Department of Neurosurgery, Klinikum der Ludwig-Maximilians-Universität München, Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany.
Acta Neurochir (Wien). 2012 Oct;154(10):1861-8. doi: 10.1007/s00701-012-1386-1. Epub 2012 Jul 13.
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.
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.
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.
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.
在这项初步研究中，我们比较了近红外吲哚菁绿视频血管造影（ICGVA）和术中计算机断层扫描（iCT）的优缺点，以研究这些方法是否是获取血管即时信息和潜在脑灌注受损的补充或竞争方法在血管神经外科手术中。
这项可行性研究前瞻性纳入了一小部分患者（n = 10），在放置动脉瘤夹后立即进行 ICGVA。随后进行术中颅 CT 血管造影（iCTA），然后使用 40 层滑动龙门 CT 扫描仪进行动态灌注 CT 扫描（iCTP）。使用这两种技术分析主要（含动脉瘤）动脉的血管通畅性、新生穿支动脉的可视化以及夹闭后脑灌注情况。
ICGVA 能够可视化显微镜视野内所有主要血管和穿支动脉的血流和血管通畅性，但无法显示手术野深部的血管。即使是少量的脑实质覆盖也会影响血管的检测。iCTA 可在 7/10 例夹闭的动脉瘤中获得高质量的图像。由于广泛的线圈伪影，1 例 PICA 动脉瘤和 1 例以前接受过线圈治疗的复发性动脉瘤术中 CTA 无法充分评估。iCTA 无法检测到小的穿支动脉。术中 CTP 可在 5/10 例中获得足够质量的全脑血流和脑灌注评估，并能进行充分的术中决策。
ICGVA 和 iCT 的联合应用是可行的，具有非常好的诊断成像质量，采集时间短，对手术流程干扰小。这两种技术相辅相成，而不是相互竞争的分析工具，有助于评估局部（ICGVA/iCTA）和区域性（iCTA/iCTP）血流和脑灌注信息，这些信息是在颅内动脉瘤夹闭后即刻获得的。
