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Budohoski KP, Raygor K, Tonetti DA, Narsinh KH, Winkler EA, Dowd C, Abla AA. Intraoperative Angiogram Using C-Arm Fluoroscopy and Direct Common Carotid Artery Puncture During Surgical Treatment of Paraclinoid Aneurysms. World Neurosurg 2022; 165:95-99. [PMID: 35779758 DOI: 10.1016/j.wneu.2022.06.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intraoperative angiography (IOA) has been shown to be a useful adjunct in surgical treatment of cerebral aneurysms. However, its use can be limited by hybrid operating room availability. On the other hand, the use of C-arm fluoroscopy can add challenges to IOA during navigation of the aortic arch and selection of the great vessels. We aimed to describe a simple method of IOA that can be applied during surgery of paraclinoid aneurysms and can be performed in a normal operating room without the need to navigate the aortic arch. METHODS In patients undergoing surgery for paraclinoid aneurysms with need for cervical carotid artery exposure, IOA was performed using a single plane C-arm fluoroscopy unit after direct puncture of the carotid artery. RESULTS Five patients were included: 2 with subarachnoid hemorrhage, 2 with unruptured aneurysm and history of subarachnoid hemorrhage, and 1 with unruptured aneurysm. There were 2 internal carotid blister aneurysms, 2 ophthalmic artery aneurysms, and 1 superior hypophyseal artery aneurysm. IOA was performed using direct carotid puncture through the neck incision required for proximal control. In all cases, intraoperative images were of sufficient quality to determine the completeness of aneurysm occlusion as well as parent and branching vessel patency. There were no postoperative infarctions and no complications related to IOA. CONCLUSIONS IOA using direct carotid puncture can be performed in a standard operating room with the use of a C-arm, eliminating the need to catheterize the great vessels of the aortic arch.
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Affiliation(s)
- Karol P Budohoski
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
| | - Kunal Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher Dowd
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Durner G, Wahler H, Braun M, Kapapa T, Wirtz CR, König R, Pala A. The value of intraoperative angiography in the time of indocyanine green videoangiography in the treatment of cerebrovascular lesions: Efficacy, workflow, risk-benefit and cost analysis A prospective study. Clin Neurol Neurosurg 2021; 205:106628. [PMID: 33895619 DOI: 10.1016/j.clineuro.2021.106628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/28/2021] [Accepted: 03/28/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Intraoperative digital subtraction angiography (ioDSA) allows early treatment evaluation after neurovascular procedures. However, the value and efficiency of this procedure has been discussed controversially. We have evaluated the additional value of hybrid operating room equipped with an Artis Zeego robotic c-arm regarding cost, efficiency and workflow. Furthermore, we have performed a risk-benefit analysis and compared it with indocyanine green (ICG) angiography. METHODS For 3 consecutive years, we examined all neurovascular patients, treated in the hybrid operating theater in a risk-benefit analysis. After using microdoppler and ICG angiography for best operative result, every patient received an additional ioDSA to look for remnants or unfavorable clip placement which might lead to a change of operating strategy or results. Furthermore, a workflow-analysis reviewing operating steps, staff positioning, costs, technical errors or complications were conducted on randomly selected cases. RESULTS 54 patients were enrolled in the risk-benefit analysis, 22 in the workflow analysis. The average duration of a cerebrovascular operation was 4 h 58 min 2 min 35 s accounted for ICG angiography, 46 min 4 s for ioDSA. Adverse events occurred during one ioDSA. In risk-benefit analysis, ioDSA was able to detect a perfusion rest in 2 out of 43 cases (4,7%) of aneurysm surgery, which could not have been visualized by ICG angiography before. In arterio-venous-malformation (AVM) surgery, one of 11 examined patients (7,7%) showed a remnant in ioDSA and resulted in additional resection. The average cost of an ioDSA in Ulm University can be estimated with 1928,00€. CONCLUSION According to our results ioDSA associated complications are low. Relevant findings in ioDSA can potentially avoid additional intervention, however, due to the high costs and lower availability, the main advantage might lie in the treatment of selected patients with complexes neurovascular pathologies since ICG angiography is equally safe but associated with lower costs and better availability.
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Affiliation(s)
- Gregor Durner
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany.
| | - Hellen Wahler
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Michael Braun
- University of Ulm, Department of Neuroradiology, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Thomas Kapapa
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Christian Rainer Wirtz
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Ralph König
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
| | - Andrej Pala
- University of Ulm, Department of Neurosurgery, Ludwig Heilmeyerstr. 2, 89312 Günzburg, Germany
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Küçükyürük B, Korkmaz TŞ, Nemayire K, Özlen F, Kafadar AM, Akar Z, Kaynar MY, Sanus GZ. Intraoperative Fluorescein Sodium Videoangiography in Intracranial Aneurysm Surgery. World Neurosurg 2020; 147:e444-e452. [PMID: 33373739 DOI: 10.1016/j.wneu.2020.12.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Fluorescein sodium (FNa) videoangiography (VA) was performed to evaluate blood flow within vessels and exclusion of the aneurysm after surgical clipping of intracranial aneurysms. The aim of this study was to report results of FNa-VA in a case series, including benefits and limitations of the technique, and compare intraoperative findings with postoperative cerebral angiography to assess reliability of FNa-VA. METHODS The study included 64 aneurysms in 50 consecutive patients. Following clip ligation of the aneurysm, 100 mg of FNa was administered intravenously. The microscope light was switched to the FL560 integrated fluorescence module. Aneurysm sac, parent arteries, and perforating arteries were observed. RESULTS FNa-VA promoted real-time assessment of the surgical field in three-dimensional view through the binoculars with good image quality. In 79.68% of aneurysms, FNa-VA confirmed satisfactory clip application, as FNa did not penetrate into the aneurysm. In 14.06% of aneurysms, a homogeneous yellow-green color change occurred, which was accepted as a false-positive sign. In 6.25% of aneurysms, FNa seeped into the aneurysm emitting a heterogeneous green signal, which slowly dispersed throughout the sac. Postoperative angiography revealed satisfactory results. Small neck remnants were present in 5 patients, and mild parent artery stenosis was found in 3 patients. No ischemic event occurred secondary to parent artery or perforating artery occlusion. CONCLUSIONS FNa-VA adds greatly to the safety of surgical treatment of intracranial aneurysms, particularly in lesions situated in deep locations, by enabling real-time inspection, which facilitates safer manipulation and evaluation of structures in question.
