Cranial sonolucent prosthesis: a window of opportunity for neuro-oncology (and neuro-surgery).

INTRODUCTION: Ultrasound (US) is a versatile technology, able to provide a real-time and multiparametric intraoperative imaging, and a promising way to treat neuro-oncological patients outside the operating room. Anyhow, its potential is limited both in imaging and therapeutic purposes by the existence of the bone shielding. To enhance the spectrum of uses, our group has designed a dedicated US-translucent cranial prosthesis. Herein, we provide the proof of concept of a long-term US-based follow-up and a potential bedside therapeutic exploitation of US. METHODS: The prosthesis was first implanted in a cadaveric specimen to record any issue related to the cranioplasty procedure. Hence, the device was implanted in a patient undergoing surgery for a multi-recurrent anaplastic oligodendroglioma. US multiparametric scans through the device were acquired at 3, 6, 9, and 30 months after the procedure. RESULTS: The prosthesis could be modeled and implanted through ordinary instruments, with no concerns over safety and feasibility. Trans-prosthesis multiparametric US imaging was feasible, with image quality comparable to intraoperative US. Long-term follow-up in an outpatient setting was possible with no adverse events. Trans-prosthesis mechanical interaction with microbubbles was also feasible during follow-up. CONCLUSIONS: This report provides the first proof of concept for a potential breakthrough in the management of neuro-oncological patients. Indeed, through the implantation of an artificial acoustic window, the road is set to employ US both for a more dynamic long-term follow-up, and for US-guided therapeutic applications.

Robot assisted laser-interstitial thermal therapy with iSYS1 and Visualase: how I do it.

BACKGROUND: Laser-interstitial thermal therapy (LITT) is an ablative treatment based on a surgically implanted laser-emitting catheter to induce a focal ablation of the pathological tissue. The main indications in neurosurgery are primary brain tumors, metastases, radiation necrosis, and pediatric brain tumors. Several approaches have been proposed to implant the laser-emitting catheter, both in frameless and frame-based conditions. METHODS: We report our approach for Robot assisted laser-interstitial thermal therapy of brain lesions with iSYS1 and Visualase (Medtronic). CONCLUSIONS: iSYS1 represents a significant adjunct to LITT procedures and may be safely implemented in routine laser-catheter positioning.

Dynamic assessment of venous anatomy and function in neurosurgery with real-time intraoperative multimodal ultrasound: technical note.

The relevance of the cerebral venous system is often underestimated during neurosurgical procedures. Damage to this draining system can have catastrophic implications for the patient. Surgical decision-making and planning must consider each component of the venous compartment, from the medullary draining vein to the dural sinuses and extracranial veins. Intraoperative ultrasound (ioUS) permits the real-time study of venous compartments using different modalities, thus allowing complete characterization of their anatomical and functional features. The B-mode (brightness mode) offers a high-resolution anatomical representation of veins and their relationships with lesions. Doppler modalities (color, power, spectral) allow the study of blood flow and identification of vessels to distinguish their functional characteristics. Contrast-enhanced US allows one to perform real-time angiosonography showing both the functional and the anatomical aspects of vessels. In this technical report, the authors demonstrate the different applications of multimodal ioUS in neurosurgery for identifying the anatomical and functional characteristics of the venous compartment. They discuss the general principles and technical nuances of ioUS and analyze their potential implications for the study of various venous districts during neurosurgical procedures.

Contrast-enhanced MR Imaging versus Contrast-enhanced US: A Comparison in Glioblastoma Surgery by Using Intraoperative Fusion Imaging.

