Download PDF
J Neurol Surg B Skull Base 2017; 78(05): 408-412
DOI: 10.1055/s-0037-1602777
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Indocyanine Green Fluorescence to Evaluate Nasoseptal Flap Viability in Endoscopic Endonasal Cranial Base Surgery

Edward E. Kerr
1   Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
,
Ali Jamshidi
1   Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
,
Ricardo L. Carrau
1   Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
2   Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
,
Raewyn G. Campbell
2   Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
,
Leo F. Ditzel Filho
1   Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
,
Bradley A. Otto
1   Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
2   Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
,
Daniel M. Prevedello
1   Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
2   Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
› Author Affiliations
Further Information

Publication History

02 July 2016

24 March 2017

Publication Date:
05 June 2017 (online)

    Permissions and Reprints

Abstract

Objectives The pedicled nasoseptal flap (NSF) has dramatically reduced postoperative cerebrospinal fluid leakage following endoscopic endonasal approach (EEA) surgery. Although rare, its arterial supply may be damaged during harvest or may be preoperatively damaged for numerous reasons. Early recognition permits harvesting a contralateral flap before sacrificing its pedicle as part of the surgical exposure or use of an alternative flap.

Design Technical feasibility study and case series.

Setting Tertiary care university-associated medical center.

Participants Five patients requiring an EEA with NSF reconstruction.

Main Outcome Measures During NSF harvest, intravenous indocyanine green (IVICG) was administered, and a customized endoscopic system was used to visualize the emerging fluorescence. At the end of each case, just before final positioning of the NSF, additional IVICG was administered, and the custom endoscope was again introduced to evaluate fluorescence.

Results In four patients, the entire NSF fluoresced brightly with IVICG on initial harvest and before final positioning. One patient showed heterogeneous fluorescence of the pedicle and distal parts of the NSF at both stages. All NSFs healed well without complication.

Conclusion IVICG facilitates real-time evaluation NSF's arterial supply. This may provide early recognition of arterial compromise, allowing the harvest of alternate flaps or modification of surgery.

Keywords

indocyanine green - ICG - fluorescence - indocyanine green fluorescence - indocyanine green endoscope - endoscopic endonasal - nasoseptal flap - nasoseptal artery - skull base

Note

No portion of this article has been previously presented or published.


 

  • References

  • 1 Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 2005; 19 (01) E3
    CrossrefPubMedGoogle Scholar
  • 2 Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 2005; 19 (01) E4
    CrossrefPubMedGoogle Scholar
  • 3 Attia M, Kandasamy J, Jakimovski D. , et al. The importance and timing of optic canal exploration and decompression during endoscopic endonasal resection of tuberculum sella and planum sphenoidale meningiomas. Neurosurgery 2012; 71 (1, Suppl Operative): 58-67
    CrossrefPubMedGoogle Scholar
  • 4 Zada G, Du R, Laws Jr ER. Defining the “edge of the envelope”: patient selection in treating complex sellar-based neoplasms via transsphenoidal versus open craniotomy. J Neurosurg 2011; 114 (02) 286-300
    CrossrefPubMedGoogle Scholar
  • 5 Cavallo LM, Solari D, Esposito F, Cappabianca P. The endoscopic endonasal approach for the management of craniopharyngiomas involving the third ventricle. Neurosurg Rev 2013; 36 (01) 27-37 , discussion 38
    CrossrefPubMedGoogle Scholar
  • 6 Schmidt RF, Choudhry OJ, Raviv J. , et al. Surgical nuances for the endoscopic endonasal transpterygoid approach to lateral sphenoid sinus encephaloceles. Neurosurg Focus 2012; 32 (06) E5
    CrossrefPubMedGoogle Scholar
  • 7 McLaughlin N, Bresson D, Ditzel Filho LF. , et al. Vidian nerve neurofibroma removed via a transpterygoid approach. Minim Invasive Neurosurg 2011; 54 (5-6): 250-252
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Kassam AB, Thomas A, Carrau RL. , et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63 (01) (Suppl. 01) ONS44-ONS52 , discussion ONS52–ONS53
    PubMedGoogle Scholar
  • 9 Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA. Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery. Neurosurg Focus 2012; 32 (06) E7
    CrossrefPubMedGoogle Scholar
  • 10 Pinheiro-Neto CD, Carrau RL, Prevedello DM. , et al. Use of acoustic Doppler sonography to ascertain the feasibility of the pedicled nasoseptal flap after prior bilateral sphenoidotomy. Laryngoscope 2010; 120 (09) 1798-1801
    CrossrefPubMedGoogle Scholar
  • 11 Ambekar S, Babu A, Pandey P, Devi IB. Intraoperative assessment of STA-MCA bypass patency using near-infrared indocyanine green video-angiography: a preliminary study. Neurol India 2012; 60 (06) 604-607
    CrossrefPubMedGoogle Scholar
  • 12 Imizu S, Kato Y, Sangli A, Oguri D, Sano H. Assessment of incomplete clipping of aneurysms intraoperatively by a near-infrared indocyanine green-video angiography (Niicg-Va) integrated microscope. Minim Invasive Neurosurg 2008; 51 (04) 199-203
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Kim DL, Cohen-Gadol AA. Indocyanine-green videoangiogram to assess collateral circulation before arterial sacrifice for management of complex vascular and neoplastic lesions: technical note. World Neurosurg 2013; 79 (02) 404.e1-404.e6
    PubMedGoogle Scholar
  • 14 Son YJ, Kim JE, Park SB, Lee SH, Chung YS, Yang HJ. Quantitative analysis of intraoperative indocyanine green video angiography in aneurysm surgery. J Cerebrovasc Endovasc Neurosurg 2013; 15 (02) 76-84
    CrossrefPubMedGoogle Scholar
  • 15 Wilson EM, Halsey Jr JH, Vitek JJ. Validation of jugular venous flow as an index of total cerebral blood flow. Stroke 1972; 3 (03) 300-321
    CrossrefPubMedGoogle Scholar
  • 16 Hide T, Yano S, Shinojima N, Kuratsu J. Usefulness of the indocyanine green fluorescence endoscope in endonasal transsphenoidal surgery. J Neurosurg 2015; 122 (05) 1185-1192
    CrossrefPubMedGoogle Scholar
  • 17 Litvack ZN, Zada G, Laws Jr ER. Indocyanine green fluorescence endoscopy for visual differentiation of pituitary tumor from surrounding structures. J Neurosurg 2012; 116 (05) 935-941
    CrossrefPubMedGoogle Scholar
  • 18 Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM. Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg 2008; 108 (04) 715-728
    CrossrefPubMedGoogle Scholar
  • 19 Kasemsiri P, Carrau RL, Otto BA. , et al. Reconstruction of the pedicled nasoseptal flap donor site with a contralateral reverse rotation flap: technical modifications and outcomes. Laryngoscope 2013; 123 (11) 2601-2604
    CrossrefPubMedGoogle Scholar
  • 20 Rivera-Serrano CM, Bassagaisteguy LH, Hadad G. , et al. Posterior pedicle lateral nasal wall flap: new reconstructive technique for large defects of the skull base. Am J Rhinol Allergy 2011; 25 (06) e212-e216
    CrossrefPubMedGoogle Scholar
  • 21 Fortes FS, Carrau RL, Snyderman CH. , et al. Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope 2007; 117 (06) 970-976
    CrossrefPubMedGoogle Scholar