gms | German Medical Science

Objective: Indocyanin green (ICG) video-angiography (VA) in cerebral aneurysm surgery allows intraoperative confirmation of blood flow in parent-, branching and perforating vessels and assessment of remnant aneurysm parts after clip application. A retrospective analysis was conducted to determine the advantages of the method.

Method: A total number of 246 procedures in 232 patients harboring 295 aneurysms operated on using ICG-VA was investigated (159 women, 73 men, mean age 54 yrs., 124 after SAH and 122 for incidental aneurysms). In 185 patients, singular and in 47 patients multiple aneurysms were clipped (mean diameter 6.9 mm, from 2–40 mm). No ICG-VA associated complications occurred. Intraoperative micro-vascular Doppler sonography was performed before ICG- VA in all patients, postoperative DSA was available in 121 patients (52, 2%) for retrospective comparative analysis.

Results: In 22 of 242 procedures (9.1%), the clip position was modified intraoperatively as a consequence of ICG-VA. Stenosis of parent vessels (16 patients) or occlusion of perforators (6 patients) were the most common problems detected. In 11 patients (4.5%), a residual perfusion of the aneurysm was observed. Both findings were independent of aneurysm location. In 2 patients (0.8%), aneurysm puncture revealed residual blood flow within the aneurysm, not detected by ICG- VA before. In the postoperative DAS, unexpected small (<2 mm) aneurysm neck remnants were found in 11 of 121 patients (9.1%), which were not detected in the ICG-VA intraoperatively. However, these remained without consequence except one patient with a 6 mm residual aneurysm dome, which was subsequently coil embolized.

Conclusions: In our large consecutive patient cohort, ICG-VA proved to be a helpful intraoperative tool and led to a significant intraoperative clip modification rate of 15%. However, small neck remnants (<2 mm) and one 6 mm residual aneurysm were missed by intraoperative ICG angiography in up to 10% of patients. Our results confirm that DSA is indispensable for postoperative quality assessment in complex aneurysm surgery.