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Usefulness of an Image Fusion Model Using Three-Dimensional CT and MRI with Indocyanine Green Fluorescence Endoscopy as a Multimodal Assistant System in Endoscopic Transsphenoidal Surgery.

Inoue A, Ohnishi T, Kohno S, Nishida N, Nakamura Y, Ohtsuka Y, Matsumoto S, Ohue S - Int J Endocrinol (2015)

Bottom Line: Methods.Results.Additionally, the ICG endoscope was a useful real-time monitoring tool for ETSS.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan.

ABSTRACT
Purpose. We investigate the usefulness of multimodal assistant systems using a fusion model of preoperative three-dimensional (3D) computed tomography (CT) and magnetic resonance imaging (MRI) along with endoscopy with indocyanine green (ICG) fluorescence in establishing endoscopic endonasal transsphenoidal surgery (ETSS) as a more effective treatment procedure. Methods. Thirty-five consecutive patients undergoing ETSS in our hospital between April 2014 and March 2015 were enrolled in the study. In all patients, fusion models of 3D-CT and MRI were created by reconstructing preoperative images. In addition, in 10 patients, 12.5 mg of ICG was intravenously administered, allowing visualization of surrounding structures. We evaluated the accuracy and utility of these combined modalities in ETSS. Results. The fusion model of 3D-CT and MRI clearly demonstrated the complicated structures in the sphenoidal sinus and the position of the internal carotid arteries (ICAs), even with extensive tumor infiltration. ICG endoscopy enabled us to visualize the surrounding structures by the phasic appearance of fluorescent signals emitted at specific consecutive elapsed times. Conclusions. Preoperative 3D-CT and MRI fusion models with intraoperative ICG endoscopy allowed distinct visualization of vital structures in cases where tumors had extensively infiltrated the sphenoidal sinus. Additionally, the ICG endoscope was a useful real-time monitoring tool for ETSS.

No MeSH data available.


Related in: MedlinePlus

Preoperative image of a fusion model of 3D-CT and MRI and intraoperative endoscopic view along with ICG endoscopic views at each elapsed time in Case 2. (a) Preoperative sagittal Gd-enhanced MRI in Case 2 showing a cystic lesion in the sellar and suprasellar region. (b) A fusion model of 3D-CT and MRI demonstrating an anatomical relationship between bilateral ICAs and the pituitary gland that is flattened at the sellar floor. The bony structures are partially eliminated (asterisks: C3; stars: C4) and the normal pituitary gland (PG). (c) Endoscopic view demonstrating the structures around the sella that correspond to the fusion model. (d, e, f) ICG endoscopic views visualizing bilateral ICAs in the carotid prominences (stars) at the earliest phase, followed by ICS (arrowheads), and the normal pituitary gland (PG) at 5 to 10 s later.
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fig3: Preoperative image of a fusion model of 3D-CT and MRI and intraoperative endoscopic view along with ICG endoscopic views at each elapsed time in Case 2. (a) Preoperative sagittal Gd-enhanced MRI in Case 2 showing a cystic lesion in the sellar and suprasellar region. (b) A fusion model of 3D-CT and MRI demonstrating an anatomical relationship between bilateral ICAs and the pituitary gland that is flattened at the sellar floor. The bony structures are partially eliminated (asterisks: C3; stars: C4) and the normal pituitary gland (PG). (c) Endoscopic view demonstrating the structures around the sella that correspond to the fusion model. (d, e, f) ICG endoscopic views visualizing bilateral ICAs in the carotid prominences (stars) at the earliest phase, followed by ICS (arrowheads), and the normal pituitary gland (PG) at 5 to 10 s later.

Mentions: Case 2. A 64-year-old man complained of deterioration of visual function and general fatigue. Laboratory studies showed a low plasma level of all adenohypophyseal hormones. Gd-enhanced MRI showed a cystic lesion in the sella (Figure 3(a)). A reconstructed 3D-CT and MRI fusion model allowed localization of the ICAs, optic nerves, and the normal pituitary gland, which were observed through the thinning bone structures (Figure 3(b)). Under the guidance of the 3D-CT and MRI fusion model, we made a preoperative plan and decided how best to open the sellar floor, particularly to expose the upper part of the dura mater because the normal pituitary located in the sellar floor and the anterior-superior part of the sella was determined to be the appropriate site for opening the cyst wall. Intraoperative endoscopic views correlated with the fusion model images (Figure 3(c)). Introduction of the ICG endoscope allowed visualization of the bilateral ICAs 10 s after ICG flushing; the ICS could be seen 20 s later, and the normal pituitary gland could be seen 25 s later (Figures 3(d), 3(e), and 3(f)). The cyst contents were removed, and a part of the cyst wall was removed and used for histological examination. The histological diagnosis was Rathke's cleft cyst. Postoperatively, the patient's visual function improved, although he still required hormone replacement therapy, including hydrocortisone and levothyroxine. Nonetheless, his condition has not deteriorated, nor has diabetes insipidus appeared.


