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Intraoperative Fluorescence for GBM Resection

July 08, 2015


Fluorescein fluorescence appears to be specially relevant for resection of recurrent GBM. This is a 58 year old male who presented with a recurrent right temporal glioblastoma multiforme. You can see the appearance of the tumor and its location and size. Due to his good neurological condition, he underwent resection. Linear incision was used, previous area of craniotomy. Craniotomy was further extended beyond the borders of previous surgery. Scoring in the area of previous surgery and extent of recurrent tumor reaching the surface of the pia. No navigation was used. You can see the demarcation between the contrast enhancing tumor and the pre tumoral area that is not enhancing, in this case Three milligram per kilogram of fluorescein was injected at the time of intubation. I continued to use fluorescein guidance and fluorescence guidance to remove the tumor. You can see the pre tumoral area or the infiltrative part of the tumor can actually look like normal white matter, but actually it's tumorous. That's why fluorescein fluorescence can be specially effective in guiding gross total removal of the contrast enhancing part of the tumor. I continue to circumferentially dissect the tumor. Here's under white light. The demarcation is not as clear. Here is the demarcation between the tumorous and a normal white matter portions of the brain. Here's the more posterior part of the tumor. You can see the tumor is quite clearly enhancing. Tumor's being debulked. Here's the normal appearing part of the brain relatively again, good demarcation between the tumor and the normal white matter. This border clearly corresponds to the border found using MR navigation intra operatively. One more time demonstrating the borders between the tumor and the white matter using fluorescein fluorescence again under white light, the infiltrative or very borders of the enhancing part of the tumor can appear normal to white matter. But under fluorescein fluorescence there is definitely a demarcating border. Navigation confirmed gross total resection of the tumor. Further inspection revealed this very small enhancing nodules that can be effectively removed. This small nodules may be overlooked if fluorescence is not used, as the small nodules can hide within the folds of the resection cavity. Here's the funnel view of the resection cavity. It's only minor amount of fluorescence. And postoperative MRI demonstrated gross total removal of the mass. Thank you.

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