Real-Time Overlapping of Indocyanine Green—Video Angiography With White Light Imaging for Vascular Neurosurgery: Technique, Implementation, and Clinical Experience

2020 ◽  
Vol 19 (4) ◽  
pp. 453-460 ◽  
Author(s):  
Dimitrios Athanasopoulos ◽  
Axel Heimann ◽  
Makoto Nakamura ◽  
Irini Kakaletri ◽  
Oliver Kempski ◽  
...  
Keyword(s):  
Blood Flow ◽  
Indocyanine Green ◽  
Real Time ◽  
White Light ◽  
Multispectral Imaging ◽  
Tissue Perfusion ◽  
Indocyanine Green Videoangiography ◽  
Black And White ◽  
Surgical Clip ◽  
Vascular Neurosurgery

Abstract BACKGROUND Fluorescent-guided techniques in vascular neurosurgery can be demonstrated via black and white indocyanine green videoangiography (ICG-VA). Multispectral imaging (MFL) is a new method, which overlaps fluorescence with the white light and provides a fluorescent white light augmented reality image to the surgeon. OBJECTIVE To investigate (a) whether MFL can enhance the visualization of the blood-flow with simultaneous visualization of the anatomic structures and (b) if MFL can ergonomically improve the microvascular surgical treatment compared to ICG-VA. METHODS A digital imaging of the blood flow after intravenous injection of ICG on 7 pigs was performed in real time under white light, standard fluorescence, and MFL. The blood flow was interrupted with a surgical clip, demonstrating the blockage of the blood flow. We prospectively included 30 patients with vascular deformities. The vasculature was visualized on the microscope's monitor and through the microscope's eyepiece. RESULTS In the animal experiment, the visualization of the anatomy and the blood flow under MFL produced high resolution images. The occlusion of blood vessels demonstrated sufficiently the blockage of tissue perfusion and its reperfusion after clip removal. During all 30 surgical cases, the MFL technique and the direct delivery of the pseudo-colored image through the eyepiece allowed for enhanced anatomic and dynamic data. CONCLUSION MFL was shown to be superior to the classic ICG-VA, delivering enhanced data and notably improving the workflow due to the simultaneous and precise white light visualization of the blood flow and the surrounding anatomic structures.

scholarly journals Integration of Indocyanine Green Videoangiography With Operative Microscope: Augmented Reality for Interactive Assessment of Vascular Structures and Blood Flow

2015 ◽  
Vol 11 (2) ◽  
pp. 252-258 ◽  
Author(s):  
Nikolay L Martirosyan ◽  
Jesse Skoch ◽  
Jeffrey R Watson ◽  
G Michael Lemole ◽  
Marek Romanowski ◽  
...  
Keyword(s):  
Blood Flow ◽  
Indocyanine Green ◽  
Real Time ◽  
Femoral Artery ◽  
White Light ◽  
Near Infrared ◽  
Field Of View ◽  
Fluorescence Angiography ◽  
Indocyanine Green Videoangiography ◽  
Operative Microscope

Abstract BACKGROUND Preservation of adequate blood flow and exclusion of flow from lesions are key concepts of vascular neurosurgery. Indocyanine green (ICG) fluorescence videoangiography is now widely used for the intraoperative assessment of vessel patency. OBJECTIVE Here, we present a proof-of-concept investigation of fluorescence angiography with augmented microscopy enhancement: real-time overlay of fluorescence videoangiography within the white light field of view of conventional operative microscopy. METHODS The femoral artery was exposed in 7 anesthetized rats. The dissection microscope was augmented to integrate real-time electronically processed near-infrared filtered images with conventional white light images seen through the standard oculars. This was accomplished by using an integrated organic light-emitting diode display to yield superimposition of white light and processed near-infrared images. ICG solution was injected into the jugular vein, and fluorescent femoral artery flow was observed. RESULTS Fluorescence angiography with augmented microscopy enhancement was able to detect ICG fluorescence in a small artery of interest. Fluorescence appeared as a bright-green signal in the ocular overlaid with the anatomic image and limited to the anatomic borders of the femoral artery and its branches. Surrounding anatomic structures were clearly visualized. Observation of ICG within the vessel lumens permitted visualization of the blood flow. Recorded video loops could be reviewed in an offline mode for more detailed assessment of the vasculature. CONCLUSION The overlay of fluorescence videoangiography within the field of view of the white light operative microscope allows real-time assessment of the blood flow within vessels during simultaneous surgical manipulation. This technique could improve intraoperative decision making during complex neurovascular procedures.

