Minipterional Craniotomy for Treatment of Unruptured Middle Cerebral Artery Aneurysms. A Single-Center Comparative Analysis with Standard Pterional Approach as Regard to Safety and Efficacy of Aneurysm Clipping and the Advantages of Reconstruction

Neurologic and Neuropsychological Outcomes for Treatment of Unruptured Middle Cerebral Artery Aneurysms: Standard Pterional Versus Minipterional Approach in a Retrospective Single-Center Analysis

BACKGROUND

In accordance with technique advancement and minimal invasiveness surgical approaches, the minipterional has progressively replaced the standard pterional approach for treatment of unruptured middle cerebral artery (MCA) aneurysms. Nowadays, multimodal intraoperative resources including microDoppler and microflow probes, indocyanine green videoangiography, and neurophysiologic monitoring constitute a fundamental prerequisite for increasing the safety of the clipping procedure. Our study investigated and compared in a single-center experience the effect of the evolution of a minimally invasive and multimodal approach in unruptured MCA aneurysm surgery by measuring postoperative complication rate, recovery time, and long-term neuropsychological and functional outcomes.

METHODS

One hundred and thirty-one patients who underwent surgical treatment for unruptured MCA aneurysms at our institution were evaluated retrospectively. Patients' clinical, radiologic, and surgical reports were collected. Cognitive evaluation and quality of life were assessed through validated tests in telephone interviews. Patients who met the inclusion criteria were divided into 2 groups: "PT (pterional)" and "MPT (minipterional)."

RESULTS

Ninety-two patients were included in the analysis. A significant reduction of postoperative complication rates and new-onset postoperative seizures was recorded in the MPT group (P value = 0.006). Severe cognitive deficits were lower in the MPT group, although without a clear statistical correlation.

CONCLUSIONS

Decreased complication rates, faster recovery time, and a trend toward better cognitive and functional performances were documented for the MPT group of patients. In our experience, the minipterional approach with multimodality-assisted microsurgery reduced neurologic complications and recovery time and improved long-term cognitive outcome and quality of life.

Assessment of postoperative pain, dysesthesia, and weather sensitivity after pterional and temporal neurosurgical approaches

OBJECTIVE

Many neurosurgical approaches require incision of the temporal muscle (TM). Consequently, patients often report reduced opening of the mouth, facial asymmetry, numbness, and pain after lateral craniotomies. A systematic assessment of these postoperative subjective complaints is lacking in the literature. Therefore, in this study, the authors evaluate subjective complaints after pterional, frontolateral-extended pterional, or temporal craniotomy using a 6-item questionnaire. They examine the association of these subjective complaints with the extent of the mobilization of the TM.

METHODS

The questionnaire assessed complaints about limited opening of the mouth, pain in the mastication muscles, facial asymmetry, sensory deficits in the temporal region, weather sensitivity, and headache. Eligible patients with benign intracranial processes operated on using lateral cranial approaches between 2016 and 2019 were included. The questionnaire was answered before surgery (baseline) and 3 and 15 months after surgery. Surgeons documented the extent of TM incision.

RESULTS

Among the 55 patients in this study, all complaints apart from headache showed an increase at a statistically significant rate at 3 months postoperatively, that is, limited mouth opening (p < 0.0001), pain in the mastication muscles (p < 0.0001), an impression of asymmetry in the mastication muscles (p = 0.0002), sensory disturbances in the temporal region (p < 0.0001), and weather sensitivity (p < 0.001). Only pain in the mastication muscles showed a relevant decrease at 15 months postsurgery (p = 0.058). The extent of the mobilized TM was associated with pain in the mastication muscles at 3 months (p = 0.0193).

CONCLUSIONS

Subjective complaints in patients following lateral craniotomy can be detected. As the extent of the mobilized TM relevantly influenced pain in the mastication muscles, the authors conclude that one should sparsely mobilize the TM. Furthermore, a neurosurgeon should be aware and warn the patient of subjective postoperative complaints and inform the patient about their natural course.