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Affiliation(s)
- Barış Küçükyürük
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey.
| | - Taha Şükrü Korkmaz
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Kelvin Nemayire
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey; Department of Neurosurgery, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Fatma Özlen
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Ali Metin Kafadar
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Ziya Akar
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Mehmet Yaşar Kaynar
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
| | - Galip Zihni Sanus
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
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Ares WJ, Kenmuir CL, Panczykowski DM, Weiner GM, Jadhav AP, Jovin TG, Gross BA, Jankowitz BT. A Critical Analysis of the Utility of Intraoperative Angiography. World Neurosurg 2017; 110:e84-e89. [PMID: 29107166 DOI: 10.1016/j.wneu.2017.10.095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Intraoperative digital subtraction angiography (ioDSA) is touted as the gold standard imaging evaluation for aneurysm clip constructs. Candid evaluations of its limitations are sparse. METHODS A prospectively collected hospital billing database was queried to identify craniotomies for aneurysm clipping from January 2010 to December 2013. We evaluated the rate of occult residual and parent vessel stenosis determined on follow-up angiography for patients undergoing ioDSA and those not undergoing ioDSA. Comparisons were performed via Fisher exact test, with P < 0.05 considered statistically significant. RESULTS From our database search, we found 187 patients who underwent ioDSA after aneurysm clipping and an additional 91 patients who did not. Results from ioDSA influenced operative management in 17% of cases. Sixty-four patients with 70 treated aneurysms undergoing ioDSA had postoperative angiography; 7 occult residuals were discovered, yielding a 10% false-negative rate, with 10% of aneurysms showing residual. Occult residuals at the middle cerebral artery bifurcation represented most discovered residuals (6/7). Thirty-two patients with 37 treated aneurysms did not undergo ioDSA and had angiographic follow-up; 24% of patients were found to have residual aneurysms (P = 0.08 compared with patients undergoing ioDSA). Residuals at the anterior communicating artery (ACoA) represented 56% of all residuals, whereas the ACoA represented only 18% of aneurysms clipped. The rate of residuals was significantly higher than that for patients with clipped ACoA aneurysms undergoing ioDSA (P = 0.008). CONCLUSIONS ioDSA influenced management in nearly one fifth of cases. It can be particularly beneficial in detecting residuals for ACoA aneurysms; its benefit was less apparent for middle cerebral artery aneurysms.
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Affiliation(s)
- William J Ares
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Cynthia L Kenmuir
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David M Panczykowski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gregory M Weiner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ashu P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tudor G Jovin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Dellaretti M, da Silva Martins WC, Dourado JC, Faglioni W, Quadros RS, de Souza Moraes VV, de Souza Filho CBA. Angiographic and epidemiological characteristics associated with aneurysm remnants after microsurgical clipping. Surg Neurol Int 2017; 8:198. [PMID: 28904825 PMCID: PMC5590350 DOI: 10.4103/sni.sni_109_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/06/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Despite new techniques for the treatment of cerebral aneurysms, the percentage of aneurysm remnants after surgical intervention seems to be relatively constant. The objective of this study was to assess angiographic and epidemiological features associated with aneurysm remnants after microsurgical clipping. METHODS This study was conducted from February 2009 to August 2012 on a series of 90 patients with 105 aneurysms referred to the Santa Casa of Belo Horizonte who were surgically treated and angiographically controlled. RESULTS Surgical clipping was considered incomplete in 13.3% of the aneurysms. The mean age of cases with an aneurysm remnant was 57.5 years, whereas the mean age without aneurysm remnant was 49.7 years (P = 0.02). Aneurysm remnants were detected more frequently on the internal carotid artery, nevertheless, no statistically significant differences were verified when comparing the locations. Aneurysm size in the preoperative angiography verified that the mean size of aneurysms operated was 6.56 mm, such that in cases showing a postoperative remnant, the mean size was 9.7 mm and in cases with complete clipping it was 6.08 mm (P = 0.02). Postoperative angiography showed that, in cases with residual aneurysm, the number of clips used was higher - a mean of 1.8 for complete clipping and 3.1 for incomplete clipping (P < 0.001). CONCLUSIONS Aneurysm size and patient age showed significant correlations with residual intracranial aneurysm. The mean number of clips used was higher in cases with incomplete occlusion.
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Affiliation(s)
- Marcos Dellaretti
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil.,Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Jules Carlos Dourado
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - Wilson Faglioni
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Ricardo Souza Quadros
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil
| | | | - Carlos Batista Alves de Souza Filho
- Department of Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.,Department of Neurosurgery, Hospital Mater Dei, Belo Horizonte, Minas Gerais, Brazil.,Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Martirosyan NL, Skoch J, Watson JR, Lemole GM, Romanowski M, Anton R. Integration of indocyanine green videoangiography with operative microscope: augmented reality for interactive assessment of vascular structures and blood flow. Neurosurgery 2015; 11 Suppl 2:252-7; discussion 257-8. [PMID: 25710107 DOI: 10.1227/neu.0000000000000681] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Preservation of adequate blood flow and exclusion of flow from lesions are key concepts of vascular neurosurgery. Indocyanine green (ICG) fluorescence videoangiography is now widely used for the intraoperative assessment of vessel patency. OBJECTIVE Here, we present a proof-of-concept investigation of fluorescence angiography with augmented microscopy enhancement: real-time overlay of fluorescence videoangiography within the white light field of view of conventional operative microscopy. METHODS The femoral artery was exposed in 7 anesthetized rats. The dissection microscope was augmented to integrate real-time electronically processed near-infrared filtered images with conventional white light images seen through the standard oculars. This was accomplished by using an integrated organic light-emitting diode display to yield superimposition of white light and processed near-infrared images. ICG solution was injected into the jugular vein, and fluorescent femoral artery flow was observed. RESULTS Fluorescence angiography with augmented microscopy enhancement was able to detect ICG fluorescence in a small artery of interest. Fluorescence appeared as a bright-green signal in the ocular overlaid with the anatomic image and limited to the anatomic borders of the femoral artery and its branches. Surrounding anatomic structures were clearly visualized. Observation of ICG within the vessel lumens permitted visualization of the blood flow. Recorded video loops could be reviewed in an offline mode for more detailed assessment of the vasculature. CONCLUSION The overlay of fluorescence videoangiography within the field of view of the white light operative microscope allows real-time assessment of the blood flow within vessels during simultaneous surgical manipulation. This technique could improve intraoperative decision making during complex neurovascular procedures.
