Assessment of blood flow in perforating arteries during intracranial aneurysm surgery with intraoperative videoangiography using indocyanine green

OBJECTIVEThe quality of surgical treatment of intracranial aneurysms is determined by complete aneurysm occlusion while preserving blood flow in the parent, branching, and perforating arteries. For a few years, there has been a nearly noninvasive and cost-effective technique for intraoperative flow evaluation: microscope-integrated indocyanine green videoangiography (mICG-VA). This method allows for real-time information about blood flow in the aneurysm and the involved vessels, but its limitations are seen in the evaluation of structures located in the depth of the surgical field, especially through small craniotomies. To compensate for these drawbacks, an endoscope-integrated ICG-VA (eICG-VA) was developed. The objective of the present study was to assess the use of eICG-VA in comparison with mICG-VA for intraoperative blood flow evaluation.METHODSIn the period between January 2011 and January 2015, 216 patients with a total of 248 intracranial saccular aneurysms were surgically treated in the Department of Neurosurgery of Saarland University Medical Center in Homburg/Saar, Germany. During 95 surgeries in 88 patients with a total of 108 aneurysms, intraoperative evaluation was performed with both eICG-VA and mICG-VA. After clipping, evaluation of complete aneurysm occlusion and flow in the parent, branching, and perforating arteries was performed using both methods. Intraoperative applicability of each technique was compared with the other and with postoperative digital subtraction angiography as a standard evaluation technique.RESULTSEvaluation of completeness of aneurysm occlusion and of flow in the parent, branching, and perforating arteries was more successful with eICG-VA than with mICG-VA, especially for aneurysm neck assessment (88.9% vs 69.4%). For 63.9% of the aneurysms (n = 69), both methods were equivalent, but in 30.6% of the cases (n = 33), the eICG-VA provided better results for evaluating the post-clipping situation. In 4.6% of these aneurysms (n = 5), the information given by the additional endoscope considerably changed the surgical procedure. Thus, one residual aneurysm (0.9%), two neck remnants (1.9%), and two branch occlusions (1.9%) could be prevented. Nevertheless, two incomplete aneurysm occlusions (1.9%) and six neck remnants (5.6%) were revealed by postoperative digital subtraction angiography.CONCLUSIONSEndoscope-integrated ICG-VA seems to be an improvement that might increase the quality of aneurysm surgery by providing additional information. It offers higher illumination, magnification, and an extended viewing angle. Its main advantage is its ability to assess deep-seated aneurysms, especially through small craniotomies, but further studies are required.

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ASSESSMENT OF FLOW IN PERFORATING ARTERIES DURING INTRACRANIAL ANEURYSM SURGERY USING INTRAOPERATIVE NEAR‐INFRARED INDOCYANINE GREEN VIDEOANGIOGRAPHY

Neurosurgery ◽

10.1227/01.neu.0000333795.21468.d4 ◽

2008 ◽

Vol 62 (suppl_3) ◽

pp. ONS-63-ONS-73 ◽

Cited By ~ 31

Author(s):

Jean G. de Oliveira ◽

Jürgen Beck ◽

Volker Seifert ◽

Manoel J. Teixeira ◽

Andreas Raabe

Keyword(s):

Intracranial Aneurysm ◽

Indocyanine Green ◽

Near Infrared ◽

Aneurysm Surgery ◽

Indocyanine Green Videoangiography ◽

Perforating Arteries

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Endoscopic indocyanine green video angiography in aneurysm surgery: an innovative method for intraoperative assessment of blood flow in vasculature hidden from microscopic view

Journal of Neurosurgery ◽

10.3171/2012.5.jns112300 ◽

2012 ◽

Vol 117 (2) ◽

pp. 302-308 ◽

Cited By ~ 42

Author(s):

Yoshihisa Nishiyama ◽

Hiroyuki Kinouchi ◽

Nobuo Senbokuya ◽

Tatsuya Kato ◽

Kazuya Kanemaru ◽

...

