Discrete or diffuse intramedullary tumor? Contrast-enhanced intraoperative ultrasound in a case of intramedullary cervicothoracic hemangioblastomas mimicking a diffuse infiltrative glioma: technical note and case report

Abstract

<jats:p>Hemangioblastomas are benign, highly vascularized intramedullary lesions that may also extend into the intradural space. Surgery represents the standard therapy, with the goal of obtaining complete resection even at the risk of neurological morbidity. MRI is the gold standard for diagnosis and assessment of intramedullary tumors. Nevertheless, sometimes MRI may not accurately differentiate between different types of intramedullary tumors, in particular if they are associated with syringes or intra- and peritumoral cysts. This could subsequently affect surgical strategies. Intraoperative ultrasound (ioUS) has become in the last few years a very useful tool for use during neurosurgical procedures. Various ioUS modalities such as B-mode and Doppler have been applied during neurosurgical procedures. On the other hand, the use of contrast-enhanced ultrasound (CEUS) is not yet well defined and standardized in this field. We report a case of a young patient harboring a cervicothoracic intramedullary tumor, for which the preoperative neuroradiologi-cal diagnosis was in favor of a diffuse astrocytoma with nodular components whereas ioUS demonstrated 3 distinct intramedullary nodules. CEUS showed highly vascularized lesions, compatible with hemangioblastomas. These findings, particularly those obtained with CEUS, allowed better definition of the lesions for diagnosis, enhanced understanding of the physiopathological aspects, and permitted the localization of all 3 nodules, thus limiting spinal cord manipulation and allowing complete resection of the lesions, with an uneventful postoperative neurological course.</jats:p> <jats:p>To the best of our knowledge, this is the first report of the use of intraoperative CEUS in a case of intramedullary hemangioblastoma.</jats:p>

Intraoperative contrast-enhanced ultrasound for intramedullary spinal neoplasms: patient series

“…Systematic research regarding CEUS characteristics of a wider range of CNS tumors will be necessary to adequately determine its role as a useful adjunct for resection of intramedullary spinal tumors. Preliminary case reports by Vetrano et al, 21 Han et al., 22 and our case series suggest that intraoperative CEUS is useful for the assessment of location, borders, and vascularity of intramedullary tumors. In cases of enhancing tumors, CEUS may also help to confirm completeness of initial resection.…”

“…18 Intraoperative contrast-enhanced ultrasound (CEUS) has been proposed as a means of enhancing tumor boundaries to facilitate resection of brain tumors; however, many of these proposals provide a limited pathological scope. [19][20][21][22] Here we present a case series evaluating the intraoperative utility of CEUS in visualizing intramedullary spinal cord tumors with various preoperative MRI characteristics.…”

Use of Intraoperative Ultrasound During Spinal Surgery

“…Authors have previously reported using ultrasound for resection of intramedullary lesions such as tumors and cavernomas, extramedullary lesions such as posttraumatic cysts, placement of syringo-subarachnoid shunts, and also the obliteration of spinal dural arteriovenous fistulae. [10][11][12]14,[16][17][18][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] Typically, when preparing for intradural surgery, the bony exposure is planned based on a preoperative CT or MRI. A durotomy is then made by roughly approximating where the lesion should be based on adjacent landmarks.…”

Sporadic and von Hippel–Lindau Related Hemangioblastomas of Brain and Spinal Cord: Multimodal Imaging for Intraoperative Strategy

“…In recent years, the introduction of new intraoperative imaging techniques has considerably changed surgical strategies in neuro-oncology, and these advancements also advanced the mainstays of HB surgery. For example, some studies have shown the role of intraoperative ultrasound (IOUS) in nodule detection [ 14 , 15 ], while contrast-enhanced ultrasound (iCEUS) analysis highlights the tumor and its vascular supply, also in deep-seated areas not directly visible on the brain or spinal cord surface [ 16 ]. Different fluorescent intraoperative dyes have been considered to help identify intramedullary HBs, thus reducing brain and spinal cord manipulation and the risks of postoperative worsening, increasing the extent of resection.…”