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Dellaretti M, Guimarães Soares A, Douglas de Oliveira Lima A, Tavares de Melo M, Dilella Acherman N, Faglioni Junior W, Silva Costa B. Application of fluorescein sodium videoangiography in aneurysm surgery. J Clin Neurosci 2024; 126:228-233. [PMID: 38968808 DOI: 10.1016/j.jocn.2024.06.027] [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: 05/14/2024] [Revised: 06/02/2024] [Accepted: 06/30/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND The use of fluorescent technologies in vascular neurosurgery emerged after indocyanine green video angiography (ICG-VA) was first described in 2003. As data supporting the efficiency of ICG in preventing postoperative complications has grown substantially, it has now established itself as the standard of care. However, the predominant literature centers on ICG techniques, leaving the evaluation of cost-effective fluorescein tools pending. We report the results of a prospective study in which we demonstrated the impact of intraoperative fluorescein videoangiography (FL-VA) in aneurysm surgery. METHODS Between December 2021 and September 2022, a total of 57 patients underwent craniotomy for intracranial aneurysm surgery. After aneurysm clipping, we administered a 0.5 mg/Kg of sodium fluorescein, and the intracranial area of interest was inspected through the microscope integrated module. The following data were collected: patient age and sex; number of clipped aneurysms; aneurysm location, size, and rupture status; Hunt Hess grade; intraoperative rupture; aneurysm calcification and thrombosed aneurysm; visualization of blood flow in perforating arteries; need for a clip adjustment after FL-VA analysis by neurosurgeon. RESULTS For the surgical clipping of 64 aneurysms in 57 patients, 80 FL-VA studies were performed. Clip adjustments were performed following FL-VA in 13 aneurysms. FL-VA had an impact on 20 % of the clipping. In seven aneurysms, clip adjustment was due to the "presence of residual aneurysm", in three cases due to the "presence of neck", and in three cases due to "adjacent vessel stenosis". Regarding the evaluation of flow in the perforating vessels, it was possible, with a good and detailed image in all cases. CONCLUSION The use of FL-VA has a significant impact in aneurysm surgery, enhancing effectiveness and safety. The dosage of 0.5 mg/kg administered is sufficient for assessing both aneurysm occlusion and the presence of flow in adjacent vessels.
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Affiliation(s)
- Marcos Dellaretti
- Department of Neurosurgery, Santa Casa BH Hospital, Belo Horizonte, MG, Brazil; Santa Casa BH College, Belo Horizonte, MG, Brazil.
| | | | - Alan Douglas de Oliveira Lima
- Department of Neurosurgery, Santa Casa BH Hospital, Belo Horizonte, MG, Brazil; Santa Casa BH College, Belo Horizonte, MG, Brazil
| | | | | | - Wilson Faglioni Junior
- Department of Neurosurgery, Santa Casa BH Hospital, Belo Horizonte, MG, Brazil; Santa Casa BH College, Belo Horizonte, MG, Brazil
| | - Bruno Silva Costa
- Department of Neurosurgery, Santa Casa BH Hospital, Belo Horizonte, MG, Brazil
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Kırış T, Akçakaya MO. Comparison of intraoperative sodium fluorescein and indocyanine green videoangiography during intracranial aneurysm and arteriovenous malformation surgery. Clin Neurol Neurosurg 2024; 244:108414. [PMID: 39002271 DOI: 10.1016/j.clineuro.2024.108414] [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: 04/26/2024] [Revised: 06/13/2024] [Accepted: 06/28/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVE Indocyanine green (ICG) and sodium fluorescein (Na-Fl) are two fluorophores, which are used for videoangiography purposes. This prospective study reports our experience by using surgical microscopes equipped with two special filters. We compared the imaging efficacy of Na-FL and ICG videoangiography techniques during aneurysm and arteriovenous malformations (AVM) surgeries. PATIENT AND METHODS Fourtynine consecutive patients were operated between September 2015 and December 2022. Patients with ruptured/unruptured aneurysms or with AVMs presented with/without hemorrhage were included to the current study. RESULTS There were a total of 48 aneurysms and 11 AVMs in 49 patients in the current study. Na-Fl enables the surgeon to manipulate vessels and aneurysms real-time. ICG provides the ability to watch the videoangiography repeatedly and understand the angioarchitecture. The use of FLOW-800 module allows the surgeon to make concrete judgements about the flow dynamics of AVMs and therefore ICG videoangiography found useful in AVM surgery. Na-Fl has been found more useful for the evalution of the low caliber perforating arteries and anatomical features of the aneursym dome in aneurysm surgery. CONCLUSION The results of our series demonstrated the safety and efficacy of Na-Fl use in the surgery of aneurysms and AVMs. Both the ICG and Na-Fl videoangiographies are easy to perform and complimentary to each other. Combined use of these two mediums may provide better surgical results, considering the separate advantages and disadvantages of these both techniques.
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Affiliation(s)
- Talat Kırış
- Department of Neurosurgery, American Hospital, Istanbul, Turkey
| | - Mehmet Osman Akçakaya
- Department of Neurosurgery, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey.
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Sasaki T, Murakami K, Saito A, Haryu S, Kameyama M, Takahashi Y, Takamuro S, Kato N, Endo T. Usefulness of Transcranial Motor Evoked Potential in Clipping Surgery for Cerebral Aneurysms-Introduction of a New Protocol for Stable Monitoring. Neurol Med Chir (Tokyo) 2023; 63:409-419. [PMID: 37380449 PMCID: PMC10556210 DOI: 10.2176/jns-nmc.2023-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/17/2023] [Indexed: 06/30/2023] Open
Abstract
The usefulness of transcranial motor evoked potentials (Tc-MEPs) in clipping surgery has been reported. However, numerous false positive and false negative cases were reported. We report the usefulness of a new protocol compared with direct cortical MEP (Dc-MEP).Materials were 351 patients who underwent aneurysmal clipping under simultaneous monitoring of Tc- and Dc-MEPs. A total of 337 patients without hemiparesis and 14 with hemiparesis were separately analyzed. Intraoperative changes of Tc-MEP thresholds were examined in the first 50 patients without hemiparesis. The stimulation strength of Tc-MEP was set at +20% of the stimulation threshold. As thresholds changed intraoperatively, thresholds were examined every 10 min and changed stimulation strength.Stimulation thresholds of Tc-MEP were significantly decreased after craniotomy and significantly increased after CSF aspiration. The recording ratios of Tc- and Dc-MEPs were 98.8% and 90.5%, respectively. Out of 304 patients without MEP change, 5 patients developed transient or mild hemiparesis with infarction of the territory of the perforating artery arising from the posterior communicating artery. Out of 31 patients whose MEP transiently disappeared, 3 patients developed transient or mild hemiparesis. The other two patients without MEP recovery manifested persistent hemiparesis. In 14 patients with preoperative hemiparesis, 3 patients whose healthy/affected ratio of Tc-MEP was large developed severe persistent hemiparesis.We clarified the intraoperative changes of Tc-MEP thresholds for the first time. A new protocol of Tc-MEP that followed thresholds and changed stimulation strength to +20% of thresholds is useful for stable monitoring. The usefulness of Tc-MEP is the same as that or better than that of Dc-MEP.
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Affiliation(s)
- Tatsuya Sasaki
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
| | | | | | - Shinya Haryu
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
| | - Masayuki Kameyama
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
| | | | - Satoru Takamuro
- School of Medicine, Tohoku Medical and Pharmaceutical University
| | - Nana Kato
- School of Medicine, Tohoku Medical and Pharmaceutical University
| | - Toshiki Endo
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
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Spetzger U. Enhance Safety in Aneurysm Surgery: Strategies for Prevention of Intraoperative Vascular Complications. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:53-64. [PMID: 37548724 DOI: 10.1007/978-3-030-12887-6_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Complications during surgery for intracranial aneurysms can be devastating. Notorious pitfalls include premature rupture, parent vessel occlusion, local cerebral injury and brain contusion, and incomplete neck obliteration. These unfavorable intraoperative events can result in major neurological deficits with permanent morbidity and even mortality. Herein, the author highlights the relevant surgical strategies used in his daily practice of aneurysm surgery (e.g., aneurysm clipping with adenosine-induced temporary cardiac arrest), application of which may help prevent vascular complications and enhance surgical safety through reduction of the associated risks, thus allowing improvement of postoperative outcomes. Overall, all described methods and techniques should be considered as small pieces in the complex puzzle of prevention of vascular complications during aneurysm surgery.
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Affiliation(s)
- Uwe Spetzger
- Department of Neurosurgery, Klinikum Karlsruhe, Karlsruhe, Germany.
- Faculty of Computer Science, Institute for Anthropomatics, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany.
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Hama S, Yokoi T, Okada M, Uemura T, Takamatsu K, Nakamura H. Microvascular neural blood flow assessment for a chronic nerve compression neuropathy mouse model by fluorescein angiography. Neurol Res 2022; 44:937-945. [DOI: 10.1080/01616412.2022.2072101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Shunpei Hama
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuya Yokoi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
- Department of Orthopaedic Surgery, Seikeikai Hospital, Osaka, Japan
| | - Mitsuhiro Okada
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuya Uemura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, Osaka, Japan
| | - Kiyohito Takamatsu
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
- Department of Orthopaedic Surgery, Yodogawa Christian Hospital, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Świątnicki W, Urbaniak F, Szymański J, Szymańska A, Komuński P. Intra-operative fluorescein videoangiography-related nephrotoxicity in intracranial aneurysm surgery: Single center, observational cohort study. Clin Neurol Neurosurg 2021; 203:106597. [PMID: 33725507 DOI: 10.1016/j.clineuro.2021.106597] [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: 01/13/2021] [Revised: 02/08/2021] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Intra-operative fluorescein video angiography (FL-VA) has been given increasing attention recently and several studies reported its high utility in neurovascular surgery. The aim of this study was to evaluate the safety of FL-VA in a prospective, single-center cohort of patients operated due to cerebral aneurysms. PATIENTS AND METHODS This is an observational cohort study including 150 patients operated due to intracranial aneurysms. The study group consisted of 70 consecutive patients operated with the use of fluorescein video angiography. Post-operative acute kidney injury (AKI) occurrence as well as systemic adverse reactions were reported and further compared with 80 matched controls where FL-VA was not used. Statistical analysis was performed using non-parametric tests (Fisher's exact test). RESULTS Post-operative AKI was observed in 17,1% of patients in the study group with only half presenting with acute functional impairment. All of these patients presented initially due to aneurysm rupture. Pre-existing renal dysfunction and hypertension occurred in 16,7% and 33,3%, respectively. No systemic complications following FL-VA were reported. When compared to matched controls, no statistically significant difference regarding AKI occurrence was observed between these two patient populations. CONCLUSION Intra-operative fluorescein video angiography proved to have a good safety profile in our cohort. The results of this study suggest that post-operative acute kidney injury observed in patients with subarachnoid hemorrhage is not related to fluorescein use.