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Affiliation(s)
- Nikolay L Martirosyan
- *Division of Neurosurgery, University of Arizona, Tucson, Arizona; ‡Neurosurgery Research Laboratory, University of Arizona, Tucson, Arizona; §Department of Biomedical Engineering, University of Arizona, Tucson, Arizona
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Starke RM, Dumont AS. Intraoperative Imaging and Assessment of Cerebral Blood Flow in Cerebrovascular Surgery: Hybrid Operating Rooms, Intraoperative Angiography and Magnetic Resonance Imaging, Doppler Ultrasound, Cerebral Blood Flow Probes, Endoscopic Assistance, Indocyanine Green Videography, and Laser Speckle Contrast Imaging. World Neurosurg 2014; 82:e693-6. [DOI: 10.1016/j.wneu.2013.10.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/18/2013] [Indexed: 10/26/2022]
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Washington CW, Derdeyn CP, Chicoine MR, Cross DT, Dacey RG, Moran CJ, Rich KM, Zipfel GJ. Comparing routine versus selective use of intraoperative cerebral angiography in aneurysm surgery: a prospective study. J Neurointerv Surg 2014; 8:75-80. [PMID: 25423951 DOI: 10.1136/neurintsurg-2014-011515] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 11/09/2014] [Indexed: 11/04/2022]
Abstract
INTRODUCTION While the use of intraoperative angiography (IA) has been shown to be a useful adjunct in aneurysm surgery, its routine use remains controversial. OBJECTIVE We wished to determine if IA is required in all patients undergoing aneurysm surgery (ie, routine IA) or if intraoperative assessment can reliably predict the need for IA (ie, select IA). METHODS We prospectively evaluated all patients undergoing craniotomy for aneurysm clipping. In these patients, the treating surgeons were asked to record whether they felt IA was required at two time points: (1) prior to surgery and (2) immediately after clip application but before IA. All patients underwent IA as per the institutional protocol. IA results and the need for post-IA clip adjustments were recorded. RESULTS Of the 200 patients enrolled, 197 were included for analysis. IA was deemed necessary on preoperative assessment in 144 cases (73%) and on post-clip assessment in 116 cases (59%). Post-clip IA demonstrated 47 (24%) positive findings and post-IA clip adjustments were made in 19 of 198 cases (10%). On preoperative assessment, there were four cases where IA was deemed unnecessary, yet post-IA clip adjustment was required, resulting in a sensitivity of 79% and false negative rate of 8%. Regarding post-clip assessment, there were five cases where IA was thought to be unnecessary and clip adjustment was required, resulting in a sensitivity of 73% and false negative rate of 6%. CONCLUSIONS The accuracy of a strategy of select IA was not improved by assessing the need for IA immediately after aneurysm clipping versus prior to surgery onset. This suggests that intraoperative assessment regarding the adequacy of aneurysm clip application should be viewed with caution.
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Affiliation(s)
- Chad W Washington
- Department of Neurological Surgery, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA Department of Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Colin P Derdeyn
- Department of Neurological Surgery, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA Department of Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA Department of Neurology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - DeWitte T Cross
- Department of Neurological Surgery, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA Department of Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Ralph G Dacey
- Department of Neurological Surgery, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Christopher J Moran
- Department of Neurological Surgery, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA Department of Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Keith M Rich
- Department of Neurological Surgery, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA Department of Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA Department of Neurology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, Saint Louis, Missouri, USA
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Arikan F, Vilalta J, Torne R, Chocron I, Rodriguez-Tesouro A, Sahuquillo J. Monitorización intraoperatoria de la presión tisular de oxígeno: aplicaciones en neurocirugía vascular. Neurocirugia (Astur) 2014; 25:275-85. [DOI: 10.1016/j.neucir.2014.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/17/2014] [Accepted: 03/23/2014] [Indexed: 10/25/2022]
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Washington CW, Zipfel GJ, Chicoine MR, Derdeyn CP, Rich KM, Moran CJ, Cross DT, Dacey RG. Comparing indocyanine green videoangiography to the gold standard of intraoperative digital subtraction angiography used in aneurysm surgery. J Neurosurg 2013; 118:420-7. [DOI: 10.3171/2012.10.jns11818] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of aneurysm surgery is complete aneurysm obliteration while sparing associated arteries. Indocyanine green (ICG) videoangiography is a new technique that allows for real-time evaluation of blood flow in the aneurysm and vessels. The authors performed a retrospective study to compare the accuracy of ICG videoangiography with intraoperative angiography (IA), and determine if ICG videoangiography can be used without follow-up IA.
Methods
From June 2007 through September 2009, 155 patients underwent craniotomies for clipping of aneurysms. Operative summaries, angiograms, and operative and ICG videoangiography videos were reviewed. The number, size, and location of aneurysms, the ICG videoangiography and IA findings, and the need for clip adjustment after ICG videoangiography and IA were recorded. Discordance between ICG videoangiography and IA was defined as ICG videoangiography demonstrating aneurysm obliteration and normal vessel flow, but post-IA showing either an aneurysmal remnant and/or vessel occlusion requiring clip adjustment.
Results
Thirty-two percent of patients (49 of 155) underwent both ICG videoangiography and IA. The post-ICG videoangiography clip adjustment rate was 4.1% (2 of 49). The overall rate of ICG videoangiography–IA agreement was 75.5% (37 of 49) and the ICG videoangiography–IA discordance rate requiring post-IA clip adjustment was 14.3% (7 of 49). Adjustments were due to 3 aneurysmal remnants and 4 vessel occlusions. These adjustments were attributed to obscuration of the residual aneurysm or the affected vessel from the field of view and the presence of dye in the affected vessel via collateral flow. Although not statistically significant, there was a trend for ICG videoangiography–IA discordance requiring clip adjustment to occur in cases involving the anterior communicating artery complex, with an odds ratio of 3.3 for ICG videoangiography–IA discordance in these cases.
Conclusions
These results suggest that care should be taken when considering ICG videoangiography as the sole means for intraoperative evaluation of aneurysm clip application. The authors further conclude that IA should remain the gold standard for evaluation during aneurysm surgery. However, a combination of ICG videoangiography and IA may ultimately prove to be the most effective strategy for maximizing the safety and efficacy of aneurysm surgery.