Keyword(s):

Blood Flow ◽

Indocyanine Green ◽

Cerebral Aneurysms ◽

Aneurysm Surgery ◽

Excitation Light ◽

Video Images ◽

Procedural Complication ◽

A New Technique ◽

Unruptured Cerebral Aneurysms ◽

Perforating Arteries

Recently, intraoperative fluorescence video angiography using indocyanine green (ICG) has been widely used in aneurysm surgery. This is a simple and useful method to confirm complete occlusion of the aneurysm lumen and preservation of blood flow in the arteries around the aneurysm. However, the observation field of ICG video angiography is limited under a microscope, making it difficult to confirm the flow in the arteries behind the parent arteries or aneurysm. The authors developed a new technique of intraoperative endoscopic ICG video angiography to assess the blood flow in perforating arteries hidden by the parent arteries or aneurysm. The endoscope emits excitation light with a wavelength of approximately 800 nm, and video images were obtained through a cut filter. The authors used this ICG fluorescence endoscope in treating 3 patients with unruptured cerebral aneurysms. During clip placement, the endoscope was inserted to confirm aneurysm occlusion. Then, ICG was intravenously administered, and the fluorescence in the vessels was observed via the endoscope as well as under the microscope. The blood flow in the perforating arteries was clearly identified, and no procedural complication occurred. The authors conclude that the technique is very useful and facilitates intraoperative real-time assessment of the patency of perforating arteries behind parent arteries or aneurysms.

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Use of indocyanine green videoangiography during intracranial aneurysm surgery reduces the incidence of postoperative ischaemic complications

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2013.04.002 ◽

2014 ◽

Vol 21 (1) ◽

pp. 67-72 ◽

Cited By ~ 6

Author(s):

Leon Tat Lai ◽

Michael Kerin Morgan

Keyword(s):

Intracranial Aneurysm ◽

Indocyanine Green ◽

Aneurysm Surgery ◽

Indocyanine Green Videoangiography

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Intraoperative indocyanine green angiography in intracranial aneurysm surgery: Microsurgical clipping and revascularization

Clinical Neurology and Neurosurgery ◽

10.1016/j.clineuro.2009.08.017 ◽

2009 ◽

Vol 111 (10) ◽

pp. 840-846 ◽

Cited By ~ 31

Author(s):

Chi-Yuan Ma ◽

Ji-Xin Shi ◽

Han-Dong Wang ◽

Chun-Hua Hang ◽

Hui-Lin Cheng ◽

...

Keyword(s):

Intracranial Aneurysm ◽

Indocyanine Green ◽

Indocyanine Green Angiography ◽

Aneurysm Surgery ◽

Microsurgical Clipping

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Blood flow disturbance in perforating arteries attributable to aneurysm surgery

Journal of Neurosurgery ◽

10.3171/jns-07/07/0060 ◽

2007 ◽

Vol 107 (1) ◽

pp. 60-67 ◽

Cited By ~ 66

Author(s):

Tatsuya Sasaki ◽

Namio Kodama ◽

Masato Matsumoto ◽

Kyouichi Suzuki ◽

Yutaka Konno ◽

...

Keyword(s):

Blood Flow ◽

Cerebral Infarction ◽

Clinical Symptoms ◽

Motor Evoked Potential ◽

Parent Artery ◽

Aneurysm Surgery ◽

Flow Disturbance ◽

Perforating Artery ◽

Evoked Potential Monitoring ◽

Perforating Arteries

Object The object of this study was to investigate patients with cerebral infarction in the area of the perforating arteries after aneurysm surgery. Methods The authors studied the incidence of cerebral infarction in 1043 patients using computed tomography or magnetic resonance imaging and the affected perforating arteries, clinical symptoms, prognosis, and operative maneuvers resulting in blood flow disturbance. Results Among 46 patients (4.4%) with infarction, the affected perforating arteries were the anterior choroidal artery (AChA) in nine patients, lenticulostriate artery (LSA) in nine patients, hypothalamic artery in two patients, posterior thalamoperforating artery in five patients, perforating artery of the vertebral artery (VA) in three patients, anterior thalamoperforating artery in nine patients, and recurrent artery of Heubner in nine patients. Sequelae persisted in 21 (45.7%) of the 46 patients; 13 (28.3%) had transient symptoms and 12 (26.1%) were asymptomatic. Sequelae developed in all patients with infarctions in perforating arteries in the area of the AChA, hypothalamic artery, or perforating artery of the VA; in four of five patients with posterior thalamoperforating artery involvement; and in two of nine with LSA involvement. The symptoms of anterior thalamoperforating artery infarction or recurrent artery of Heubner infarction were mild and/or transient. The operative maneuvers leading to blood flow disturbance in perforating arteries were aneurysmal neck clipping in 21 patients, temporary occlusion of the parent artery in nine patients, direct injury in seven patients, retraction in five patients, and trapping of the parent artery in four patients. Conclusions The patency of the perforating artery cannot be determined by intraoperative microscopic inspection. Intraoperative motor evoked potential monitoring contributed to the detection of blood flow disturbance in the territory of the AChA and LSA.

