Department of Neurosurgery, University Hospital Münster, Münster, Germany.
Oper Neurosurg (Hagerstown). 2018 Sep 1;15(3):325-331. doi: 10.1093/ons/opx269.
Spinal cord and brain stem lesions require a judicious approach with an optimized trajectory due to a clustering of functions on their surfaces. Intraoperative mapping helps locate function. To confidently locate such lesions, neuronavigation alone lacks the desired accuracy and is of limited use in the spinal cord.
To evaluate the clinical value of fluoresceins for initial delineation of such critically located lesions.
We evaluated fluorescein guidance in the surgical resection of lesions with blood-brain barrier disruption demonstrating contrast enhancement in magnet resonance imaging in the spinal cord and in the brain stem in 3 different patients. Two patients harbored a diffuse cervical and thoracic spinal cord lesion, respectively. Another patient suffered metastatic lesions in the brain stem and at the floor of the fourth ventricle. Low-dose fluorescein (4 mg/kg body weight) was applied after anesthesia induction and visualized using the Zeiss Pentero 900 Yellow560 filter (Carl Zeiss, Oberkochen, Germany).
Fluorescein was helpful for locating lesions and for defining the best possible trajectory. During resection, however, we found unspecific propagation of fluorescein within the brain stem up to 6 mm within 3 h after application. As these lesions were otherwise distinguishable from surrounding tissue, monitoring resection was not an issue.
Fluorescein guidance is a feasible tool for defining surgical entry zones when aiming for surgical removal of spinal cord and brain stem lesions. Unselective fluorescein extravasation cautions against using such methodology for monitoring completeness of resection. Providing the right timing, a window of pseudoselectivity could increase fluoresceins' clinical value in these cases.
脊髓和脑干病变需要谨慎处理，优化轨迹，因为它们的表面功能集中。术中映射有助于定位功能。为了准确地定位这些病变，单纯的神经导航缺乏所需的准确性，在脊髓中使用有限。
评估荧光素在最初描绘这些关键位置病变中的临床价值。
我们评估了荧光素引导在 3 例不同患者的脊髓和脑干中磁共振成像显示血脑屏障破坏的增强对比病变的手术切除中的作用。2 例患者分别患有弥漫性颈胸段脊髓病变。另一名患者患有脑干和第四脑室底部的转移性病变。在麻醉诱导后应用低剂量荧光素（4mg/kg 体重），并使用蔡司 Pentero 900 Yellow560 滤镜（德国卡尔蔡司公司）进行可视化。
荧光素有助于定位病变并确定最佳的可能轨迹。然而，在切除过程中，我们发现荧光素在脑干内的非特异性传播，在应用后 3 小时内可达 6 毫米。由于这些病变与周围组织其他部位不同，因此监测切除不是问题。
荧光素引导是一种可行的工具，用于定义手术切除脊髓和脑干病变的手术进入区。非选择性荧光素外渗告诫不要使用这种方法来监测切除的完整性。如果时机正确，假选择性的窗口可以增加荧光素在这些情况下的临床价值。