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Affiliation(s)
| | | | | | - Colin P. Derdeyn
- 1Departments of Neurological Surgery,
- 2Neurology, and
- 3Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M. Rich
- 1Departments of Neurological Surgery,
- 3Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J. Moran
- 1Departments of Neurological Surgery,
- 3Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, St. Louis, Missouri
| | - DeWitte T. Cross
- 1Departments of Neurological Surgery,
- 3Radiology, Washington University Center for Stroke and Cerebrovascular Disease, Washington University School of Medicine, St. Louis, Missouri
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Balamurugan S, Agrawal A, Kato Y, Sano H. Intra operative indocyanine green video-angiography in cerebrovascular surgery: An overview with review of literature. Asian J Neurosurg 2012; 6:88-93. [PMID: 22347330 PMCID: PMC3277076 DOI: 10.4103/1793-5482.92168] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Microscope integrated Near infra red Indocyanine green video angiography (NIR ICG VA) has been frequently used in cerebrovascular surgery. It is believed to be a simple and reliable method with acquisition of real time high spatial resolution images. The aim of this review article was to evaluate the efficacy of intra operative Indocyanine green video angiography (ICG VA) in Aneurysm, brain arteriovenous malformations (AVM) and extracranial-intracranial (EC-IC) bypass surgeries and also to analyze its limitations. Intra operative imaging is a very useful tool in guiding surgery; thus, avoiding surgical morbidity. Now-a-days, many cerebrovascular units are using ICG VA rather than Doppler and intra operative DSA in most of their aneurysm surgeries, and surgeons are incorporating this technique for AVM and in EC-IC bypass surgeries too. This article is an overview of the beneficial effects of ICG VA in cerebrovascular surgery and will also point out its limitations in various circumstances. Intra operative ICG VA gives high resolution, real time images of arterial, capillary, and venous flow of cerebral vasculature. Although it gives adequate information about the clipped neck, parent/branching artery and perforator involvement, it has some limitations like viewing the neck residuals located behind the aneurysm, thick walled atherosclerotic vessels, and thrombosed aneurysms. In AVM surgery, it is useful in detecting the residual nidus in diffuse type AVM, but cannot be relied in deep seated AVMs and it gives exact information about the anastomosis site in EC-IC bypass, thus, avoiding early bypass graft failure. NIR ICG VA is a simple, reliable, and quick method to pick up subtle findings in cerebrovascular procedures. But in selected cases of aneurysms, endoscopy and intra operative Digital substraction angiography (DSA) may be helpful, whereas in deep seated AVMs, navigation may be required as an adjunct to confirm intra operative findings.
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Affiliation(s)
- S Balamurugan
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Japan
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Chalouhi N, Theofanis T, Jabbour P, Dumont AS, Gonzalez LF, Starke RM, Dalyai RT, Hann S, Rosenwasser R, Tjoumakaris S. Safety and Efficacy of Intraoperative Angiography in Craniotomies for Cerebral Aneurysms and Arteriovenous Malformations. Neurosurgery 2012; 71:1162-9. [DOI: 10.1227/neu.0b013e318271ebfc] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
In an era of indocyanine angiography, the routine use of intraoperative angiography (IOA) in the surgical treatment of aneurysms and vascular malformations is controversial.
OBJECTIVE:
To retrospectively assess the safety and efficacy of IOA and to determine predictors of surgical revision.
METHODS:
Between 2003 and 2011, IOA was performed during surgical treatment of 976 aneurysms, 101 arteriovenous malformations (AVMs), and 16 arteriovenous fistulas.
RESULTS:
In 80 of 976 aneurysms (8.2%), IOA prompted clip repositioning. The reason for readjustment was residual aneurysm in 54.7%, parent vessel occlusion in 42.9%, and both in 2.4% of cases. In multivariate analysis, increasing aneurysm size (P < .001), ruptured aneurysm (P < .001), and increasing number of vessels injected (P < .001) were strong predictors of clip readjustment. There was a strong trend for posterior circulation aneurysm location to predict clip repositioning (P = .06). IOA revealed residual nidus/fistula requiring further intervention in 9 of 101 AVMs (8.9%) and 3 of 16 arteriovenous fistulas (18.8%). Of 9 AVMs requiring a surgical revision, 2 (22.2%) were Spetzler-Martin grade II, 5 (55.6%) were grade III, and 2 (22.2%) were grade IV. Mean Spetzler-Martin grade was 3.0 in AVMs requiring surgical revision compared with 2.3 in those not requiring revision (P = .05). IOA-related complications were all transient or minor and occurred in 0.99% of patients; none resulted in permanent morbidity.
CONCLUSION:
IOA remains a valuable tool in the surgical treatment of brain vascular abnormalities, guiding surgical re-exploration in > 8% of cases. Easy access to an angiographer and routine use of IOA are important factors contributing to procedural safety and efficacy.
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Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Thana Theofanis
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Aaron S. Dumont
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - L. Fernando Gonzalez
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Richard T. Dalyai
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Shannon Hann
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Bacigaluppi S, Fontanella M, Manninen P, Ducati A, Tredici G, Gentili F. Monitoring techniques for prevention of procedure-related ischemic damage in aneurysm surgery. World Neurosurg 2011; 78:276-88. [PMID: 22381314 DOI: 10.1016/j.wneu.2011.11.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 10/05/2011] [Accepted: 11/22/2011] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe the application of intraoperative monitoring techniques during aneurysm surgery and to discuss the advantages and limitations of these techniques in prevention of postoperative neurologic deficits. METHODS Articles found in the literature through PubMed for the time frame 1980-2011 and the authors' personal files were reviewed. RESULTS Various techniques for detection of vascular insufficiency are available, including direct methods to measure cerebral blood flow and indirect methods to evaluate the integrity of neurologic pathways. CONCLUSIONS The choice of monitoring modality should be governed by the vessel and by the vascular territory most at risk during the planned procedure with proper awareness of the potential limits related to each technique. Aneurysm surgery monitoring should help to address issues of continuity and provide a morphologic and functional assessment. Although the use of monitoring devices is still not routine in aneurysm surgery and no standards have been established, combining different monitoring techniques is crucial to optimize aneurysm surgery and avoid or minimize complications.
