Novel Software-Derived Workflow in Extracranial-Intracranial Bypass Surgery Validated by Transdural Indocyanine Green Videoangiography

World Neurosurg. 2020 Feb;134:e892-e902. doi: 10.1016/j.wneu.2019.11.038. Epub 2019 Nov 14.


Background: The introduction of image-guided methods to bypass surgery has resulted in optimized preoperative identification of the recipients and excellent patency rates. However, the recently presented methods have also been resource-consuming. In the present study, we have reported a cost-efficient planning workflow for extracranial-intracranial (EC-IC) revascularization combined with transdural indocyanine green videoangiography (tICG-VA).

Methods: We performed a retrospective review at a single tertiary referral center from 2011 to 2018. A novel software-derived workflow was applied for 25 of 92 bypass procedures during the study period. The precision and accuracy were assessed using tICG-VA identification of the cortical recipients and a comparison of the virtual and actual data. The data from a control group of 25 traditionally planned procedures were also matched.

Results: The intraoperative transfer time of the calculated coordinates averaged 0.8 minute (range, 0.4-1.9 minutes). The definitive recipients matched the targeted branches in 80%, and a neighboring branch was used in 16%. Our workflow led to a significant craniotomy size reduction in the study group compared with that in the control group (P = 0.005). tICG-VA was successfully applied in 19 cases. An average of 2 potential recipient arteries were identified transdurally, resulting in tailored durotomy and 3 craniotomy adjustments. Follow-up patency results were available for 49 bypass surgeries, comprising 54 grafts. The overall patency rate was 91% at a median follow-up period of 26 months. No significant difference was found in the patency rate between the study and control groups (P = 0.317).

Conclusions: Our clinical results have validated the presented planning and surgical workflow and support the routine implementation of tICG-VA for recipient identification before durotomy.

Keywords: Cerebral revascularization; EC–IC bypass surgery; Flow augmentation; Flow replacement; STA-MCA bypass; Transdural ICG-VA; Virtual planning.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Carotid Artery, Internal, Dissection / surgery
  • Carotid Stenosis / surgery
  • Cerebral Angiography
  • Cerebral Revascularization / methods*
  • Coloring Agents
  • Craniotomy / methods
  • Dura Mater / surgery
  • Female
  • Humans
  • Indocyanine Green
  • Male
  • Middle Aged
  • Middle Cerebral Artery / surgery*
  • Moyamoya Disease / surgery
  • Retrospective Studies
  • Software*
  • Surgery, Computer-Assisted / methods*
  • Temporal Arteries / surgery*
  • Treatment Outcome
  • Workflow*
  • Young Adult


  • Coloring Agents
  • Indocyanine Green