution to segmentation for clinical training, encompassing margin uncertainty and the curation of large datasets. Methods - 30 ultrasound images of brain lesions in 30 patients were annotated by 4 annotators - 1 neuroradiologist and 3 neurosurgeons. The annotation variation of the 3 neurosurgeons was first measured, and then the annotations of each neurosurgeon were individually compared to the neuroradiologist's, which served as a reference standard as their segmentations were further refined by cross-reference to the preoperative magnetic resonance imaging (MRI). The following statistical metrics were used: Intersection Over Union (IoU), Sørensen-Dice Similarity Coefficient (DSC) and Hausdorff Distance (HD). These annotations were then converted into bounding boxes for the same evaluation. Results - There was a moderate level of interobserver variance between the neurosurgeons [ I o U : 0.789 , D S C : 0.876 , H D : 103.227 ] and a larger level of variance when compared against the MRI-informed reference standard annotations by the neuroradiologist, mean across annotators [ I o U : 0.723 , D S C : 0.813 , H D : 115.675 ] . After converting the segments to bounding boxes, all metrics improve, most significantly, the interquartile range drops by [ I o U : 37 % , D S C : 41 % , H D : 54 % ] . Conclusion - This study highlights the current challenges with detecting and defining tumour boundaries in neuro-oncological intraoperative brain ultrasound. We then show that bounding box annotation could serve as a useful complementary approach for both clinical and technical reasons.

Imaging adjuvants in pediatric surgical oncology.

Surgery is a crucial component of pediatric cancer treatment, but conventional methods may lack precision. Image-guided surgery, including fluorescent and radioguided techniques, offers promise for enhancing tumor localization and facilitating precise resection. Intraoperative molecular imaging utilizes agents like indocyanine green to direct surgeons to occult deposits of tumor and to delineate tumor margins. Next-generation agents target tumors directly to improve specificity. Radioguided surgery, employing tracers like metaiodobenzylguanidine (MIBG), complements fluorescent techniques by allowing for detection of tumors at a greater depth. Dual-labeled agents combining both modalities are under development. Three-dimensional modeling and virtual/augmented reality aid in preoperative planning and intraoperative guidance. The above techniques show great promise to benefit patients with pediatric tumors, and their continued development will almost certainly improve surgical outcomes.

Role of intraoperative ultrasound and MRI to aid grade of resection of pediatric low-grade gliomas: accumulated experience from 4 centers.

PURPOSE: Pediatric low-grade gliomas (pLGG) are the most common brain tumors in children and achieving complete resection (CR) in pLGG is the most important prognostic factor. There are multiple intraoperative tools to optimize the extent of resection (EOR). This article investigates and discusses the role of intraoperative ultrasound (iUS) and intraoperative magnetic resonance imaging (iMRI) in the surgical treatment of pLGG. METHODS: The tumor registries at Tuebingen, Rome and Pretoria were searched for pLGG with the use of iUS and data on EOR. The tumor registries at Liverpool and Tuebingen were searched for pLGG with the use of iMRI where preoperative CR was the surgical intent. Different iUS and iMRI machines were used in the 4 centers. RESULTS: We included 111 operations which used iUS and 182 operations using iMRI. Both modalities facilitated intended CR in hemispheric supra- and infratentorial location in almost all cases. In more deep-seated tumor location like supratentorial midline tumors, iMRI has advantages over iUS to visualize residual tumor. Functional limitations limiting CR arising from eloquent involved or neighboring brain tissue apply to both modalities in the same way. In the long-term follow-up, both iUS and iMRI show that achieving a complete resection on intraoperative imaging significantly lowers recurrence of disease (chi-square test, p < 0.01). CONCLUSION: iUS and iMRI have specific pros and cons, but both have been proven to improve achieving CR in pLGG. Due to advances in image quality, cost- and time-efficiency, and efforts to improve the user interface, iUS has emerged as the most accessible surgical adjunct to date to aid and guide tumor resection. Since the EOR has the most important effect on long-term outcome and disease control of pLGG in most locations, we strongly recommend taking all possible efforts to use iUS in any surgery, independent of intended resection extent and iMRI if locally available.

D2BGAN: Dual Discriminator Bayesian Generative Adversarial Network for Deformable MR-Ultrasound Registration Applied to Brain Shift Compensation.