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Affiliation(s)
- Wojciech Świątnicki
- Department of Neurosurgery, Maria Skłodowska-Curie Regional Specialist Hospital, District of Łódź-North, Zgierz, Poland.
| | - Filip Urbaniak
- Department of Neurosurgery, Maria Skłodowska-Curie Regional Specialist Hospital, District of Łódź-North, Zgierz, Poland
| | | | - Anna Szymańska
- Faculty of Economics and Sociology, University of Lodz, Poland
| | - Piotr Komuński
- Department of Neurosurgery, Maria Skłodowska-Curie Regional Specialist Hospital, District of Łódź-North, Zgierz, Poland
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Belykh E, Zhao X, Ngo B, Farhadi DS, Kindelin A, Ahmad S, Martirosyan NL, Lawton MT, Preul MC. Visualization of brain microvasculature and blood flow in vivo: Feasibility study using confocal laser endomicroscopy. Microcirculation 2021; 28:e12678. [PMID: 33426724 DOI: 10.1111/micc.12678] [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: 05/01/2020] [Accepted: 12/31/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Qualitative and quantitative analyses of blood flow in normal and pathologic brain and spinal cord microvasculature were performed using confocal laser endomicroscopy (CLE). METHODS Blood flow in cortical, dural, and spinal cord microvasculature was assessed in vivo in swine. We assessed microvasculature under normal conditions and after vessel occlusion, brain injury due to cold or surgical trauma, and cardiac arrest. Tumor-associated microvasculature was assessed in vivo and ex vivo in 20 patients with gliomas. RESULTS We observed erythrocyte flow in vessels 5-500 µm in diameter. Thrombosis, flow arrest and redistribution, flow velocity changes, agglutination, and cells rolling were assessed in normal and injured brain tissue. Microvasculature in in vivo CLE images of gliomas was classified as normal in 68% and abnormal in 32% of vessels on the basis of morphological appearance. Dural lymphatic channels were discriminated from blood vessels. Microvasculature CLE imaging was possible for up to 30 minutes after a 1 mg/kg intravenous dose of fluorescein. CONCLUSIONS CLE imaging allows assessment of cerebral and tumor microvasculature and blood flow alterations with subcellular resolution intraoperative imaging demonstrating precise details of real-time cell movements. Research and clinical scenarios may benefit from this novel intraoperative in vivo microscopic fluorescence imaging modality.
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Affiliation(s)
- Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Xiaochun Zhao
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Brandon Ngo
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Dara S Farhadi
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Adam Kindelin
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Saif Ahmad
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nikolay L Martirosyan
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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SHIMADA K, YAMAMOTO Y, MIYAMOTO T, SOGABE S, FUJIHARA T, NAKAJIMA K, MIZOBUCHI Y, KANEMATSU Y, TAKAGI Y. Efficacy of Intra-arterial Indocyanine Green Videoangiography in Hemangioblastoma Surgery: A Case Report. NMC Case Rep J 2021; 8:295-300. [PMID: 35079478 PMCID: PMC8769404 DOI: 10.2176/nmccrj.cr.2020-0281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/19/2020] [Indexed: 11/20/2022] Open
Abstract
Intravenous indocyanine green (ICG) videoangiography is reportedly useful for vascular neurosurgery, and for treating hemangioblastoma due to its high vascularity. Videoangiography obtained after intra-arterial ICG injection has emerged as a more useful option than that after intravenous injection. This report offers the first description of a case of hemangioblastoma successfully treated using intra-arterial ICG videoangiography, and describes the efficacy of this technique. A 20-year-old man presented with progressive cerebellar ataxia and dysphagia. Magnetic resonance imaging (MRI) revealed an enhanced solid tumor in the medulla oblongata. Digital subtraction angiography (DSA) showed a highly vascularized tumor. Surgery was performed to remove the tumor in a hybrid operating room. A catheter was introduced into the vertebral artery (VA) for intra-arterial ICG videoangiography. Superficial feeders and drainers were identified and flow dynamic changes in the tumor were assessed by intra-arterial ICG videoangiography. The tumor was removed after confirming lack of flow in the drainer. Intra-arterial ICG videoangiography was more useful than intravenous ICG videoangiography in hemangioblastoma surgery for identifying feeders and drainers and assessing flow dynamics in the tumor. Use of Flow 800 made these findings simpler and easier to evaluate.
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Affiliation(s)
- Kenji SHIMADA
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yoko YAMAMOTO
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Takeshi MIYAMOTO
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Shu SOGABE
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Toshitaka FUJIHARA
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Kohei NAKAJIMA
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yoshihumi MIZOBUCHI
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yasuhisa KANEMATSU
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yasushi TAKAGI
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
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Ito Y, Suzuki K, Ichikawa T, Watanabe Y, Sato T, Sakuma J, Saito K. Intraoperative Fluorescence Cerebral Angiography by Laser Surgical Microscopy: Comparison With Xenon Microscopy and Simultaneous Observation of Cerebral Blood Flow and Surrounding Structures. Oper Neurosurg (Hagerstown) 2020; 16:700-706. [PMID: 29897605 DOI: 10.1093/ons/opy159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Laser surgical microscopes should enable uniform illumination of the operative field, and require less luminous energy compared with existing xenon surgical microscopes. OBJECTIVE To examine the utility of laser illumination in fluorescence cerebral angiography. METHODS Fluorescein sodium (fluorescein) was used as a fluorescent dye. We first compared the clarity of cerebral blood flow images collected by fluorescence angiography between the laser illumination and xenon illumination methods. We then assessed use of the laser illuminator for simultaneous observation of blood flow and surrounding structures during fluorescence angiography. Furthermore, the study was designed to evaluate usefulness of the thus determined excitation light in clinical cases. RESULTS Fluorescence angiography using blue light laser for excitation provided higher clarity and contrast blood flow images compared with using blue light generated from a xenon lamp. Further, illumination with excitation light consisting of a combination of 3 types of laser (higher level of blue light, no green light, and lower level of red light) enabled both blood flow and surrounding structures to be observed through the microscope directly by the surgeon. CONCLUSION Laser-illuminated fluorescence angiography provides high clarity and contrast images of cerebral blood flow. Further, a laser providing strong blue light and weak red light for excitation light enables simultaneous visual observation of fluorescent blood flow and surrounding structures by the surgeon using a surgical microscope. Overall, these data suggest that laser surgical microscopes are useful for both ordinary operative manipulations and fluorescence angiography.
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Affiliation(s)
- Yuhei Ito
- Department of Neurosurgery, Fukushima Red Cross Hospital, Fukushima-shi, Fukushima, Japan.,Department of Neurosurgery, Fukushima Medical University, Fukushima-shi, Fukushima, Japan
| | - Kyouichi Suzuki
- Department of Neurosurgery, Fukushima Red Cross Hospital, Fukushima-shi, Fukushima, Japan
| | - Tsuyoshi Ichikawa
- Department of Neurosurgery, Fukushima Red Cross Hospital, Fukushima-shi, Fukushima, Japan
| | - Yoichi Watanabe
- Department of Neurosurgery, Fukushima Red Cross Hospital, Fukushima-shi, Fukushima, Japan
| | - Taku Sato
- Department of Neurosurgery, Fukushima Medical University, Fukushima-shi, Fukushima, Japan
| | - Jun Sakuma
- Department of Neurosurgery, Fukushima Medical University, Fukushima-shi, Fukushima, Japan
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Medical University, Fukushima-shi, Fukushima, Japan
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Inoue A, Kohno S, Ohnishi T, Nishida N, Suehiro S, Nakamura Y, Matsumoto S, Nishikawa M, Ozaki S, Shigekawa S, Watanabe H, Senba H, Nakaguchi H, Taniwaki M, Matsuura B, Kitazawa R, Kunieda T. Tricks and traps of ICG endoscopy for effectively applying endoscopic transsphenoidal surgery to pituitary adenoma. Neurosurg Rev 2020; 44:2133-2143. [PMID: 32889658 DOI: 10.1007/s10143-020-01382-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/02/2020] [Accepted: 09/01/2020] [Indexed: 11/27/2022]
Abstract
Differentiating tumor from normal pituitary gland is very important for achieving complete resection without complications in endoscopic endonasal transsphenoidal surgery (ETSS) for pituitary adenoma. To facilitate such surgery, we investigated the utility of indocyanine green (ICG) fluorescence endoscopy as a tool in ETSS. Twenty-four patients with pituitary adenoma were enrolled in the study and underwent ETSS using ICG endoscopy. After administering 12.5 mg of ICG twice an operation with an interval > 30 min, times from ICG administration to appearance of fluorescence on vital structures besides the tumor were measured. ICG endoscopy identified vital structures by the phasic appearance of fluorescent signals emitted at specific consecutive elapsed times. Elapsed times for internal carotid arteries did not differ according to tumor size. Conversely, as tumor size increased, elapsed times for normal pituitary gland were prolonged but those for the tumor were reduced. ICG endoscopy revealed a clear boundary between tumors and normal pituitary gland and enabled confirmation of no more tumor. ICG endoscopy could provide a useful tool for differentiating tumor from normal pituitary gland by evaluating elapsed times to fluorescence in each structure. This method enabled identification of the boundary between tumor and normal pituitary gland under conditions of a low-fluorescence background, resulting in complete tumor resection with ETSS. ICG endoscopy will contribute to improve the resection rate while preserving endocrinological functions in ETSS for pituitary adenoma.
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Affiliation(s)
- Akihiro Inoue
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Shohei Kohno
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Takanori Ohnishi
- Department of Neurosurgery, Washoukai Sadamoto Hospital, 1-6-1 Takehara, Matsuyama, Ehime, 790-0052, Japan
| | - Naoya Nishida
- Department of Otolaryngology, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Satoshi Suehiro
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yawara Nakamura
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Shirabe Matsumoto
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Masahiro Nishikawa
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Saya Ozaki
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Seiji Shigekawa
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Hideaki Watanabe
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Hidenori Senba
- Department of Lifestyle-Related Medicine and Endocrinology, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Hironobu Nakaguchi
- Department of Lifestyle-Related Medicine and Endocrinology, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Mashio Taniwaki
- Division of Diagnostic Pathology, Ehime University Hospital, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Bunzo Matsuura
- Department of Lifestyle-Related Medicine and Endocrinology, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Riko Kitazawa
- Division of Diagnostic Pathology, Ehime University Hospital, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Takeharu Kunieda
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
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Shimada K, Yamaguchi T, Miyamoto T, Sogabe S, Korai M, Okazaki T, Kanematsu Y, Satomi J, Nagahiro S, Takagi Y. Efficacy of intraarterial superselective indocyanine green videoangiography in cerebral arteriovenous malformation surgery in a hybrid operating room. J Neurosurg 2020; 134:1544-1552. [PMID: 32442970 DOI: 10.3171/2020.3.jns20319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although intravenous indocyanine green (ICG) videoangiography has been reported to be useful when applied to cerebral arteriovenous malformation (AVM) surgery, the ICG that remains after the procedure makes it difficult to understand the anatomy, to evaluate nidus blood flow changes, and to repeat ICG videoangiography within a short time. Intraarterial ICG videoangiography has emerged as a way to overcome these limitations. The current study presents the results of intraarterial ICG videoangiography undertaken in patients with cerebral AVMs. METHODS Intraarterial ICG videoangiography was performed in 13 patients with cerebral AVMs. Routine intraoperative digital subtraction angiography at the authors' institution is performed in a hybrid operating room during AVM surgery and includes the added step of injecting ICG to the contrast medium that is administered through a catheter. RESULTS Predissection studies were able to visualize the feeder in 12 of 13 cases. The nidus was visualized in 12 of 13 cases, while the drainer was visualized in all cases. After total dissection of the nidus, there was no ICG filling in the drainers found in any of the cases. Washout of the ICG took 4.4 ± 1.3 seconds in the feeders, 9.2 ± 3.5 seconds in the drainers, and 20.9 ± 3.4 seconds in all of the vessels. Nidus flow reduction was confirmed during dissection in 9 of 9 cases. Flow reduction was easy to recognize due to each span being very short. Color-encoded visualization and objective data obtained by Flow 800 analysis reinforced these findings. CONCLUSIONS The results showed that intraarterial ICG videoangiography was more useful than intravenous ICG videoangiography in cerebral AVM surgery. This was especially effective in the identification of the feeder, nidus, and drainer and in the assessment of the flow dynamics of the nidus. Use of Flow 800 made it simpler and easier to evaluate these findings.
