Superselective Indocyanine Green Angiography for Selective Revascularization in the Management of Peripheral Cerebral Aneurysms

A. Gruber; C. Dorfer; G. Bavinzski; H. Standhardt; H. Ferraz-Leite; E. Knosp

doi:10.3174/ajnr.A2424

Abstract

SUMMARY: This report describes the management of a fusiform peripheral middle cerebral artery aneurysm by endovascular parent artery occlusion under bypass protection. Localization of the recipient cortical artery was accomplished after craniotomy by superselective injection of diluted ICG dye via a microcatheter positioned proximal to the aneurysm. This report demonstrates that superselective ICG angiography can be a beneficial alternative technique to identify the best anastomosis site intraoperatively.

ABBREVIATIONS:

DSA: digital subtraction angiography
ICG: indocyanine green
MCA: middle cerebral artery
PAO: parent artery occlusion

Intracranial fusiform aneurysms occurring beyond the circle of Willis are rare and challenging lesions.^{1⇓⇓⇓–5} Possible therapeutic strategies include deconstructive techniques such as trapping and endovascular PAO as well as reconstructive techniques such as direct clipping and stent reconstruction.^{1,4,6⇓⇓⇓⇓–11} Deconstructive procedures are often performed under bypass protection to preserve cerebral perfusion distal to the occluded aneurysm.^3⇓–5 Correct localization of the cortical recipient artery distal to the aneurysm is of importance for selective revascularization. Identification of this branch is possible by surgical dissection, neuronavigation, and stereotactic techniques as well as intraoperative DSA.^{12⇓⇓–15}

In this technical case report, we describe the management of a fusiform peripheral MCA aneurysm by endovascular PAO under bypass protection. Localization of the recipient cortical artery was accomplished after craniotomy by superselective injection of diluted ICG dye via a microcatheter positioned proximal to the aneurysm.^1,16 Fluorescent activity in the corresponding distal cortical artery was detected under the operation microscope.

Case Report/Technique

A 21-year-old woman was admitted with the incidental MR imaging finding of a 10-mm vascular lesion in the posterior limb of the left insular cistern (Fig 1A). DSA disclosed a fusiform peripheral MCA aneurysm (Fig 1B). In view of the eloquence of the dependent distal vascular territory, surgical trapping and endovascular PAO were considered impracticable. Stent reconstruction of the aneurysm was considered but deferred because of the tortuosity of the aneurysm and the caliber mismatch between the proximal and distal parent arteries. The decision was made to occlude the aneurysm under bypass protection. Because the team of vascular neurosurgeons involved in the management of cerebral aneurysms at our center is cross-experienced in the surgical and endovascular management of cerebrovascular lesions, a strategy of endovascular PAO immediately after bypass surgery was developed.

Fig 1.

A and B, MR imaging and DSA detecting a fusiform peripheral left MCA aneurysm. C, Intraoperative superselective microangiography demonstrating the aneurysm and the distal cortical recipient artery for selective revascularization. D and E, Microsurgical exploration and intravenous ICG angiography showing the cerebral vasculature at the craniotomy site. F, Microcatheter ICG injection (0.1 mg/ml) selectively opacifies the vascular territory distal to the aneurysm. G, Selective revascularization via a monopedicle arterial low-flow bypass is performed with the anastomosis site within the previously identified vascular territory. H and I, Control angiograms before and after aneurysm occlusion demonstrating bypass patency and correct selective peripheral revascularization. Arrows indicate later anastomosis site.

