Clinical practice of intraoperative ultrasound in brain tumor surgery

doi:10.3969/j.issn.1672-6731.2025.02.005

Abstract

Abstract:

Intraoperative ultrasound (iUS) is a low-cost, portable and user-friendly auxiliary tool in brain tumor surgery, yet there is a lack of standardized operational guidelines. This review begins with the ultrasound physics and summarizes the workflow of iUS, followed by a grading system for ultrasonographic visibility of intracerebral lesions, iUS in assessing brain tumor resection, the limitations of iUS-guided brain tumor resection, multimodal ultrasound imaging, and the application of artificial intelligence (AI) in iUS. This review shows the clinical practice of iUS in brain tumor surgery from multiple perspectives and proposes practical standards.

Key words: Brain neoplasms, Ultrasonography, Monitoring, intraoperative, Multimodal imaging, Review

摘要：

术中超声（iUS）是脑肿瘤手术中一种低成本、简便且易操作的辅助工具，但缺乏规范化操作指南。本文阐述iUS原理和应用流程、脑内病变超声可见度分级系统、iUS在脑肿瘤特别是胶质瘤切除评估中的应用效果和局限性、多模态超声成像及人工智能在iUS中的应用，多角度展示iUS在脑肿瘤手术中的应用，并提出实践规范。

关键词: 脑肿瘤, 超声检查, 监测，手术中, 多模态成像, 综述

Jia-he GUO, Xiao-lei ZHANG, Kai ZHANG. Clinical practice of intraoperative ultrasound in brain tumor surgery[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2025, 25(2): 126-135.

郭嘉禾, 张晓磊, 张恺. 术中超声在脑肿瘤诊断与治疗中的应用[J]. 中国现代神经疾病杂志, 2025, 25(2): 126-135.

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URL: https://journal11.magtechjournal.com/cjcnn/EN/10.3969/j.issn.1672-6731.2025.02.005

https://journal11.magtechjournal.com/cjcnn/EN/Y2025/V25/I2/126

Figures/Tables 7

Figure 1 iUS findings of brain structures The whole brain ultrasonography of a patient with craniostenosis. The skull exhibited pronounced hyperechoic characteristics (Panel 1a). Ultrasonography of longitudinal fissure and surrounding structures from a patient with IDH-wild type glioblastoma showed tumor invasion of the cingulate gyrus. Medially, the falx cerebri was hyperechoic (blue dotted lines indicate). The corpus callosum (arrow indicates) lay below it (Panel 1b). Ultrasonography of peri-basal ganglia structures from a patient with Sturge-Weber syndrome showed the basal ganglia with isoechoic signals, the lateral insular structures and the lateral sulcus (red dotted lines indicate). Medially, the hypoechoic lateral ventricle (thin arrow indicates) could be seen, with the hypoechoic thalamus located posteromedially. Hyperechoic choroid plexus (thick arrow indicates) was visible within the ventricle (Panel 1c). Ultrasonography of medial temporal lobe structures from the same patient with Sturge - Weber syndrome showed the hippocampal head (thick arrow indicates), the hippocampal body (thin arrow indicates), and the hypoechoic midbrain (at the level of the quadrigeminal plate, green dotted lines indicate) medial to the hippocampus. The suprasellar cistern was located anterior to the midbrain. The posterior cerebral artery traversed between the medial hippocampal head and the midbrain (Panel 1d).

Figure 2 Ultrasound probe selection BK Medical 6C2 probe was used for a whole brain ultrasonography of anaplastic astrocytoma with pilocytic features. The imaging depth was 18 cm, with a frequency of 3.50 MHz and a gain of 4 dB (Panel 2a). BK Medical N13C5 probe was used for a conventional craniotomy ultrasonography of IDH - mutant astrocytoma. The imaging depth was 8 cm, with a frequency of 8 MHz and a gain of 9 dB (Panel 2b). BK Medical N11C5s probe was used for burr hole ultrasonography of diffuse leptomeningeal glioneuronal tumor. The imaging depth was 6 cm, with a frequency of 8 MHz and a gain of - 3 dB (Panel 2c).

Figure 3 Ultrasound probe preparation Aseptic cover (Panel 3a). Sterilized ultrasound probe (Panel 3b).

Table 1. A practical grading system of ultrasonographic visibility for intracerebral lesions^[11]

分级	可见度	边界	描述
0级	不可见	不可见	病变不可见
1级	差	差	病变难以辨别，与周围正常脑组织边界不清
2级	好	差	病变可辨别，与周围正常脑组织边界不清
3级	好	好	病变可辨别，与周围正常脑组织边界清晰

Figure 4 Preoperative MRI and iUS findings of pediatric - type diffuse high - grade glioma classified as ultrasonographic visibility Grade 1 Axial T₂WI showed the lesion as hyperintense with diffuse infiltrative growth and no clear boundaries in the left temporal lobe (arrow indicates, Panel 4a). iUS (Panel 4b) and T₂- FLAIR in the same ultrasound field of view (Panel 4c) couldn't distinguish the tumor, making the lesion difficult to identify, with unclear boundaries from surrounding normal tissue, consistent with Grade 1 (arrows indicate).

Figure 5 Preoperative MRI and iUS findings of IDH -mutant astrocytoma (WHO grade 4) classified as ultrasonographic visibility Grade 2 Axial enhanced T₁WI showed the mass lesion as hypointense with patchy enhancement and diffuse infiltrative growth in the left frontal lobe (arrow indicates, Panel 5a). iUS showed the tumor as hyperechoic with mixed echoes internally. The lesion was discernible but has unclear boundaries with surrounding normal tissue, consistent with Grade 2 (arrow indicates, Panel 5b). T₂ -FLAIR in the same ultrasound field of view showed hyperintensity of the lesion and cystic changes appearing as hypointensity (arrow indicates, Panel 5c).

Figure 6 Preoperative MRI and iUS findings of anaplastic astrocytoma with pilocytic features classified as ultrasonographic visibility Grade 3 Axial enhanced T₁WI showed significant enhancement of the lesion, with internal necrosis and surrounding hypointense edema in the right frontal lobe (arrow indicates, Panel 6a). iUS showed the tumor as markedly hyperechoic, distinguishable from surrounding edema, with hypoechoic cystic changes internally. The lesion was discernible with clear boundaries from surrounding normal tissue, consistent with Grade 3 (arrow indicates, Panel 6b). T₂ -FLAIR in the same ultrasound field of view showed mixed hyperintensity - isointensity of the lesion, accompanied by surrounding hyperintense edema (arrow indicates, Panel 6c).

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