Clinical Neurology and Neurosurgery 198 (2020) 106105

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Clinical Neurology and Neurosurgery

journal homepage: www.elsevier.com/locate/clineuro

Contrast enhanced ultrasound (CEUS) applications in neurosurgical and T

neurological settings – New scenarios for brain and spinal cord
ultrasonography. A systematic review
G.M. Della Pepaa,*, Grazia Mennaa, Tamara Iusb, Rina Di Bonaventuraa, Roberto Altieric,
Enrico Marchesea, Alessandro Olivia, Giovanni Sabatinoa,d, Giuseppe La Roccaa,d
a
Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Italy
b
Neurosurgery Unit, Department of Neuroscience, Santa Maria Della Misericordia, University Hospital, Udine, Italy
c
Division of Neurosurgery, Department of Neurosciences, Policlinico "G.Rodolico" University Hospital, Catania, Italy
d
Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy

A R T I C LE I N FO A B S T R A C T

Keywords: Contrast-enhanced ultrasound (CEUS) is a real-time, feasible technique. Both intraoperatively and bedside, it
Contrast enhanced ultrasound (CEUS) satisfies the need for serial assessment and easy performability. Initially employed in neuro-oncology, it has
Brain tumors recently overcome this first application. We aimed to evaluate the literature and give a comprehensive view of its
Spinal tumors use in the fields listed below.
Intraoperative imaging
A systematic review of all pertinent literature was performed via PubMed access according PRISMA P
Neuro-oncology
guidelines. Studies not involving human adults and not reporting original data were excluded. Cross-check of
references of selected articles was performed to complete bibliographical research. 67 articles were then grouped
by field of application: Oncology (26 articles) further subdivided in a) cranial tumors (23 articles) and b) spinal
tumors (3 articles); Vascular (31 articles), divided in three sections: a) aneurysms, AVMs and AVFs surgery (6
articles), b) cerebral perfusion assessment and acute stroke patients management (15 articles), c) carotid plaques
treatment (10 articles); TBI (2 articles); Pediatrics (4 articles); Peripheral nerve surgery (2 articles) and others (2
articles).
CEUS versatility across the aforementioned areas was analyzed, underlining its complementarity to other
well-settled imaging techniques. This review is focused on reporting CEUS advantages and disadvantages,
suggesting a further broadening of the already numerous applications.

1. Introduction introduction of contrast-enhanced ultrasound (CEUS) in the field neuro-

oncology, following the leads of other surgeries such as thyroid and
Neurosurgery is experiencing the rediscovery of intraoperative ul- hepatic surgery.
trasound (ioUS). In particular, growing enthusiasm was shown after the Those experiences in literature proved the integration of ioUS and

Abbreviations: AVFs, arteriovenous fistula; AVMs, arteriovenous malformations; API, absolute peak intensity; CAS, carotid stenting; CBF, cerebral blood flow; CDUS,
cranial doppler ultrasound; CE, contrast enhancement; CEA, carotid endarterectomy; CEUS, contrast- enhanced ultrasound; CPP, cerebral perfusion pressure; CSF,
cerebrospinal fluid; CT, computed tomography; dAVF, dural arteriovenous fistula; DSA, digital subtraction angiography; DWI, diffusion weighted imaging; EFSUMB,
European federation of the societies for ultrasound in medicine and biology; HII, hypoxic ischemic injury; HGG, high grade glioma; hs-CRP, high sensitivity C reactive
protein; GBM, glioblastoma; GKR, gamma knife radiation; FD, flow diverter; ICG-VA, indocyanine green video angiography; ICP, intra cranial pressure; iCT, in-
traoperative CT; iMRI, intraoperative MRI; ICU, intensive care unit; ioUS, intra operative ultrasound; LGG, low grade gliomas; MCAs, middle cerebral artery
aneurysms; MI, mechanical index; MVD, micro vessel density; MRI, magnetic resonance imaging; NICU, neonatal intensive care unit; NPH, normal perfused
hemisphere; PIHI, phase inversion harmonic imaging; pCT, perfusion CT; pMRI, perfusion MRI; PWI, perfusion weighted imaging; RFA, radio frequency ablation; rt-,
UPI real time ultrasound perfusion imaging; TBI, traumatic brain injury; TCCS, transcranial color-coded duplex sonography; TCD, transcranial doppler; TIA, transient
ischemic attack; TIC, time intensity curve; TFUS, transfontanellar ultrasound; VEGF, vascular endothelial growth factor; UM, uveal melanoma; US, ultrasound; 5-
ALA, 5-aminolevulinic acid
⁎
Corresponding author at: Institute of Neurosurgery, Catholic University of Rome, Largo A. Gemelli 8, 00168, Rome, Italy.
E-mail address: giuseppemaria.dellapepa@policlinicogemelli.it (G.M. Della Pepa).

