ICG Flow 800 technology targeted STA-MCA microvascular bypass for exclusion of deep-seated fusiform MCA aneurysm: 2-dimensional operative video

The authors present the case of an 18-year-old male with a deep-seated left fusiform dissecting M3 aneurysm for which endovascular treatment was not applicable. At the open surgery, they used the less commonly reported FLOW 800 fluorescent indocyanine green (ICG) videoangiography, before and after parental aneurysmal artery temporary clipping, to locate the distal outflow branch of the aneurysm and use it as the recipient artery for a superficial temporal artery–M4 bypass, excluding the aneurysm by clipping the parental artery. Repeated ICG FLOW 800 angiography confirmed bypass patency and adequate blood flow. The aneurysm’s exclusion from circulation was confirmed by digital subtraction angiography postoperatively. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21183

Use of Gelatin-thrombin Hemostatic Matrix for Control of Ruptured Cerebral Aneurysm

Background The use of thrombin-based hemostatic agents (TBHAs) has become common practice in most neurosurgical procedures, both cranial and spinal. Methods We present the case of a 40-year-old woman who was referred to our institution with intense headache and Fisher grade 3 subarachnoid hemorrhage (SAH) mainly at the level of the right sylvian fissure, caused by a 5.71-mm right middle cerebral artery (MCA) bifurcation aneurysm, with hourglass morphology and a bleb on the bottom. Cerebral angiography demonstrated aneurysm enlargement, compared with the prior angiographic computerized tomography scan. Results A right pterional craniotomy was performed. After initial arachnoid dissection to get proximal vascular control, but before we obtained it, we witnessed profuse bleeding from the aneurysm. Floseal, a gelatin-thrombin matrix sealant, was sprayed over the breach of the aneurysm, and cottonoids were gently pressed with a self-retaining spatula, stopping the hemorrhage. After that, we obtained proximal control with an extradural clinoidectomy and temporary clipping of the right internal carotid artery (ICA) and MCA. Finally, aneurysm dissection and final clipping were performed with the application of two clips. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. Conclusion Intraoperative aneurysm rupture (IAR) is a dangerous event that carries great risks—even death. Proper use of TBHAs is a useful and safe way to stop the bleeding, take a deep breath, and achieve proximal vascular control. To the best of our knowledge, this is the first report of the use of TBHA during aneurysm clipping.

Subtemporal, Transapical, and Transcavernous Approach to Clip Low-Lying Basilar Tip Aneurysm: 2-Dimensional Operative Video

Basilar tip aneurysm clipping is technically challenging because of the depth of operative corridor, rarity in presentation, and important perforators supplying deep, critical structures. Two major approaches to basilar tip aneurysms include (1) a frontotemporal (transorbital) trans-sylvian approach for most aneurysms and (2) a modified subtemporal approach for aneurysms with low-lying necks. A 53-yr-old woman presented to our institution with a large unruptured basilar tip aneurysm notable for a low, broad neck (6.4 mm). After discussion of risks and benefits of endovascular vs surgical options, the patient consented to operative intervention. She underwent a right frontotemporal craniotomy with zygomatic osteotomy, intradural petrous apicectomy, elective sectioning of the fourth cranial nerve (CN IV), and intracavernous removal of the dorsum sellae and posterior clinoid process to provide more space for aneurysm dissection. After temporary clipping of the basilar artery, the perforating arteries were dissected free from the aneurysm and the aneurysm occluded with 2 fenestrated clips. Important technical nuances of the approach include (1) achieving ample working room for temporary occlusion aneurysm dissection, (2) careful dissection of the perforators and contralateral P1, and (3) utilization of 2 fenestrated clips to accommodate and preserve the ipsilateral P1 segment. Postoperative angiogram showed complete aneur-ysmal occlusion. Postoperatively, the patient demonstrated mild cognitive impairment and a right CN IV palsy. At 6-wk follow-up, cognition recovered to normalcy. More recently, at 12-mo follow-up, the patient noted intermittent diplopia. Formal neuro-ophthalmologic assessment confirmed persistence of a CN IV palsy treated with prism lenses but no other neurological deficits.

Prevention of complication in cerebral aneurysm microsurgery, associated with their non-radical clipping

