- Department of Neurosurgery, Kindai University Faculty of Medicine, Osaka, Japan
Department of Neurosurgery, Kindai University Faculty of Medicine, Osaka, Japan
DOI:10.4103/2152-7806.183526Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Kubota H, Sanada Y, Nagatsuka K, Yoshioka H, Iwakura M, Kato A. Safe and accurate sylvian dissection with the use of indocyanine green videoangiography. Surg Neurol Int 03-Jun-2016;7:
How to cite this URL: Kubota H, Sanada Y, Nagatsuka K, Yoshioka H, Iwakura M, Kato A. Safe and accurate sylvian dissection with the use of indocyanine green videoangiography. Surg Neurol Int 03-Jun-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/safe-and-accurate-sylvian-dissection-with-the-use-of-indocyanine-green-videoangiography/
Background:Sylvian dissection is an essential microneurosurgical skill for neurosurgeons. The safe and accurate opening of the sylvian fissure is desirable for a good prognosis.
Methods:The aim of this report is to demonstrate the use of indocyanine green (ICG) videoangiography to recognize the superficial sylvian vein (SSV) and thus enable a wide opening of the sylvian fissure, especially in patients with subarachnoid hemorrhage (SAH).
Results:The small tributary flowing into the SSV was distinguishable from a passing one, which deeply entered the insula. In addition, an entering point of a tributary to the SSV, which ran perpendicular to the insula, was occasionally determined. SSV, which was barely discernable in a reddish SAH involving the sylvian fissure, was clearly demarcated using ICG videoangiography. Two representative cases of sylvian dissection are herein presented.
Conclusion:The performance of ICG videoangiography before sylvian dissection is a simple and useful method for identifying a vital approach route for safe and accurate sylvian dissection, and it reduces the risk of causing any accidental injury to the veins in the sylvian fissure.
Keywords: Distal sylvian dissection, indocyanine green videoangiography, superficial sylvian vein
Sylvian dissection is a mandatory skill for exposing the insula and reaching the deep areas of the brain in vascular and neoplastic surgery. The many variations of the sylvian veins consist of superficial and deep sylvian veins, which are three-dimensionally anastomosed with the tributaries from the frontal, temporal, parietal lobes, and the insula.[
After a dural incision, an injection of ICG (5 mg) (Daiichi Sankyo Co., Ltd., Tokyo, Japan) and bolus saline (20 ml) was observed through an FL800 system mounted on a Leica OH-4 microscope (Leica Microsystems GmbH, Wetzlar, Germany).
A tributary flowing into SSV was distinguished from one which passed the SSV [
(a) Indocyanine green videoangiography demonstrated that a temporosylvian vein (arrow) is recognized to pass by the superficial sylvian vein, and not to flow into it. (b) Insular veins (arrow), which deeply appeared from the insula, are observed to enter each frontal and temporal superficial sylvian vein. These insular veins were barely detectable without indocyanine green videoangiography. The arrows show the same positions of the veins
We herein present two representative cases of patients with SAH. Patient 1 showed a thick SAH with a ruptured MCA bifurcation aneurysm [
(a) The bulging and reddish brain appearance of the surface with the subarachnoid hemorrhage after the dural incision. (b) Indocyanine green videoangiography. The sylvian fissure (dotted line) is estimated from the branches of the middle cerebral artery. The superficial sylvian vein is clearly identified after the administration of indocyanine green. The frontosylvian and temporosylvian veins empty into the superficial sylvian vein (arrowhead) and flow toward the temporal lobe. (c) A wide sylvian opening is obtained after the skeletonization of the superficial sylvian vein (arrowhead) from the temporal lobe. The arrowheads show the same positions of the superficial sylvian vein
Patient 2 had a ruptured internal carotid-posterior communicating artery aneurysm with a hypoplastic SSV at the proximal sylvian fissure [
(a) The brain surface with the subarachnoid hemorrhage. (b) The locations of the superficial sylvian vein (arrowhead) and the sylvian fissure (dotted line) as visualized by indocyanine green videoangiography. No tributaries from the temporal lobe enter the superficial sylvian vein. (c) The temporal side of the superficial sylvian vein (arrowhead) is dissected and the superficial sylvian vein is moved to the frontal side. (d) The superficial sylvian vein at the distal sylvian fissure (arrow) is skeletonized from the frontal and temporal sides by dissection, resulting in a space of sufficient width for the sylvian fissure. The arrowheads show the same positions of the superficial sylvian vein
The superficial and deep sylvian veins are key structures for achieving a wide opening of the sylvian fissure. A distal part of the sylvian fissure shows anatomically complicated venous drainage to achieve a wide sylvian opening. Frigeri et al.[
The cerebral vein is easily damaged due to its relatively thin walls, thus meticulous manipulation is required to preserve these veins during sylvian dissection and avoid causing brain swelling and venous infarction. The risk of injury to the vein, however, increases in patients with SAH because SSV is barely distinguishable within SAH, and the adhesion among the veins, arachnoid, and pia mater on the bulging brain surface makes dissection difficult. The application of ICG in the visualization of venous circulation has been reported with regard to predicting venous sacrifice[
The performance of ICG videoangiography before dissection may help reduce the incidence of accidental injury of the veins in the sylvian fissure. The authors hope that this method will be widely utilized at the beginning of sylvian dissection.
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