https://doi.org/10.1016/j.clineuro.2020.106105
Received 16 March 2020; Received in revised form 19 July 2020; Accepted 21 July 2020
Available online 24 July 2020
0303-8467/ © 2020 Elsevier B.V. All rights reserved.
G.M. Della Pepa, et al.
CEUS to be a valuable tool in different neurosurgical scenarios: it
provides a truly real-time, feasible and modern intraoperative imaging
technique, allowing the assessment of unexposed, hidden, anatomical
and pathological structures [1,11]. Hence, these characteristics made
CEUS survey ideal as an intraoperative support in the resection of
gliomas. However, besides this traditional role, more and more in-
novative applications in a variety of neurosurgical intraoperative set-
tings are, nowadays, constantly reported. Novelties of is application in
preliminary cases and first large series paved the way to clinical
translation also in neurological scenarios; this new technology is cur-
rently adopted by a larger number of users and fields of applications are
continuously growing. The aim of our study is to comprehensively re-
view CEUS uses in different fields of neurosurgery and neurology, both
as an intraoperative and a bedside tool, including cranial and spinal
oncology, vascular neurosurgery, stroke, traumatic brain injury (TBI),
pediatric and peripheral nerve surgery. Ultimately, the paper aims to
give a glance at the ongoing future perspectives.
2. Methods
The protocol of this systematic review was written in accordance
with the PRISMA-P (Preferred Reporting Items for Systematic Review
and Meta-Analysis Protocols) guidance. An online literature research
was conducted using PubMed access. Last research was launched in
December 2019.
The algorithm used the terms: “CEUS” “contrast-enhanced ultra-
sound” “brain” “neurosurgery” “hydrocephalus” “aneurysms” “brain
perfusion” “stroke” “carotid plaques” “glioblastoma” “brain tumors”
“AVM” “cerebral aneurysms” as key words in various combinations.
85 unique articles were identified. After the searches, the duplicates
were removed (n = 10). The abstracts found in multiple searches to
identify potentially eligible articles for inclusion were read.
The following criteria have been used to identify studies to be in-
cluded in the review (Fig. 1):
2.1. Types of participants
Studies involving humans treated for a neurosurgical condition
were considered for inclusion.
2.2. Interventions
Any study evaluating CEUS application in a clinical neurosurgical
setting were retained for inclusion in the review.
2.3. Types of studies
We included any study matching the aforementioned criteria and
reporting original data. Since the paper aims in highlighting un-
conventional CEUS uses, were included in the review.
Exclusion criteria of the studies included: review studies (n = 5),
studies not involving humans (n = 3). Cross check of references of the
selected articles was performed in order to complete bibliographical
research.
Unique articles were identified. All potentially eligible studies (n =
67) were retrieved and full-text articles reviewed to determine elig-
ibility.
Results were grouped in five main categories according to the CEUS
field of application:
- Oncology further subdivided in a) cranial tumors and b) spinal tu-
mors
- Vascular, comprising three subgroups: a) aneurysms, arteriovenous
malformations (AVMs) and arteriovenous fistula (AVFs); b) cerebral
perfusion assessment and acute stroke patients management; c)
Carotid plaques treatment.
2
Clinical Neurology and Neurosurgery 198 (2020) 106105
- Traumatic brain injury (TBI);
- Pediatrics;
- Peripheral nerve surgery and Other applications
3. Results
A total of 67 papers about the use of CEUS in different fields of
neurosurgery and matching the aforementioned criteria were published
from 1999 to 2019 (last search launched in December 2019). Papers
corresponding to its application domains were as follows: Oncology (26
articles) further subdivided in a) cranial tumors (23 articles) and b)
spinal tumors (3 articles); Vascular (31 articles), divided in three sec-
tions: a) aneurysms, AVMs and AVFs surgery (6 articles), b) cerebral
perfusion assessment and acute stroke patients management (15 arti-
cles), c) carotid plaques treatment (10 articles); TBI (2 articles);
Pediatrics (4 articles); Peripheral nerve surgery (2 articles) and others
(2 articles).
3.1. Cranial neuro-oncology (Table 1)
A total of 23 studies were included. Reports and series on CEUS uses
in cranial neuro-oncology can be summarized of follows:
- Information about the perfusion of healthy and tumoral tissue and
differentiation between tumor types (4 studies) [2–5].
- Differentiating tumor recurrence from radionecrosis (2 studies)
[6,7];
- Improving resection margin in glioma surgery [8–12] (6 studies)
also in association with 5-Aminolevulinic Acid (5-ALA) in High
Grade Glioma (HGG) (1 study) [13];
- Intratumoral vasculature assessment in vessels rich tumors, such as
hemangioblastomas (3 studies) [14–16];
- Applied as a biopsy guidance (2 studies) [17,18];
- Follow up modality in cranial tumors (5 studies) [19–23].
3.2. Spinal tumors (Table 2)
Applications of CEUS in spinal tumor resection has been reported in
3 reports:
- To correct localize an intramedullary hemangioblastoma (1 case)
[24] and a dorsal schwannoma [25]
- Vascular assessment and intraoperative strategy guidance in a dorsal
hemangiopericytoma (1 case) [26,27].
3.3. Aneurysms, AVMs and AVFs (Table 3)
6 articles have been found regarding the use of CEUS in aneurysms,
AVMs and AVFs surgery:
- Assessment of aneurysm exclusion and real-time study of fluid dy-
namics and demonstration of successful surgical intervention (1
study) [28].
- synergistic intraoperative utilization with indocyanine green video-
angiography (ICG-VA) in the flow assessment of a MCA aneurysm (1
study) [29].
- Assessment of aneurysm exclusion in comparison with digital sub-
traction angiography (DSA) (3 studies) [30–32].
- Use in spinal dural AVFs (dAVFs) surgery (2 cases) [33,34].
3.4. Cerebral perfusion assessment and acute stroke patients management
(Table 4)
15 studies were identified in this section. A comprehensive sys-
tematic review was published in 2017 by Vinke et al. [35], encom-
passing 43 studies and including 861 patients. The level of evidence
G.M. Della Pepa, et al.
Fig. 1. Protocol of the systematic review in accordance with the PRISMA-P guidelines.
provided by the aforementioned work was high: we have chosen to
further include in this section only those papers evaluating:
- CEUS as a new method to measure cerebral perfusion in patients
with acute brain injury (1 study) [35].
- besides CEUS feasibility in perfusion assessment, its application in
detecting pathological changes in stroke patients [36]. In particular,
an increasing number of studies reported CEUS applicability to
stroke patients (5 studies) [37–41].
- potential of contrast- enhanced ultrasound for the discrimination of
ischemic versus normally perfused brain tissue (5 studies) [42–46],
- CEUS capability to detected mismatch compared to gold standard
(perfusion CT (pCT) and perfusion MRI (pMRI)(1 study) [47].
- Application as a follow-up strategy (2 studies) [48,47].
3.5. Carotid plaques (Table 5)
10 studies were included. These can be summarized as follows:
- CEUS feasibility in monitoring plaques building up inside carotid
arteries (4 studies) [49–52].
- Evaluation of vulnerable plaques, detect neovascularization and
recurrence of ischemic stroke/TIA episodes (5 studies) [53–58].
- Comparison of CEUS to 3D MRI is assessment of carotid plaques (1
study) [56].
3.6. TBI (Table 6)
Overall, 2 studies were published about the application of CEUS to
TBI. Not only they compared its accuracy to ioUS [57], but they also
underlined whether CEUS has the potential for both intraoperative and
3
Clinical Neurology and Neurosurgery 198 (2020) 106105
bedside assessment of cerebral perfusion, evaluating its changes in re-
sponse to decompressive craniotomy and others therapies aimed at
preventing secondary ischemia [58].
3.7. Pediatrics (Table 7)
4 studies were included. Proven to be particularly useful as it de-
lineates cerebral pathology with high soft-tissue contrast [59]. CEUS
was performed in infants with various neurological conditions; and the
results obtained compared to those of non-enhanced Transfontanellar
ultrasound (TFUS) and MRI [60]. Hwang et al. [61,62], tried to eluci-
date quantitative parameters and qualitative perfusion patterns in
neonates with a diagnosis of hypoxic ischemic injuries (HII). Ad-
ditionally, a pioneering case report highlighted its utility to diagnose
brain death, with significant clinical implications in neonates who may
not be eligible for commonly used radiologic studies [63].
3.8. Peripheral nerve surgery and other applications (Table 8)
4 studies were identified in this section. We reviewed two articles
about its application in peripheral nerve surgery, enhancing the dif-
ferential diagnostic distinction on malignant soft tissue masses [64],
[65].
One other singular application was by Venturini et al. [66] pro-
spectively investigated CEUS in the quantitative assessment of the re-
sponse of uveal melanoma (UM) to gamma knife radiation (GKR) in a
clinical setting. In a last noteworthy paper, Becker et al. [67], used
bedside transcranial CEUS ventriculography in critically ill patients.
 Table 1
Cranial tumors [23 papers].
AUTHOR YEAR N OF PATIENTS APPLICATION OBSERVATIONS
G.M. Della Pepa, et al.

J. U. Harrer et al., 2003 27 4 tumor groups (high grade gliomas, meningiomas, metastases, and other tumors) Identification of brain tumors, differentiation between different tumor types (not
2003 detailed) and additional information about tumor perfusion.
J. U. Harrer et al., 2004 2 High grade gliomas Comparison with pMRI in tumor classification and perfusion evaluation; possible
2004 use as follow-up for recurrence or response to antiangiogenic therapy.
Kanno et al., 2005 2005 40 Intracranial tumors (14 gliomas, 6 meningiomas, 3 hemangioblastomas, 2 malignant Facilitation of intra operative real-time navigation and assessment of
lymphomas, 3 other primary neoplasms, 9 metastatic tumors, and 3 nonneoplastic lesions) intratumoral vasculature (especially for vessels rich tumors such as
hemangioblastomas).
Vicenzini et al., 2006 2006 1 High grade glioma Comparison with pre-op pMRI in brain perfusion evaluation and high grade
lesion identification due to increased angiogenesis in the peripheral part.
Engelhardt et al., 2007 7 3 gliomas 3 metastasis 1 dysembryoplastic- neuroepithelial tumor Intra-op improvement of real-time topographic diagnosis and monitoring of
2007 resection; possible application in both pre- and postoperative setting.
J.U. Harrer et al., 2008 13 6 benign tumors (4 meningiomas, 2 low grade gliomas) and 19 malignant tumors (high Comparison with pMRI in assessing microvascular characteristics of brain tumors
2008 grade gliomas) with no significant difference for PI, PG, AUC.
Vicenzini et al., 2008 2008 20 5 intracerebral hemorrhages, 5 meningiomas, 8 glioblastomas without large necrotic areas, Bedside technique for noninvasive staging of tumors, possible use in recurrence
2 glioblastomas with large necrotic areas or radionecrosis post-operative evaluation.
Prada et al., 2014 2014 69 47 high grade gliomas and 22 low grade gliomas Evaluation of lesions according to their vascular pattern and degree of
enhancement. Possible role in highlighting tumor remnants.
Prada et al., 2014 2014 71 53 gliomas [16 low grade, 9 anaplastic, 28 glioblastoma], 4 meningiomas, 6 metastases, 2 Detection of intraoperative tumor residues (high sensitivity and specificity).
ependymomas, 1 pituitary adenoma, 1 hemangioblastoma, 1 ganglioglioma, 1 central
neurocytoma, 1 abscess, 1 radionecrosis
Yu et al., 2015 2015 120 44 low grade gliomas and 76 high grade gliomas Visualization of tumor vascularization with identification and interruption of
feeding arteries. Procedure redone after tumor debulking.
Prada et al., 2015 2015 18 Skull base tumors (10 meningiomas, 3 craniopharyngiomas, 2 giant pituitary adenomas, 1 Assessment of real time tissue perfusion in fusion imaging.

