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 » Objective
 » Discussion
 » Conclusion
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Table of Contents    
VIDEO SECTION-OPERATIVE NUANCES: STEP BY STEP
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1551-1553

Real-Time 2D Ultrasound Guided Frameless Biopsy of a Multifocal Glioma: Improving Accuracy and Diagnostic Yield


Neurosurgery Services, Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission05-Apr-2021
Date of Decision05-Apr-2021
Date of Acceptance13-Dec-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Prakash Shetty
Neurosurgery Services, Dept of Surgical oncology, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333481

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 » Abstract 


Background and Introduction: Intraoperative ultrasound imaging can be a multi-dimensional tool with various applications, including localization, resection control, and biopsy of brain tumors.
Objective: We demonstrate a frameless biopsy technique by using real-time 2D ultrasound (RT-2DUS) for localizing and guiding the biopsy of cranial tumors.
Technique: A 60-year-old male presented with progressive right hemiparesis, memory, and behavioral disturbances. MRI brain showed a multifocal lesion in the left temporal, parietal, and occipital lobes with extension into the splenium. He underwent left parietal mini-craniotomy with frameless RT-2DUS-guided biopsy.
Result: Postoperative US scan showed a small biopsy site hematoma. Histopathology confirmed it to be IDH-negative primary glioblastoma. For multifocal glioma, the patient underwent adjuvant WBRT with concurrent and adjuvant temozolomide.
Conclusion: RT-2DUS improves the sampling accuracy of the tumor by detecting the solid component of the lesion intraoperatively. In addition, the detection of operative site hematoma can be picked up immediately, avoiding post-procedure imaging.


Keywords: 2D ultrasound, frameless brain biopsy, intraoperative ultrasound, ultrasound-guided biopsy
Key Message: Intraoperative imaging is becoming an integral part of a neurosurgeon's armory for dealing with neuro-oncology. Ultrasound is a fast, real-time, cheap, universally available imaging modality. It is equally useful and accurate for the biopsy of intracranial lesions with improved diagnostic yield.


How to cite this article:
Yeole U, Singh V, Shetty P, Moiyadi A. Real-Time 2D Ultrasound Guided Frameless Biopsy of a Multifocal Glioma: Improving Accuracy and Diagnostic Yield. Neurol India 2021;69:1551-3

How to cite this URL:
Yeole U, Singh V, Shetty P, Moiyadi A. Real-Time 2D Ultrasound Guided Frameless Biopsy of a Multifocal Glioma: Improving Accuracy and Diagnostic Yield. Neurol India [serial online] 2021 [cited 2022 Jan 26];69:1551-3. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1551/333481


In the current era of immunohistochemical characterization of tumors in neuropathology and targeted therapies, tissue diagnosis through biopsy or surgical resection is essential. There are two techniques for tissue diagnosis: frame-based image-guided and frameless navigation-guided stereotactic biopsy. Both are well established as diagnostic procedures.[1] Ultrasound has proven to be an advantageous intraoperative imaging technique for guiding biopsy. We previously published our results on US use for biopsy and its utility in improving the diagnostic yield.[2]


 » Objective Top


We are demonstrating one of the intraoperative applications of ultrasound imaging in neurosurgery. The real-time 2D ultrasound imaging modality for biopsy of intracranial lesions is shown in this video.

Case study

A 60-year-old-man, a retired officer, presented with progressive headache, vomiting, forgetfulness, and irrelevant talk for 15 days. He had progressive right-side spastic hemiparesis with upper motor neuron facial palsy for 3 months. He was a wheelchair user and had decreased verbal response with recent memory disturbances.

MRI brain imaging showed a T2W hyperintense lesion in the left temporal and the splenial region, predominantly nonenhancing on post-contrast T1W images. He was started on levetiracetam and dexamethasone preoperatively and evaluated for pre-anesthetic fitness.

Procedure

He was planned for a left parietal mini-craniotomy and frameless RT-2DUS guided biopsy. Under general anesthesia, the head was positioned with a rotation toward the right. A linear incision was marked over the left parietal region. In a sterile fashion, a mini craniotomy was performed. It was large enough to fit in a curved linear probe with a small footprint (29 mm × 10 mm) and a frequency range of 5–13 MHz (Craniotomy N13C5 transducer, ®BK Medical Denmark) from bk5000 IOS system (® BK Medical, Denmark). The probe is provided with a side attachment for a needle guide. The advantage of a needle guide is that the needle always remains in the scanning plane of ultrasound. It has three slots for passing the biopsy needle corresponding to the three trajectories, visualized as dotted lines on the ultrasound image monitor. Transdural ultrasound was performed to localize the high-grade component (solid tumor) for biopsy. The biopsy area was aligned in the path of one of the three trajectories, and the biopsy needle was advanced under real-time imaging guidance to the biopsy point. Multiple biopsies were performed from the temporal and splenial part of the lesion with a side-cutting biopsy needle. Post-biopsy-check ultrasound showed a small clot at the biopsy point. The craniotomy flap was fixed with plates and screws, and the incision was closed in layers.

Video Link: https://youtu.be/yOJfA3J3Mvc

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Video timeline with audio transcript:

This operative video demonstrates a technique of real-time 2D ultrasound-guided biopsy for a multifocal glioma.

(0:00:07) A 60-year-old retired gentleman presented to OPD with progressive headaches, vomiting, forgetfulness, and irrelevant talk for 15 days. On clinical examination, he had right-side spastic hemiparesis with upper motor neuron facial palsy. He was a wheelchair user and had decreased verbal response with recent memory disturbances.