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Affiliation(s)
- Kenji Shimada
- 1Department of Neurosurgery, Tokushima University Hospital, Tokushima
| | - Tadashi Yamaguchi
- 1Department of Neurosurgery, Tokushima University Hospital, Tokushima
| | - Takeshi Miyamoto
- 1Department of Neurosurgery, Tokushima University Hospital, Tokushima
| | - Shu Sogabe
- 1Department of Neurosurgery, Tokushima University Hospital, Tokushima
| | - Masaaki Korai
- 2Department of Neurosurgery, Shikoku Medical Center for Children and Adults, Zentsuji, Kagawa
| | - Toshiyuki Okazaki
- 3Department of Spine, Spinal Cord, Peripheral Nerve Surgery, Shin-yurigaoka General Hospital, Kawasaki, Kanagawa
| | | | | | - Shinji Nagahiro
- 5Department of Neurosurgery, Yoshinogawa Hospital, Itano, Tokushima, Japan
| | - Yasushi Takagi
- 1Department of Neurosurgery, Tokushima University Hospital, Tokushima
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12
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Zhao X, Belykh E, Cavallo C, Valli D, Gandhi S, Preul MC, Vajkoczy P, Lawton MT, Nakaji P. Application of Fluorescein Fluorescence in Vascular Neurosurgery. Front Surg 2019; 6:52. [PMID: 31620443 PMCID: PMC6759993 DOI: 10.3389/fsurg.2019.00052] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/27/2019] [Indexed: 12/26/2022] Open
Abstract
Background: Fluorescein sodium (FNa) is a fluorescent drug with a long history of use for assessing retinal blood flow in ophthalmology; however, its application in vascular neurosurgery is only now gaining popularity. This review summarizes the current knowledge about using FNa videoangiography in vascular neurosurgery. Methods: We performed a literature review on the usage of FNa for fluorescent videoangiography procedures in neurosurgery. We analyzed methods of injection, dosages of FNa, visualizing platforms, and interpretation of FNa videoangiography. We also reviewed practical applications of FNa videoangiography during various vascular neurosurgeries. Results: FNa videoangiography can be performed with intraarterial (intracarotid) or intravenous dye injections. Both methods provide excellent resolution with enhanced fluorescence that shows intravascular blood flow on top of visible surrounding anatomy, and both allow simultaneous purposeful microsurgical manipulations. Although it is invasive, an intracarotid FNa injection results in faster contrast appearance and higher-intensity fluorescence and requires a lower dose per injection (reported range, 1–50 mg) compared with peripheral intravenous FNa injection (reported range, 75–2,000 mg or 1–1.5 mg/kg body weight). Four optical excitation/detection tools for FNa videoangiography have been successfully used: conventional xenon-light operating microscope with a special filter set, pencil-type light-emitting diode probe with a filter set, laser-illumination operating microscope, and an endoscope with a filter set. FNa videoangiography was reported to be feasible and useful in various clinical scenarios, such as examining the feeders and drainers in arteriovenous malformation surgery, checking the patency of a microvascular anastomosis, and assessing blood flow during aneurysm clipping. FNa videoangiography can be repeated during the same procedure and used along with indocyanine green (ICG) videoangiography. Conclusions: Compared with ICG videoangiography, FNa videoangiography has the advantages of enabling real-time inspection and better visualization at deep locations; however, thick vessel walls limit visualization of FNa in larger vessels. FNa videoangiography is a useful tool in multiple neurovascular scenarios and merits further studies to establish its clinical value.
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Affiliation(s)
- Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States.,Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Daniel Valli
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
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Fatima N, Al Sulaiti G, Al Rumaihi G. Onyx Embolization of Distal Middle Cerebral Artery Aneurysm in a Patient with Nontraumatic Subdural Hematoma. Asian J Neurosurg 2019; 14:915-918. [PMID: 31497128 PMCID: PMC6703069 DOI: 10.4103/ajns.ajns_58_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Distal cortical middle cerebral artery (MCA) aneurysm is a rare entity. Despite the challenging procedure, the role of endovascular treatment is emerging due to its safety and efficacy in obliterating the microaneurysm. We report a 25-year-old male, who presented with a history of dizziness and headache for almost 2 weeks. Computed tomography scan showed a right front parietal subdural hematoma (SDH). We could not identify any underlying defining etiology of SDH neither head injury nor coagulopathy disorder. Therefore, diagnostic cerebral angiogram was performed, which showed a microaneurysm in the distal right MCA cortical branch. Hence, complete obliteration of this microaneurysm was performed using Onyx for endovascular embolization. Therefore, this case report demonstrates the efficacy of this modality in the treatment of microaneurysms with SDH.
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Affiliation(s)
- Nida Fatima
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
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14
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Matano F, Mizunari T, Murai Y, Kubota A, Fujiki Y, Kobayashi S, Morita A. Quantitative Comparison of the Intraoperative Utility of Indocyanine Green and Fluorescein Videoangiographies in Cerebrovascular Surgery. Oper Neurosurg (Hagerstown) 2019; 13:361-366. [PMID: 28521359 DOI: 10.1093/ons/opw020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 04/19/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A quantitative analysis comparing indocyanine green videoangiography (ICG-VAG) and fluorescein videoangiography (FL-VAG) in cerebrovascular surgery has not been reported so far. OBJECTIVE To clear the differences of characteristics of ICG-VAG and FL-VAG by quantitative assessment. METHODS We prospectively analyzed results from 23 patients (3 males; mean age at surgery: 60.9 years, range: 14-75 years) at our hospital from August 2014 to July 2015. Eighteen patients had cerebral aneurysms for clipping, and 5 had intracranial arterial stenosis for superficial temporal artery (STA)-middle cerebral artery bypass. We imported data from the operative image data, converted by Audio Video Interleave to Aquacosmos as picture fluorescence intensity-analyzing software. Regions of interest were set at the parent artery, dome of aneurysms, and perforating artery in cases of clipping of aneurysms, and setting at 3 points in STA, in case of bypass. The transition of fluorescence intensity at each region of interest was calculated and plotted using Aquacosmos. RESULTS Thick-walled artery, such as parent artery ( P = .0017) and STA ( P = .0182), was more significantly visualized by ICG-VAG than FL-VAG, whereas the perforating artery, especially in deep surgical fields, such as anterior communicating artery, internal carotid artery, and basilar artery, was better visualized by FL-VAG than ICG-VAG ( P < .0001). CONCLUSION In this quantitative analysis of fluorescence study, ICG-VAG showed greater efficacy than FL-VAG in visualizing relatively thick arteries, such as parent artery and STA. However, FL-VAG has greater efficacy than ICG-VAG in visualizing perforating artery, especially in deep surgical fields with characteristic vessel walls.
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Affiliation(s)
- Fumihiro Matano
- Department of Neurosurgery, Chiba Hokusoh Hospital, Chiba, Japan
| | | | - Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Asami Kubota
- Department of Neurosurgery, Chiba Hokusoh Hospital, Chiba, Japan
| | - Yu Fujiki
- Department of Neurosurgery, Chiba Hokusoh Hospital, Chiba, Japan
| | - Shiro Kobayashi
- Department of Neurosurgery, Chiba Hokusoh Hospital, Chiba, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
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15
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Leal RTM, Fernandes RA, Escudeiro GP, Rodrigues RMC, Monteiro R, Landeiro JA. Universal fluorescence module for intraoperative fluorescein angiography-a technical report. Acta Neurochir (Wien) 2019; 161:1343-1348. [PMID: 31053910 DOI: 10.1007/s00701-019-03904-6] [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: 02/25/2019] [Accepted: 04/05/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Even in specialized centers, suboptimal aneurysm clipping can be as high as 12%. Intraoperative fluorescence angiography with indocyanine green and, more recently, fluorescein sodium have been shown to be a good method for intraoperative flow assessment. However, the cost with the apparatus it entails limits its widespread use. We have developed a low-cost universal fluorescence module (FM) designed to visualize fluorescein and perform intraoperative angiography. The purpose of this paper is to describe this device as well as to present our early experience with its use in the treatment of cerebral aneurysms. METHOD A FM was designed and built using a cyan-blue narrow bandpass (460 to 490 nm) excitation filter and a yellow-orange longpass (blocking wavelengths under 520 nm) barrier filter mounted on a 3D-printed holding tray in a specific disposition to perfectly match the light source and the objective lens of the surgical microscope. It allowed switching from white light to fluorescence mode in a simple and sterile fashion. Its perfect attachment to the microscope was possible by reusing the lens fittings extracted from used original drape sets that would otherwise be discarded. Four patients underwent aneurysm clipping using the FM at two institutions from April to September 2018. RESULTS A bright green fluorescence against a dark background was observed after intravenous bolus of fluorescein. Blood vessels became obviously distinct from non-contrast-filled structures such as clipped aneurysms and the brain. Vascular anatomy could be appreciated without any distortion, including perforating arteries. CONCLUSIONS Intraoperative fluorescence angiography was successfully performed with the use of this universal FM after intravenous injection of fluorescein sodium. This simple and low-cost device may be useful in resource-limited centers, where other sorts of intraoperative angiography are not available.
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Grüter BE, Täschler D, Rey J, Strange F, Nevzati E, Fandino J, Marbacher S, Coluccia D. Fluorescence Video Angiography for Evaluation of Dynamic Perfusion Status in an Aneurysm Preclinical Experimental Setting. Oper Neurosurg (Hagerstown) 2019; 17:432-438. [DOI: 10.1093/ons/opz011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 01/29/2019] [Indexed: 01/08/2023] Open
Abstract
Abstract
BACKGROUND
Experimental studies to assess aneurysm occlusion or perfusion typically rely on macroscopic examination or histological analysis but cannot assess dynamic perfusion.
