Intraoperative EC-IC Bypass Blood Flow Assessment With Indocyanine Green Angiography in Moyamoya and Non-Moyamoya Ischemic Stroke

Awano, Takayuki; Sakatani, Kaoru; Yokose, Noriaki; Kondô, Yûkô; Igarashi, Takahiro; Hoshino, Tetsuya; Nakamura, Shin; Fujiwara, Norio; Murata, Yoshinori; Katayama, Yoichi; Shikayama, Takahiro; Miwa, Makoto

doi:10.1016/j.wneu.2010.03.027

Cited by 51 publications

(35 citation statements)

References 16 publications

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“…We speculate that the sign could indicate a focal increase in CBF in pial vessels in MMD because bypass flow through the anastomosed STA is reportedly larger in MMD than in atherosclerosis owing to a larger gradient pressure. 7 Therefore, this differs from the preoperative ivy sign showing chronically engorged pial vasculature because of ischemia. 5 Our results also showed that the postoperative de novo ivy sign diminished in the follow-up, indicating that the de novo ivy sign is a transient hemodynamic change after bypass surgery.…”

Section: May 2014mentioning

confidence: 94%

De Novo Ivy Sign Indicates Postoperative Hyperperfusion in Moyamoya Disease

Horie

Morikawa

Morofuji

et al. 2014

Stroke

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MethodsBeginning January 2010, consecutive patients with MMD who underwent STA-MCA anastomosis were prospectively analyzed. The indication for surgical revascularization was symptomatic or hemodynamic compromise on single-photon emission computed tomography. All patients were diagnosed with MMD according to angiographic Background and Purpose-The ivy sign on fluid-attenuated inversion recovery MRI is a specific finding in moyamoya disease (MMD). This sign indicates decreased cerebral perfusion, dilated pial vasculature, and slow leptomeningeal collateral flow. This study aimed to clarify the characteristics of perioperative changes in the ivy sign in relation to cerebral hyperperfusion, which frequently occurs in MMD of unknown pathogenesis. Methods-This prospective study included patients with MMD who underwent superior temporal artery-middle cerebral artery single bypass. Fluid-attenuated inversion recovery MRI was performed to evaluate the appearance of the ivy sign in the ipsilateral hemisphere preoperatively and on postoperative days 2 and 30. The ivy sign was assessed in combination with perioperative symptoms and cerebral hemodynamics using single-photon emission computed tomography. Results-Of 42 consecutive patients (55 sides) who underwent bypass surgery, 32 (58.2%) showed an increase in the ivy sign (de novo ivy sign) on postoperative day 2; this had disappeared by day 30. Interestingly, these 32 patients had a significantly higher incidence of hyperperfusion on single-photon emission computed tomography and hyperperfusion syndrome, and there was no correlation between the de novo ivy sign and a preoperative ivy sign or the preoperative cerebral hemodynamics. In multivariate analysis, a de novo ivy sign was significantly correlated with postoperative hyperperfusion. Conclusions-In

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Section: May 2014mentioning

confidence: 94%

De Novo Ivy Sign Indicates Postoperative Hyperperfusion in Moyamoya Disease

Horie

Morikawa

Morofuji

et al. 2014

Stroke

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“…2,4,7,10 The qualitative value of this technique can also be quantified using specialized image analysis software. Awano et al 1 recently analyzed the ICG perfusion area at the point at which fluorescence intensity reached the maximum level. In a similar manner, the time course of ICG fluorescence intensity can also be analyzed at a specific region of interest to quantify graft flow in real time.…”

Section: Discussionmentioning

confidence: 99%

Flow-based evaluation of cerebral revascularization using near-infrared indocyanine green videoangiography

