Intraoperative Imaging for Intracerebral Hemorrhage
This paper reviews the current intraoperative imaging tools that are available to assist neurosurgeons in the treatment of intracerebral hemorrhage (ICH). This review shares the authors' experience with each modality and discusses the advantages, potential limitations, and disadvantages of each.
Surgery for ICH is directed at blood clot removal, reduction of intracranial pressure, and minimization of secondary damage associated with hematoma breakdown products. For effective occlusion and safe obliteration of vascular anomalies associated with ICH, vascular neurosurgeons today require a thorough understanding of the various intraoperative imaging modalities available for obtaining real-time information. Use of one or more of these modalities may improve the surgeon's confidence during the procedure, the patient's safety during surgery, and surgical outcome.
The modern techniques discussed include 1) indocyanine green–based video angiography, which provides real-time information based on high-quality images showing the residual filling of vascular pathological entities and the patency of blood vessels of any size in the surgical field; and 2) intraoperative angiography, which remains the gold standard intraoperative diagnostic test in the surgical management of cerebral aneurysms and arteriovenous malformations. Hybrid procedures, providing multimodality image-guided surgeries and combining endovascular with microsurgical strategies within the same surgical session, have become feasible and safe. Microdoppler is a safe, noninvasive, and reliable technique for evaluation of hemodynamics of vessels in the surgical field, with the advantage of ease of use. Intraoperative MRI provides an effective navigation tool for cavernoma surgery, in addition to assessing the extent of resection during the procedure. Intraoperative CT scanning has the advantage of very high sensitivity to acute bleeding, thereby assisting in the confirmation of the extent of hematoma evacuation and the extent of vascular anomaly resection. Intraoperative ultrasound aids navigation and evacuation assessment during intracerebral hematoma evacuation surgeries. It supports the concept of minimally invasive surgery and has undergone extensive development in recent years, with the quality of ultrasound imaging having improved considerably.
Image-guided therapy, combined with modern intraoperative imaging modalities, has changed the fundamentals of conventional vascular neurosurgery by presenting real-time visualization of both normal tissue and pathological entities. These imaging techniques are important adjuncts to the surgeon's standard surgical armamentarium. Familiarity with these imaging modalities may help the surgeon complete procedures with improved safety, efficiency, and clinical outcome.
Intracerebral hemorrhage occurs in many conditions and has a wide spectrum of causes; most commonly, ICH occurs as a result of degenerative vascular disease, amyloid angiopathy, and hemorrhagic transformations of ischemic strokes. However, up to 10% of ICHs are due to underlying vascular structural anomalies (AVMs, aneurysms, and cavernous angiomas being the most common). Other less common vascular malformations include sinus or cortical vein thrombosis, arteriovenous fistula, and arterial dissection.
Intracerebral hemorrhage is associated with a high early mortality rate and a significant long-term morbidity rate. Among all stroke subtypes, it is considered to be the one with the highest mortality rate. Hematoma volume is an important predictor of 30-day mortality, and hematoma growth is a principal cause of early neurological deterioration. One should especially emphasize the high percentage of vascular pathological entities associated with ICH in the pediatric population, in which such entities were confirmed in a recent series in 61% of pediatric patients.
Therapy for ICH is directed at blood clot removal, reduction of intracranial pressure, and of secondary associated damage. In the International Surgical Trial in Intracerebral Haemorrhage (STICH), the effect of medical versus surgical management of ICH was compared, but, except for a small subgroup of patients who experienced a benefit from surgery, no significant advantage was demonstrated for any of the treatments.
The concept of "suction surgeries" (referring to ICH removal through large craniotomies) is now obsolete. Vascular neurosurgeons treating ICH should be prepared to deal not only with clot removal but also with the underlying cause. These tasks are often complex, both from the morphological and the technical point of view, and increase the risk for potential vessel compromise. For effective occlusion and safe obliteration of vascular anomalies, the neurosurgeon today may require intraoperative imaging modalities for obtaining real-time information. The use of intraoperative imaging modalities is of particular relevance when preoperative vascular imaging studies are negative but the intraoperative findings reveal a discrete lesion. In these complex cases the surgeon has to adapt and perform the procedure without a complete picture of the task ahead. Intraoperative imaging assessment in such situations can be particularly informative.
Along with the advances in neurosurgical techniques, significant progress has been made in the field of intraoperative imaging, especially intraoperative neurovascular imaging. From the development of uniplane angiography, the first description of CT contrast infusion to identify vascular lesions, and Doppler techniques to MR angiography and transcranial Doppler, reliable intraoperative imaging technologies have been developed. Several intraoperative modalities have been implemented: ICG-VA, iDSA, iCT, iMRI, iMD, and 3D iUS. These new imaging techniques and the concept of true hybrid rooms providing multimodality image-guided surgeries have improved diagnostics considerably. Such techniques may significantly assist the surgeon in challenging cases.
This paper reviews the current intraoperative imaging tools and the clinical use of each modality. Our experience with the various modalities and their advantages and potential limitations are discussed.