OBJECTIVE
To describe an easy-to-implement and inexpensive fluorescence angiographic technique for the in vivo assessment and imaging of the dynamic perfusion status of aneurysms and their underlying blood vessels in a rat model.
METHODS
In a rat sidewall aneurysm model, the angiographic setup included 2 bandpass filters, a video camera, and a bicycle spotlight. After 48 rats underwent fluorescein angiography, dissections were performed to confirm the perfusion status by macroscopic and histologic examination of the aneurysm.
RESULTS
Direct injection of 0.2 mL fluorescein 10% Faure achieved strong, clear visibility in all 48 aneurysms. Macro-/microscopic examination identified residual perfusion in 25 and complete healing in 23 aneurysms. Fluorescein imaging identified 21 of these 25 aneurysms (84%) with residual perfusion and 22 of 23 aneurysms (96%) with no residual perfusion.
CONCLUSION
Our fluorescein imaging technique proved efficient for the evaluation of aneurysm patency and parent artery integrity in this experimental setting. Fluorescein is nontoxic, can be re-administered if needed, and, in this technique, can expand the armamentarium for the preclinical evaluation of dynamic perfusion status.
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Affiliation(s)
- Basil Erwin Grüter
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Dominik Täschler
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Jeannine Rey
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Fabio Strange
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Edin Nevzati
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Daniel Coluccia
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Cerebrovascular Research Group, Department for BioMedical Research, University of Bern, Bern, Switzerland
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17
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Matsukawa H, Kamiyama H, Miyazaki T, Kinoshita Y, Ota N, Noda K, Shonai T, Takahashi O, Tokuda S, Tanikawa R. Comprehensive analysis of perforator territory infarction on postoperative diffusion-weighted imaging in patients with surgically treated unruptured intracranial saccular aneurysms. J Neurosurg 2019; 132:1088-1095. [PMID: 30835684 DOI: 10.3171/2018.11.jns181235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 11/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Perforator territory infarction (PTI) is still a major problem needing to be solved to achieve good outcomes in aneurysm surgery. However, details and risk factors of PTI diagnosed on postoperative MRI remain unknown. The authors aimed to investigate the details of PTI on postoperative diffusion-weighted imaging (DWI) in patients with surgically treated unruptured intracranial saccular aneurysms (UISAs). METHODS The data of 848 patients with 1047 UISAs were retrospectively evaluated. PTI was diagnosed on DWI, which was performed the day after aneurysm surgery. Clinical and radiological characteristics were compared between UISAs with and without PTI. Poor outcome was defined as an increase in 1 or more modified Rankin Scale scores at 12 months after aneurysm surgery. RESULTS Postoperative DWI was performed in all cases, and it revealed PTI in 56 UISA cases (5.3%). Forty-three PTIs occurred without direct injury and occlusion of perforators (43 of 56, 77%). Poor outcome was more frequently observed in the PTI group (17 of 56, 30%) than the non-PTI group (57 of 1047, 5.4%) (p < 0.0001). Thalamotuberal arteries (p < 0.01), lateral striate arteries (p < 0.01), Heubner's artery (p < 0.01), anterior median commissural artery (p < 0.05), terminal internal carotid artery perforators (p < 0 0.01), and basilar artery perforator (p < 0 0.01) infarctions were related to poor outcome by adjusted residual analysis. On multivariate analysis, statin use (OR 10, 95% CI, 3.3-31; p < 0.0001), specific aneurysm locations (posterior communicating artery [OR 4.1, 95% CI 2.1-8.1; p < 0.0001] and basilar artery [OR 3.1, 95% CI 1.1-8.9; p = 0.031]), larger aneurysm size (OR 1.1, 95% CI 1.1-1.2; p = 0.043), and permanent decrease of motor evoked potential (OR 38, 95% CI 3.1-468; p = 0.0045) were related to PTI. CONCLUSIONS Despite efforts to avoid PTI, it occurred even without direct injury, occlusion of perforators, or evoked potential abnormality. Therefore, surgical treatment of UISAs, especially with the aforementioned risk factors of PTI, should be more carefully considered. The evaluation of PTI in the territory of the above-mentioned perforators could be useful in helping predict the clinical course in patients after aneurysm surgery.
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Affiliation(s)
| | | | | | | | - Nakao Ota
- 1Department of Neurosurgery, Stroke Center, and
| | - Kosumo Noda
- 1Department of Neurosurgery, Stroke Center, and
| | | | - Osamu Takahashi
- 3Center for Clinical Epidemiology, Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
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Analysis for risk factors of 12-month neurological worsening in patients with surgically treated small-to-moderate size unruptured intracranial aneurysms. J Clin Neurosci 2018; 58:160-164. [PMID: 30279118 DOI: 10.1016/j.jocn.2018.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/05/2018] [Accepted: 08/08/2018] [Indexed: 11/24/2022]
Abstract
The risk associated with surgical treatment for small-to-moderate size unruptured intracranial aneurysms (SMUIAs, defined as <15 mm) has not been well characterized. Authors aimed to investigate risk factors for poor outcome in surgical treatment of SMUIAs. The data of prospectively collected 801 consecutive patients harboring 971 surgically treated SMUIAs was evaluated. Neurological worsening (NW) was defined as an increase in 1 or more modified Rankin Scale at 12-month. Clinical and radiological characteristics were compared. Neurological worsening was observed in 45 (4.6%). In multivariate analysis, only perforator territory infarction (PTI) on postoperative diffusion-weighted imaging (odds ratio (OR), 13; 95% confidence interval (CI), 4.9-32, p < 0.0001), and aneurysm locations (paraclinoid (OR, 6.9; 95% CI, 3.1-15, p < 0.0001), basilar artery (OR, 4.5; 95% CI, 1.5-14, p = 0.008), vertebral artery (OR, 11; 95% CI, 3.3-34, p < 0.0001)) were related to neurological worsening. Multivariate analysis showed that statin use (OR, 12; 95% CI, 3.8-39, p < 0.0001) and aneurysm locations (internal carotid artery-posterior communicating artery (OR, 3.9; 95% CI, 1.8-8.2, p < 0.0001) and basilar artery (OR, 6.3; 95% CI, 2.3-17, p = 0.008)), and aneurysm size >10 mm (OR, 5.3; 95% CI, 1.8-15, p = 0.003) were related to PTI. Although all SMUIAs should be carefully considered whether to be treated, those with statins, specific locations, and larger sizes should perhaps be more meticulously contemplated, and neurosurgeons should continue to avoid PTI.
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Sato T, Bakhit M, Suzuki K, Sakuma J, Fujii M, Murakami Y, Ito Y, Sure U, Saito K. A Novel Intraoperative Laser Light Imaging System to Simultaneously Visualize Visible Light and Near-Infrared Fluorescence for Indocyanine Green Videoangiography. Cerebrovasc Dis Extra 2018; 8:96-100. [PMID: 30056450 PMCID: PMC6120366 DOI: 10.1159/000490872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/23/2018] [Indexed: 12/16/2022] Open
Abstract
Background Intraoperative indocyanine green videoangiography (ICG-VA) has been reported to be utilized in various cerebrovascular surgeries, wherein the blood flow is noticeably shown in white with a black background. ICG flow alone, but not other structures, can be observed using ICG-VA. We developed a novel high-resolution intraoperative imaging system using laser light source for simultaneously visualizing both visible light and near-infrared (NIR) fluorescence images of ICG-VA. Methods We used a novel system for 14 cerebrovascular cases. The operative field was illuminated via an operating microscope using a novel laser light source with four bands at 464 (blue), 532 (green), 640 (red), and 785 nm (NIR region). The observed light from the operative field was split using a beam splitter cube into visible (420– 660 nm) and NIR fluorescence emission light (832–900 nm). Images from the color video and NIR fluorescence emission windows were merged for visualization on a monitor screen simultaneously. Laser light was compared with xenon light, and both setups were tested for cerebrovascular surgeries. Results Laser light has numerous advantages over xenon light. The present setup clearly visualized the color operative field with enhanced blood flow. Complete clipping or incomplete clipping with neck remnant or remnant flow into an aneurysm was confirmed in aneurysm surgeries. Feeding arteries and draining veins were easily distinguished in case of arteriovenous malformation. Conclusions Using the present setup, we can observe the color operative field and enhanced blood flow using ICG in real time. This setup could facilitate various cerebrovascular surgeries.
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Affiliation(s)
- Taku Sato
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan.,Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Mudathir Bakhit
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Kyouichi Suzuki
- Department of Neurosurgery, Fukushima Red Cross Hospital, Fukushima, Japan
| | - Jun Sakuma
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Masazumi Fujii
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Yuta Murakami
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Yuhei Ito
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
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Narducci A, Onken J, Czabanka M, Hecht N, Vajkoczy P. Fluorescein videoangiography during extracranial-to-intracranial bypass surgery: preliminary results. Acta Neurochir (Wien) 2018; 160:767-774. [PMID: 29307022 DOI: 10.1007/s00701-017-3453-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 12/26/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Over the last years, intraoperative use of fluorescein is gaining ground in the field of neurosurgery, due to development of a microscope-integrated YELLOW 560 module, with reported experiences in brain malignancies, aneurysms, and arteriovenous malformation surgery. The aim of this study is to determine the feasibility and value of fluorescein videoangiography during bypass procedures. METHODS The authors enrolled 11 patients who underwent extracranial-to-intracranial bypass for moyamoya disease, atherosclerotic steno-occlusive cerebrovascular disease, and flow replacement during a giant middle cerebral artery (MCA) aneurysm treatment. Patients underwent fluorescein videoangiography using microscope-integrated fluorescence module. RESULTS In all 11 cases, good bypass patency was intraoperatively demonstrated through fluorescein videoangiography and confirmed by post-operative digital subtraction angiography or computed tomographic angiography. The technique seems to be less sensible than standard indocyanine green videoangiography in terms of flow velocity assessment during first pass and does not benefit from a dedicated software to perform hemodynamic parameter analysis (i.e., FLOW 800). Fluorescein videoangiography was able to show a higher number of vessels than indocyanine green videoangiography, providing an extremely well-defined view of cortical vascular network, also in deeper cortical areas. In case of deep-seated anastomosis, it allowed real-time manipulation of neurovascular structures, making it possible a safe analysis of vessels in deep surgical field during videoangiography observation. CONCLUSIONS Fluorescein videoangiography is a cost-effective, easy-to-use, fast and safe intraoperative tool and is useful to assess graft patency and extent of cortical vascular network also in deeper cortical areas. In case of deep-seated anastomosis, it provides the great advantage of performing real-time manipulation of neurovascular structures during videoangiography observation. It could represent a valuable complementary or alternative technique to assess intraoperative bypass function.
