Indocyanine green videoangiography for recipient vessel stratification in superficial temporal artery–middle cerebral artery bypass surgery

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  • 1 Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Germany; and
  • | 2 Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Switzerland
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OBJECTIVE

In superficial temporal artery–middle cerebral artery (STA-MCA) bypass surgery, recipient vessel properties are likely one of the main reasons for bypass failure. In daily practice, most surgeons select the recipient with the largest diameter. However, selection of the ideal recipient remains debatable because there are no objective selection criteria if multiple potential recipients exist. Here, the authors assessed the benefit of using indocyanine green videoangiography (ICG-VA) to optimize recipient vessel selection in patients undergoing STA-MCA bypass surgery for hemodynamic compromise.

METHODS

All patients who had undergone STA-MCA bypass procedures with pre- and postanastomosis ICG-VA between 2010 and 2019 were eligible for inclusion in this study. The primary bypass surgeon was blinded to the preanastomosis ICG-VA. Preanastomosis white-light and ICG-VA images were compared to determine the identifiability of potential recipient vessels and pathological flow patterns. After completion of the anastomosis, a second (postanastomosis) ICG-VA image was used to analyze the flow increase within the chosen recipient based on the vessel diameter, initial recipient blood flow, initial sequence of appearance on ICG-VA, initial blood flow direction within the recipient, and orientation of the bypass graft. ICG-VA, FLOW 800, and intraoperative white-light images, as well as demographic, clinical, and radiographic patient data, were retrospectively analyzed by a clinician who was not directly involved in the patients’ care.

RESULTS

Sixty patients underwent 65 STA-MCA bypass procedures with pre- and postanastomosis ICG-VA. The ICG-VA permitted identification of a significantly higher number of potential recipient vessels (median 4, range 1–9) than the white-light images (median 2, range 1–5; p < 0.001), with detection of pathological flow patterns in 20% of all procedures. No association was found between the diameter and blood flow within potential recipients (Spearman r = 0.07, p = 0.69). After bypass grafting, the highest flow increase was noted in recipients with an initially low flow (p < 0.01), a late appearance (p < 0.01), and an initially retrograde flow direction (p = 0.02). Interestingly, flow increase was not significantly influenced by the recipient diameter (p = 0.09) or graft orientation (p = 0.44).

CONCLUSIONS

ICG-VA facilitates identification of potential recipient vessels and detection of pathological flow patterns. Recipients with an initially low flow, a late appearance, and a retrograde flow seem to bear the highest potential for flow increase, possibly due to a higher hemodynamic need for revascularization.

ABBREVIATIONS

ACVD = arteriosclerotic cerebrovascular disease; AI = arbitrary intensity; ICG-VA = indocyanine green videoangiography; MMV = moyamoya vasculopathy; ROI = region of interest; STA-MCA = superficial temporal artery–middle cerebral artery.
Illustrations from Marx and Schroeder (pp 318–326). Copyright Henry W. S. Schroeder. Published with permission.

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Contributor Notes

Correspondence Peter Vajkoczy: Charité Universitätsmedizin Berlin, Germany. peter.vajkoczy@charite.de.

INCLUDE WHEN CITING Published online August 28, 2020; DOI: 10.3171/2020.5.JNS20642.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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