'What's in a name', a systematic review of the pterional craniotomy for aneurysm surgery and its many modifications with a proposal for simplified nomenclature

BACKGROUND

The pterional or frontosphenotemporal craniotomy has stood the test of time and continues to be a commonly used method of managing a variety of neurosurgical pathology. Already described in the beginning of the twentieth century and perfected by Yasargil in the 1970s, it has seen many modifications. These modifications have been a normal evolution for most neurosurgeons, tailoring the craniotomy to the patients' specific anatomy and pathology. Nonetheless, an abundance of variations have appeared in the literature.

METHODS

A search strategy was devised according to the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. To identify articles investigating the variations in the pterional approach, the following search terms were applied: (pterional OR minipterional OR supraorbital) AND (approach OR craniotomy OR technique).

RESULTS

In total, 3552 articles were screened with 74 articles being read in full with 47 articles being included for review. Each article was examined according the name of the technique, temporalis dissection technique, craniotomy technique and approach.

CONCLUSION

This systematic review gives an overview of the different techniques and modifications to the pterional craniotomy since it was initially described. We advocate for the use of a more standardised nomenclature that focuses on the target zone to simplify the management approach to supratentorial aneurysms.

The Use of Intraoperative Microvascular Doppler in Vascular Neurosurgery: Rationale and Results-A Systematic Review

Surgical treatment of neurovascular lesions like intracranial aneurysms, arteriovenous malformations and arteriovenous dural fistulas is still associated with high morbidity. Several recent studies are providing increasing insights into reliable tools to improve surgery and reduce complications. Inadvertent vessel compromise and incomplete occlusion of the lesion represent the most possible complications in neurovascular surgery. It is clear that direct visual examination alone does not allow to identify all instances of vessel compromise. Various modalities, including angiography, microvascular Doppler and neurophysiological studies, have been utilized for hemodynamics of flow vessels in proper clipping of the aneurysm or complete obliteration of the lesion. We intended to review the current knowledge about the intraoperative microvascular Doppler (iMDS) employment in the most updated literature, and explore the most recent implications not only in intracranial aneurysms but also in neurovascular lesions like arteriovenous malformations (AVMs) and arteriovenous dural fistulas (AVDFs). According to the PRISMA guidelines, systematic research in the most updated platform was performed in order to provide a complete overview about iMDS employment in neurovascular surgery. Twelve articles were included in the present paper and analyzed according to specific research areas. iMDS employment could represent a crucial tool to improve surgery in neurovascular lesions. The safety and effectiveness of the surgical treatment of neurovascular lesions like intracranial aneurysm and other neurovascular lesions like AVMs and AVDFs requires careful and accurate consideration regarding the assessment of anatomy and blood flow. Prognosis may depend on suboptimal or incomplete exclusion of the lesion.

Clipping of Anterior Circulation Aneurysms: Operative Instructions and Safety Rules for Young Cerebrovascular Surgeons

INTRODUCTION

Due to the constant development of the technique, in the last 30 years, the endovascular treatment of the intracranial aneurysms (IAs) has gradually superseded the traditional surgery in the majority of centers. However, clipping still represents the best treatment for some anterior circulation IAs according to their angioarchitectural, topographical, and hemodynamic characteristics. Thus, the identification of residual indications for clipping and the maintenance of training programs in vascular neurosurgery appear nowadays more important than ever.

MATERIALS AND METHODS

We reviewed our last 10-year institutional experience of ruptured and unruptured IAs clipping. We appraised in detail all technical refinements we adopted during this time span and analyzed the difficulties we met in teaching the aneurysm clipping technique to residents and fellows. Then, we described the algorithm of safety rules we used to teach young neurosurgeons how to surgical approach anterior circulation IAs and develop a procedural memory, which may intervene in all emergency situations.

RESULTS

We identified seven pragmatic technical key points for clipping of the most frequent anterior circulation IAs and constructed a didactic approach to teach young cerebrovascular surgeons. In general, they concern craniotomy; cisternostomy; obtaining proximal control; cranial nerve, perforator, and vein preservation; necessity of specific corticectomy; aneurysm neck dissection; and clipping.

CONCLUSION

In the setting of an IA clipping, particularly when ruptured, the young cerebrovascular surgeon needs to respect an algorithm of safety rules, which are essential not only to avoid major complications, but they may intervene during the difficulties helping to manage potentially life-tethering conditions.

