Surgical Workflow Analysis: Ideal Application of Navigated Linear Array Ultrasound in Low-Grade Glioma Surgery

Background Intraoperative imaging in low-grade glioma (LGG) surgery can facilitate residual tumor control and improve surgical outcome. The aim of the study was to evaluate the ideal application and typical interactions of intraoperative MRI (iMRI), conventional low-frequency intraoperative ultrasound (cioUS), and high-frequency linear array intraoperative ultrasound (lioUS) to optimize surgical workflow. Methods Prospectively, we included 11 patients with an LGG. Typical procedural workflow in the iMRI suite was recorded with a compatible software. We took notes of duration, frequency of application, the surgeon's evaluation of image quality, and the respective benefit of lioUS (15 MHz), cioUS (7 MHz), and iMRI (1.5 T). With the help of the workflow software, we meticulously analyzed ∼ 55 hours of surgery. Results During the interventions, lioUS was used more often (76.3%) than cioUS (23.7%) and showed a better mean image quality (1 = best to 6 = worst) of 2.08 versus 3.26 with cioUS. The benefit of the lioUS application was rated with an average of 2.27, whereas the cioUS probe only reached a mean value of 3.83. The most common application of lioUS was resection control (42.6%); cioUS was used mainly for orientation (63.2%). Overall, lioUS was used more often and was rated better for both the purposes just described regarding image quality and benefit. Estimated residual tumor based on lioUS alone was lower than the final residual tumor detected with iMRI (7.5% versus 14.5%). The latter technique was rated as the best imaging modality for resection control in all cases followed by lioUS. Conclusion We provide proof of principle for workflow assessment in cranial neurosurgery. Although iMRI remains the imaging method of choice, lioUS has shown to be beneficial in a combined setup. Evaluation of lioUS was significantly superior to cioUS in most indications except for subcortical lesions.