Temporary Clip Research Articles

Surgical Management of a Ruptured Dissecting Anterior Cerebral Artery (A2) Aneurysm Utilizing Contralateral Frontopolar for Reconstruction: 2-Dimensional Operative Video.

Dissecting aneurysms can pose an immense surgical challenge, and intervention often involves high risk for rerupture because of the volatile nature of the fibrin thrombus overlying the rupture site. This patient presented following rupture of a dissecting aneurysm along the A2 segment of the anterior cerebral artery (ACA). The patient underwent a right orbitozygomatic craniotomy, and the aneurysm was approached within the interhemispheric fissure. Manipulation of the aneurysm dome resulted in intraoperative rerupture of the aneurysm, which was controlled by the application of a temporary clip on the parent A2 proximally and distally. Aneurysmectomy of the thin diseased vessel wall was performed. The defect was filled by transecting the frontopolar branch of the ACA and sewing the frontopolar branch onto the aneurysmectomy defect. This provided a suitable patch for the ACA defect. Postprocedural indocyanine green angiography demonstrated patency of the A2 and the anastomosed frontopolar branch. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Precise MEP monitoring with a reduced interval is safe and useful for detecting permissive duration for temporary clipping

Although temporary clipping of the parent artery is an indispensable technique in clipping surgery for intracranial aneurysms, the permissive duration of temporary clipping is still not well known. The aim of this study is to confirm the safety of precise motor evoked potential (MEP) monitoring and to estimate the permissive duration of temporary clipping for middle cerebral artery (MCA) aneurysm based on precise MEP monitoring results. Under precise MEP monitoring via direct cortical stimulation every 30 seconds to 1 minute, surgeons released a temporary clip and waited for MEP amplitude to recover following severe (>50%) reduction of MEP amplitude during temporary clipping. Precise MEP monitoring was safely performed. Twenty-eight instances of temporary clipping were performed in 42 MCA aneurysm clipping surgeries. Because precise MEP monitoring could be used to determine when to release a temporary clip even with a severe reduction in MEP amplitude due to lengthy temporary clipping, no patients experienced permanent postoperative hemiparesis. Based on logistic regression analysis, if a temporary clip is applied for 312 seconds or more, there is a higher probability of a severe reduction in MEP amplitude. We should therefore release temporary clips after 5 minutes in order to avoid permanent postoperative hemiparesis.

Evaluation of Ischemia Following Clipping of Anterior Circulation Aneurysms with Respect to Temporary Clipping Using Diffusion-Weighted Magnetic Resonance Imaging: A Prospective Study

AbstractTemporary vessel occlusion enables a surgeon dissect aneurysm and clip with a lower risk of intraoperative hemorrhage with the associated risk of ischemia. There are studies on permissible time of occlusion of the parent artery using temporary clip; however, the actual incidence of silent ischemic events in patients with aneurysms treated with microsurgical clipping is not well documented. We are trying to look for the association between temporary clipping and incidence of ischemia through this study. The study concluded the statistically significant association between the maximum time of single clip application and ischemia. Intermittent multiple temporary clippings can prevent ischemia instead of a single clipping of longer duration.

How I do it: surgical clip reconstruction of a large, partially thrombosed, ruptured middle cerebral artery aneurysm.

Ruptured large and partially thrombosed aneurysms are challenging lesions to treat successfully. We describe the surgical treatment of a large, ruptured partially thrombosed middle cerebral artery (MCA) aneurysm. Once the Sylvian fissure is dissected, temporary clips are placed, and the clot is evacuated with simple microsuction and ultrasonic aspiration. The aneurysm is then carefully clip reconstructed to avoid compromise of the parent vessels. In cases of surgical clipping of large, thrombosed aneurysms, it is important to be aware of a few, but critically important, pitfalls to ensure successful outcome.

Impact of Postoperative Infarcts in Determining Outcome after Clipping of Anterior Communicating Artery Aneurysms.

