Foster Chase H, Morone Peter J, Tomlinson Samuel B, Cohen-Gadol Aaron A
Department of Neurological Surgery, George Washington University Hospital, Washington, DC, United States.
Department of Neurological Surgery, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, United States.
Front Surg. 2019 Dec 11;6:70. doi: 10.3389/fsurg.2019.00070. eCollection 2019.
Indocyanine green (ICG) is a fluorescent molecule that enables visualization of hemodynamic flow through blood vessels. The first description of its application to the resection of arteriovenous malformations (AVMs) did not occur until 2007. Since then, industry leaders have rapidly integrated this optical technology into the intraoperative microscope, and the use of ICG videoangiography (VA) has since become routine in AVM surgery among some academic centers. A number of case series have been published since the introduction of ICG VA to AVM neurosurgery. These early reports with small sample sizes were largely qualitative, assigning to the technology "usefulness" and "benefit" scores as perceived by the operators. This lack of objectivity prompted the development of FLOW 800 software, a proprietary technology of Carl Zeiss Meditec AG (Oberkochen, Germany) that can quantify relative fluorescence intensity under the microscope to generate color maps and intensity curves for and analyses, respectively. However, subsequent case series have done little to quantify the effect of ICG VA on outcomes. The available literature predominately concludes that ICG VA, although intuitive to deploy and interpret, is limited by its dependence on direct illumination and visualization. The subcortical components of AVMs represent a natural challenge to ICG-based flow analysis, and the scope of ICG VA has therefore been limited to AVMs with a high proportion of superficial angioarchitecture. As a result, digital subtraction angiography has remained the gold standard for confirming AVM obliteration. In this review, we provide an overview of the existing literature on ICG VA in AVM resection surgery. In addition, we describe our own experiences with ICG VA and AVMs and offer the senior author's surgical pearls for optimizing the marriage of fluorescence flow technology and AVM resection surgery.
吲哚菁绿（ICG）是一种荧光分子，可实现对血管内血流动力学的可视化。直到2007年才首次描述其在动静脉畸形（AVM）切除术中的应用。从那时起，行业领先者迅速将这种光学技术集成到术中显微镜中，自那以后，吲哚菁绿视频血管造影（VA）在一些学术中心的AVM手术中已成为常规操作。自将吲哚菁绿VA引入AVM神经外科以来，已经发表了许多病例系列。这些早期样本量较小的报告大多是定性的，根据操作者的感知为该技术赋予“有用性”和“益处”评分。这种缺乏客观性促使了FLOW 800软件的开发，这是卡尔蔡司医疗技术股份公司（德国奥伯科亨）的一项专有技术，它可以量化显微镜下的相对荧光强度，分别生成用于[此处原文可能有缺失内容]分析的彩色图和强度曲线。然而，随后的病例系列几乎没有对吲哚菁绿VA对手术结果的影响进行量化。现有文献主要得出结论，吲哚菁绿VA虽然易于部署和解读，但受其对直接照明和可视化的依赖所限。AVM的皮质下成分对基于吲哚菁绿的血流分析构成了自然挑战，因此吲哚菁绿VA的应用范围仅限于浅表血管结构比例高的AVM。结果，数字减影血管造影仍然是确认AVM闭塞的金标准。在本综述中，我们概述了关于吲哚菁绿VA在AVM切除手术中的现有文献。此外，我们描述了我们自己使用吲哚菁绿VA和AVM的经验，并提供资深作者的手术技巧，以优化荧光血流技术与AVM切除手术的结合。