119 Visualization of Vascular Structures of the Brain Through a Novel Multispectral Fluorescence Microscope After Intravenous Application of ICG

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 226-226
Author(s):  
Dimitrios Athanasopoulos
Keyword(s):  
Blood Flow ◽  
Blood Vessels ◽  
Intravenous Injection ◽  
White Light ◽  
Surgical Microscope ◽  
Light Image ◽  
Fluorescent Image ◽  
Surgical Clip ◽  
Vascular Structures ◽  
The Brain

Abstract INTRODUCTION Vascular structures are intraoperatively visualized through the eye-piece of a surgical microscope. The blood flow within the blood vessels can be demonstrated via indocyanine green (ICG) fluorescence. In this study we wanted to find out whether the development of a novel fluorescent surgical microscope, overlapping a multispectral fluorescent image on a white light image, is superior, equal or inferior, compared to the previous models. Moreover, it shall be proved, whether multispectral fluorescence enhances surgeon's orientation through the precise and clearer visualization of blood vessels and the blood flow. METHODS A total of 8 porcine animal models were used. After fixation of the animal's head the parietal cortex and the cortical blood vessels were exposed. A digital imaging of the arterial perfusion, capillary transition and venous drainage after intravenous injection of ICG (5 ml; 5 mg/ml) was then performed. The blood flow was artificially blocked by a surgical clip. After repetitive intravenous injection of ICG and visualisation with multispectral view, the surgical clip was removed and the reperfusion of the brain tissue was visualized with the real time ICG perfusion. RESULTS >The visualization of the anatomical structures of the surgical field under white light as well as the image overlapping were easily performed. The occlusion of blood vessels with surgical clips demonstrate a blockage of the ICG perfusion on the multispectral fluorescent image. The ICG perfusion was again demonstrated after removing the surgical clip and reperfusion of the blood vessel. CONCLUSION Multispectral fluorescence was shown to be superior to the classic ICG fluorescence. With the development of a novel multispectral surgical microscope, which overlaps a fluorescent image on a white light image, the data delivered to the surgeon are enhanced, compared to the previous models. Moreover, the surgeons's orientation is improved thanks to the clear visualization of blood vessels and the blood flow.

scholarly journals Blood Flow Assessment of Arteriovenous Malformations Using Intraoperative Indocyanine Green Videoangiography

2019 ◽  
Vol 2019 ◽  
pp. 1-8 ◽  
Author(s):  
Naoki Kato ◽  
Vincent Prinz ◽  
Julius Dengler ◽  
Peter Vajkoczy
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Indocyanine Green ◽  
Region Of Interest ◽  
Flow Dynamics ◽  
Flow Index ◽  
Indocyanine Green Videoangiography ◽  
Blood Flow Index ◽  
High Resolution Images ◽  
The Individual

Intraoperative indocyanine green (ICG) videoangiography is widely used in patients undergoing neurosurgery. FLOW800 is a recently developed analytical tool for ICG videoangiography to assess semi-quantitative flow dynamics; however, its efficacy is unknown. In this study, we evaluated its functionality in the assessment of flow dynamics of arteriovenous malformation (AVM) through ICG videoangiography under clinical settings. ICG videoangiography was performed in the exposed AVM in eight patients undergoing surgery. FLOW800 analysis was applied directly, and gray-scale and color-coded maps of the surgical field were obtained. After surgery, a region of interest was placed on the individual vessels to obtain time-intensity curves. Parameters of flow dynamics, including the maximum intensity, transit time, and cerebral blood flow index, were calculated using the curves. The color-coded maps provided high-resolution images; however, reconstruction of colored images was restricted by the depth, approach angle, and brain swelling. Semi-quantitative parameters were similar among the feeders, niduses, and drainers. However, a higher cerebral blood flow index was observed in the feeders of large AVM (>3 cm) than in those of small AVM (P < 0.05). Similarly, the cerebral blood flow index values were positively correlated with the nidus volume (P < 0.01). FLOW800 enabled visualization of the AVM structure and safer resection, except in case of deep-seated AVM. Moreover, semi-quantitative values in the individual vessels through using ICG intensity diagram showed different patterns according to size of the AVM. ICG videoangiography showed good performance in evaluating flow dynamics of the AVM in patients undergoing surgery.

scholarly journals Comparison of Indocyanine Green Angiography and Laser Speckle Contrast Imaging for the Assessment of Vasculature Perfusion

Neurosurgery ◽  
2012 ◽  
Vol 71 (5) ◽  
pp. 1023-1031 ◽  
Author(s):  
Erica L. Towle ◽  
Lisa M. Richards ◽  
S. M. Shams Kazmi ◽  
Douglas J. Fox ◽  
Andrew K. Dunn
Keyword(s):  
Blood Flow ◽  
Indocyanine Green ◽  
Single Point ◽  
Tissue Perfusion ◽  
Laser Speckle ◽  
Optical Methods ◽  
Contrast Imaging ◽  
Laser Speckle Contrast Imaging ◽  
Speckle Contrast ◽  
Excellent Method