Has intraoperative neuromonitoring changed the surgery for unruptured middle cerebral artery aneurysms? A retrospective comparative study

Intraoperative neurophysiological monitoring (IONM) represents one of the available technologies able to assess ischemia and aimed to improve surgical outcome reducing the treatment related morbidity in surgery for intracranial aneurysms. Many studies analyzing the impact of IONM are poised by the heterogeneity bias affecting the cohorts. We report our experience with IONM for surgery of unruptured middle cerebral artery (MCA) aneurysm in order to highlight its influence on functional and radiological outcome and surgical strategy. We retrospectively reviewed all MCA unruptured aneurysms treated between January 2013 and June 2021 by our institutional neurovascular team. Patients were divided into 2 groups according to the use of IONM. A total of 153 patients were included in the study, 52 operated on without IONM and 101 with IONM. The groups did not differ preoperatively regarding clinical status and aneurysm characteristics. Patients operated with IONM had better functional outcomes at discharge as well as at follow-up (p= 0.048, p=0.041) due to lower symptomatic ischemia and better radiological outcome due to lower rate of unexpected aneurysmal remnants (p= 0.0173). The introduction of IONM changed the use of temporary clipping (TeC), increasing its average duration (p= 0.01) improving the safety of dissecting and clipping the aneurysm. IONM in surgery for unruptured MCA aneurysm could improve the efficacy and safety of clipping strategy in the way it showed a role in changing the use of TeC and was associated to the reduction of unexpected aneurysmal remnants' rate and improvement in both short- and long-term patient's outcome.

Early Exposure of the Dorsal Surface of M1 Segment via the Distal Transsylvian Approach for Clipping of Anteroinferior-Projecting Middle Cerebral Artery Bifurcation Aneurysms

Background Middle cerebral artery bifurcation (MCAB) aneurysms are common intracranial aneurysms. Anteroinferior-projecting MCAB aneurysms, with M1 segment usually embedded into the deep part of the Sylvian fissure, cause some surgical challenges. The distal transsylvian approach (DTSA) allows M1 exposure from the dorsal surface for proximal control in the early step. Therefore, this study aimed to demonstrate the efficacy and safety of DTSA for clipping anteroinferior-projecting MCAB aneurysms.

Methods Among 97 patients with MCA aneurysms, 13 with anteroinferior-projecting MCAB aneurysms who underwent aneurysm clipping via the DTSA between June 2018 and January 2021 were retrospectively evaluated for the aneurysm obliteration rate, surgical complications, and outcomes.

Results Ten patients (76.9%) had ruptured MCAB aneurysms and three (23.1%) had incidentally discovered unruptured MCAB aneurysms. Favorable outcome was achieved in 100% of patients with good grade. The complete aneurysm obliteration rate was 100% without intraoperative lenticulostriate artery injury. Twelve (92.3%) patients had early identified distal M1 segment for proximal control, and one (7.7%) patient had premature rupture of aneurysm that achieved favorable outcome at 3 months postoperatively. Difficult M1 exposure and premature rupture occurred in the patient with MCAB located above the Sylvian fissure line. Permanent postoperative neurological deficit was detected in one patient due to severe vasospasm.

Conclusion DTSA, which simplify the early exposure of the dorsal surface of distal M1, is safe and effective for clipping anteroinferior-projecting MCAB aneurysms without extensive Sylvian fissure dissection. High-positioned MCAB requires careful dissection of the aneurysm neck with consideration of tentative clipping preparation.

Clipping versus coiling for treatment of middle cerebral artery aneurysms: a retrospective Italian multicenter experience

Endovascular treatment has emerged as the predominant approach in intracranial aneurysms. However, surgical clipping is still considered the best treatment for middle cerebral artery (MCA) aneurysms in referral centers. Here we compared short- and long-term clinical and neuroradiological outcomes in patients with MCA aneurysms undergoing clipping or coiling in 5 Italian referral centers for cerebrovascular surgery. We retrospectively reviewed 411 consecutive patients admitted between 2015 and 2019 for ruptured and unruptured MCA aneurysm. Univariate and multivariate analyses of the association between demographic, clinical, and radiological parameters and ruptured status, type of surgical treatment, and clinical outcome at discharge and follow-up were performed. Clipping was performed in 340 (83%) cases, coiling in 71 (17%). Clipping was preferred in unruptured aneurysms and in those showing collateral branches originating from neck/dome. Surgery achieved a higher rate of complete occlusion at discharge and follow-up. Clipping and coiling showed no difference in clinical outcome in both ruptured and unruptured cases. In ruptured aneurysms age, presenting clinical status, intracerebral hematoma at onset, and treatment-related complications were significantly associated with outcome at both short- and long-term follow-up. The presence of collaterals/perforators originating from dome/neck of the aneurysms also worsened the short-term clinical outcome. In unruptured cases, only treatment-related complications such as ischemia and hydrocephalus were associated with poor outcome. Clipping still seems superior to coiling in providing better short- and long-term occlusion rates in MCA aneurysms, and at the same time, it appears as safe as coiling in terms of clinical outcome.