Development of cerebral infarcts following clipping of ruptured intracranial aneurysm is one of the major determinants of functional outcome in patients with subarachnoid hemorrhage (SAH). The aim of this study is to evaluate the factors affecting development of postoperative infarcts, its incidence, pattern, and functional outcome. This study includes 118 patients of spontaneous SAH because of ruptured anterior communicating artery aneurysm, who underwent clipping. Relevant points in history, preoperative and intraoperative findings, and postoperative outcome are evaluated. 29 of 118 (24.5%) patients developed postoperative radiological infarcts. Approximately 37.9%, 17.2%, and 3.4% patients developed isolated infarcts, respectively, in anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) territory. About 20.7% patients developed infarcts in deep perforator territory. Nine of 29 (31.3%) patients developed multiple-vessel territory infarcts. Patients with poor preoperative neurologic status, prior history of seizure, and history of intraoperative rupture had higher chances of development of infarcts. Development of infarct was irrespective of temporary clipping (TC), duration of clipping, and elective versus rescue clipping. Development of infarcts adversely affected the outcome in significant proportions. Among patients with infarcts, unilateral ACA territory infarcts showed best prognosis, whereas all patients with multiple territory infarcts and PCA territory infarcts died. Age or sex of the patients did not affect the functional outcome. Timing of development of infarcts has no influence on functional recovery. Development of symptomatic infarct is the sole important predictor of functional outcome. A crowded neurovascular neighborhood and complex variations in local angioarchitecture make anterior communication (ACOM) territory predisposed to operative insults. Elective TC and aggressive management of cerebral vasospasm are recommended to prevent development of infarcts.

Orbitozygomatic Craniotomy for Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Giant intracranial aneurysms pose a significant surgical challenge because of the associated difficulty in achieving adequate visualization of the parent artery and aneurysm neck. This patient had an incidentally identified giant anterior communicating artery aneurysm. An orbitozygomatic craniotomy was performed for aneurysm exposure and aneurysmal neck dissection. Aneurysm dome opening and thrombectomy was performed to debulk the aneurysmal mass, which facilitated subsequent aneurysmal neck visualization. Sequential utilization of temporary clips of the bilateral A1 and bilateral A2 vessels reduced hemorrhage during thrombectomy. Multiple permanent clips were applied along the dissected aneurysm neck to permit occlusion. A small fracture of the aneurysm neck was identified, and cotton was applied with subsequent tamponade utilizing a fenestrated clip to maintain hemostasis. Indocyanine green fluoroscopy was used to verify parent and distant vessel patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Adenosine-Induced Transient Asystole During Surgical Treatment of Basilar Artery Aneurysms

To evaluate the safety and efficacy of adenosine-induced transient asystole (AITA) during surgery for basilar artery aneurysms. All the patients with basilar artery aneurysms operated using AITA at our institute during two years period (August 2013-July 2015) were included in this study. Adenosine was used in 11 patients with 13 basilar artery aneurysms. Seven of these aneurysms were basilar bifurcation aneurysms, four were basilar-superior cerebellar artery junction aneurysms, and two were distal basilar trunk aneurysms. The indications for AITA were narrow corridor for placement of temporary clip in 11 aneurysms, intraop rupture in 1 aneurysm, and circumferential dissection of a large aneurysm in 1. The mean dose of adenosine used for inducing asystole was 19.4 mg (range: 15-30 mg) and the mean total dose of adenosine used was 40.6 mg (range: 18-90 mg). A mean of 2 (range: 1-5) AITAs were required during surgical treatment of these aneurysms. The mean duration of a systole was 27 s (range: 9-76 s). There were no complications related to AITA in these patients except for transient rebound hypertension in one patient. Check angiogram revealed complete obliteration of 11 aneurysms and small residual neck in 2 aneurysms. Modified Rankin Scale at three months of follow-up was 0 in seven patients, 1 in two patients, 4 in one patient, and 6 in one patient. AITA during surgical management of basilar artery aneurysms is a safe and effective technique and has an important role during surgery for these aneurysms.

Microsurgical clipping of distal basilar trunk aneurysm during adenosine-induced profound hypotension

A 46-year-old male presented with a history of sudden severe headache 1 week back, altered sensorium and right hemiparesis for 2 days. On examination, Glasgow Coma Scale (GCS) was E4V4M6 and the patient had right hemiparesis (power – 4/5). Computed tomography (CT) revealed diffuse subarachnoid hemorrhage (Fisher's Grade III). CT angiogram revealed distal basilar trunk aneurysm arising between the origin of the left posterior cerebral artery and superior cerebellar artery, ectatic dilatation of distal basilar trunk, and a left middle cerebral artery (MCA) bifurcation aneurysm. Basilar trunk aneurysm was approached through subtemporal route and aneurysm was clipped during adenosine-induced profound hypotension (AIPH) without application of temporary clip. Single bolus 6 mg of adenosine was given, and aneurysm was successfully clipped during AIPH (systolic <60 mmHg). There were no complications related to adenosine. Ectatic part of distal basilar trunk was wrapped with Teflon. The left MCA bifurcation aneurysm was clipped in the same session. At 3-month follow-up, the patient's sensorium was normal (GCS-E4V5M6) and the right hemiparesis improved (4+/5). Adenosine enhances the safety of clipping these aneurysms by providing transient cardiac arrest or profound hypotension. In developing countries, microsurgical clipping is a cost-effective treatment option for basilar artery aneurysms.

