Case report of indocyanine green endoscopy for intrasellar pituitary adenoma resection

Indocyanine green (ICG) angiography has become an established technology in many surgical fields, as well as in neurosurgery with the first application of microscope-integrated indocyanine angiography, which dates to 2003.1 More recently we observed the integration of ICG into endoscopic visualization (e-ICG), which resulted in different applications during the endoscopic endonasal approach ranging from evaluation of intranasal flap perfusion to differentiation of pituitary neuroendocrine tumors from normal gland or even as a predictive factor of postoperative visual function after expanded approaches.2-8 A 49-year-old woman was admitted to our hospital after a 1-year history of amenorrhea and radiologic finding of an intrasellar lesion. The clinical picture was compatible with a nonfunctioning pituitary neuroendocrine tumor, and the mass was completely removed by means of an endoscopic endonasal approach with intraoperative use of e-ICG (Video 1). A 25 mg intravenous bolus of ICG was injected immediately after completion of the sphenoid phase of the approach. ICG was visualized with a dedicated ICG-integrated endoscope coupled to an IMAGE1 S camera system set on Chroma enhancement mode. Near-infrared excitation of fluorescence (780-820 nm) was obtained using a D-light P Cold Light Fountain. At follow-up, the patient experienced resolution of her symptoms, without residues or relapses on control magnetic resonance. This case sheds light on some possible applications and advantages of e-ICG, including visualization of internal carotid arteries before the sellar opening, individuation of the pituitary gland, its distinction from the adenomatous tissue, and the possible evaluation of its degree of compression.