4
posterior fossa epidermoid, 2 dermoid cyst)
Prada et al., 2015 2015 58 41 gliomas, 8 metastases, 6 meningiomas, 2 cavernomas, 1 ependymoma Evaluation of quantitative perfusion data in real time in both neoplastic (safe
tumor resection) and non-neoplastic lesions (biopsy guidance).
Lekht et al., 2016 2016 5 3 primary tumors (gemistocytic astrocytoma, glioblastoma multiforme, and meningioma), Identification of residual tumor mass to increase the extent of resection.
1 metastatic lesion (melanoma), and 1 tumefactive demyelinating lesion (multiple
sclerosis)
Prada et al., 2016 2016 10 GBM [3D iCEUS] Correct localization of the needle in intraoperative biopsy and
assessment of intraoperative resection control.
Arlt et al., 2016 2016 50 21 GBM (including 2 with recurrent tumors), 2 grade III astrocytoma (1 recurrent tumor), Evaluation of glioma borders; comparison of quantitative parameters among
4 with astrocytoma grade II, 2 oligodendroglioma grade II, 18 metastasis (1 recurrent glioma, peritumoral brain edema and normal brain tissue.
tumor) and 3 meningioma (1 grade I meningioma, 1 grade II meningioma, 1 recurrent
grade III meningioma).
L. G. Cheng et al., 2017 88 38 LGG and 50 HGG Differentiation of radionecrosis from tumor recurrence due to lack of CE.
2017
Mattei et al., 2017 2017 1 Metastasis (large-cell lung carcinoma) Demonstration of the overlap between iCEUS and pre-op CE T1 to identify
location, margins, morphologic features, and dimensions.
Del Bene et al., 2017 2017 10 GBM Information about tumor location, morphologic features, perfusion patterns and
tumor remnants in fusion imaging setting with MRI.
Wu et al., 2018 2018 15 Gliomas (tumor grading was not specified) Use in combination with US, color Doppler flow imaging and MRI in pre, intra
and post-op assessment.
Yan et al., 2018 2018 26 (RFA + Surgery N = 13, Meningiomas Association with CDUS to perform intraoperative embolization for a tumor and
Surgery N = 13) to provide real time data about the hemodynamic effects produced.
Della Pepa et al., 2019 1 Posterior fossa hemangioblastoma Comparison between real-time fusion imaging (CEUS+ MRI) and preoperative
2019 gadolinium-enhanced MRI in tumor identification.
Wu et al., 2019 2019 16 HGG Association with 5-ALA in HGG surgery, with improvement on the extent of
resection compared to standard microsurgery, CEUS or 5-ALA alone.
Della Pepa et al., 2019 49 HGG Evaluation of lesions according to their vascular pattern and degree of
2019 enhancement. Possible role in highlighting tumor remnants.
Clinical Neurology and Neurosurgery 198 (2020) 106105
 Table 2
Spinal tumors [3 papers].
AUTHOR YEAR N OF PATIENTS APPLICATION OBSERVATIONS

Vetrano et al., 2015 2015 1 Intramedullary hemangioblastoma Definition and localization of the lesion, enhancement of physiopathological aspects and achievement of complete resection without
unnecessary spinal cord manipulation.
G.M. Della Pepa, et al.

Vetrano et al., 2015 2015 1 Dorsal schwannoma Correct localization of the lesion as extramedullary and description of its perfusion pattern.
Della Pepa et al., 2018 2018 1 Dorsal hemangiopericytoma recurrence Real-time visualization of tumor characteristics, vascular patterns and potential residuals, all of them achieved through minimal exposure.

5
Table 3
Aneurysms, AVMs and AVFs [6 papers].
AUTHOR YEAR N OF PATIENTS APPLICATION OBSERVATIONS

Turner et al., 2005 2005 141 Aneurysms Comparison with DSA in assessing the long-term stability of the occlusion after endovascular treatment.
Hölscher et al., 2007 2007 11 6 MCA aneurysms Real-time study of fluid dynamics and demonstration of successful surgical intervention.
5 AVMs
Wendl et al., 2015 2015 12 Aneurysms Comparison with DSA in occlusion monitoring after endovascular treatment, demonstrating its supportive role because of micro
vascularization display.
Prada et al., 2017 2017 1 Spinal dAVF Pre and post-ligation real-time visualization of both fistulous site and blood flow changes occurring.
Della Pepa et al., 2018 2018 1 Spinal dAVF Integration with CDUS to identify of fistulous point and evaluate its correct occlusion.
Acerbi et al., 2019 2019 1 Fusiform partially thrombosed distal left MCA Synergistic intraoperative utilization with ICG-VA in studying parenchymal perfusion, aneurysm flow and occlusion.
aneurysm
Clinical Neurology and Neurosurgery 198 (2020) 106105
 Table 4
Cerebral perfusion assessment and acute stroke patients’ management [15 papers].
AUTHOR YEAR N OF PATIENTS APPLICATION OBSERVATIONS

Gerriets et al, 1999 1999 47 Various cerebrovascular condition Improvement of diagnostic potential of TCCS in patients with temporal bone window failure.
Federlein et al., 2000 2000 21 Patients Stroke Highlight of pathological brain tissue with possible implications in estimation of final infarcts size and clinical
G.M. Della Pepa, et al.

14 Control prognosis.
Seidel et al., 2003 2003 24 patients MCA stroke Recognition of stroke-related perfusion deficits areas.
Eyding et al., 2004 2004 4 Stroke Detection of pathological perfusion in acute stroke by means of the bilateral approach.
Kern et al, 200 2004 15 MCA stroke Accountability in combination with MRI and PWI both as a screening method and for follow-up assessments in
stroke unit patients.
Wiesmann et al., 2004 2004 23 MCA stroke Display of cerebral perfusion deficits in acute ischemic stroke, with PHI mode yielding additional information.
Kunz et al., 2006 2006 132 Evaluation of cerebrovascular Comparison with DSA results in a cohort of patients admitted because of ischemic symptoms ascribed to cerebral
symptoms arteries.
Eyding et al.,2006 2006 27 Stroke Evaluation of of bilateral PIHI in differentiating between infarcted at-risk tissue in acute stroke in patients with a
stable or improving clinical course at 12 h from onset.
Eyding et al., 2007 2007 34 Stroke Comparison of two serial UPI within the first 36h after symptoms onset to evaluate perfusion alterations in acute
stroke.
Meyer-Wiethe et al., 2007 2007 10 MCA stroke Employment of TIC as a parameter to differentiate normal and hypoperfused brain areas, comparing results with
MRI ones.
Kern et al., 2011 2011 23 MCA stroke Assessement of cerebral perfusion through the intact skull in a rt-UPI with a low MI setting.
Saito et al., 2013 2013 18 [11 healthy volunteer, 7 pts with ACA Brain perfusion Semiquantitative evaluation of brain perfusion and brain ischemia risk in patients with occlusive cerebrovascular
occlusion] disease in the anterior circulation.
Bilotta et al., 2016 2016 12 Acute ischemic stroke Assessment of brain perfusion changes after decompressive craniotomy and hemodynamic and ventilator
management strategies.
Reitmeir et al., 2017 2017 16 [Simbolo] out of 30 Acute MCA stroke Mismatch detection compared to the gold standard (CTP and MR), demonstrating high specificity and sensitivity.
E.J. Vinke et al., 2017 2017 Systematic review (43 studies included, Cerebral perfusion quantification Assessment of tolerability, repeatability, reproducibility and accuracy of different CEUS techniques, with
861 patients) limited data regarding techniques’ feasibility in acute brain injury patients.

