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Improvement of optic nerve pial blood supply visualized through indocyanine green videoangiography after resection of a tuberculum sellae meningioma: 2-dimensional operative video
Description:
Improvement of optic nerve pial blood supply visualized through indocyanine green videoangiography after resection of a tuberculum sellae meningioma: 2-dimensional operative video
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https://cadmoremediastorage.blob.core.windows.net/f3eb78b7-0bb6-4864-89af-5cd0a38f96a8/videoscrubberimages/Scrubber_212.jpg
Duration:
T00H10M24S
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https://stream.cadmore.media/player/f3eb78b7-0bb6-4864-89af-5cd0a38f96a8
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https://cadmoreoriginalmedia.blob.core.windows.net/f3eb78b7-0bb6-4864-89af-5cd0a38f96a8/21-155.mp4?sv=2019-02-02&sr=c&sig=qEghfw8B2BnkFdupeAm%2B%2FlaMSvC4bnqYBGAPzJi156s%3D&st=2025-01-15T04%3A12%3A59Z&se=2025-01-15T06%3A17%3A59Z&sp=r
Upload Date:
2021-11-23T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video demonstrates the improvement of the optic nerve pial blood supply visualized during the indocyanine green videoangiography after the resection of a tuberculum sellae meningioma. The patient was a 48-year-old female presenting with a history of progressive headache, galactorrhea, and mild visual field impairment as well recurrent high serum prolactin levels, despite treatment with cabergoline. Preoperative visual field examination demonstrated both sides compromised but with a slightly greater and more diffuse deficit on the right eye.
SPEAKER: Preoperative MRI demonstrated a mass highly suggestive of a tuberculum sellae meningioma. And there was no evidence of optic canal invasion. Here, we can better see the lesion that measured around 17 by 10 mm. Now, we can observe the tumor in the three orthogonal planes. And here, the displacement of the left optic nerve, which the right nerve just touched by the tumor, which is interesting considering that the visual field examination of the right nerve was slightly worse regarding the left.
SPEAKER: And considering worsening of symptoms, microsurgical resection was indicated. The patient was placed supine with the head rotated at 30 degrees to the contralateral side and slightly deflect. Skin incision running from in front of tragus to the contralateral midpupillary line behind the hairline is employed. During elevation of the cutaneous flap, it's important to take care to preserve at least the frontal branch of the superficial temporal artery.
SPEAKER: It is important to prepare a wide pedicled pericranial flap to help later in the closure of skull based effects. And now, we can observe the flap prepared in this case. Temporalis muscle is dissected using a superficial technique to preserve the frontalis branch of the facial nerve. And then, the soft tissues close to the orbital rim are further elevated in a supraperiosteal fashion. Following the section of temporalis muscle from the underlying bone, it is reflected inferiorly, and the fronto-orbital craniotomy is performed.
SPEAKER: In this 3D model, we can observe the bone flap. An important burr hole is at MacCarty keyhole exposing both the orbit and anterior fossa. And the last osteotomy to release the bone flap is through the orbital roof access and using this point. As we can observe from this inner perspective, additional removal of the orbital roof to increase the space is performing after taking out the main bone flap.
SPEAKER: And this piece can be put back in the end during reconstruction. Now, we can observe the exposure through the craniotomy window and demonstrate the opening of frontal sinus, which must be cranialized and previous harvested pericardial flap can help during its closure. And now, we can observe the exposure around the region of tuberculum sellae. Following Sylvian fissure dissection, the tumor, right optic nerve, internal carotid artery, and olfactory tract were exposed.
SPEAKER: And progressively the optic chiasm is being demonstrated. Since the beginning, it is important to dissect preserving the arachnoid planes. Now, it is possible to demonstrate a branch of the superior hypophyseal artery running towards the right optic nerve compressed by the tumor. Before starting to resect the lesion, an ICG videoangiography was performed. And here, we have the view of the surgical field.
SPEAKER: A bolus injection of 25 mg of indocyanine green was applied in a peripheral vein diluted in 5 ml of distillate water. And the fluorescence mode of the microscope was activated. We observed initially, the filling of the internal carotid artery and then, the intracranial structures as the meningioma and observed just a modest filling of the optic nerve pial vessels.