Factors determining the best surgical exposure and safe clip positioning in surgical treatment of anterior communicating artery (AComA) aneurysms - particular significance of AComA complex rotation in the axial plane.

The aim of this study was to evaluate whether Anterior Communicating Artery (AComA) complex rotation in axial plane may influence the ease of surgical exploration in this region and safety of clip positioning when left vs right-sided approach is compared. This is a retrospective study based on analysis of patients operated due to AComA aneurysm, both ruptured and unruptured. AComA complex position in relation to coronal plane was evaluated using 3D-CTA VR reconstructions. Next, comparison between surgical approach from the side where A1-A2 junction (angle) was located anterior and posterior to coronal plane was performed in relation to surgical difficulties and intra- and postoperative complications. Subgroup statistical analysis revealed that there is a strong and statistically significant correlation between AComA complex rotation and surgical difficulties expressed by the need of repeated temporary clip application and brain transgression. When anterior vs posterior angle side approach was compared in relation to surgical difficulties and complications, there was a statistically significant difference with strong correlation (p &lt; 0.05) in favour of posterior angle side approach. Interestingly, in 72.7% and 45.5% of patients that were operated from the side where A1-A2 junction was located posterior to coronal plane, the approach was performed form the side of a non-dominant A1 and aneurysm dome projection side, respectively. Despite its limitations, our results suggest that microsurgical clipping strategy of AComA aneurysms should at least include AComA complex rotation in axial plane, besides well acknowledged factors, when deciding from which side these lesions will be approached.

Laparoscopic Vessel Clipping at Myomectomy - Uterine, Ovarian and Sampsons Artery

Video Objective To demonstrate the occlusion of three areas: the uterine artery, the round ligament and the infundibulopelvic ligament during myomectomy as a blood-sparing technique. Setting Two young patients presented with severe dysmenorrhea, AUB and subfertility. They underwent laparoscopic myomectomy, for whom the uterine artery, infundibulo-pelvic ligament and round ligament were occluded prior to the first uterine incision. Interventions After a survey, it was decided to use the lateral approach to uterine artery occlusion. The landmark was identified with traction on the medial umbilical ligament. The peritoneum was incised, and the ureter and uterine artery were exposed with careful blunt dissection. Temporary surgical clips were placed on bilateral uterine arteries. Subsequently, bilateral IP and round ligaments were similarly occluded. With devascularisation achieved, a linear incision was made over the myoma using a unipolar hook and carried through the serosa right to the myoma. Myometrium was sutured using the baseball technique. Myopia was removed by morcellation. Surgical clips were successfully removed from the uterine arteries and both IP and round ligaments. Peritoneal lavage was carried out, and Intercede barrier (Ethicon, Johnson & Johnson, Neuchatel, Switzerland) was placed. Blood loss was estimated by subtracting the instilled rinsing volume from the volume of fluid collected in the suction drain at the end of procedure. There were no post-operative complications. Conclusion Occlusion both the infundibulo-pelvic and round ligaments prior to laparoscopic myomectomy is a simple, reversible procedure, and does not significantly increase operative times. When used in conjunction with transient uterine artery occlusion, it may serve to further limit blood loss during surgery and hasten recovery. Larger studies are needed to define surgical outcomes, and recognize short and long term complications, if any.

Rescue Cerebral Revascularization in Patients with Progressive Steno-Occlusive Ischemia of the Anterior Intracranial Circulation

Despite the failure of 2 randomized controlled trials assessing the utility of bypass for steno-occlusive cerebrovascular disease, a specific subset of patients with progressive and/or refractory symptoms may benefit from cerebral revascularization. This study assessed the efficacy and outcomes of bypass surgery for progressive and/or refractory steno-occlusive cerebrovascular disease. A retrospective database review was performed to identify patients who underwent bypass for progressive and/or refractory steno-occlusive disease of the internal carotid artery or middle cerebral artery over a 4-year period (July 2014-July 2018). Surgical and clinical outcomes were recorded. Seventeen patients (average age 62 ± 11 years) underwent extracranial-intracranial bypass for refractory and/or progressive steno-occlusive disease of the internal carotid artery or middle cerebral artery. Thirteen patients presented with stroke, 3 presented with recurrent transient ischemic attacks, and 1 presented with progressive hemiparesis. All patients had preoperative perfusion imaging deficits. Average temporary clip time was 35 ± 8 minutes. An interposition graft was used in 7 patients. There was 3 ischemic and 3 hemorrhagic perioperative strokes (35%); all were minor or related to anticoagulation. Over an average of 10 ± 10 months of follow-up, there were no ischemic strokes in the bypass-dependent territories. Of 17 patients, 16 (78%) achieved a Glasgow Outcome Scale score ≥4, and 13 (85%) achieved a modified Rankin Scale score ≤2. Bypass for steno-occlusive disease of the anterior intracranial circulation is a potentially effective treatment for patients with progressive and/or refractory ischemic symptoms, although the complication rate is significant. Optimal patient selection criteria and timing of surgery remain open questions.

