Application of intraoperative indocyanine green videoangiography to brain tumor surgery

Background  

Videoangiography using indocyanine green (ICG) has been used in the ophthalmologic field for a long time. It was introduced to the neurosurgical field several years ago but has been limited to vascular surgeries. We applied ICG videoangiography to brain tumor surgery and evaluated the usefulness.     

Evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery

Neurosurgical Review - The primary aim of this study is to assess the value of intraoperative near-infrared indocyanine green videoangiography (ICGA) during intracranial aneurysm surgery....     

Evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery

The primary aim of this study is to assess the value of intraoperative near-infrared indocyanine green videoangiography (ICGA) during intracranial aneurysm surgery. Altogether, 129 patients harboring 152 intracranial aneurysms were recruited in this study between March 2007 and December 2008 and the clinical data were retrospectively analyzed. Intraoperative ICGA was performed to examine the completeness of the aneurysm clipping and the patency of the parent arteries in all cases. The intraoperative findings were compared with that of postoperative digital subtraction angiography (DSA). On all of the patients, 276 successful ICGA investigations were performed intraoperatively. The image quality and resolution were excellent, allowing real-time assessment of the cerebral circulation. Indocyanine green (ICG) angiographic results could be divided into arterial, capillary, and venous phases, comparable to those observed with postoperative DSA. In all cases, the postoperative angiographic results corresponded to the intraoperative ICGA findings. In three cases, the information provided by intraoperative ICG angiography significantly changed the surgical procedure. Intraoperative ICG videoangiography may be a useful tool in real-time evaluation of the aneurysm clipping. Its simplicity and easy reproducibility all suggest it to be carried out as a routine procedure during aneurysm surgery.     

Prospective evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery

OBJECT: The authors prospectively compared a new technique of surgical microscope-based indocyanine green (ICG) videoangiography with intraoperative or postoperative digital subtraction (DS) angiography. METHOD: The technique was performed during 187 surgical procedures in which 124 aneurysms in 114 patients were clipped. Using a newly developed setup, the ICG technique has been integrated into an operating microscope (Carl Zeiss Co., Oberkochen, Germany). A microscope-integrated light source containing infrared excitation light illuminates the operating field. The dye is injected intravenously into the patient, and intravascular fluorescence from within the blood vessels is imaged using a video camera attached to the microscope. The patency of parent, branching, and perforating arteries and documentation of clip occlusion of the aneurysm as shown by ICG videoangiography were compared with intraoperative or postoperative findings on DS angiography. The results of ICG videoangiography corresponded with intra- or postoperative DS angiography in 90% of cases. The ICG technique missed mild but hemodynamically irrelevant stenosis that was evident on DS angiography in 7.3% of cases. The ICG technique missed angiographically relevant findings in three cases (one hemodynamically relevant stenosis and two residual aneurysm necks [2.7% of cases]). In two cases the missed findings were clinically and surgically inconsequential; in the third case, a 4-mm residual neck may require a second procedure. Indocyanine green videoangiography provided significant information for the surgeon in 9% of cases, most of which led to clip correction. CONCLUSIONS: Microscope-based ICG videoangiography is simple and provides real-time information about the patency of vessels of all sizes and about the aneurysm sac. This technique may be useful during routine aneurysm surgery as an independent form of angiography or as an adjunct to intra- or postoperative DS angiography.     

The use of intraoperative near-infrared indocyanine green videoangiography in the microscopic resection of hemangioblastomas

Background  

The authors assessed the usefulness of intraoperative near-infrared indocyanine green videoangiography (ICG-VA) in the microscopic resection of hemangioblastomas.     

Near-infrared indocyanine green videoangiography for assessment of carotid endarterectomy

Background  

Intraoperative fluorescence angiography with indocyanine green (ICG) as a tracer has recently been introduced as a novel technique for neurosurgery. We evaluated the feasibility and efficacy of near-infrared (NIR) indocyanine green (ICG) videoangiography for patients undergoing carotid endarterectomy (CEA).     

