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Song J, Mao Y. Giant Aneurysm Management. Adv Tech Stand Neurosurg 2022; 44:133-160. [PMID: 35107677 DOI: 10.1007/978-3-030-87649-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The treatment of giant aneurysms has always been a challenge in the field of neurovascular disease. Giant aneurysms are larger in size and are associated with thrombosis development and the calcification of the aneurysmal wall and neck, which often interfere with direct clipping. Most giant aneurysms have a wide neck with an incomplete thrombus, making complete embolization almost impossible. Giant aneurysms of different sites have entirely different hemodynamic characteristics. Moreover, aneurysms at the same site may exhibit very different hemodynamics among different individuals. Therefore, careful assessment of each case is required before and during treatment to develop and carry out an individualized treatment plan.
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Affiliation(s)
- Jianping Song
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China. .,Neurosurgical Institute of Fudan University, Shanghai, China. .,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China. .,National Center for Neurological Disorders, Shanghai, China.
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Świątnicki W, Szymański J, Szymańska A, Komuński P. Intraoperative fluorescein video angiography in intracranial aneurysm surgery: single-center, observational cohort study. Acta Neurol Belg 2021; 121:1487-1493. [PMID: 32378140 DOI: 10.1007/s13760-020-01365-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/24/2020] [Indexed: 01/26/2023]
Abstract
The aim of this study was to compare the incidence of postoperative, surgery-related complications in patients where fluorescein video angiography (FL-VA) was performed with those operated without intraoperative verification. This is an observational cohort study including 97 patients who were selected for microsurgical clipping due to intracranial aneurysm. First 52 patients enrolled in the study were operated prior to introduction of fluorescein fluorescence in our surgical workflow. These patients were considered as controls. The study group consisted of 45 consecutive patients operated with the use of fluorescein video angiography and by the same surgical team. Outcomes in both groups were compared using non-parametric test (Mann-Whitney U). Intraoperative fluorescein video angiography revealed aneurysm remnant or inadvertent vessel occlusion in 17.8% of patients. Following clip reposition, a repeated FL-VA was performed to confirm restoration of blood flow and/or complete aneurysm obliteration. Intraoperative findings were later confirmed using computed tomography angiography (CTA). None of the patients in our study group developed surgery-related complications; whereas in the control group, aneurysm remnant was discovered in 7.7%, brain ischemia in 9.6% and both of the latter in 5.8% of patients. Difference in treatment-related outcome was statistically significant (p < 0.05). Intraoperative fluorescein video angiography successfully identified aneurysm residual and adjacent artery occlusion leading to excellent outcome following clip reposition.
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Affiliation(s)
- Wojciech Świątnicki
- Department of Neurosurgery, Maria Sklodowska-Curie Hospital, 35, Parzeczewska street, 95-100, Zgierz, Poland.
| | - Jarosław Szymański
- Faculty of Economics and Sociology, University of Lodz, 39, Rewolucji 1905r. street, 90-214, Lodz, Poland
| | - Anna Szymańska
- Faculty of Economics and Sociology, University of Lodz, 39, Rewolucji 1905r. street, 90-214, Lodz, Poland
| | - Piotr Komuński
- Department of Neurosurgery, Maria Sklodowska-Curie Hospital, 35, Parzeczewska street, 95-100, Zgierz, Poland
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The role of intraoperative videoangiography in aneurysm surgery—a comparative study from a tertiary care hospital. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00106-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Indocyanine green (ICG) is a near-infrared (NIR) fluorescent dye. After intravenous injection, it reaches the vessels of the brain within 30 s. A real-time visualization of the cerebral vasculature is possible.
Results
The infarction rate and the postoperative rebleed rate in the pre-ICG era group were higher than in the ICG era.
Conclusion
Intraoperative ICGVA is a safe and effective method to confirm the exclusion of the clipped aneurysm from the circulation. It also helps to assess the patency of the surrounding vessels.
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Durner G, Wahler H, Braun M, Kapapa T, Wirtz CR, König R, Pala A. The value of intraoperative angiography in the time of indocyanine green videoangiography in the treatment of cerebrovascular lesions: Efficacy, workflow, risk-benefit and cost analysis A prospective study. Clin Neurol Neurosurg 2021; 205:106628. [PMID: 33895619 DOI: 10.1016/j.clineuro.2021.106628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/28/2021] [Accepted: 03/28/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Intraoperative digital subtraction angiography (ioDSA) allows early treatment evaluation after neurovascular procedures. However, the value and efficiency of this procedure has been discussed controversially. We have evaluated the additional value of hybrid operating room equipped with an Artis Zeego robotic c-arm regarding cost, efficiency and workflow. Furthermore, we have performed a risk-benefit analysis and compared it with indocyanine green (ICG) angiography. METHODS For 3 consecutive years, we examined all neurovascular patients, treated in the hybrid operating theater in a risk-benefit analysis. After using microdoppler and ICG angiography for best operative result, every patient received an additional ioDSA to look for remnants or unfavorable clip placement which might lead to a change of operating strategy or results. Furthermore, a workflow-analysis reviewing operating steps, staff positioning, costs, technical errors or complications were conducted on randomly selected cases. RESULTS 54 patients were enrolled in the risk-benefit analysis, 22 in the workflow analysis. The average duration of a cerebrovascular operation was 4 h 58 min 2 min 35 s accounted for ICG angiography, 46 min 4 s for ioDSA. Adverse events occurred during one ioDSA. In risk-benefit analysis, ioDSA was able to detect a perfusion rest in 2 out of 43 cases (4,7%) of aneurysm surgery, which could not have been visualized by ICG angiography before. In arterio-venous-malformation (AVM) surgery, one of 11 examined patients (7,7%) showed a remnant in ioDSA and resulted in additional resection. The average cost of an ioDSA in Ulm University can be estimated with 1928,00€. CONCLUSION According to our results ioDSA associated complications are low. Relevant findings in ioDSA can potentially avoid additional intervention, however, due to the high costs and lower availability, the main advantage might lie in the treatment of selected patients with complexes neurovascular pathologies since ICG angiography is equally safe but associated with lower costs and better availability.
