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