Abstract
Background
In this pilot study we compared advantages and drawbacks of near-infrared indocyanine green videoangiography (ICGVA) and intraoperative computed tomography (iCT) to investigate if these are complementary or competitive methods to acquire immediate information about blood vessels and potential critical impairment of brain perfusion during vascular neurosurgery.
Methods
A small subset of patients (n = 10) were prospectively enrolled in this feasibility study and received ICGVA immediately after placement of the aneurysm clips. An intraoperative cranial CT angiography (iCTA) was followed by dynamic perfusion CT scan (iCTP) using a 40-slice, sliding-gantry, CT scanner. The vascular patency of major (aneurysm bearing) arteries, visualisation of arising perforating arteries and brain perfusion after clip application were analysed with both techniques.
Results
The ICGVA was able to visualise blood flow and vascular patency of all major vessels and perforating arteries within the visual field of the microscope, but failed to display vessels located within deeper areas of the surgical field. Even small coverage with brain parenchyma impaired detection of vessels. With iCTA high image quality could be obtained in 7/10 cases of clipped aneurysms. Intraoperative CTA was not sufficiently evaluable in one PICA aneurysm and one case of a previously coiled recurrent aneurysm, due to extensive coil artefacts. Small, perforating arteries could not be detected with iCTA. Intraoperative CTP allowed the assessment of global blood flow and brain perfusion in sufficient quality in 5/10 cases, and enabled adequate intraoperative decision making.
Conclusion
A combination of ICGVA and iCT is feasible, with very good diagnostic imaging quality associated with short acquisition time and little interference with the surgical workflow. Both techniques are complementary rather than competing analysing tools and help to assess information about local (ICGVA/iCTA) as well as regional (iCTA/iCTP) blood flow and cerebral perfusion immediately after clipping of intracranial aneurysms.
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Comment
The comparison of the described techniques is of scientific interest and iCTA may definitely be helpful for the vascular neurosurgeon in some special situations in addition to or instead of the other techniques with their limitations. The problem may be that we do not know without intraoperative—and also somewhat time-consuming—conventional angiography which of the techniques (ICGVA or iCTA) is to be trusted during surgery. With usually limited resources, the purchase of the relatively slow and complex technique of iCTA would further increase the indirect expenses of clipping in addition to already having the expensive microscopes equipped with ICGVA. Naturally, patient safety comes first, but it is doubtful whether iCTA is a necessity in everyday practice, even in a dedicated neurovascular centres.
Mika Niemelä
Juha Hernesniemi
Helsinki, Finland
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Schnell, O., Morhard, D., Holtmannspötter, M. et al. Near-infrared indocyanine green videoangiography (ICGVA) and intraoperative computed tomography (iCT): are they complementary or competitive imaging techniques in aneurysm surgery?. Acta Neurochir 154, 1861–1868 (2012). https://doi.org/10.1007/s00701-012-1386-1
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DOI: https://doi.org/10.1007/s00701-012-1386-1