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Usefulness of three-dimensional navigable intraoperative ultrasound in resection of brain tumors with a special emphasis on malignant gliomas



Intraoperative imaging is increasingly being used in resection of brain tumors. Navigable three-dimensional (3D)-ultrasound is a novel tool for planning and guiding such resections. We review our experience with this system and analyze our initial results, especially with respect to malignant gliomas.


A prospective database for all patients undergoing sononavigation-guided surgery at our center since this surgery’s introduction in June 2011 was queried to retrieve clinical data and technical parameters. Imaging was reviewed to categorize tumors based on enhancement and resectability. Extent of resection was also assessed.


Ninety cases were operated and included in this analysis, 75 % being gliomas. The 3D ultrasound mode was used in 87 % cases (alone in 40, and combined in 38 cases). Use of combined mode function [ultrasound (US) with magnetic resonance (MR) images] facilitated orientation of anatomical data. Intraoperative power Doppler angiography was used in one-third of the cases, and was extremely beneficial in delineating the vascular anatomy in real-time. Mean duration of surgery was 4.4 hours. Image resolution was good or moderate in about 88 % cases. The use of the intraoperative imaging prompted further resection in 59 % cases. In the malignant gliomas (51 cases), gross-total resection was achieved in 47 % cases, increasing to 88 % in the “resectable” subgroup.


Navigable 3D US is a versatile, useful and reliable intraoperative imaging tool in resection of brain tumors, especially in resource-constrained settings where Intraoperative MR (IOMR) is not available. It has multiple functionalities that can be tailored to suit the procedure and the experience of the surgeon.

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Intraoperative Ultrasound


Two dimensional


Three dimensional


Intraoperative Magnetic resonance Imaging


Computed Tomography


Aminolevulinc acid


Power doppler


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We would like to thank all the members of our neuro-oncology working group and Mr. Thomson Verghese (clinical nurse coordinator) for assistance in the clinical work and data collection.

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Correspondence to Aliasgar V. Moiyadi.

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Supplementary Fig. 1

Medial frontal glioblastoma. Snapshot from the navigation screen showing the post contrast MR image (left) and corresponding Us image (center). Note the US image shows hyperechoic tumor beyond the contrast enhancing MR tumor component. Also, the ventricular system is very well delineated on the US image, facilitating orientation. (JPEG 195 kb)

High resolution image (TIFF 1992 kb)

Supplementary Fig. 2

Posterior frontal glioma. Snapshot from the navigation screen. Left panel shown the MR image with a white outlined rectangle denoting the sector scanned by the US. The corresponding US image is shown in the center panel. It depicts the structural heterogeneity of the tumor. Also noteworthy is the brainshift that is apparent as compared to the preoperative MRI. (JPEG 174 kb)

High resolution image (TIFF 1770 kb)

Supplementary Fig. 3

Medial frontal glioma. Snapshot from the navigation screen. Left panel shows the preoperative contrast enhanced MR images in “dual anyplane” view. The center panel shows the corresponding US images. Note that the tumor is hyperechoic (and therefore not cystic but containing solid necrotic areas), though the MR shows a hypointense non-enhancing central core. (JPEG 239 kb)

High resolution image (TIFF 2696 kb)

Supplementary Fig. 4

Parietal Glioma. Snapshot from the navigation screen. Left panel shows the preoperative contrast enhanced MR images in “dual anyplane” view. The center panel shows the corresponding US images. Note that the tumor is hypoechoic (and therefore cystic) as reflected in the MR, which shows a hypointense non-enhancing central core. (JPEG 193 kb)

High resolution image (TIFF 3224 kb)

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Moiyadi, A.V., Shetty, P.M., Mahajan, A. et al. Usefulness of three-dimensional navigable intraoperative ultrasound in resection of brain tumors with a special emphasis on malignant gliomas. Acta Neurochir 155, 2217–2225 (2013).

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