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Affiliation(s)
- Gregor Durner
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany.
| | - Hellen Wahler
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Michael Braun
- University of Ulm, Department of Neuroradiology, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Thomas Kapapa
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Christian Rainer Wirtz
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Ralph König
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Andrej Pala
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
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Peñate-Medina T, Kraas E, Luo K, Humbert J, Zhu H, Mertens F, Gerle M, Rohwedder A, Damoah C, Will O, Acil Y, Kairemo K, Wiltfang J, Glüer CC, Scherließ R, Sebens S, Peñate-Medina OP. Utilizing ICG Spectroscopical Properties for Real-Time Nanoparticle Release Quantification <i>In vitro</i> and <i>In vivo</i> in Imaging Setups. Curr Pharm Des 2021; 26:3828-3833. [PMID: 32188378 DOI: 10.2174/1381612826666200318170849] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/13/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Nanoparticle imaging and tracking the release of the loaded material from the nanoparticle system have attracted significant attention in recent years. If the release of the loaded molecules could be monitored reliably in vivo, it would speed up the development of drug delivery systems remarkably. METHODS Here, we test a system that uses indocyanine green (ICG) as a fluorescent agent for studying release kinetics in vitro and in vivo from the lipid iron nanoparticle delivery system. The ICG spectral properties like its concentration dependence, sensitivity and the fluctuation of the absorption and emission wavelengths can be utilized for gathering information about the change of the ICG surrounding. RESULTS We have found that the absorption, fluorescence, and photoacoustic spectra of ICG in lipid iron nanoparticles differ from the spectra of ICG in pure water and plasma. We followed the ICG containing liposomal nanoparticle uptake into squamous carcinoma cells (SCC) by fluorescence microscopy and the in vivo uptake into SCC tumors in an orthotopic xenograft nude mouse model under a surgical microscope. CONCLUSION Absorption and emission properties of ICG in the different solvent environment, like in plasma and human serum albumin, differ from those in aqueous solution. Photoacoustic spectral imaging confirmed a peak shift towards longer wavelengths and an intensity increase of ICG when bound to the lipids. The SCC cells showed that the ICG containing liposomes bind to the cell surface but are not internalized in the SCC-9 cells after 60 minutes of incubation. We also showed here that ICG containing liposomal nanoparticles can be traced under a surgical camera in vivo in orthotopic SCC xenografts in mice.
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Affiliation(s)
- Tuula Peñate-Medina
- Section Biomedical Imaging, Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Eike Kraas
- Section Biomedical Imaging, Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Kunliang Luo
- Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitatsklinikum Schleswig-Holstein Campus Kiel, Christian Albrechts Universitat zu Kiel, Germany
| | - Jana Humbert
- Section Biomedical Imaging, Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Hanwen Zhu
- Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitatsklinikum Schleswig-Holstein Campus Kiel, Christian Albrechts Universitat zu Kiel, Germany
| | - Fabian Mertens
- Christian-Albrechts-Universität Kiel, Department of Pharmaceutics and Biopharmaceutics, Grasweg 9a D-24118 Kiel, Germany
| | - Mirko Gerle
- Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitatsklinikum Schleswig-Holstein Campus Kiel, Christian Albrechts Universitat zu Kiel, Germany
| | - Arndt Rohwedder
- Section Biomedical Imaging, Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Christabel Damoah
- Section Biomedical Imaging, Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Olga Will
- Section Biomedical Imaging, Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Yahya Acil
- Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitatsklinikum Schleswig-Holstein Campus Kiel, Christian Albrechts Universitat zu Kiel, Germany
| | - Kalevi Kairemo
- Department of Nuclear Medicine - The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Jörg Wiltfang
- Klinik für Mund-, Kiefer- und Gesichtschirurgie, Universitatsklinikum Schleswig-Holstein Campus Kiel, Christian Albrechts Universitat zu Kiel, Germany
| | - Claus-C Glüer
- Section Biomedical Imaging, Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Regina Scherließ
- Christian-Albrechts-Universitat Kiel, Department of Pharmaceutics and Biopharmaceutics, Grasweg 9a D-24118 Kiel, Germany
| | - Susanne Sebens
- Institut für Experimentelle Tumorforschung (IET), Arnold-Heller-Str. 3, Building U3024105, Kiel, Germany
| | - Oula Peñate Peñate-Medina
- Institut für Experimentelle Tumorforschung (IET), Arnold-Heller-Str. 3, Building U3024105, Kiel, Germany
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Ma L, Fei B. Comprehensive review of surgical microscopes: technology development and medical applications. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-200292VRR. [PMID: 33398948 PMCID: PMC7780882 DOI: 10.1117/1.jbo.26.1.010901] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/04/2020] [Indexed: 05/06/2023]
Abstract
SIGNIFICANCE Surgical microscopes provide adjustable magnification, bright illumination, and clear visualization of the surgical field and have been increasingly used in operating rooms. State-of-the-art surgical microscopes are integrated with various imaging modalities, such as optical coherence tomography (OCT), fluorescence imaging, and augmented reality (AR) for image-guided surgery. AIM This comprehensive review is based on the literature of over 500 papers that cover the technology development and applications of surgical microscopy over the past century. The aim of this review is threefold: (i) providing a comprehensive technical overview of surgical microscopes, (ii) providing critical references for microscope selection and system development, and (iii) providing an overview of various medical applications. APPROACH More than 500 references were collected and reviewed. A timeline of important milestones during the evolution of surgical microscope is provided in this study. An in-depth technical overview of the optical system, mechanical system, illumination, visualization, and integration with advanced imaging modalities is provided. Various medical applications of surgical microscopes in neurosurgery and spine surgery, ophthalmic surgery, ear-nose-throat (ENT) surgery, endodontics, and plastic and reconstructive surgery are described. RESULTS Surgical microscopy has been significantly advanced in the technical aspects of high-end optics, bright and shadow-free illumination, stable and flexible mechanical design, and versatile visualization. New imaging modalities, such as hyperspectral imaging, OCT, fluorescence imaging, photoacoustic microscopy, and laser speckle contrast imaging, are being integrated with surgical microscopes. Advanced visualization and AR are being added to surgical microscopes as new features that are changing clinical practices in the operating room. CONCLUSIONS The combination of new imaging technologies and surgical microscopy will enable surgeons to perform challenging procedures and improve surgical outcomes. With advanced visualization and improved ergonomics, the surgical microscope has become a powerful tool in neurosurgery, spinal, ENT, ophthalmic, plastic and reconstructive surgeries.