Purpose To compare contrast material enhancement of glioblastoma multiforme (GBM) with intraoperative contrast-enhanced ultrasonography (US) versus that with preoperative gadolinium-enhanced T1-weighted magnetic resonance (MR) imaging by using real-time fusion imaging. Materials and Methods Ten patients with GBM were retrospectively identified by using routinely collected, anonymized data. Navigated contrast-enhanced US was performed after intravenous administration of contrast material before tumor resection. All patients underwent tumor excision with navigated intraoperative US guidance with use of fusion imaging between real-time intraoperative US and preoperative MR imaging. With use of fusion imaging, glioblastoma contrast enhancement at contrast-enhanced US (regarding location, morphologic features, margins, dimensions, and pattern) was compared with that at gadolinium-enhanced T1-weighted MR imaging. Results Fusion imaging for virtual navigation enabled matching of real-time contrast-enhanced US scans to corresponding coplanar preoperative gadolinium-enhanced T1-weighted MR images in all cases, with a positional discrepancy of less than 2 mm. Contrast enhancement of gadolinium-enhanced T1-weighted MR imaging and contrast-enhanced US was superimposable in all cases with regard to location, margins, dimensions, and morphologic features. The qualitative analysis of contrast enhancement pattern demonstrated a similar distribution in contrast-enhanced US and gadolinium-enhanced T1-weighted MR imaging in nine patients: Seven lesions showed peripheral inhomogeneous ring enhancement, and two lesions showed a prevalent nodular pattern. In one patient, the contrast enhancement pattern differed between the two modalities: Contrast-enhanced US showed enhancement of the entire bulk of the tumor, whereas gadolinium-enhanced T1-weighted MR imaging demonstrated peripheral contrast enhancement. Conclusion Glioblastoma contrast enhancement with contrast-enhanced US is superimposable on that provided with preoperative gadolinium-enhanced T1-weighted MR imaging regarding location, margins, morphologic features, and dimensions, with a similar enhancement pattern in most cases. Thus, contrast-enhanced US is of potential use in the surgical management of GBM. © RSNA, 2017 Online supplemental material is available for this article.

Intraoperative cerebral angiosonography with ultrasound contrast agents: how I do it.

BACKGROUND: Intraoperative vessel visualization is highly desirable, especially when the target is related to or close to main vessels, such as in the skull base and vascular surgery. Contrast-enhanced ultrasound (CEUS) is an imaging technique that allows visualization of tissue perfusion and vascularization through the infusion of purely intravascular ultrasound contrast agents (UCA). METHODS: After cerebral scanning with B-mode ultrasound (US) CEUS is performed, UCA are injected and insonated with low mechanical index US. A UCA-specific harmonic signal is transduced using a contrast-specific algorithm to obtain real-time angiosonography (ASG). CONCLUSIONS: Real-time intraoperative ASG is a rapid, reliable, repeatable method for vessel visualization and evaluation of tissue perfusion.

Extracellular vesicles: The key for precision medicine in glioblastoma.

Glioblastoma (GBM) represents the most aggressive and lethal disease of the central nervous system. Diagnosis is delayed following the occurrence of symptoms, and treatment is based on standardized approaches that are unable to cope with its heterogeneity, mutability, and invasiveness. The follow-up of patients relies on burdensome schedules for magnetic resonance imaging (MRI). However, to personalize treatment, biomarkers and liquid biopsy still represent unmet clinical needs. Extracellular vesicles (EVs) may be the key to revolutionize the entire process of care for patients with GBM. EVs can be collected noninvasively (eg, blood) and impressively possess multilayered information, which is constituted by their concentration and molecular cargo. EV-based liquid biopsy may facilitate GBM diagnosis and enable the implementation of personalized treatment, resulting in customized care for each patient and for each analyzed time point of the disease, thereby tackling the distinctive heterogeneity and mutability of GBM that confounds effective treatment. Herein, we discuss the limitations of current GBM treatment options and the rationale behind the need for personalized care. We also review the evidence supporting GBM-associated EVs as a promising tool capable of fulfilling the still unmet clinical need for effective and timely personalized care of patients with GBM.

Multiparametric Intraoperative Ultrasound in Oncological Neurosurgery: A Pictorial Essay.

Intraoperative ultrasound (ioUS) is increasingly used in current neurosurgical practice. This is mainly explained by its affordability, handiness, multimodal real-time nature, and overall by its image spatial and temporal resolution. Identification of lesion and potential residue, analysis of the vascularization pattern, and characterization of the nature of the mass are only some of the advantages that ioUS offers to guide safe and efficient tumor resection. Technological advances in ioUS allow to achieve both structural and functional imaging. B-mode provides high-resolution visualization of the lesion and of its boundaries and relationships. Pioneering modes, such as contrast-enhanced ultrasound (CEUS), ultrasensitive Doppler, and elastosonography, are tools with great potential in characterizing different functional aspects of the lesion in a qualitative and quantitative manner. As already happening for many organs and pathologies, the combined use of different US modalities offers new insights in a multiparametric fashion. In this study, we present the potential of our multiparametric approach for ioUS during neuro-oncological surgery. In this effort, we provide a pictorial essay focusing on the most frequent pathologies: low- and high-grade gliomas, meningiomas, and brain metastases.

