The “Squeezing Maneuver” in Microsurgical Clipping of Intracranial Aneurysms Assisted by Indocyanine Green Videoangiography

2014 ◽  
Vol 10 (2) ◽  
pp. 208-213 ◽  
Author(s):  
Alessandro Della Puppa ◽  
Oriela Rustemi ◽  
Marta Rossetto ◽  
Giorgio Gioffrè ◽  
Marina Munari ◽  
...  
Keyword(s):  
Indocyanine Green ◽  
Intracranial Aneurysms ◽  
Aneurysm Surgery ◽  
Radiological Findings ◽  
Indocyanine Green Videoangiography ◽  
Microsurgical Clipping ◽  
Intraoperative Detection ◽  
Small Series ◽  
Vessel Patency ◽  
Derived Data

Abstract BACKGROUND: Indocyanine green videoangiography (ICGV) is becoming routine in intracranial aneurysm surgery to assess intraoperatively both sac obliteration and vessel patency after clipping. However, ICGV-derived data have been reported to be misleading at times. We recently noted that a simple intraoperative maneuver, the “squeezing maneuver,” allows the detection of deceptive ICGV data on aneurysm exclusion and allows potential clip repositioning. The squeezing maneuver is based on a gentle pinch of the dome of a clipped aneurysm when ICGV documents its apparent exclusion. OBJECTIVE: To present the surgical findings and the clinical outcome of this squeezing maneuver. METHODS: Data from 23 consecutive patients affected by intracranial aneurysms who underwent the squeezing maneuver were analyzed retrospectively. The clip was repositioned in all cases when the dyeing of the sac was visualized after the maneuver. RESULTS: In 22% of patients, after an initial ICGV showing the aneurysm exclusion after clipping, the squeezing maneuver caused the prompt dyeing of the sac; in all cases, the clip was consequently repositioned. A calcification/atheroma of the wall/neck was predictive of a positive maneuver (P = .001). The aneurysm exclusion rate at postoperative radiological findings was 100%. CONCLUSION: With the limits of our small series, the squeezing maneuver appears helpful in the intraoperative detection of misleading ICGV data, mostly when dealing with aneurysms with atheromatic and calcified walls.

Application of Intraoperative FLOW 800 Indocyanine Green Videoangiography Color-Coded Maps for Microsurgical Clipping of Intracranial Aneurysms

2019 ◽  
Vol 131 ◽  
pp. e192-e200 ◽  
Author(s):  
Lukas Goertz ◽  
Marion Hof ◽  
Marco Timmer ◽  
Andre Pascal Schulte ◽  
Christoph Kabbasch ◽  
...  
Keyword(s):  
Indocyanine Green ◽  
Intracranial Aneurysms ◽  
Indocyanine Green Videoangiography ◽  
Microsurgical Clipping ◽  
Flow 800

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

2007 ◽  
Vol 61 (suppl_3) ◽  
pp. ONS-63-ONS-73 ◽  
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.

Microsurgical Clipping of Anterior Choroidal Artery Aneurysms: A Systematic Approach to Reducing Ischemic Complications in an Experience with 146 Patients

2019 ◽  
Vol 17 (4) ◽  
pp. 413-423 ◽  
Author(s):  
Ethan A Winkler ◽  
Alex Lu ◽  
Jan-Karl Burkhardt ◽  
W Caleb Rutledge ◽  
John K Yue ◽  
...  
Keyword(s):  
Indocyanine Green ◽  
Systematic Approach ◽  
Anterior Choroidal Artery ◽  
Indocyanine Green Videoangiography ◽  
Microsurgical Clipping ◽  
Ischemic Complications ◽  
Anterior Choroidal ◽  
Intraoperative Rupture ◽  
Temporary Clipping ◽  
Choroidal Artery