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Affiliation(s)
- Susanna Bacigaluppi
- Department of Neurosciences and Biomedical Technologies, University of Milano Bicocca, Monza, Italy.
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14
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15
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Khurana VG, Seow K, Duke D. Intuitiveness, quality and utility of intraoperative fluorescence videoangiography: Australian Neurosurgical Experience. Br J Neurosurg 2010; 24:163-72. [PMID: 20121384 DOI: 10.3109/02688690903518247] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The authors have undertaken a study of their intraoperative experience with indocyanine green fluorescence videoangiography (ICGFV). In particular, the intuitiveness, image quality and clinical utility of this technology have been assessed. METHODS The records of forty-six consecutive craniotomies utilising ICGFV have been retrospectively reviewed: There were 27 aneurysms, 2 extracranial-intracranial (EC-IC) bypasses, 5 arteriovenous malformations (AVM), 1 dural arteriovenous fistula (DAVF), 3 cavernomas, 5 meningiomas, and 3 gliomas. ICGFV was used in 5 awake-craniotomy patients. ICGFV was performed using a Leica OH4 surgical microscope with integrated near-infrared camera and ICG-PULSION. RESULTS All attempts of intraoperative ICGFV were intuitive. Image quality and resolution were excellent. Arterial and venous phases were comparable to digital subtraction angiography (DSA) but field of view was relatively limited. In 12 operations (26%) the surgeon was substantially benefited from ICGFV findings. In 22 operations (48%), ICGFV was useful but did not influence surgical management. ICGFV was of no benefit in 11 operations (24%) and was misleading in 1 (2%). In this series, ICGFV was of benefit to 1 of 11 (9%) patients with an intracranial neoplasm or cavernoma. CONCLUSIONS ICGFV is safe, intuitive and provides neurosurgeons with high quality, valuable, real-time imaging of cerebrovascular anatomy. It can assist in intraoperative surgical management and/or stroke prevention particularly during aneurysm clipping, EC-IC bypass and AVM/DAVF surgery.
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Affiliation(s)
- Vini G Khurana
- Department of Neurosurgery, The Canberra Hospital, Canberra, ACT, Australia.
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16
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Ma CY, Shi JX, Wang HD, Hang CH, Cheng HL, Wu W. Intraoperative indocyanine green angiography in intracranial aneurysm surgery: Microsurgical clipping and revascularization. Clin Neurol Neurosurg 2009; 111:840-6. [PMID: 19747765 DOI: 10.1016/j.clineuro.2009.08.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Revised: 07/20/2009] [Accepted: 08/17/2009] [Indexed: 12/01/2022]
Abstract
BACKGROUND The goal of this report is to illustrate the use of intraoperative indocyanine green (ICG) angiography in the surgical management of intracranial aneurysms, including microsurgical clipping and revascularization. METHODS This study included a series of 45 patients who were surgically treated between June 2007 and May 2008 for intracranial aneurysms. Fourty-three of the patients had anterior circulation aneurysms, and 2 had posterior circulation aneurysms. Forty-one patients were treated with microsurgical clipping. Four patients underwent revascularization combined with aneurysm dissection or trapping. Intraoperative ICG angiography was used to visualize the aneurysm clipping, patency of parent artery or graft. The ICG angiography technique is described, with particular reference to evaluation of the aneurysm clipping and revascularization. RESULTS Eighty-nine ICG angiography procedures were performed in 45 patients with intracranial aneurysms. The aneurysms were completely obliterated for all patients, and the grafts were patented for all except 1 patient. Pre-clipping ICG angiography showed the relationship of aneurysm and its parent artery clearly. After aneurysms being clipped, intraoperative ICG angiography found remnant of aneurysms, stenosis or occlusion of parent arteries and grafts in 8 cases, which were revised in the same surgical procedure. The results of ICG angiography correlated well with postoperative DSA in 97% patients. CONCLUSION ICG angiography can provide real-time information and guide revision in the same surgical procedure for the management of intracranial aneurysms.
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Affiliation(s)
- Chi-Yuan Ma
- Department of Neurosurery, Nanjing Jinling Hospital, Nanjing University, School of Medicine, 305 East Zhongshan Road, Nanjing 210002, China
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17
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Komotar RJ, Zacharia BE, Mocco J, Connolly ES. CONTROVERSIES IN THE SURGICAL TREATMENT OF RUPTURED INTRACRANIAL ANEURYSMS. Neurosurgery 2008; 62:396-407; discussion 405-7. [DOI: 10.1227/01.neu.0000316006.26635.b0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
THE MANAGEMENT OF aneurysmal subarachnoid hemorrhage has evolved over time, including the use of the microscope for aneurysm clip application, improved imaging modalities, endovascular methods for aneurysm treatment, dedicated neurointensive care units, and more aggressive therapy for cerebral vasospasm. Although these advancements have reduced the morbidity and mortality associated with aneurysmal subarachnoid hemorrhage, outcomes for this patient population continue to leave much room for improvement. This work highlights controversial adjuvant techniques, maneuvers, and therapies surrounding the surgical treatment of ruptured cerebral aneurysms that currently lack a consensus opinion. These treatments include centralized care in high-volume centers, as well as the use of antifibrinolytic therapy, routine cerebrospinal fluid diversion, intraoperative hypothermia, temporary clip application, neuroprotective drugs, intraoperative angiography, and decompressive hemicraniectomy. Although definitive answers will only be possible through future multicenter collaboration, we review the controversy surrounding these adjuncts and report the consensus opinion from a highly experienced audience.
