2026 Proffered Presentations
S034: ENDOSCOPIC ENDONASAL ANGIOGRAPHY WITH INDOCYANINE GREEN PREDICTS VISUAL DEFICITS AFTER SUPRASELLAR TUMOR REMOVAL: A PROSPECTIVE MULTICENTER TRIAL
Daniel Quintana, BA1; Robert C Osorio, MD1; Carl Snyderman, MD, MBA2; Paul Gardner, MD2; Eric Wang, MD2; Georgios Zenonos, MD2; Garret W Choby, MD2; Ezequiel Goldschmidt, MD, PhD1; 1Department of Neurological Surgery, University of California San Francisco, California, USA; 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
Objective: Postoperative visual deficits remain a concern after endoscopic endonasal surgery (EES) for sellar and suprasellar lesions. At present, no feasible, reliable method exists to predict optic apparatus perfusion and outcomes. Endonasal indocyanine green (ICG) angiography has emerged as a promising approach to visualize chiasmal perfusion intraoperatively. This study aimed to determine whether intraoperative endoscopic ICG angiography can predict new postoperative visual deficits and to assess feasibility, safety, and incremental value beyond established risk factors.
Methods: This multicenter prospective cohort study at two tertiary neurosurgical centers enrolled 33 patients with suprasellar lesions treated via EES. ICG was administered prior to closure when the optic chiasm was visible. Fluorescence of the superior hypophyseal artery (SHA) branches surrounding the optic chiasm was recorded 10 seconds after ICG was seen within the anterior cerebral arteries (ACAs). Pre- and postoperative visual acuity and visual field testing were used to assess visual function.
Results: A total of 33 patients (age: 49.2 ± 20.3, 51.5% female) were included in this study. Preoperatively, 23 patients (69.7%) presented with bilateral visual acuity and visual field deficits. Among 33 patients, ICG filling of SHA branches was observed in 29 (87.9%), while 4 (12.1%) showed no filling. New or worsened postoperative visual deficits occurred in 3/4 (75%) of patients without ICG filling versus 0/29 (0%) with filling (p < 0.001). No other significant differences were found between groups.
Conclusion: This two-center prospective study supports ICG angiography as a useful method to assess optic chiasm perfusion during endoscopic endonasal surgery. Lack of chiasmal fluorescence persisting beyond 10 seconds strongly suggests compromised chiasmal perfusion and is strongly associated with new or worsening postoperative visual deficits. Patients with diminished chiasmatic perfusion could benefit from maintaining mean arterial pressure above 80mm Hg, close monitoring in intensive care unit, and high dose steroids.
Figure 1. Flowchart of patient cohort. ICG filling corresponds to fluorescence of the superior hypophyseal artery (SHA) branches within ten seconds of anterior cerebral artery (ACA) fluorescence. Postoperative deficits compared to initial visual status before surgery. PitNET = pituitary neuroendocrine tumor.
.png)
Figure 2. Intraoperative ICG angiography of the superior hypophyseal arteries (SHA) during endoscopic endonasal surgery. Top center: Schematic of the anterior circulation showing superior hypophyseal artery (Su. Hy. A.) branches supplying the optic chiasm with normal (left) or abnormal (right) ICG fluorescence. Bottom left, “+”: Representative case with robust ICG fluorescence of SHA branches within 10 seconds of anterior cerebral artery (Ant. Cer. A.) filling, indicating preserved chiasmal perfusion. Bottom right, “–”: Case without ICG filling of SHA branches despite ACA fluorescence, consistent with compromised chiasmal perfusion.
Figure 3. Analysis of association between ICG filling of the superior hypophyseal artery (SHA) branches enveloping the optic chiasm and new postoperative visual deficits for both institutions. Values are shown as number (%), mean ± SD or median [IQR] unless indicated otherwise. Boldface type indicates statistical significance (p < 0.05). EOR = Extent of Resection; GTR = Gross Total Resection; NTR = Near Total Resection; STR = Subtotal Resection; LOS = Length of Stay.