Figure 2 - uploaded by Sukhdeep Jhawar
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Preoperative DSA of Case 2. (a) Right common carotid AP angiogram showing right parietal convexity AVM receiving feeders from the middle cerebral and anterior cerebral artery. An incidental aneurysm also noted at the internal carotid and posterior communicating artery junction. (b) Right lateral vertebral angiogram showing supply from the posterior cerebral artery. Note feeders from the lateral posterior choroidal artery (arrow). (c) Right common carotid AP angiograph after embolization showing diminished feeders from the middle cerebral artery and anterior cerebral artery. (d) Right vertebral AP angiograph post embolization showing deep feeders from the posterior cerebral artery and lateral posterior choroidal artery
Source publication
To discuss the role of FLOW 800 innovative software for analytical color visualization and objective evaluation of fluorescence videos obtained by microscope-integrated intraoperative indocyanine green (ICG) fluorescence angiography in arteriovenous malformations (AVM) surgery.
Microscope-integrated intraoperative FLOW 800 was used and evaluated in...
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Background: Fluorescein sodium (FNa) is a fluorescent drug with a long history of use for assessing retinal blood flow in ophthalmology; however, its application in vascular neurosurgery is only now gaining popularity. This review summarizes the current knowledge about using FNa videoangiography in vascular neurosurgery.
Methods: We performed a lit...
Citations
... Raabe et al. (6,7) first demonstrated that the dynamic flow of indocyanine green (ICG) in anastomotic vessels can help in determining the patency and direction of intraoperative blood flow (8)(9)(10). A host of studies (11)(12)(13)(14) have proven that intraoperative ICG video angiography (ICG-VA) and current commercial software can be employed to generate time-delayed color maps to monitor regional CBF and evaluate improvements in cortex perfusion around the anastomotic site after bypass. As an image postprocessing software, this software is unable to achieve continuous real-time and dynamic analysis of CBF and cannot quantify the flow direction of each blood vessel. ...
Microvascular imaging based on indocyanine green is an important tool for surgeons who carry out extracranial–intracranial arterial bypass surgery. In terms of blood perfusion, indocyanine green images contain abundant information, which cannot be effectively interpreted by humans or currently available commercial software. In this paper, an automatic processing framework for perfusion assessments based on indocyanine green videos is proposed and consists of three stages, namely, vessel segmentation based on the UNet deep neural network, preoperative and postoperative image registrations based on scale-invariant transform features, and blood flow evaluation based on the Horn–Schunck optical flow method. This automatic processing flow can reveal the blood flow direction and intensity curve of any vessel, as well as the blood perfusion changes before and after an operation. Commercial software embedded in a microscope is used as a reference to evaluate the effectiveness of the algorithm in this study. A total of 120 patients from multiple centers were sampled for the study. For blood vessel segmentation, a Dice coefficient of 0.80 and a Jaccard coefficient of 0.73 were obtained. For image registration, the success rate was 81%. In preoperative and postoperative video processing, the coincidence rates between the automatic processing method and commercial software were 89 and 87%, respectively. The proposed framework not only achieves blood perfusion analysis similar to that of commercial software but also automatically detects and matches blood vessels before and after an operation, thus quantifying the flow direction and enabling surgeons to intuitively evaluate the perfusion changes caused by bypass surgery.
... The chance for new deficit for SP grade B and SP C was found as high as 32 and 73 % respectively. Despite advances in other modalities surgical extirpation is still represents the main treatment option (22). ...
... In 2011 Kato et al. reported a valuable microsurgery addition to the conventional ICG and Doppler ultrasound. Flow 800 represents an analytical color map visualized by a microscope (22). Identification of blood direction via the fluorescence presents the bAVM hemodynamic and it is safe for the patients and staff and it can be repeated multiple times. ...
Background:
Arteriovenous malformation (bAVM) presents maldevelopment of the brain's vessels with a direct connection between cerebral arteries and veins. By current data, patients from Spetzler Ponce A (SP) are found to benefit from the treatment. Considering the outcome, most of SP C and some of the SP B are the most debatable.
Objective:
Arteriovenous malformation presents maldevelopment of the brain's vessels with a consequent direct connection between cerebral arteries and veins. The annual risk of hemorrhage in adults is reported for 2-3 %. They usually present with unilateral headaches seizures and intracranial hemorrhage. By current data, patients from Spetzler Ponce A (SP) are found to benefit from the treatment. Considering the outcome, most of SP C and some of the SP B are the most debatable.
