Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Assessment and Comparison of Three Dimensional Exoscopes for Near-Infrared Fluorescence-Guided Surgery Using Second-Window Indocyanine-Green

  • Cho, Steve S. (Department of Neurosurgery, Hospital of the University of Pennsylvania) ;
  • Teng, Clare W. (Perelman School of Medicine at the University of Pennsylvania) ;
  • Ravin, Emma De (Perelman School of Medicine at the University of Pennsylvania) ;
  • Singh, Yash B. (Department of Neurosurgery, Hospital of the University of Pennsylvania) ;
  • Lee, John Y.K. (Department of Neurosurgery, Hospital of the University of Pennsylvania)
  • Received : 2021.08.10
  • Accepted : 2021.09.23
  • Published : 2022.07.01
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Abstract

Objective : Compared to microscopes, exoscopes have advantages in field-depth, ergonomics, and educational value. Exoscopes are especially well-poised for adaptation into fluorescence-guided surgery (FGS) due to their excitation source, light path, and image processing capabilities. We evaluated the feasibility of near-infrared FGS using a 3-dimensional (3D), 4 K exoscope with near-infrared fluorescence imaging capability. We then compared it to the most sensitive, commercially-available near-infrared exoscope system (3D and 960 p). In-vitro and intraoperative comparisons were performed. Methods : Serial dilutions of indocyanine-green (1-2000 ㎍/mL) were imaged with the 3D, 4 K Olympus Orbeye (system 1) and the 3D, 960 p VisionSense Iridium (system 2). Near-infrared sensitivity was calculated using signal-to-background ratios (SBRs). In addition, three patients with brain tumors were administered indocyanine-green and imaged with system 1, with two also imaged with system 2 for comparison. Results : Systems 1 and 2 detected near-infrared fluorescence from indocyanine green concentrations of >250 ㎍/L and >31.3 ㎍/L, respectively. Intraoperatively, system 1 visualized strong near-infrared fluorescence from two, strongly gadolinium-enhancing meningiomas (SBR=2.4, 1.7). The high-resolution, bright images were sufficient for the surgeon to appreciate the underlying anatomy in the near-infrared mode. However, system 1 was not able to visualize fluorescence from a weakly-enhancing intraparenchymal metastasis. In contrast, system 2 successfully visualized both the meningioma and the metastasis but lacked high resolution stereopsis. Conclusion : Three-dimensional exoscope systems provide an alternative visualization platform for both standard microsurgery and near-infrared fluorescent guided surgery. However, when tumor fluorescence is weak (i.e., low fluorophore uptake, deep tumors), highly sensitive near-infrared visualization systems may be required.

Keywords

Acknowledgement

Supported in part by the Institute for Translational Medicine and Therapeutics of the Perelman School of Medicine at the University of Pennsylvania (JYKL). Research reported in this publication was also supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000003 (JYKL). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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