6
Table 5
Carotid plaques [10 papers].
AUTHOR YEAR N OF PATIENTS APPLICATION OBSERVATIONS

Shao et al., 2014 2014 Retrospective study 74 Atherosclerotic carotid stenosis Feasibility as perioperative assessment method to decide whether carotid endarterectomy (CEA) or carotid stenting (CAS) should be
performed.
Ballotta et al., 2014 2014 57 Symptomatic low-grade carotid disease Analysis of carotid plaque morphology and characteristics.
Hamada et al., 2016 2016 55 Carotid plaques Comparison with US in carotid plaques’ rupture detection rate with ulcerated appearance on CEUS to histological fibrous cap
disruption.
Xiong et al., 2017 2017 115 Carotid plaques Correlation between degree of enhancement, immunohistochemical plaques parameters and serum high sensitivity C reactive protein
(hs-CRP) levels, suggesting a combined use in vulnerability evaluation.
Schmidt et al., 2017 2017 17 High grade internal carotid artery Feasibility in showing vulnerable plaques’ features such as: hemorrhage, inflammation, differentiation between symptomatic and
stenosis asymptomatic stenosis.
Oikawa et al., 2017 2017 70 Internal carotid artery stenosis Association of preo-op CEUS findings with the development of micro embolic signals on TCD during carotid artery exposure in
CEA.
Shimada et al., 2017 2017 Cross sectional 53 Carotid plaques Comparison and proof of its overlap with 3D MRI plaque imaging.
Amamoto et al., 2019 2019 97 Carotid plaques Evaluation of the relationship between intra-plaque vessels size and carotid plaque histology, showing a possible association with
plaque’s rupture and restoration.
Motoyama et al., 2019 2019 71 Carotid plaques Complementary use with MRI in pre-operative assessement of intraplaque neovascularization and hemorrhage.
Li et al. 2019 2019 91 Carotid plaques Evaluation of the relationship between carotid intraplaque neovascularization and ischemic stroke in TIA.
Clinical Neurology and Neurosurgery 198 (2020) 106105
G.M. Della Pepa, et al.
Table 6
Traumatic Brain Injury [2 papers].
AUTHOR YEAR N OF PATIENTS APPLICATION OBSERVATIONS
Heppner et al., 2006 2006 6 TBI Intraoperative evaluation of cerebral perfusion and postoperative assessment of both the effect of
decompressive surgery and the responses to therapies aimed at preventing secondary ischemia.
He et al., 2013 2013 32 TBI Assessment of its effectiveness compared to iOUS in classifying and in treating TBI.
4. Discussion
4.1. CEUS in neurosurgery: general observations
Standard B-mode ultrasound has been present since several years in
many neurosurgical operating rooms: it represented de facto one of the
first tools to study anatomy through unexposed, hidden, parenchymal
tissue. For this reason, it is incorrect to classify ioUS/CEUS use as an
innovation, being it more a rediscovery: ioUS has been employed in
neurosurgery since the 1960s [68] and it granted intraoperative ima-
ging and navigation well before more evolved technologies, such as
intraoperative CT (iCT), intraoperative MRI (iMRI), ICG-VA and navi-
gation, were broadly available.
Nonetheless, significant limitations of ioUS as a reliable and feasible
application in neurosurgery were represented by both imaging inter-
pretation, unfamiliar to neurosurgeons, and artifacts related to ma-
nipulation. Good evidence of this is that as surgical resection advances,
the ioUS image quality decreases: due to surgically-induced artifacts
and edema, imaging interpretation becomes challenging [69]. More-
over, all information provided by ultrasound (US) relies on echogenity
of insonated structures: no dynamic information, such as overall vas-
cularization, is given through standard B-Mode ultrasonography.
Even though the aforementioned limitations could have prevented
further research, major technological advancements in the US field,
such as image fusion for navigation, CEUS, and elastosonography have
been developed; new applications in their usage in neurosurgery, al-
though on a small scale, have constantly been achieved and reported in
recent years [11,16,70–72].
Being capable of highlighting tumor tissue not relying on its echo-
genicity but on its vascularization, CEUS has been specifically found to
be a versatile innovation. Introduced in other medical branches, such as
hepatic oncological surgery, the technique is feasible in both diagnostic
and intraoperative settings: it allows practitioners to differentiate be-
tween benign and malignant lesions, helps in localizing the target and
controls treatment efficacies [1,11].
On the heel of these observations, CEUS intraoperative experiences
have been borrowed to neurosurgery to overcome the strains of stan-
dard B-Mode US imaging.
CEUS is a harmonic imaging modality that depicts the distribution
of microbubbles contrast agent in tissues. Thanks to their structure,
sulfur hexafluoride–filled lipidic microbubbles cannot diffuse to the
interstitial space, giving a representation of the vascular district only.
The degree of contrast enhancement is a consequence of the density of
the capillaries, which in turn is proportional to tissue activity [11,73].
Microbubbles are visible through a contrast-specific algorithm that
permits a real-time assessment of contrast-enhancement (CE), mea-
surement of vascularity of focal lesions during different dynamic
phases, and analysis of tissue perfusion; CEUS algorithm suppresses the
linear US echo, thus producing a specific representation only of the
microbubbles. In other words, images are a direct representation of
vascularization and become independent from tissue echogenity.
Furthermore, microbubbles, being micron-sized, are not able to extra-
vasate from vessels and behave as a purely intravascular contrast agent,
allowing to study all vascular tree districts: arterial, venous, and ca-
pillary [11,74]. On these bases, CEUS has been introduced in neuro-
surgery for the intraoperative visualization of brain tumors: it is a dy-
namic modality which permits to visualize them according to their
7
Clinical Neurology and Neurosurgery 198 (2020) 106105
degree of vascularization [10,69].
This first application has led to the following use in a variety of
neurosurgical fields. As shown in the herein presented review, con-
sistent literature has been published describing CEUS use in settings
other than cerebral neurooncology, including spinal oncology, vascular
neurosurgery (cerebral and spinal), TBI, pediatric and peripheral nerve
surgery. A review of the various possible field of application has been
recently published by Kearn et al. [75], maily focusing on oncological
and vascular applications. However, recent experiences, in some cases
pivotal, display possible CEUS applications in a variety of other set-
tings, including transfontanellar studies in pediatrics, intraoperative
guidance for embolization, TBI, peripheral nerve and spinal cord on-
cology that will herein discussed.
Besides their undisputed value, traditional intraoperative imaging
techniques (CT scan and MRI) have several limitations, including costs,
temporary stop of surgical procedure and time wasting. These im-
portant strains make iCT and intraoperative iMRI hardly repeatable
during surgery [76].
Conversely, as demonstrated by several experiences, CEUS/ioUS is a
feasible intraoperative imaging technique, as it is readily repeatable,
dynamic, inexpensive and provides a truly real-time dynamic visuali-
zation of anatomical characteristics and vascular patterns in several
neurosurgical settings. Assessment is rapid, can be performed any time
during surgery, and is independent of brain-shift [1,26,27,33,72].
Moreover, microbubbles do not only allow the visualization of high
definition intraoperative images after craniotomy, but, as reported
later, can enhance the resolution of intracranial arteries also in tran-
scranial studies at bedside [30–32]. In fact, alongside the main in-
traoperative role, which exploits the craniotomic window to overcome
the relative impermeability of the cranial theca, and that provides with
excellent image resolution of the entire intracranial space, it seems
appropriate to highlight the potential role of transcranial CEUS also as a
bedside technique. It has been proposed as an attractive technique
because it is non-invasive and has high temporal resolution. Given the
nature of the technique, both accurate diagnosis and serial monitoring
of perfusion abnormalities are feasible, for example in critical care
settings.
However its bedside application has important disadvantages and
drawbakcs compared to the traditional intraoperative use. First, the
performance and interpretation of bedside CEUS exams would require
proper training for technologists and radiologist, a limitation shared by
its routine application in an intraoperative setting as well. Second,
several requirements need to be met before such a technique can be
implemented in a critical care effectively: repeatability and reproduci-
bility of the techniques are strongly affected by subject-related char-
acteristics, namely attenuation of echo signal by the skull, hetero-
geneity of the temporal bone density and physiologic fluctuations of
cerebral perfusion, which can seriously affect the quality of the as-
sessment.
Nevertheless, beyond perfusion studies, recent and preliminary ex-
periences have shown how CEUS can improve the quality of images
through the transcranial window acting as a parenchymal 'contrast'
emphasizing sulci, cisterns, ependymal spaces and therefore improving
the interpretability of this type of imaging also in the identification and
follow-up of brain organic pathologies.
Fig. 2 summarizes the major fields of application of CEUS in neu-
rosurgery from the herein presented review.
G.M. Della Pepa, et al. Clinical Neurology and Neurosurgery 198 (2020) 106105