Methods:
The study included a cohort of bAVM patients referred to Fujita Health University Bantane Hotokukai Hospital, Nagoya, Aichi, Japan where the main author (AA) has completed an international cerebrovascular fellowship under the mentorship of Professor Yoko Kato. Japanese Stroke Guidelines (JSG) were used for the treatment decision. Patients were graded according to the Spetzler Ponce (SP) system. Considering American Heart Association criteria (AHA), embolization was used as a part of multimodal treatment. Intraoperative microscopic video tools included Indocyanine green ICG, FLOW 800 and dual image video angiography DIVA. Clinical outcomes were measured using Modified Ranking Score (mRs).
Results:
A total of eleven patients with brain bAVM were studied with a median age of 32 years [IQR = 22-52]. There were ten patients presented with supratentorial and a single patient with infratentorial AVM. Patients were graded according to the Spetzler Ponce (SP) system. There were eight patients in SP A (72,7%), one in group B (9 %) while the rest of them were in C (18 %). Two patients had associated aneurysms that required treatment. The median size of the AVM nidus was 3,50 cm [IQR= 2-5]. Deep venous drainage was found in six patients while three were located in eloquent zones. Clinical outcomes were considered good by mRs <2 in eight patients, seven from the surgically treated group (72,7 % respectively). Surgery median length time was 427, 5 minutes; [IQR =320 - 463] with complete AVM resection in all patients and no mortality recorded in this cohort with the median follow up of 39,5 months [IQR = 19-59].
Conclusion:
Ideal management of bAVM is still controversial. Those complex vascular lesions require multimodal treatment in a majority of cases in highly specialized centers. In SP A patients, surgery provides the best results with a positive outcome and a small number of complications. With the improvement of endovascular feeder occlusion SP B patients become prone to a more positive outcome. Nowadays, intraoperative microscopic tools such as FLOW 800, ICG and DIVA are irreplaceable while improving safety to deal with bAVM. For SP C patients, a combination of endovascular and stereotactic radiosurgery was found to be a good option in the present time.
... The indication for each ICG video during the AVM resection was recorded. As recommended by Hanggi et al. [8,9], the ICG videos were classified into three categories based on the phase of AVM surgery: (i) primary resection (pre-resection), (ii) intra-resection, and (iii) postresection. Positive and negative attributes of each ICG video recording were recorded. ...
... Microscope-integrated near-infrared ICG videoangiography has been used regularly in vascular neurosurgery for several years. FLOW 800 is a reliable and useful addition to microscope-integrated color ICG videoangiography [9]. The color map can easily identify the feeder arteries, draining veins, passage arteries, cortical arteries, and cortical veins. ...
Background:
Arteriovenous malformation(AVM) have long-term "blood stealing" characteristics, which result in complicated hemodynamic features. To analyze the application of intraoperative indocyanine green angiography with FLOW 800 software in AVM surgeries.
Methods:
Data on 17 patients undergoing surgery with ICG fluorescence were collected in Beijing Tiantan Hospital. To analyze the hemodynamic features of AVM and the influence on the peripheral cortex of AVM resection, we assessed the following hemodynamic parameters: maximum intensity, slope of rise, time to half-maximal fluorescence, and transit time from arteries to veins.
Results:
In the 17 superficial AVMs studied, the time-delay color mode of the FLOW 800 software was superior to the traditional playback mode for identifying feeding arteries, draining veins, and their relation to normal cortical vessels. The maximum fluorescence intensity and slope of the ICG fluorescence curve of feeder arteries and draining veins were higher than those of normal peripheral vessels (P < 0.05). The transit times in AVMs were significantly shorter than those in normal peripheral vessels (P < 0.05). After AVM resection, cerebral flow increased in the cortex, and local cycle time becomes longer, although the differences were not significant (P > 0.05).
Conclusions:
Hemodynamic parameter analysis provided quality guidance for the resection of AVMs and could also be used in estimating changes in blood flow in the local cortex to identify abnormal hyperperfusion and residual nidus.
... The indication for each ICG video during the AVM resection was recorded. As recommended by Hanggi et al [8,9] , the ICG videos were classified into three categories based on the phase of AVM surgery: (i) primary resection (pre-resection), (ii) intra-resection, and (iii) post resection. Positive and negative attributes of each ICG video recording were recorded. ...