Usefulness of an Image Fusion Model Using Three-Dimensional CT and MRI with Indocyanine Green Fluorescence Endoscopy as a Multimodal Assistant System in Endoscopic Transsphenoidal Surgery.

Inoue A, Ohnishi T, Kohno S, Nishida N, Nakamura Y, Ohtsuka Y, Matsumoto S, Ohue S - Int J Endocrinol (2015)

Preoperative image of a fusion model of 3D-CT and MRI and intraoperative endoscopic view along with ICG endoscopic views at each elapsed time in Case 2. (a) Preoperative sagittal Gd-enhanced MRI in Case 2 showing a cystic lesion in the sellar and suprasellar region. (b) A fusion model of 3D-CT and MRI demonstrating an anatomical relationship between bilateral ICAs and the pituitary gland that is flattened at the sellar floor. The bony structures are partially eliminated (asterisks: C3; stars: C4) and the normal pituitary gland (PG). (c) Endoscopic view demonstrating the structures around the sella that correspond to the fusion model. (d, e, f) ICG endoscopic views visualizing bilateral ICAs in the carotid prominences (stars) at the earliest phase, followed by ICS (arrowheads), and the normal pituitary gland (PG) at 5 to 10 s later.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4539066&req=5

fig3: Preoperative image of a fusion model of 3D-CT and MRI and intraoperative endoscopic view along with ICG endoscopic views at each elapsed time in Case 2. (a) Preoperative sagittal Gd-enhanced MRI in Case 2 showing a cystic lesion in the sellar and suprasellar region. (b) A fusion model of 3D-CT and MRI demonstrating an anatomical relationship between bilateral ICAs and the pituitary gland that is flattened at the sellar floor. The bony structures are partially eliminated (asterisks: C3; stars: C4) and the normal pituitary gland (PG). (c) Endoscopic view demonstrating the structures around the sella that correspond to the fusion model. (d, e, f) ICG endoscopic views visualizing bilateral ICAs in the carotid prominences (stars) at the earliest phase, followed by ICS (arrowheads), and the normal pituitary gland (PG) at 5 to 10 s later.
Mentions: Case 2. A 64-year-old man complained of deterioration of visual function and general fatigue. Laboratory studies showed a low plasma level of all adenohypophyseal hormones. Gd-enhanced MRI showed a cystic lesion in the sella (Figure 3(a)). A reconstructed 3D-CT and MRI fusion model allowed localization of the ICAs, optic nerves, and the normal pituitary gland, which were observed through the thinning bone structures (Figure 3(b)). Under the guidance of the 3D-CT and MRI fusion model, we made a preoperative plan and decided how best to open the sellar floor, particularly to expose the upper part of the dura mater because the normal pituitary located in the sellar floor and the anterior-superior part of the sella was determined to be the appropriate site for opening the cyst wall. Intraoperative endoscopic views correlated with the fusion model images (Figure 3(c)). Introduction of the ICG endoscope allowed visualization of the bilateral ICAs 10 s after ICG flushing; the ICS could be seen 20 s later, and the normal pituitary gland could be seen 25 s later (Figures 3(d), 3(e), and 3(f)). The cyst contents were removed, and a part of the cyst wall was removed and used for histological examination. The histological diagnosis was Rathke's cleft cyst. Postoperatively, the patient's visual function improved, although he still required hormone replacement therapy, including hydrocortisone and levothyroxine. Nonetheless, his condition has not deteriorated, nor has diabetes insipidus appeared.

Bottom Line: Methods.Results.Additionally, the ICG endoscope was a useful real-time monitoring tool for ETSS.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Ehime University School of Medicine, 454 Shitsukawa, Toon, Ehime 791-0295, Japan.

ABSTRACT
Purpose. We investigate the usefulness of multimodal assistant systems using a fusion model of preoperative three-dimensional (3D) computed tomography (CT) and magnetic resonance imaging (MRI) along with endoscopy with indocyanine green (ICG) fluorescence in establishing endoscopic endonasal transsphenoidal surgery (ETSS) as a more effective treatment procedure. Methods. Thirty-five consecutive patients undergoing ETSS in our hospital between April 2014 and March 2015 were enrolled in the study. In all patients, fusion models of 3D-CT and MRI were created by reconstructing preoperative images. In addition, in 10 patients, 12.5 mg of ICG was intravenously administered, allowing visualization of surrounding structures. We evaluated the accuracy and utility of these combined modalities in ETSS. Results. The fusion model of 3D-CT and MRI clearly demonstrated the complicated structures in the sphenoidal sinus and the position of the internal carotid arteries (ICAs), even with extensive tumor infiltration. ICG endoscopy enabled us to visualize the surrounding structures by the phasic appearance of fluorescent signals emitted at specific consecutive elapsed times. Conclusions. Preoperative 3D-CT and MRI fusion models with intraoperative ICG endoscopy allowed distinct visualization of vital structures in cases where tumors had extensively infiltrated the sphenoidal sinus. Additionally, the ICG endoscope was a useful real-time monitoring tool for ETSS.

No MeSH data available.


Related in: MedlinePlus