Application of indocyanine green video angiography in parasagittal meningioma surgery

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>There are no doubts about the role that indocyanine green video angiography (ICGVA) can play in current vascular neurosurgery. Conversely, in brain tumor surgery, and particularly in meningioma surgery, this role is still unclear. Vein management is pivotal for approaching parasagittal meningiomas, because venous preservation is strictly connected to both extent of resection and clinical outcome. The authors present the technical traits and the postoperative outcome of the application of ICGVA in patients undergoing parasagittal meningioma surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors retrospectively collected demographic, radiological, intraoperative, and follow-up data in 43 patients with parasagittal meningiomas who underwent surgery with the assistance of ICGVA at Padua Neurosurgical Department between October 2010 and July 2013. Intraoperative ICGVA findings at different stages (before dural opening, after dural opening, during resection, after resection) were reviewed. Additional data on functional monitoring, temporary venous clipping, and flow measurements were also recorded. The overall postoperative outcome was evaluated by assessing both the extent of resection and the clinical outcome data.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The ICGVA studies were performed 125 times in 43 patients, providing helpful data for vein management and tumor resection in all stages of surgery. In 16% of meningiomas completely occluding the superior sagittal sinus, the ICGVA data differed from radiological findings and changed the surgical approach. In 20% of cases the intraoperative ICGVA findings directly guided the surgical strategy: venous sacrifice was necessary in 7 cases, without postoperative consequences; temporary clipping with neurophysiological monitoring proved to be predictive of safe venous sacrifice. In 7% of cases the ICGVA data needed to be supplemented with flow measurements. Simpson Grade I–II and Grade III resections were achieved in 86% and 14% of cases, respectively, with a 4.6% rate of overall morbidity.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>This study shows that ICGVA can assist the different stages of parasagittal meningiomas surgery, guiding the vein management and tumor resection strategies with a favorable final clinical outcome. However, in the authors' experience the use of other complementary tools was mandatory in selected cases to preserve functional areas. Further studies are needed to confirm that the application of ICGVA in parasagittal meningioma surgery may improve the morbidity rate, as reported in this study.</jats:p></jats:sec>

The application of fluorescence techniques in meningioma surgery—a review

“…Transdural video angiography applies ICG VA to visualize cortical veins, dural venous sinuses, and/or tumor boundaries prior to dural opening in 46 patients [39–42, 45, 46]. It allowed for a tailored dural opening without damaging underlying vasculature and the possibility of assessing vessel patency and blood flow (direction) [40–42, 45]. One group described the “Eclipse sign” [43, 44], which occurs after coagulating feeding arteries, dura mater, and middle meningeal arteries.…”

“…Venous video angiography has been applied in 97 patients. According to the authors, the rate of resection was occasionally increased by confirming occlusion of veins using ICG VA in thrombosed veins [36, 40, 45, 47], identifying collateral venous drainage with [36, 39, 48] or without [39] subsequent venous sacrifice, and determining the relation of veins with the tumor (draining versus collateral veins) [39, 42, 45].…”

Indocyanine green as an adjunct for resection of insular gliomas

“…After injection, the dye binds to plasma proteins within 1 to 2 s and remains intravascular in conditions of normal vascular permeability. The dye is not metabolized by the body and is excreted by the liver with a plasma half-life of 150 s.[ 1 ]…”

“…It has also been used to detect venous anatomy during parasagittal meningioma surgery, to detect blood flow in tumor vasculature and to differentiate pituitary tumors from the normal gland. [ 1 11 ] We describe the use of ICG to detect normal vasculature within insular tumors thus preserving the vessels and preventing postoperative deficits. Iwasaki et al .…”

“…There are a few recent reports where ICG has been used to identify venous sinuses in meningioma surgery [ Video ]. [ 1 ] We present five cases where ICG was used to identify branches of the middle cerebral artery during insular glioma surgery thereby allowing a safe surgical resection.…”