... Microscope-integrated near-infrared ICG videoangiography has been used regularly in vascular neurosurgery for several years. FLOW 800 is a reliable and useful addition to microscope-integrated color ICG videoangiography [9] . The color map can easily identify the feeder arteries, draining veins, passage arteries, cortical arteries, and cortical veins. ...
To analyze the application of intraoperative indocyanine green (ICG) angiography with FLOW 800 software in arteriovenous malformation (AVM) surgeries. Data on 17 patients undergoing surgery with ICG fluorescence were collected. To analyze the hemodynamic features of AVM and the influence on the peripheral cortex of AVM resection, we assessed the following hemodynamic parameters: maximum intensity, slope of rise, time to half-maximal fluorescence, and transit time from arteries to veins. In the 17 superficial AVMs studied, the time delay color mode of FLOW 800 software was superior to the traditional playback mode for identifying feeding arteries, draining veins, and their relation to normal cortical vessels.The maximum fluorescence intensity and slope of the ICG fluorescence curve of feeder arteries and draining veins were higher than those of normal peripheral vessels (P 0.05). Hemodynamic parameter analysis provided quality guidance for the resection of AVMs and could also be used in estimating changes in blood flow in the local cortex to identify abnormal hyperperfusion and residual nidus.
... The indication for each ICG video during the AVM resection was recorded. As recommended by Hanggi et al [8,9] , the ICG videos were classi ed into three categories based on the phase of AVM surgery: (i) primary resection (preresection), (ii) intra-resection, and (iii) post resection. Positive and negative attributes of each ICG video recording were recorded. ...
... Microscope-integrated near-infrared ICG videoangiography has been used regularly in vascular neurosurgery for several years. FLOW 800 is a reliable and useful addition to microscope-integrated color ICG videoangiography [9] . ...
Background: Arteriovenous malformation(AVM) have long-term “blood stealing” characteristics, which result in complicated hemodynamic features. To analyze the application of intraoperative indocyanine green angiography with FLOW 800 software in AVM surgeries.
Methods: Data on 17 patients undergoing surgery with ICG fluorescence were collected. To analyze the hemodynamic features of AVM and the influence on the peripheral cortex of AVM resection, we assessed the following hemodynamic parameters: maximum intensity, slope of rise, time to half-maximal fluorescence, and transit time from arteries to veins.
Results：In the 17 superficial AVMs studied, the time delay color mode of FLOW 800 software was superior to the traditional playback mode for identifying feeding arteries, draining veins, and their relation to normal cortical vessels.The maximum fluorescence intensity and slope of the ICG fluorescence curve of feeder arteries and draining veins were higher than those of normal peripheral vessels (P < 0.05). The transit times in AVMs were significantly shorter than those in normal peripheral vessels (P < 0.05).After AVM resection, cerebral flow increased in the cortex, and local cycle time become longer, although the differences were not significant (P > 0.05).
Conclusions:Hemodynamic parameter analysis provided quality guidance for the resection of AVMs and could also be used in estimating changes in blood flow in the local cortex to identify abnormal hyperperfusion and residual nidus.
... Previously, we introduced our preliminary experience with the application of FLOW 800 in cerebral AVM surgeries. [5,21] Since then, more reports on its cerebral applications have emerged which we have discussed in great detail elsewhere, [22] and here, we just mention them in brief. Holling et al. reported five cases of pial or dural arteriovenous fistula treated microsurgically using FLOW 800. ...
Objective and Background
To evaluate possible roles for indocyanine green (ICG)-based FLOW 800 software in surgical treatment of cerebral arteriovenous malformations (AVMs).
Methods
We perform ICG videoangiography several times for each step of AVM resection to elucidate feeders, drainers, and cerebral perfusion.
Results
Since 2010, 22 AVM surgeries in our department have been conducted using FLOW 800 intraoperatively. We demonstrated ICG angiograms, color-coded images, and semi-quantitative curves for AVMs. By reviewing all these modalities, we would define vascular structure of the AVM, proceed with resection, and finally recheck for any remnant.
Conclusions
ICG FLOW 800 software helps the surgeon to recognize feeding and draining vessels of an AVM intraoperatively. Further studies to evaluate semi-quantitative acquired data regarding blood flow and tissue perfusion are warranted.