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Affiliation(s)
- Ling Ma
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
| | - Baowei Fei
- University of Texas at Dallas, Department of Bioengineering, Richardson, Texas, United States
- University of Texas Southwestern Medical Center, Department of Radiology, Dallas, Texas, United States
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Rennert RC, Strickland BA, Ravina K, Bakhsheshian J, Fredrickson V, Carey J, Russin JJ. Intraoperative Assessment of Cortical Perfusion After Intracranial-To-Intracranial and Extracranial-To-Intracranial Bypass for Complex Cerebral Aneurysms Using Flow 800. Oper Neurosurg (Hagerstown) 2020; 16:583-592. [PMID: 29897545 DOI: 10.1093/ons/opy154] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/22/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Revascularization strategies for complex cerebral aneurysms are largely based on subjective interpretation of flow demands, or indirect measures of perfusion in at-risk territories. Indocyanine Green -based flow analyses ((ICG-BFA); Flow 800, Carl Zeiss, Oberkochen, Germany) provide a real-time, semiquantitative measure of intraoperative cortical perfusion during cerebral bypass surgery for complex aneurysms. OBJECTIVE To determine the utility of intraoperative ICG-BFA for assessing cortical perfusion in at-risk territories during cerebral bypass for complex aneurysms requiring vessel sacrifice. METHODS Retrospective analysis of consecutive patients from a prospective, single-institution open cerebrovascular database. RESULTS Intraoperative ICG-BFA confirmed adequate cortical perfusion in 2 patients with fusiform posterior circulation aneurysms, treated with a posterior inferior cerebellar artery (PICA)-PICA and occipital artery (OA)-to-third segment of the posterior cerebral artery (P3) bypass with proximal vessel sacrifice, respectively. ICG-BFA was used in a third patient that underwent clip reconstruction/ intracranial-to-intracranial bypass for a large middle cerebral artery (MCA) bifurcation aneurysm requiring sacrifice of the temporal M2 branch. In this case, a frontal M3 to temporal M3 side-to-side anastomosis was created to arborize the MCA tree and allow filling of both M2 territories through a single M2 branch. After aneurysm reconstruction, ICG-BFA identified an inadvertent occlusion of the frontal M2 that left the entire MCA distribution reliant on collateral flow but did not cause a neuromonitoring change. Repeat ICG-BFA after clip re-arrangement demonstrated aneurysm occlusion and equal flow in both frontal and temporal MCA cortical distributions from the arborization. CONCLUSION ICG-BFA is a useful adjunct for intraoperative cortical flow assessment during cerebral revascularization for complex aneurysms requiring vessel sacrifice.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California San Diego, San Diego, California
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kristine Ravina
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Vance Fredrickson
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joseph Carey
- Department of Plastic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jonathan J Russin
- Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Ye X, Wang L, Li MT, Chen XL, Wang H, Ma L, Wang R, Zhang Y, Cao Y, Zhao YL, Zhang D, Wang S. Hemodynamic changes in superficial arteriovenous malformation surgery measured by intraoperative ICG fluorescence videoangiography with FLOW 800 software. Chin Neurosurg J 2020; 6:29. [PMID: 32922958 PMCID: PMC7416385 DOI: 10.1186/s41016-020-00208-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/09/2020] [Indexed: 12/16/2022] Open
Abstract
Background Arteriovenous malformation(AVM) have long-term "blood stealing" characteristics, which result in complicated hemodynamic features. To analyze the application of intraoperative indocyanine green angiography with FLOW 800 software in AVM surgeries. Methods Data on 17 patients undergoing surgery with ICG fluorescence were collected in Beijing Tiantan Hospital. To analyze the hemodynamic features of AVM and the influence on the peripheral cortex of AVM resection, we assessed the following hemodynamic parameters: maximum intensity, slope of rise, time to half-maximal fluorescence, and transit time from arteries to veins. Results In the 17 superficial AVMs studied, the time-delay color mode of the FLOW 800 software was superior to the traditional playback mode for identifying feeding arteries, draining veins, and their relation to normal cortical vessels. The maximum fluorescence intensity and slope of the ICG fluorescence curve of feeder arteries and draining veins were higher than those of normal peripheral vessels (P < 0.05). The transit times in AVMs were significantly shorter than those in normal peripheral vessels (P < 0.05). After AVM resection, cerebral flow increased in the cortex, and local cycle time becomes longer, although the differences were not significant (P > 0.05). Conclusions Hemodynamic parameter analysis provided quality guidance for the resection of AVMs and could also be used in estimating changes in blood flow in the local cortex to identify abnormal hyperperfusion and residual nidus.
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Affiliation(s)
- Xun Ye
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Liang Wang
- Department of Neurosurgery, Tianjin Fifth Center Hospital, Tianjin, 300450 China.,Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 China
| | - Ming-Tao Li
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Xiao-Lin Chen
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Li Ma
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Yuan-Li Zhao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050 China
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Park JH, Lee JY, Jeon HJ, Lim BC, Park SW, Cho BM. Safety and completeness of using indocyanine green videoangiography combined with digital subtraction angiography for aneurysm surgery in a hybrid operating theater. Neurosurg Rev 2019; 43:1163-1171. [PMID: 31317284 DOI: 10.1007/s10143-019-01141-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 06/02/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
This study aimed to evaluate the safety and completeness of using intraoperative indocyanine green videoangiography (ICGV) combined with intraoperative angiography (IOA) for aneurysm clipping in a hybrid operating room (hOR). All patients who underwent microsurgical clipping in the hOR were identified from prospectively maintained neurosurgical databases. Medical charts and operative videos with ICGV and IOA were reviewed to determine the adequacy of clipping, and clinical and angiographic outcomes were retrospectively analyzed. Fifty-four cerebral aneurysms (ruptured, 31; unruptured, 23) in 50 patients (mean age, 59.4 ± 10.9 y; M:F, 22:28) were evaluated with ICGV and IOA during clipping. Additional IOA led to a clip adjustment during surgery in 9/54 (16.7%) aneurysms for which ICGV had been initially performed. Post-clip perforator compromise occurred in two (3.7%) cases, with a patient with an unruptured aneurysm experiencing permanent injury (grade 3 hemiparesis) and patient with a ruptured aneurysm experiencing transient deficit. Post-clip parent vessel stenosis occurred in one (1.9%) case; however, an ischemic event did not occur because the flow patency was identified by IOA. No other patients with unruptured aneurysms developed new neurologic deficits at discharge. Favorable outcomes (Glasgow Outcome Score [GOS], 4 or 5) were observed in 26/31 patients with ruptured aneurysms. Five patients had unfavorable outcomes (GOS, 2 or 3) from the initial insult. Post-treatment angiography within 1 week showed complete occlusion in 52 (96.3%) aneurysms and minor remnants in two (3.7%) aneurysms. Using combined ICGV and IOA in a hOR may improve the safety and completeness of microsurgical aneurysm clipping.
