- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin 53792, USA
Mustafa K. Baskaya
Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin 53792, USA
DOI:10.4103/2152-7806.118936Copyright: © 2013 Gürer B This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Bora Gürer, Antar V, Cikla U, Bauer A, Baskaya MK. Intraoperative dynamic assessment of the posterior communicating artery and its branches by indocyanine green videoangiography. Surg Neurol Int 25-Sep-2013;4:122
How to cite this URL: Bora Gürer, Antar V, Cikla U, Bauer A, Baskaya MK. Intraoperative dynamic assessment of the posterior communicating artery and its branches by indocyanine green videoangiography. Surg Neurol Int 25-Sep-2013;4:122. Available from: http://sni.wpengine.com/surgicalint_articles/intraoperative-dynamic-assessment-of-the-posterior-communicating-artery-and-its-branches-by-indocyanine-green-videoangiography/
Background:True hemodynamic assessment of the posterior communicating artery (PComA) by preoperative angiography in terms of its perforators and configuration (adult vs. fetal vs. transitional) can be challenging in the surgical treatment of aneurysms involving the PComA, posterior cerebral artery, and basilar artery. Indocyanine green videoangiography (ICG-VA) is a widely accepted new technique in the surgical treatment of intracranial aneurysms to assess the patency of the parent artery, branches, and residual flow within the aneurysm after clipping.
Case Description:Here we report two cases in which ICG-VA was utilized to assess either the direction of flow in the PComA or preservation of the PComA perforators with temporary clip application before dividing the PComA.
Conclusions:Our experience is that ICG-VA can be used to assess the main trunk, and perforating branches of the PComA providing real-time, dynamic intraoperative information of the surgical field. Therefore we suggest that ICG-VA may increase the safety of surgical treatment of aneurysm involving PComA.
Keywords: Aneurysm, basilar artery, indocyanine green videoangiography, perforating arteries, posterior communicating artery
The main goal of aneurysm surgery is the obliteration of the aneurysm with preservation of flow in the parent artery, its branches, and perforators.[
During surgical clipping of the basilar bifurcation or P1 segment of posterior cerebral artery (PCA) aneurysms, if the basilar bifurcation is quite high in relation to the dorsum sella or the posterior communicating artery (PComA) is tethering the PCA, dividing the PComA might allow surgeon to access the aneurysm safely, provided that PComA is not a fetal type. Once the decision is made to divide the PComA, extreme care must be exercised to avoid injury to the anterior thalamoperforating arteries arising from the PComA.[
Clipping of the PComA aneurysms has a reputation of being easy due to the fact that the aneurysm neck and the PComA origin can be included in the clip blades if the PComA is not of the fetal type. However, there are rare cases in which the assessment of dynamics, configuration, and flow direction of the PComA cannot be assessed by preoperative radiologic studies.
Here we report two cases in which ICG-VA was utilized to assess the preservation of the PComA perforators with temporary clip application before dividing the PComA to allow wider access to the basilar and posterior cerebral arteries.
A 42-year-old female presented with Hunt and Hess grade IV subarachnoid hemorrhage (SAH), which improved to grade III after placement of a ventriculostomy. Computed tomography (CT) and CT angiography revealed a diffuse SAH and ruptured basilar tip aneurysm [
(a) Computed tomography revealing diffuse subarachnoid hemorrhage. (b) 3D-reconstruction of digital subtraction revealing a broad base small aneurysm of the basilar tip. (c) Digital subtraction angiography revealing quite high basilar tip in relation to the dorsum sella. (d) Postoperative digital subtraction angiography revealing the total obliteration of the aneurysm
A 47-year-old female presented with headache. CT angiography and a four-vessel angiogram revealed a PComA–PCA junction aneurysm on the right hemisphere and P1 segment aneurysm on the left side [Figure
Preoperative computed tomography-angiography (a) and digital subtraction angiography (b) revealing right posterior communicating artery-posterior cerebral artery and left P1 segment aneurysms. Postoperative intravenous-digital subtraction angiography (c, d) revealing the total obliteration of the aneurysm with presentation of the P1 perforating branch
The ICG-VA has been widely used in cerebrovascular surgery and the reliability of ICG-VA has been previously demonstrated in aneurysm, arteriovenous malformation, and dural arteriovenous fistula surgeries.[
Many authors reported that PComA can be safely divided or occluded when needed in aneurysm surgery,[
All of these previous reports were presented before the ICG-VA era, and the vascular integrity had been assessed visually. In this present report, we suggest that ICG-VA provides safe and real-time assessment of the flow and the perforating arteries. In this technique, the first ICG-VA is performed to assess the normal anatomy of the PComA and perforators. Temporary clip is then applied for mimicking the division of the PComA. Under temporary clipping a second ICG-VA is performed to prove the patency of the PComA perforators and the direction of the flow. If the PComA is divided, another ICG-VA is performed to verify the final situation after division.
Anatomical studies showed that most of the PComA perforating arteries seldom arise from the posterior half of the vessel.[
The basilar artery aneurysm surgery is still a challenging procedure for neurosurgeons because these aneurysms are closely related to perforating arteries of the PCA. During an approach to the basilar tip, the PCA may be tethered by the PComA and cannot be mobilized. Also, the PComA may interfere with visibility and manipulation around the aneurysm neck.[
To assess vessel patency, numerous intraoperative techniques have been developed, such as intraoperative DSA, microvascular Doppler ultrasonography, and ICG-VA. Of these, IA is the most sensitive and the gold standard.[
In this study, we report our experience utilizing ICG-VA in assessing the main trunk and perforating branches of the PComA providing real-time, dynamic intraoperative information about the surgical field. Therefore, we believe that ICG-VA may increase the safety of the clipping procedure in the treatment of PComA, PCA, and basilar tip aneurysms.
The Authors thank Gregory C. Kujoth, PhD, for technical assistance in video editing.
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