Abstract BACKGROUND: Assessment of the vasculature is critical for overall success in cranial vascular neurological surgery procedures. Although several methods of monitoring cortical perfusion intraoperatively are available, not all are appropriate or convenient in a surgical environment. Recently, 2 optical methods of care have emerged that are able to obtain high spatial resolution images with easily implemented instrumentation: indocyanine green (ICG) angiography and laser speckle contrast imaging (LSCI). OBJECTIVE: To evaluate the usefulness of ICG and LSCI in measuring vessel perfusion. METHODS: An experimental setup was developed that simultaneously collects measurements of ICG fluorescence and LSCI in a rodent model. A 785-nm laser diode was used for both excitation of the ICG dye and the LSCI illumination. A photothrombotic clot model was used to occlude specific vessels within the field of view to enable comparison of the 2 methods for monitoring vessel perfusion. RESULTS: The induced blood flow change demonstrated that ICG is an excellent method for visualizing the volume and type of vessel at a single point in time; however, it is not always an accurate representation of blood flow. In contrast, LSCI provides a continuous and accurate measurement of blood flow changes without the need of an external contrast agent. CONCLUSION: These 2 methods should be used together to obtain a complete understanding of tissue perfusion.

scholarly journals Indocyanine green videoangiography for recipient vessel stratification in superficial temporal artery–middle cerebral artery bypass surgery

2020 ◽  
pp. 1-9
Author(s):  
Johannes Goldberg ◽  
Peter Vajkoczy ◽  
Nils Hecht
Keyword(s):  
Blood Flow ◽  
White Light ◽  
Bypass Surgery ◽  
Flow Direction ◽  
Superficial Temporal Artery ◽  
Flow Patterns ◽  
Low Flow ◽  
Indocyanine Green Videoangiography ◽  
Recipient Vessel ◽  
Potential Recipient

OBJECTIVEIn superficial temporal artery–middle cerebral artery (STA-MCA) bypass surgery, recipient vessel properties are likely one of the main reasons for bypass failure. In daily practice, most surgeons select the recipient with the largest diameter. However, selection of the ideal recipient remains debatable because there are no objective selection criteria if multiple potential recipients exist. Here, the authors assessed the benefit of using indocyanine green videoangiography (ICG-VA) to optimize recipient vessel selection in patients undergoing STA-MCA bypass surgery for hemodynamic compromise.METHODSAll patients who had undergone STA-MCA bypass procedures with pre- and postanastomosis ICG-VA between 2010 and 2019 were eligible for inclusion in this study. The primary bypass surgeon was blinded to the preanastomosis ICG-VA. Preanastomosis white-light and ICG-VA images were compared to determine the identifiability of potential recipient vessels and pathological flow patterns. After completion of the anastomosis, a second (postanastomosis) ICG-VA image was used to analyze the flow increase within the chosen recipient based on the vessel diameter, initial recipient blood flow, initial sequence of appearance on ICG-VA, initial blood flow direction within the recipient, and orientation of the bypass graft. ICG-VA, FLOW 800, and intraoperative white-light images, as well as demographic, clinical, and radiographic patient data, were retrospectively analyzed by a clinician who was not directly involved in the patients’ care.RESULTSSixty patients underwent 65 STA-MCA bypass procedures with pre- and postanastomosis ICG-VA. The ICG-VA permitted identification of a significantly higher number of potential recipient vessels (median 4, range 1–9) than the white-light images (median 2, range 1–5; p < 0.001), with detection of pathological flow patterns in 20% of all procedures. No association was found between the diameter and blood flow within potential recipients (Spearman r = 0.07, p = 0.69). After bypass grafting, the highest flow increase was noted in recipients with an initially low flow (p < 0.01), a late appearance (p < 0.01), and an initially retrograde flow direction (p = 0.02). Interestingly, flow increase was not significantly influenced by the recipient diameter (p = 0.09) or graft orientation (p = 0.44).CONCLUSIONSICG-VA facilitates identification of potential recipient vessels and detection of pathological flow patterns. Recipients with an initially low flow, a late appearance, and a retrograde flow seem to bear the highest potential for flow increase, possibly due to a higher hemodynamic need for revascularization.

scholarly journals Idiopathic dissecting cerebral aneurysm of the distal anterior cerebral artery in an infant successfully treated with aneurysmectomy: illustrative case