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Affiliation(s)
- Jong-Hwa Park
- Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 150, Seongan-ro, Gangdong-gu, Seoul, 134-701, Republic of Korea
| | - Jong Young Lee
- Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 150, Seongan-ro, Gangdong-gu, Seoul, 134-701, Republic of Korea
| | - Hong Jun Jeon
- Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 150, Seongan-ro, Gangdong-gu, Seoul, 134-701, Republic of Korea.
| | - Byung Chul Lim
- Department of Neurosurgery, Dana Neurosurgical Clinic, Gangwon National University College of Medicine, 59, Jungang-ro, Chuncheon-si, Gangwon-do, 24353, Republic of Korea
| | - Seoung Woo Park
- Department of Neurosurgery, Gangwon National University Hospital, Gangwon National University College of Medicine, 156, Baengnyeong-ro, Chuncheon-si, Gangwon-do, 200-722, Republic of Korea
| | - Byung Moon Cho
- Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, 150, Seongan-ro, Gangdong-gu, Seoul, 134-701, Republic of Korea
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Marbacher S, Mendelowitsch I, Grüter BE, Diepers M, Remonda L, Fandino J. Comparison of 3D intraoperative digital subtraction angiography and intraoperative indocyanine green video angiography during intracranial aneurysm surgery. J Neurosurg 2019; 131:64-71. [PMID: 30004279 DOI: 10.3171/2018.1.jns172253] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 01/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE During the last decade, improvements in real-time, high-resolution imaging of surgically exposed cerebral vasculature have been realized with the successful introduction of intraoperative indocyanine green video angiography (ICGVA) and technical advances in intraoperative digital subtraction angiography (DSA). With the availability of 3D intraoperative DSA (3D-iDSA) in hybrid operating rooms, the present study offers a contemporary comparison for rates of accuracy and discordance. METHODS In this retrospective study of prospectively collected data, 140 consecutive patients underwent microsurgical treatment of intracranial aneurysms (IAs) in a hybrid operating room. Variables analyzed included patient demographics, aneurysm-specific characteristics, intraoperative ICGVA and 3D-iDSA findings, and the need for intraoperative clip readjustment. The authors defined the discordance rate of the two modalities as a false-negative finding that necessitated clip repositioning after 3D-iDSA. RESULTS In 120 patients, ICGVA and 3D-iDSA were used to evaluate 134 IA obliterations. Of 215 clips used, 29 (14%) were repositioned intraoperatively, improving the surgical result in all 29 patients (24%). Repositioning was prompted by visual inspection and microvascular Doppler ultrasonography in 8 (28%), ICGVA in 13 (45%), and 3D-iDSA in 7 (24%) patients. Clip repositioning was needed in 7 patients (6%) based on 3D-iDSA, yielding an ICGVA accuracy rate of 94%. Five (71%) of the ICGVA-3D-iDSA discordances that prompted clip repositioning occurred at the anterior communicating artery complex. CONCLUSIONS A combination of vascular monitoring techniques most often achieved correct intraoperative interpretation of complete IA occlusion and parent artery integrity. Compared with 3D-iDSA imaging, ICGVA demonstrated high accuracy. Despite the relatively low discordance rate, iDSA was confirmed to be the gold standard. Improved imaging quality, including 3D-iDSA, supports its routine use in IA surgery, obviating the need for postoperative DSA.
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Affiliation(s)
| | | | | | - Michael Diepers
- 2Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Switzerland
| | - Luca Remonda
- 2Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Switzerland
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11
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Norat P, Soldozy S, Elsarrag M, Sokolowski J, Yaǧmurlu K, Park MS, Tvrdik P, Kalani MYS. Application of Indocyanine Green Videoangiography in Aneurysm Surgery: Evidence, Techniques, Practical Tips. Front Surg 2019; 6:34. [PMID: 31281818 PMCID: PMC6596320 DOI: 10.3389/fsurg.2019.00034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/22/2019] [Indexed: 12/29/2022] Open
Abstract
Establishing blood vessel patency in neurovascular surgery is an essential component in treating cerebrovascular disorders. Given the difficulty in confirming complete obliteration of the aneurysm sac, ICG videoangiography has emerged as an intraoperative tool that provides neurosurgeons immediate feedback on the status of vessel flow, allowing for surgical modifications to be made without delay. ICG initially emerged as a tool for assessing hepatic, cardiac, and retinovascular function. It is an inert compound with a high affinity for plasma proteins and fluorescence properties making it the ideal candidate for assessment of vessel patency in neurovascular procedures. Requiring only a bolus peripheral vein injection and integration of a near-infrared imaging device into the surgical microscope, ICG can be visualized without disrupting operating room workflow or the surgical field. Quick response time, high-spatial resolution, and low complication rates are features of ICG videoangiography that prove advantageous when compared to the gold standard intra- and postoperative digital subtraction angiography (DSA). Despite this, ICG is not without limitations, specifically in the setting of atherosclerotic vessels, giant, and complex aneurysms. Additionally, there are instances where DSA may prove superior in detecting vessel stenosis and outflow obstruction, prompting the recommendation of ICG as an adjunct to, rather than complete replacement of DSA. In this article, the authors provide a brief overview of the biochemical properties and historical origins of ICG viedoangiography in addition to discussing its current application in aneurysm surgery.
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Affiliation(s)
- Pedro Norat
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Sauson Soldozy
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Mazin Elsarrag
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Jennifer Sokolowski
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Kaan Yaǧmurlu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Min S Park
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Petr Tvrdik
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - M Yashar S Kalani
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, United States
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Factors influencing cerebral aneurysm obliteration and reliability of indocyanine green video-angiography. Acta Neurochir (Wien) 2018; 160:269-276. [PMID: 29134343 DOI: 10.1007/s00701-017-3379-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 10/29/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Indocyanine green video-angiography (ICG-V) is commonly used for intraoperative confirmation of aneurysm obliteration following clipping. However, direct puncture of the aneurysm wall occasionally results in blood leakage in patients for whom ICG-V has indicated complete closure. Therefore, the present study aimed to determine the reliability of ICG-V for confirming complete aneurysm closure, and to elucidate the factors underlying aneurysm obliteration and the occurrence of false-negative ICG-V findings. METHODS Between June 2012 and June 2016, 89 patients (107 aneurysms total) undergoing aneurysm clipping were examined using ICG-V to confirm aneurysm closure. In ICG-V-negative cases, further confirmation of complete aneurysm closure was obtained via direct puncture of the aneurysm wall, except in cases where this procedure was deemed unsafe. To elucidate the possible causes of ICG-V inaccuracies, positive, negative, and false-negative ICG-V findings were compared in terms of aneurysm location (maximum height and length), neck width (parallel and orthogonal directions to the branching vessels), wall thickness around the neck, bifurcation angle, and direction of the clipping closure line. Statistical analyses were performed using the Welsh's t test and Chi-square test. RESULTS Intraoperative ICG-V detected seven cases of incomplete aneurysm closure (6.5%), defined as positive ICG-V findings. Following direct aneurysm wall puncture, nine patients (8.4%) exhibited false-negative ICG-V findings. A Chi-square test revealed that false-negative ICG-V findings were significantly influenced by the presence of heterogeneous arteriosclerosis, and wall thickening at the clipping site, which were subjectively defined by the surgeon and confirmed by an independent observer, depending on the wall color and hardness, respectively. CONCLUSIONS Although ICG-V is useful for intraoperative confirmation of aneurysm obliteration, our findings further highlight the risk of false-negative ICG-V findings. Acknowledgement of risk factors is crucial for efficient detection of false-negative ICG-V findings.