Objective ‒ to analyze the effectiveness of intraoperative contact Doppler, repositioning the clip on the aneurysm and pilot clipping of the cervical aneurysm as the main methods of prevention of inadequate clipping of the cervical aneurysm in patients with intraoperative rupture of aneurysms. Materials and methods. Due to the use of intraoperative contact ultrasound Doppler control it was possible to avoid inadequate clipping of cerebral aneurysms in 16 cases, of which in 12 (75.00 %) cases ‒ incomplete clipping of cerebral aneurysms, in 3 (18.75 %) cases ‒ compression of the aneurysm’s artery-carrier, in 1 (6.25 %) case ‒ slipping of the clip with cerebral aneurysm. Perioperative examination of patients, in addition to intraoperative contact ultrasound Doppler control of radical clipping cerebral aneurysms, included clinical and neurological examination, computed tomography of the brain, cerebral angiography, ultrasound duplex scanning of the main vessels of the head and neck. In the analysis of observations of inadequate clipping of cerebral aneurysms (according to contact intraoperative Doppler), the following parameters were considered: size, location of cerebral aneurysm, timing of surgery after subarachnoid hemorrhage, anatomical forms of intracranial hemorrhage. Results. The purpose of the operations was to devascularize saccular aneurysm to prevent its re-rupture, to reduce the mass effect caused by intracerebral hematoma; reduction of intracranial pressure, rehabilitation of basal cisterns of the brain., But in the postoperative period there was a tendency to worsen the results of treatment, the appearance of focal neurological symptoms on the background of cerebral vasospasm with subsequent development of ischemic complications in patients with III‒V degree according to the Hunt‒Hess Scale on admission, in patients with prolonged temporary clipping of the cerebral aneurysm-artery and prolonged mechanical manipulation of the cerebral arteries and cerebral aneurysm. It should be noted that all patients in our sample, with complicated clipping of cerebral saccular aneurysms, had an intraoperative rupture of the MA, which complicated the process of clipping the saccular aneurysm and prolonged the time of surgery and was one of the inducers of postoperative aggravating consequences. There was a tendency to worsen the results of treatment in patients with III–IV degree according to the Hunt‒Hess Scale. Thus, patients with 1 point according to the Glasgow Outcome Scale, there were 2 patients who had II and III degrees according to Hunt–Hess Scale at hospitalization; among discharged patients with 3 point according to Glasgow Outcome Scale was dominated by patients from the second century according to Hunt‒Hess Scale at hospitalization, among patients with 5 point according to Glasgow Outcome Scale dominated patients who had I degree according to the Hunt‒Hess Scale at hospitalization. Conclusions. Inadequate clipping of the cervix cerebral aneurysm is the main type of non-hemorrhagic complications in the surgery of cerebral aneurysms. The Inadequate clipping of the cervix of the cerebral aneurysm includes the presence of residual blood flow in the cerebral aneurysm after its clipping, stenosis/compression of the main and perforating cerebral arteries with a clip, slipping of the clip from the aneurysm. Among the factors influencing the radical and adequate clipping of the cervix cerebral aneurysm are the size, location of the aneurysm, atherosclerotic lesions of the walls of the arteries and neck of the aneurysm and transferred subarachnoid hemorrhage. Reliable methods of prevention of inadequate clipping of saccular aneurysm are the use of intraoperative Doppler blood flow control, pilot clipping of complex aneurysms, optimization and individualization of surgical access. Aggravating factors that lead to unsatisfactory results of treatment of patients and negative clinical dynamics after the operation of clipping cerebral saccular aneurysm are: severe condition of the patient before surgery (III‒V gr. according to the Hunt‒Hess Scale), severe cerebral edema, intraoperative rupture of saccular aneurysm, long-term mechanical manipulations on cerebral arteries (long-term temporary clipping of saccular aneurysm, isolation of saccular aneurysm and «neighboring» cerebral arteries from arachnoid adhesions, frequent repositioning of the clip).

Temporary Clipping of the Intracavernous Internal Carotid Artery: A Novel Technique for Proximal Control

BACKGROUND Securing proximal control in complex paraclinoid aneurysm surgery through traditional techniques may be challenging and risky in certain situations. Advancements of anatomical knowledge of the cavernous sinus (CS) and hemostasis have made it more accessible as a surgical option. OBJECTIVE To describe the technique of temporary clipping of the horizontal segment of the intracavernous internal carotid artery (IC-ICA) in preparation for permanent clipping of complex paraclinoid aneurysms. METHODS Through an extradural pretemporal approach, the lateral wall of the CS is exposed. The dura between the trochlear nerve and V1 is opened, and access is made to the horizontal segment of the IC-ICA. After circumferential dissection, the temporary clip can be introduced to the artery, and the extradural clinoidectomy can be continued under secured proximal control. RESULTS Seven patients with complex paraclinoid aneurysms were treated between May 2013 and May 2016 by the senior author. Temporary clipping of the IC-ICA was performed in all cases. Average time to achieve proximal control was 22.6 min (22.6 ± 13.8). One patient developed transient oculomotor palsy postoperatively. There were no other complications. CONCLUSION When the exposed clinoidal segment of the internal carotid artery does not offer sufficient proximal space for temporary clipping, the extradural approach can be extended to the horizontal portion of the IC-ICA. In our experience, this technique is a quick, reliable, and safe alternative to the classical modalities of temporary occlusion.

Unilateral absence of the internal carotid artery associated with anterior communicating artery aneurysms: Systematic review and a proposed management algorithm

Background: Absence or hypoplasia of the internal carotid artery (ICA) is a rare congenital anomaly that is mostly unilateral and highly associated with other intracranial vascular anomalies, of which saccular aneurysm is the most common. Blood flow to the circulation of the affected side is maintained by collateral pathways, some of which include the anterior communicating artery (Acom) as part of their anatomy. Therefore, temporary clipping during microsurgery on Acom aneurysms in patients with unilateral ICA anomalies could jeopardize these collaterals and place the patient at risk of ischemic damage. In this paper, we review the literature on cases with a unilaterally absent ICA associated with Acom aneurysms and provide an illustrative case. Methods: We combined our experience of one case of a unilaterally absent ICA associated with an Acom aneurysm with the 33 existing publications on the same subject in the literature, for a total of 40 cases. We provide a detailed systematic literature review of this association of vascular anomalies, exploring different aspects regarding the collateral pathways and how they impact management strategies and propose a management algorithm to deal with such association. Results: The mean age was 48.2 ± 16.5 years. The aneurysmal rupture was the most common presentation (75%). Agenesis was observed in 70% of patients, followed by hypoplasia (20%) and, finally, aplasia (10%). Lie Type A was the most common pattern of collaterals (50%), with Types B and D being of almost equal proportions. Most aneurysms were located at the A1-Acom junction contralateral to the anomalous side (Fisher’s Exact test; P = 0.03). One case of temporary clipping was reported in the literature. Conclusion: Acom aneurysms in patients with unilateral ICA anomalies, given they are more commonly present contralaterally, could be of acquired etiology, warranting periodic screening in asymptomatic patients. Temporary clipping might be safe in patients with Type D collateral pattern, while those with Types A or B may require intraoperative rupture risk assessment and a tailored management plan to avoid disrupting collateral flow and causing ischemia.