Esthetics outcomes in patients submitted to pterional craniotomy and its variants: A scoping review

Background:

Highly performed nowadays, the pterional craniotomy (PC) has several widespread variants. However, these procedures are associated with complications such as temporalis muscle atrophy, facial nerve frontal branch damage, and masticatory difficulties. The postoperative cranial aesthetic is, nonetheless, the main setback according to patients. This review aims to map different pterional approaches focusing on final aesthetics.

Methods:

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Studies were classified through the Oxford method. We searched PubMed/MEDLINE, EMBASE, and Cochrane Library from January 1969 to February 2021 for cohorts and randomized clinical trials that met our inclusion criteria.

Results:

1484 articles were initially retrieved from the databases. 1328 articles did not fit the inclusion criteria. 118 duplicates were found. 38 studies were found eligible for the established criteria. 27 (71.05%) were retrospective cohorts, with low evidence level. Only 5 (13.15%) clinical trials were found eligible to the criteria. The majority of the studies (36/38) had the 2B OXFORD evidence level. A limited number of studies addressed cosmetic outcomes and patient satisfaction. The temporal muscle atrophy or temporal hollowing seems to be the patient’s main complaint. Only 17 (44.73%) studies addressed patient satisfaction regarding the aesthetics, and only 10 (26.31%) of the studies reported the cosmetic outcome as a primary outcome. Nevertheless, minimally invasive approaches appear to overcome most cosmetic complaints and should be performed whenever possible.

Conclusion:

There are several variants of the classic PC. The esthetic outcomes are poorly evaluated. The majority of the studies were low evidence articles.

Chimeric Anterolateral Thigh Flap in Skull Base Reconstruction: A Case-Based Update and Literature Review

Oncologic and traumatic neurosurgery may have to cope with the issue of skull base defects, which are associated with increased risk of meningitis, epidural abscess and cerebro-spinal fluid (CSF) leak. The aim of skull base reconstruction is to repair the dural exposure and to separate the intracranial contents from the nonsterile sino-nasal cavities and extracranial space. Currently, many different surgical techniques have been described, and one of the most performed is the use free flap. In the present paper we performed a case-based update and literature review of the use of chimeric anterolateral thigh free flap harvested from rectus femoris, reporting the case of a 68-year-old man with recurrent spheno-ethmoidalis plane meningioma.

Surgical Treatment of Middle Cerebral Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons

BACKGROUND AND OBJECTIVE

 Clipping is still considered the treatment of choice for middle cerebral artery (MCA) aneurysms due to their angioarchitectural characteristics as they are often bifurcation dysplasias, needing a complex reconstruction rather than a simple exclusion. Thus, maintaining this surgical expertise is of paramount importance to train of young cerebrovascular surgeons. To balance for the increasingly limited experience due the worldwide general inclination toward the endovascular approaches, it is important to provide to the young neurosurgeons rules and operative nuances to guide this complex surgery. We describe the technical algorithm we use to teach our residents to approach ruptured and unruptured MCA aneurysms, which may help to develop a procedural memory useful to perform an effective and safe surgery.

MATERIALS AND METHODS

 We reviewed our last 10 years' institutional experience of about 400 cases of ruptured and unruptured MCA aneurysms clipping, analyzing our technical refinements and the difficulties in residents and young neurosurgeons teaching, to establish fundamental key-points and design a didactic algorithm that includes operative instructions and safety rules.

RESULTS

 We recognized seven pragmatic technical key points regarding craniotomy, sylvian fissure opening, basal cisternostomy, proximal vessel control, lenticulostriate arteries preservation, aneurysm neck microdissection, and clipping to use as a didactic algorithm for teaching residents, and as operative instructions for inexperienced neurosurgeons.