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Riva M, Amin-Hanjani S, Giussani C, De Witte O, Bruneau M. Indocyanine Green Videoangiography in Aneurysm Surgery: Systematic Review and Meta-Analysis. Neurosurgery 2017; 83:166-180. [DOI: 10.1093/neuros/nyx387] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 06/24/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Although digital subtraction angiography (DSA) may be considered the gold standard for intraoperative vascular imaging, many neurosurgical centers rely only on indocyanine green videoangiography (ICG-VA) for the evaluation of clipping accuracy. Many studies have compared the results of ICG-VA with those of intraoperative DSA; however, a systematic review summarizing these results is still lacking.
OBJECTIVE
To analyze the literature in order to evaluate ICG-VA accuracy in the identification of aneurysm remnants and vessel stenosis after aneurysm clipping.
METHODS
We performed a systematic literature review of ICG-VA accuracy during aneurysm clipping as compared to microscopic visual observation (primary endpoint 1) and DSA (primary endpoint 2). Quality of studies was assessed with the QUADAS-2 tool. Meta-analysis was performed using a random effects model.
RESULTS
The initial PubMed search resulted in 2871 records from January 2003 to April 2016; of these, 20 articles were eligible for primary endpoint 1 and 11 for primary endpoint 2. The rate of mis-clippings that eluded microscopic visual observation and were identified at ICG-VA was 6.1% (95% CI: 4.2-8.2), and the rate of mis-clippings that eluded ICG-VA and were identified at DSA was 4.5% (95% CI: 1.8-8.3).
CONCLUSION
Because a proportion of mis-clippings cannot be identified with ICG-VA, this technique should still be considered complementary rather than a replacement to DSA during aneurysm surgery. Incorporating other intraoperative tools, such as flowmetry or electrophysiological monitoring, can obviate the need for intraoperative DSA for the identification of vessel stenosis. Nevertheless, DSA likely remains the best tool for the detection of aneurysm remnants.
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Affiliation(s)
- Matteo Riva
- Department of Neurosurgery, University of Brussels, Erasme Hospital, Brussels, Belgium
- Laboratory of Tumor Immuno-logy and Immunotherapy, KU Leuven, Leuven, Belgium
- Neurosurgery, Depart-ment of Medicine and Surgery, University of Milano-Bicocca, San Gerardo University Hospital, Monza, Italy
| | | | - Carlo Giussani
- Neurosurgery, Depart-ment of Medicine and Surgery, University of Milano-Bicocca, San Gerardo University Hospital, Monza, Italy
| | - Olivier De Witte
- Department of Neuro-surgery, University of Brussels, Erasme Hospital, Brussels, Belgium
| | - Michael Bruneau
- Department of Neuro-surgery, University of Brussels, Erasme Hospital, Brussels, Belgium
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Doss VT, Goyal N, Humphries W, Hoit D, Arthur A, Elijovich L. Comparison of Intraoperative Indocyanine Green Angiography and Digital Subtraction Angiography for Clipping of Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2015; 3:129-34. [PMID: 26279659 DOI: 10.1159/000381148] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Residual aneurysm after microsurgical clipping carries a risk of aneurysm growth and rupture. Digital subtraction angiography (DSA) remains the standard to determine the adequacy of clipping. Intraoperative indocyanine green (ICG) angiography is increasingly utilized to confirm optimal clip positioning across the neck and to evaluate the adjacent vasculature. OBJECTIVE We evaluated the correlation between ICG and DSA in clipped intracranial aneurysms. METHODS A retrospective study of patients who underwent craniotomy and microsurgical clipping of intracranial aneurysms with ICG for 2 years. Patient characteristics, presentation details, operative reports, and pre- and postclipping angiographic images were reviewed to determine the adequacy of the clipping. RESULTS Forty-seven patients underwent clipping with ICG and postoperative DSA: 57 aneurysms were clipped; 23 patients (48.9%) presented with subarachnoid hemorrhage. Nine aneurysms demonstrated a residual on DSA not identified on ICG (residual sizes ranged from 0.5 to 4.3 mm; average size: 1.8 mm). Postoperative DSA demonstrated no branch occlusions. CONCLUSION Intraoperative ICG is useful in the clipping of intracranial aneurysms to ensure a gross patency of branch vessels; however, the presence of residual aneurysms and subtle changes in flow in branch vessels is best seen by DSA. This has important clinical implications with regard to follow-up imaging and surgical/endovascular management.
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Affiliation(s)
- Vinodh T Doss
- Department of Neurology, University of Tennessee Health Sciences Center., USA ; Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Neurosurgery, University of Tennessee Health Sciences Center., USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Sciences Center., USA
| | - William Humphries
- Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
| | - Dan Hoit
- Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
| | - Adam Arthur
- Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Sciences Center., USA ; Department of Neurosurgery, University of Tennessee Health Sciences Center., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
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Roessler K, Krawagna M, Dörfler A, Buchfelder M, Ganslandt O. Essentials in intraoperative indocyanine green videoangiography assessment for intracranial aneurysm surgery: conclusions from 295 consecutively clipped aneurysms and review of the literature. Neurosurg Focus 2014; 36:E7. [PMID: 24484260 DOI: 10.3171/2013.11.focus13475] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Indocyanine green (ICG) videoangiography (VA) in cerebral aneurysm surgery allows confirmation of blood flow in parent, branching, and perforating vessels as well as assessment of remnant aneurysm parts after clip application. A retrospective analysis and review of the literature were conducted to determine the current essential advantages of ICG-VA in aneurysm surgery. METHODS The authors retrospectively evaluated all aneurysm cases treated with the aid of intraoperative ICG-VA at a single institution between 2007 and 2013. They also analyzed the literature published since the initial description of ICG-VA in 2003. RESULTS Two hundred forty-six procedures were performed in 232 patients harboring 295 aneurysms. The patients, whose mean age was 54 years, consisted of 159 women and 73 men. One hundred twenty-four surgeries were performed after subarachnoid hemorrhage, and 122 were performed for incidental aneurysms. Single aneurysms were clipped in 185 patients, and multiple aneurysms were clipped in 47 (mean aneurysm diameter 6.9 mm, range 2-40 mm). No complications associated with ICG-VA occurred. Intraoperative microvascular Doppler ultrasonography was performed before ICG-VA in all patients, and postoperative digital subtraction angiography (DSA) studies were available in 121 patients (52.2%) for retrospective comparative analysis. In 22 (9%) of 246 procedures, the clip position was modified intraoperatively as a consequence of ICG-VA. Stenosis of the parent vessels (16 procedures) or occlusion of the perforators (6 procedures), not detected by micro-Doppler ultrasonography, were the most common problems demonstrated on ICG-VA. In another 11 procedures (4.5%), residual perfusion of the aneurysm was observed and one or more additional clips were applied. Vessel stenosis or a compromised perforating artery occurred independent of aneurysm location and was about equally common in middle cerebral artery and anterior communicating artery aneurysms. In 2 procedures (0.8%), aneurysm puncture revealed residual blood flow within the lesion, which had not been detected by the ICG-VA. In the postoperative DSA studies, unexpected small (< 2 mm) aneurysm neck remnants, which had not been detected on intraoperative ICG-VA, were found in 11 (9.1%) of 121 patients. However, these remnants remained without consequence except in 1 patient with a 6-mm residual aneurysm dome, which was subsequently embolized with coils. CONCLUSIONS In a large cohort of consecutive patients, ICG-VA proved to be a helpful intraoperative tool and led to a significant intraoperative clip modification rate of 15%. However, small, < 2-mm-wide neck remnants and a 6-mm residual aneurysm were missed by intraoperative ICG-VA in up to 10% of patients. Results in this study confirm that DSA is indispensable for postoperative quality assessment in complex aneurysm surgery.