SPEAKER: After a careful inspection, it is possible to identify a pattern of filling of the superior pial network in a horizontal fashion. Apparently, by collateral flow from the ophthalmic artery anteriorly and the chiasmatic vessels posteriorly as the blood does not seem to come from inside the optic nerve itself. But apparently, come gradually filling the anterior and posterior extremities of the pial vessels.
SPEAKER: Following the ICG videoangiography the lesion has started to be removed. Optic nerve is initially released from its arachnoid adhesions to allow safer manipulation of the mass during its resection. Tumor removal starts through its base coagulating its attachment to the region around tuberculum sellae to, from the beginning, attack its blood supply.
SPEAKER: Progressively, the whole extent of the attachment of the mass is being coagulated and sectioned under constant irrigation. Here, advancing more to the left side. And now, the attachment is approaching deeper. The removal of the tumor should respect the arachnoid planes around it to preserve the surrounding neurovascular structures.
SPEAKER: As we can observe, the arachnoid membranes in the inferior and deeper corner of this section of the mass. And here, more from the left side of tumor attachment is coagulated. Now, the inferior corner of the right side of tumor attachment is finally sectioned and releasing the side exposing the arachnoid membranes deeper. And here, a superior hypophyseal artery running side is arachnoid is demonstrated.
SPEAKER: Vessels that must be preserved when dissecting around the optic apparatus as they are an important source of blood supply to optic nerves. Then dissection progressed more to the contralateral side coagulating and sectioning the left side of tumor attachment. And gradually, we see exposed the left optic nerve and contralateral internal carotid artery. With attention to preserve the arachnoid planes during dissection.
SPEAKER: Now, we are dissecting the left side of the tumor displacing the left optic nerve releasing the arachnoid adhesions of the side of the mass. After circumferential dissection, the mass can be removed en bloc, demonstrating the side of tumor attachment while removing it. And here, we can observe the preservation of the previously identified superior hypophyseal artery inside the arachnoid membranes.
SPEAKER: Now, we are dissecting around the left optic nerve and expose the course of internal carotid artery. Drilling of the region of tumor attachment is performed. Here a residual tumor is identified in the interior wall of sella. And then, it is successfully dissected and removed.
SPEAKER: Intraoperatively invasion of the optic canal was not identified from neither side. And it was not shown in the preoperative images, either. Therefore, the optic canal was not open, in this case. We look for eventual other tumor remnants and remove small pieces and proceed to additional drilling and coagulation of the area of tumor attachment to achieve a Simpson grade I resection. Following tumor removal, we perform the new ICG videoangiography with the same methodology used before.
SPEAKER: We observe initially filling of internal carotid artery and then, the intracranial structures as the previous identified superior hypophyseal artery running between the optic nerves. We can observe a faster filling of pial vessels of right optic nerve and observe an apparent engorgement of the superior pial network which seemed to fill supply by vessels from inside the optic nerve in a vertical fashion.
SPEAKER: We hypothesize that the tumor compromised vessels supplying the inferior pial network, and after tumor resection the blood supply of this network improved. And consequently, the intrinsic optic nerve blood supply, which in its turn, increased blood flow to the superior pial network. Now, we have both ICG videoangiographies before and after resection and can observe the improvement of optic nerve pial blood supply following tumor removal.
SPEAKER: We put the previous both videos side by side a little bit accelerated for the purpose of comparison. However, we can better see the difference here through this color maps according to the fluorescence signal intensity. We captured a sequence of still images from the native ICG video with intervals of 1 second using the software GOM Player and then converted the grayscale images to a color map based in a lookup table of 16 colors using the software ImageJ.
SPEAKER: Here, we can better see the difference of blood flow in the superior pial network. We consider as the time point zero when the related signal intensity of the internal carotid artery measuring the software ImageJ reached 100, to standardize the comparison. Using the software ImageJ, we selected a region of interest over the right optic nerve and built a chart of fluorescence signal intensity. To facilitate the comparative, the baseline values obtained by the region of interest were discounted to normalize the comparison and allow both curves to start from signal intensity zero.
SPEAKER: We can observe significant improvement of signal intensity, what means blood supply, following resection. Postoperative MRI demonstrated a complete tumor resection relieving the compressive effect of the lesion. As we can observe in the FIESTA sequence, as well in the postcontrast T1-weighted images. We see the axial and now the coronal and sagittal cuts. Now, we have a comparative between before and after resection exposing resolution of compressive effect over the optic apparatus, especially over the left optic nerve.