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Esposito G, Regli L. Intraoperative tools for cerebral bypass surgery. Acta Neurochir (Wien) 2018; 160:775-778. [PMID: 29322266 DOI: 10.1007/s00701-017-3455-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 12/26/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Giuseppe Esposito
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
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Longatti P, Boaro A, Canova G, Fiorindi A. The subependymal microvascular network revealed by endoscopic fluorescence angiography. J Neurosurg Sci 2017; 64:347-352. [PMID: 29115098 DOI: 10.23736/s0390-5616.17.04098-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The subependymal vascularization of the cerebral ventricles has been described in anatomical studies on human specimens. Its identification in vivo during neuroendoscopic navigation could have anatomical interest and may lead to a safer ventricular navigation, also avoiding unexpected bleeding. The traditional endoscopic visualization allows the certain identification of only the main vessels. In this study we describe the features of the subependymal vascular network (SEVN) enhanced by sodium fluorescein (SF) angiography. We compare these findings with the vascular patterns visible under white light to evaluate the sensitivity of this technique in unveiling the most distant branches of the SEVN. METHODS We reviewed the video records of 39 fluorescein-assisted neuroendoscopic procedures. Steerable fiberscopes equipped with a dual observation mode for both white light and fluorescence were used. After preliminary inspection of the ventricular cavities, the camera was switched to the blue light fluorescent mode. Identical portion of ventricular walls observed in both modalities were compared and analyzed to enhance potential differences of the vascular features. RESULTS The main veins were positive (fluorescein enhanced) in 10 patients (25.6%), vessels of smaller diameter visible also under white light presented a detectable fluorescence in 27 patients (69.2%), the micro SEVN, not visible under with light, was revealed by SF in 21 patients (53.8%). CONCLUSIONS Fluorescein-guided neuroendoscopy deserves closer investigation since it allows detection of small vessels, not otherwise visible, in the ventricle walls. This method could be applied to ameliorate the knowledge of the environment the surgeon is working on, leading as a result to a safer navigation, also by avoiding minor bleedings.
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Affiliation(s)
- Pierluigi Longatti
- Department of Neurosurgery, Hospital of Treviso, University of Padua, Padua, Italy
| | - Alessandro Boaro
- Department of Neurosurgery, Hospital of Treviso, University of Padua, Padua, Italy
| | - Giuseppe Canova
- Department of Neurosurgery, Hospital of Treviso, University of Padua, Padua, Italy
| | - Alessandro Fiorindi
- Department of Neurosurgery, Hospital of Treviso, University of Padua, Padua, Italy -
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Kakucs C, Florian IA, Ungureanu G, Florian IS. Fluorescein Angiography in Intracranial Aneurysm Surgery: A Helpful Method to Evaluate the Security of Clipping and Observe Blood Flow. World Neurosurg 2017; 105:406-411. [DOI: 10.1016/j.wneu.2017.05.172] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/29/2017] [Accepted: 05/30/2017] [Indexed: 12/23/2022]
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24
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History, Evolution, and Continuing Innovations of Intracranial Aneurysm Surgery. World Neurosurg 2017; 102:673-681. [DOI: 10.1016/j.wneu.2017.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 01/30/2017] [Accepted: 02/01/2017] [Indexed: 12/19/2022]
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25
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Hashimoto K, Kinouchi H, Yoshioka H, Kanemaru K, Ogiwara M, Yagi T, Wakai T, Fukumoto Y. Efficacy of Endoscopic Fluorescein Video Angiography in Aneurysm Surgery—Novel and Innovative Assessment of Vascular Blood Flow in the Dead Angles of the Microscope. Oper Neurosurg (Hagerstown) 2017; 13:471-481. [DOI: 10.1093/ons/opw042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/27/2017] [Indexed: 11/15/2022] Open
Abstract
Abstract
BACKGROUND: In aneurysm surgery, assessment of the blood flow around the aneurysm is crucial. Recently, intraoperative fluorescence video angiography has been widely adopted for this purpose. However, the observation field of this procedure is limited to the microscopic view, and it is difficult to visualize blood flow obscured by the skull base anatomy, parent arteries, and aneurysm.
OBJECTIVE: To demonstrate the efficacy of a new small-caliber endoscopic fluorescence video angiography system employing sodium fluorescein in aneurysm surgery for the first time.
METHODS: Eighteen patients with 18 cerebral aneurysms were enrolled in this study. Both microscopic fluorescence angiography and endoscopic fluorescein video angiography were performed before and after clip placement.
RESULTS: Endoscopic fluorescein video angiography provided bright fluorescence imaging even with a 2.7-mm-diameter endoscope and clearly revealed blood flow within the vessels in the dead angle areas of the microscope in all 18 aneurysms. Consequently, it revealed information about aneurysmal occlusion and perforator patency in 15 aneurysms (83.3%) that was not obtainable with microscopic fluorescence video angiography. Furthermore, only endoscopic video angiography detected the incomplete clipping in 2 aneurysms and the occlusion of the perforating branches in 3 aneurysms, which led to the reapplication of clips in 2 aneurysms.
CONCLUSION: The innovative endoscopic fluorescein video angiography system we developed features a small-caliber endoscope and bright fluorescence images. Because it reveals blood flow in the dead angle areas of the microscope, this novel system could contribute to the safety and long-term effectiveness of aneurysm surgery even in a narrow operative field.
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Affiliation(s)
- Koji Hashimoto
- Department of Neurosurgery, Interdis-ciplinary Graduate School of Medicine and Engineering, University of Yama-nashi, Yamanashi, Japan
| | - Hiroyuki Kinouchi
- Department of Neurosurgery, Interdis-ciplinary Graduate School of Medicine and Engineering, University of Yama-nashi, Yamanashi, Japan
| | - Hideyuki Yoshioka
- Department of Neurosurgery, Interdis-ciplinary Graduate School of Medicine and Engineering, University of Yama-nashi, Yamanashi, Japan
| | - Kazuya Kanemaru
- Department of Neurosurgery, Interdis-ciplinary Graduate School of Medicine and Engineering, University of Yama-nashi, Yamanashi, Japan
| | - Masakazu Ogiwara
- Department of Neurosurgery, Interdis-ciplinary Graduate School of Medicine and Engineering, University of Yama-nashi, Yamanashi, Japan
| | - Takashi Yagi
- Department of Neurosurgery, Interdis-ciplinary Graduate School of Medicine and Engineering, University of Yama-nashi, Yamanashi, Japan
| | - Takuma Wakai
- Department of Neurosurgery, Interdis-ciplinary Graduate School of Medicine and Engineering, University of Yama-nashi, Yamanashi, Japan
| | - Yuichiro Fukumoto
- Department of Neurosurgery, Interdis-ciplinary Graduate School of Medicine and Engineering, University of Yama-nashi, Yamanashi, Japan
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Thien A, Rao JP, Ng WH, King NKK. The Fluoropen: a simple low-cost device to detect intraoperative fluorescein fluorescence in stereotactic needle biopsy of brain tumors. Acta Neurochir (Wien) 2017; 159:371-375. [PMID: 27943078 DOI: 10.1007/s00701-016-3041-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/23/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of fluorescein fluorescence-guided stereotactic needle biopsy has been shown to improve diagnostic accuracy and to expedite operative procedure in the stereotactic needle biopsy of high-grade gliomas. We developed a device (Fluoropen) for detecting fluorescence in brain tumor tissues obtained by fluorescein fluorescence-guided stereotactic needle biopsy. METHODS The Fluoropen is a device consisting of a light source fitted with color filters to create the required emission and visualization wavelengths. The proof-of-concept study consisted of four consecutive patients who underwent fluorescein fluorescence-guided frameless stereotactic biopsy of brain tumor. Each sample was examined for the presence of fluorescence using the Fluoropen and compared with a microscope with fluorescence visualization capability. RESULTS A total of six samples were obtained from four stereotactic needle biopsy procedures. Four out of five samples (80%) taken from the contrast-enhancing part of the tumors were shown to be fluorescent under the microscope fitted with fluorescence module and the Fluoropen. One non-contrast enhancing lesion was non-fluorescent using both the microscope fitted with fluorescence module and the Fluoropen. The Fluoropen was shown to have 100% concordance with the microscope fitted with fluorescence module. CONCLUSIONS The Fluoropen is a low-cost and simple standalone device for the detection of fluorescein fluorescence that can expedite stereotactic needle biopsy by providing instant confirmation of the diagnostic sample and therefore avoid the need for an intraoperative frozen section. In patients with non-contrast enhancing tumors and those who were pre-treated with dexamethasone prior to surgery, fluorescein fluorescence-guided stereotactic needle biopsy will need to be used with caution.
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Affiliation(s)
- Ady Thien
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Jai Prashanth Rao
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Nicolas Kon Kam King
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
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Joo SP, Kim TS. The Clinical Importance of Perforator Preservation in Intracranial Aneurysm Surgery: An Overview with a Review of the Literature. Chonnam Med J 2017; 53:47-55. [PMID: 28184338 PMCID: PMC5299129 DOI: 10.4068/cmj.2017.53.1.47] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/16/2016] [Accepted: 08/16/2016] [Indexed: 12/29/2022] Open
Abstract
Clipping for intracranial aneurysms is done to achieve complete occlusion of the aneurysm without a remnant sac. Despite modern advancements of neurosurgical techniques, morbidity related to the clipping of intracranial aneurysms still exists. Clip occlusion of a parent artery or small hidden perforators commonly leads to permanent neurological deficits, and is a serious and unwanted complication. Thus, preserving blood flow in the branches and perforators of a parent artery is very important for successful surgery without postoperative morbidity and mortality. The aim of this review article is to discuss the consequences of perforator injury and how to avoid this phenomenon in aneurysm surgeries using intraoperative monitoring devices.
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Affiliation(s)
- Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Tae-Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Dual-Image Videoangiography During Intracranial Microvascular Surgery. World Neurosurg 2016; 99:572-579. [PMID: 28024974 DOI: 10.1016/j.wneu.2016.12.070] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Indocyanine green videoangiography (ICG-VA) is a valuable tool to assess vessel and aneurysm patency during neurovascular surgical procedures. However, ICG-VA highlights vascular structures, which appear white over a black background. Anatomic relationships are sometimes difficult to understand at first glance. Dual-image videoangiography (DIVA) enables simultaneous visualization of light and near-infrared fluorescence images of ICG-VA. METHODS The DIVA system was mounted on an OPMI Pentero Flow 800 intraoperative microscope. DIVA was used during microsurgical procedures on 5 patients who were operated for aneurysm clipping and superficial temporal artery-middle cerebral artery bypass. RESULTS DIVA provides real-time simultaneous visualization of aneurysm and vessels and surrounding structures including brain, nerves, and surgical clips. Although visual contrast between vessels and background is higher with standard black-and-white imaging, DIVA makes it easier to understand anatomic relationships between intracranial structures. DIVA also provides better vision of the depth of field. CONCLUSIONS DIVA has the potential to become a widely used intraoperative tool to check patency of intracranial vessels. It should be considered as an adjunct to standard ICG-VA for better understanding of vascular anatomy in relation to surrounding structures and can have an impact on decision making during surgery.
