Clipping Cerebral Aneurysm
- 19 Downloads
The goal of cerebral aneurysm surgery is the complete occlusion of the aneurysm while preserving the patency of the parent, branching, and perforating arteries. In particular, indocyanine green (ICG) angiography-based near-infrared fluorescence imaging has become more popular in the recent years due to its convenience and accuracy. However, its application has various pitfalls that should be considered.
ICG angiography is an essential intraoperative adjunct in order to observe obstructive cerebral aneurysm by microsurgical clipping and perforating arteries around the cerebral aneurysm.
Dual-image videoangiography , a high-resolution intraoperative imaging system to simultaneously visualize both visible light and near-infrared fluorescence images in ICG angiography, would be a standard microscopic adjunct in microscopic cerebral aneurysm surgeries. In contrast, the combination of all available intraoperative adjuncts complements each other, because of some problems that remain to be solved in ICG angiography.
KeywordsCerebral aneurysm Perforating artery Indocyanine green angiography Dual-image videoangiography Clipping
We present two cases of aneurysms. Case 1 is a case of right vertebral artery (VA)-posterior inferior cerebral artery (PICA) aneurysm. Dual-image videoangiography (DIVA) simultaneously visualizes both light and near-infrared fluorescence images from Indocyanine green ( ICG) videoangiography. After clipping the aneurysm, DIVA clearly shows the anatomical relation of the occluded aneurysm, the clip, and the lower cranial nerves and also confirms the preservation of blood flow in the VA and PICA. Case 2 is a case of an anterior communicating aneurysm. After clipping an anterior communicating aneurysm, DIVA shows one of two hypothalamic arteries is obliterated by the clip. However, standard ICG angiography shows a patent single hypothalamic artery. Therefore, there is a risk to miss the mistakenly occluded hypothalamic artery. (From https://www.fmu.ac.jp/home/ns/diva_movie/diva.html with permission from Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan) (MOV 2902172 kb)
- 3.Kodama N, Sasaki T, Kawakami M, Sato M, Asari J. Cisternal irrigation therapy with urokinase and ascorbic acid for prevention of vasospasm after aneurysmal subarachnoid hemorrhage. Outcome in 217 patients. Surg Neurol. 2000;53:110–7; discussion 117–8.Google Scholar
- 7.Kotowski M, Naggara O, Darsaut TE, Nolet S, Gevry G, Kouznetsov E, et al. Safety and occlusion rates of surgical treatment of unruptured intracranial aneurysms: a systematic review and meta-analysis of the literature from 1990 to 2011. J Neurol Neurosurg Psychiatry. 2013;84:42–8.CrossRefGoogle Scholar
- 12.Kodama N, Endo Y, Oinuma M, Sakuma J, Suzuki K, Matsumoto M, et al. The principles and pitfalls on using doppler ultrasonography during surgery. No Shinkei Geka. 2005;33:109–17 (in Japanese).Google Scholar
- 20.Killory BD, Nakaji P, Gonzales LF, Ponce FA, Wait SD, Spetzler RF. Prospective evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green angiography during cerebral arteriovenous malformation surgery. Neurosurgery. 2009;65:456–62; discussion 462.CrossRefGoogle Scholar
- 21.Kamp MA, Slotty P, Turowski B, Etminan N, Steiger HJ, Hanggi D, et al. Microscope-integrated quantitative analysis of intraoperative indocyanine green fluorescence angiography for blood flow assessment: First experience in 30 patients. Neurosurgery. 2012;70:65–73; discussion 73–4.Google Scholar
- 23.Bruneau M, Appelboom G, Rynkowski M, Van Cutsem N, Mine B, De Witte O. Endoscope-integrated icg technology: first application during intracranial aneurysm surgery. Neurosurg Rev. 2013;36:77–84; discussion 84–5.Google Scholar
- 24.Nishiyama Y, Kinouchi H, Senbokuya N, Kato T, Kanemaru K, Yoshioka H, et al. Endoscopic indocyanine green video angiography in aneurysm surgery: an innovative method for intraoperative assessment of blood flow in vasculature hidden from microscopic view. J Neurosurg. 2012;117:302–8.CrossRefGoogle Scholar
- 25.Sato T, Suzuki K, Sakuma J, Takatsu N, Kojima Y, Sugano T, et al. Development of a new high-resolution intraoperative imaging system (dual-image videoangiography, DIVA) to simultaneously visualize light and near-infrared fluorescence images of indocyanine green angiography. Acta Neurochir. 2015;157:1295–301.Google Scholar
- 26.Sato T, Bakhit MS, Suzuki K, Sakuma J, Fujii M, Murakami Y, Ito Y, Sure U, Saito K. A novel intraoperative laser light imaging system to simultaneously visualize visible light and near-infrared fluorescence for indocyanine green videoangiography. Cerebrovasc Dis Extra. 2018;8:96–100.CrossRefGoogle Scholar
- 28.Sato T, Sakuma J, Suzuki K, Oda K, Kuromi Y, Yamada M, et al. Usefulness of a new high-resolution intraoperative imaging system to simultaneously visualize visible light and near-infrared fluorescence for indocyanine green angiography. Surg Cereb Stroke. 2016;44:362–6. (in Japanese).Google Scholar
- 29.Sato T, Itakura T, Suzuki K, Sakuma J, Fujii M, Bakhit M, et al. Motor evoked potential monitoring and novel laser light imaging system to simultaneously visualize light and near-infrared fluorescence images in aneurysmal surgery. Surg Cereb Stroke, in press. (in Japanese).Google Scholar