Intraoperative Near-infrared Indocyanine Green Videoangiography Research Articles

Spinal Hemangioblastomas in Von Hippel-Lindau Disease Mimicking a Spinal Dural Arteriovenous Fistula

Introduction Spinal hemangioblastomas (HBs) are rare tumors that are closely associated with a diagnosis of Von Hippel-Lindau disease (VHL). A tissue diagnosis is needed to make the diagnosis of HB because many other entities can present similarly, which may require different management strategies. We present the first case in the literature of multiple intramedullary spinal HBs and VHL that mimicked a spinal dural arteriovenous fistula (dAVF) on radiological imaging. Material and Method Case illustration and literature review. Results A 60-year-old man was referred to our clinic for evaluation of progressive radiculomyelopathy and evidence of a T10 dAVF on MRI and MRA. MRI demonstrated perimedullar hypervascularity dorsal to the spinal cord from T10 to L1, and associated T2 signal change within the spinal cord. Prominent radicular arteries were identified at the exiting right T10 nerve root sleeve which was suspicious for the fistulous point. The patient underwent a T10-T12 laminoplasty for intradural exploration and possible ligation of the fistula; however, intraoperative findings included multiple small intra- and extramedullary vascular nodules along the spinal cord. Six lesions were biopsied, revealing a diagnosis of HB and VHL. Indocyanine green angiography (ICG) was used to rule out a concomitant dAVF. He is being managed expectantly and undergoing routine screening for VHL. He was discharged on postoperative day 3, and he reported symptom improvement at 2-week follow-up. Conclusion The present case is the first reported in the literature to describe multiple spinal HBs, in the setting of VHL, that appeared to be dAVF preoperatively. The patient's late clinical presentation, the greater degree of associated hypervascularity, and atypical vascular morphology were unique features, which highlight the diversity of this disease. Disclosure of Interest None declared References Wanebo JE, Lonser RR, Glenn GM, Oldfield EH. 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J Neurosurg 2006;105(2):248–255 Killory BD, Nakaji P, Maughan PH, Wait SD, Spetzler RF. Evaluation of angiographically occult spinal dural arteriovenous fistulae with surgical microscope-integrated intraoperative near-infrared indocyanine green angiography: report of 3 cases. Neurosurgery 2011;68(3):781-787, discussion 787 Wong GK, Zhu XL, Ng HK, et al. Hemangioblastoma of filum terminale associated with arteriovenous shunting. Surg Neurol 2007;68(2):211–214, discussion 214–215 Lonser RR, Weil RJ, Wanebo JE, DeVroom HL, Oldfield EH. Surgical management of spinal cord hemangioblastomas in patients with von Hippel-Lindau disease. J Neurosurg 2003;98(1):106–116 Tamura Y, Hirota Y, Miyata S, Yamada Y, Tucker A, Kuroiwa T. The use of intraoperative near-infrared indocyanine green videoangiography in the microscopic resection of hemangioblastomas. Acta Neurochir (Wien) 2012;154(8):1407–1412, discussion 1412 Cramer F, Kimsey MW. 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The use of intraoperative near-infrared indocyanine green videoangiography in the microscopic resection of hemangioblastomas

The authors assessed the usefulness of intraoperative near-infrared indocyanine green videoangiography (ICG-VA) in the microscopic resection of hemangioblastomas. From January 2009 to February 2012, nine consecutive patients (seven men, two women) who underwent surgery for hemangioblastomas using intraoperative ICG-VA were included in this study. Surgery was performed on four cystic cerebellar lesions with mural nodules, two solid tumors (one in the cerebellar hemisphere and one in the medulla oblongata), one spinal tumor and multiple tumors in two patients with von Hippel-Lindau disease. Of the nine patients, three were treated for recurrent tumor. The ICG-induced fluorescence images of hemangioblastomas with variable presentation were evaluated. All tumors could be completely removed en bloc. Blood flow in the tumor and tumor-related vessels at the brain surface were clearly detected by ICG-VA in all cases, except one recurrent tumor where postoperative adhesive scar tissue obstructed ICG-induced fluorescence resulting in poor delineation of the blood flow patterns and tumor margins. ICG-VA was also helpful for detecting the multiple small mural nodules within the cyst or the tumors buried under thin gliotic neural tissue despite reduced fluorescence. Intraoperative ICG-VA is a safe and easy modality for confirming the vascular flow patterns in hemangioblastomas. In addition, ICG-VA provided useful information for intracystic small lesions or lesions concealed under thin brain tissue in order to accomplish total resection of these tumors.