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Assessment of Flow in Perforating Arteries During Intracranial Aneurysm Surgery Using Intraoperative Near-Infrared Indocyanine Green Videoangiography

Operative Neurosurgery ◽

10.1227/01.neu.0000289715.18297.08 ◽

2007 ◽

Vol 61 (suppl_3) ◽

pp. ONS-63-ONS-73 ◽

Cited By ~ 23

Author(s):

Jean G. de Oliveira ◽

Jürgen Beck ◽

Volker Seifert ◽

Manoel J. Teixeira ◽

Andreas Raabe

Keyword(s):

Indocyanine Green ◽

Visual Information ◽

Intracranial Aneurysms ◽

Near Infrared ◽

Aneurysm Surgery ◽

Indocyanine Green Videoangiography ◽

Small Arteries ◽

Perforating Artery ◽

Clip Application ◽

Perforating Arteries

Abstract Objective: Perforating arteries are commonly involved during the surgical dissection and clipping of intracranial aneurysms. Occlusion of perforating arteries is responsible for ischemic infarction and poor outcome. The goal of this study is to describe the usefulness of near-infrared indocyanine green videoangiography (ICGA) for the intraoperative assessment of blood flow in perforating arteries that are visible in the surgical field during clipping of intracranial aneurysms. In addition, we analyzed the incidence of perforating vessels involved during the aneurysm surgery and the incidence of ischemic infarct caused by compromised small arteries. Methods: Sixty patients with 64 aneurysms were surgically treated and prospectively included in this study. Intraoperative ICGA was performed using a surgical microscope (Carl Zeiss Co., Oberkochen, Germany) with integrated ICGA technology. The presence and involvement of perforating arteries were analyzed in the microsurgical field during surgical dissection and clip application. Assessment of vascular patency after clipping was also investigated. Only those small arteries that were not visible on preoperative digital subtraction angiography were considered for analysis. Results: The ICGA was able to visualize flow in all patients in whom perforating vessels were found in the microscope field. Among 36 patients whose perforating vessels were visible on ICGA, 11 (30%) presented a close relation between the aneurysm and perforating arteries. In one (9%) of these 11 patients, ICGA showed occlusion of a P1 perforating artery after clip application, which led to immediate correction of the clip confirmed by immediate reestablishment of flow visible with ICGA without clinical consequences. Four patients (6.7%) presented with postoperative perforating artery infarct, three of whom had perforating arteries that were not visible or distant from the aneurysm. Conclusion: The involvement of perforating arteries during clip application for aneurysm occlusion is a usual finding. Intraoperative ICGA may provide visual information with regard to the patency of these small vessels.

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Endoscope-integrated indocyanine green video-angiography for cerebral aneurysm surgery: a more effective technique

Innovative Neurosurgery ◽

10.1515/ins-2015-0004 ◽

2015 ◽

Vol 3 (3-4) ◽

Author(s):

Ittichai Sakarunchai ◽

Yoko Kato ◽

Yasuhiro Yamada ◽

Thomas Tommy

Keyword(s):

Indocyanine Green ◽

Cerebral Aneurysm ◽

Conventional Technique ◽

Parent Artery ◽

Aneurysm Surgery ◽

Small Vessels ◽

Aneurysm Clipping ◽

Unruptured Cerebral Aneurysm ◽

Deep Area ◽

Perforating Arteries

AbstractMicroscope-integrated indocyanine green video-angiography (mICG-VA) is used as an adjunct to aneurysm surgery in checking for small compromised perforating arteries and the remnant of an aneurysmal neck. A limitation of mICG-VA is the inability to access the deep area where small vessels are located behind the aneurysm sac or the parent artery. The endoscope-integrated ICG-VA (eICG-VA) is not only a tool in obtaining a wide angle of surgical view, but also is a technique to detect real-time blood flow during aneurysm clipping.Patients with an unruptured cerebral aneurysm who had conventional endoscope-assisted microsurgery and eICG-VA were enrolled. We compared the efficacy and additional details of imaging from both types of procedures.The data of seven patients were reviewed. In two cases of small perforating arteries that were hidden by the aneurysm sacs, more details were detected by eICG-VA. While the performance of the conventional technique was limited, the eICG-VA revealed a wide view in the deep area during aneurysm clipping.The eICG-VA provides more details of the aneurysm, especially in small perforating vessels that were hidden by the aneurysm. It can resolve the limitations of the conventional endoscope and mICG-VA.

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