A 5F sheath was placed at the right groin and a 5F macrocatheter was advanced into the left common carotid artery. The frontal branch of the superficial temporal artery was of sufficient size and was used as the donor vessel for an arterial low-flow bypass. After microsurgical dissection of this branch, craniotomy, and dural opening, an SL 10 microcatheter (Boston Scientific, Fremont, California) was coaxially advanced through the macrocatheter into the left MCA and navigated under fluoroscopic road-mapping control to a superselective position proximal to the aneurysm. Thereafter, selective angiograms were obtained, and the position and morphology of the distal cortical recipient artery were assessed (Fig 1C). ICG dye (ICG-PULSION; PULSION Medical Systems, Munich, Germany) was then applied via a peripheral vein (25 mg), and the morphology of the cortical vasculature at the craniotomy site was studied under an operation microscope (Zeiss Pentero; Carl Zeiss, Oberkochen, Germany; Fig 1D, –E). After 10 minutes, 2 mL of ICG dye diluted to 0.1 mg/ml was injected superselectively via the microcatheter into the parent artery of the aneurysm. Under the operation microscope, fluoroscopic activity could be detected selectively in the vascular territory supplied by the injected artery and a suitable cortical recipient artery could be identified easily (Fig 1F). After withdrawal of the microcatheter, bypass surgery was completed (Fig 1G). At the end of the operation, another microcatheter access to the aneurysm was performed, and endovascular PAO was accomplished by using detachable coils (Fig 1H). The correct localization of the anastomosis was verified by selective intraoperative DSA of the external carotid artery territory (Fig 1I).

Discussion

In this article, we describe the intraoperative identification of a cortical recipient artery for selective revascularization of a peripheral vascular territory. The technique described may not be necessary in all cases of small peripheral aneurysms, where the distal recipient artery may easily be identified by surgical dissection. However, when selective revascularization of a distal vascular territory is required in the management of larger or more complex peripheral aneurysms and endovascular expertise is available, this technique can be a reasonable alternative. Intraoperative microcatheter manipulations were easily possible, and monoplane imaging quality was comparable to that of standard endovascular angiography suites. Permanent flushing of all catheter systems with heparinized saline is mandatory to avoid thromboembolic complications and did not adversely affect coagulation intraoperatively. The concentration of the ICG dye for intra-arterial injection was adjusted to simulate arterial ICG concentrations after intravenous bolus injections. Because the operation room setup allowed for endovascular interventions and the catheter systems were already in place, the aneurysm was obliterated via the endovascular route. The most suitable surgical or endovascular technique to obliterate such aneurysms is usually chosen individually on a case-by-case basis, and it is not the purpose of this report to advocate either technique.

Conclusions

Peripheral intracranial aneurysms can be managed effectively by surgical or endovascular PAO under bypass protection.^3⇓–5 When selective revascularization of a vascular territory distal to the aneurysm is required, localization of the correct cortical recipient vessel is of importance. Superselective ICG angiography as described in this report can be a beneficial alternative technique to identify the best anastomosis site intraoperatively.

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Received August 26, 2010.
Accepted after revision September 29, 2010.

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[1] 1.↵
Dashti R,
Laakso A,
Niemelä M,
et al
. Microscope-integrated near-infrared indocyanine green videoangiography during surgery of intracranial aneurysms: the Helsinki experience. Surg Neurol 2009; 71: 543– 50; discussion 550
CrossRef PubMed

[2] Dashti R,

[3] Laakso A,

[4] Niemelä M,

[5] et al

[6] 2.↵
Dashti R,
Hernesniemi J,
Niemelä M,
et al
. Microneurosurgical management of distal middle cerebral artery aneurysms. Surg Neurol 2007; 67: 553– 63
CrossRef PubMed

[7] Dashti R,

[8] Hernesniemi J,

[9] Niemelä M,

[10] et al

[11] 3.↵
El Beltagy M,
Muroi C,
Imhof HG,
et al
. Peripheral large or giant fusiform middle cerebral artery aneurysms: report of our experience and review of literature. Acta Neurochir Suppl 2008; 103: 37– 44
CrossRef PubMed

[12] El Beltagy M,

[13] Muroi C,

[14] Imhof HG,

[15] et al

[16] 4.↵
Nussbaum ES,
Madison MT,
Goddard JK,
et al
. Peripheral intracranial aneurysms: management challenges in 60 consecutive cases. J Neurosurg 2009; 110: 7– 13
CrossRef PubMed

[17] Nussbaum ES,

[18] Madison MT,

[19] Goddard JK,

[20] et al

[21] 5.↵
Sakamoto S,
Ikawa F,
Kawamoto H,
et al
. Acute surgery for ruptured dissecting aneurysm of the M3 portion of the middle cerebral artery. Neurol Med Chir (Tokyo) 2003; 4: 188– 91

[22] Sakamoto S,

[23] Ikawa F,

[24] Kawamoto H,

[25] et al

[26] 6.↵
Andreou A,
Ioannidis I,
Mitsos A
. Endovascular treatment of peripheral intracranial aneurysms. AJNR Am J Neuroradiol 2007; 28: 355– 61
Abstract/FREE Full Text