(0:00:31) MRI brain imaging showed a T2W hyperintense lesion in the left temporal and the splenial region, predominantly nonenhancing on post-contrast T1W images. He was started on levetiracetam and dexamethasone preoperatively and evaluated for pre-anesthetic fitness.

(0:00:50) We planned for a left parietal mini-craniotomy and RT-2DUS-guided biopsy of the multifocal glioma.

(0:00:59) He was positioned supine with his head turned to the right side under general anesthesia. Linear left parietal incision was marked over the parietal eminence. In a sterile fashion, a mini-craniotomy was performed. A nursing assistant arranged a BK ultrasound machine with a cranial N13C5 transducer.

(0:01:21) After fixing the US probe with the needle guide, a transdural 2DUS scan was acquired to localize the lesion following craniotomy. The projected path tracker feature of the BK machine was utilized to decide on the trajectory. Here we chose the lateral most trajectory to enter the lesion, avoiding all possible vital structures. A small durotomy was made at the entry point of the needle. A closed side-cutting stereotactic needle attached to a 5cc syringe for the aspiration was inserted through the durotomy slowly in rotatory motion to enter the lesion. After opening the needle, under continuous real-time imaging, multiple biopsies were taken in different meridians during a single insertion of the needle by rotating its cutting surface. The needle was removed slowly in a similar rotatory fashion after closing.

(0:02:15) Post-biopsy 2DUS showed a small clot at the biopsy site and along the needle insertion path. After confirming that representative tissue was biopsied through frozen section analysis, the craniotomy flap was fixed with plates and screws, and the skin was closed in a layered manner.

(0:02:35) The patient was extubated and shifted to the recovery room for observation overnight. No new neurological deficits were noted till discharge.

(0:02:43) These are the references used in this manuscript along with our previous publication on comparative analysis of 2D versus 3D ultrasound-guided biopsy techniques.

Outcome

We discharged the patient in stable neurological condition on postoperative day 2. Histopathological examination revealed primary glioblastoma, IDH wild type with ATRX loss. He was started on adjuvant chemo-radiotherapy as per standard Stupp protocol.

Pearls and pitfalls

IOUS is an effective and useful intraoperative imaging technique. This imaging technique is advantageous over MR because it is easier, cheaper, and almost universal in all operating setups with real-time imaging guidance, which is practically impossible with MR. The representative yield for our series 2DUS versus 3DnUS-guided biopsy was 98.4%, with a diagnostic yield of 92.8%.[2]

The significant advantage of using real-time ultrasound imaging for biopsy are as follows:

  1. Less operative time than navigation-guided stereotactic biopsy procedures, which require setting up a navigation system.[2],[3]
  2. Stereotactic biopsy procedures require rigid frame fixation followed by navigation protocol CT or MR scan for lesion localization and marking coordinates and deciding entry point along with trajectory.
  3. It is less prone to technical and mechanical errors as it does not involve using a navigation system.
  4. Biopsy is based on real-time imaging and hence not prone to registration errors, brain shift seen with the frameless biopsy system.
  5. Can view post-biopsy status in real-time, such as biopsy site hematoma.


The only real disadvantage of this technique is the necessity to perform a mini-craniotomy instead of a burr-hole performed in other methods. However, the dural opening is only at the entry point of the needle; thus, intradural invasion is similar to that in stereotactic biopsies. In addition, as imaging is real-time, it is operator-dependent and involves an initial learning curve with anatomical orientation and understanding of ultrasound images.


 » Discussion Top


This operative video demonstrated a simple technique of performing RT-2DUS-guided biopsy of deep-seated lesions. Transdural US following craniotomy delineates lesion, and real-time imaging can compensate for the brain shift to target the likely representative tissue for biopsy. BK machine's trajectory guiding feature helps to avoid vasculature (with color Doppler function) and ventricles. With three options available for directing the needle, we can choose the shortest and safest trajectory to the desired point; this lends flexibility to the surgeon, which is not available with other frame-based stereotactic procedures. The needle is always in the plane of insonation as the needle guide is fixed to the probe. This is more advantageous than a freehand needle biopsy in which keeping the needle in the insonating plane is difficult.

The limitation of all biopsy procedures, a nondiagnostic yield, is a limitation of histopathological evaluation rather than the procedure itself when the US is used for real-time imaging as missing the representative tissue is very rare (<2%).[2]


 » Conclusion Top


To conclude, RT-IOUS is a safe, simple, and technically reliable real-time imaging technique for biopsy procedures. It is equally effective as other biopsy techniques with the added advantage of real-time imaging.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Apuzzo ML, Chandrasoma PT, Cohen D, Zee C-S, Zelman V. Computed imaging stereotaxy: Experience and perspective related to 500 procedures applied to brain masses. Neurosurgery 1987;20:930-7.  Back to cited text no. 1
    
2.
Patil AD, Singh V, Sukumar V, Shetty PM, Moiyadi AV. Comparison of outcomes of free-hand 2-dimensional ultrasound-guided versus navigated 3-dimensional ultrasoundguided biopsy for supratentorial tumours: A single-institution experience with 125 cases. Ultrasonography 2019;38:255-63.  Back to cited text no. 2
    
3.
Smith JS, Quiñones-Hinojosa A, Barbaro NM, McDermott MW. Frame-based stereotactic biopsy remains an important diagnostic tool with distinct advantages over frameless stereotactic biopsy. J Neurooncol 2005;73:173-9.  Back to cited text no. 3
    




 

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