Abstract BACKGROUND Aneurysms of the anterior choroidal artery (AChA) have been associated with high treatment-associated morbidity due to ischemic complications. OBJECTIVE To report a large clinical experience of microsurgically treated AChA aneurysms and describe a systematic approach to reduce ischemic complications. METHODS One hundred forty-six patients with AChA aneurysms were retrospectively reviewed from a prospectively maintained database. Clinical characteristics, surgical techniques, clinical outcomes, arterial infarction, and use of intraoperative adjuncts (ie, ultrasonography, indocyanine green videoangiography, and neuromonitoring) were analyzed. RESULTS In total, one hundred forty-three aneurysms (97.9%) were clipped. Temporary clipping was utilized in 47 cases (32.2%) with mean occlusion time of 5.6 min. Arterial infarction occurred in 12 patients (8.2%). In clipped aneurysms, 90.5% were completely obliterated, 8.8% had minimal residual (<5% of original), and 0.7% were incompletely occluded (>5% of original). Mortality (2.7%) was limited to patients with high-grade subarachnoid hemorrhage. Indocyanine green videoangiography and neuromonitoring altered operative technique in ∼20% of cases. Multivariate logistic regression identified intraoperative rupture as the sole predictor for arterial infarction. CONCLUSION Open microsurgical clipping remains a safe, effective treatment for AChA aneurysms. Microsurgical technique is paramount in preserving AChA patency and reducing ischemic complications. Despite increasing reliance on qualitative measures of AChA blood flow (videoangiography and ultrasonography) and neurophysiological monitoring, these technologies aid us infrequently. However, these adjuncts provide important safety checks for AChA patency. Temporary clipping must be used judiciously to lower the risk of intraoperative rupture while limiting possible ischemia in the AChA territory.

Indocyanine Green Videoangiography in Aneurysm Surgery: Systematic Review and Meta-Analysis

Neurosurgery ◽  
2017 ◽  
Vol 83 (2) ◽  
pp. 166-180 ◽  
Author(s):  
Matteo Riva ◽  
Sepideh Amin-Hanjani ◽  
Carlo Giussani ◽  
Olivier De Witte ◽  
Michael Bruneau
Keyword(s):  
Systematic Review ◽  
Indocyanine Green ◽  
Primary Endpoint ◽  
Meta Analysis ◽  
Visual Observation ◽  
Aneurysm Surgery ◽  
Indocyanine Green Videoangiography ◽  
Aneurysm Clipping ◽  
Vessel Stenosis ◽  
Pubmed Search

Abstract BACKGROUND Although digital subtraction angiography (DSA) may be considered the gold standard for intraoperative vascular imaging, many neurosurgical centers rely only on indocyanine green videoangiography (ICG-VA) for the evaluation of clipping accuracy. Many studies have compared the results of ICG-VA with those of intraoperative DSA; however, a systematic review summarizing these results is still lacking. OBJECTIVE To analyze the literature in order to evaluate ICG-VA accuracy in the identification of aneurysm remnants and vessel stenosis after aneurysm clipping. METHODS We performed a systematic literature review of ICG-VA accuracy during aneurysm clipping as compared to microscopic visual observation (primary endpoint 1) and DSA (primary endpoint 2). Quality of studies was assessed with the QUADAS-2 tool. Meta-analysis was performed using a random effects model. RESULTS The initial PubMed search resulted in 2871 records from January 2003 to April 2016; of these, 20 articles were eligible for primary endpoint 1 and 11 for primary endpoint 2. The rate of mis-clippings that eluded microscopic visual observation and were identified at ICG-VA was 6.1% (95% CI: 4.2-8.2), and the rate of mis-clippings that eluded ICG-VA and were identified at DSA was 4.5% (95% CI: 1.8-8.3). CONCLUSION Because a proportion of mis-clippings cannot be identified with ICG-VA, this technique should still be considered complementary rather than a replacement to DSA during aneurysm surgery. Incorporating other intraoperative tools, such as flowmetry or electrophysiological monitoring, can obviate the need for intraoperative DSA for the identification of vessel stenosis. Nevertheless, DSA likely remains the best tool for the detection of aneurysm remnants.

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