Utility of Indocyanine Green Videoangiography with FLOW 800 Analysis in Brain Tumor Resection - Venous Protection Tchnique

Background: When it comes to central nervous system tumor resection, preserving vital venous structures to avoid devastating consequences such as brain edema and hemorrhage is important. Wheras, in clinical practice, it is difficult to obtain clear and vivid intraoperative venous visualization and blood flow analysis.Methods: We retrospectively reviewed patients underwent brain tumor resection through the application of indocyanine green videoangiography (ICG-VA) integrated with FLOW 800 from February 2019 to December 2020 and presented our clinical cases to demonstrate the process of venous preservation. Galen vein, sylvian vein and superior cerebral veins were included in our cases.Results: Clear documentations of the veins from different venous groups were obtained via ICG-VA integrated with FLOW 800, which semiquantitatively analyzed the flow dynamics. ICG-VA integrated with FLOW 800 enabled us to achieve brain tumor resection without venous injury and obstructing the venous flux.Conclusions: ICG-VA integrated with FLOW 800 is an available method for venous preservation, though further comparison between ICG-VA integrated with FLOW 800 and other techniques of intraoperative blood flow monitoring is needed.

Improvement of optic nerve pial blood supply visualized through indocyanine green videoangiography after resection of a tuberculum sellae meningioma: 2-dimensional operative video

Ischemia of the optic nerve (ON) is an important cause of visual field deficit provoked by tuberculum sellae (TS) meningiomas. Indocyanine green (ICG) videoangiography could provide prognostic information. Moreover, it allows new insight into the pathophysiology of visual disturbance. The authors present the case of a 48-year-old woman with visual field impairment. Magnetic resonance imaging (MRI) depicted a lesion highly suggestive of a TS meningioma. Following microsurgical resection, ICG videoangiography demonstrated improvement of right ON pial blood supply. In this case, there was one lesion causing visual impairment through both direct compression over the left ON and ischemia to the right nerve. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21155

Application of Indocyanine Green Videoangiography in Cerebellar Hemangioblastoma Surgery as a Valuable Adjunctive Surgical Tool

Introduction : Surgery for cerebellar hemangioblastoma can be challenging because of the tumor’s location in the posterior fossa and its inherent nature of hypervascularity. Methods We reviewed a total of seven consecutive patients who received microsurgery adjunction with indocyanine green (ICG) videoangiography. Results Our study included four female and three male patients. All tumors were located in the cerebellum. We used ICG videoangiography for the purposes of identifying a small tumor inside the cyst in one case, for defining feeding arteries and draining veins in three cases, for confirming residual tumor in the resection cavity in two cases, and for assessment of tumor shunt flow in one case of extremely hypervascular hemangioblastoma. Median blood loss during surgery was 100 mL, and total resection was achieved in all cases with no complications. No adverse effects of ICG videoangiography were observed. Conclusions ICG videoangiography is a very useful adjunctive tool for cerebellar hemangioblastoma surgery.

Detection of impending perfusion deficits by intraoperative computed tomography (iCT) in aneurysm surgery of the anterior circulation

Background The aim of our study was to evaluate the additional benefit of intraoperative computed tomography (iCT), intraoperative computed tomography angiography (iCTA), and intraoperative computed tomography perfusion (iCTP) in the intraoperative detection of impending ischemia to established methods (indocyanine green videoangiography (ICGVA), microDoppler, intraoperative neuromonitoring (IONM)) for initiating timely therapeutic measures. Methods Patients with primary aneurysms of the anterior circulation between October 2016 and December 2019 were included. Data of iCT modalities compared to other techniques (ICGVA, microDoppler, IONM) was recorded with emphasis on resulting operative conclusions leading to inspection of clip position, repositioning, or immediate initiation of conservative treatment strategies. Additional variables analyzed included patient demographics, aneurysm-specific characteristics, and clinical outcome. Results Of 194 consecutive patients, 93 patients with 100 aneurysms received iCT imaging. While IONM and ICGVA were normal, an altered vessel patency in iCTA was detected in 5 (5.4%) and a mismatch in iCTP in 7 patients (7.5%). Repositioning was considered appropriate in 2 patients (2.2%), where immediate improvement in iCTP could be documented. In a further 5 cases (5.4%), intensified conservative therapy was immediately initiated treating the reduced CBP as clip repositioning was not considered causal. In terms of clinical outcome at last FU, mRS0 was achieved in 85 (91.4%) and mRS1-2 in 7 (7.5%) and remained mRS4 in one patient with SAH (1.1%). Conclusions Especially iCTP can reveal signs of impending ischemia in selected cases and enable the surgeon to promptly initiate therapeutic measures such as clip repositioning or intraoperative onset of maximum conservative treatment, while established tools might fail to detect those intraoperative pathologic changes.

