Elsevier

World Neurosurgery

Volume 82, Issues 3–4, September–October 2014, Pages e495-e501
World Neurosurgery

Peer-Review Report
Usefulness of Tumor Blood Flow Imaging by Intraoperative Indocyanine Green Videoangiography in Hemangioblastoma Surgery

https://doi.org/10.1016/j.wneu.2013.02.009Get rights and content

Objective

Hemangioblastomas remain a surgical challenge because of their arteriovenous malformation–like character. Recently, indocyanine green (ICG) videoangiography has been applied to neurosurgical vascular surgery. The aim of this study was to evaluate the usefulness of tumor blood flow imaging by intraoperative ICG videoangiography in surgery for hemangioblastomas.

Methods

Twenty intraoperative ICG videoangiography procedures were performed in 12 patients with hemangioblastomas. Seven lesions were located in the cerebellum, two lesions were in the medulla oblongata, and three lesions were in the spinal cord.

Results

Ten procedures were performed before or during dissection, and 10 procedures were performed after tumor resection. ICG videoangiography could provide dynamic images of blood flow in the tumor and its related vessels under surgical view. Interpretation of these dynamic images of tumor blood flow was useful for discrimination of transit feeders (feeders en passage) and also for estimation of unexposed feeders covered with brain parenchyma. Postresection ICG videoangiography could confirm complete tumor resection and normalized blood flow in surrounding vessels.

Conclusions

In surgery for hemangioblastomas, careful interpretation of dynamic ICG images can provide useful information on transit feeders and unexposed hidden vessels that cannot be directly visualized by ICG.

Introduction

Hemangioblastomas are highly vascular tumors that occur predominantly in the cerebellum and spinal cord and comprise 1.5%–2.5% of intracranial and 3%–4% of spinal tumors 1, 6, 11, 16. They mainly present as sporadic events, but 20%–30% of cases are associated with von Hippel-Lindau disease. Hemangioblastomas are histologically benign tumors, and complete resection results in a favorable outcome. However, this tumor remains a surgical challenge because of its arteriovenous malformation (AVM)–like character 1, 11, 16. In hemangioblastoma surgery, it is important to distinguish between transit feeders (which have branches supplying the tumor) and adjacent nonfeeding arteries.

Indocyanine green (ICG) videoangiography has been recently applied to the neurosurgical field 2, 5, 10, 12, 13, 15. Previous reports have shown that intraoperative ICG videoangiography was useful in extracranial–intracranial bypass surgery and in the treatment of cerebral aneurysms 10, 13, 15. Here, we report the usefulness of tumor blood flow imaging by intraoperative ICG videoangiography in surgery for hemangioblastomas. ICG videoangiography can provide useful information on transit feeders (feeders en passage) and unexposed hidden vessels by careful interpretation of dynamic images of tumor blood flow.

Section snippets

Patient Population

Twenty ICG videoangiography procedures were performed in 12 patients with hemangioblastomas. The patient characteristics are summarized in Table 1. The mean age at the time of surgery was 47.3 years (range 15–82 years). Seven lesions were located in the cerebellum. Five of these 7 cerebellar lesions were cystic and 2 lesions were solid. Two lesions were located in the medulla oblongata, and 3 lesions were in the spinal cord.

ICG Videoangiography

We used an OPMI Pentero surgical microscope (Carl Zeiss, Co.,

Results

One to three ICG videoangiography procedures were performed in each operation. The timing of ICG videoangiography is summarized in Table 1. Among 20 ICG videoangiograms, 10 procedures were performed before or during dissection, and 10 procedures were performed after removal of the tumor.

In pre-resection studies, the feeding arteries were visualized in six of seven cases (86%) by ICG. The tumor was visualized in all eight cases (100%), and the drainers were visualized in seven of nine cases

Case 1 (Patient 7)

A 37-year-old woman with known von Hippel-Lindau disease presented with ataxia. Magnetic resonance (MR) imaging revealed a cystic lesion with a homogeneously enhancing mural nodule in the cerebellar hemisphere (Figure 1A). She underwent surgery to remove the tumor. In the surgery, we could easily detect the mural nodule and the main feeding artery. However, it was difficult to distinguish between transit feeding arteries and adjacent nonfeeding arteries. Therefore, ICG videoangiography was

Discussion

Hemangioblastomas are highly vascular tumors that have AVM-like characters. Therefore, strategies based on the cerebrovascular surgery are necessary for the treatment of this tumor 1, 11, 16. First of all, identification and elimination of feeding arteries of the tumor should be done in surgery. With diminishing blood supply, the tumor shrinks and then careful dissection around the tumor margin should be carried out 1, 11, 16. It has been reported that intraoperative microvascular Doppler is

Conclusion

In surgery for hemangioblastomas, ICG videoangiography can provide useful information on discrimination between transit feeders and adjacent nonfeeding arteries by careful interpretation of dynamic flow images under the surgical microscopic view. Interpretation of tumor blood flow can also be useful for estimating unexposed hidden feeding arteries and draining veins that cannot be directly visualized by ICG.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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