2021 ◽  
Vol 1 (9) ◽  
Author(s):  
Suguru Nagamitsu ◽  
Natsue Kaneko ◽  
Toshikazu Nagatsuna ◽  
Hiroaki Yasuda ◽  
Manabu Urakawa ◽  
...  
Keyword(s):  
Blood Flow ◽  
Indocyanine Green ◽  
Cerebral Artery ◽  
Peripheral Blood ◽  
Anterior Cerebral Artery ◽  
Pathological Examination ◽  
Peripheral Blood Flow ◽  
Indocyanine Green Videoangiography ◽  
Imaging Results ◽  
Distal Anterior Cerebral Artery

BACKGROUNDIdiopathic dissecting cerebral aneurysms (IDCAs) are male dominant but are extremely rare in children. Many IDCAs in children are located in the posterior cerebral artery and the supraclinoid internal cervical artery. No cases of IDCA of the distal anterior cerebral artery (ACA) have been reported.OBSERVATIONSA previously healthy 7-month-old boy experienced afebrile seizures and presented at the authors’ hospital 1 week after the first seizure. He was not feeling well but had no neurological deficits. The authors diagnosed a ruptured aneurysm of the right distal ACA based on imaging results. He underwent emergency craniotomy to prevent re-rupture of the aneurysm. Using intraoperative indocyanine green videoangiography, the authors confirmed peripheral blood flow and then performed aneurysmectomy. Pathological examination of the aneurysm revealed a thickened intima, fragmentation of the internal elastic lamina, and a hematoma in the aneurysmal wall. The authors ultimately diagnosed IDCA because no cause was indicated, including a history of trauma. The boy recovered after surgery and was subsequently discharged with no complications.LESSONSThe authors reported, for the first time, IDCA of the distal ACA in an infant. The trapping technique is often used for giant fusiform aneurysms in infants. Indocyanine green videoangiography is useful for evaluating peripheral blood flow during trapping in this case.

scholarly journals Endoscope- versus microscope-integrated near-infrared indocyanine green videoangiography in aneurysm surgery

2019 ◽  
Vol 131 (5) ◽  
pp. 1413-1422 ◽  
Author(s):  
Gerrit Fischer ◽  
Jana Rediker ◽  
Joachim Oertel
Keyword(s):  
Blood Flow ◽  
Indocyanine Green ◽  
Digital Subtraction Angiography ◽  
Digital Subtraction ◽  
Aneurysm Surgery ◽  
Indocyanine Green Videoangiography ◽  
Aneurysm Neck ◽  
Aneurysm Occlusion ◽  
Perforating Arteries

OBJECTIVEThe quality of surgical treatment of intracranial aneurysms is determined by complete aneurysm occlusion while preserving blood flow in the parent, branching, and perforating arteries. For a few years, there has been a nearly noninvasive and cost-effective technique for intraoperative flow evaluation: microscope-integrated indocyanine green videoangiography (mICG-VA). This method allows for real-time information about blood flow in the aneurysm and the involved vessels, but its limitations are seen in the evaluation of structures located in the depth of the surgical field, especially through small craniotomies. To compensate for these drawbacks, an endoscope-integrated ICG-VA (eICG-VA) was developed. The objective of the present study was to assess the use of eICG-VA in comparison with mICG-VA for intraoperative blood flow evaluation.METHODSIn the period between January 2011 and January 2015, 216 patients with a total of 248 intracranial saccular aneurysms were surgically treated in the Department of Neurosurgery of Saarland University Medical Center in Homburg/Saar, Germany. During 95 surgeries in 88 patients with a total of 108 aneurysms, intraoperative evaluation was performed with both eICG-VA and mICG-VA. After clipping, evaluation of complete aneurysm occlusion and flow in the parent, branching, and perforating arteries was performed using both methods. Intraoperative applicability of each technique was compared with the other and with postoperative digital subtraction angiography as a standard evaluation technique.RESULTSEvaluation of completeness of aneurysm occlusion and of flow in the parent, branching, and perforating arteries was more successful with eICG-VA than with mICG-VA, especially for aneurysm neck assessment (88.9% vs 69.4%). For 63.9% of the aneurysms (n = 69), both methods were equivalent, but in 30.6% of the cases (n = 33), the eICG-VA provided better results for evaluating the post-clipping situation. In 4.6% of these aneurysms (n = 5), the information given by the additional endoscope considerably changed the surgical procedure. Thus, one residual aneurysm (0.9%), two neck remnants (1.9%), and two branch occlusions (1.9%) could be prevented. Nevertheless, two incomplete aneurysm occlusions (1.9%) and six neck remnants (5.6%) were revealed by postoperative digital subtraction angiography.CONCLUSIONSEndoscope-integrated ICG-VA seems to be an improvement that might increase the quality of aneurysm surgery by providing additional information. It offers higher illumination, magnification, and an extended viewing angle. Its main advantage is its ability to assess deep-seated aneurysms, especially through small craniotomies, but further studies are required.

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