The Clinical Importance of Perforator Preservation in Intracranial Aneurysm Surgery: An Overview with a Review of the Literature

Abstract

Clipping for intracranial aneurysms is done to achieve complete occlusion of the aneurysm without a remnant sac. Despite modern advancements of neurosurgical techniques, morbidity related to the clipping of intracranial aneurysms still exists. Clip occlusion of a parent artery or small hidden perforators commonly leads to permanent neurological deficits, and is a serious and unwanted complication. Thus, preserving blood flow in the branches and perforators of a parent artery is very important for successful surgery without postoperative morbidity and mortality. The aim of this review article is to discuss the consequences of perforator injury and how to avoid this phenomenon in aneurysm surgeries using intraoperative monitoring devices.

Keywords: Arteries; Intracranial Aneurysm; Monitoring, Intraoperative; Neurosurgical Procedures; Surgical Instruments.

FIG. 1. Schematic illustration of relationships between aneurysms and perforators. The aneurysms involving these perforators arise at four sites: (1) Origin of the anterior choroidal artery, (2) internal carotid bifurcation, (3) middle cerebral artery bifurcation, (4) anterior communicating artery. Courtesy by Rosner et al.

FIG. 2. Representative case of internal carotid artery bifurcation aneruysm. (A) Intraoperative findings of multiple perforators arising behind aneurysm. (B) Indocyanine green video angiography findings showing perforator preservation after aneurysm clipping.