Cho Steve S, Buch Vivek P, Teng Clare W, De Ravin Emma, Lee John Y K
Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
World Neurosurg. 2020 Apr;136:326. doi: 10.1016/j.wneu.2020.01.135. Epub 2020 Jan 26.
A potential application of near-infrared (NIR) fluorescence imaging using second-window indocyanine green (SWIG) is demonstrated. We hypothesized that because the pituitary lacks a blood-brain barrier, we might visualize the pituitary stalk using SWIG. A 52-year-old, right-handed man presented to our clinic for evaluation of progressive loss of vision. Physical examination was significant for loss of right peripheral vision and near-complete loss of left field vision. Prolactin was high-normal at 16.2 mg/dL. Brain magnetic resonance imaging demonstrated a 36-mm sellar mass extending superiorly and laterally crossing the intracranial left internal carotid artery, consistent with a nonfunctional pituitary macroadenoma. We elected to pursue left pterional craniotomy for resection. The patient was eligible for our SWIG clinical trial and consented to the study. SWIG is a novel, investigational technique using Food and Drug Administration-approved indocyanine green to enhance visualization of neoplastic tissue intraoperatively. The patient received 2.5 mg/kg of indocyanine green intravenously approximately 24 hours preoperatively. Intraoperatively, under white-light microscopy, the tumor was easily identified and distinguished from the optic nerves and internal carotid artery. After debulking of the gross tumor, NIR visualization using a laser-equipped endoscope demonstrated strong NIR fluorescence in the pituitary stalk. Despite the distorted anatomy, this technique enabled us to confidently identify and preserve the pituitary stalk. Postoperatively, the patient had persistently high urine output that normalized in 24 hours without desmopressin (sodium 139-140 mmol/L); after uneventful recovery, he was discharged with mild improvement in visual function. This case demonstrated a potential use of our SWIG protocol. As the stalk demonstrates strong NIR fluorescence after high-dose indocyanine green administration, surgeons may be able to better localize and preserve the stalk even in complex skull base tumor cases where the anatomy may be significantly distorted.
本文展示了使用第二窗口吲哚菁绿（SWIG）的近红外（NIR）荧光成像的潜在应用。我们推测，由于垂体缺乏血脑屏障，我们或许可以使用SWIG可视化垂体柄。一名52岁的右利手男性因进行性视力丧失前来我院就诊。体格检查发现右侧周边视野丧失，左侧视野几乎完全丧失。催乳素水平略高于正常，为16.2mg/dL。脑部磁共振成像显示一个36mm的鞍区肿块，向上和向外延伸，穿过颅内左侧颈内动脉，符合无功能垂体大腺瘤。我们选择进行左额颞开颅切除术。该患者符合我们的SWIG临床试验条件并同意参加研究。SWIG是一种新型的研究技术，使用美国食品药品监督管理局批准的吲哚菁绿来增强术中肿瘤组织的可视化。患者在术前约24小时静脉注射2.5mg/kg吲哚菁绿。术中，在白光显微镜下，肿瘤很容易被识别，并与视神经和颈内动脉区分开来。在切除大部分肿瘤后，使用配备激光的内窥镜进行近红外可视化显示垂体柄有强烈的近红外荧光。尽管解剖结构扭曲，但该技术使我们能够自信地识别并保留垂体柄。术后，患者持续高尿量在24小时内未使用去氨加压素即恢复正常（血钠139 - 140mmol/L）；在顺利康复后，他出院时视觉功能有轻度改善。该病例展示了我们的SWIG方案的潜在用途。由于在高剂量吲哚菁绿给药后垂体柄显示出强烈的近红外荧光，即使在解剖结构可能严重扭曲的复杂颅底肿瘤病例中，外科医生或许也能够更好地定位并保留垂体柄。