Application of intraoperative near-infrared indocyanine green videoangiography and analysis of fluorescent intensity in cerebral aneurysm surgery

Objective To study the application of intraoperative near - infrared indocyanine green videoangiography and visual analysis of blood flow dynamics in cerebral aneurysm clipping surgery,and analyze the advantages and limitations.Methods 47 patients with 51 intracranial aneurysms were treated by microsurgical clipping.Intraoperative ICG videoangiography was performed before or/and after clip application.The infrared fluorescence module integrated into the surgical microscope was used to visualize fluorescent areas in surgical field and permitted the recording of a video of the emitted fluorescent light.The recorded video signal was then constantly analyzed by an integrated analytical visualization tool for rapid interpretation of the fluorescence video sequences with intensity diagram.Results All of the images provided high resolution allowing real time assessment of the blood flow of parent artery,arterial branches or small perforators.Incomplete clipping of 4 anearysms were detected by using ICG angiography.Perforating arteries arising closed to or from aneurysmal neck were identified in the surgical eid of 15 aneurysms and the ICG angiography allowed real time assessment of the blood flow.The intensity diagram of ICG angiography provided important imformation in three cases.Conclusions ICG video angiography could provide high resolution images allowing real time assessment of the blood flow of parent artery,arterial branches or small perforators to improve the outcome of intracranial aneurysm surgery.The intensity diagram function is useful as an adjunct to ICG video angiography for documenting the blood flow. Key words: Intracranial aneurysm; Indocyanine green; Angiograpny; Microsurgery

Intraoperative near-infrared indocyanine green–videoangiography (ICG–VA) and graphic analysis of fluorescence intensity in cerebral aneurysm surgery

We present our preliminary experience with intraoperative near-infrared indocyanine green–videoangiography (ICG–VA) and analysis of blood flow dynamics using fluorescence intensity assessment in cerebral aneurysm clipping surgery. Thirty-nine patients with 43 intracranial aneurysms underwent microsurgical clipping. Intraoperative ICG–VA was performed before and after clip application. An infrared fluorescence module integrated into a surgical microscope was used to visualize fluorescence in the surgical field and we recorded the emitted fluorescent light. An integrated analytical visualization tool simultaneously analyzed the video sequence and converted it into an intensity diagram, which allowed an objective evaluation of the results rather than the subjective assessment of fluorescence using ICG–VA. Overall, ICG–VA was performed 137 times. Incomplete clipping was detected in four patients, which allowed suitable adjustment to completely obliterate the aneurysm. In 12 patients, perforators arising close to, or from, the aneurysmal neck were identified in the surgical field. In three patients, the ICG–VA intensity diagram provided valuable information leading to modification of the primary surgical maneuver. ICG–VA provides high resolution images allowing real-time assessment of the blood flow in the parent artery and arterial branches, including the perforators. The intensity diagram is useful for providing a more objective record of the hemodynamics than the traditional ICG–VA, which relies more on subjective assessment and may allow interobserver variability. We conclude that ICG–VA, combined with the intensity diagram, can reduce the morbidity and complications associated with aneurysm clipping and improve patient outcomes.

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

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

The application of intraoperative near-infrared indocyanine green videoangiography and analysis of fluorescence intensity in cerebrovascular surgery

Objective:To evaluate the usefulness and limitations of the intraoperative near-infrared (NIR) indocyanine green videoangiography (ICG-VA) and analysis of fluorescence intensity in cerebrovascular surgery.Methods:Forty-eight patients received ICG-VA during various surgical procedures from May 2010 to August 2010. Included among them were 45 cases of cerebral aneurysms and 3 cases of cerebral arteriovenous malformations (AVMs). The infrared fluorescence module integrated into the surgical microscope was used to visualize fluorescent areas in the surgical field. An integrated analytical visualization tool constantly analyzed the fluorescence video sequence and generated it in the form of an intensity diagram for objective interpretation.Results:Overall, the procedure of ICG VA was done 158 times in 48 patients. There was no adverse effect of ICG dye. In cerebral aneurysm cases, the images obtained were of high resolution. In 4 cases, incomplete clipping was detected by ICG-VA and allowed suitable adjustment to completely obliterate the aneurysm. In 3 aneurysm cases, the intensity diagram of ICG VA provided valuable information. ICG-VA identified the feeding arteries, the draining veins, and nidus in all 3 AVM cases, which was confirmed by an immediate analysis of fluorescence intensity.Conclusions:ICG-VA provides high resolution images allowing real-time assessment of the blood flow in surgical field. The intensity analysis function, in addition, is a useful adjunct to improve the accuracy of the clipping and decrease the complication rates in cerebral aneurysm cases. In cerebral AVM cases, with the help of color map and intensity diagram function, the superficial feeders, drainers, and nidus can be identified easily.