During neurosurgical procedures, the neuro-navigation system's accuracy is affected by the brain shift phenomenon. One popular strategy is to compensate for brain shift using intraoperative ultrasound (iUS) registration with pre-operative magnetic resonance (MR) scans. This requires a satisfactory multimodal image registration method, which is challenging due to the low image quality of ultrasound and the unpredictable nature of brain deformation during surgery. In this paper, we propose an automatic unsupervised end-to-end MR-iUS registration approach named the Dual Discriminator Bayesian Generative Adversarial Network (D2BGAN). The proposed network consists of two discriminators and a generator optimized by a Bayesian loss function to improve the functionality of the generator, and we add a mutual information loss function to the discriminator for similarity measurements. Extensive validation was performed on the RESECT and BITE datasets, where the mean target registration error (mTRE) of MR-iUS registration using D2BGAN was determined to be 0.75 ± 0.3 mm. The D2BGAN illustrated a clear advantage by achieving an 85% improvement in the mTRE over the initial error. Moreover, the results confirmed that the proposed Bayesian loss function, rather than the typical loss function, improved the accuracy of MR-iUS registration by 23%. The improvement in registration accuracy was further enhanced by the preservation of the intensity and anatomical information of the input images.

Progress in the application of ultrasound in glioma surgery.

Brain glioma, which is highly invasive and has a poor prognosis, is the most common primary intracranial tumor. Several studies have verified that the extent of resection is a considerable prognostic factor for achieving the best results in neurosurgical oncology. To obtain gross total resection (GTR), neurosurgery relies heavily on generating continuous, real-time, intraoperative glioma descriptions based on image guidance. Given the limitations of existing devices, it is imperative to develop a real-time image-guided resection technique to offer reliable functional and anatomical information during surgery. At present, the application of intraoperative ultrasound (IOUS) has been indicated to enhance resection rates and maximize brain function preservation. IOUS, which is promising due to its lower cost, minimal operational flow interruptions, and lack of radiation exposure, can enable real-time localization and precise tumor size and form descriptions while assisting in discriminating residual tumors and solving brain tissue shifts. Moreover, the application of new advancements in ultrasound technology, such as contrast-enhanced ultrasound (CEUS), three-dimensional ultrasound (3DUS), noninvasive ultrasound (NUS), and ultrasound elastography (UE), could assist in achieving GTR in glioma surgery. This article reviews the advantages and disadvantages of IOUS in glioma surgery.

Ultrasound-guided approach to surgery for nodal recurrence following lateral neck dissection for differentiated thyroid carcinoma. A single institution experience.

Introduction: Total thyroidectomy (TT) and central neck dissection (CND) had a significant effect on the reduction of local recurrence compared with TT alone. Lateral Neck Dissection (LND) was performed in all the cases with therapeutic intent. The suspicion of nodal recurrence is provided by the appearance of one or more enlarged nodes in the central and/or laterocervical compartment during the follow up period. Methods: From January 2018 to November 2023, 16 patients at the University General Surgery unit of the Polyclinic of Foggia underwent reoperation due to nodal recurrence after previously undergoing total thyroidectomy with central and lateral cervical dissection. Results: All surgical interventions were approached with intraoperative ultrasound performed by the operating surgeon. In all cases, ultrasound identification of the suspicious lymph node led to histological confirmation of malignancy. In only two cases it was necessary to carry out an extemporaneous intraoperative histological examination. No complications were recorded during the operations. Conclusions: Surgical reintervention in patients with nodal recurrence is challenging and requires an assessment by members of the interdisciplinary team. The ideal method should be economically convenient, easy to practice, with a quick learning curve, easily reproducible, and safe for patients. Intraoperative, ultrasound-guided, is a safe and effective technique. It facilitates tumor localization and removal, especially in patients requiring re-operative neck surgery.

Intraoperative Ultrasound: An Old but Ever New Technology for a More Personalized Approach to Brain Tumor Surgery.

BACKGROUND: Although the use of transcranial ultrasound dates to the mid-20th century, the main purpose of this research work is to standardize its use in the resection of brain tumors. This is due to its wide availability, low cost, lack of contraindications, and absence of harmful effects for the patient and medical staff, along with the possibility of real-time verification of the complete resection of tumor lesions and minimization of vascular injuries or damage to adjacent structures. METHODS: A retrospective study was conducted from June to December 2022. The study included eight patients (three men and five women) aged between 32 and 76 years. Histological examination revealed two high-grade gliomas, one low-grade glioma, and five metastatic lesions. RESULTS: The low-grade glioma appeared as a homogeneously echogenic structure and easily distinguishable from brain parenchyma, whereas metastases and high-grade gliomas showed higher echogenicity, being identified as malignant lesions due to areas of low echogenicity necrosis and peritumoral edema identified as a hyperechogenic structure. CONCLUSIONS: The use of intraoperative transcranial ultrasound constitutes an important tool for neurosurgeons during tumor resection. Although it is easy to use, intraoperative ultrasound requires a relatively short learning curve and a good understanding of the fundamentals of ultrasound. Its main advantage over neuronavigation is that it is not affected by the "brain shift" phenomenon that commonly occurs during tumor resection, since the ultrasound images are updated during surgery.