Parietooccipital GBM: Fluorescein Fluorescence

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Here's another video discussing the resection of a Parietooccipital Glioblastoma using YELLOW 560 technique. It's a 58 year-old female who presented with progressive visual dysfunction, was known to have a heterogeneously and somewhat ring enhancing mass in the area of the left parietal occipital area. Patient underwent resection of the tumor in the lateral position. A linear incision was utilized as demonstrated here. Dura was opened in a cruciate fashion. This tumor ended up to be quite vascular. The yellow 560 module using fluorescein fluorescence was used to identify the tumor via small corticotomy. When the GBM is so vascular, it's ideal to remain in the periphery of the tumor, and avoid getting into the nidus of the mass as it can lead to ample amount of bleeding. In this case, there was no easy identifiable periphery at the beginning of the operation, until the mass was decompressed. I tried to remove the tumor via relatively a small corticotomy, and some decompression or internal debulking of the tumor was necessary, before the tumor could be sacrificially disconnected from the surrounding peritumoral white matter. Here's the use of the fluorescein fluorescence to identify the proliferative periphery of the tumor. Obviously the center of the tumor that is necrotic will not enhance with the fluorescein. The only way to achieve hemostasis obviously is to remove the tumor. Here you can see a small amount of tumor that was left behind, that was not evident under white light. Neuronavigation confirmed the location and the identity of the mass. Here, the use of the pituitary rongeurs to remove the residual tumor. Again, further inspection of the resection cavity revealed small residual nodules of the tumor that were removed. Here's a final view of the resection cavity. No significant enhancement by fluorescein is apparent. CSF, obviously stains some with the fluorescein. I'm very satisfied in this case, with the extent of resection and the results of fluorescein fluorescence. Post operative angiogram in this case demonstrated gross total removal of the mass, without any complicating feature. Thank you.


Anshu Warade

Sir, what is the dose of sodium fluorescein used?

Apr 14, 2017 07:32 AM


Aaron Cohen-Gadol

Thanks for the good question. I inject 3mg/kg of fluorescein (bolus, IV) at the time of patients’ intubation.  There is usually a 30-45 minutes delay between injection and resection. If this time interval is not respected, the operative field will be contaminated with additional amount of fluorescein, complicating tumor contrast differentiation.

Apr 14, 2017 07:49 AM

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