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Affiliation(s)
- Ricardo J. Komotar
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Brad E. Zacharia
- Department of Neurological Surgery, Columbia University, New York, New York
| | - J Mocco
- Department of Neurological Surgery, Columbia University, New York, New York
| | - E. Sander Connolly
- Department of Neurological Surgery, Columbia University, New York, New York
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18
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Detección de episodios de hipoxia tisular isquémica mediante la monitorización neurofisiológica intraoperatoria combinada con la monitorización de la oxigenación tisular en la cirugía aneurismática. Neurocirugia (Astur) 2008. [DOI: 10.1016/s1130-1473(08)70234-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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19
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Lopez KA, Waziri AE, Granville R, Kim GH, Meyers PM, Connolly ES, Solomon RA, Lavine SD. CLINICAL USEFULNESS AND SAFETY OF ROUTINE INTRAOPERATIVE ANGIOGRAPHY FOR PATIENTS AND PERSONNEL. Neurosurgery 2007; 61:724-9; discussion 729-30. [DOI: 10.1227/01.neu.0000298900.84720.d0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Kim A. Lopez
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Allen E. Waziri
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Robert Granville
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Grace H. Kim
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Philip M. Meyers
- Departments of Neurological Surgery and Radiology, Columbia University Medical Center, New York, New York
| | - E. Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Robert A. Solomon
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Sean D. Lavine
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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20
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Fagundes-Pereyra WJ, Hoffman WE, Misra M, Charbel FT. Clip readjustment in aneurysm surgery after flow evaluation using the ultrasonic perivascular probe: case report. ARQUIVOS DE NEURO-PSIQUIATRIA 2005; 63:339-44. [PMID: 16100988 DOI: 10.1590/s0004-282x2005000200028] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Occlusion or stenosis of a parent vessel or its distal branches is a major cause of poor patient outcome after cerebral aneurysm surgery. Despite great attempts to preserve patency at the time of clip application, intraoperative visual observation may not reveal arterial compromise or occlusion. Quantitative measurement of blood flow in cerebral vessels during aneurysm surgery can help prevent ischaemia and improve patient outcome. We report a case of a large complex middle cerebral artery (MCA) aneurysm in which perivascular microflow probes were used to measure blood flow quantitatively in MCA and its branches before and after aneurysm clipping. Following aneurysm clipping, blood flow in the MCA branches were significantly reduced to less than its initial baseline value with occlusion of the inferior M2 segment. Prompt detection of compromised blood flow gave the surgeon the opportunity to adjust the clip. This adjustment was performed several times until restore MCA flow to its preclipping values. Intraoperative quantitative vessel-flow measurements were safe and may have prevented cerebral ischaemia and neurological deficit to this patient.
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Affiliation(s)
- Walter J Fagundes-Pereyra
- Department of Neurosurgery, University of Illinois at Chicago, 912 South Wood St. Chicago, Illinois 60612, USA.
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21
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Hoh BL, Cheung AC, Rabinov JD, Pryor JC, Carter BS, Ogilvy CS. RESULTS OF A PROSPECTIVE PROTOCOL OF COMPUTED TOMOGRAPHIC ANGIOGRAPHY IN PLACE OF CATHETER ANGIOGRAPHY AS THE ONLY DIAGNOSTIC AND PRETREATMENT PLANNING STUDY FOR CEREBRAL ANEURYSMS BY A COMBINED NEUROVASCULAR TEAM. Neurosurgery 2004; 54:1329-40; discussion 1340-2. [PMID: 15157289 DOI: 10.1227/01.neu.0000125325.22576.83] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2003] [Accepted: 02/11/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE At many centers, patients undergo both computed tomographic angiography (CTA) and digital subtraction angiography (DSA). This practice negates most of the advantages of CTA, and it renders the risks and disadvantages of the two techniques additive. Previous reports in the literature have assessed the sensitivity and specificity of CTA compared with DSA; however, these investigations have not analyzed the clinical implications of a protocol that replaces DSA with CTA as the only diagnostic and pretreatment planning study for patients with cerebral aneurysms. METHODS Since late 2001/early 2002, the combined neurovascular unit of the Massachusetts General Hospital has adopted a prospective protocol of CTA in place of DSA as the only diagnostic and pretreatment planning study for patients with cerebral aneurysms (ruptured and unruptured). We report the results obtained during the 12-month period from January 2002 to January 2003. RESULTS During the study period, 223 patients with cerebral aneurysms underwent initial diagnostic evaluation for cerebral aneurysm by the combined neurovascular team of Massachusetts General Hospital. Of the 223 patients, 109 patients had confirmed subarachnoid hemorrhage (Group A) and 114 patients did not have SAH (Group B). All of these patients were included in the prospective CTA protocol. Cerebral aneurysm treatment was initiated on the basis of CTA alone in 93 Group A patients (86%), in 89 Group B patients (78%), and in 182 patients (82%) overall. Treatment consisted of surgical clipping in 152 patients (68%), endovascular coiling in 56 patients (25%), endovascular parent artery balloon occlusion in 4 patients (2%), and external carotid artery to internal carotid artery bypass and carotid artery surgical occlusion in 2 patients (1%). Nine patients (4%) did not undergo treatment. The cerebral aneurysm detection rate by CTA was 100% for the presenting aneurysm (ruptured aneurysm in Group A or symptomatic/presenting aneurysm in Group B) in both groups. The detection rate by CTA for total cerebral aneurysms, including incidental multiple aneurysms, was 95.3% in Group A, 98.3% in Group B, and 97% overall. The overall morbidity associated with DSA (pretreatment or as intraoperative or postoperative clip evaluation) was one patient (1.3%) with a minor nonneurological complication, one patient (1.3%) with a minor neurological complication, and no patients (0%) with a major neurological complication. CONCLUSION We have demonstrated promising results with a prospective protocol of CTA in place of DSA as the only diagnostic and pretreatment planning study for patients with ruptured and unruptured cerebral aneurysms. It seems safe and effective to make decisions regarding treatment on the basis of CTA, without performing DSA, in the majority of patients with ruptured and unruptured cerebral aneurysms.
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Affiliation(s)
- Brian L Hoh
- Department of Radiology, Massachusetts General Hospital, and Harvard Medical School, Boston, 02114, USA
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22
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Klopfenstein JD, Spetzler RF, Kim LJ, Feiz-Erfan I, Han PP, Zabramski JM, Porter RW, Albuquerque FC, McDougall CG, Fiorella DJ. Comparison of routine and selective use of intraoperative angiography during aneurysm surgery: a prospective assessment. J Neurosurg 2004; 100:230-5. [PMID: 15086229 DOI: 10.3171/jns.2004.100.2.0230] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECT Whether routine intraoperative angiography is necessary for cerebral aneurysm surgery is currently under debate. In this study the authors prospectively assessed the cerebrovascular surgeon's accuracy in predicting the need for intraoperative angiography. METHODS Between January 2002 and January 2003, 200 consecutive patients (141 female and 59 male patients, mean age 52.8 years) with 235 aneurysms underwent routine intraoperative angiography. Before the operation, the surgeons indicated whether they believed that intraoperative angiography was necessary. Their responses were recorded as "intraoperative angiography necessary" or "intraoperative angiography unnecessary." Regardless of the response, all patients underwent intraoperative angiography after the aneurysm had been clipped. Changes in treatment resulting from intraoperative angiography were compared with surgeons' preoperative predictions of the need for intraoperative angiography. Intraoperative angiography was predicted to be necessary in 41 cases (20%) and unnecessary in 159 cases (80%). Its use altered treatment in 14 patients. Seven of these patients were among the group in which intraoperative angiography was deemed necessary and seven were in the group in which it was considered unnecessary. In the latter group, two patients had residual aneurysms, three had parent vessel occlusion, and two had previously undiagnosed aneurysms. Only one patient (0.5%) sustained a major intraoperative complication attributed to angiography. CONCLUSIONS Given the frequency of significant disease that remains undetected if intraoperative angiography is used on a selective basis and the low complication rate associated with the procedure, the use of intraoperative angiography should be considered in the majority of aneurysm cases.