Neurophysiology-Guided Laser Interstitial Thermal Therapy: A Synergistic Approach For Motor Function Preservation. Technical Note.

BACKGROUND: Laser interstitial thermal therapy (LITT) is a minimally invasive ablative technique with specific indications for neuro-oncology, especially in the case of lesions in eloquent areas. Even being performed through a small catheter under stereotactic conditions, the risk of damaging vital structures such as white matter tracts or cortical eloquent areas is not negligible. The mechanism of damage can be related to catheter insertion or to excessive laser ablation. An accurate preoperative workup, aimed at locating the eloquent structures, can be combined with a real-time intraoperative neurophysiologic monitoring to reduce surgical morbidity while maximizing the efficacy of LITT. METHODS: We developed a synergistic approach for neurophysiology-guided LITT based on state-of-the-art technologies, namely, magnetoencephalography, diffusion tensor imaging, and intraoperative neurophysiologic monitoring. RESULTS: As a result, we improved the planning phase thanks to a more precise representation of functional structures that allows the simulation of different trajectories and the identification of the most suitable trajectory to treat the lesion while respecting the functional boundaries. Catheter insertion is conducted under continuous neurophysiologic feedback and the ablation phase is modeled on the functional boundaries identified by stimulation, allowing it to be extremely accurate. CONCLUSIONS: An integrated approached guided by neurophysiology is able to reduce the surgical morbidity even in a relatively accurate technique such as LITT. To the best of our knowledge, this represents the first report on this synergistic approach which could really impact the treatment of tumors in eloquent areas. Future studies are needed in the effort to implement this approach in functional or epilepsy neurosurgery as well.

Falcine meningiomas.

Falcine meningiomas (FMs) are defined as meningiomas arising from the falx, covered by the overlying brain parenchyma, and not involving the superior sagittal sinus (SSS). FMs together with parasagittal meningiomas represent the second most common location of intracranial meningioma. Clinical presentation depends on the dimensions and location of the FM. Surgery for FM removal deserves several considerations related to bridging veins, anterior cerebral artery branches, arterial feeders, SSS involvement, FM locations, and FM dimensions. In this chapter the principal aspects influencing surgical strategy are analyzed together with approaches and management.

5-ALA Fluorescence in Case of Brain Abscess by Aggregatibacter Mimicking Glioblastoma.

BACKGROUND: At present, the differential diagnosis of magnetic resonance imaging enhancing lesions can still be challenging. Preoperative imaging is a valuable tool characterized by high informative value, even if false-positive and false-negative results are possible. In this context, 5-aminolevulenic acid (5-ALA) represents a significant adjunct in glioblastoma (GBM) surgery displaying an assumed specific accumulation only in tumor cells. However, it was anecdotally reported that in some cases it can also be detected in nonneoplastic lesions mimicking GBM, thus potentially leading to misdiagnosis. Moreover, precise identification of involved pathogens from intraoperative brain samples may remain difficult. We report the case of an abscess from Aggregatibacter mimicking a GBM both during preoperative imaging and intraoperatively, since showing 5-ALA fluorescence. CASE DESCRIPTION: A 54-year-old man presented with intense cephalalgia, vomiting, and scotomas in his left eye. Brain magnetic resonance imaging demonstrated a right temporo-occipital rim-enhancing mass, highly suggestive of a GBM, and for this reason the patient underwent 5-ALA-guided complete removal. Histopathologic analysis proved the lesion to be a bacterial abscess from Aggregatibacter as confirmed by polymerase chain reaction on bacterial deoxyribonucleic acid. CONCLUSIONS: 5-ALA fluorescence may not be specifically involved only in malignant tumor cells, thus raising the suspect for alternative diagnoses to GBM and inviting caution into fluorescence-guided surgery.

Applications of Focused Ultrasound in Cerebrovascular Diseases and Brain Tumors.