... FLOW 800 is software that generates an analytical color map, which is then integrated with the microscopic field. [6][7][8][9][10] In addition, FLOW 800 (Zeiss) performs a region of interest (ROI) analysis, which detects slight differences in blood flow. It is generally accepted that neurosurgical intraoperative ICG-VA can estimate blood flow within blood vessels during vascular surgery, including aneurysmal clipping and arteriovenous malformation removal. ...
BACKGROUND AND IMPORTANCE: During intramedullary lesion surgery, the lesion site and the posterior median sulcus (PMS) should be accurately identified prior to myelotomy to avoid severe injury of the posterior funiculus. However, intramedullary lesions are fundamentally invisible until the myelotomy is performed. Furthermore, the PMS location is frequently unclear due to lesion-induced swelling or distortion of the spinal cord. Intraoperative indocyanine green videoangiography (ICG-VA) followed by FLOW 800 analysis, which shows vascularization of the spinal parenchyma, may provide a solution for these problems in specific cases.
CLINICAL PRESENTATION: A 61-year-old woman suffering from claudication visited our department. Magnetic resonance imaging (MRI) revealed a cystic lesion at the level of Th11. A solid portion was not detected in the T1-weighted images following gadolinium administration. We made a diagnosis of ventriculus terminalis and performed a lesion resection. Prior to opening the PMS, ICG-VA was performed, which revealed an avascular area representing the intramedullary cyst. The PMS was the most avascular area observed in the time–intensity analysis executed using FLOW 800 software (Zeiss, Oberkochen, Germany). Thus, it was helpful in determining the site for myelotomy, which should be performed at the center of the extent of the lesion. The patient was discharged 23 days after the operation, ambulating independently.
CONCLUSION: Intraoperative ICG-VA followed by FLOW 800 analysis was applied to a case of intramedullary cystic lesion. This technique may be helpful in performing safer intramedullary cystic lesion surgery because it enables visualization of the lesion location and confirmation of the PMS.
... Our literature review revealed interesting studies addressing the utility of ICG-VA in highlighting specific hemodynamic features of AVMs as opposed to cavernous angiomas [36]. Based on the encouraging data already available in patients with AVM [54], Faber et al. [55], Jhawar et al. [56] and Kato et al. [57], independently, focused on the possibility to enhance traditional ICG-VA with a color encoded analysis (FLOW 800) to better visualize intraoperatively non-ruptured or deep-seated brain AVMs. Also, Kamp et al. [58] measured the different flow times (mean rise time, mean time to peak, mean transit time) associated with ICG-VA in different brain pathologies. ...
... Our literature review did not reveal significant differences in ICG-VA pattern in ruptured and un-ruptured AVM. However, several authors highlighted the importance of flow analysis in visualization of un-ruptured AVMs as well as the role of ICG-VA in the identification of AVM after the evacuation of a hematoma, as in the present case [36,56,57]. ...
Objective:
Indocyanine green videoangiography (ICG-VA) with FLOW 800 has been used as a visualization tool to guide arteriovenous malformation (AVM) surgery since 2011. We performed a systematic review and evaluated the quality of evidence available on this topic. In addition, we present a series of our own cases to demonstrate the unique use of ICG-VA in the localization and removal of deeper-seated AVMs.
Methods:
Using PRISMA guidelines for systematic reviews, we identified articles related to ICG-VA with FLOW 800 in AVM surgeries using search terms. Articles were screened, reviewed, and the quality of the evidence was analyzed according to GRADE criteria. We performed a retrospective chart review of our own cases of AVM removal with ICG-VA and FLOW 800.
Results:
Our search revealed 27 relevant articles, 17 of which met our inclusion criteria. The quality of the body of evidence was determined to be "very low" according to GRADE criteria. We used ICG-VA with FLOW 800 analysis in 14 cases of microsurgical AVM removal. This technique provided unique insights in localization of deep-seated AVMs in 8 cases (57%). There was no AVM residual as assessed by 6 month follow up angiogram.
Conclusions:
We present cases highlighting the usefulness of this technique for localization in certain AVMs and propose that ICG may guide removal of deeper-seated AVMs, since it can reveal surface feeders and draining veins that can be followed to a hidden nidus. Larger, registry-based studies are needed to confirm these findings and improve the overall quality of evidence.
