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Journal of Neurosurgical Sciences 2019 December;63(6):688-96

DOI: 10.23736/S0390-5616.19.04862-8


lingua: Inglese

“Dark corridors” in 5-ALA resection of high-grade gliomas: combining fluorescence-guided surgery and contrast-enhanced ultrasonography to better explore the surgical field

Giuseppe M. DELLA PEPA 1 , Tamara IUS 2, Grazia MENNA 1, Giuseppe LA ROCCA 1, 3, Claudio BATTISTELLA 4, Alessandro RAPISARDA 1, Edoardo MAZZUCCHI 1, Fabrizio PIGNOTTI 3, Andrea ALEXANDRE 5, Enrico MARCHESE 1, Alessandro OLIVI 1, Giovanni SABATINO 1, 3

1 Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy; 2 Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, Udine, Italy; 3 Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy; 4 Department of Medical Area, University of Udine, Udine, Italy; 5 Institute of Neuroradiology, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy

BACKGROUND: Increasing the extent of resection (EOR) is considered a main goal in high grade glioma (HGG) surgery. Significant advancements have been recently made to assist surgery: namely the use of 5-aminolevulinic acid (5ALA) and the application of contrast-enhanced ultrasound (CEUS) embody two of the most recently introduced tools in the neuro-oncology field. A combined approach including the two techniques has been suggested in literature. Our primary aim is to identify in which conditions CEUS final survey has a real impact in a 5-ALA guided context and assess which preoperative tumor characteristics, with specific attention to working corridors can predict strains of the fluorescence guided procedure and hence recommend the use of the combined technique.
METHODS: Forty-nine HGG glioma surgeries were performed at our institution with the abovementioned protocol between January 2016 and June 2016. Based on preoperative MRI, we stratified glioma characteristics according to three determinants: localization (deep versus superficial), size (<3.5 versus >3.5 cm) and shape (regular versus irregular).
RESULTS: CEUS modified 5-ALA guided resection in 11 cases (22.45%): this appeared to be associated with statistically significance to deep tumor localization (P=0.04) and irregular/multi-lobulated margins (P=0.003). On the other hand, tumor size alone did not appear as a statistically significant determinant.
CONCLUSIONS: When dark corridors are presents or when overlying brain parenchyma hinders illumination, drawbacks to the 5-ALA assistance can be expected, hence CEUS final survey has a crucial role of ‘refinement’. In those selected cases, an integrated 5ALA+CEUS protocol was shown as advisable in EOR improvement.

KEY WORDS: Fluorescence; Contrast media; Aminolevulinic acid; Glioma

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