Oncology and cerebrovascular disease constitute two of the most common diseases afflicting the central nervous system. Standard of treatment of these pathologies is based on multidisciplinary approaches encompassing combination of interventional procedures such as open and endovascular surgeries, drugs (chemotherapies, anti-coagulants, anti-platelet therapies, thrombolytics), and radiation therapies. In this context, therapeutic ultrasound could represent a novel diagnostic/therapeutic in the armamentarium of the surgeon to treat these diseases. Ultrasound relies on mechanical energy to induce numerous physical and biological effects. The application of this technology in neurology has been limited due to the challenges with penetrating the skull, thus limiting a prompt translation as has been seen in treating pathologies in other organs, such as breast and abdomen. Thanks to pivotal adjuncts such as multiconvergent transducers, magnetic resonance imaging (MRI) guidance, MRI thermometry, implantable transducers, and acoustic windows, focused ultrasound (FUS) is ready for prime-time applications in oncology and cerebrovascular neurology. In this review, we analyze the evolution of FUS from the beginning in 1950s to current state-of-the-art. We provide an overall picture of actual and future applications of FUS in oncology and cerebrovascular neurology reporting for each application the principal existing evidences.

Intraoperative ultrasonography (ioUS) characteristics of focal cortical dysplasia (FCD) type II b.

PURPOSE: Focal cortical dysplasia (FCD) is one of the major causes of drug-resistant epilepsy. Surgery has proved to be the treatment of choice, however up to a third of patients experience only partial resection. Ill-defined borders and lesions embedded in eloquent areas are two of the main drawbacks of FCD surgery. Preliminary experiences with intraoperative ultrasound (ioUS) have proved its feasibility and potential. We analyzed FCD' ioUS findings in our patients with FCD and compared them with magnetic resonance (MRI) ones. METHODS: We retrospectively reviewed all records of patients with focal medically refractory epilepsy who underwent ioUS guided surgery between November 2014 and October 2017. Lesions other than FCD or FCD associated with other pathological entities were not considered. Patients' preoperative MRI and ioUS features were analyzed according to up-to-date literature and than compared. RESULTS: A homogeneous population of five patients with type IIb FCD was evaluated. Focal cortical thickening and cortical ribbon hyper-intensity, blurring of the grey-white matter junction and hyper-intensity of the subcortical white matter on T2-weighted/FLAIR images were present in all patients. Cortical features had a complete concordance between ioUS and MRI. In particular ioUS thickening and hyper-echogenicity of cortical ribbon were identified in all cases (100%). Contrary, hyper-echoic subcortical white matter was detected in 60% of the patients. IoUS images resulted in clearer lesion borders than MRI images. CONCLUSION: Our study confirms the potentials of ioUS as a valuable diagnostic tool to guide FCD surgeries.

Intraoperative Strain Elastosonography in Brain Tumor Surgery.

BACKGROUND: Sonoelastography is an ultrasound imaging technique able to assess mechanical properties of tissues. Strain elastography (SE) is a qualitative sonoelastographic modality with a wide range of clinical applications, but its use in brain tumor surgery has been so far very limited. OBJECTIVE: To describe the first large-scale implementation of SE in oncological neurosurgery for lesions discrimination and characterization. METHODS: We analyzed retrospective data from 64 patients aiming at (i) evaluating the stiffness of the lesion and of the surrounding brain, (ii) assessing the correspondence between B-mode and SE, and (iii) performing subgroup analysis for gliomas characterization. RESULTS: (i) In all cases, we visualized the lesion and the surrounding brain with SE, permitting a qualitative stiffness assessment. (ii) In 90% of cases, lesion representations in B-mode and SE were superimposable with identical morphology and margins. In 64% of cases, lesion margins were sharper in SE than in B-mode. (iii) In 76% of cases, glioma margins were sharper in SE than in B-mode. Lesions morphology/dimensions in SE and in B-mode were superimposable in 89%. Low-grade (LGG) and high-grade (HGG) gliomas were significantly different in terms of stiffness and stiffness contrast between tumors and brain, LGG appearing stiffer while HGG softer than brain (all P < ·001). A threshold of 2.5 SE score had 85.7% sensitivity and 94.7% specificity in differentiating LGG from HGG. CONCLUSION: SE allows to understand mechanical properties of the brain and lesions in examination and permits a better discrimination between different tissues compared to B-mode. Additionally, SE can differentiate between LGG and HGG.

Clinical Significance of Extracellular Vesicles in Plasma from Glioblastoma Patients.

