How to Achieve Brain Tissue Resection with GLOW400 AR

Clinical case by Prof. Akihide Kondo

GLOW400 AR Fluorescence in anatomy view, image courtesy of Prof. Kondo Leica_Microsystems_GLOW400_AR_Fluorescence_in_brain_tumor_surgery.jpg

Intraoperative MRI is one form of real-time intraoperative visualization, but if more in-depth visualization to identify a tumor during surgery is wanted, intraoperative fluorescence diagnostics is available. In this article, we interviewed Professor Akihide Kondo about his clinical experience of glioma surgery with the GLOW400 Augmented Reality fluorescence application for brain tumor surgery from Leica Microsystems.

Background

The current consensus to achieve safe and favorable treatment outcomes in glioma surgery is “maximal safe resection” which involves removing as much of the tumor as possible without causing neurologic deficit.

Even if the boundaries of the tumor can be identified based on preoperative MRI, for the tumor width or span, the practical problem is the identification of the bottom area, which is left to the surgeon's judgment.

5-ALA, which is used in intraoperative fluorescence diagnostics, has been approved because it contributes to maximal safe resection and overall survival (OS). However, it should be noted that more data needs to be accumulated, and further discussion is required in the future regarding its features, capabilities, and method of use.

Conventional intraoperative fluorescence diagnostics has the disadvantages of low excitation light, unclear boundaries, and surgery must be performed while constantly switching to white light, because of lack of anatomical information in dark conditions due to the use of blue light. It is the cause of eye fatigue in the surgeon. The GLOW400 AR fluorescence was developed in response to the demand of having all information available in one single screen. 

Case study

As the tumor was being resected, strong fluorescence was achieved, and the surrounding vessels could also be identified. For delicate procedures, we switched to normal white light as needed, but the switching could be done within 1.5 to 2 seconds.

Video 1: GLOW400 Anatomy mode, starting from white light mode. Video courtesy of Prof. Kondo.

Video 1: GLOW400 Anatomy view. Video courtesy of Prof. Kondo

Fig. 1: The operation was performed in heads-up surgery, displayed on two screens simultaneously. It is also possible to display on a single screen (fig. 1). Image courtesy of Prof. Kondo.
Fig. 1: The operation was performed in heads-up surgery, displayed on two screens simultaneously. It is also possible to display on a single screen (fig. 1). Image courtesy of Prof. Kondo. GLOW400 Anatomy mode.
Fig. 2: Compared to the actual resected tumor (upper image) placed on top of a gauze, details including the gauze fibers can be seen in the bottom left image using conventional fluorescence and the bottom center image using the GLOW400 Anatomy view. The bottom right image uses the GLOW400 Highlighted Fluorescence view. Image courtesy of Prof. Kondo
Fig. 2: Compared to the actual resected tumor (upper image) placed on top of a gauze, details including the gauze fibers can be seen in the bottom left image using conventional fluorescence and the bottom center image using the GLOW400 Anatomy view. The bottom right image uses the GLOW400 Highlighted Fluorescence view. Image courtesy of Prof. Kondo.

Simultaneously check surrounding structures and boundaries

Considering the properties of 5-ALA, techniques that avoid excessive tumor resection are needed, and the fence-post technique is a useful method to achieve that (Fig. 3).

Fig. 3: Fence-post technique. Image courtesy of Prof. Kondo.
Fig. 3: Fence-post technique. Image courtesy of Prof. Kondo.

Video 2: GLOW400 Anatomy mode, starting from white light mode. Video courtesy of Prof. Kondo.

In this case, as the area around the fence-post was opened up, fluorescence was observed near the fence-post, which were clearly visible.

And we were able to perform a surgery where the boundaries were clearly identifiable. The “Anatomy View” allows for finding boundaries while also checking surrounding structures (Fig. 4).

Fig. 4: GLOW400 AR Fluorescence in anatomy view, image courtesy of Prof. Kondo.
Fig. 4: GLOW400 AR Fluorescence in anatomy view, image courtesy of Prof. Kondo.

About Evolved ARveo 8

At Leica Microsystems, we aim to navigate the evolving landscape of neurosurgery with you using our advanced AR technology. Our ARveo 8 ecosystem, integrates the ARveo 8 digital visualization microscope, GLOW800 and GLOW400 3D clinical applications, and the MyVeo surgical visualization headset. 

Disclaimer

This document is a rewrite of the co-hosted Afternoon Seminar at the 82nd Annual Meeting of the Japanese Society of Neurosurgery. The statements of the healthcare professionals included in this presentation reflect only their opinion and personal experience. Not all products or services are approved or offered in every market and approved labeling and instructions may vary between countries. Please contact your local Leica representative for details.

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