Use of a near-infrared vein finder to define cortical veins and dural sinuses prior to dural opening

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Near-infrared (NIR) light is commonly used to map venous anatomy in the upper extremities to gain intravenous access for line placement. In this report, the authors describe the use of a common and commercially available NIR vein finder to delineate the cortical venous anatomy prior to dural opening.

During a variety of cranial approaches, the dura was directly visualized using an NIR vein finder. The NIR light source allowed for recognition of the underlying cortical venous anatomy, dural sinuses, and underlying pathology before the dura was opened. This information was considered when tailoring the dural opening. When the dura was illuminated with the NIR vein finder, the underlying cortical and sinus venous anatomy was evident and correlated with the observed cortical anatomy. The vein finder was also accurate in locating superficial lesions and pathological dural veins. A complete accordance in the findings on the pre– and post–dural opening images was observed in all cases.

This simple, inexpensive procedure is readily compatible with operative room workflow, necessitates no head fixation, and offers a real-time image independent of brain shift.

ABBREVIATIONS dAVF = dural arteriovenous fistula; ICG-VA = indocyanine green videoangiography; MCA = middle cerebral artery; NIR = near-infrared.

Article Information

Correspondence Ezequiel Goldschmidt: University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, Pittsburgh, PA. goldschmidted@upmc.edu.

INCLUDE WHEN CITING Published online August 2, 2019; DOI: 10.3171/2019.5.JNS19297.

Disclosures Dr. Gardner reports owning stock in SPIWay and giving a sponsored talk on behalf of Zeiss.

© AANS, except where prohibited by US copyright law.

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    Case 1. Identifying normal anatomy using NIR vein finder in a patient with an MCA infarct. A: Preoperative scan showing a right MCA territory infarct with extensive edema and mass effect. B: Postoperative image after decompression showing resolution of the midline shift. C: Anatomical localization of the cortical veins prior to dural opening, using the vein finder under direct visualization. D: Image obtained using the NIR vein finder in which major superficial venous structures become evident. E: The underlying brain after the dura was opened, with complete correlation with the NIR vein finder image. F: Brain surface illuminated with NIR light. CV = central vein; SSV = superficial sylvian vein; vL = vein of Labbé; vT = vein of Trolard. Figure is available in color online only.

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    Case 2. Left pterional approach for a sphenoid wing meningioma. A: Contrast-enhanced T1-weighted MR image showing the lesion (asterisk). After the dura was exposed (B) and illuminated with the NIR vein finder (C), the sylvian vein (arrow) and its affluents (arrowheads) were identified. D: After the dura was opened, the location of the veins (arrow and arrowheads) was confirmed. Figure is available in color online only.

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    Case 3. Identification of pathological vessels with the NIR vein finder. A: T2-weighted MR image showing abnormal engorged veins in the right parietal region. B: Right external carotid artery angiogram showing branches from the middle meningeal artery and the occipital artery going into the Cognard type IV dAVF and draining only through cortical veins. C: Sagittal T1-weighted image showing evidence of tonsillar herniation. D: Postoperative angiogram demonstrating complete obliteration of the dAVF. E: Right parietal craniotomy. F: The NIR vein finder) is held about 30 cm away from the surgical field. G: When the NIR vein finder is used, an abnormal engorged cortical vein is seen. H: Dural opening, taking care to avoid the engorged vein. The y-shaped dark structure is the cortical expression of the dAVF. cv = cortical veins; d = dura; mma = middle meningeal artery; oa = occipital artery; s = skull; vf = NIR vein finder. Figure is available in color online only.

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    Case 4. Identification of a superficial cortical lesion using the NIR vein finder. A: Contrast-enhanced T1-weighted MR image showing a right parietal intraaxial tumor with ring enhancement and cortical expression (arrow). B: The NIR vein finder was applied prior to dural opening, and the surface expression of the tumor and a draining vein were evident. C: These findings were confirmed after dural opening; however, brain herniation through the defect caused these structures to shift upward. t = tumor; v = vein. Figure is available in color online only.

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    Cases 5 and 6. Case 5 (A–F). Identification of dural sinuses and underlying lesions using NIR vein finder. Contrast-enhanced axial (A) and coronal (B) MR images showing a large left-sided parasagittal meningioma (asterisk). After the initial craniotomy was performed (C), the NIR vein finder was used to visualize the superior sagittal sinus (SSS) (arrows), which was only partially exposed (D). The craniotomy was then completed, exposing the SSS entirely (E), which was confirmed with NIR light (F). The arrows point to the SSS. Case 6 (G–J). Contrast-enhanced coronal (G) and axial (H) MR images showing an enhancing extraaxial lesion (asterisk) in the left petroclival region. I: A left-sided extended retromastoid approach was performed, and the transverse and sigmoid sinuses were exposed. J: The NIR vein finder successfully identified both major sinuses. A small amount of epidural blood and thermal electrocautery are seen as dark spots in the NIR spectrum and can generate false-positive findings. Sig. = sigmoid; Trans. = transverse. Figure is available in color online only.

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