Intraoperative cerebral angiosonography with ultrasound contrast agents: how I do it
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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).
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).
Real-time intraoperative ASG is a rapid, reliable, repeatable method for vessel visualization and evaluation of tissue perfusion.
• ASG permits to assess vessel position, dimension, and relationships; it also allows a qualitative evaluation of flow entity and direction.
• ASG shows vessels in depth without the need of their direct exposure, as for fluorescence-guided surgery.
• ASG permits to study the entire vascular tree without the necessity to set gain or pulse repetition frequency as in Doppler imaging.
• Vessels of interest can be visualized following their entire length across the surgical field, along the arterial, capillary, and venous districts.
• ASG scan is repeatable multiple times throughout the operation, and each exam could be recorded as a clip to be visualized at a later stage.
• In case of neoplastic lesion, ASG characterizes the perfusion pattern in three phases: arterial, venous, and parenchymal, permitting to visualize afferent and efferent vessels, facilitating the surgical strategy.
• During tumor debulking, ASG shows the remaining distance to major vessels, providing information to avoid direct vessel damage.
• In tumor and AVM surgery, ASG shows nidus or tumoral remnants that might be covered by healthy tissue, thus not visible on the surface.
• In case of aneurysm surgery, post-clipping angiosonographic control confirms proper aneurysm exclusion and distal vessels flow.
KeywordsIntraoperative imaging Ultrasound Contrast-enhanced ultrasound Angiography Angiosonography Vascular surgery Skull base
ASG application in a case of right frontal metastasis, showing relationships between the lesion and anterior circulation arteries (MP4 46166 kb)
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