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Zhao B, Cao Y, Zhao Y, Wu J, Wang S. Functional MRI-guided microsurgery of intracranial arteriovenous malformations: study protocol for a randomised controlled trial. BMJ Open 2014; 4:e006618. [PMID: 25341453 PMCID: PMC4208052 DOI: 10.1136/bmjopen-2014-006618] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Intracranial arteriovenous malformations (AVMs) are associated with high morbidity and mortality. Modern microsurgery has improved the results of surgical treatment of AVMs; however, the treatment of AVMs, particularly eloquently located AVMs, still carries a high risk. Functional MRI (fMRI) has been reported to be used for the preoperative evaluation of AVMs in small case series. The purpose is to identify the utility and efficacy of fMRI-guided microsurgery of AVMs in a large randomised controlled trial. METHODS AND ANALYSIS The study is a prospective, randomised controlled clinical trial. This study will enrol a total of 600 eligible patients. These eligible patients will be randomised to the standard microsurgery group and the fMRI-guided microsurgery group in a 1:1 ratio. Patient baseline characteristics and AVM architecture and characteristics will be described. In the fMRI-guided group, fMRI mapping of an eloquent cortex in all AVMs will be identified. Surgical complications and outcomes at pretreatment, post-treatment, at discharge and at 1-month, 3-month and 6-month follow-up intervals will be analysed using the modified Rankin Scale (mRS). This trial will determine whether fMRI-guided microsurgery could improve outcomes in patients with AVMs and also identify the safety and efficacy of fMRI-guided microsurgery. ETHICS AND DISSEMINATION The study protocol and written informed consent were reviewed and approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (ky2012-016-02). Study findings will be disseminated in the printed media. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT01758211.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
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Caplan JM, Sankey E, Yang W, Radvany MG, Colby GP, Coon AL, Tamargo RJ, Huang J. Impact of Indocyanine Green Videoangiography on Rate of Clip Adjustments Following Intraoperative Angiography. Neurosurgery 2014; 75:437-43; disucssion 444. [DOI: 10.1227/neu.0000000000000468] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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18
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Indocyanine green videoangiography methodological variations: review. Neurosurg Rev 2014; 38:49-57; discussion 57. [PMID: 25171963 DOI: 10.1007/s10143-014-0570-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 06/22/2014] [Accepted: 07/22/2014] [Indexed: 12/22/2022]
Abstract
Indocyanine green videoangiography (ICGVA) procedures have become widespread within the spectrum of microsurgical techniques for neurovascular pathologies. We have conducted a review to identify and assess the impact of all of the methodological variations of conventional ICGVA applied in the field of neurovascular pathology that have been published to date in the English literature. A total of 18 studies were included in this review, identifying four primary methodological variants compared to conventional ICGVA: techniques based on the transient occlusion, intra-arterial ICG administration via catheters, use of endoscope system with a filter to collect florescence of ICG, and quantitative fluorescence analysis. These variants offer some possibilities for resolving the limitations of the conventional technique (first, the vascular structure to be analyzed must be exposed and second, vascular filling with ICG follows an additive pattern) and allow qualitatively superior information to be obtained during surgery. Advantages and disadvantages of each procedure are discussed. More case studies with a greater number of patients are needed to compare the different procedures with their gold standard, in order to establish these results consistently.
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Fusco MR, Ogilvy CS. Perspectives: has intraoperative near infrared indocyanine green video-angiography replaced formal angiography in aneurysm surgery? World Neurosurg 2014; 82:e587-8. [PMID: 25138424 DOI: 10.1016/j.wneu.2014.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/14/2014] [Indexed: 11/20/2022]
Affiliation(s)
- Matthew R Fusco
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Hardesty DA, Thind H, Zabramski JM, Spetzler RF, Nakaji P. Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery. J Clin Neurosci 2014; 21:1377-82. [PMID: 24736193 DOI: 10.1016/j.jocn.2014.02.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/05/2014] [Indexed: 10/25/2022]
Abstract
Intraoperative angiography in cerebrovascular neurosurgery can drive the repositioning or addition of aneurysm clips. Our institution has switched from a strategy of intraoperative digital subtraction angiography (DSA) universally, to a strategy of indocyanine green (ICG) videoangiography with DSA on an as-needed basis. We retrospectively evaluated whether the rates of perioperative stroke, unexpected postoperative aneurysm residual, or parent vessel stenosis differed in 100 patients from each era (2002, "DSA era"; 2007, "ICG era"). The clip repositioning rate for neck residual or parent vessel stenosis did not differ significantly between the two eras. There were no differences in the rate of perioperative stroke or rate of false-negative studies. The per-patient cost of intraoperative imaging within the DSA era was significantly higher than in the ICG era. The replacement of routine intraoperative DSA with ICG videoangiography and selective intraoperative DSA in cerebrovascular aneurysm surgery is safe and effective.
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Affiliation(s)
- Douglas A Hardesty
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013, USA
| | - Harjot Thind
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013, USA
| | - Joseph M Zabramski
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013, USA
| | - Robert F Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013, USA
| | - Peter Nakaji
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013, USA.