Utility of Indocyanine Green Videoangiography with FLOW 800 Analysis in Brain Tumor Resection - Venous Protection Technique

Background: When it comes to central nervous system tumor resection, preserving vital venous structures to avoid devastating consequences such as brain edema and hemorrhage is important. Wheras, in clinical practice, it is difficult to obtain clear and vivid intraoperative venous visualization and blood flow analysis.Methods: We presented our clinical cases to demonstrate the process of venous preservation during surgical resection through the application of indocyanine green videoangiography (ICG-VA) integrated with FLOW 800. Galen vein, sylvian vein and superior cerebral veins of the brain were included.Results: Clear documentations of the veins from different venous groups were obtained via ICG-VA integrated with FLOW 800, which semiquantitatively analyzed the flow dynamics. ICG-VA integrated with FLOW 800 enabled us to achieve brain tumor resection without venous injury and obstructing the venous flux.Conclusions: ICG-VA integrated with FLOW 800 is an efficient method for venous preservation, though further comparison between ICG-VA integrated with FLOW 800 and other techniques of intraoperative blood flow monitoring is needed.

Microsurgical Management of a Marginal Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video

Dural arteriovenous fistulas (DAVFs) are benign but may present with life-threatening hemorrhage or symptoms of venous hypertension (eg, progressive myelopathy).1-3 DAVFs follow well-described anatomic patterns.4 The marginal sinus is located between the layers of the dura, circumferentially around the foramen magnum. It communicates with the basal venous plexus of the clivus anteriorly and the occipital sinus posteriorly.5,6 Arterial supply to the dura in this region that fistulizes into the sinus arises from meningeal branches from the V3 or V4 segments. A man in his early 70s presented with chronic neck pain and new onset of left arm and face paresthesias. He had brisk patellar reflexes bilaterally and a marginal sinus DAVF, with numerous dilated veins around the cisterna magna, causing dorsal cervicomedullary compression. Angiography confirmed the diagnosis of DAVF rather than arteriovenous malformation. Endovascular embolization was considered, but surgery was preferable because of poor transarterial access. The patient underwent left far lateral craniotomy and C1 laminectomy with exposure of the condylar fossa. The dura was carefully elevated laterally, revealing a network of dilated tortuous veins, with multiple points of fistulous connection within the dura emanating in a large venous varix. Indocyanine green videoangiography showed the aberrant flow dynamics. The fistulous point was occluded with aneurysm clips on the venous side, then cauterized and interrupted. The patient was discharged within 3 d of surgery and had full resolution of symptoms at 6 wk. Angiography confirmed complete obliteration of the DAVF. The patient provided written informed consent for treatment. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Thrombectomy and Clip Occlusion of a Giant, Stent-Coiled Basilar Bifurcation Aneurysm: 3-Dimensional Operative Video

Giant basilar apex aneurysms are associated with significant therapeutic challenges.1–6 Multiple techniques exist to treat giant basilar apex aneurysms, including direct clipping, stent-assisted coil embolization, and proximal occlusion with bypass revascularization.7–9 Hypothermic circulatory arrest was a useful adjunct for surgical repair of these aneurysms but has been abandoned because of associated risks.10,11 Rapid ventricular pacing can achieve similar aneurysm softening with minimal risks and assist in clip occlusion. This case illustrates clip occlusion of a giant, partially thrombosed, previously stent-coiled basilar apex aneurysm in a 15-yr-old boy with progressive cranial neuropathies and sensorimotor impairment. Although a wire was placed preoperatively for ventricular pacing, it was not needed during the procedure. Patient consent was obtained. A right-sided orbitozygomatic craniotomy transcavernous approach with anterior and posterior clinoidectomies was performed. The basilar quadrification was dissected, and proximal control was obtained. After aneurysm trapping, the aneurysm was incised and thrombectomized using an ultrasonic aspirator. Back-bleeding from the aneurysm was anticipated, and ventricular pacing was ready, but back-bleeding was minimal. With the coil mass left in place, stacked, fenestrated clips were applied in a tandem fashion to occlude the aneurysm neck. Indocyanine green videoangiography confirmed occlusion of the aneurysm and patency of parent and branch arteries. The patient was at a neurological baseline after the operation, with improvement in motor skills and cognition at 3-mo follow-up. This case demonstrates the use of trans-sylvian-transcavernous exposure, rapid ventricular pacing, and thrombectomy amid previous coils and stents to clip a giant, thrombotic basilar apex aneurysm. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Effects of endothelial defects and venous interposition grafts on the acute incidence of thrombus formation within microvascular procedures

Endothelial defects (ED) and the usage of interposition vein grafts (IVG) are known risk factors for free flap failure. This experimental study aimed to compare both situations of thrombus formation and fluorescence angiographic behavior. Indocyanine green videoangiography (ICGVA) with the FLOW 800 tool was systematically performed in groups I = ED, II = IVG, and III = ED and IVG (each n = 11). ICGVA was able to detect thrombosis in five animals and safely ruled it out in 26 with two false-positive cases (sensitivity, specificity, and positive and negative predictive values were 100%, 90%, 62%, and 100%, respectively). The difference between visually and ICGVA-assisted ED measurements was significant (p = 0.04). The areas of thrombosis showed no significant difference. Moreover, ICGVA detected a decrease of all parameters at the ED area and/or within the IVG section in all groups. The presence of an endothelial defect had a higher impact on thrombus formation than the IVG usage. ICGVA is qualitatively able to detect endothelial defects and clinically evident thrombosis. However, the quantitative values are not yet attributable to one of the clinical scenarios that may jeopardize free flap transfer.