Enhanced analysis of intracerebral arterioveneous malformations by the intraoperative use of analytical indocyanine green videoangiography: technical note

In cerebral arterioveneous malformations (AVMs) detailed intraoperative identification of feeding arteries, nidal vessels and draining veins is crucial for surgery. Intraoperative imaging techniques like indocyanine green videoangiography (ICG-VAG) provide information about vessel architecture and patency, but do not allow time-dependent analysis of intravascular blood flow. Here we report on our first experiences with analytical indocyanine green videoangiography (aICG-VAG) using FLOW 800 software as a useful tool for assessing the time-dependent intraoperative blood flow during surgical removal of cerebral AVMs. Microsope-integrated colour-encoded aICG-VAG was used for the surgical treatment of a 38-year-old woman diagnosed with an incidental AVM, Spetzler Martin grade I, of the left frontal lobe and of a 26-year-old man suffering from seizures caused by a symptomatic AVM, Spetzler Martin grade III, of the right temporal lobe. Analytical ICG-VAG visualization was intraoperatively correlated with in situ micro-Doppler investigation, as well as preoperative and postoperative digital subtraction angiography (DSA). Analytical ICG-VAG is fast, easy to handle and integrates intuitively into surgical procedures. It allows colour-encoded visualization of blood flow distribution with high temporal and spatial resolution. Superficial major and minor feeding arteries can be clearly separated from the nidus and draining veins. Effects of stepwise vessel obliteration on velocity and direction of AVM blood flow can be objectified. High quality of visualization, however, is limited to the site of surgery. Colour-encoded aICG-VAG with FLOW 800 enables intraoperative real-time analysis of arterial and venous vessel architecture and might, therefore, increase efficacy and safety of neurovascular surgery in a selected subset of superficial AVMs.     

吲哚菁绿荧光造影术在高颈段脊髓血管母细胞瘤手术中的初步应用

正脊髓血管母细胞瘤是一种高度血管化的良性肿瘤,首选手术治疗,肿瘤全切者可达根治。但是手术中易出现难以控制的出血,造成视野不清,盲目地切瘤和止血容易造成脊髓严重损伤。神经外科医师一直致力于寻找最安全切除脊髓血管母细胞瘤手术的辅助工具,包括术前数字减影血管造影(digital subtraction angiography,DSA)、术前三维CT血管造影(three-dimensional computed tomography     

Intraoperative control of extracranial-intracranial bypass patency by near-infrared indocyanine green videoangiography

OBJECT: Recently, intraoperative fluorescence angiography in which indocyanine green (ICG) is used as a tracer has been introduced as a novel technique to confirm successful aneurysm clipping. The aim of the present study was to assess whether ICG videoangiography is also suitable for intraoperative confirmation of extracranial-intracranial bypass patency. METHODS: Forty patients undergoing cerebral revascularization for hemodynamic cerebral ischemia (11 patients), moya-moya disease (18 patients), or complex intracranial aneurysms (11 patients) were included. Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery was performed 35 times in 30 patients (five patients with moyamoya underwent bilateral procedures), STA-posterior cerebral artery bypass surgery in two patients, and saphenous vein (SV) high-flow bypass surgery in eight patients. In each patient, following the completion of the anastomosis, ICG (0.3 mg/kg body weight) was given systemically via an intravenous bolus injection. A near-infrared light emitted by laser diodes was used to illuminate the operating field and the intravascular fluorescence was recorded using an optical filter-equipped video camera. The findings of ICG videoangiography were compared with those of postoperative digital subtraction (DS) or computerized tomography (CT) angiography. In all cases excellent visualization of cerebral arteries, the bypass graft, and brain perfusion was noted. Indocyanine green videoangiography was used to identify four nonfunctioning STA-MCA bypasses, which could be revised successfully in all cases. In two cases of SV high-flow bypasses, ICG videoangiography revealed stenosis at the proximal anastomotic site, which was also revised successfully. In all cases the final findings of ICG videoangiography could be positively validated during the postoperative course by performing DS or CT angiography. CONCLUSIONS: Indocyanine green videoangiography provides a reliable and rapid intraoperative assessment of bypass patency. Thus, ICG videoangiography may help reduce the incidence of early bypass graft failure.     

An analysis of flow dynamics in cerebral cavernous malformation and orbital cavernous angioma using indocyanine green videoangiography

Background  

Cerebral cavernous malformations (CCMs) are known to be vascular anomalies with low perfusion because of being angiographically occult. We attempted direct visualization of blood flow within CCMs and orbital cavernous angiomas (CAs), and analyzed flow dynamics using indocyanine green videoangiography (ICG-VAG).     

