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Fluorescein-guided resection of plexiform neurofibromas: how I do it

  • How I Do it - Peripheral Nerves
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Abstract

Background

Plexiform neurofibromas (PN) can determine pain, nerve function impairment, and, when extremely large, also deformity. Surgical is often partial, with possible recurrence, and the risk of malignant transformation.

Method

We describe the surgical strategy in a case of huge multiple plexiform neurofibromas of the left arm. We attempted to achieve a safe resection under the intraoperative guidance of fluorescein, with a dedicated microscope filter (YELLOW560). This technique can be also applied to other locations.

Conclusion

Fluorescein-guided surgery, coupled with intraoperative neurophysiological monitoring, increases the safe resection rate, considering the risks of neurological deficits and the possible malignant transformation.

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Author information

Authors and Affiliations

  1. Neurosurgery Unit III, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy

    Ignazio G. Vetrano & Vittoria Nazzi

  2. Developmental Neurology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via G. Celoria 11, 20133, Milan, Italy

    Veronica Saletti

Authors
  1. Ignazio G. Vetrano
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  2. Veronica Saletti
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  3. Vittoria Nazzi
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Corresponding author

Correspondence to Ignazio G. Vetrano.

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Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

The patient and next of kin have consented to the submission of this “How I Do It” to the journal.

Ethical approval

All procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Additional information

Key points

(1) Be sure that patients know the very low risks related to fluorescein injection.

(2) Correctly place the needles for EMG

(3) Strong collaboration with neurophysiologists for IOM to avoid irreversible nerve damages.

(4) Before the first YELLOW560 visualization, wait at least 30’ after fluorescein administration

(5) Recognize intact nerves before the piecemeal resection.

(6) Intraoperative ultrasounds and color Doppler can identify major vessels

(7) Neurofibromas, also the subcutaneous components, appear intensely fluorescent if compared with normal nerves

(8) The vessels show intermediate fluorescence, due to fluorescein intravascular diffusion.

(9) Following fluorescence, the resection rate can be greatly increased: its limits are established by IOM. The main goal is to avoid neurological impairment

(10) A close neuroradiological and clinical follow-up is necessary in case of large remnants

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This article is part of the Topical Collection on Peripheral Nerves

Electronic supplementary material

The video shows the different phases of the surgical procedures, from positioning and skin incision to the tumor removal. Preoperative MRI and intraoperative Doppler-US examination are depicted too. (MP4 253,977 kb)

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Vetrano, I.G., Saletti, V. & Nazzi, V. Fluorescein-guided resection of plexiform neurofibromas: how I do it. Acta Neurochir 161, 2141–2145 (2019). https://doi.org/10.1007/s00701-019-04038-5

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  • DOI: https://doi.org/10.1007/s00701-019-04038-5

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