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Intraoperative assessment of spinal vascular flow in the surgery of spinal intramedullary tumors using indocyanine green videoangiography.

Takami T, Yamagata T, Naito K, Arima H, Ohata K - Surg Neurol Int (2013)

Bottom Line: There were no complications or side-effects related to ICG-VA.All angiographic images were well integrated into the microscopic view.Intraoperative vascular flow assessment using ICG-VA was easy, repeatable, and practical without any significant procedure-related risks.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.

ABSTRACT

Background: The authors demonstrate the utility of indocyanine green videoangiography (ICG-VA) for intraoperative vascular flow assessment in the surgery of a variety of spinal intramedullary tumors to achieve an additional level of safety as well as precision with the surgical procedure.

Methods: Fourteen patients with spinal intramedullary tumors (nine cervical and five thoracic) operated on between August 2011 and April 2013 were included in the present study. A fluorescence surgical microscope was used to perform ICG-VA after standard exposure of the lesion to assess the dynamic flow of the spinal microvasculature.

Results: Twenty-seven ICG-VA injections were performed in 14 cases. Pathological diagnosis of the tumors included ependymoa, astrocytoma, cavernous malformation, or hemagioblastoma. There were no complications or side-effects related to ICG-VA. Intraoperative ICG-VA provided dynamic flow images of the spinal microvasculature in accordance with the progress of surgical procedures. Angiographic images could be divided into arterial, capillary, and venous phases. All angiographic images were well integrated into the microscopic view. The utility of ICG-VA could be summarized into three categories: (1) Localization of normal spinal arteries and veins, (2) assessment of posterior spinal venous circulation, and (3) differentiation of feeding arteries, tumor, and draining veins.

Conclusions: Intraoperative vascular flow assessment using ICG-VA was easy, repeatable, and practical without any significant procedure-related risks. ICG-VA can be used for careful analysis of spinal microvascular flow or anatomical orientation, which is necessary to ensure safe and precise resection of spinal intramedullary tumors.

No MeSH data available.


Related in: MedlinePlus

Intraoperative photographs from Patient 12. (a) Photographs showing a slightly swollen spinal cord. b-c. Photographs from the early phase of indocyanine green videoangiography (ICG-VA) showing the posterior spinal arteries on both sides (arrows) (b), and from the late phase of ICG-VA showing the stagnation of venous flow (arrowheads) of posterior spinal veins and the pial venous plexus crossing veins on the posterior median sulcus (c). d-f. Photographs obtained after the complete removal of the ependymoma, showing well preserved sulcal central branches of the anterior spinal artery (arrows) and the posterior sulcal central veins (d, e) and the surrounding gliotic tissue (f)
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Figure 2: Intraoperative photographs from Patient 12. (a) Photographs showing a slightly swollen spinal cord. b-c. Photographs from the early phase of indocyanine green videoangiography (ICG-VA) showing the posterior spinal arteries on both sides (arrows) (b), and from the late phase of ICG-VA showing the stagnation of venous flow (arrowheads) of posterior spinal veins and the pial venous plexus crossing veins on the posterior median sulcus (c). d-f. Photographs obtained after the complete removal of the ependymoma, showing well preserved sulcal central branches of the anterior spinal artery (arrows) and the posterior sulcal central veins (d, e) and the surrounding gliotic tissue (f)

Mentions: In cases of a posterior median sulcus (PMS) or posterolateral sulcus (PLS) approach to the tumor, such as for ependymomas, astrocytomas, or cavernous malformations, posterior spinal arteries on both sides were well differentiated from posterior spinal veins or the pial venous plexus using ICG-VA [Figures 1b and 2b]. Venous circulation of posterior spinal veins or the pial venous plexus crossing just over the PMS or PLS was also assessed using ICG-VA. If stagnation or slow flow of the venous circulation of these crossing veins was suggested [Figures 1c and 2c], the veins were coagulated with a microbipolar coagulator at very low power levels under continuous saline irrigation. Otherwise, the thick posterior spinal vein was gently dissected and separated from the PMS or PLS. The PMS or PLS opening was made using a diamond knife, and the myelotomy was extended rostrally or caudally using a microdissector to meticulously splay the spinal tissue. When the tumor was encountered, gentle dissection of the tumor–cord interface was continued in the longitudinal plane over the extent of the tumor. With care to protect the adjacent dorsal and lateral columns, the tumor or capsule was removed segmentally or in one piece. In cases where the tumor–cord interface was not evident, the tumor removal was not continued. In cases of cavernous malformation, the surrounding hemosiderin stained tissue was not resected. After resection of the tumor, posterior sulcal central veins or sulcal central branches of the anterior spinal artery were analyzed using ICG-VA [Figures 1e and 2e].


