Standardized and Quantitative ICG Perfusion Assessment: Feasibility and Reproducibility in a Multicentre Setting

Indocyanine green near-infrared fluorescence (ICG-NIRF) imaging is widely used to assess tissue perfusion, yet its subjective interpretation limits correlation with postoperative parathyroid function. To address this, the Workflow model for ICG-angiography integrating Standardization and Quantification (WISQ) was developed. This exploratory prospective multicenter study evaluated the reproducibility of WISQ in adults undergoing total thyroidectomy at two Dutch university centres. Patients with contraindications to ICG or prior neck surgery were excluded. Intraoperative imaging used standardized camera settings with blood volume-adjusted ICG dosing, and perfusion curves were analyzed using predefined regions of interest. Eighty patients were included. Significant inter-centre variability was observed in maximum fluorescence intensity, inflow slope, and outflow slope (n = 30). At the lead centre, outflow was the most promising predictor of postoperative hypoparathyroidism (HPT) (median -0.33 [IQR -0.49--0.15] a.f.u./s for HPT vs. -0.68 [-0.91--0.41], n = 17, p = 0.08), although no parameter significantly predicted HPT. Repeated ICG injections consistently produced lower maximal intensities irrespective of injection rate, and reproducible curves were achieved only when ICG was freshly dissolved at 0.5 mg/mL instead of 2.5 mg/mL. These findings indicate that ICG concentration and injection technique influence perfusion kinetics and underscore the need to update WISQ with standardized injection dilution to improve its clinical utility.