Januszewski

Beecher

Chalif

et al. 2014

FOC

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Object Indocyanine green (ICG) videoangiography has been established as a noninvasive technique to gauge the patency of a bypass graft; however, intraoperative graft patency may not always correlate with graft flow. Altered flow through the bypass graft may directly cause delayed graft occlusion. Here, the authors report on 3 types of flow that were observed through cerebral revascularization procedures. Methods Between February 2009 and September 2013, 48 bypass procedures were performed. Excluded from analysis were those cases in which ICG videoangiography was not performed during surgery (whether it was not available or there was a technical issue with the microscope or the quality of ICG angiography) and/or in which angiography or CT angiography was not done within 24–72 hours after surgery. After anastomosis, bypass patency was assessed first using a noninvasive technique and then with ICG videoangiography, and flow through the graft was characterized. Patients who received a vein or radial artery graft were also evaluated with intraoperative angiography. Results Thirty-three patients eligible for analysis were retrospectively analyzed. The patients had undergone extracranial-intracranial (EC-IC) or IC-IC bypass for ischemic stroke (13 patients), moyamoya disease (10 patients), and complex aneurysms (10 patients; 6 giant or large aneurysms, 2 carotid blister-like aneurysms, and 2 dissecting posterior inferior cerebellar artery [PICA] aneurysms). Thirty-six bypasses were performed including 26 superficial temporal artery (STA)–middle cerebral artery (MCA) bypasses (2 bilateral and 1 double-barrel), 6 EC-IC vein grafts, 1 EC-IC radial artery graft, 1 PICA-PICA bypass, 1 MCA–posterior cerebral artery bypass, and 1 occipital artery–PICA bypass. Robust anterograde flow (Type I) was noted in 31 grafts (86%). Delayed but patent graft enhancement and anterograde flow (Type II) was observed in 4 cases (11%); 1 of these cases with an EC-IC vein graft degraded gradually to very delayed flow with no continuity to the bypass site (Type III). Additionally, 1 STA-MCA bypass graft revealed no convincing flow (Type III). The 5 patients with Type II or III grafts were evaluated with a flow probe and reexploration of the bypass site, and in all cases the reason the graft became occluded was believed to be recipient-vessel competitive flow. In no case was there evidence of stenosis or a technical issue at the site of the anastomosis. Three patients with Type II and the 1 patient with Type III flow (11% of procedures) did not have a patent bypass on postoperative imaging. Conclusions Indocyanine green videoangiography is reliable for evaluating flow through the EC-IC or IC-IC bypass. The type of flow observed through the graft has a direct relationship with postoperative imaging findings. Despite the possibility of competitive flow, Type III and some Type II flows through the graft indicate the need for graft evaluation and anastomosis exploration.

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“…The ICG perfusion area in Moyamoya patients was significantly larger than that in non-Moyamoya patients, and the cortical oxygen saturation in the Moyamoya patients was significantly lower than that in the other patients. The study showed that ICG angiography with injection of ICG into the bypass artery could allow quantitative assessment of bypass blood flow [34].…”

Section: Applications In Cerebral Artery Bypass Surgerymentioning

confidence: 98%

Lighting Up Neurovascular Surgery

Krakauer¹,

Kalani²

2014

Cureus

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Patient care has been revolutionized by the introduction of fluorescent dyes and the incorporation of fluorescence technology in disciplines ranging from ophthalmology to neurovascular surgery. These technologies enable clinicians and surgeons to produce accurate and real-time images of difficult-to-see structures within the human body, providing a crucial step to not only understanding biological processes but also advancing treatments. Isosulfan blue, fluorescein, and 5-aminolevulinic acid have proven useful in multiple fields of medicine. Indocyanine green (ICG) is another key fluorescent dye. Combined with specialized intraoperative microscopes, it is ideal for vascular studies because it diffuses easily from vessels into the interstitial space. Ultimately, images of the vascular system within the surgical field can be observed on a video screen in real time. Today ICG allows neurosurgeons to evaluate the quality of an aneurysm clipping, the potential for residual flow in a fistula or malformation, and the patency of a bypass. With introduction of other dyes and improvements in imaging techniques, we are likely to see an expansion in application of fluorescent technology in neurosurgery and other fields, which will ultimately lead to better patient care and outcomes.

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Intraoperative EC-IC Bypass Blood Flow Assessment With Indocyanine Green Angiography in Moyamoya and Non-Moyamoya Ischemic Stroke

Cited by 51 publications

References 16 publications

De Novo Ivy Sign Indicates Postoperative Hyperperfusion in Moyamoya Disease

De Novo Ivy Sign Indicates Postoperative Hyperperfusion in Moyamoya Disease

Flow-based evaluation of cerebral revascularization using near-infrared indocyanine green videoangiography

Lighting Up Neurovascular Surgery

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