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Ichikawa T, Suzuki K, Watanabe Y, Sato T, Sakuma J, Saito K. Development of and Clinical Experience with a Simple Device for Performing Intraoperative Fluorescein Fluorescence Cerebral Angiography: Technical Notes. Neurol Med Chir (Tokyo) 2015; 56:141-9. [PMID: 26597335 PMCID: PMC4791308 DOI: 10.2176/nmc.tn.2015-0188] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To perform intraoperative fluorescence angiography (FAG) under a microscope without an integrated FAG function with reasonable cost and sufficient quality for evaluation, we made a small and easy to use device for fluorescein FAG (FAG filter). We investigated the practical use of this FAG filter during aneurysm surgery, revascularization surgery, and brain tumor surgery. The FAG filter consists of two types of filters: an excitatory filter and a barrier filter. The excitatory filter excludes all wavelengths except for blue light and the barrier filter passes long waves except for blue light. By adding this FAG filter to a microscope without an integrated FAG function, light from the microscope illuminating the surgical field becomes blue, which is blocked by the barrier filter. We put the FAG filter on the objective lens of the operating microscope correctly and fluorescein sodium was injected intravenously or intra-arterially. Fluorescence (green light) from vessels in the surgical field and the dyed tumor were clearly observed through the microscope and recorded by a memory device. This method was easy and could be performed in a short time (about 10 seconds). Blood flow of small vessels deep in the surgical field could be observed. Blood flow stagnation could be evaluated. However, images from this method were inferior to those obtained by currently commercially available microscopes with an integrated FAG function. In brain tumor surgery, a stained tumor on the brain surface could be observed using this method. FAG could be performed with a microscope without an integrated FAG function easily with only this FAG filter.
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Development of a new high-resolution intraoperative imaging system (dual-image videoangiography, DIVA) to simultaneously visualize light and near-infrared fluorescence images of indocyanine green angiography. Acta Neurochir (Wien) 2015; 157:1295-301. [PMID: 26148906 DOI: 10.1007/s00701-015-2481-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 06/12/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Intraoperative indocyanine green videoangiography (ICG-VA) has been widely used in vascular surgery, where vessels are clearly shown as white on a black background. However, other structures cannot be observed during ICG-VA. We have developed a new, high-resolution intraoperative imaging system (dual-image VA [DIVA]) to simultaneously visualize both light and near-infrared (NIR) fluorescence images from ICG-VA, allowing observation of other structures. METHODS The operative field was illuminated via an operating microscope by halogen and xenon lamps with a filter to eliminate wavelengths over 780 nm. In the camera unit, visible light was filtered to 400-700 nm and NIR fluorescence emission light was filtered to 800-900 nm using a special sensor unit with an optical filter. Light and NIR fluorescence images were simultaneously visualized on a single monitor. RESULTS Our system clearly visualized the operative field together with fluorescence-enhanced blood flow. In aneurysm surgeries, we could confirm incomplete clipping with the neck remnant or with remnant flow into the aneurysm. In cases of arteriovenous malformation or arteriovenous fistula, feeding arteries and draining veins were easily distinguished. CONCLUSIONS This system allows observation of the operative field and enhanced blood flow by ICG together in real time and may facilitate various types of neurovascular surgery.
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Therapeutic Clip Occlusion of the Anterior Choroidal Artery Involved with Partially Thrombosed Fusiform Aneurysm: A Case Report. J Stroke Cerebrovasc Dis 2015; 24:e227-30. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 04/11/2015] [Accepted: 04/17/2015] [Indexed: 11/21/2022] Open
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Abstract
The neuroendoscope, with its higher magnification, better observation, and additional illumination, can provide us information that may not be available with the microscope in aneurysm surgery. Furthermore, recent advancement of the holding systems for the endoscope allows surgeons to perform microsurgical manipulation using both hands under the simultaneous endoscopic and microscopic monitoring. With this procedure, surgeons can inspect hidden structures, dissect perforators at the back of the aneurysm, identify important vessel segments without retraction of the aneurysm or arteries, and check for completion of clipping. In addition, we have recently applied endoscopic indocyanine green video angiography to aneurysm surgery. This newly developed technique can offer real-time assessment of the blood flow of vasculatures in the dead angles of the microscope, and will reduce operative morbidity related to vascular occlusion, improve the durability of aneurysm surgery by reducing incomplete clipping, and thus promote the outcome of aneurysm surgery.
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Affiliation(s)
- Hideyuki Yoshioka
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
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Hide T, Yano S, Shinojima N, Kuratsu JI. Usefulness of the indocyanine green fluorescence endoscope in endonasal transsphenoidal surgery. J Neurosurg 2015; 122:1185-92. [PMID: 25723307 DOI: 10.3171/2014.9.jns14599] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT To avoid disorientation during endoscopic endonasal transsphenoidal surgery (ETSS), the confirmation of anatomical landmarks is essential. Neuronavigation systems can be pointed at exact sites, but their spatial resolution power is too low for the detection of vessels that cannot be seen on MR images. On Doppler ultrasonography the shape of concealed arteries and veins cannot be visualized. To address these problems, the authors evaluated the clinical usefulness of the indocyanine green (ICG) endoscope. METHODS The authors included 38 patients with pituitary adenomas (n = 26), tuberculum sellae meningiomas (n = 4), craniopharyngiomas (n = 3), chordomas (n = 2), Rathke's cleft cyst (n = 1), dermoid cyst (n = 1), or fibrous dysplasia (n = 1). After opening the sphenoid sinus and placing the ICG endoscope, the authors injected 12.5 mg of ICG into a peripheral vein as a bolus and observed the internal carotid arteries (ICAs), cavernous sinus, intercavernous sinus, and pituitary. RESULTS The ICA was clearly identified by a strong fluorescence signal through the dura mater and the covering thin bone. The intercavernous and cavernous sinuses were visualized a few seconds later. In patients with tuberculum sellae meningiomas, the abnormal tumor arteries in the dura were seen and the vague outline of the attachment was identified. At the final inspection after tumor removal, perforators to the brain, optic nerves, chiasm, and pituitary stalk were visualized. ICG fluorescence signals from the hypophyseal arteries were strong enough to see and spread to the area of perfusion with the passage of time. CONCLUSIONS The ICA and the patent cavernous sinus were detected with the ICG endoscope in real time and at high resolution. The ICG endoscope is very useful during ETSS. The authors suggest that the real-time observation of the blood supply to the optic nerves and pituitary helps to predict the preservation of their function.
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Affiliation(s)
- Takuichiro Hide
- Department of Neurosurgery, Kumamoto University Graduate School of Medical Science, Kumamoto, Japan
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Inoue A, Ohnishi T, Kohno S, Nishida N, Nakamura Y, Ohtsuka Y, Matsumoto S, Ohue S. Usefulness of an Image Fusion Model Using Three-Dimensional CT and MRI with Indocyanine Green Fluorescence Endoscopy as a Multimodal Assistant System in Endoscopic Transsphenoidal Surgery. Int J Endocrinol 2015; 2015:694273. [PMID: 26339240 PMCID: PMC4539066 DOI: 10.1155/2015/694273] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/15/2015] [Indexed: 11/25/2022] Open
Abstract
Purpose. We investigate the usefulness of multimodal assistant systems using a fusion model of preoperative three-dimensional (3D) computed tomography (CT) and magnetic resonance imaging (MRI) along with endoscopy with indocyanine green (ICG) fluorescence in establishing endoscopic endonasal transsphenoidal surgery (ETSS) as a more effective treatment procedure. Methods. Thirty-five consecutive patients undergoing ETSS in our hospital between April 2014 and March 2015 were enrolled in the study. In all patients, fusion models of 3D-CT and MRI were created by reconstructing preoperative images. In addition, in 10 patients, 12.5 mg of ICG was intravenously administered, allowing visualization of surrounding structures. We evaluated the accuracy and utility of these combined modalities in ETSS. Results. The fusion model of 3D-CT and MRI clearly demonstrated the complicated structures in the sphenoidal sinus and the position of the internal carotid arteries (ICAs), even with extensive tumor infiltration. ICG endoscopy enabled us to visualize the surrounding structures by the phasic appearance of fluorescent signals emitted at specific consecutive elapsed times. Conclusions. Preoperative 3D-CT and MRI fusion models with intraoperative ICG endoscopy allowed distinct visualization of vital structures in cases where tumors had extensively infiltrated the sphenoidal sinus. Additionally, the ICG endoscope was a useful real-time monitoring tool for ETSS.
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Affiliation(s)
- Akihiro Inoue
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan
- *Akihiro Inoue:
| | - Takanori Ohnishi
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Shohei Kohno
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Naoya Nishida
- Department of Otolaryngology, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Yawara Nakamura
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Yoshihiro Ohtsuka
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Shirabe Matsumoto
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Shiro Ohue
- Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan
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Lane B, Bohnstedt BN, Cohen-Gadol AA. A prospective comparative study of microscope-integrated intraoperative fluorescein and indocyanine videoangiography for clip ligation of complex cerebral aneurysms. J Neurosurg 2014; 122:618-26. [PMID: 25526265 DOI: 10.3171/2014.10.jns132766] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors prospectively analyzed 2 microscope-integrated videoangiography techniques using intravenous indocyanine green (ICG) and fluorescein for assessment of cerebral aneurysm obliteration and adjacent vessel patency. METHODS The authors prospectively enrolled 22 patients who underwent clip ligation of their aneurysm and used intraoperative videoangiography to assess obliteration of the aneurysmal sac and patency of the adjacent branching and perforating arteries. Patients underwent ICG videoangiography (ICG-VA) and the newly developed fluorescein videoangiography (FL-VA) using microscope-integrated fluorescence modules. Two independent observers compared the videoangiography recordings for value and quality to assess aneurysm exclusion and the patency of adjacent arteries. RESULTS All 22 patients first underwent FL-VA and then ICG-VA after clip application. In 7 cases (32%), FL-VA provided superior detail to assess perforating arteries (4 cases), distal branches (2 cases), and both (1 case); such detail was not readily available on ICG-VA. In 1 patient, ICG-VA offered better visualization of posterior communicating artery aneurysm occlusion than FL-VA because of staining artifact on the aneurysm dome from the adjacent tentorium. In 2 patients, FL-VA offered the needed advantage of real-time manipulation of the vessels and flow assessment by visualization through the operating microscope oculars. In 2 other cases, ICG-VA was more practical for repeat usage because of its more efficient clearance from the intravascular space. The ICG-VA image quality was often degraded at higher magnification in deep operative fields, partly due to chromatic aberration. Both ICG-VA and FL-VA afforded restricted views of vasculature based on the angle of surgical approach and obscuration by blood clot, aneurysm, or brain tissue. CONCLUSIONS Compared with ICG-VA, FL-VA can potentially provide an improved visualization of vasculature at high magnification in deep surgical fields. ICG-VA is more effective for repeated use during clip repositioning due to ICG's minimal vascular wall extravasation. Therefore, in certain cases, FL-VA may offer some advantages and play a complementary role along with ICG-VA in intraoperative fluorescence evaluation during microsurgical management of aneurysms.