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Della Puppa A, Rustemi O, Rossetto M, Gioffrè G, Munari M, Charbel FT, Scienza R. The “Squeezing Maneuver” in Microsurgical Clipping of Intracranial Aneurysms Assisted by Indocyanine Green Videoangiography. Oper Neurosurg (Hagerstown) 2014; 10 Suppl 2:208-12; discussion 212-3. [DOI: 10.1227/neu.0000000000000334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Abstract
BACKGROUND:
Indocyanine green videoangiography (ICGV) is becoming routine in intracranial aneurysm surgery to assess intraoperatively both sac obliteration and vessel patency after clipping. However, ICGV-derived data have been reported to be misleading at times. We recently noted that a simple intraoperative maneuver, the “squeezing maneuver,” allows the detection of deceptive ICGV data on aneurysm exclusion and allows potential clip repositioning. The squeezing maneuver is based on a gentle pinch of the dome of a clipped aneurysm when ICGV documents its apparent exclusion.
OBJECTIVE:
To present the surgical findings and the clinical outcome of this squeezing maneuver.
METHODS:
Data from 23 consecutive patients affected by intracranial aneurysms who underwent the squeezing maneuver were analyzed retrospectively. The clip was repositioned in all cases when the dyeing of the sac was visualized after the maneuver.
RESULTS:
In 22% of patients, after an initial ICGV showing the aneurysm exclusion after clipping, the squeezing maneuver caused the prompt dyeing of the sac; in all cases, the clip was consequently repositioned. A calcification/atheroma of the wall/neck was predictive of a positive maneuver (P = .001). The aneurysm exclusion rate at postoperative radiological findings was 100%.
CONCLUSION:
With the limits of our small series, the squeezing maneuver appears helpful in the intraoperative detection of misleading ICGV data, mostly when dealing with aneurysms with atheromatic and calcified walls.
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Affiliation(s)
| | - Oriela Rustemi
- Department of Neurosurgery and Padua University Hospital, Padua, Italy
| | - Marta Rossetto
- Department of Neurosurgery and Padua University Hospital, Padua, Italy
| | - Giorgio Gioffrè
- Department of Neurosurgery and Padua University Hospital, Padua, Italy
| | - Marina Munari
- Department of Anaesthesiology, Padua University Hospital, Padua, Italy
| | - Fady T. Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Renato Scienza
- Department of Neurosurgery and Padua University Hospital, Padua, Italy
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Della Puppa A, Volpin F, Gioffre G, Rustemi O, Troncon I, Scienza R. Microsurgical clipping of intracranial aneurysms assisted by green indocyanine videoangiography (ICGV) and ultrasonic perivascular microflow probe measurement. Clin Neurol Neurosurg 2014; 116:35-40. [DOI: 10.1016/j.clineuro.2013.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 10/08/2013] [Accepted: 11/09/2013] [Indexed: 11/25/2022]
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Lai LT, Morgan MK. Use of indocyanine green videoangiography during intracranial aneurysm surgery reduces the incidence of postoperative ischaemic complications. J Clin Neurosci 2013; 21:67-72. [PMID: 24090515 DOI: 10.1016/j.jocn.2013.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 03/31/2013] [Accepted: 04/02/2013] [Indexed: 11/16/2022]
Abstract
Microscope-integrated near-infrared indocyanine green videoangiography (ICGVA) has been shown to be a useful adjunct for intracranial aneurysm surgery. That the routine application of this technique reduces the risk of postoperative ischaemic complication, however, has not been reported. We present a retrospective matched-pair comparison of ICGVA guided aneurysm surgery versus historic control surgical cohort treated by the same author. Index patients and controls were matched for aneurysm size, location, patient demographics, risk factors, comorbidities, and surgical treatments. Ninety-one eligible patients with 100 intracranial aneurysms were treated using ICGVA assistance. There were no statistically significant differences between the two groups in terms of patient age, sex, risk factors, comorbidities and aneurysm characteristics. Of the 100 aneurysms in the ICGVA group, 107 investigations of ICGVA were performed. In 79 aneurysms (79.0%), ICGVA was considered useful but did not affect surgical management. In six patients (6.0%), ICGVA led to a crucial change of intraoperative strategies. In nine patients (9.0%), it was considered critical in assuring patency of small perforators. ICGVA was of no benefit in four patients (4.0%) and was misleading in two (2.0%). Postoperative ischaemic complications occurred in three patients (3.3%) in the ICGVA group compared with seven patients (7.7%) in the control group (p<0.001). Our study supports the use of ICGVA in aneurysm surgery as a safe and effective modality of intraoperative blood flow assessment. With all limitations of a retrospective matched-pair comparison, the use of ICGVA during routine aneurysm surgery reduces the incidence of postoperative ischaemic complications.
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Affiliation(s)
- Leon Tat Lai
- The Australian School of Advanced Medicine, 2 Technology Place, Macquarie University, Sydney, NSW 2109, Australia.
| | - Michael Kerin Morgan
- The Australian School of Advanced Medicine, 2 Technology Place, Macquarie University, Sydney, NSW 2109, Australia
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Son YJ, Kim JE, Park SB, Lee SH, Chung YS, Yang HJ. Quantitative analysis of intraoperative indocyanine green video angiography in aneurysm surgery. J Cerebrovasc Endovasc Neurosurg 2013; 15:76-84. [PMID: 23844351 PMCID: PMC3704998 DOI: 10.7461/jcen.2013.15.2.76] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/17/2013] [Accepted: 06/11/2013] [Indexed: 11/23/2022] Open
Abstract
Objective Indocyanine green (ICG) videoangiography (VA) is being used in assessment of blood flow during cerebrovascular surgery. However, data collected during ICG angiography are usually interpreted qualitatively. In this study, quantitative analysis of ICG angiogram was attempted. Materials and Methods ICG VA, performed during aneurysm surgery was analyzed retrospectively. The angiogram was captured serially in regular time interval. The stacked images were then fed into an image analysis program, ImageJ. The selected areas of interest were as follows: parent and branch vessels, and dome of aneurysm. Changes of signals of measurement points were plotted. The time to peak, washout time, and the peak intensity between areas were compared. Results Among the 16 cases enrolled in this study, five cases were anterior communicating artery aneurysms, and 11 cases were middle cerebral artery bifurcation aneurysms. There was no signal intensity of aneurysm dome in our series. No difference in time to peak or maximum signal intensity was observed between vessels in each case. The average time to peak was 9.0 and washout time was 31.3 seconds. No significant difference in time profile was observed between anterior communicating artery aneurysms and middle cerebral artery bifurcation aneurysms. Conclusion Findings of this study demonstrate that quantitative analysis is possible using a personal computer and common video capture and analysis software. It can be a good adjunctive to evaluation of vascular status during aneurysm surgery. It displays time profiles of multiple points of interest over time, and is helpful in objective evaluation of changes of blood flow over time. It might be helpful in various fields of cerebrovascular surgery.