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Affiliation(s)
- Jeffrey D Klopfenstein
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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23
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Lee MC, Macdonald RL. Intraoperative Cerebral Angiography: Superficial Temporal Artery Method and Results. Neurosurgery 2003; 53:1067-74; discussion 1074-5. [PMID: 14580273 DOI: 10.1227/01.neu.0000088739.89056.04] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2003] [Accepted: 05/21/2003] [Indexed: 12/13/2022] Open
Abstract
Abstract
OBJECTIVE
To report the method for and results of intraoperative cerebral angiography performed via the superficial temporal artery, for assessment of cerebral aneurysm surgery.
METHODS
All patients undergoing craniotomies for treatment of intracranial aneurysms were prospectively entered into a database. A policy of performing angiography via the superficial temporal artery in appropriate cases was instituted. This procedure was performed with retrograde catheterization of the superficial temporal artery, as it coursed over the zygomatic arch, with an 18-gauge, 1.88-inch, intravenous catheter and hand injection of contrast material, with intraoperative digital subtraction fluoroscopic guidance.
RESULTS
Thirty-six patients who underwent 38 craniotomies for clipping of 43 aneurysms underwent intraoperative angiography via the superficial temporal artery. There were six unexpected findings (14%), including four unexpected arterial occlusions and two unexpected residual aneurysms. One aneurysm was observed to be patent when it was punctured, after intraoperative angiography had indicated no filling of the aneurysm. Additional clips were placed. Three patients (8%) developed multiple arterial infarctions in the territory of the injected carotid artery, for which multiple causes were possible. Adequate angiographic images could usually be obtained with this method.
CONCLUSION
Intraoperative angiography via the superficial temporal artery is simple and is not associated with substantial complications. It is a reasonable alternative to transfemoral angiography for detection of adverse consequences of intracranial aneurysm clipping.
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Affiliation(s)
- Max C Lee
- Department of Surgery, Pritzker School of Medicine and the University of Chicago Medical Center, Chicago, Illinois 60637, USA
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24
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Chicoine MR. Microsurgery and clipping: the gold standard for the treatment of intracranial aneurysms. J Neurosurg Anesthesiol 2003; 15:61-3. [PMID: 12499987 DOI: 10.1097/00008506-200301000-00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri 63110, USA
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25
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Nanda A, Willis BK, Vannemreddy PSSV. Selective intraoperative angiography in intracranial aneurysm surgery: intraoperative factors associated with aneurysmal remnants and vessel occlusions. SURGICAL NEUROLOGY 2002; 58:309-14; discussion 314-5. [PMID: 12504291 DOI: 10.1016/s0090-3019(02)00884-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The objective of this study was to assess the role of selective intraoperative angiography and to analyze the factors associated with faulty clip application. METHODS Two hundred thirty-eight patients undergoing surgery for intracranial aneurysms were studied consecutively for intraoperative angiography (IOA)-related events. The procedure was performed in 155 operations. Demographic details, clinical grade of the patient, location and size of the aneurysm, intraoperative rupture, application of the temporary clip, IOA findings, and final outcome were analyzed. RESULTS In the 155 patients in the series, there were 125 anterior circulation aneurysms and 30 on the vertebrobasilar system. Aneurysms were smaller than 10 mm in 63% of the patients, and 19 were giant aneurysms. Thirty-eight percent were unruptured, 36% were Hunt and Hess Grades I and II, 21% were Grade III, and 5% were Grades IV and V. An intraoperative rupture occurred in 18 operations. Intraoperative angiography was normal in 88%; in 11 cases (7%) there was a residual neck, and in 8 (5%), occlusion of the artery was observed. An incomplete clipping was significantly related to intraoperative rupture of the aneurysm (p < 0.008) and anterior location of the aneurysm (p = 0.05), whereas vessel occlusion had a significant association with posterior location of the aneurysm (p < 0.0005). An eventful IOA had significant association with poor outcome (p < 0.003). CONCLUSION Intraoperative rupture and a posterior location of the aneurysm had a significant correlation with residual aneurysm and vessel occlusion, respectively. The use of IOA is justified in aneurysms associated with these factors.
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Affiliation(s)
- Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, 71130, USA
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26
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Chiang VL, Gailloud P, Murphy KJ, Rigamonti D, Tamargo RJ. Routine intraoperative angiography during aneurysm surgery. J Neurosurg 2002; 96:988-92. [PMID: 12066932 DOI: 10.3171/jns.2002.96.6.0988] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECT The routine use of intraoperative angiography as an aid in the surgical treatment of aneurysms is uncommon. The advantages of the ability to visualize residual aneurysm or unintended occlusion of parent vessels intraoperatively must be weighed against the complications associated with repeated angiography and prolonged vascular access. The authors reviewed the results of their routine use of intraoperative angiography to determine its safety and efficacy. METHODS Prospectively gathered data from all aneurysm cases treated surgically between January 1996 and June 2000 were reviewed. A total of 303 operations were performed in 284 patients with aneurysms; 24 patients also underwent postoperative angiography. Findings on intraoperative angiographic studies prompted reexploration and clip readjustment in 37 (11%) of the 337 aneurysms clipped. Angiography revealed parent vessel occlusion in 10 cases (3%), residual aneurysm in 22 cases (6.5%), and both residual lesion and parent vessel occlusion in five cases (1.5%). When compared with subsequent postoperative imaging, false-negative results were found on two intraoperative angiograms (8.3%) and a false-positive result was found on one (4.2%). Postoperative angiograms obtained in both false-negative cases revealed residual anterior communicating artery aneurysms. Both of these aneurysms also subsequently rebled, requiring reoperation. In the group that underwent intraoperative angiography, in 303 operations eight patients (2.6%) suffered complications, of which only one was neurological. CONCLUSIONS In the surgical treatment of intracranial aneurysms, the use of routine intraoperative angiography is safe and helpful in a significant number of cases, although it does not replace careful intraoperative inspection of the surgical field.