CONCLUSION

 In the setting of clipping MCA aneurysms, respect for surgical rules is of paramount importance to perform an effective and safe procedure, ensure the best aneurysm exclusion, and preserve the flow in collaterals and perforators.

Comparison Between Minipterional Craniotomy Associated With Focused Sylvian Fissure Opening and Standard Pterional Approach With Extended Sylvian Fissure Dissection for Treatment of Unruptured Middle Cerebral Artery Aneurysms

BACKGROUND

In our institution, standard pterional craniotomy (PC) with an extended Sylvian fissure opening (ESFO) represented the standard approach for unruptured middle cerebral artery (MCA) aneurysm clipping until 2014, when we progressively started to prefer minipterional craniotomy (MPC) associated with a focused Sylvian fissure opening (FSFO). In the present study, we compared our results in terms of the efficacy of clipping and the rate of complications with these 2 different techniques.

METHODS

We included patients with small- and medium-size unruptured MCA aneurysms from January 2008 to December 2018 with follow-up of >12 months. The clinical and radiologic data were reviewed from the medical records. The outcomes were measured in terms of efficacy (aneurysmal exclusion rate) and safety (intracranial complication rate).

RESULTS

Overall, 134 patients who had presented with unruptured MCA aneurysms <1.5 cm were treated at our institution from January 2007 to December 2018: PC and ESFO were used in 73 patients and MPC and FSFO in 61. The demographics and angioarchitectural features were comparable between the 2 groups, except for age, which was older in the FSFO group. The aneurysm exclusion rate was not different between the 2 groups. The intracranial complication rate was, overall, significantly lower in the FSFO group (P < 0.001), especially for the rate of postoperative seizures. Finally, the FSFO group had had shorter postoperative hospitalization and better short- and long-term clinical outcomes.

CONCLUSIONS

The association between MPC and FSFO should represent the standard of treatment of unruptured MCA aneurysms in all referral cerebrovascular centers, allowing for the achievement of the same efficacy of standard PC with ESFO and minimizing the complications.

Minipterional craniotomy for surgical clipping of anterior circulation aneurysms: compatibility between the feasibility, safety and efficiency

Objective

The aim of this study was to assess the feasibility, safety and efficiency of minipterional craniotomy (MPT) for surgical clipping of anterior circulation aneurysms.

Methods

A retrospective study was conducted to compare the MPT from Jan 2015 to Dec 2018 and conventional pterional craniotomy (CPT) from Jan 2012 to Dec 2013 in unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms (RIA). The feasibility and safety of MPT and CPT were assessed by analyzing medical records, radiologic imaging, and clinical outcomes. The efficiency of MPT and CPT were based on a survey research of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry.

Results

Total 628 patients who underwent 458 MPT (UIA:313, RIA:145) and 170 CPT (UIA: 106, RIA: 64) with anterior circulation aneurysms were included in this study. The baseline characteristics between MPT and CPT had no difference (p>0.05). There was no difference in the incidence of postoperative hemorrhage or ischemic lesions between MPT and CPT (p>0.05). The incidence of surgical wound infection was lower in MPT (0.4%) than CPT (3.5%) (p=0.002). More than 90% of postoperative pain disappeared faster in MPT (14.25±4.83 days) than CPT (27.59±10.35 days), and the feeling of facial asymmetry in surgical side was also lower for MPT (1.7%) than CPT (7.6%) (p<0.001). In the MPT, no patients presented with progress to chronic pain, masticatory disability, discomfort of maximal mouth opening or permanent facial palsy.

Conclusions

We suggest that MPT and CPT had similar clinical outcomes, and MPT showed better functional and cosmetic outcomes than CPT in terms of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Therefore, MPT for surgical clipping of anterior circulation aneurysms can be a compatible technique that satisfies the feasibility, safety and efficiency.