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Affiliation(s)
- Brandon Lane
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, Indiana
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Hide T, Yano S, Kuratsu JI. Indocyanine green fluorescence endoscopy at endonasal transsphenoidal surgery for an intracavernous sinus dermoid cyst: case report. Neurol Med Chir (Tokyo) 2014; 54:999-1003. [PMID: 25446381 PMCID: PMC4533358 DOI: 10.2176/nmc.cr.2014-0087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The complete resection of intracavernous sinus dermoid cysts is very difficult due to tumor tissue adherence to important anatomical structures such as the internal carotid artery (ICA), cavernous sinus, and cranial nerves. As residual dermoid cyst tissue sometimes induces symptoms and repeat surgery may be required after cyst recurrence, minimal invasiveness is an important consideration when selecting the surgical approach to the lesion. We addressed a recurrent intracavernous sinus dermoid cyst by the endoscopic endonasal transsphenoidal approach assisted by neuronavigation and indocyanine green (ICG) endoscopy to confirm the ICA and patency of the cavernous sinus. The ICG endoscope detected the fluorescence signal from the ICA and cavernous sinus; its intensity changed with the passage of time. The ICG endoscope was very useful for real-time imaging, and its high spatial resolution facilitated the detection of the ICA and the patent cavernous sinus. We found it to be of great value for successful endonasal transsphenoidal surgery.
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Affiliation(s)
- Takuichiro Hide
- Department of Neurosurgery, Kumamoto University Graduate School of Medical Science
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Lane BC, Cohen-Gadol AA. A prospective study of microscope-integrated intraoperative fluorescein videoangiography during arteriovenous malformation surgery: preliminary results. Neurosurg Focus 2014; 36:E15. [PMID: 24484253 DOI: 10.3171/2013.11.focus13483] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors report on the use of a recently developed microscope-integrated fluorescent module using low-dose intravenous fluorescein for videoangiography during arteriovenous malformation (AVM) surgery. METHODS The authors analyzed the application of a low-dose intraoperative fluorescein in 4 consecutive patients undergoing AVM surgery. The ability to distinguish the associated vessels of the AVM from normal vessels and to assess the degree of AVM obliteration based on videoangiography of venous drainage was specifically analyzed. RESULTS All 4 patients underwent fluorescein angiography without complication. In each case, videoangiography confirmed recognition of feeding arteries and draining veins through the operating oculars under the fluorescent mode. In one case involving a large frontal AVM, videoangiography demonstrated mainly cortical veins on the surface of the AVM and alerted the senior author to first tackle the feeding arteries in the interhemispheric space. While evaluating the flow within the different draining veins after most of the AVM was disconnected, videoangiography also prioritized the order for disconnection of large draining veins to allow mobilization the AVM and exposure of the remaining deep arterial feeders. In the other 3 cases, videoangiography allowed easy recognition of the angioarchitecture of the AVMs, estimated its cortical boundaries, and most importantly, assessed the flow within the draining veins before their disconnection. CONCLUSIONS The authors found fluorescein videoangiography to be a useful adjunct in resection of AVMs. This technology offers the unique ability to visualize fluorescent vessels and nonfluorescent tissues in near-natural colors simultaneously and permits microsurgical manipulation of relevant structures under the fluorescent mode. Larger-scale studies are needed to establish its efficacy and wider applicability.
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Affiliation(s)
- Brandon C Lane
- Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery, Indianapolis, Indiana
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Ichikawa T, Suzuki K, Watanabe Y. Intra-arterial fluorescence angiography with injection of fluorescein sodium from the superficial temporal artery during aneurysm surgery: technical notes. Neurol Med Chir (Tokyo) 2014; 54:490-6. [PMID: 24477067 PMCID: PMC4533452 DOI: 10.2176/nmc.tn.2013-0232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Intra-arterial fluorescence angiography from a catheter inserted into the external carotid artery (ECA) via the superficial temporal artery (STA) allowed us to satisfactorily evaluate cerebral arterial and venous blood flow. We report this novel method that allowed for repeated angiography within minutes with a low risk of complications due to catheter placement from the STA. The STA was secured at the edge of the standard skin incision during cerebral aneurysm surgery. A 3 Fr catheter was inserted approximately 5 cm to 10 cm into the STA. After manual injection of 5 ml of 20 times diluted 10% fluorescein sodium (fluorescein), fluorescein reached the intracranial internal carotid artery (ICA) through the common carotid artery or anastomoses between the ECA and ICA. Fluorescence emission from the cerebral arteries, capillaries, and veins was clearly observed through the microscope and results were recorded. Quick dye clearance makes it possible to reexamine within 1 minute. In addition, we made a graph of the fluorescence emission intensity in the arteries, capillaries, and veins using fluorescence analysis software. With intravenous fluorescence angiography, dye remains in the vessels for a long time. When repeated examinations are necessary, intervals of approximately 10 minutes are required. There were some cases we could not correctly evaluate with intravenous injection due to weak fluorescence emission. Fluorescence angiography with intra-arterial injection from a catheter inserted into the carotid artery or another major vessel, like conventional angiography, has a risk of procedure-related complications. We report our new method since it solved these problems and is useful.
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YOSHIOKA H, NISHIYAMA Y, KANEMARU K, SENBOKUYA N, HASHIMOTO K, HANIHARA M, YAGI T, HORIKOSHI T, KINOUCHI H. Endoscopic Fluorescence Video Angiography in Aneurysm Surgery. ACTA ACUST UNITED AC 2014. [DOI: 10.2335/scs.42.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kuroda K, Kinouchi H, Kanemaru K, Nishiyama Y, Ogiwara M, Yoshioka H, Horikoshi T. Intra-arterial injection fluorescein videoangiography in aneurysm surgery. Neurosurgery 2013; 72:ons141-50; discussion ons150. [PMID: 23147788 DOI: 10.1227/neu.0b013e3182752f32] [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 To visualize blood flow in the arteries and aneurysm during surgery, intravenous fluorescence videoangiography has been used. However, the image contrast with this procedure is diminished by repeated study because the dye remains for about 10 minutes after injection. OBJECTIVE To determine the optimal dye concentration and to clarify the usefulness of fluorescein videoangiography by intra-arterial dye injection. METHODS In the pilot study, fluorescein sodium dissolved at various concentrations was illuminated with excitation light, and fluorescence was detected by cameras. The fluorescence of 0.001% fluorescein sodium solution mixed with plasma at various concentrations was then examined. In 13 aneurysm patients, dye solution was administered through the catheter for intraoperative digital subtraction angiography. The intravenous injection method was also performed, and the findings were compared. RESULTS Dye was clinically used at a concentration of 0.005% to 0.1% on the basis of the results of the pilot study. Fluorescence emission from the vessels and aneurysms was clearly observed by both methods; however, arterial injection provided brighter emission, resulting in clearer demonstration of the bloodstream than venous injection. Dye clearance was also quicker, which allowed repeat injections without delay. Dye filling in the aneurysm indicating incomplete occlusion was detected in 2 cases, and occlusion of the perforating artery was observed in 2 cases. CONCLUSION Intra-arterial fluorescein videoangiography provides brighter and clearer imaging of blood flow with a smaller dose of dye than intravenous videoangiography. It can be repeated within a short time and is useful for detecting incomplete clipping or unexpected obstruction of arteries.
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Affiliation(s)
- Katsuhiro Kuroda
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Yamanashi, Japan
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Yoshioka H, Kinouchi H, Nishiyama Y, Kanemaru K, Yagi T, Hanihara M, Horikoshi T. Advantage of microscope integrated for both indocyanine green and fluorescein videoangiography on aneurysmal surgery: case report. Neurol Med Chir (Tokyo) 2013; 54:192-5. [PMID: 24097092 PMCID: PMC4533429 DOI: 10.2176/nmc.cr2012-0256] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Neck clipping of a large middle cerebral artery aneurysm was performed using a newly developed surgical microscope integrated with modules for both indocyanine green (ICG) and fluorescein videoangiography. During surgery, ICG and fluorescein videoangiography by intra-arterial or intravenous injection were safely carried out without interrupting the surgical procedure. Based on the findings obtained from the case, we evaluated the differences between the dyes and the injection routes. With intra-arterial injection, fluorescein offered sharper contrast images and was better at depicting fine arteries than ICG. Patchy staining of vessel walls was observed in intravenous fluorescein videoangiography, while it was not evident in ICG. Intra-arterial injection method had a great advantage in the rapid clearance of the dyes, which allowed us to perform repeated videoangiography within a short period, and was useful in detecting incomplete clipping in this case; however, catheter insertion requires additional work and carries a potential risk. Use of a microscope integrated for both ICG and fluorescein videoangiography would be another method for repeated evaluation. Namely, alternate use of the dyes enables us to perform videoangiography in a short time even via intravenous injection.
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Affiliation(s)
- Hideyuki Yoshioka
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
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Distal middle cerebral artery aneurysm: A proposition of microsurgical management. Neurochirurgie 2013; 59:121-7. [PMID: 23806761 DOI: 10.1016/j.neuchi.2013.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 04/20/2013] [Accepted: 04/23/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Based on a cohort of patients treated on distal middle cerebral artery (MCA) aneurysm by microsurgical approach, the objectives were to assess the following: the postoperative functional outcome, study the causes of early neurological deterioration and to determine the predictive factors of favourable outcome. PATIENTS AND METHODS From a neurovascular prospective database, this retrospective longitudinal study included all the patients treated for cerebral aneurysm located on the distal segment of the MCA over two decades (January 1990-December 2011). The patients were all treated by microsurgical clipping exclusion. Any aneurysm was associated to infectious angiopathy. Data were retrieved from the patient's medical charts. The outcome was analysed twice: during the immediate postoperative period and at 6 months according to the modified Rankin scale. The relative risk was estimated for each variable and the prognostic factors were assessed using a multivariate logistic regression model (P<0.05). RESULTS Twenty-eight patients, mean age 40±13.3 years (median: 43 years; range 6-70 years) were divided into the ruptured group (n=20) and unruptured group (n=8). In the ruptured group, the initial clinical status was good (WFNS I-III) in 12 patients (60%) and poor in eight (40%) with an intracerebral haematoma (ICH) in 11 (55%). For both groups, the aneurysm location on the distal MCA decreased at a rate from 64.8% of the insular segment to 25% of the opercular then 10.7% to the cortical. During the hospital stay, neurological deterioration occurred in 16 patients (57.2%). The diagnosed causes were cerebral ischaemia in 10 (35.6%), initial ICH in three (10.7%), hydrocephalus in two (7.1%) and epilepsy in one (7.1%). At 6 months, a favourable outcome (mRS 0-2) was observed in 19 patients (68.1%), a definitive morbidity in seven (24.9%) and death in two (7.2%). Based on the prognostic factors, only the absence of immediate postoperative neurological deterioration was identified as significant for a favourable outcome. CONCLUSION These rare cerebral aneurysms resulted in a high proportion of poor initial status related to a frequent ICH. Cerebral ischaemia was a major cause of the immediate neurological deterioration and the absence of immediate neurological deterioration was the single identified prognostic factor.