4.2. Cranial neuro-oncology

Assessment of neonatal brain perfusion at the time of injury, during resuscitation, and hours after resuscitation, with improved detection of symmetric

Demonstration of altered perfusion pattern in the central gray nuclei and cortex. Possible use as a diagnostic tool to identify infants with HII at risk for
The use of CEUS during neuro-oncological procedures has been
recently included in the guidelines from the European Federation of the
Societies for Ultrasound in Medicine and Biology (EFSUMB), re-
presenting a paradigm shift for the use of US in neurosurgery [77].
Brain death diagnosis’ confirmation in infants with open fontanelles through qualitative and quantitative assessment of brain perfusion.
In comparison with other imaging modes, CEUS showed itself as a
rapid, practical, and cost - effective technique, suggesting additional
and alternative information about brain tumor vasculature and perfu-
sion, being B mode limited in providing only morphological informa-
tion regarding the lesion. In their seminal study, Prada et al. [78] de-
monstrated how once enhanced, the tumor is highlighted and reveals
Feasibility as a bedside alternative modality in assessing neonatal brain injury, with good results compared to MRI.

other specific characteristics of both Low Grade Gliomas (LGGs) and

HGGs.
LGG show a mild, dotted CE with diffuse appearance and blurred
margins. Arterial feeders are usually not identifiable, microbubbles
transit is regular and organized, venous drainage is diffuse through
numerous capillaries and consequently not discernible [79]. Relying
not on its echogenicity but upon vascularization, CEUS proved to be
particularly valuable in differentiating oncological tissue from sur-
rounding edema, thus helping in depicting the true limits of infiltration
[9,79,80].
HGG have a high CE with a more nodular, nonhomogeneous ap-
pearance and fast perfusion patterns¸ with a rapid CE, marked by rapid
arterial phase, very fast CE peak, and chaotic transit of microbubbles
within the lesion. The arterial supply was clearly visible, showing many
macrovessels within the lesion and a typical peripheral enhancement
that moved toward the inner areas of the lesion. The venous phase was
rapid (5–10 s), and the venous drainage system was diffuse, with
multiple medullary veins aiming toward the periventricular zone. CEUS
in HGGs is useful in differentiating solid from cystic components. In the
specific case of glioblastoma (GBMs), CEUS CE is consistent in pro-
liferating areas and, on the contrary, no CE at all is seen in necrotic
zones and surrounding brain parenchyma. Two CE patterns are iden-
tifiable in GBM: (1) heterogeneous with nodular high CE spots inter-
spersed by low-CE areas of necrosis and (2) peripheral rim CE sur-
global perfusion abnormalities.

rounding a central core of necrosis without CE. In all cases, GBM shows
a clearly demarcated border after UCA administration due to the dif-
permanent brain injury.

ferent vascularization of the tumor and healthy brain parenchyma [78].

The extent of resection is nowadays a well established determinant
OBSERVATIONS

for prognosis in HGG patients. Highlighting the residual tumor tissue

with great accuracy and overcoming the difficulties of ultrasound in-
terpretation caused by artifacts, edema, and surgical manipulation
[1,10,81], CEUS has been demonstrated valuable in guiding tumor re-
section and embodies one of the most recent innovations in HGGs
surgery.
Brain death diagnosis
Neonatal brain injury

Furthermore, in a series of publications, CEUS showed its capability

in identifying tumor remnants after HGG surgery [1,9,10]. These are
APPLICATION

Neonatal HII

Neonatal HII

generally defined as nodular tissue at the edges of the surgical cavity,

depicting an early and persistent enhancement, compared to sur-
rounding brain parenchyma. Because of artifacts due to surgical ma-
nipulation, B-mode evaluation alone can show unclear results if per-
N OF PATIENTS

formed after neurosurgical resection. In the advanced phase of surgery,

CEUS can fill the gap left by ioUS, guiding the surgeon also in the final
survey at the end of the procedure [82]. Moreover, US is independent of
brainshift and this grants useful information to surgeons throughout the
12

procedure also in advanced phases of resection, such as final survey at

2

the end of the procedure.

YEAR

2014
2017

2018

2018

Della Pepa et al. [1,83] recently published an institutional series:

Pediatrics [4 papers].

CEUS potential in detecting inadvertent residuals proved particularly

Hwang et al., 2018)
Hwang et al., 2017

Hwang et al., 2018

Kastler et al., 2014

effective in a 5-ALA guided setting, where the resection is built with the
5-ALA assistance, and CEUS supplementary supports the surgeon by
providing information before and after resection. Incomplete resections
AUTHOR

also in a 5-ALA setting can indeed result from residual tumour covered
Table 7

by blood, cottonoid, or overlapping normal brain: in these scenarios it

does not light up under blue-light conditions and can be missed [79].