New Technique for Management of Separate Right Posterior and Anterior Portal Veins in Pure 3D Laparoscopic Living Donor Right Hepatectomy

BackgroundPure laparoscopic donor hepatectomy, including right hepatectomy, is being increasingly performed at experienced centers (Kim et al. Transplantation 101:1106–1110, 2017; Han et al. Medicine (Baltimore) 96:e8076, 2017; Suh et al. Am J Transplant 18:434–443, 2018; Hong et al. Br J Surg 105:751–759, 2018; Lee et al. Transplantation 102:1878–1884, 2018). However, anatomical variations in the portal vein remain major challenges and are regarded as contraindications by some centers. Using a stapler or clip in donors with these anatomical variations may result in kinking of the remnant portal vein due to the thick linear bite, as well as a reduction in the length of the graft portal vein. This report describes a liver donor with separate right posterior and anterior portal veins who underwent pure 3D laparoscopic donor right hepatectomy, focusing on a new technique of managing separate two portal veins. MethodsA 45-year-old man offered to donate part of his liver to his father, who required a liver transplant for alcoholic liver cirrhosis. The father’s Child-Pugh score was 7 and his Model for End-Stage Liver Disease score was 10.7. Donor height was 175.4 cm, body weight was 79.9 kg, and body mass index was 26.0 kg/m2. Preoperative computed tomography and magnetic resonance cholangiopancreatography showed that the donor had separate right posterior and anterior portal veins. Estimated graft-to-recipient weight ratio was 1.4% and remnant liver volume was 35.7%. The entire procedure was performed under 3D laparoscopic view using a flexible scope and real-time indocyanine green fluorescence cholangiography. The right posterior and anterior portal veins were divided using Hem-O-Lok clips. After retrieving the liver, the stumps of the portal veins were replaced with polypropylene sutures, followed by removal of the Hem-O-Lok clips (SNUH technique). ResultsThe total operation time was 365 min, with no transfusion and no intraoperative complications. The portal veins were divided safely without any torsion or stricture. The stumps of the portal veins were sutured after retrieval of the liver graft, with suturing requiring about 12 min. The donor was discharged on postoperative day 7 with no complications. ConclusionThe SNUH technique, consisting of temporary clipping, intracorporeal suturing, and clip removal is safe and useful for pure laparoscopic right hepatectomy in donors with anatomic variations in the portal vein.

Double-balloon trapping for coil embolization of ruptured internal carotid artery aneurysm: A novel technique

Introduction:Endovascular treatment of complex ruptured aneurysms in the internal carotid (IC) artery is extremely challenging. Navigation of double-balloon catheters becomes all the more difficult in tortuous vessels.Patients and Methods:A 57-year-old female with more than three times previously ruptured left IC artery aneurysm with subarachnoid hemorrhage had a left IC small aneurysm with a neck of 3.2 mm. Proximal and distal balloons were inflated in left IC artery in respect to the aneurysm, to prevent further rupture during navigation of the microcatheter and first coil.Discussion:The technique uses two balloons placed proximal and distal to the ruptured aneurysm, to reduce further bleeding, just as the application of temporary clips, followed by inertion of coils rapidly to obliterate the aneurysm.Conclusion:It is a novel technique of double-balloon trapping of proximal and distal segment of IC artery with aneurysm coiling technique as an alternative to balloon-assisted coiling and stent-assisted coiling in patients with ruptured aneurysm.

Diagnostic accuracy of somatosensory evoked potentials during intracranial aneurysm clipping for perioperative stroke.

