Desórdenes neurológicos

Procedural Paradigm in Intraoperative Aneurysm Clipping with Microdoppler Ultrasound, Near-Infrared Indocyanine Green Videoangiography and Intraoperative Angiography

Abstract

Athanasios K Petridis, Adrian Kinzel, Lutz Schreiber and Richard Parvin

Introduction: The aim of surgical treatment of aneurysm is complete aneurysm obliteration and maintenance of a physiologic flow in the proximal and distal vessels. To avoid any risks of failing these aims intraoperative- angiography was introduced in neurosurgery first, followed by microdoppler-ultrasonography and lately with Indocyanine-Green-Videoangiography (ICG-VA). After reviewing the literature and analysing our own results with the different methods we propose an intraoperative paradigm to optimize aneurysm clipping with the least risk of vessel occlusion or residual aneurysm.

Patients and methods: Twenty-five incidental aneurysms (bleeding aneurysms were excluded) were clipped in 2012 in our hospital with intraoperative use of microdoppler and ICG-VA. All patients received postoperative cerebral angiography. The surgical results with use of these methods were compared to postoperative angiography. Review of literature has been performed and a procedural flow chart was created.

Results: In 20/25 (80%) patients the combination of microdoppler and ICG-VA led to an optimisation and repositioning of the clip intraoperatively. In the remaining 5 patients clip re-positioning was not necessary since optimal position was confirmed. Reasons for clip re-positioning were stenosis of the vessels related to the aneurysm or a residual aneurysm neck. None of the patients needed another surgery according to postsurgical angiography. Review of the literature implicates a complemental role for microdoppler, ICG-VA and intraoperative-angiography since every method has its own advantages and disadvantages. We propose a flow chart for the use of all three methods together.

Conclusion: Microdoppler, ICG-VA and intraoperative-angiography should be used in concert under special circumstances. Using them in a given order according to their simplicity, speed and cost effectiveness may reduce complications related to the microsurgical clip placement for intracranial aneurysms. However, prospective studies are needed to prove our observations