Ludwig M.Auer Vera Van Velthoven Intraoperative Ultrasound Imaging in Neurosurgery Comparison with CT and MRI With 466 Figures in 547 Separate Illustrations Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong
LUDWIG M. AUER, M. D., Professor of Neurosurgery Neurosurgical Department, University Hospital Graz, Austria Neurosurgical Department, Krankenhaus Nordstadt Haltenhoffstrasse 41, D-3000 Hannover 1 VERA VAN VELTHOVEN, M. D., Assistant Professor of Neurosurgery Neurosurgical Department, University Hospital De Pinte Laan, B-9000 Gent ISBN-13:978-3-642-74047-3 e-isbn-13:978-3-642-74045-9 DOl: 1O.l007/978-3-642-74045-9 Library of Congress Cataloging-in-Publication Data. Auer, Ludwig M., 1948-. Intraoperative ultrasound imaging in neurosurgery: comparison with CT and MRI 1 Ludwig M. Auer, Vera Van Velthoven. p. cm. Bibliography: p. Includes index. ISBN-13:978-3-642-74047-31. Brain-Surgery. 2. Ultrasonic encephalography. 3. Brain-Tomography. 4. Brain-Magnetic resonance imaging. 5. Operative ultrasonography. I. Velthoven, Vera Van, 1953-. II. Title. [DNLM: 1. Brain--pathology. 2. Surgery, Operative. 3. Ultrasonic Diagnosis. WL 141 A917i] RD594.A84 1990 617'.481059-dc19 DNLM/DLC for Library of Congress 89-6052 CIP This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its version of June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. Springer-Verlag Berlin Heidelberg 1990 Softcoverreprintof the hardcover 1st edition 1990 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product Liability: The publishers can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Reproduction of the figures: Gustav Dreher GmbH, D-7000 Stuttgart 2122/3130-543210 - Printed on acid-free paper
Preface Almost a decade has passed since intraoperative real-time ultrasound imaging became available for routine use in daily practice. Our own initial difficulties in the handling of this technique and the interpretation of images stimulated us to put together this introductory atlas based on the cumulative experience from over 500 neurosurgical intraoperative investigations, the first book to appear on this topic. This volume is thus intended primarily as a practical guide to the handling of the instruments, anatomical orientation in the intracranial cavity and the interpretation of pathomorphological changes on ultrasound images. In order to facilitate recognition of well-known image patterns, we have emphasized the comparison of ultrasound with conventional neuroimaging methods such as computerized tomography (CT) and magnetic resonance imaging (MRI). Not all of the examples shown in this atlas are typical lesions where ultrasound imaging is of practical use for one reason or another; rather, we selected the cases on didactic grounds, to allow the reader first to become accustomed to the appearance of parts of the brain on ultrasound images, and thereafter to recognize a variety of pathomorphological changes which have previously been diagnosed by means of other imaging techniques such as CT or MRI. A separate chapter is then dedicated to those applications where we found intraoperative ultrasound imaging to be of real practical use. We are indebted to Prof. Dr. E. Vogler, Head of the Department of Radiology of the University of Graz, and his colleagues for kindly allowing us to use the CT and MR images of our patients for this atlas. We also thank the staff of the Department of Neurosurgery of the University of Graz for their cooperation in so many intraoperative ultrasound investigations, and we are especially grateful to Anton Pein for his technical assistance, to Elga Poschl for preparing all the photographs of CT and MR images and above all to Elfriede Meier for her patient and reliable secretarial assistance in the preparation of the manuscript. We also want to thank Mr. W. Bergstedt and Mrs. M. Griindler of Springer-Verlag and their team for their generous assistance and marvellous cooperation in the composition of this atlas. L.M.Auer V. Van Velthoven
Contents General Introduction......... 1 Technical Remarks... 3 Generation of Ultrasound Waves. 3 Origin of Tissue Echoes...... 4 Transformation of Ultrasound Waves 4 Importance of Ultrasound Frequency for Imaging in Neurosurgery. 6 Artifacts and Limitations in the Interpretation of Images. 6 Biological Effects of Ultrasound Imaging........... 7 Note on the Technical Equipment............... 7 Practical Handling of the Ultrasound Probe During Investigation 10 Imaging with Dura Closed or Open?.............. 10 Landmarks for Orientation in the Normal Brain and Intracranium 11 Horizontal View......................... 12 Orientation of the Sector Plane in the Intracranial Space: Hand-Eye Coordination 12 Sagittal View............ 16 Coronal View........... 18 Orientation in the Posterior Fossa 20 Intracranial Pathomorphology 23 General Remarks. 23 Gliomas.... 24 Meningiomas... 47 Metastases... 65 Ventricular Tumors. 78 Posterior Fossa Lesions 83 Other Tumors.. 92 Brain Abscesses... 97 Hydrocephalus..... 99 Subarachnoid Hemorrhage, Aneurysms and Arteriovenous Malformations 108 Intracerebral Hematomas............................ 122 Practical Application of Intraoperative Imaging... 131 Intraoperative Anatomical Orientation...... 131 Intraoperative Control Mter Tumor Removal. 147 Ultrasound-Guided Stereotaxy.......... 152 Endoscopic Evacuation of Intracerebral Hematomas 156 Endoscopic Biopsy of Cystic Brain Tumors.... 159 Ultrasound-Guided Biopsy of Brain Tumors... 166 Ultrasound-Guided Drainage of Brain Abscesses 169 References......................... 170 Subject Index...................................... 172