Role of endoscopy in multi-modality monitoring during aneurysm surgery: A single center experience with 175 consecutive unruptured aneurysms

Abstract

Objective and background: Unruptured aneurysm surgery is a challenge to all vascular neurosurgeons as the patient is asymptomatic and no even slight neurological deficits should be expected postoperatively. To this aim, multi-modality checking of the vessels during the surgery is highly recommended to assure of the patency of the parent and perforator arteries next to an aneurysm. In this paper, we present our experience in the last 1.5 years with emphasis on the role of endoscope assisted microsurgery.

Methods: One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years. All patients underwent endoscope assisted microsurgery with pre- and post-clipping indocyanine green angiography. In selected cases, motor evoked potential monitoring was implemented.

Results: No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively. Our illustrative cases show how endoscopy may help the surgeon to visualize hidden vessels behind and medial to an aneurysm.

Conclusions: Our results indicated that multi-modality monitoring during unruptured aneurysm surgeries is associated with excellent outcome. Endoscope is able to show blind corners during aneurysm surgery which cannot be routinely observed with microscope and its application in aneurysm surgery assists the surgeon to make certain of complete neck clipping and preservation of perforating arteries around the aneurysm.

Keywords: Brain; clipping; endoscopy; monitoring; unruptured aneurysm.

Figure 1

An internal carotid artery (ICA) postcommunicating segment aneurysm with the neck medially located. (a) Despite gentle retraction of the brain, the aneurysm neck and the surrounding vessels cannot be visualized well. (b) Some slight manipulation of the ICA with a suction tip to open a corridor is practiced but still indocyanine green angiography is not able to show the perforating arteries. (c) An endoscope is introduced to the field under microscopic vigilance. (d) Neck of the aneurysm as well as the medially located perforators come into the endoscopic view. (e) An angled fenestrated clip is inserted in parallel to the ICA to obstruct the medially located neck. (f) Endosopic view after insertion of the aneurysm clip to confirm complete obliteration of the neck without engulfment of the perforators

Figure 2

(a) Internal carotid artery choroidal segment aneurysm in 71-year-old man [case 5 in Table 3]. (b) Intra-operative view of the aneurysm and (c) the same view after fluorescence angiography. (d) Endoscopic view showing the perforators behind the aneurysm. (e) Clipping of the aneurysm and (f) postaneurysm clipping demonstrating perforators. The patient recovered fully from the anesthesia when 6 h later he developed contra-lateral incomplete hemiparesis which despite aggressive medical therapy turned into a complete hemiplegia after 36 h