Abstract and Introduction
Abstract
This paper reviews the current intraoperative imaging tools that are available to assist neurosurgeons in the treatment of intracerebral hemorrhage (ICH). This review shares the authors' experience with each modality and discusses the advantages, potential limitations, and disadvantages of each.
Surgery for ICH is directed at blood clot removal, reduction of intracranial pressure, and minimization of secondary damage associated with hematoma breakdown products. For effective occlusion and safe obliteration of vascular anomalies associated with ICH, vascular neurosurgeons today require a thorough understanding of the various intraoperative imaging modalities available for obtaining real-time information. Use of one or more of these modalities may improve the surgeon's confidence during the procedure, the patient's safety during surgery, and surgical outcome.
The modern techniques discussed include 1) indocyanine green–based video angiography, which provides real-time information based on high-quality images showing the residual filling of vascular pathological entities and the patency of blood vessels of any size in the surgical field; and 2) intraoperative angiography, which remains the gold standard intraoperative diagnostic test in the surgical management of cerebral aneurysms and arteriovenous malformations. Hybrid procedures, providing multimodality image-guided surgeries and combining endovascular with microsurgical strategies within the same surgical session, have become feasible and safe. Microdoppler is a safe, noninvasive, and reliable technique for evaluation of hemodynamics of vessels in the surgical field, with the advantage of ease of use. Intraoperative MRI provides an effective navigation tool for cavernoma surgery, in addition to assessing the extent of resection during the procedure. Intraoperative CT scanning has the advantage of very high sensitivity to acute bleeding, thereby assisting in the confirmation of the extent of hematoma evacuation and the extent of vascular anomaly resection. Intraoperative ultrasound aids navigation and evacuation assessment during intracerebral hematoma evacuation surgeries. It supports the concept of minimally invasive surgery and has undergone extensive development in recent years, with the quality of ultrasound imaging having improved considerably.
Image-guided therapy, combined with modern intraoperative imaging modalities, has changed the fundamentals of conventional vascular neurosurgery by presenting real-time visualization of both normal tissue and pathological entities. These imaging techniques are important adjuncts to the surgeon's standard surgical armamentarium. Familiarity with these imaging modalities may help the surgeon complete procedures with improved safety, efficiency, and clinical outcome.
Introduction
Intracerebral hemorrhage occurs in many conditions and has a wide spectrum of causes; most commonly, ICH occurs as a result of degenerative vascular disease, amyloid angiopathy, and hemorrhagic transformations of ischemic strokes. However, up to 10% of ICHs are due to underlying vascular structural anomalies (AVMs, aneurysms, and cavernous angiomas being the most common). Other less common vascular malformations include sinus or cortical vein thrombosis, arteriovenous fistula, and arterial dissection.
Intracerebral hemorrhage is associated with a high early mortality rate and a significant long-term morbidity rate. Among all stroke subtypes, it is considered to be the one with the highest mortality rate. Hematoma volume is an important predictor of 30-day mortality, and hematoma growth is a principal cause of early neurological deterioration. One should especially emphasize the high percentage of vascular pathological entities associated with ICH in the pediatric population, in which such entities were confirmed in a recent series in 61% of pediatric patients.
Therapy for ICH is directed at blood clot removal, reduction of intracranial pressure, and of secondary associated damage. In the International Surgical Trial in Intracerebral Haemorrhage (STICH), the effect of medical versus surgical management of ICH was compared, but, except for a small subgroup of patients who experienced a benefit from surgery, no significant advantage was demonstrated for any of the treatments.
The concept of "suction surgeries" (referring to ICH removal through large craniotomies) is now obsolete. Vascular neurosurgeons treating ICH should be prepared to deal not only with clot removal but also with the underlying cause. These tasks are often complex, both from the morphological and the technical point of view, and increase the risk for potential vessel compromise. For effective occlusion and safe obliteration of vascular anomalies, the neurosurgeon today may require intraoperative imaging modalities for obtaining real-time information. The use of intraoperative imaging modalities is of particular relevance when preoperative vascular imaging studies are negative but the intraoperative findings reveal a discrete lesion. In these complex cases the surgeon has to adapt and perform the procedure without a complete picture of the task ahead. Intraoperative imaging assessment in such situations can be particularly informative.
Along with the advances in neurosurgical techniques, significant progress has been made in the field of intraoperative imaging, especially intraoperative neurovascular imaging. From the development of uniplane angiography, the first description of CT contrast infusion to identify vascular lesions, and Doppler techniques to MR angiography and transcranial Doppler, reliable intraoperative imaging technologies have been developed. Several intraoperative modalities have been implemented: ICG-VA, iDSA, iCT, iMRI, iMD, and 3D iUS. These new imaging techniques and the concept of true hybrid rooms providing multimodality image-guided surgeries have improved diagnostics considerably. Such techniques may significantly assist the surgeon in challenging cases.
This paper reviews the current intraoperative imaging tools and the clinical use of each modality. Our experience with the various modalities and their advantages and potential limitations are discussed.
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