Neuronavigated Ultrasound in Neuro-Oncology: A True Real-Time Intraoperative Image.

OBJECTIVE: Ultrasound is considered a real-time imaging method in neuro-oncology because of its highly rapid image acquisition time. However, to our knowledge, there are no studies that analyze the additional surgical time that it requires. METHODS: A prospective study of 100 patients who underwent intra-axial brain tumor resection with navigated intraoperative ultrasound. The primary outcomes were lesion visibility grade on ultrasound and concordance with preoperative magnetic resonance imaging (MRI) scan, intraoperative ultrasound usage time, and percentage of tumor resection on ultrasound and comparison with postoperative MRI scan. RESULTS: The breakdown of patients included the following: 53 high-grade gliomas, 26 metastases, 14 low-grade gliomas, and 7 others. Ninety-six percent of lesions were clearly visualized. The tumor border was clearly delimited in 71%. Concordance with preoperative MRI scan was 78% (P < 0.001). The mean time ± SD for sterile covering of the probe was 2.16 ± 0.5 minutes, and the mean image acquisition time was 2.49 ± 1.26 minutes. Insular tumor location, low-grade glioma, awake surgery, and recurrent tumor were statistically associated with an increased ultrasound usage time. Ultrasound had a sensitivity of 94.4% and a specificity of 100% for residual tumor detection. CONCLUSIONS: Neuronavigated ultrasound can be considered a truly real-time intraoperative imaging method because it does not increase surgical time significantly and provides optimal visualization of intra-axial brain lesions and residual tumor.

Application of a Thrombin-Gelatin Matrix in the Management of Intractable Hemorrhage During Stereotactic Biopsy.

BACKGROUND: Few studies have been published about percutaneous techniques for management of surgical bed hemorrhage during a stereotactic biopsy, a serious complication that may affect patient outcome. We describe the injection of a thrombin-gelatin matrix through the biopsy cannula as an effective method to arrest surgical bed bleeding that does not respond to conventional methods of hemostasis. METHODS: We prospectively documented image-guided stereotactic brain biopsy procedures in 30 awake patients between July 2014 and July 2017 at our center. Among patients presenting with intractable surgical bed bleeding, a thrombin-gelatin matrix injection through the biopsy cannula was performed. Details of the injection technique, surgical outcome, and complications were recorded. RESULTS: Among 30 documented stereotactic brain biopsies, 3 (10%) had intractable surgical bed bleeding during the procedure. In all 3 cases, thrombin-gelatin matrix was injected, and an immediate arrest of hemorrhage was achieved. None of the patients required a craniotomy or further invasive measure to achieve hemostasis. No postoperative complications were recorded. CONCLUSIONS: Our preliminary results suggest that thrombin-gelatin matrix injection is a simple, safe, and effective stereotactic practice to manage persistent surgical bed bleeding that cannot be arrested by standard, conventional hemostatic methods.