PURPOSE: Glioblastoma (GBM) is the most common primary brain tumor. The identification of blood biomarkers reflecting the tumor status represents a major unmet need for optimal clinical management of patients with GBM. Their high number in body fluids, their stability, and the presence of many tumor-associated proteins and RNAs make extracellular vesicles potentially optimal biomarkers. Here, we investigated the potential role of plasma extracellular vesicles from patients with GBM for diagnosis and follow-up after treatment and as a prognostic tool. EXPERIMENTAL DESIGN: Plasma from healthy controls (n = 33), patients with GBM (n = 43), and patients with different central nervous system malignancies (n = 25) were collected. Extracellular vesicles were isolated by ultracentrifugation and characterized in terms of morphology by transmission electron microscopy, concentration, and size by nanoparticle tracking analysis, and protein composition by mass spectrometry. An orthotopic mouse model of human GBM confirmed human plasma extracellular vesicle quantifications. Associations between plasma extracellular vesicle concentration and clinicopathologic features of patients with GBM were analyzed. All statistical tests were two-sided. RESULTS: GBM releases heterogeneous extracellular vesicles detectable in plasma. Plasma extracellular vesicle concentration was higher in GBM compared with healthy controls (P < 0.001), brain metastases (P < 0.001), and extra-axial brain tumors (P < 0.001). After surgery, a significant drop in plasma extracellular vesicle concentration was measured (P < 0.001). Plasma extracellular vesicle concentration was also increased in GBM-bearing mice (P < 0.001). Proteomic profiling revealed a GBM-distinctive signature. CONCLUSIONS: Higher extracellular vesicle plasma levels may assist in GBM clinical diagnosis: their reduction after GBM resection, their rise at recurrence, and their protein cargo might provide indications about tumor, therapy response, and monitoring.

Meningioma and Bone Hyperostosis: Expression of Bone Stimulating Factors and Review of the Literature.

BACKGROUND: Several hypotheses have been proposed regarding the mechanisms underlying meningioma-related hyperostosis. In this study, we investigated the role of osteoprotegerin (OPG), insulin-like growth factor 1 (IGF-1), endothelin 1 (ET-1), and bone morphogenetic protein (BMP) 2 and 4. METHODS: A total of 149 patients (39 males and 110 females; mean age, 62 years) who underwent surgery were included. Depending on the relationship with the bone, meningiomas were classified as hyperostotic, osteolytic, infiltrative, or unrelated. Expression of OPG, and IGF-1, ET-1, BMP-2, and BMP-4 was evaluated by tissue microarray analysis of surgical samples. RESULTS: Our series comprised 132 cases of grade I, 14 cases of grade II, and 3 cases of grade III meningiomas, according to the World Health Organization classification. Based on preoperative computed tomography scan, the cases were classified as follows: hyperostotic, n = 11; osteolytic, n = 11; infiltrative, n = 15; unrelated to the bone, n = 108. Four cases were excluded from the statistical analysis. Using receiver operating characteristic curve analysis, we identified a 2% cutoff for the mean value of IGF-1 that discriminated between osteolytic and osteoblastic lesions; cases with a mean IGF-1 expression of <2% were classified as osteolytic (P = 0.0046), whereas those with a mean OPG expression of <10% were classified as osteolytic (P = 0.048). No other significant relationships were found. CONCLUSIONS: Expression of OPG and expression of IGF-1 were found to be associated with the development of hyperostosis. Preliminary findings suggest that hyperostosis can be caused by an overexpression of osteogenic molecules that influence osteoblast/osteoclast activity. Based on our results, further studies on hyperostotic bony tissue in meningiomas are needed to better understand how meningiomas influence bone overproduction.

Advanced Ultrasound Imaging in Glioma Surgery: Beyond Gray-Scale B-mode.