Intraoperative assessment of spinal vascular flow in the surgery of spinal intramedullary tumors using indocyanine green videoangiography.

Takami T, Yamagata T, Naito K, Arima H, Ohata K - Surg Neurol Int (2013)

Intraoperative photographs from Patient 12. (a) Photographs showing a slightly swollen spinal cord. b-c. Photographs from the early phase of indocyanine green videoangiography (ICG-VA) showing the posterior spinal arteries on both sides (arrows) (b), and from the late phase of ICG-VA showing the stagnation of venous flow (arrowheads) of posterior spinal veins and the pial venous plexus crossing veins on the posterior median sulcus (c). d-f. Photographs obtained after the complete removal of the ependymoma, showing well preserved sulcal central branches of the anterior spinal artery (arrows) and the posterior sulcal central veins (d, e) and the surrounding gliotic tissue (f)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3815013&req=5

Figure 2: Intraoperative photographs from Patient 12. (a) Photographs showing a slightly swollen spinal cord. b-c. Photographs from the early phase of indocyanine green videoangiography (ICG-VA) showing the posterior spinal arteries on both sides (arrows) (b), and from the late phase of ICG-VA showing the stagnation of venous flow (arrowheads) of posterior spinal veins and the pial venous plexus crossing veins on the posterior median sulcus (c). d-f. Photographs obtained after the complete removal of the ependymoma, showing well preserved sulcal central branches of the anterior spinal artery (arrows) and the posterior sulcal central veins (d, e) and the surrounding gliotic tissue (f)
Mentions: In cases of a posterior median sulcus (PMS) or posterolateral sulcus (PLS) approach to the tumor, such as for ependymomas, astrocytomas, or cavernous malformations, posterior spinal arteries on both sides were well differentiated from posterior spinal veins or the pial venous plexus using ICG-VA [Figures 1b and 2b]. Venous circulation of posterior spinal veins or the pial venous plexus crossing just over the PMS or PLS was also assessed using ICG-VA. If stagnation or slow flow of the venous circulation of these crossing veins was suggested [Figures 1c and 2c], the veins were coagulated with a microbipolar coagulator at very low power levels under continuous saline irrigation. Otherwise, the thick posterior spinal vein was gently dissected and separated from the PMS or PLS. The PMS or PLS opening was made using a diamond knife, and the myelotomy was extended rostrally or caudally using a microdissector to meticulously splay the spinal tissue. When the tumor was encountered, gentle dissection of the tumor–cord interface was continued in the longitudinal plane over the extent of the tumor. With care to protect the adjacent dorsal and lateral columns, the tumor or capsule was removed segmentally or in one piece. In cases where the tumor–cord interface was not evident, the tumor removal was not continued. In cases of cavernous malformation, the surrounding hemosiderin stained tissue was not resected. After resection of the tumor, posterior sulcal central veins or sulcal central branches of the anterior spinal artery were analyzed using ICG-VA [Figures 1e and 2e].

Bottom Line: There were no complications or side-effects related to ICG-VA.All angiographic images were well integrated into the microscopic view.Intraoperative vascular flow assessment using ICG-VA was easy, repeatable, and practical without any significant procedure-related risks.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.

ABSTRACT

Background: The authors demonstrate the utility of indocyanine green videoangiography (ICG-VA) for intraoperative vascular flow assessment in the surgery of a variety of spinal intramedullary tumors to achieve an additional level of safety as well as precision with the surgical procedure.

Methods: Fourteen patients with spinal intramedullary tumors (nine cervical and five thoracic) operated on between August 2011 and April 2013 were included in the present study. A fluorescence surgical microscope was used to perform ICG-VA after standard exposure of the lesion to assess the dynamic flow of the spinal microvasculature.

Results: Twenty-seven ICG-VA injections were performed in 14 cases. Pathological diagnosis of the tumors included ependymoa, astrocytoma, cavernous malformation, or hemagioblastoma. There were no complications or side-effects related to ICG-VA. Intraoperative ICG-VA provided dynamic flow images of the spinal microvasculature in accordance with the progress of surgical procedures. Angiographic images could be divided into arterial, capillary, and venous phases. All angiographic images were well integrated into the microscopic view. The utility of ICG-VA could be summarized into three categories: (1) Localization of normal spinal arteries and veins, (2) assessment of posterior spinal venous circulation, and (3) differentiation of feeding arteries, tumor, and draining veins.

Conclusions: Intraoperative vascular flow assessment using ICG-VA was easy, repeatable, and practical without any significant procedure-related risks. ICG-VA can be used for careful analysis of spinal microvascular flow or anatomical orientation, which is necessary to ensure safe and precise resection of spinal intramedullary tumors.

No MeSH data available.


Related in: MedlinePlus