Name:
Application of FLOW 800 in extracranial-to-intracranial bypass surgery for moyamoya disease
Description:
Application of FLOW 800 in extracranial-to-intracranial bypass surgery for moyamoya disease
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/1173c88d-5fd9-4482-9e14-88d484af0977/videoscrubberimages/Scrubber_156.jpg
Duration:
T00H07M05S
Embed URL:
https://stream.cadmore.media/player/1173c88d-5fd9-4482-9e14-88d484af0977
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/1173c88d-5fd9-4482-9e14-88d484af0977/21-191.mp4?sv=2019-02-02&sr=c&sig=srZI73QJWRopHyhdbZ67d7VwY%2BUK0JZr%2FdUh8wFFF78%3D&st=2024-04-30T11%3A27%3A57Z&se=2024-04-30T13%3A32%3A57Z&sp=r
Upload Date:
2021-12-02T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This is a video demonstrating the application of FLOW 800 in extracranial-to-intracranial bypass surgery for moyamoya disease. The FLOW 800 software, designed by Zeiss, utilizes indocyanine green-based based videoangiography performed at a region of interest through a semiquantitative analysis, based on time to half-maximum intensity and fluorescence intensity. The results are viewed in two-dimensional color maps in the form of delay, intensity, and speed.
SPEAKER: For simplicity, we will only focus on the delay maps in this video. Our case demonstration begins with an 18-year-old male with Down syndrome, presenting with recurrent episodes of left facial droop, left arm numbness, and a dysarthria lasting minutes with complete resolution. On clinical exam he demonstrates moderate cognitive impairment, but otherwise neurologically intact. Preoperative digital subtraction angiography demonstrates an occlusion of the right internal carotid artery, with reconstitution of the right M1 segment via moyamoya collaterals and delayed right hemisphere perfusion.
SPEAKER: And extracranial-to-intracranial bypass was recommended, and the patient and family were agreeable. After mapping the parietal division of the superficial temporal artery using a Doppler an incision is made, and the superficial temporal artery is skeletonized prior to performing a frontotemporal craniotomy. The dura is opened in a styloid fashion and the STA is positioned along the posterior margin.
SPEAKER: A suitable M4 recipient site is identified and ICG videoangiography is performed for baseline FLOW 800 data. As is typical in moyamoya patients, there is hyperemia along the cortical surface. The recipient vessel measures 1.2 mm in diameter and the distal STA measures to be of roughly equivalent size. A flowmeter is used to determine the cut flow velocity of the STA.
SPEAKER: The donor vessel is then temporarily occluded and flushed with heparinized saline. Temporary clips are used to occlude the recipient vessel and an ellipsoid arteriotomy is performed. The site is flush with heparinized saline, followed by indigo carmine dye. Once the heel and toe are sutured, an end-to-side anastomosis is performed using 10-0 sutures and an interrupted fashion.
SPEAKER: Following completion of the anastomosis, the temporary clips are removed and hemostasis is achieved. The total occlusion time for this case was 16 minutes. Postanastomosis ICG videoangiography is then performed and the FLOW 800 data is processed.
SPEAKER: When comparing the pre- and postanastomosis color maps, the previously seen blue and green that dominated the preanastomosis map was replaced with more yellow-orange hues, consistent with decreased delay and increased perfusion along the cortical surface. The flowmeter found prebypass maximal M4 flow to be retrograde at 5.04 ml/min. Following bypass, proximal M4 had retrograde flow of 5.76 ml/min and anterograde flow of 28.4 ml/min along the distal M4.
SPEAKER: Postoperative angiogram at 6 months demonstrates patency of the bypass, with supply to 75% of the middle cerebral artery distribution. The patient remained neurologically at his baseline without event 1 year following surgery. The next case demonstrates the concept of prebypass competing flows. This patient also underwent an EC-IC bypass for symptomatic moyamoya disease.
SPEAKER: However, the prebypass ICG videoangiography demonstrates retrograde filling of the distal MCA by collaterals competing with the anterograde flow from stenosed vessels proximally. Following an end-to-side STA-MCA bypass, flow now appears to be dominated by the bypass. The FLOW 800 color map demonstrates improved perfusion diffusely along the cortical surface, with diminished delay following the bypass.
SPEAKER: Flowmeter measurements demonstrate preanastomosis M4 flow to be 1.4 ml/min. Postbypass, proximal M4 appears to fill retrograde at 12.3 ml/min, and distal M4 fills anterograde at 37.8 ml/min. In contrast, this last case demonstrates the development of competing flows following bypass. Similar moyamoya patient undergoing an STA-MCA bypass, had prebypass ICG videoangiography demonstrating delayed anterograde filling of the M4 branch.
SPEAKER: Postbypass, ICG is visualized filling the proximal M4 anterograde until reaching the anastomosis site with only trickling into the distal M4 branches. During the end of the injection, ICG is visualized in the STA and dominating the flow into the distal M4 in an anterograde fashion, with minimal flow into the proximal M4, demonstrating competing flow between the graphed and the proximal M4.
SPEAKER: Nevertheless, FLOW 800 color maps demonstrate increased perfusion of the cortical surface. In regard to the keys in obtaining accurate FLOW 800 data, the injections must be performed through the same intravenous access point under comparable hemodynamic pressures. There must be close communication with the anesthesia team to ensure that the rate and volume of ICG and subsequent flush are reproducible.
SPEAKER: Finally, a vital tool is the PositionMemory feature of the robotic visualization system for microscopic accuracy between maps. Overall, FLOW 800 provides a surgeon with real-time information regarding cortical perfusion previously not available.