Introduction: Glioma surgery is aimed at obtaining maximal safe tumor resection while preserving or improving patient's neurological status. For this reason, there is growing interest for intra-operative imaging in neuro-oncological surgery. Intra-operative ultrasound (ioUS) provides the surgeon with real-time, anatomical and functional information. Despite this, in neurosurgery ioUS mainly relies only on gray-scale brightness mode (B-mode). Many other ultrasound imaging modalities, such as Fusion Imaging with pre-operative acquired magnetic resonance imaging (MRI), Doppler modes, Contrast Enhanced Ultrasound (CEUS), and elastosonography have been developed and have been extensively used in other organs. Although these modalities offer valuable real-time intra-operative information, so far their usage during neurosurgical procedures is still limited. Purpose: To present an US-based multimodal approach for image-guidance in glioma surgery, highlighting the different features of advanced US modalities: fusion imaging with pre-operative acquired MRI for Virtual Navigation, B-mode, Doppler (power-, color-, spectral-), CEUS, and elastosonography. Methods: We describe, in a step-by-step fashion, the applications of the most relevant advanced US modalities during different stages of surgery and their implications for surgical decision-making. Each US modality is illustrated from a technical standpoint and its application during glioma surgery is discussed. Results: B-mode offers dynamic morphological information, which can be further implemented with fusion imaging to improve image understanding and orientation. Doppler imaging permits to evaluate anatomy and function of the vascular tree. CEUS allows to perform a real-time angiosonography, providing valuable information in regards of parenchyma and tumor vascularization and perfusion. This facilitates tumor detection and surgical strategy, also allowing to characterize tumor grade and to identify residual tumor. Elastosonography is a promising tool able to better define tumor margins, parenchymal infiltration, tumor consistency and permitting differentiation of high grade and low grade lesions. Conclusions: Multimodal ioUS represents a valuable tool for glioma surgery being highly informative, rapid, repeatable, and real-time. It is able to differentiate low grade from high grade tumors and to provide the surgeon with relevant information for surgical decision-making. ioUS could be integrated with other intra-operative imaging and functional approaches in a synergistic manner to offer the best image guidance for each patient.

Spinal Dural Arteriovenous Fistula: Is There a Role for Intraoperative Contrast-Enhanced Ultrasound?

BACKGROUND: Intraoperative imaging during surgical ligation of a spinal dural arteriovenous fistula (SDAVF) is usually based on fluorescence angiography, intraoperative Doppler ultrasound, and intraoperative digital subtraction angiography. We investigated the potential role of contrast-enhanced ultrasound (CEUS) during surgical management of SDAVF. The main features of SDAVF on CEUS before treatment are described as well as their modifications after surgical ligation. CASE DESCRIPTION: CEUS was performed using harmonic imaging with a second-generation ultrasound contrast agent in a case of right D6 SDAVF. Initial CEUS scan demonstrated the location of the arterialized vein draining in the dilated perimedullary plexus and augmented enhancement of the spinal cord secondary to intramedullary capillary congestion and augmented flow. The postligation scan demonstrated interruption of the arterialized vein and restoration of normal blood flow in spinal cord and perimedullary plexus. CONCLUSIONS: CEUS allowed real-time visualization before and after ligation of the site of the fistula and blood flow changes occurring in the spinal cord and perimedullary plexus. CEUS is a valuable tool in SDAVF surgery without the limitations of Doppler imaging and possibly can be integrated with other imaging modalities such as fluorescence angiography.

Mutations targeting the coagulation pathway are enriched in brain metastases.

Brain metastases (BMs) are the most common malignancy of the central nervous system. Recently it has been demonstrated that plasminogen activator inhibitor serpins promote brain metastatic colonization, suggesting that mutations in serpins or other members of the coagulation cascade can provide critical advantages during BM formation. We performed whole-exome sequencing on matched samples of breast cancer and BMs and found mutations in the coagulation pathway genes in 5 out of 10 BM samples. We then investigated the mutational status of 33 genes belonging to the coagulation cascade in a panel of 29 BMs and we identified 56 Single Nucleotide Variants (SNVs). The frequency of gene mutations of the pathway was significantly higher in BMs than in primary tumours, and SERPINI1 was the most frequently mutated gene in BMs. These findings provide direction in the development of new strategies for the treatment of BMs.

Intraoperative cerebral ultrasound for third ventricle colloid cyst removal: case report.

PURPOSE: To assess the usefulness of intraoperative Ultrasound (ioUS) and Echo-Color-Doppler (ECD) for the surgical removal of a specific deep-sited lesion. METHODS: Case report of a woman underwent surgery of a third ventricle colloid cyst removal. RESULTS: The ioUS technique depicted the deep intraventricular lesion and all the anatomical structures surrounding the lesion; helping us defining the best trajectory for the safest surgical removal. CONCLUSION: In our experience ioUS and ECD have demonstrated to be a reliable and useful intraoperative tool in neurosurgery, not only for superficial tumors but for deep intraventicular lesions as well.