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Affiliation(s)
- Young-Je Son
- Department of Neurosurgery, Seoul National University Boramae Hospital, Republic of Korea
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Esposito G, Durand A, Van Doormaal T, Regli L. Selective-targeted extra-intracranial bypass surgery in complex middle cerebral artery aneurysms: correctly identifying the recipient artery using indocyanine green videoangiography. Neurosurgery 2013; 71:ons274-84; discussion ons284-5. [PMID: 22902337 DOI: 10.1227/neu.0b013e3182684c45] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Treatment of complex middle cerebral artery (MCA) aneurysms often requires vessel sacrifice or prolonged temporary occlusion with extra- to intracranial (EC-IC) bypass to preserve perfusion. A crucial surgical step is the identification of the bypass recipient artery matching the distal territory of the involved vessel. OBJECTIVE To report about the feasibility and efficiency of an indocyanine green videoangiography (ICG-VA) assisted technique for identification of cortical recipient vessels to perform selective-targeted EC-IC bypass. METHODS The proposed technique is based on the analysis of differences in the timing of filling of M4 vessels seen on serial ICG-VAs. A delayed fluorescence can be visualized either primarily on a baseline ICG-VA or secondarily on an ICG-VA performed during temporary occlusion of the involved MCA branch. M4 branches presenting delayed fluorescence represent suitable bypass recipient arteries. We report 7 consecutive patients treated for complex MCA aneurysms with selective-targeted EC-IC bypass. RESULTS Application of the proposed technique permitted the correct identification of recipient arteries (cortical branches of the involved MCA segment) in all patients. The cortex distal to the occlusion filled concomitantly on ICG-VA at the end of surgery. All patients underwent successful treatment of the aneurysm, including a cortical bypass. There were no ischemic complications, and a favorable clinical outcome was achieved in all patients (modified Rankin Scale at follow-up ≤ modified Rankin Scale preoperative). CONCLUSION The proposed ICG-VA-based technique enables reliable and accurate identification of the cortical recipient artery and eliminates the risk of erroneous revascularization of noninvolved territories.
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Affiliation(s)
- Giuseppe Esposito
- Department of Neurosurgery, Division of Neuroscience, Rudolf Magnus Institute, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, the Netherlands.
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Özgiray E, Aktüre E, Patel N, Baggott C, Bozkurt M, Niemann D, Başkaya MK. How reliable and accurate is indocyanine green video angiography in the evaluation of aneurysm obliteration? Clin Neurol Neurosurg 2012; 115:870-8. [PMID: 22959212 DOI: 10.1016/j.clineuro.2012.08.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 06/27/2012] [Accepted: 08/12/2012] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Indocyanine green video angiography (ICG-VA) has been recently introduced into neurovascular surgery and gained a role in assessing vessel patency and obliteration of intracranial aneurysms (IA) after clipping. Although its correlation with intra-postoperative angiography was demonstrated in previous studies, difficulties in evaluating aneurysm obliteration have not been reported. We report reliability and accuracy of ICG-VA in 109 clipped aneurysms with attention given to five cases in which ICG-VA evaluation resulted in false indication that aneurysms were secure in terms of complete obliteration. MATERIALS AND METHODS A retrospective chart review was performed of IAs surgically treated by a single surgeon from January 2009. In all cases, aneurysm obliteration was confirmed by a combination of microdoppler ultrasonography (MUSG), ICG-VA, and post-operative angiography. RESULTS ICG-VA appropriately assessed vessel patency and aneurysm obliteration in 93.5% of aneurysms clipped. In four cases (3.6%), puncturing the dome of the aneurysm after satisfactory clipping revealed persistent flow within the aneurysm despite ICG-VA showing no flow after clipping. In one case (0.9%), ICG-VA showed persistent flow within the aneurysm and MUSG did not, and puncture of the dome confirmed no flow within the aneurysm. In one case (0.9%), ICG-VA failed to demonstrate residual neck. CONCLUSION ICG-VA is a simple and safe procedure and an important adjunct to microsurgical clipping of aneurysm. Although ICG-VA assesses vessel patency and obliteration of aneurysms in most cases, applying the principles of microsurgery in aneurysm clipping remains a main tool for obtaining the complete obliteration of aneurysm along with preservation of the normal vasculature.
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Affiliation(s)
- Erkin Özgiray
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53792, USA
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Bruneau M, Appelboom G, Rynkowski M, Van Cutsem N, Mine B, De Witte O. Endoscope-integrated ICG technology: first application during intracranial aneurysm surgery. Neurosurg Rev 2012; 36:77-84; discussion 84-5. [PMID: 22918545 DOI: 10.1007/s10143-012-0419-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 05/23/2012] [Accepted: 07/15/2012] [Indexed: 10/28/2022]
Abstract
Microscopic indocyanine green videoangiography (mICG-VA) has gained wide acceptance during intracranial aneurysm surgery by lowering rates of incomplete clipping and occlusion of surrounding vessels. However, mICG-VA images are limited to the microscopic view and some deeper areas, including the aneurysm sac/neck posterior side, cannot be efficiently assessed as they are hidden by the aneurysm, clips, or surrounding structures. Contrarily, endoscopes allow a wider area of visualization, but neurosurgical endoscopes to date only provided visual data. We describe the first application of endoscope ICG-integrated technology (eICG) applied in an initial case of anterior communicating artery aneurysm clipping. This new technique provided also relevant information regarding aneurysm occlusion and patency of parent and branching vessels and small perforating arteries. eICG-VA provided additional information compared to mICG-VA by magnifying areas of interest and improving the ability to view less accessible regions, especially posterior to the aneurysm clip. Obtaining eICG sequences required currently the microscope to be moved away from the operating field. eICG-VA was only recorded under infrared illumination which prevented tissue handling, but white-infrared light views could be interchanged instantaneously. Further development of angled endoscopes integrating the ICG technology and dedicated filters blocking the microscopic light could improve visualization capacities even further. In conclusion, as a result of its ability to reveal structures around corners, the eICG-VA technology could be beneficial when used in combination with mICG-VA to visualize and confirm vessel patency in areas that were previously hidden from the microscope.
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Affiliation(s)
- Michaël Bruneau
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles-ULB, Route de Lennik, 808, 1070, Brussels, Belgium.
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Faber F, Thon N, Fesl G, Rachinger W, Guckler R, Tonn JC, Schichor C. Enhanced analysis of intracerebral arterioveneous malformations by the intraoperative use of analytical indocyanine green videoangiography: technical note. Acta Neurochir (Wien) 2011; 153:2181-7. [PMID: 21894496 DOI: 10.1007/s00701-011-1141-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Accepted: 08/22/2011] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Florian Faber
- Department of Neurosurgery, Klinikum Grosshadern, Ludwig-Maximilians-University, Munich, Germany.
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Current Indications for Indocyanine Green Angiography. World Neurosurg 2011; 76:405-6. [DOI: 10.1016/j.wneu.2011.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 05/02/2011] [Indexed: 11/19/2022]
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