Clinical StudyIntraoperative near-infrared indocyanine green–videoangiography (ICG–VA) and graphic analysis of fluorescence intensity in cerebral aneurysm surgery
Introduction
The principle challenge in aneurysm surgery is to achieve complete obliteration of the sac while maintaining the patency of the parent artery, its nearby branches and any perforators. Following Raabe et al.’s report in 2003,1 several authors have recommended the use of indocyanine green videoangiography (ICG–VA) as an adjunct during intracranial aneurysm clipping.[2], [3], [4], [5], [6], [7] During intraoperative ICG–VA, neurosurgeons have relied on direct inspection of blood flow fluorescence to determine whether an aneurysm has been obliterated completely. To our knowledge, a microscope-integrated module that provides a record of fluorescence as an intensity diagram, in addition to the traditional near-infrared (NIR) ICG–VA, has not been evaluated. We present our experience with intraoperative ICG–VA and a graphic representation of fluorescence intensity to better understand the hemodynamics in cerebral aneurysm surgery. The clinical usefulness of this method is assessed.
Section snippets
Patient population
Thirty-nine consecutive patients (12 male, 27 female, mean age 61.1 years, range 31–78 years) underwent microsurgical clipping at our center between May 2010 and July 2010. A total of 43 intracranial aneurysms were clipped (7 ruptured, 36 unruptured). Ruptured intracranial aneurysms were categorized as Hunt and Hess (H&H) grade II in one patient, H&H grade III in three patients, and H&H grade IV in three patients. Of the 36 patients with unruptured aneurysms, four patients also had other
Results
We treated 43 aneurysms in 39 consecutive patients. Of these, 41 aneurysms were treated by clipping alone. Another two broad-neck, giant ICA aneurysms were treated by intentional reconstruction of the aneurysmal neck followed by endovascular coiling. None of the 41 aneurysms managed by clipping alone showed signs of major branch occlusion or residual aneurysm on the postoperative 3D–CTA.
ICG–VA was performed 137 times in 39 patients. The minimal interval between two consecutive procedures was 5
Discussion
ICG is an NIR fluorescent tri-carbocyanine dye used in medical diagnostics. The dye is injected intravenously, binds tightly to the plasma proteins and remains confined to the intravascular system. With a half-life of 3 minutes to 4 minutes, ICG is eliminated from the circulation into the bile exclusively via hepatic metabolism. Traditionally ICG has been used for evaluating cardiac output, hepatic function and in the assessment of blood flow across vascular anastomoses. ICG is also used widely
Conclusion
ICG–VA provides high resolution images and it allows a real-time assessment of the blood flow in the parent artery, arterial branches and adjacent small perforators. Interpretation of this information is, however, subjective. The intensity diagram is a very useful adjunct to ICG–VA for objectively documenting the blood flow in the aneurysm sac and perforators. This feedback is invaluable in optimizing the benefits and minimizing the complications during surgery for intracranial aneurysms.
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Cited by (31)
Photoacoustic Monitoring of the Viability of Mesenchymal Stem Cells Labeled with Indocyanine Green
2019, IRBMCitation Excerpt :The mechanism of uptake and secretion of ICG has been demonstrated to follow a saturable carrier-mediated transport process which can be described by the Michaelis–Menten equation [10,13,25]. Moreover, ICG has been widely used as clinical fluorescent dye, especially in angiographic diagnosis, due to its high contrast, sensitivity, safety, and low cost [26,27]. Yet, ICG does not have high fluorescence quantum yield (2.5% in water, 1.2% in blood), so a large part of the absorbed photon energy can be transferred to the non-radiative relaxation of molecules which can enhance photoacoustic wave generation after irradiation of short laser pulses [28].
Role of intraoperative indocyanine green video-angiography to identify small, posterior fossa arteriovenous malformations mimicking cavernous angiomas. Technical report and review of the literature on common features of these cerebral vascular malformations
2015, Clinical Neurology and NeurosurgeryCitation Excerpt :Intraoperative angiography [13–16] and microscope-integrated indocyanine green video-angiography (ICG-VA) [17] are helpful tools in the surgical management of cerebral vascular malformations. Initially tested to help in intracranial aneurysms surgery [18–27] and to assess cerebral blood flow [28–31], ICG-VA has gained popularity also for its application in brain and spinal AVMs and arterio-venous fistulas [32–37]. Recently, positive experiences with ICG-VA during brain tumor surgery [38–40], resection of cerebral or spinal cord cavernous angiomas [41,42] and carotid endoarterectomy [43] have also been reported.
Indocyanine green video-angiography in neurosurgery: A glance beyond vascular applications
2014, Clinical Neurology and NeurosurgeryCitation Excerpt :ICG is often compared to micro-doppler and digital subtraction angiography (DSA) to evaluate vascular anatomy, before and after clipping, and to assess correct position of the clip, presence of aneurysm residuals, patency of normal vessels. Few studies focused specifically on paraclinoid aneurysms [10,19] and on quantitative blood flow study [7,12,18](which allows an objective evaluation of the results rather than the subjective assessment of fluorescence using ICG-VA). One interesting paper reports about a patient suffering from a giant aneurysm of the right MCA; Indocyanine green was injected inside the aneurysm in order to identify a target middle cerebral artery branch (MCA) for bypass and allowing confident preservation of blood supply to distal areas to the sacrificed vessel [11].
Numerical Model for Cerebrovascular Hemodynamics with Indocyanine Green Fluorescence Videoangiography
2023, Journal of Korean Neurosurgical SocietyIntraoperative indocyanine green video angiography (ICG–VA) with FLOW 800 software in complex intracranial aneurysm surgery
2021, Chinese Neurosurgical Journal