Raabe A, Nakaji P, Beck J, et al. Prospective evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery. J Neurosurg.103(6):982-989

Department of Neurosurgery, Neurocenter, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
Journal of Neurosurgery (Impact Factor: 3.23). 01/2006; 103(6):982-9. DOI: 10.3171/jns.2005.103.6.0982
Source: PubMed

ABSTRACT The authors prospectively compared a new technique of surgical microscope-based indocyanine green (ICG) videoangiography with intraoperative or postoperative digital subtraction (DS) angiography.
The technique was performed during 187 surgical procedures in which 124 aneurysms in 114 patients were clipped. Using a newly developed setup, the ICG technique has been integrated into an operating microscope (Carl Zeiss Co., Oberkochen, Germany). A microscope-integrated light source containing infrared excitation light illuminates the operating field. The dye is injected intravenously into the patient, and intravascular fluorescence from within the blood vessels is imaged using a video camera attached to the microscope. The patency of parent, branching, and perforating arteries and documentation of clip occlusion of the aneurysm as shown by ICG videoangiography were compared with intraoperative or postoperative findings on DS angiography. The results of ICG videoangiography corresponded with intra- or postoperative DS angiography in 90% of cases. The ICG technique missed mild but hemodynamically irrelevant stenosis that was evident on DS angiography in 7.3% of cases. The ICG technique missed angiographically relevant findings in three cases (one hemodynamically relevant stenosis and two residual aneurysm necks [2.7% of cases]). In two cases the missed findings were clinically and surgically inconsequential; in the third case, a 4-mm residual neck may require a second procedure. Indocyanine green videoangiography provided significant information for the surgeon in 9% of cases, most of which led to clip correction.
Microscope-based ICG videoangiography is simple and provides real-time information about the patency of vessels of all sizes and about the aneurysm sac. This technique may be useful during routine aneurysm surgery as an independent form of angiography or as an adjunct to intra- or postoperative DS angiography.

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Available from: Peter Nakaji, Sep 10, 2014
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    • "In the last decade, our group and others have successfully utilized ICGA in surgery for elective and ruptured cerebral aneurysms, intracranial–extracranial bypass, and cerebral arteriovenous malformations [9–24]. ICGA has similar rates of clip repositioning and parent vessel stenosis when compared head-to-head with either intraoperative or postoperative DSA [9] [23] [25]. Published studies have focused on the technical sensitivity and specificity of ICGA when compared to a ''gold standard'' of intraoperative or postoperative DSA in patients receiving both imaging modalities. "
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    ABSTRACT: Intraoperative angiography in cerebrovascular neurosurgery can drive the repositioning or addition of aneurysm clips. Our institution has switched from a strategy of intraoperative digital subtraction angiography (DSA) universally, to a strategy of indocyanine green (ICG) videoangiography with DSA on an as-needed basis. We retrospectively evaluated whether the rates of perioperative stroke, unexpected postoperative aneurysm residual, or parent vessel stenosis differed in 100 patients from each era (2002, "DSA era"; 2007, "ICG era"). The clip repositioning rate for neck residual or parent vessel stenosis did not differ significantly between the two eras. There were no differences in the rate of perioperative stroke or rate of false-negative studies. The per-patient cost of intraoperative imaging within the DSA era was significantly higher than in the ICG era. The replacement of routine intraoperative DSA with ICG videoangiography and selective intraoperative DSA in cerebrovascular aneurysm surgery is safe and effective.
    Journal of Clinical Neuroscience 04/2014; 21(8). DOI:10.1016/j.jocn.2014.02.006 · 1.32 Impact Factor
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    • "Intraoperative fluorescence angiography is helpful in performing 'Matas test' during clipping ACoA GIA (Murai, 2011) or ensuring the patency of the parent artery and perforators. However, in 5% of cases the image quality is poor (Raabe, 2005). The limitations of fluorescence angiography refer to GIAs affected by calcifications, thrombosed and those with thick walls (Snyder, 2011). "
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    Aneurysm, free online edition edited by Yasuo Murai, 08/2012: chapter Giant Intracranial Aneurysms – Surgical Treatment, Accessory Techniques and Outcome.: pages 351-382; InTech, Janeza Trdine 9, 51000 Rijeka, Croatia., ISBN: 978-953-51-0730-9
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    • "Prior to temporary clipping, blood pressure may be elevated pharmacologically and cerebral protectants such as barbiturates, propofol, or etomidate can be administered to reduce the risk of ischemia. Finally, after placement of the permanent clip on the aneurysmal neck, intraoperative micro-Doppler, non-invasive near infrared indocyanine green videoangiography, or invasive intraoperative cerebral angiography are employed to assess the patency of the parent artery as well as the entire occlusion of the aneurysm neck (Raabe et al., 2005; Dashti et al., 2007). A case of clipping of a right MCA aneurysm is illustrated in Figure 1 "
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    ABSTRACT: Intracranial aneurysms are present in roughly 5% of the population, yet most are often asymptomatic and never detected. Development of an aneurysm typically occurs during adulthood, while formation and growth are associated with risk factors such as age, hypertension, pre-existing familial conditions, and smoking. Subarachnoid hemorrhage, the most common presentation due to aneurysm rupture, represents a serious medical condition often leading to severe neurological deficit or death. Recent technological advances in imaging modalities, along with increased understanding of natural history and prevalence of aneurysms, have increased detection of asymptomatic unruptured intracranial aneurysms (UIA). Studies reporting on the risk of rupture and outcomes have provided much insight, but the debate remains of how and when unruptured aneurysms should be managed. Treatment methods include two major intervention options: clipping of the aneurysm and endovascular methods such as coiling, stent-assisted coiling, and flow diversion stents. The studies reviewed here support the generalized notion that endovascular treatment of UIA provides a safe and effective alternative to surgical treatment. The risks associated with endovascular repair are lower and incur shorter hospital stays for appropriately selected patients. The endovascular treatment option should be considered based on factors such as aneurysm size, location, patient medical history, and operator experience.
    Frontiers in Neurology 07/2011; 2:45. DOI:10.3389/fneur.2011.00045
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