8
G.M. Della Pepa, et al.
Table 8
Peripheral nerves surgery and other applications [4 papers].
AUTHOR YEAR N OF PATIENTS APPLICATION
Loizides at al., 2012 2012 2 Musculoskeletal masses evaluation (1 Schwannoma, 1
Peripheral nerve sheath tumor)
Pedro et al., 2015 2015 3 1 MPNST
1 Extrapleural SFT
1 Ancient schwannoma
Becker et al, 2012 2012 6 EVD
Venturini et al., 2015 10 Uveal melanoma
2015
Moreover, in deep fields or conditions of non-orthogonal working cor-
ridors, microscope light might fail to thoroughly illuminate the surgical
field, resulting in blind corners facilitating a partial removal. Thus,
CEUS final survey has a role of refinement of the 5-ALA procedure by
identifying sub-centimetric remnants. The two techniques approach the
surgical field from a different point of view: 5-ALA fluorescence is a
result of direct microscope illumination, whereas ultrasounds in-
vestigate through brain tissue, depicting also distant, unexposed,
hidden cerebral or neoplastic anatomy. Indeed, they observe two dif-
ferent phenomena: 5-ALA is an expression of glial cell metabolism,
whereas CEUS is a consequence of pathological tumour vascularisation.
When integrated, these complementary techniques increase the chance
of identifying neoplastic residual tissue. This is especially true when
tumors are multilobated, display an irregular shape or deeply lo-
cated83].
CEUS assisted intraoperative imaging does not modify the overall
surgical procedure, as it does not interrupt the central phase of surgery
and the overall surgical strategy, is not time demanding and does not
require expensive equipment; these considerations are surely im-
portant, especially when compared with other intraoperative imaging
techniques.
Also, CEUS provides other valuable information to identify vascular
supply, giving further insight into the surgical strategy, facilitating
vascular deafferentation and removal, thus maximizing resection
voiding neurological sequelae resulting from damaged healthy brain
tissue or vessels [14].
Serious weaknesses of CEUS in vascularization assessment are: angle
of insonation susceptibility, low flow veins not always visible, small
vessels overestimation due to blooming artifacts that scatter color
Fig. 2. Diagrammatic representation of the fields of application of CEUS in neurosurgery.
9
Clinical Neurology and Neurosurgery 198 (2020) 106105
OBSERVATIONS
Definition of perfusion pattern types as a diagnostic tool to
differentiate malignancy.
Enhancement of the differential diagnostic potential in respect to
ultrasound.
Bedside measurement of ventricle width, ventricle
communication, and CSF transfer in critically ill patients.
Quantitative assessment of UM vascularization and perfusion
monitoring of the lesion after GKR.
signals nearby the vessel margins [16]. Possible limitations in the as-
sessment of resection margin are: evaluating the tumor removal degree
of patients with recurrent gliomas or patients with gliomas after
radiotherapy [3] as proven by Yu on 120 patients.
CEUS can also be compared with pMRI in both preoperative and
postoperative setting: Prada et al. [12] demonstrated how US offers a
morphologic representation of GBM similar to the one provided by
preoperative gadolinium- enhanced T1-weighted MRI. However, it is
important to keep in mind how the presented results show some lim-
itations, namely a possible inclusion bias (being a retrospective study)
and a qualitative analysis based on a subjective evaluation of the
overlap between the two imaging modalities. Harrer et al. compared,
instead, CEUS with pMRI in a postoperative setting [5,19]: they sug-
gested it as a cost -effective method in evaluating changes in tumor
vascularity during the follow-up period in patients with brain tumors
who are undergoing radiotherapy, chemotherapy, or antiangiogenic
therapy.
When combined with fusion imaging including US with MRI, CEUS
has several advantages over B mode alone [22,23]: 1) detection of poor
sonographic visibility tumor 2) better recognition of the tumor and
edema tissue compared with reconstructive preoperative coplanar en-
hanced MRI in real time and multiplane from different angles 3) ap-
plication by neurosurgeons who lack the expertise in US technology as
an easier way to discern the structure of the brain 4) improved or-
ientation and compensation for the brain shift. However, there are some
strains that may weaken these results: 1) small sample sizes 2) suit-
ability for mainly solid component brain tumors than mainly cystic
component ones due to the deformation after the cranial bone is opened
in the latter.
G.M. Della Pepa, et al.
Some recent reports highlighted other potential applications of
CEUS in cranial oncological surgery, although these experiences are still
anecdotal with few cases reported. Apart from the evaluation of in-
traoperative resection control, CEUS has been used as biopsy guidance
to correct localize the needle and target the most representative sam-
ples for pathology [17,18] or to guide and assess hemodynamic effects
after intraoperative embolization of highly vascularized tumors such as
hemangioblastomas [14,72]. In addition, CEUS use can space from a
bedside technique adding helpful information not only in noninvasive
staging of tumors but also in differentiating tumor recurrence from
radionecrosis as postulated by Vincenzini et al. [6] and Mattei et al. [7];
relying on microbubbles diffusion through vascularization radio-
necrosis shows a completely different, poorer, enhancement patter
compared to HGGs.
CEUS has thus proven its utility in:
1) highlight tumors and their phases compared to brain parenchyma
[5],
2) characterize glioma grade [8,9,78],
3) assess vascularization and degree of overall perfusion [9,78],
4) show vascular rearrangement that takes place with tumor removal
[16],
5) highlight residual tumor (especially feasible in a 5-ALA setting)
[1,3,9],
6) aid surgical decision making through serial imaging assessment of
surgical anatomy [2,5,17,19],
7) help in differential diagnosis of radionecrosis with neoplastic tissue
due to its lack of contrast enhancement [6,7],
8) guide to intraoperative biopsy and tissue sampling [17,18].
In conclusion, the role of CEUS in brain neuroncology is now well
defined and experiences in this sector are no longer considered pioneer.
There is now a consolidated literature on the subject, and more and
more centers are using this method as a 'support' to traditional surgery.
It appears to be valuable especially in a multimodality imaging context
where different methods to ‘enhance vision’ merge multiple source in-
formation. Along with other advanced vision modalities (such as 5-ALA
and fluorescein), the micro-bubbles play a fundamental support both in
preliminary and finishing stages of surgery.
In addition its integration with other advanced ultrasound methods
(such as intraoperative brain elastographic studies in low grade gliomas
or focal ultrasonography to enhance direct delivery of chemotherapics)
might prove determinant advancements in the treatment of low and
high grade gliomas in the future.
4.3. Spinal tumors
Primary spinal tumors are relatively rare lesions, for which MRI
represents the gold standard for diagnosis. Nevertheless, MRI may not
always differentiate accurately between different types of in-
tramedullary tumors: even if not well defined nor standardized, the role
of CEUS in this surgical field appears as a problem solver. Even though
a small number of cases was reported, it has proven to be a simple and
relatively inexpensive technique representing a real-time dynamic
procedure that can be performed during spinal tumor surgery. Its
benefits include:
1) better characterization of the location of the intramedullary lesions
[24,25];
2) easier identification of vascular structures, giving further insight in
vascular deafferentation and then surgical removal [24–27];
3) possible combination with color-Doppler to better identify the main
arterial feeders and draining vessels [26,27];
4) as for HGG surgery CEUS helps in the identification of inadvertent
remants [26].
10
Clinical Neurology and Neurosurgery 198 (2020) 106105
Important drawbacks in this setting are:
1) possibility to analyze one portion of the lesion at the time;
2) reduced visibility of low-flow veins and possible overestimation of
small vessels due to blooming artifacts;
3) less defined imaging due to a reduced depth of the explored surgical
field compared to brain surgery [26,27,33].
In the spinal oncological context that this method appears particu-
larly promising. Although studies in this specific field are still extremely
limited, it appears significant the possibility of an easy integration with
other US tools, to evaluate, as an example, the vascularization of the
‘healty’ cord and the tumor-cord interface. It is a matter of fact that
these two factors are paramount determinants in spinal cord oncolo-
gical surgery. Hence, CEUS dynamic flow data, integrated with the
power- and color-doppler information are of undisputed value in lim-
iting vascular sequelae. Moreover, in spinal cord surgery it is particu-
larly relevant to correctly assess the tumor-cord interface (discrete vs
diffuse) and to limit the 'blind manipulation' of delicate structures. The
intrinsic US ability to 'see through the cord’ enables to identify relevant
anatomy without exposing it; this appears definitely relevant in a sur-
gery with limited working spaces limited margins for safe manipula-
tion.
Furthermore, the increasing miniaturization of the US probes will
certainly ease and further boost this instrument in spinal cord surgery.
4.4. Aneurysms, AVMs and AVFs
Providing an angiogram-like display of the parent and downstream
vessel segments in high spatial resolution, CEUS might be a feasible tool
for both aneurysms and AVMs treatment. Indeed, it could implement
their intraoperative management by providing real-time imaging: this is
true both in the visualization of the vascular supply before the inter-
vention and in flow assessment at the end of the procedure [29]. Fur-
thermore, since it allows the identification of target vessels even when
covered by brain parenchyma, it could be synergistically used with ICG-
VA (which relies on direct vessels visualization) in situations in which a
complex approach is required.
Focusing on aneurysms, CEUS was found particularly useful in oc-