[27] Andreou A,

[28] Ioannidis I,

[29] Mitsos A

[30] 7.↵
Biondi A,
Jean B,
Vivas E,
et al
. Giant and large peripheral cerebral aneurysms: etiopathologic considerations, endovascular treatment, and long-term follow-up. AJNR Am J Neuroradiol 2006; 27: 1685– 92
Abstract/FREE Full Text

[31] Biondi A,

[32] Jean B,

[33] Vivas E,

[34] et al

[35] 8.↵
Cloft HJ,
Kallmes DF,
Jensen ME,
et al
. Endovascular treatment of ruptured, peripheral cerebral aneurysms: parent artery occlusion with short Guglielmi detachable coils. AJNR Am J Neuroradiol 1999; 20: 308– 10
Abstract/FREE Full Text

[36] Cloft HJ,

[37] Kallmes DF,

[38] Jensen ME,

[39] et al

[40] 9.↵
Eckard DA,
O'Boynick PL,
McPherson CM,
et al
. Coil occlusion of the parent artery for treatment of symptomatic peripheral intracranial aneurysms. AJNR Am J Neuroradiol 2000; 21: 137– 42
Abstract/FREE Full Text

[41] Eckard DA,

[42] O'Boynick PL,

[43] McPherson CM,

[44] et al

[45] 10.↵
Turk AS,
Niemann DB,
Ahmed A,
et al
. Use of self-expanding stents in distal small cerebral vessels. AJNR Am J Neuroradiol 2007; 28: 533– 36
Abstract/FREE Full Text

[46] Turk AS,

[47] Niemann DB,

[48] Ahmed A,

[49] et al

[50] 11.↵
Zhang J,
Lv X,
Jiang C,
et al
. Endovascular treatment of cerebral aneurysms with the use of stents in small cerebral vessels. Neurol Res 2010; 32: 119– 22
CrossRef PubMed

[51] Zhang J,

[52] Lv X,

[53] Jiang C,

[54] et al

[55] 12.↵
Carvalho FG,
Godoy BL,
Reis M,
et al
. Frameless stereotactic navigation for intraoperative localization of infectious intracranial aneurysm. Arq Neuropsiquiatr 2009; 67: 911– 13
CrossRef PubMed

[56] Carvalho FG,

[57] Godoy BL,

[58] Reis M,

[59] et al

[60] 13.↵
Elowiz EH,
Johnson WD,
Milhorat TH
. Computerized tomography (CT) localized stereotactic craniotomy for excision of a bacterial intracranial aneurysm. Surg Neurol 1995; 44: 265– 69
CrossRef PubMed

[61] Elowiz EH,

[62] Johnson WD,

[63] Milhorat TH

[64] 14.↵
Harris A,
Levy E,
Kanal E,
et al
. Infectious aneurysm clipping by an MRI/MRA wand-guided protocol. A case report and technical note. Pediatr Neurosurg 2001; 35: 90– 93
CrossRef PubMed

[65] Harris A,

[66] Levy E,

[67] Kanal E,

[68] et al

[69] 15.↵
Steinberg GK,
Guppy KH,
Adler JR,
et al
. Stereotactic, angiography-guided clipping of a distal, mycotic intracranial aneurysm using the Cosman-Roberts-Wells system: technical note. Neurosurgery 1992; 30: 408– 11
PubMed

[70] Steinberg GK,

[71] Guppy KH,

[72] Adler JR,

[73] et al

[74] 16.↵
Raabe A,
Nakaji P,
Beck J,
et al
. Prospective evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery. J Neurosurg 2005; 103: 982– 89
PubMed

[75] Raabe A,

[76] Nakaji P,

[77] Beck J,

[78] et al

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Superselective Indocyanine Green Angiography for Selective Revascularization in the Management of Peripheral Cerebral Aneurysms

Abstract

ABBREVIATIONS:

Case Report/Technique

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Conclusions

References

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Superselective Indocyanine Green Angiography for Selective Revascularization in the Management of Peripheral Cerebral Aneurysms

Abstract

ABBREVIATIONS:

Case Report/Technique

Discussion

Conclusions

References

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