A surgical first: Application of indocyanine green fluorescence imaging for endoscopic third ventriculostomy in an infant

Abstract Introduction: Neonatal hydrocephalus requires early recognition and appropriate surgical management to prevent long term sequalae. Definitive surgical management includes cerebrospinal fluid (CSF) diversion through a CSF shunt insertion, or neuro-endoscopic third ventriculostomy with or without choroid plexus cauterization. Surgical decision-making and the chosen approach are based on patient age, etiology, imaging, and comorbidities. Endoscopic third ventriculostomy (ETV) has been proven to provide a reasonable treatment option for hydrocephalus in children under 12 months of age. To our knowledge we report for the first time the application of indocyanine green fluorescence imaging to visualize the basilar artery during an ETV to prevent from harming the vessel. Patients and methods: A 7mo old patient with a history of preterm delivery at 27 weeks of gestation and intraventricular bleeding grade 2 developed consecutive hydrocephalus due to aqueductal obstruction. Indication was made for ETV. Results: ETV was carried out. During the procedure indocyanine green was applied to visualize the basilar artery prior to opening the floor of the third ventricle. This provided the surgical team with a clear picture of the anatomy thus enabling ETV while safely sparing the basilar artery. Discussion: ETV in infants are demanding procedures. The risk of harming the basilar artery is immanent as the vessel with its known anatomical variants cannot be clearly visualized through the floor of the third ventricle. With the application of indocyanine green fluorescence imaging this can be overcome providing an increased safety during the actual ETV. To our knowledge this is the first report on the use of indocyanine green fluorescence imaging for pediatric ETV. It might offer a new range of safety while providing minimal invasive neuro-endoscopic procedures to infant patients.