Use of Second Window ICG in spinal cord biopsy of a mildly contrast-enhancing lesion: Technical note and review of the literature

IntroductionIndocyanine green (ICG) is commonly used to visualize cerebral vasculature, particularly in the management of cerebral aneurysms. There have also been attempts to use ICG for visualization of tumors. Injection of ICG followed by immediate fluorescence microscopy is limited by the short time window for imaging and administration and restricted depth of imaging. Second Window Indocyanine Green (SWIG) addresses these issues by allowing for longer contrast times and the imaging of deeper regions of brain tissue. Biopsy of spinal cord lesions is often difficult for a variety of reasons, including the delicate nature of the tissue and differentiating normal from lesional tissue visually, especially in lesions with heterogeneous enhancement.MethodsIn this case report, we describe the use of second window ICG to facilitate the visualization of a spinal cord lesion and subsequent biopsy of the lesion.ResultsThis patient is a 24-year-old female who had recurrence of a suprasellar germinoma. An MRI of the rest of the neuraxis was performed to assess for the presence of drop metastases. The spinal cord from C2-5 was expanded with areas of patchy enhancement; however, this lesion was asymptomatic. The patient's oncologist requested a biopsy of this lesion to help direct subsequent care of her recurrent germinoma. The day before surgery, the patient had an intravenous injection of ICG dye. She then underwent a C3-5 laminectomy for biopsy of her cervical intramedullary lesion. After opening of the dura, no visible abnormality of the spinal cord could be identified. A Stryker endoscope showed an area of ICG uptake in the cord at approximately the C3-4 level. A midline myelotomy was centered over the ICG demarcated area and several samples were taken for pathology. Final biopsy results determined the lesion to be spinal cord parenchyma with perivascular and intraparenchymal lymphocytes – not consistent with spinal cord tumor or germinoma.ConclusionSecond Window ICG is effective in visualizing otherwise visually unremarkable spinal cord lesions. This technology can facilitate biopsy of these lesions and possibly their surgical resection.     

Transient anisocoria after a traumatic cervical spinal cord injury: A case report

Context: Autonomic dysreflexia and dysautonomia can be a common complication following spinal cord injury, especially at levels of T6 and above and can lead to complications associated with the pupil. In this case report, we review autonomic dysreflexia, the anatomy and physiology of the sympathetic nervous system of the eye, as well as review the clinical relevance in understanding autonomic and pupillary changes in response to autonomic dysfunction.

Findings: We present a patient with an incomplete C4 level injury who was found to have isolated anisocoria on two separate occasions during his acute inpatient rehabilitation stay.

Conclusion/Clinical Relevance: Anisocoria associated with abnormal sympathetic activation may be a clinical sign of dysautonomia.     

Anaesthesia for endoscopic surgery

Anaesthesia for endoscopic airway surgery involves unique challenges. The anaesthetist and surgeon are working in close anatomical proximity and the concept of shared airway is never more relevant. Understanding the planned procedure and the needs of the surgeon for access to the surgical field will enable the provision of anaesthesia and airway management using a variety of techniques. Planning for safe induction, maintenance and emergence of anaesthesia will also be guided by the specific pathology and patient characteristics and requires effective communication between the surgeon and anaesthetist.     

Double-balloon enteroscopy for retrieving retained small-bowel video capsule endoscopes: a systematic review

Abstract

Background and aim: Capsule retention is the most common adverse event associated with video capsule endoscopy. The use of double-balloon enteroscopy-assisted capsule endoscope retrieval has been increasingly reported in recent years. However, evidence is limited regarding its success rate, associated factors, and subsequent clinical outcomes.

Methods: A systematic review of relevant studies published before January 2019 was performed. Successful retrieval rate and associated factors, rate of endoscopic balloon dilation, and outcomes after double-balloon enteroscopy were summarized and pooled.

Results: Within 154 associated original articles, 12 including 150 cases of capsule retrieval by double-balloon enteroscopy were included. The estimated pooled successful retrieval rate was 86.5% (95% confidence interval, 75.6–95.1%). Anterograde approach and capsules retained in the jejunum or trapped by malignant strictures were associated with a higher successful retrieval rate than the retrograde approach (62/83 [74.7%] vs. 10/38 [26.3%], p?<?.001) and capsules retained in the ileum (41/41 [100.0%] vs. 43/58 [74.1%], p?<?.001) or trapped by benign strictures (21/21 [100.0%] vs. 65/83 [78.3%], p?=?.043). Endoscopic balloon dilation was performed in 38.8% (95% confidence interval, 22.3–56.3%) of patients with benign strictures. Two perforations (1.3%) were reported as severe adverse events after double-balloon enteroscopy. A significantly lower surgery rate was found among cases with successful video capsule removal compared with unsuccessful cases (7.2% vs. 38.5%, p?=?.002).

Conclusions: Double-balloon enteroscopy is feasible and safe for removing retained video capsule endoscopes, and its use could decrease the need for surgery in patients with benign strictures and facilitate subsequent surgery in patients with malignant strictures.