Keyhole clipping of a low-lying basilar apex aneurysm without posterior clinoidectomy utilizing endoscopic indocyanine green video angiography
- Department of Neurosurgery, Rush University Medical Center, Chicago,
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois.
Ricky H. Wong
Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois.
DOI:10.25259/SNI_582_2019Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Andrew K. Wong, Ricky H. Wong. Keyhole clipping of a low-lying basilar apex aneurysm without posterior clinoidectomy utilizing endoscopic indocyanine green video angiography. 28-Feb-2020;11:31
How to cite this URL: Andrew K. Wong, Ricky H. Wong. Keyhole clipping of a low-lying basilar apex aneurysm without posterior clinoidectomy utilizing endoscopic indocyanine green video angiography. 28-Feb-2020;11:31. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=9885
Background:Basilar apex (BX) aneurysms are surgically challenging due to their anatomic location, need to traverse neurovascular structures, and proximity to multiple perforator arteries. Surgical approaches often require extensive bone resection and neurovascular manipulation. Visualization of low-lying BX aneurysms is typically obscured by the posterior clinoid and upper clivus and poses a unique challenge. Subtemporal or anterolateral approaches with a posterior clinoidectomy are often required to achieve adequate exposure, though these maneuvers can add invasiveness, risk, and morbidity to the procedure. Endoscopes and, more recently, fluoroscopic angiography capable endoscopes offer the possibility of providing improved visualization with less exposure allowing for minimally invasive clipping.
Case Description:We present the case of a 42-year-old female with incidentally found 5 mm middle cerebral artery and 5 mm BX aneurysms. She underwent a minimally invasive supraorbital keyhole craniotomy for the clipping of both aneurysms. While the posterior clinoid obstructed the necessary visualization for the BX aneurysm, use of endoscopy and endoscopic fluoroscopic angiography allowed for safe and successful clipping without the need for a posterior clinoidectomy.
Conclusion:This represents the first reported case of a BX aneurysm clipping through a minimally invasive keyhole craniotomy using endoscopic indocyanine green video angiography. Use of endoscopic indocyanine green angiography, combined with keyhole endoscopic approaches, allows for safe minimally invasive clipping of challenging posterior circulation aneurysms.
Keywords: Basilar apex aneurysm, Endoscopic indocyanine green, Endoscopic surgery, Keyhole craniotomy, Minimally invasive aneurysm clipping
Basilar apex (BX) aneurysms are anatomically situated in one of the most challenging areas for a neurosurgeon to access. While the array of endovascular tools used to treat various aneurysms and the proportion of aneurysms treated through such procedures increases, there continues to be a certain subset of patients with BX aneurysms who could benefit from clipping.[
A 42-year-old female presenting with headaches was found to have a 5 mm laterally projecting right middle cerebral artery (MCA) bifurcation aneurysm and a 5 mm BX aneurysm [
Preoperative computed tomography angiography (CTA) evaluation of the patient’s aneurysms revealed aneurysms amenable for surgical clipping through a supraorbital keyhole approach (SOKA). The MCA bifurcation aneurysm was noted to be at the level of the lesser wing of the sphenoid bone and evaluation of the anatomical accessibility of the BX aneurysm was determined using the orbital roof-dorsum estimation line as previously described.[
Orbital roof-dorsum estimation line. (a) Orbital height (red line) as measured by the line extending from the anterior skull base along the sagittal scout line (yellow line) to the intersection with the horizontal orthogonal line (blue solid) from the roof of the orbit to the sagittal scout line (b) orbital height line as determined on coronal section translated onto the coronal scout line in the sagittal plane with the orbital roof-dorsum estimation line (green line) extending from the superior point to the top of the posterior clinoid process. In this patient, this line estimates that the most conservative proximal exposure from a supraorbital approach is the neck of the aneurysm.
The patient was positioned supine and the head was placed in three-point fixation. A right-sided approximately 5 cm eyebrow incision was made extending from the supraorbital notch to just lateral to the superior temporal line [
Basilar apex aneurysm (a) microscopic exposure through oculomotor carotid window obstructed by the posterior clinoid (dashed line) (b) endoscopic exposure (c) endoscopic indocyanine green angiography (d) aneurysm clip placement (e) endoscopic view of clip construct (f) endoscopic indocyanine green angiography demonstrating complete aneurysm obliteration with maintenance of perforating arteries. BA: Basilar artery, SCA: Superior cerebellar artery, PCA: Posterior cerebral artery, Perf: Perforator artery, *: Basilar apex aneurysm.
Postoperative CTA confirmed adequate placement of clips with no residual [
Aneurysms of the BX represent some of the most challenging aneurysms for the neurosurgeon. They are situated deep within the intracranial space and bound by neurovascular structures and critical perforators. While there has been a shift toward treating a majority of these aneurysms through endovascular techniques, there remains a subset of patients for whom surgical clipping continues to be the ideal treatment including those with wide-necked or small aneurysms, those who have failed endovascular treatment, and younger patients where a more definitive upfront treatment is desired.[
Critical to the success of any aneurysm surgery is the ability to completely include the aneurysm neck with the surgical clip while maintaining patency of the parent vessel and perforators. Intraoperative strategies to achieve this include electrophysiological monitoring, microDopplers, digital subtraction angiography (DSA), and ICG-VA.[
Classically, approaches to BX aneurysms were through subtemporal, pterional, or orbitozygomatic craniotomies. While the subtemporal approach offers a shorter working distance and a more exposed view of the proximal BA, which can be useful for low lying BX aneurysms, it is significantly limited by the inability to visualize contralateral perforators as well as the need for temporal lobe retraction.[
Improved exposure and visualization of deep-seated structures can alternatively be achieved using endoscopes. By advancing the ocular lens past visually obstructive proximal structures and through the OCW or COW, these gateways become pivot points for the camera rather than bottlenecks.[
In 2013, Bruneau et al. described the first reported use of eICG-VA in aneurysm surgery for a patient with an unruptured anterior communicating artery aneurysm.[
There have been relatively few studies on the use of eICG- VA and most studies to date offer an evaluation of eICG- VA as compared to mICG-VA. As such, surgical exposure was achieved to allow for mICG-VA evaluation and only then was eICG-VA deployed to further scrutinize clip placement.[
In this report, we describe the first minimally invasive keyhole approach for the surgical clipping of a BX aneurysm using eICG-VA. As with any aneurysm clipping, but paramount in BX aneurysms, careful evaluation of preoperative imaging studies as well as a strong understanding of the anatomy is critical to the success of the surgery. Furthermore, knowing the individual strengths and limitations of both the microscope and the endoscope allows you to use them in a complementary fashion to reduce unnecessary exposure and morbidity while maintaining the quality of clip placement. In this case, we were able to estimate the amount of BX exposure we would achieve with a supraorbital approach.[
While endovascular technology continues to evolve, there remains a subset of aneurysms that could benefit from definitive surgical clipping. The full use of surgical technology such as endoscopes and eICG-VA can allow for reduced invasiveness and morbidity while maintaining efficacy in treatment.
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