Intraoperative Imaging Techniques for Brain Tumor Surgery

Maximal safe resection of brain tumours relies increasingly on real-time visualisation of tumour boundaries, surrounding vasculature and evolving anatomy. Traditional neuronavigation systems, which register preoperative images to the patient, lose accuracy as the brain deforms under gravity and tissue removal—a phenomenon known as brain shift. To address this, intraoperative imaging modalities such as intraoperative magnetic resonance imaging (iMRI) and intraoperative ultrasound (iUS) have been adopted. iMRI provides high-contrast anatomical updates but demands significant infrastructure and prolongs surgical workflow. By contrast, iUS offers rapid, repeatable imaging, now enhanced through Doppler modes, contrast-enhanced ultrasound (CEUS) and elastography to delineate tumour vascular patterns and tissue stiffness. Fluorescence-guided surgery using agents like 5-aminolevulinic acid or fluorescein facilitates real-time visual differentiation of malignant cells under specialised lighting. Emerging optical techniques—including confocal laser endomicroscopy (CLE) and optical coherence tomography—bring near-histological resolution directly at the resection margin, enabling on-the-fly cellular assessment. The combination of these approaches, often fused with preoperative MRI in hybrid navigation platforms, allows surgeons to update their strategy continuously, minimise residual disease and preserve critical functional tissue.

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Intraoperative Imaging Techniques for Brain Tumor Surgery publication trend

The graph below shows the total number of articles in intraoperative imaging techniques for brain tumor surgery across all publications each year (not limited to Nature Index journals).

Technical terms

Neuronavigation: A computer-assisted system that aligns preoperative imaging with the patient’s anatomy to guide surgical instruments.

Brain shift: Intraoperative movement and deformation of brain structures that degrades the accuracy of preoperative image guidance.

Intraoperative MRI (iMRI): Magnetic resonance imaging acquired during surgery to update anatomical information and confirm extent of resection.

Intraoperative ultrasound (iUS): Real-time sonographic imaging used intraoperatively to visualise tumour margins, vascular structures and cavity changes.

Confocal laser endomicroscopy (CLE): A miniaturised optical microscope that provides in vivo cellular-level imaging at the resection margin.

Contrast-enhanced ultrasound (CEUS): Ultrasound imaging enhanced by microbubble agents to improve contrast between tumour and normal tissue based on vascular perfusion.

References

1. Fluorescein-stained confocal laser endomicroscopy versus conventional frozen section for intraoperative histopathological assessment of intracranial tumors. Neuro-Oncology (2024).
2. ReMIND: The Brain Resection Multimodal Imaging Database. Scientific Data (2024).
3. Intraoperative Fluorescence Imaging for Personalized Brain Tumor Resection: Current State and Future Directions. Frontiers in Surgery (2016).
4. Advanced Ultrasound Imaging in Glioma Surgery: Beyond Gray-Scale B-mode. Frontiers in Oncology (2018).
5. Confocal Laser Endomicroscopy for Diagnosis and Histomorphologic Imaging of Brain Tumors In Vivo. PLOS ONE (2012).
6. Intraoperative ultrasound in brain tumor surgery: A review and implementation guide. Neurosurgical Review (2022).
7. Brain Shift in Neuronavigation of Brain Tumors: An Updated Review of Intra-Operative Ultrasound Applications. Frontiers in Oncology (2021).