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Okuda T, Yoshioka H, Kato A. Fluorescence-guided surgery for glioblastoma multiforme using high-dose fluorescein sodium with excitation and barrier filters. J Clin Neurosci 2012; 19:1719-22. [PMID: 23036170 DOI: 10.1016/j.jocn.2011.12.034] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 12/17/2011] [Indexed: 11/28/2022]
Abstract
We have developed a technique of fluorescence-guided surgery using high-dose fluorescein sodium (20mg/kg) with excitation and barrier filters for glioblastoma multiforme surgery. This technique was used in 10 patients, with surgery proceeding as expected in all patients. There were no complications or permanent side effects. This method uses filters to help distinguish between the usually invisible tumor and the brain surface, as well as allowing a detailed assessment of the positional relationships with tumor vessels and the surrounding normal vessels. As sufficient yellow staining was present even without filters, delicate microsurgery was also possible under a normal white-light microscope. Both environments could be used as necessary during surgery according to the requirements of resection, thereby improving the reliability and safety of surgery.
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Affiliation(s)
- Takeshi Okuda
- Department of Neurosurgery, Kinki University School of Medicine, 377-2, Ohno-Higashi, Osaka-Sayama, Osaka 589-8511, Japan.
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Nishiyama Y, Kinouchi H, Senbokuya N, Kato T, Kanemaru K, Yoshioka H, Horikoshi T. Endoscopic indocyanine green video angiography in aneurysm surgery: an innovative method for intraoperative assessment of blood flow in vasculature hidden from microscopic view. J Neurosurg 2012; 117:302-8. [DOI: 10.3171/2012.5.jns112300] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recently, intraoperative fluorescence video angiography using indocyanine green (ICG) has been widely used in aneurysm surgery. This is a simple and useful method to confirm complete occlusion of the aneurysm lumen and preservation of blood flow in the arteries around the aneurysm. However, the observation field of ICG video angiography is limited under a microscope, making it difficult to confirm the flow in the arteries behind the parent arteries or aneurysm. The authors developed a new technique of intraoperative endoscopic ICG video angiography to assess the blood flow in perforating arteries hidden by the parent arteries or aneurysm. The endoscope emits excitation light with a wavelength of approximately 800 nm, and video images were obtained through a cut filter. The authors used this ICG fluorescence endoscope in treating 3 patients with unruptured cerebral aneurysms. During clip placement, the endoscope was inserted to confirm aneurysm occlusion. Then, ICG was intravenously administered, and the fluorescence in the vessels was observed via the endoscope as well as under the microscope. The blood flow in the perforating arteries was clearly identified, and no procedural complication occurred. The authors conclude that the technique is very useful and facilitates intraoperative real-time assessment of the patency of perforating arteries behind parent arteries or aneurysms.
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Ueba T, Abe H, Matsumoto J, Higashi T, Inoue T. Efficacy of indocyanine green videography and real-time evaluation by FLOW 800 in the resection of a spinal cord hemangioblastoma in a child: case report. J Neurosurg Pediatr 2012; 9:428-31. [PMID: 22462710 DOI: 10.3171/2011.12.peds11286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 19-month-old child was gradually suffering from gait disturbance and was referred by his pediatrician to the authors' institution. Spinal MRI showed Gd-enhanced spinal cord tumor and congestive myelopathy. Intraoperatively the lesion was seen to be a hemangioblastoma. Because discrimination of the arterialized draining veins from the feeding arteries was difficult, indocyanine green videography was conducted to differentiate them. Real-time evaluation by FLOW 800 revealed that the slope of the average signal intensity in the feeding artery was steeper than that of the arterialized veins. The tumor was successfully resected, and postoperative indocyanine green videography showed total removal of the tumor as a signal-negative region; the circulation time between the feeding artery and the main draining vein was prolonged from 2.5 to 5.5 seconds. Indocyanine green videography and real-time evaluation by FLOW 800 were objective and effective for the excision of a tumor retaining the arteriovenous shunt. The patient recovered from congestive myelopathy and gait disturbance.
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Affiliation(s)
- Tetsuya Ueba
- Department of Neurosurgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
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Intra-arterial indocyanine green angiography in the management of spinal arteriovenous fistulae: technical case reports. Spine (Phila Pa 1976) 2012; 37:E264-7. [PMID: 21738090 DOI: 10.1097/brs.0b013e31822ba834] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN We first present 2 cases of spinal arteriovenous fistulae (AVFs) successfully treated with the help of intra-arterial indocyanine green (ICG) angiography. OBJECTIVE To demonstrate the efficacy of intra-arterial ICG angiography in spinal AVFs compared with the role of intravenous ICG injection and intraoperative digital subtraction angiography (DSA). SUMMARY OF BACKGROUND DATA Intravenous ICG fluorescent angiography is an emerging intraoperative tool to recognize vascular anatomy. The technique is quite simple and provides real-time vascular hemodynamics in the operative field. However, it takes time for the ICG to be washed out; therefore, repeat studies are somewhat tedious and time consuming, especially in spinal AVFs with multiple shunts/drainer. In this setting, intraoperative DSA has still been the standard to confirm the complete obliteration, although this has a risk of radiation exposure and renal failure. METHODS Two patients, a 46-year-old man with spinal dural AVF at the cervicomedullary junction and a 68-year-old woman with spinal perimedullary AVF at the conus medullaris, were surgically treated with the help of intra-arterial ICG angiography. RESULTS We introduced a catheter into the target artery and injected 0.05 mg ICG in 2 mL of normal saline in multiple, short intervals. This approach enabled us to detect the residual shunt/drainer and confirm complete obliteration. With this technique, a tiny amount of ICG was used in the operative field to clearly label only the affected vessels. Intraoperative DSA was not performed in these cases. CONCLUSION These cases demonstrate that intra-arterial ICG angiography is a powerful tool for visualizing spinal AVFs in terms of addressing the disadvantages of intravenous ICG injection and intraoperative DSA.
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Murai Y, Adachi K, Takagi R, Koketsu K, Matano F, Teramoto A. Intraoperative Matas test using microscope-integrated intraoperative indocyanine green videoangiography with temporary unilateral occlusion of the A1 segment of the anterior cerebral artery. World Neurosurg 2012; 76:477.e7-477.e10. [PMID: 22152581 DOI: 10.1016/j.wneu.2011.03.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 03/30/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the present study was to assess a new technique of surgical microscope-based indocyanine green (ICG) videoangiography (VAG) to confirm the patency of the anterior communicating artery (AcomA) after clipping AcomA aneurysms. METHODS Aneurysmal clipping of five cases of unruptured, broad-neck AcomA aneurysm was performed using the Carl Zeiss Surgical Microscope OPMI Pentero INFRARED 800. RESULTS In all five patients, after clipping AcomA aneurysms, the patency of AcomA was confirmed using ICGVAG findings and temporary unilateral occlusion of the A1 segment of the anterior cerebral artery using temporary clips. Images were excellent and enabled a real-time surgical assessment because the structures of interest, including vessels, perforating arteries, or residual aneurysm neck, were visible to the surgeon's eye under the microscope in all five patients. CONCLUSIONS ICGVAG and temporary unilateral occlusion with clips provides a simple, reliable, real-time, and rapid intraoperative assessment of the patency of AcomA. This technique may help to improve the quality of neurosurgical procedures.
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Affiliation(s)
- Yasuo Murai
- Department of Neurosurgery, Nippon Medical School, Tokyo, Japan.
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Lin J, Zhao J, Zhao Y, Zhang D, Wang R, Qiao H, Wang S. Multiple intraoperative monitoring-assisted microneurosurgical treatment for anterior circulation cerebral aneurysm. J Int Med Res 2011; 39:891-903. [PMID: 21819722 DOI: 10.1177/147323001103900323] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study investigated the efficacy of multiple intraoperative monitoring techniques including indocyanine green angiography (ICGA), somatosensory evoked potential (SSEP) and motor evoked potential (MEP) in the clinical outcome of microneurosurgical treatment for anterior circulation cerebral aneurysm. Fifty-two anterior circulation cerebral aneurysms (Hunt and Hess [H&H] grades 0, 1 or 2) from 45 Chinese in-patients were completely clipped. In one patient, ICGA directed neurosurgeons to readjust aneurysmal clips in order to eliminate a residual aneurysm and restore patency of a branching artery. SSEP/MEP directed neurosurgeons to implement intervention measures in 12 patients for recovery of SSEP/MEP changes, and SSEP/MEP changes partially/totally recovered in 11 of these 12 patients (91.6%). Postoperative motor deficits were observed in three patients, two of which were Glasgow Outcome Scale level 3 (4.4%). In conclusion, for patients with anterior circulation cerebral aneurysm (H&H grade < 3), multiple intraoperative monitoring was beneficial for finding residual aneurysms, detecting ischaemic events in the perforating arteries and reducing severe postoperative motor deficiency.
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Affiliation(s)
- J Lin
- Department of Neurosurgery, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
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Gruber A, Dorfer C, Standhardt H, Bavinzski G, Knosp E. Prospective Comparison of Intraoperative Vascular Monitoring Technologies During Cerebral Aneurysm Surgery. Neurosurgery 2011; 68:657-73; discussion 673. [PMID: 21164372 DOI: 10.1227/neu.0b013e31820777ee] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Microscope integrated intraoperative near-infrared indocyanine green angiography (ICGA) provides assessment of the cerebral vasculature in the operating field.
OBJECTIVE:
To prospectively compare the value of ICGA-derived information during cerebral aneurysm surgery with data simultaneously generated from other intraoperative monitoring and vascular imaging techniques.
METHODS:
Data from 104 patients with 123 cerebral aneurysms who were operated on were prospectively recorded. Results of intraoperative vascular monitoring and descriptions of how this information influenced intraoperative decision making were analyzed.
RESULTS:
Clip repositioning was necessary in 30 of 123 aneurysms (24.4%) treated. Parent artery occlusion was documented by microvascular Doppler ultrasound in 4 aneurysms. ICGA disclosed parent artery stenoses not detected by sonography in 7 cases. Neuroendoscopy was used in 13 cases of midline aneurysms to confirm perforator patency after clipping, and disclosed aneurysm misclipping undetected by ICGA and digital subtraction angiography in 1 aneurysm. The information from DSA and ICGA corresponded in 120 of 123 aneurysms operated on (97.5 %). In 1 patient, ICGA underestimated a relevant parent artery stenosis detected by digital subtraction angiography. In 2 patients with relevant aneurysmal misclipping, digital subtraction angiography and ICGA led to conflicting results that could be clarified only when both methods were used and interpreted together.
CONCLUSION:
The intraoperative monitoring and vascular imaging methods compared were complementary rather than competitive in nature. None of the devices used were absolutely reliable when used as a stand-alone method. Correct intraoperative assessment of aneurysm occlusion, perforating artery patency, and parent artery reconstruction was possible in all patients when these techniques were used in combination.
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Affiliation(s)
- Andreas Gruber
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Harald Standhardt
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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González-Darder J, Verdú-López y F, Quilis-Quesada V. Manejo y tratamiento microquirúrgico de las dilataciones infundibulares de la arteria comunicante posterior. Serie de nueve casos y revisión de la literatura. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70026-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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