Intraoperative Use of Endoscope, a Valuable, Adjunctive Tool for the Surgical Management of Anterior Communicating Artery Aneurysm Surgery: Our Institutional Experience.

BACKGROUND: Anterior communicating (A-com) artery region is very complex; perforators are not always visualized on the microscope. The neuroendoscope with its higher magnification, better observation, and additional illumination can provide us information that may not be available with the microscope in aneurysm surgery. OBJECTIVE: The objective was to study the use of endoscope in surgical management of A-com aneurysm surgery and its advantages, whether and how it changes operative management. MATERIALS AND METHODS: We studied 25 serial cases of A-com aneurysm at Bantane Hospital, Fujita University, Japan, from November 2018 to October 2019. Once aneurysm was exposed, we did preclipping indocyanine green (ICG) study and examination with endoscope. After clipping, we again did ICG and endoscopic assessment. Preclipping and postclipping endoscopic information was used and necessary changes were made in the operative decisions. Whether endoscope gives any additional information over microscope and ICG which led to change in the operative decision was assessed. RESULTS: In six out of 25 A-com aneurysm patients, the use of endoscope has given additional information over microscope, and ICG leading to change in the operative plans such as readjustment of the clip/application of the second clip or release of perforator compromise. CONCLUSION: Simultaneous endoscopic and microscopic guidance can reveal important information hidden from the microscope. Thus, this method increases the safety and durability of the A-com aneurismal clipping.

Intraoperative Use of Microscope-Integrated Flow 800 - A Valuable Tool in Surgical Management of Anterior Communicating Artery Aneurysm: Our Institutional Experience.

BACKGROUND: Flow 800 is microscope-integrated analytical visualization tool which analyses the indocyanine green (ICG) video sequence and converts it into an intensity diagram. This allows an objective evaluation of the result rather than subjective assessment of ICG fluorescence. The anatomy of anterior communicating artery region is complex because of multiple vessels and perforators in small space; hence, there is a need of objective assessment tool which can give precise idea about vascular compromise. Flow 800 can serve as a valuable tool in this complex surgery. OBJECTIVE: The objective of this study was to evaluate the utility of microscope-integrated fluorescent ICG videoangiography (Flow 800) in A-com aneurysm surgery. MATERIALS AND METHODS: We used Flow 800 in ten consecutive patients of A-com aneurysm surgery from July 2019 to October 2019. We studied patient characteristics, intraoperative observation of ICG and Flow 800, and corresponding changes made in the operative decisions. RESULTS: The use of Flow 800 helped in intraoperative decision of four out of ten patients of A-com aneurysm. In two patients, incomplete clipping was confirmed with Flow 800 and the second clip was applied. In the third patient, perforator compromise was found hence needed clip readjustment, whereas in the fourth patient, ICG was inconclusive and Flow 800 confirmed complete clipping of aneurysm. CONCLUSION: Flow 800 is a conclusive reproducible and objective tool for early detection of vascular compromise of multiple vessels and perforators in A-com aneurysm surgery. It gives a better idea of vasculature, especially where ICG is ambiguous or inconclusive.

Outcome Analysis of Surgical Clipping for Incidental Internal Carotid Posterior Communicating and Anterior Choroidal Artery Aneurysms.

INTRODUCTION: Surgical outcome and ischemic complications of Internal carotid Posterior Communicating (IC PC) and anterior choroidal aneurysms have been questionable due to frequent occlusion of the anterior choroid artery and also due to low incidence of true anterior choroid artery aneurysms. The present series describes the postoperative outcome after clipping of such aneurysms at a single centre. METHODS: A retrospective analysis of 73 cases with IC PC and Anterior choroidal aneurysms performed at a Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Aichi, Japan from 2014 to 2018 have been studied and emphasis is made on the demography and ischemic complications. RESULTS: A total of 73 patients with IC PC and anterior choroidal aneurysms were studied, out of which 57 patient had a true IC PC aneurysm, 14 patients had aneurysms involving the anterior choroidal artery and only 2 patients had aneurysms which involved both the IC PC and the anterior choroidal arteries. None of the patients had a permanent Anterior Choroidal Artery syndrome, whereas only 2 out of the 73 patients had postoperative complications in the form of transient hemiparesis. CONCLUSION: Ischemic complications following surgical clipping of IC PC and anterior choroidal aneurysms can be minimised by meticulous micro dissection to identify the anterior choroidal artery thus preserving the patency of the same.

Microcirugía asistida por endoscopia en el clipado de aneurismas gigantes y del segmento carotídeo comunicante posterior / Endoscopic assited microsurgery for clipping of giant aneurysms and carotid portion of posterior communicating aneurysms

Objetivo. Describir la utilidad de la endoscopia en el clipado microquirúrgico de aneurismas cerebrales. Descripción: Paciente de 62 años de edad con diagnóstico de aneurisma gigante de la arteria carótida interna (ICA) asociado amúltiples aneurismas, uno de ellos en el segmento carotídeo comunicante posterior (Pcom). Intervención. Se resolvió el aneurisma gigante carotídeo y el comunicante posterior con técnica microquirúrgica mediante el clipado,y éste último se clipó con la asistencia del endoscopio. Conclusión. En casos con aneurismas de ICA gigantes y aneurismas ICA-PcomA la microcirugía asistida por endoscopia provee acceso a las áreas ocultas al microscopio, permitiendo una apropiada oclusión del cuello aneurismático con preservación de perforantes

Objective. To describe the importance of the aid of the neuroendoscopein the microsurgery of cerebral aneurysms. Description. 62 years old female patient with an internal carotidartery giant aneurysm (ICA) and multiple aneurysms, one of them in the posterior communicant carotid segment (pcom). Intervention. Both of them were treated with microsurgery, and the pcom aneurysm was clipped with the assistance of endoscopy. Conclusion. In cases with giant and pcom aneurysms the endoscope assisted microsurgery is useful, providing good access to hidden fields to microscope, allowing a properlyocclusion and preservation of perforators branches.

Clipado de aneurismas grandes y gigantes asistidos por técnicas de compresión por succión retrógrada / Assisted clipping of giant and big aneurysms by the technique of decompression by retrograde suction

Objetivo. Presentar la experiencia del Hospital Fujita Health University en el clipado de aneurismas cerebrales de tamaño grande y gigante asistida por descompresión por succión retrógrada, analizando sus ventajas y desventajas.Material y método. Análisis retrospectivo de 30 pacientes con diagnóstico de aneurismas cerebrales grandes y gigantes tratados por clipado asistido por descompresión succión retrógrada tratados entre Noviembre 2005 y Junio 2010. La técnica quirúrgica y el pronóstico fueron revisados. Resultados. Todos los aneurismas fueron clipados correctamente, y posteriormente se realizaron angiotomografías 3D o angiografías con sustracción digital, demostrando permeabilidad de ramos perforantes, y clipado aneurismático sin cuello remanente. En esta serie no hubo mortalidad postoperatoria. Conclusión. La técnica de descompresión por succión retrógrada es de gran utilidad en el tratamiento definitivo de aneurismas grandes y gigantes.