Intraoperative Near-infrared Indocyanine Green Videoangiography Performed with a Surgical Microscope – Applications in Cerebrovascular Surgery
Intraoperative Near-infrared Indocyanine Green Videoangiography Performed with a Surgical Microscope – Applications in Cerebrovascular Surgery
Fluorescence angiography was first used by ophthalmologists to measure retinal blood flow by using the fluorescent dye fluorescein. Feindel et al.1,2 were the first to apply the concept of fluorescence angiography to the intraoperative visualisation of cerebral vertebral arteries and cerebral microcirculation in patients undergoing neurosurgical procedures.3,4 With the use of indocyanine green (ICG) as a novel fluorescent dye, and its integration into a compact system that takes advantage of modern video technology, fluorescence angiography has recently re-emerged as a viable option.5,6 Raabe et al.5,6 were the first to demonstrate that ICG videoangiography is suitable for the intraoperative assessment of cerebral vascular flow, thereby providing a useful adjunct for the intraoperative control of vessel patency and aneurysm occlusion during standard aneurysm surgery. Woitzik et al.7 also showed the efficacy of ICG videoangiography during extracranial–intracranial bypass surgeries.
The advantage of ICG over fluorescein is that the light emission is more intense and easier to detect and is characterised by lower rates of adverse reactions, which makes it comparable to other types of contrast media.5–7 ICG was approved by the US Food and Drug Administration (FDA) in 1956 and 1975 for cardiocirculatory measurements, liver function tests and ophthalmic angiography.1,2 In this article, we will present cases in which ICG videoangiography is useful during treatment, to demonstrate the efficacy of the technique in the field of cerebrovascular surgery and to show that the method is a safe and simple method for assessing the microcirculation of the brain.
Method and Patient Case Studies
Microscope Integration of Indocyanine Green Videoangiography
The Carl Zeiss Co. (Oberkochen, Germany) integrated the ICG videoangiography technology into its microscope. The system was designed to integrate near-infrared (NIR) imaging into the surgical miscroscope to assist in obtaining high-resolution and high-contrast NIR images. The operating field was illuminated by a light source with a wavelength covering part of the ICG absorption band (range 700–850nm, maximum 805nm). ICG dye was injected into a peripheral vein as a bolus (the standard 25mg dose dissolved in 10ml of water), and ICG fluorescence was induced after the dye solution arrived in the vessels of the NIR light-illuminated field of interest. The fluorescence (range 780–950nm, maximum 835nm) was recorded by a nonintensified video camera. An optical filter blocked both ambient and excitation light so that only ICG-induced fluorescence was collected. Thus, arterial, capillary and venous angiographic images could be observed on the video screen in realtime. The set-up allowed highresolution NIR images based on ICG fluorescence to be visualised without eliminating visible light during the investigation.
Patients
From January 2007 to March 2008, a total of 32 patients received ICG videoangiography during surgical procedures at Kyoto University Hospital. Included among them were eight cases of extracranial– intracranial (EC–IC) bypass, four cases of cerebral arteriovenous malformations (AVMs) and 13 cases of cerebral aneurysms.
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