clusion follow-up after endovascular treatment. As opposed to neuro-
oncological setting, in which CEUS examination can be performed only
after craniotomy, in the vascular setting, it can amplify vessels resolu-
tion also during transcranial examination. Turner et al. [30,31] pub-
lished a large series of both unenhanced and enhanced ultrasound
transcranial examinations after cerebral aneurysm coiling. Their con-
clusion was that CEUS could be used to selectively monitor intracranial
aneurysms and, if compared to DSA, is better in detecting refilling rate
in aneurysms with a minor neck remnant. In the end, they suggested to
perform trans cranial color coded duplex sonography (TCCS) ex-
amination with contrast enhancement at the time of initial surveillance
with DSA and, if findings were similar, to undertake an additional
follow-up by TCCS alone until changes in aneurysm status. Authors
underlined that a transcranial examination is cost-effective, rapid, ea-
sily repeatable and feasible compared to standard DSA or angio-MRI
monitoring.
A later study with a smaller sample size (12 cases) was published
with an important difference: in this case, they used only CEUS [32].
They evaluated the occlusion rate using a four-point grading system,
showing a high degree of agreement between CEUS with a matrix probe
and DSA: this confirmed CEUS ability to resolve small remnants when
DSA showed complete occlusion. They pointed out its several ad-
vantages as well [30,32]:
1) accurate display of flow direction and velocity
2) increased focus and resolution, allowing detection of very low flow
as often presented in coiled aneurysms
G.M. Della Pepa, et al.
3) the possibility to be performed immediately as a control examina-
tion in the intensive care unit (ICU)
4) less severe metal artifacts compared to other imaging modalities.
The main drawback underlined in both papers was the limited
acoustic window in aneurysms located outside the Circle of Willis, de-
spite the introduction of contrast agent [30,31].
In dAVFs surgery, both cranial and spinal, one of the most important
steps is the correct identification of the fistulous site. In the two re-
ported cases [33,34], CEUS allowed both pre- and post-ligation real-
time visualization of site of the fistula and blood flow changes occurring
in the spinal cord and peri-medullary plexus. Not only does it en-
compass the limitations of Doppler imaging, which can be used si-
multaneously to confirm the type of flow and flow dynamics, but as
already in the case. of aneurysms, it might be integrated with other
imaging modalities such as fluorescence [29,68]. However, larger series
are needed to determine the significance of this tool in the obliteration
of intradural spinal dAVFs [29].
As a matter of fact, in vascular neurosurgery the possibility to have
rapid, easy, and real-time information about flow is paramount. As
discussed other methodologies such as ICG-VA fail in providing in-
formation about distant and non-exposed districts, as well as to provide
a general glance.
The future challenges in the vascular context will be to provide a
semi-quantitative information about flow, along with a feasible, dy-
namic quality of information similar to intraoperative DSA.
In AVM surgery there is recently fervor about CEUS application in
identifying feeders from by-standers vessels (also deep and unexposed)
and provide overall information about devascularization of the whole
malformation and restored regular flow in draining veins before com-
pleting AVM resection.
4.5. Cerebral perfusion assessment and acute stroke patients’ management
An adequate supply of blood containing oxygen and nutrients is
crucial for the recovery and survival of brain tissue. Monitoring of
cerebral perfusion is essential in the prevention of secondary brain
damage in patients with acute brain injury. CEUS has been suggested as
a new method to measure cerebral perfusion in patients both with acute
brain injury at the ICUand in the acute state of cerebral ischemia. In
their systematic review Vinke et al. [35,84] acknowledged it as non-
invasive, has high temporal resolution technique which can be used at
the bedside; moreover, the contrast enhancement can be used for vi-
sualization of the cerebral vasculature to overcome the restricted level
of acoustic intensity. They analyzed many studies which compared
CEUS with MRI or CT for the detection of regions of ischemia, with
acceptable sensitivity and specificity. However, their main criticism
was related to the paucity of data they collected on its repeatability,
reproducibility, tolerability and accuracy of the semiquantitative ap-
proach, not to mention their heterogeneity when it comes to the results.
Moreover, they challenged the incomplete description of the technique
in several of the studies on the grounds that most of them concentrated
on the detection of hypoperfusion of the brain, while hyper-perfusion
may be as deleterious as hypoperfusion; indeed, in this context the
accuracy of CEUS for the detection of hyperperfusion has not yet been
assessed.
This aligns with the idea that for patients after ischemic stroke,
CEUS may serve as an additional clinical tool for the bedside evaluation
of brain tissue perfusion and response to recanalization therapy, with
more efforts to be made to improve its reliability [37–39]. However,
when it comes to this clinical application, two key problems arise:
1) Eyding et al [41–43] pointed out how different protocols were used
by the involved research groups and, more crucial, patients pre-
senting with acute stroke were examined at different time windows.
2) Being patients with insufficient insonation conditions were excluded
11
Clinical Neurology and Neurosurgery 198 (2020) 106105
in advance, remains questionable the percentage of stroke patients
for which the technique could represent a consistent improvement.
Indeed, in cited studies [37–39] one of the inclusion criteria was a
sufficient temporal acoustic window for conventional transcranial
color-coded sonography.
On a technical note [42,43], with the use bilateral approach two
advantages were met in comparison with the ipsilateral: cortical
structures can be evaluated, and only one examination is needed to
compare unaffected (ipsilateral) with affected (contralateral) tissue.
Besides, it was demonstrated how performance of real-time refill ki-
netics is relatively simple as compared with previous ultra-sound
methods. The adoption of this approach avoids the shadowing effect, a
significant problem associated with high MI imaging [40,46].
When evaluating its diagnostic reliability, Kunz et al. [44] found an
excellent specificity, as well as positive predictive value and an overall
high sensitivity compared to DSA. However, the dependence of visua-
lization of the distinct intracranial arterial segments on their diameters
was addressed as a potential pitfall of the technique, being its sensi-
tivity slightly lower for patients with vertebrobasilar pathologies.
Moreover, further notes have to be made on the population from which
the results were obtained: 1) patients were admitted with acute is-
chemic stroke symptoms and had slight-to-moderate neurologic deficits
2) preponderance of men 3) only Caucasian individuals were included
4) contrast was administered to all patients regardless of their bone
windows, opposite to what done in other studies [37–39].
Besides this, the ability of time intensity curve (TIC) measurements
to differentiate between normal and hypoperfused brain areas in acute
ischemic stroke using MRI (perfusion weighted imaging (PWI)/diffu-
sion weighted imaging (DWI)) as a reference value [45] was evaluated.
It resulted in a correct qualitative characterization of regional cerebral
blood flow (CBF) and suitable for a simple classification (normal versus
pathologic perfusion), even if the implementation of the TIC variable
thresholds in parametric imaging should be preceded by further studies
in the field.
Reitmer et al. [47] focused on the potential of the method in de-
tecting mismatch. The advantages are: portable diagnostic tool; exclu-
sion of hemorrhages and confirmation of hypoperfusion and thus
ischemia on site; possible application especially in prehospital stroke
management, demonstration of favorable comparison with the gold
standard pCT and pMRI. However, drawbacks of its application include:
an investigation performed on a highly selected group of patients,
methodological limitations with respect to the gold standard (2D ima-
ging plane), impossibility to perform a stable angle of insonation in 20
% of patients due to their confusional state.
As a last note, CEUS can be used as a follow-up strategy in stroke
patients: it is a fast and repeatable bedside technique [48]. However,
these potential advantages are undermined by: 1) small sample of the
study run by Bilotta et al. [48]; 2) non- validated comparison with the
other imaging technique already in use in this particular area; 3) need
for specific ecographic equipment.
4.6. Carotid plaques
Carotid atherosclerotic disease represents a major current health
problem accounting for approximately 20 % of all cases of cerebral
ischemia. Risk stratification and patient management is traditionally
based on the presence or absence of symptoms and the degree of ste-
nosis, both of which have been found to correlate with the occurrence
of stroke. US is the cornerstone of both screening and diagnostic ap-
proach of carotid disease and introduction of CE has been providing
promising results, leading to the publication of recommendation of use
[77,85]. As well summarized by the Rafailidis et al [85] in their review
of the literature, an impressive number of works demonstrated CEUS is
a feasible and effective tool to:
G.M. Della Pepa, et al.
1) Analyze plaque morphology and characteristics [52],
2) Identify vulnerable plaques and detect neovascularization
[53–55,86],
3) Perioperatively assess the procedure to be performed [49–51].
Moreover, it was recently published a comparison and a proof of the
relationship between CEUS and 3DT1-WI MRI plaque imagining [56].
However, on board with the purpose of this review, we decided to focus
only on those works in which was analyzed a prospective relationship
between CEUS on carotid intraplaque neovascularization and ischemic
