Near-Infrared Imaging with Second-Window Indocyanine Green in Newly Diagnosed High-Grade Gliomas Predicts Gadolinium Enhancement on Postoperative Magnetic Resonance Imaging

  • Steve S. Cho
  • Ryan Salinas
  • Emma De Ravin
  • Clare W. Teng
  • Carrie Li
  • Kalil G. Abdullah
  • Love Buch
  • Jasmin Hussain
  • Fahad Ahmed
  • Jay Dorsey
  • Suyash Mohan
  • Steven Brem
  • Sunil Singhal
  • John Y. K. LeeEmail author
Research Article



Intraoperative molecular imaging with tumor-targeting fluorophores offers real-time detection of neoplastic tissue. The second window indocyanine green (SWIG) technique relies on passive accumulation of indocyanine green (ICG), a near-infrared fluorophore, in neoplastic tissues. In this study, we explore the ability of SWIG to detect neoplastic tissue and to predict postoperative magnetic resonance imaging (MRI) findings intraoperatively.


Retrospective data were collected from 36 patients with primary high-grade gliomas (HGG) enrolled as part of a larger trial between October 2014 and October 2018. Patients received systemic ICG infusions at 2.5–5 mg/kg 24 h preoperatively. Near-infrared fluorescence was recorded throughout the case and from biopsy specimens. The presence/location of residual SWIG signal after resection was compared to the presence/location of residual gadolinium enhancement on postoperative MRI. The extent of resection was not changed based on near-infrared imaging.


All 36 lesions demonstrated strong near-infrared fluorescence (signal-to-background = 6.8 ± 2.2) and 100 % of tumors reaching the cortex were visualized before durotomy. In 78 biopsy specimens, near-infrared imaging demonstrated higher sensitivity and accuracy than white light for diagnosing neoplastic tissue intraoperatively. Furthermore, near-infrared imaging predicted gadolinium enhancement on postoperative MRI with 91 % accuracy, with visualization of residual enhancement as small as 0.3 cm3. Patients with no residual near-infrared signal after resection were significantly more likely to have complete resection on postoperative MRI (p value < 0.0001).


Intraoperative imaging with SWIG demonstrates highly sensitive detection of HGG tissue in real time. Furthermore, post-resection near-infrared imaging correlates with postoperative MRI. Overall, our findings suggest that SWIG can provide surgeons with MRI-like results in real time, potentially increasing resection rates.

Key words

Indocyanine green Near-infrared imaging High-grade gliomas Intraoperative MRI Postoperative MRI 


Funding Information

Supported in part by the National Institutes of Health R01 CA193556 (SS), and the Institute for Translational Medicine and Therapeutics of the Perelman School of Medicine at the University of Pennsylvania (JYKL). Research reported in this publication was also supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000003 (JKYL). In addition, research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number TL1TR001880 (SSC).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.


The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.


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Copyright information

© World Molecular Imaging Society 2019

Authors and Affiliations

  • Steve S. Cho
    • 1
    • 2
  • Ryan Salinas
    • 2
  • Emma De Ravin
    • 1
    • 2
  • Clare W. Teng
    • 1
    • 2
  • Carrie Li
    • 1
    • 2
  • Kalil G. Abdullah
    • 2
  • Love Buch
    • 2
  • Jasmin Hussain
    • 2
  • Fahad Ahmed
    • 2
  • Jay Dorsey
    • 3
  • Suyash Mohan
    • 4
  • Steven Brem
    • 2
  • Sunil Singhal
    • 5
  • John Y. K. Lee
    • 2
    Email author
  1. 1.Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of NeurosurgeryHospital of the University of PennsylvaniaPhiladelphiaUSA
  3. 3.Department of Radiation OncologyHospital of the University of PennsylvaniaPhiladelphiaUSA
  4. 4.Department of RadiologyHospital of the University of PennsylvaniaPhiladelphiaUSA
  5. 5.Department of SurgeryHospital of the University of PennsylvaniaPhiladelphiaUSA

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