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Affiliation(s)
- Veronica L Chiang
- Department of Neurosurgery and Neuroradiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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27
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Tang G, Cawley CM, Dion JE, Barrow DL. Intraoperative angiography during aneurysm surgery: a prospective evaluation of efficacy. J Neurosurg 2002; 96:993-9. [PMID: 12066933 DOI: 10.3171/jns.2002.96.6.0993] [Citation(s) in RCA: 159] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Indications for intraoperative angiography during aneurysm surgery remain unclear. To define its use, the authors report the results of a prospective study in which this modality was used in all patients undergoing surgery for intracranial aneurysms. METHODS Intraoperative angiography was performed prospectively in the surgical treatment of 517 consecutive aneurysms regardless of the lesion's location, size, or complexity. In 64 (12.4%) of 517 aneurysms intraoperative angiography findings prompted a change in surgical treatment. Residual aneurysm (47%) was the most frequent finding leading to clip revision. In 44% of cases, intraoperative angiography revealed vessel compromise. Surgery for aneurysms of the proximal internal carotid artery (ICA) was the most frequently altered, with lesions located at the superior hypophyseal artery (SHA) and clinoidal region having the highest revision rates, eight (40%) of 20 and eight (44%) of 18, respectively. Aneurysm size predicted the need for revision; giant aneurysms (> 24 mm) underwent revision in nine (29%) of 31 cases, whereas large aneurysms (15-24 mm) were revised in 12 (22%) of 54 cases. In a multivariate logistic regression model, factors related to increased revision rates included the SHA and clinoidal locations, as well as giant and large size. Ninety-five patients underwent both intraoperative and postoperative angiography. Five discrepancies were noted (95% accuracy); four were flow-related and one involved a previously unrecognized residual aneurysm. Complications attributable to intraoperative angiography occurred in 0.4% of cases. CONCLUSIONS Proximal ICA location and large aneurysm size significantly predicted revision of surgery following intraoperative angiography. Unexpected findings, even in less complex locations, are frequently identified on intraoperative angiography. Low complication rates, high accuracy, and the unexpected need for clip readjustments favor a more widespread use of intraoperative angiography.
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Affiliation(s)
- Gordon Tang
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Yanaka K, Asakawa H, Noguchi S, Matsumaru Y, Hyodo A, Anno I, Meguro K, Nose T. Intraoperative angiography evaluation of the microsurgical clipping of unruptured cerebral aneurysms. Neurol Med Chir (Tokyo) 2002; 42:193-200; discussion 201. [PMID: 12064153 DOI: 10.2176/nmc.42.193] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Intraoperative angiography evaluation of the clippings of cerebral aneurysms was investigated in a series of 38 consecutive patients with unruptured cerebral aneurysms to determine any favorable impact on the outcome. Unexpected findings including major arterial occlusion or residual aneurysm were identified. Specific variables such as the size and site of aneurysm were analyzed to determine the impact on clinical outcome and the incidence of clip modification. There were 11 large and 27 small aneurysms in this series. Mortality and permanent morbidity after microsurgical clipping were 0.0% and 2.6%, respectively. Unexpected angiographic findings necessitating clip repositioning consisted of residual aneurysm in two cases and distal branch occlusion or parent vessel stenosis in four. The need for clip modification was significantly higher for large than for small aneurysms (p = 0.007), and the rate of clip adjustment increased with increasing aneurysm size (p = 0.008). Intraoperative assessment prior to wound closure allows for the recognition and correction of defects and decreases the risk of postoperative complications. Intraoperative angiography may become important in the microsurgical clipping of unruptured cerebral aneurysms, especially large aneurysms.
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Affiliation(s)
- Kiyoyuki Yanaka
- Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki.
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Charbel FT, Gonzales-Portillo G, Hoffman WE, Ostergren LA, Misra M. Quantitative assessment of vessel flow integrity for aneurysm surgery. Technical note. J Neurosurg 1999; 91:1050-4. [PMID: 10584856 DOI: 10.3171/jns.1999.91.6.1050] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Quantitative measurement of blood flow in cerebral vessels during aneurysm surgery can help prevent ischemic injury and improve patient outcome. The authors report a case of a superior cerebellar artery (SCA) aneurysm in which perivascular microflow probes were used to measure blood flow quantitatively in both the SCA and the posterior cerebral artery before and after aneurysm clipping. Following aneurysm clipping, blood flow in the SCA was reduced to less than 25% of its initial baseline value. Prompt detection of compromised blood flow gave the surgeon the opportunity to adjust the clip and restore SCA flow to its preclipping value within 5 minutes of initial clip placement. Quantitative vessel-flow measurements were integral to the safe progression of the operation and may have prevented an adverse neurological outcome in this patient. The recommended surgical technique and the principle of operation are described.
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Affiliation(s)
- F T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, 60612, USA.
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Nakazawa T, Nakajima M, Matsuda M, Handa J. Surgery of a large paraclinoid aneurysm with the support of coil embolization. Interv Neuroradiol 1998; 4 Suppl 1:89-92. [PMID: 20673451 DOI: 10.1177/15910199980040s118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/1998] [Accepted: 08/25/1998] [Indexed: 11/16/2022] Open
Abstract
SUMMARY An attempt was made to clip the neck of a large paraclinoid aneurysm with the support of a balloon catheter, using a trapping-evacuation technique. The clip applied to the neck slipped off because of blood pressure through the posterior communicating artery which arose from the dome of the aneurysm. Therefore, using portable digital subtraction angiography (DSA) equipment, we placed interlocking detachable coils (IDCs) in the aneurysm for the purpose of reducing the intraaneurysmal pressure. Although the aneurysm was eventually trapped with two clips, this case indicates the supportive role of intravascular intervention in aneurysmal surgery when clipping an aneurysm or immediately after clip failure.
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Affiliation(s)
- T Nakazawa
- Department of Neurosurgery, Shiga University of Medical Science; Shiga, Japan
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