• William Smithee, Srikant Chakravarthi, Austin Epping, Mikaeel Kassam, Alejandro Monroy-Sosa, Adam Thota, Bhavani Kura, Richard A Rovin, Melanie B Fukui, and Amin B Kassam.
• Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA.
• World Neurosurg. 2020 Jun 1; 138: e82-e94.

BackgroundNative vessel patency and residual lesion are primary sources of morbidity in cerebrovascular surgery (CVS) that require real-time visualization to inform surgical judgment, as is available in endovascular procedures. Micro Doppler and microscopy-based indocyanine green (ICG) fluorescence are promising evolutions compared with intraoperative angiography (IA), and digital subtraction angiography (DSA) remains the gold standard. Exoscopic visualization in CVS is emerging; however, the feasibility of exoscopic-based ICG (ICG-E) for CVS has not yet been reported. To objective of the study was to provide initial experience with ICG-E video angiography in CVS.MethodsRetrospective study in which 2 ICG-E form-factors (exoscopic-coupled or self-contained handheld imager) were used to determine native vessel patency and residual and compared with DSA.ResultsEleven patients (8 aneurysms, 3 arteriovenous malformations [AVMs]) were included. ICG-E was feasible in all, providing real-time information leading to operative decisions affecting surgical judgment. For aneurysms, discordance of IA with ICG-E and DSA was 12%. In 1 patient, IA showed non-flow-restrictive branch stenosis; however, both ICG and DSA showed patency. All AVMs were fully obliterated, with 100% concordance among all modalities. ICG averaged 4.2 mg dose/run (1-4 doses/case); 1.25 mg was the lowest dose allowing visualization with no advantage with escalating dosages. There were no intraoperative/perioperative complications.ConclusionsIn this preliminary study, ICG-E was safe and feasible, providing real-time visualization informing surgical decision making. The last 4 cases (2 aneurysms and 2 AVMs) evolved toward a portable handheld device, a readily accessible real-time modality providing contextual anatomic and flow visualization. Larger studies are needed to assess broader safety, dose escalation, and efficacy.Copyright © 2020 Elsevier Inc. All rights reserved.

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