SPEAKER: Considering the visual field examination, we observed both eyes' improvement. And here, we have the Humphrey perimetry. And now, the comparison between the visual field examination through the same method, demonstrating both eyes' improvement, with a more significant improvement of the right eye. Pathology confirmed the lesion to be a meningioma. And the patient presented improvement of symptoms and no new neurological deficits on follow-up.
SPEAKER:
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video demonstrates the improvement of the optic nerve pial blood supply visualized during the indocyanine green videoangiography after the resection of a tuberculum sellae meningioma. The patient was a 48-year-old female presenting with a history of progressive headache, galactorrhea, and mild visual field impairment as well recurrent high serum prolactin levels, despite treatment with cabergoline. Preoperative visual field examination demonstrated both sides compromised but with a slightly greater and more diffuse deficit on the right eye.
SPEAKER: Preoperative MRI demonstrated a mass highly suggestive of a tuberculum sellae meningioma. And there was no evidence of optic canal invasion. Here, we can better see the lesion that measured around 17 by 10 mm. Now, we can observe the tumor in the three orthogonal planes. And here, the displacement of the left optic nerve, which the right nerve just touched by the tumor, which is interesting considering that the visual field examination of the right nerve was slightly worse regarding the left.
SPEAKER: And considering worsening of symptoms, microsurgical resection was indicated. The patient was placed supine with the head rotated at 30 degrees to the contralateral side and slightly deflect. Skin incision running from in front of tragus to the contralateral midpupillary line behind the hairline is employed. During elevation of the cutaneous flap, it's important to take care to preserve at least the frontal branch of the superficial temporal artery.
SPEAKER: It is important to prepare a wide pedicled pericranial flap to help later in the closure of skull based effects. And now, we can observe the flap prepared in this case. Temporalis muscle is dissected using a superficial technique to preserve the frontalis branch of the facial nerve. And then, the soft tissues close to the orbital rim are further elevated in a supraperiosteal fashion. Following the section of temporalis muscle from the underlying bone, it is reflected inferiorly, and the fronto-orbital craniotomy is performed.
SPEAKER: In this 3D model, we can observe the bone flap. An important burr hole is at MacCarty keyhole exposing both the orbit and anterior fossa. And the last osteotomy to release the bone flap is through the orbital roof access and using this point. As we can observe from this inner perspective, additional removal of the orbital roof to increase the space is performing after taking out the main bone flap.
SPEAKER: And this piece can be put back in the end during reconstruction. Now, we can observe the exposure through the craniotomy window and demonstrate the opening of frontal sinus, which must be cranialized and previous harvested pericardial flap can help during its closure. And now, we can observe the exposure around the region of tuberculum sellae. Following Sylvian fissure dissection, the tumor, right optic nerve, internal carotid artery, and olfactory tract were exposed.
SPEAKER: And progressively the optic chiasm is being demonstrated. Since the beginning, it is important to dissect preserving the arachnoid planes. Now, it is possible to demonstrate a branch of the superior hypophyseal artery running towards the right optic nerve compressed by the tumor. Before starting to resect the lesion, an ICG videoangiography was performed. And here, we have the view of the surgical field.
SPEAKER: A bolus injection of 25 mg of indocyanine green was applied in a peripheral vein diluted in 5 ml of distillate water. And the fluorescence mode of the microscope was activated. We observed initially, the filling of the internal carotid artery and then, the intracranial structures as the meningioma and observed just a modest filling of the optic nerve pial vessels.
SPEAKER: After a careful inspection, it is possible to identify a pattern of filling of the superior pial network in a horizontal fashion. Apparently, by collateral flow from the ophthalmic artery anteriorly and the chiasmatic vessels posteriorly as the blood does not seem to come from inside the optic nerve itself. But apparently, come gradually filling the anterior and posterior extremities of the pial vessels.
SPEAKER: Following the ICG videoangiography the lesion has started to be removed. Optic nerve is initially released from its arachnoid adhesions to allow safer manipulation of the mass during its resection. Tumor removal starts through its base coagulating its attachment to the region around tuberculum sellae to, from the beginning, attack its blood supply.
