Importance of collateral venous circulation on indocyanine green videoangiography in intracranial meningioma resection: direct evidence for venous compression theory in peritumoral edema formation

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OBJECTIVE

Indocyanine green videoangiography (ICGVA) has been used in many neurosurgical operations, including vascular and brain tumor fields. In this study, the authors applied ICGVA to intracranial meningioma surgery and evaluated it usefulness with attention to collateral venous flow.

METHODS

Forty-two patients with intracranial meningioma who underwent ICGVA during microsurgical resection were retrospectively analyzed. For ICGVA, the ICG was injected intravenously at the standard dose of 12.5 mg before and/or after tumor resection. Intravascular fluorescence from blood vessels was imaged through a microscope with a special filter and infrared excitation light to illuminate the operating field. The authors assessed the benefits of ICGVA and analyzed its findings with preoperative radiological findings on MRI.

RESULTS

ICGVA allowed real-time assessment of the patency and flow direction in very small peritumoral vessels in all cases. A safe dural incision could also be done based on information from ICGVA. The collateral venous channel due to venous obstruction of tumoral compression was found in 10 cases, and venous flow restoration after tumor resection was observed promptly after tumor resection in 4 cases. Peritumoral brain edema (PTBE) was observed on preoperative T2-weighted MRI in 19 patients. The presence of collateral venous circulation or flow restoration was significantly related to PTBE formation in multivariate analysis (p = 0.001; HR 0.027, 95% CI 0.003–0.242).

CONCLUSIONS

ICGVA, an excellent method for monitoring blood flow during meningioma resection, provides valuable information as to the presence of venous collaterals and flow restoration. Furthermore, the fact that the presence of venous collaterals was found to be associated with PTBE may directly support the venous theory as the pathogenesis of PTBE formation.

ABBREVIATIONS DSA = digital subtraction angiography; ICG = indocyanine green; ICGVA = indocyanine green videoangiography; MDS = microvascular Doppler sonography; PTBE = peritumoral brain edema; SSS = superior sagittal sinus.

Article Information

Correspondence Shin Jung: Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, South Korea. sjung@chonnam.ac.kr.

INCLUDE WHEN CITING Published online May 24, 2019; DOI: 10.3171/2019.3.JNS182308.

J.H.K. and K.S.M. contributed equally to this work and share first authorship.

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

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Identification of a small cortical vein. A and B: Preoperative sagittal (A) and axial (B) MR images showing a parasagittal meningioma in the right parietal lobe. C and D: MDS could not detect the flow of posterior small cortical veins with a diameter less than 0.5 mm (white arrows) following tumor resection. E: ICGVA image showing intact flow of all cortical veins running over the tumor bed, including the posterior small cortical vein (white arrow). Figure is available in color online only.

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    Case 2. Safe dura incision. A and B: The convexity meningioma on the left temporal lobe is identified on preoperative axial (A) and sagittal (B) MR images, and a large cortical vein is shown to pass through the lateral aspect of the tumor (B). C: Prior to dura incision, the ICGVA image shows an anatomical relationship between the large cortical vein (white arrow) and the underlying tumor (white arrowhead). D: Safe dura incision could be performed with the information of ICGVA. Figure is available in color online only.

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    Case 3. Collateral venous flow. A and B: Preoperative axial MR images showing a sphenoidal ridge meningioma with severe peritumoral edema in the left temporal lobe. C: After tumor exposure through the orbito-cranial approach, a small sylvian vein (arrowhead) is seen on the sylvian fissure. D and E: The ICGVA image shows the flow of the small sylvian vein (white arrow; D) to return to the opposite direction without entering the cavernous sinus (long white arrow indicates the venous flow direction; E).

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    Case 4. Venous flow restoration. A and B: Preoperative axial MR images showing a meningioma with peritumoral edema in the left parietal lobe. C: After the tumor is exposed, several cortical veins converge and flow into the SSS along the lateral margin of the tumor. D and E: However, one of the peritumoral cortical veins (white arrow) reveals markedly decreased blood flow on ICGVA. F: The cortical veins around the tumor are well decompressed and preserved after tumor removal. G and H: After tumor removal, the blood flow is restored in the cortical vein that had been without venous flow (white arrowhead) before tumor removal.

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    Case 5. Venous collaterals and flow restoration. A and B: Preoperative sagittal (A) and axial (B) MR images showing a meningioma with severe peritumoral edema in the left parietal lobe. C–E: Following tumor exposure, complex cortical venous circulation is seen around the tumor (C) and ICGVA shows the flow of the inferior cortical vein (white arrow; D) is blocked by the tumor and forced to flow retrograde at the tumor and vessel boundary (curved white arrow indicates the venous flow direction; E). F–H: After tumor resection, the inferior cortical vein (white arrow) is exposed on the tumor base (F), and ICGVA shows that the restored venous flow enters the SSS faster than earlier to the tumor removal (long white arrow indicates the restored venous flow direction to the SSS; G and H).

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