Near-infrared indocyanine green video angiography: a new method for intraoperative assessment of vascular flow

OBJECTIVE: We report our initial clinical experience with a new method for intraoperative blood flow assessment. The purposes of the study were to assess the use of indocyanine green (ICG) video angiography in neurovascular cases, to assess the handling and image quality, to compare the findings with postoperative angiographic results, and to evaluate the clinical value of the method in a preliminary feasibility study. METHODS: Fourteen patients with aneurysms (n = 12) or spinal (n = 1) or intracranial (n = 1) dural fistulae were included. Before and/or after aneurysm or dural fistula occlusion, ICG (25 mg) was injected intravenously. A near-infrared laser excitation light source (lambda = 780 nm) illuminated the operating field. The intravascular fluorescence of ICG (maximal lambda = 835 nm) was recorded by a nonintensified video camera, with optical filtering to block ambient and laser light for collection of only ICG-induced fluorescence. RESULTS: A total of 21 investigations were performed for 14 patients. For the 17 successful ICG video angiographic investigations, image quality and resolution were excellent, allowing intraoperative real-time assessment of the cerebral circulation. ICG angiographic results could be divided into arterial, capillary, and venous phases, comparable to those observed with digital subtraction angiography. In all cases, the postoperative angiographic results corresponded to the intraoperative ICG video angiographic findings. In three cases, the information provided by intraoperative ICG angiography significantly changed the surgical procedure. CONCLUSION: ICG video angiography is simple and provides real-time information on the patency of arterial and venous vessels of all relevant diameters, including small and perforating arteries (<0.5 mm), and the visible aneurysm sac. It may be a useful adjunct to improve the quality of neurovascular procedures and to document the intraoperative vascular flow.     

Transdural indocyanine green video-angiography of vascular malformations

Background

The role of indocyanine green video-angiography (ICG-VA) in the surgical resection of vascular malformations has been largely described; conversely, the utility of ICG-VA before dural opening (transdural ICG-VA) in this situation remains unclear. The aim of this study is to present the application of transdural ICG-VA in a consecutive series of patients in order to explore the potential provided by a transdural visualisation of vascular malformations.

Method

We retrospectively analysed the application of intra-operative ICG-VA before dural opening in 15 consecutive patients who underwent surgical resection of vascular malformations. The cases included 12 cerebral arterio-venous malformations (AVMs), 2 cerebral dural arterio-venous fistulas (dAVFs) and 1 spinal arterio-venous fistula (AVF).

Results

ICG-VA before dural opening allowed the visualisation of the site and extension of the malformation in 13 out of 15 cases, whilst arterial feeders and venous drainages were identified in 9 out of 15 cases. In two patients with dAVF, the point of fistula could be transdurally identified through ICG-VA. In 14% of cases, the size of bone flap designed on neuronavigation data was then modified according to transdural ICG-VA findings.

Conclusions

Transdural ICG-VA proved an efficient tool that allows optimising the exposure of the malformation, performing a safe dural opening and identifying dural vascular connections of the lesion.     

Limitation of temporary vascular occlusion during aneurysm surgery Study by intraoperative monitoring of cortical blood flow

The limitations of temporary vascular occlusion during aneurysm surgery as evidenced by the postoperative ischemic symptoms in relation to cerebral blood flow were studied. Six of the 39 cases had postoperative ischemic neurological deficit. When residual cerebral blood flow was below 15 mL/min/100 g, transient symptoms were seen when temporary clipping was for 10–20 minutes. When more than 20 minutes of clipping was required, irreversible deficits were found. Correlations between residual cerebral blood flow, duration of temporary clipping, and postoperative ischemic symptoms were found. The monitoring of cortical cerebral blood flow is an effective means for determining the limits of temporary vascular occlusion.     

Intraoperative assessment of cortical perfusion by indocyanine green videoangiography in surgical revascularization for moyamoya disease

Background

Postoperative hyperperfusion is a potential complication of the direct bypass procedure for moyamoya disease (MMD). However, no reliable modality is available yet for the prediction of postoperative hyperperfusion during surgery for MMD. This study aimed to investigate whether semiquantitative analysis of indocyanine green (ICG) videoangiography could contribute to the prediction of postoperative hyperperfusion in MMD.

Methods

This study included 12 hemispheres from 10 patients who underwent surgical revascularization for MMD. Intraoperative ICG videoangiography was performed before and after a direct bypass procedure. The ICG intensity-time curves were semiquantitatively analyzed to evaluate cortical perfusion by calculating the blood flow index (BFI). Using single-photon emission computed tomography (SPECT), postoperative cerebral blood flow measurements were performed thrice: immediately, and 2 and 7 days after surgery.

Results

BFI significantly increased from 21.3?±?10.5 to 38.4?±?20.0 after bypass procedures in all the hemispheres (p?p?Conclusions Our results suggest that semiquantitative analysis of BFI by intraoperative ICG videoangiography is useful in evaluating changes in cortical perfusion after bypass procedures for MMD and can predict the occurrence of early-onset hyperperfusion in MMD patients after direct bypass.