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  • Image Guided Hemicraniectomy or Strokectomy With ICG Video Angiography for Malignant Infarctions

    Final Number:

    Phillip Parry MD; Brian T. Jankowitz MD

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2012 Annual Meeting

    Introduction: Craniectomy is an established surgical treatment for malignant brain swelling. The addition of brain removal or strokectomy, may be necessary to treat persistent mass effect. A strokectomy may also be considered as an alternative surgical treatment to allow replacement of the bone flap. In order to improve the safety of resecting ischemic cortex, we describe the addition of intraoperative ICG videoangiography and image-guidance to standard surgical techniques.

    Methods: We prospectively enrolled 9 patients over 18-months presenting with malignant brain edema requiring surgical treatment. All patients had an MRI with DWI sequences and an image guided CT performed prior to surgery. These images were fused to plan the extent of strokectomy. Intraoperative ICG videoangiography was then performed to delineate brain tissue with persistent blood flow within the stroke burden conferred on the fused CT-MRI. Injections with ICG were performed through a peripheral IV while video angiography occurred with an infrared filter enabled microscope. Patients with absent blood flow in the area of their stroke burden underwent radical strokectomy with the intention of replacing the bone flap, while patients with persistent blood flow underwent selective strokectomy or simple DHC.

    Results: In all patients, image guidance and ICG runs were concordant and helped delineate the extent of infarcation. Six of the 9 patients had strokectomies. The bone flap was replaced in 2 patients who underwent strokectomy with duraplasty while the remaining patients had strokectomy plus duraplasty without bone flap replacement because of persistent cerebral edema. Three patients had persistent blood flow through their stroke volumes and were treated with DCH alone

    Conclusions: We describe a novel approach to aid in the surgical management of large volume strokes using ICG videoangiography and image guidance to allow for safe, quick and effective decision making and resection of infarcted brain.

    Patient Care: We feel that this technique offers the patient the greatest opportunity not only to survive their stroke but also reduce the inherent morbidity associated with stroke rehabilitation.

    Learning Objectives: To improve the surgical planning of radical or selective strokectomy using standard operating techniques.


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