Effectiveness of intraoperative near-infrared indocyanine green videoangiography in a case with recurrent spinal perimedullary arteriovenous fistula

Flow measurement by microvascular ultrasonic flow probe is an established procedure in intracranial vascular surgery. This study tested the application of this procedure in spinal dural arteriovenous fistula (SDAVF) treatment.Data from 12 SDAVF patients who consecutively underwent microsurgical resection with the assistance of both microflow probe and indocyanine green videoangiography (ICG-VA) were retrospectively analyzed. Flowmetry was performed on a dilated perimedullary venous plexus at different distances from the fistula point (FP). In addition, measurements were made at different phases of surgery to address specific issues: at the beginning, to identify the fistula; after temporary clipping, to evaluate proper disconnection; and after section, to exclude residual filling.Flowmetry was reliable in assessing both the value and direction of flow in all cases, thereby aiding fistula localization and confirming its disconnection. Indeed, fistula localization was helped by detection of increasing flow values approaching the FP (mean flow: 11 mL/min <10 mm vs. 3 mL/min >20 mm), while fistula disconnection was confirmed by a flow value lower than 1 mL/min (0–1 mL/min). Data from microflow probe measurements were concordant with ICG-VA data in all cases. In 3 cases, ICG-VA findings on fistula disconnection uncertain due to residual ICG dye were clarified by flowmetry.With the limits of our small series, multistage intraoperative quantitative flow measurement is a feasible, safe, and reliable adjunct in the surgical treatment of SDAVFs. The procedure provides data helpful in guiding the surgical strategy or clarifying ICG-VA data when necessary.

The Impact of Microscope-Integrated Intraoperative Near-Infrared Indocyanine Green Videoangiography on Surgery of Arteriovenous Malformations and Dural Arteriovenous Fistulae

Microscope-based intraoperative near-infrared indocyanine green (ICG) videoangiography is useful as an adjunct to intra- or postoperative digital subtraction angiography (DSA) in aneurysm surgery. To evaluate intraoperative ICG videoangiography for surgery of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (dAVFs). Seventeen patients undergoing surgical resection of intracranial AVM or AVF were enrolled into this prospective evaluation. ICG videoangiography sequences were analyzed with regard to transit times to differentiate between arterial, early venous, capillary, and venous phase as well as early passage (fistula) and delayed appearance (ischemia). ICG videoangiography was compared with pre- and postoperative angiography. Forty-six ICG videoangiographies were performed in 17 operative procedures. In 41 ICG investigations image quality and spatial resolution were excellent to analyze arterial, early venous, capillary, and venous phase. In 2 cases ICG videoangiography provided additional information to change the surgical strategy. With the exception of one case only, the postoperative angiogram corresponded to the last ICG examination performed after the resection. No side effects related to ICG injection were observed. In one patient with a deep thalamic AVM the final ICG investigation was inconclusive owing to insufficient illumination of the deep surgical field. Microscope-integrated repetitive ICG videoangiography during AVM and dAVF surgery is fast, easy to perform, and safe. This simple and safe real-time method is a useful additional tool that can potentially lower the surgical risk in complex AVMs and help avoid missed residuals.

Videoangiografía intraoperatoria con verde de indocianina durante la cirugía de aneurismas cerebrales: Experiencia inicial en 10 intervenciones quirúrgicas

The authors' objective is to report the initial appreciations on the use of the intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery in our center. 10 surgical procedures have been made in 9 patients, 5 males and 4 females between 27 and 61 years old with an average of age of 49 years during a time of 10 months between March, 2008 and January, 2009. 10 surgical procedures were performed and 11 aneurysms were clipped. Intravenous indocyanine green and surgical microscope Leica OH4 with module of vascular fluorescence intraoperating Leica FL800, with camera infrared Sony (Heerbrugg-Switzerland) were used. The information offered by this technique during the intervention is compared with the images of the postoperative angiography performed during the first 24 hours. The partial or complete occlusion and the respect to the near vessels were evaluated. The findings of the intraoperative videoangiography were the complete occlusion and absence of complications in all the cases. These results corresponded completely with the postoperative results of the angiography postoperative, except in a case where the angiography demonstrated vasoespasmo moderate without clinical repercussion that during the videoangiografía intraoperatoria was not perceived. Clinically no patient presented neurological added deficits. The intraoperative videoangiography is a tool of easy application that offers valuable information as for the complete occlusion of the aneurysm and the permeability of the adjacent vessels.

Intraoperative Near-infrared Indocyanine Green Videoangiography Performed with a Surgical Microscope - Applications in Cerebrovascular Surgery

Intraoperative Near-infrared Indocyanine Green Videoangiography Performed with a Surgical Microscope - Applications in Cerebrovascular Surgery

Detection of a residual nidus by surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography in a child with a cerebral arteriovenous malformation

With the use of indocyanine green (ICG) as a novel fluorescent dye, and its integration into a compact system that takes advantage of modern video technology, fluorescence angiography has recently reemerged as a viable option. In this report, the authors show the efficacy of ICG videoangiography in the case of a child with a cerebral arteriovenous malformation (AVM). In this case, the ICG videoangiography shows residual nidus of diffuse-type AVM. This is a safe and simple method that can be used to assess the microcirculation of the brain. The ICG videoangiography is helpful in resecting residual cerebral AVM, especially in cases of diffuse-type AVM.

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

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