Incorporation of intraoperative confocal laser endomicroscopy into the routine workflow of brain surgery

Intraoperative confocal laser endomicroscopy (CLE) offers neurosurgeons a real-time, high-resolution imaging tool to differentiate tumor tissue from normal brain parenchyma during brain tumor resection. This study aims to evaluate the feasibility of incorporating CLE into the routine workflow of brain tumor surgeries.

A prospective study was conducted to evaluate the integration of CLE in brain tumor surgeries. In all cases, the CLE probe (CONVIVO, Carl Zeiss Meditec AG) was introduced into the surgical field to acquire images at various stages of resection. This was followed by a real-time neuropathology assessment of tissue characteristics using a telepathology software platform (TSP; Zeiss CONVIVO In Vivo Pathology Suite, Carl Zeiss Meditec AG). CLE/TSP was employed in conjunction with the planned surgical technique and tools.

The CLE system was used as a co-diagnostic tool in seven consecutive cases at our institution. Recurrent glioblastoma was the most common histopathological diagnosis. Two cases were performed using minimally invasive approaches: one via an endoscopic transsphenoidal route for a sellar lesion, and another with a tubular retractor for a periventricular WHO grade 4 glioblastoma. Intraoperative ultrasound was employed in all transcranial cases. The surgical microscope was used in four procedures, the exoscope in two, and 5-ALA fluorescence-guided resection was combined with CLE in two cases. No modifications were required to the planned surgical workflow in any of the cases, and integration of CLE technology alongside standard operating procedures and tools was seamless.

CLE can be successfully integrated into the standard neurosurgical workflow for patients with brain tumors without the need for major procedural modifications, including in microscopic, endoscopic, and minimally invasive tubular approaches. With its seamless integration, CLE holds potential to improve surgical precision, enhance intraoperative decision-making, and contribute to better surgical outcomes.