Surgical Treatment of Anterior Communicating Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons

Background Anterior communicating artery (AComA) aneurysms are the most common intracranial aneurysm, accounting for 25 to 38% of all cases. In spite of the advent of modern neurointerventional treatments, they still represent a strong indication for clipping in certain anatomical and clinical conditions. However, AComA aneurysms are the deepest located aneurysms of the anastomotic circle of Willis, with a complex spatial orientation, and they are fed by bilateral branches of the anterior circulations. Although, on one hand, these aneurysms represent the most complex ones of the anterior circulation, on the other hand, the experience of young neurosurgeons is increasingly limited. Therefore, respecting operative guidelines is crucial to achieve the best aneurysm exclusion and avoid fatal intraoperative complications.

Study Objective We describe the technical algorithm we use to teach young neurosurgeons how to approach AComA aneurysms and help them to develop a procedural memory needed to perform an efficient and safe surgery.

Materials and Methods We reviewed our last 10 years of institutional experience of > 200 cases of clipping ruptured and unruptured AComA aneurysms, analyzing our technical refinements and the difficulties in teaching residents and young neurosurgeons how to establish fundamental key points and design a didactic algorithm that includes operative instructions and safety rules.

Results We identified seven pragmatic technical key points regarding craniotomy, cisternostomy, gyrus rectus corticectomy, proximal control, perforators and Heubner preservation, aneurysm neck dissection, and clipping to use in a didactic algorithm for teaching residents and as operative instructions for inexperienced neurosurgeons.

Conclusion In the setting of clipping AComA aneurysms, respect for surgical rules is of paramount importance to perform an efficacious and safe procedure and ensure the best aneurysm exclusion and preservation of neurovascular structures.

The extradural minipterional approach for the treatment of paraclinoid aneurysms: a cadaver stepwise dissection and clinical case series

Minipterional (MPT) craniotomy has recently been added to the neurosurgical armamentarium as a less invasive alternative to the pterional craniotomy for the treatment of parasellar lesions. However, its clinical applicability in the treatment of certain complex aneurysms, such as those arising in the paraclinoid region, remains unclear. To illustrate the microsurgical anatomy of a modified extradural MPT approach, which combines a classic MPT craniotomy with an extradural anterior clinoidectomy, and to demonstrate its clinical applicability in the treatment of complex paraclinoid aneurysms. A stepwise extradural MPT approach is illustrated in a cadaver study. Clinical outcome data from a series of 19 patients with 20 paraclinoid aneurysms treated surgically using the extradural MPT approach between 2016 and 2018 were retrospectively collected. In 95% of the cases, complete aneurysm occlusion was achieved. No aneurysm recurrences were seen during follow-up with a median length of 21 months. The outcome, according to the modified Rankin Scale, was 0 points in 12 patients (63%), 1 point in 6 patients (32%), and 2 points in 1 patient (5%). Four out of 6 patients (67%) with initial visual symptoms showed improvement following treatment, whereas in two (11%), vision became worse. The extradural MPT approach ensures a sufficiently large exposure of the paraclinoid region that is comparable with conventional approaches with the advantage of being minimally invasive. Our case series demonstrates the feasibility of this approach for the treatment of complex paraclinoid aneurysms.

Application of indocyanine green video angiography in vascular neurosurgery

Indocyanine green video angiography (ICG-VA) is a non-invasive, easy to use and very useful tool for various neurosurgical procedures. The first application was in neurovascular surgery, because it was born as an intravascular tracer for vessels visualization; this has been really useful in aneurysms, atero-venous malformations (AVMs) and dural fistulas surgery where identification, obliteration or patency of vessels is essential. Introduced in vascular neurosurgery since 2003, ICG-VA applications have broadened over time, both in vascular and in other neurosurgical fields. In 2003 Raabe et al. have been the first to describe the use of ICG-VA for intraoperative assessment of cerebral vascular flow, enabling visualization of vessel patency and aneurysm occlusion during aneurysm surgery. ICG-VA applications in vascular neurosurgery have significantly increased over time including complex aneurysms, bypass, atero-venous malformations (AVM) artero-venous fistulas (AVF), evaluation of cortical perfusion. The procedure can be easily repeated after 5-10 minutes. Adverse reactions are comparable to those of other types of contrast media, with frequencies of 0.05% (hypotension, arrhythmia, or, more rarely, anaphylactic shock) to 0.2% (nausea, pruritus, syncope, or skin eruptions. The aim of the present study was to systematically analyze ICG-VA applications in vascular neurosurgery, highlighting the reported advantages and disadvantages, and discussing future perspectives.