Fig. 4

Imaging of high-grades glioma by MRI with contrast, CT with contrast and IOUS. Cases a, b, c astrocytoma grade 3; arrows 1 refer to cystic part and arrows 2 refer to fleshy part with heterogeneous enhancement in MRI, faintly enhanced CT in case b, IOUS delineated well the fleshy part (hyper-echogenic) and the cystic parts (hypo-echogenic) and low edema in all images. Cases d, e, f; astrocytoma grade 4. Case d; arrows 3 refer to cystic part and arrows 4 refer to fleshy part which more delineated in IOUS image. Case e; arrows 3 refer to content of the lesion which appeared cystic in MRI and CT images but fleshy in IOUS image (mixed echogenicity) which matched intraoperative findings. Arrows 4 refer to mass boundaries which delineated well in all images. Case f; arrows 3 refer to content of the lesion which appeared fleshy with necrosis in all images but small cysts appeared in IOUS image and arrows 4 refer to mass boundaries which less delineated in CT image. The ultrasound criteria of high-grades tumors as noted in these cases are irregular contours (a, b), necrosis (e, f), brain edema(all), presence of cystic component, cystic multiplicity, cystic trabeculations, thick cystic walls (all except e), hypo-echogenicity (b, e, f), and heterogeneity