stroke. Li et al. [87] found out the grade of contrast enhancement was
an independent risk factors for ischemic stroke or recurrent TIA in
population of 91 TIA patients with a 24-month follow up. Therefore, the
grade of CEUS contrast enhancement could become a predictive indices
of ischemic stroke, identifying those patients in need of an effective
treatment. A potential source of bias coming from the exclusive selec-
tion of large plaques, a semi-quantitative grading system and a rela-
tively small sample size are however important limitations associated
with this finding. Hence, CEUS might prove in the future as a reliable
method for carotid plaques diagnosis and follow-up, especially if this is
integrated with the other common modalities readily available such as
color-doppler ultrasound, providing physician with some extra in-
formation compared to the standard carotid US evaluation that is
nowadays used.
4.7. TBI
TBI has a high death rate and incidence of disability. The condition
of brain trauma patients can change quickly so that they can become
critically unstable in a very short time due to anatomic and patho-
physiologic processing of brain trauma. The series by He et al. [57],
addressed CEUS potential to improve accuracy in the classification of
TBI and showed it can overcome the main limitations of ioUS such as
characterization of complex brain damage and viability of brain tissue
near the trauma lesion, resulting in broadening of the planned surgical
intervention. However, a weakness of the study is the lack of analysis of
correlations between absolute peak intensity (API) in CEUS and re-
covery in postsurgical longitudinal follow-up.
Not to mention, the secondary insults accompanying the initial
brain trauma are those that modern neurosurgical care intends to
minimize. Although intracranial pressure (ICP) and cerebral perfusion
pressure (CPP) measurements provide prognostic value in patients with
TBI, they do not directly measure temporal changes in CBF that occur
during secondary injury, suggesting individualized management based
on a serial assessment of regional and global CBF as more feasible.
Heppner [58] demonstrated the effectiveness of CEUS in characterizing
flow abnormalities and measuring how they were affected by inter-
ventions. Suggesting the suitability of the technique, the paper doesn’t
fail to highlight an important limitation: in the small number of patients
enrolled, a serial imaging was performed only through a craniectomy
defect or a burr hole.
Interestingly, the microvascular blood flow evaluated by pre-
operative CEUS was lowest in the one patient in whom neurological
deterioration continued after surgical intervention, but the study was
underpowered for the assessment of long-term outcomes.
4.8. Pediatrics
Neonates presenting with neurologic symptoms require rapid, non-
invasive imaging with high spatial resolution and tissue contrast. MRI is
currently the most sensitive and specific imaging modality for evalua-
tion of neurological pathology in neonatal intensive care unit (NICU) 67
Kastler et al. [60], recognizing the several challenges of this mod-
ality in the neonatal population, tried to overcome them by the use of
CEUS as a tool which could possibly allow bedside diagnosis, improving
the sensitivity and specificity of cranial US without contrast.
12
Clinical Neurology and Neurosurgery 198 (2020) 106105
Nevertheless, they pointed out a series of limitation apart from
those inherent small sample size (N = 12) and retrospective studies: the
results were not always homogenous with MRI and the delay between
the two was not comparable in all the cases; plus, the comparison with
Doppler color US was not possible. Narrowing the field from the use of
CEUS in the diagnosis of neonates with various neurological conditions
to its application to neonates with suspicion of HII, further considera-
tions are necessary. A refined diagnostic technique for identifying those
at greatest risk for hypoxic ischemic brain injury is necessary to ade-
quately target neuroprotective therapies. In their pilot study on 8 pa-
tients, Hwang et al. [62]. found out how perfusion pattern in the central
gray nuclei and cortex was altered in the setting of HII, presenting the
first perfusion maps of the neonatal and infant brain based on the de-
rivation of quantification parameters from the microbubble wash-in
curve. In addition to this, when central gray nuclei – to – cortex per-
fusion ration was plotted for all time points along with the time- in-
tensity curve, it was observed that the affected cases showed a quali-
tatively different trend from that of the normal cases. However, firm
conclusion can’t be drawn due to: 1) sample, which was small and re-
cruiting only infants with open fontanels, without taking into account
others factors such as age stratification, injury type and injury duration
2) use of different scanners and transducers which could have biased
interpretation 3) discordant findings with MRI results in 2 cases.
If we move from CEUS application as a diagnostic tool to its use in
the serial assessment of neonates with a pre-existing diagnosis of HII,
Hwang [62] et al. synthesized its main advantage in their study (N =
2): it meets the need for monitoring dynamic perfusion changes in a
bedside and convenient setting. However, they didn’t fail to notice how
implementation of CEUS in the imaging is not without challenges, both
from technical and practical point of view. Indeed, all the aforemen-
tioned studies agree on acknowledging that [59,61–63]:
1) predictive value of the main parameters assessed (wash-in slope,
area under the curve, time to peak, mean transit time) will need to
be validated in correlation with reference standard MRI
2) the 2D nature of the exam is an important limitation
3) the performance and interpretation of brain CEUS exams would
require proper training for technologists and radiologist, while an
alternative diagnostic tool, such as ultrafast Doppler, may be per-
formed more easily also by a generalized practitioner without the
need for a properly trained expert, 4) parental consent in a situation
of emotional burden could reveal itself as a challenge.
Bedside CEUS, as a future application, might potentially replace CBF
and cerebral angiography to confirm the diagnosis of brain death in
infants. Moreover, its feasibility in the delineation of the extent of in-
tracranial hemorrhage, focal lesion evaluation, optimization of the
shunting time in post hemorrhagic hydrocephalus (a major complica-
tion of intraventricular hemorrhage, whose risk is very high in pre-
mature babies) has been postulated but not yet studied [59].
On final technical side note, if the effectiveness and safety of US
contrast media in patients > 18 years has recently been evaluated; an
interesting open question is represented by the dose of contrast-agent to
use in children. As a matter of fact standard B-mode US (without CEUS
injection) in pediatric neurosurgery is widely used. The possible in-
troduction of CEUS in pediatric patients could lead to that same robust
application that has been observed over the years in adult cranial and
spinal neuro-oncology
4.9. Peripheral nerve surgery and other applications
Musculoskeletal tumors are frequently encountered in everyday
practice. Despite substantial progress in diagnostic imaging, however, a
correct diagnosis in terms of tumor subtype and definition of malignant
potential is rarely achieved based on imaging alone. Therefore, many
patients undergo guided or open surgical biopsy. With improved
G.M. Della Pepa, et al.
imaging, this might be avoided in some cases. If MRI remains the
technique of choice for the local staging of proven malignant soft-tissue
tumors, the inclusion of CEUS in the work-up can serve as a new, fast-
forward diagnostic tool also in an intraoperative setting [64,65]. As
already said before, the enhancement seen with MRI is completely
different from enhancement seen with CEUS: gadolinium-based con-
trast media leak from the vasculature into the tumor interstitium, while
ultrasound micro-bubbles are truly intravascular contrast agents that do
not extravasate, better reflecting the angiogenic activity and the ma-
lignant behavior of these tumors. However, the limited set of data is a
serious weakness of both studies on the topic [64,65].
When it comes to new approaches, CEUS was shown to be a reliable
tool for the evaluation of tumor response after radiation treatment, such
as in the case of UM [66]. Its main advantages were the assessment of
quantitative perfusion parameters, mandatory in small tumor such as
UM, and being a minimally invasive, well-tolerated technique of proven
safety. Then again, the main limitations of the study are small cohort of
patients enrolled and the relatively short follow-up.
Even if on a limited number of patients (N = 6) as well, it is worth
mentioning also the study done by Becker et al. [67] on bedside CEUS
during external ventricular drainage weaning. In these cases, CT is
necessary but intra-hospital transfer of critically ill patients is asso-
ciated with a higher mortality, is time-consuming and labor-intensive:
bedside techniques are thus desirable to evaluate ventricle width.
Transcranial sonography can show the ventricles in patients with suf-
ficient temporal acoustic window, with CEUS overcoming the limita-
tions of insufficient insonation. That being said, its main drawbacks
must be taken into account: it should be performed only by experienced
investigators and 30 min of closed observation for adverse effects are
strongly recommended after CE administration.
5. Conclusions
From our review of the pertinent literature, we can conclude that
CEUS has reached in recent years a wide utilization in various neuro-
surgical fields, mainly in neuro-oncological surgery. Despite its main
limitations in being an operator-dependent technique and its shared
drawbacks with US technology, it revealed itself as a promising tool:
CEUS is comparable and complementary to traditional imaging tech-
niques, allows for a serial assessment, is easily performable in different
settings and has a wide range of future applications yet to be explored.
Declaration of Competing Interest
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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