SPEAKER: Progressively, the whole extent of the attachment of the mass is being coagulated and sectioned under constant irrigation. Here, advancing more to the left side. And now, the attachment is approaching deeper. The removal of the tumor should respect the arachnoid planes around it to preserve the surrounding neurovascular structures.
SPEAKER: As we can observe, the arachnoid membranes in the inferior and deeper corner of this section of the mass. And here, more from the left side of tumor attachment is coagulated. Now, the inferior corner of the right side of tumor attachment is finally sectioned and releasing the side exposing the arachnoid membranes deeper. And here, a superior hypophyseal artery running side is arachnoid is demonstrated.
SPEAKER: Vessels that must be preserved when dissecting around the optic apparatus as they are an important source of blood supply to optic nerves. Then dissection progressed more to the contralateral side coagulating and sectioning the left side of tumor attachment. And gradually, we see exposed the left optic nerve and contralateral internal carotid artery. With attention to preserve the arachnoid planes during dissection.
SPEAKER: Now, we are dissecting the left side of the tumor displacing the left optic nerve releasing the arachnoid adhesions of the side of the mass. After circumferential dissection, the mass can be removed en bloc, demonstrating the side of tumor attachment while removing it. And here, we can observe the preservation of the previously identified superior hypophyseal artery inside the arachnoid membranes.
SPEAKER: Now, we are dissecting around the left optic nerve and expose the course of internal carotid artery. Drilling of the region of tumor attachment is performed. Here a residual tumor is identified in the interior wall of sella. And then, it is successfully dissected and removed.
SPEAKER: Intraoperatively invasion of the optic canal was not identified from neither side. And it was not shown in the preoperative images, either. Therefore, the optic canal was not open, in this case. We look for eventual other tumor remnants and remove small pieces and proceed to additional drilling and coagulation of the area of tumor attachment to achieve a Simpson grade I resection. Following tumor removal, we perform the new ICG videoangiography with the same methodology used before.
SPEAKER: We observe initially filling of internal carotid artery and then, the intracranial structures as the previous identified superior hypophyseal artery running between the optic nerves. We can observe a faster filling of pial vessels of right optic nerve and observe an apparent engorgement of the superior pial network which seemed to fill supply by vessels from inside the optic nerve in a vertical fashion.
SPEAKER: We hypothesize that the tumor compromised vessels supplying the inferior pial network, and after tumor resection the blood supply of this network improved. And consequently, the intrinsic optic nerve blood supply, which in its turn, increased blood flow to the superior pial network. Now, we have both ICG videoangiographies before and after resection and can observe the improvement of optic nerve pial blood supply following tumor removal.
SPEAKER: We put the previous both videos side by side a little bit accelerated for the purpose of comparison. However, we can better see the difference here through this color maps according to the fluorescence signal intensity. We captured a sequence of still images from the native ICG video with intervals of 1 second using the software GOM Player and then converted the grayscale images to a color map based in a lookup table of 16 colors using the software ImageJ.
SPEAKER: Here, we can better see the difference of blood flow in the superior pial network. We consider as the time point zero when the related signal intensity of the internal carotid artery measuring the software ImageJ reached 100, to standardize the comparison. Using the software ImageJ, we selected a region of interest over the right optic nerve and built a chart of fluorescence signal intensity. To facilitate the comparative, the baseline values obtained by the region of interest were discounted to normalize the comparison and allow both curves to start from signal intensity zero.
SPEAKER: We can observe significant improvement of signal intensity, what means blood supply, following resection. Postoperative MRI demonstrated a complete tumor resection relieving the compressive effect of the lesion. As we can observe in the FIESTA sequence, as well in the postcontrast T1-weighted images. We see the axial and now the coronal and sagittal cuts. Now, we have a comparative between before and after resection exposing resolution of compressive effect over the optic apparatus, especially over the left optic nerve.
SPEAKER: Considering the visual field examination, we observed both eyes' improvement. And here, we have the Humphrey perimetry. And now, the comparison between the visual field examination through the same method, demonstrating both eyes' improvement, with a more significant improvement of the right eye. Pathology confirmed the lesion to be a meningioma. And the patient presented improvement of symptoms and no new neurological deficits on follow-up.
SPEAKER:
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