Intratumoral Ultrasonic Aspirator Delivery of H₂O₂—A Novel Approach to Resecting Highly Vascularized Intracranial Tumors

Introduction: Several techniques described throughout the literature are suggested when dealing with highly vascular meningiomas. Among others, these include pre- and intraoperative embolization. We describe a novel technique wherein hydrogen peroxide (H₂O₂) is delivered during ultrasonic aspiration. H₂O₂ has traditionally been used as bacteriostatic and hemostatic postresection irrigation for the parenchymal surface. Recently, it has lost favor among practitioners because of suspected microscopic trauma, among other potential complications. We have found a novel use for this powerful agent bypassing these potential complications. This technique has not been described previously.

Methods: A 21-year-old man presented with seizures, left hemiparesis, and somnolence. Imaging revealed a giant right sphenoid wing meningioma. Preoperative embolization was executed, yet yielded minimal results due to mainly pial feeders. Tumor resection was done in two stages. In both stages, standard microneurosurgical techniques were used. During the first stage of resection, the CUSA was used in the traditional manner. During the second stage, we replaced the usual normal saline irrigating solution of the ultrasonic aspirator (CUSA) with 3% H₂O₂, delivering H₂O₂ to the tumor surface during ultrasonic defragmentation.

Results: The tumor was noted to be extremely vascular. During the first stage (standard), 25% resection was achieved and the patient suffered 8 L blood loss. During the second stage (novel), 95% resection was achieved with only 1.5 L of blood loss. A mild technical drawback was that very occasionally bubbles formed by the H₂O₂ reduced aspiration intensity of the CUSA. This was rectified by our flushing the CUSA using normal saline. We did not observe any other untoward effect from this technique.

Conclusion: Our previous experience with the same patient (stage 1) serves as an internal control, showcasing the dramatic benefits of using this technique. It is our initial impression that using H₂O₂ as an irrigating agent in the CUSA is safe and effective while resecting highly vascular meningiomas. This early successful result warrants further clinical validation of this novel technique.