Advantages and Limitations of Intraoperative Ultrasound Strain Elastography Applied in Brain Tumor Surgery: A Single-Center Experience

Strain elastography is an intraoperative ultrasound (ioUS) modality currently under development with various potential applications in neurosurgery.To describe the main technical aspects, usefulness, and limitations of ioUS strain elastography applied in a large case series of brain tumors.We retrospectively analyzed patients who underwent craniotomy for a brain tumor between March 2018 and March 2021. Cases with an ioUS strain elastography study were included. The elastograms were processed semiquantitatively, and the mean tissue elasticity (MTE) values were calculated from the histogram of intensities. An analysis was performed to correlate the histopathological groups and the tumor and peritumoral MTE values using the Kruskal-Wallis test and a decision tree classifier. Furthermore, elastogram quality was assessed to discuss possible artifacts and weaknesses of the ultrasound technique.One hundred two patients with the following histopathological diagnoses were analyzed: 43 high-grade gliomas, 11 low-grade gliomas, 28 meningiomas, and 20 metastases. The tumor MTE values were significantly different between the histopathological groups (P < .001). The decision tree classifier showed an area under the curve of 0.73 and a classification accuracy of 72%. The main technical limitations found in our series were the presence of artifacts after dural opening, the variability of the frequency and amplitude of the mechanical pulsations, and the challenge in evaluating deep lesions.Tumor stiffness revealed by ioUS strain elastography has a plausible histopathological correlation. Thus, this fast and versatile technique has enormous potential to be exploited in the coming years.