Somatosensory evoked potentials (SSEPs) are utilized during aneurysm clipping to detect intraoperative ischemia. We assess the diagnostic accuracy of SSEPs in predicting perioperative stroke during aneurysm clipping. A retrospective review was conducted of 429 consecutive patients who underwent surgical clipping for ruptured and unruptured cerebral aneurysms with intraoperative SSEP monitoring from 2006 to 2013. The relationship between perioperative stroke and SSEP changes was analyzed by calculating the sensitivity, specificity, and area under a Receiving Operating Characteristic curve. Sensitivity and specificity were 42% and 90%, respectively. Area under the curve was 0.66 (95% confidence interval, 0.53-0.79). Reclassification of reversible temporary clip changes to correct for paradoxical classification of SSEP false positives raised the sensitivity from 42 to 65% (p = 0.041, Chi squared test). EEG (electroencephalography) changes increased the specificity (98% vs. 90%, p < 0.001, McNemar's test), but not sensitivity (48% vs. 42%, p = 0.621, McNemar's test) of SSEPs for perioperative stroke. A stepwise logistic regression model selected SSEP amplitude loss (p = 0.006, OR = 3.7 [95% CI 1.5-9.2]) and the SSEP change duration (p = 0.034, OR = 1.8 [95% CI 1.1-3.1]) as independent predictors of perioperative stroke. SSEP changes induced by temporary clipping were highly reversible compared to other SSEP changes (94% vs. 60%, p = 0.003, Fisher exact test), and typically responded to clip removal or readjustment. SSEP changes have high specificity and modest sensitivity for perioperative stroke. Stroke risk is a function of both the magnitude of SSEP amplitude loss and the duration of its loss. Given the modest sensitivity, patients may benefit from multimodal monitoring including motor-evoked potentials during cerebral aneurysm surgery.

Transient Augmentation of Intraoperative Motor Evoked Potentials During Middle Cerebral Artery Aneurysm Surgery

To study clinical significance of augmentation of intraoperative motor evoked potentials (MEPs) during direct open surgery for middle cerebral artery (MCA) aneurysms. Between 2009 and 2017, 134 MCA aneurysm surgeries were performed with intraoperative MEP monitoring. The frequency and cause of augmentation with >50% increase of MEP amplitude from baseline were studied. Factors associated with MEP augmentation were investigated. MEP augmentation was demonstrated in 9 patients. All 9 events were observed just after application of the temporary clip to the parent artery. The ratio of the maximum amplitude to baseline was 2.6 ± 1.1 at an mean of 2.4 ± 1.1 minutes after parent artery occlusion. Ten patients who did not show MEP augmentation after parent artery occlusion were compared with the patients showing MEP augmentation. The distance of the temporary clip point from the midline was smaller in patients with MEP augmentation compared with patients without MEP augmentation (P= 0.033). MEP augmentation was thought to be an early ischemic sign preceding a significant decrease in MEPs during MCA aneurysm surgery. Transient augmentation of MEPs was more frequently observed in cases with a temporary clip applied to the more proximal part of the MCA.

Side-to-Side Anastomosis Training Model Using Rat Common Carotid Arteries.

The side-to-side anastomosis is one of the difficult bypass configurations that may be used in various complex cerebral vascular and neoplastic cases. Few pure arterial models exist for practicing this bypass subtype. To provide an optimized side-to-side anastomosis training model using rat common carotid arteries (CCA). Bilateral CCAs were exposed in the neck of 10 anesthetized Sprague-Dawley rats. The arteries were juxtaposed in parallel, using temporary aneurysm clips applied proximally and distally. CCA caliber and the length of CCA juxtaposition were measured. Side-to-side anastomosis was completed and ischemia time was recorded. Unintended complications were recorded for further analysis. Anastomosis was completed successfully in all animals. The CCAs were approximated in all animals without any difficulty or undue tension. In 2 rats, death occurred prior to completion of anastomosis, which was attributed to injury to the external jugular vein during vessel exposure. Mean ischemia time was 35 min with an average of 22 sutures done to complete the anastomosis. The average CCA caliber was 1.1±0.2 mm and the arteries could be juxtaposed for an average length of 10.2±1.5 mm. Full exposure of the cervical segment of the CCAs enables tension-free approximation of adequate length of the vessel for a side-to-side anastomosis. Avoiding complications during exposure helps in prevention of animal death during the ischemia period.

Adenosine-Assisted Management of Intracranial Aneurysm

AbstractCerebral aneurysms can be complex and variable in size, position, and morphology, resulting in difficult surgical exposure and secure clip placement. They have a high mortality rate when ruptured, and though endovascular techniques have emerged to tackle this, surgical clip ligation remains the preferred modality for some aneurysms. Various techniques that help the surgeon dissect the aneurysmal dome and apply the clip are temporary clip ligation of proximal vessels, deep hypothermic circulatory arrest, and balloon suction decompression. All of them require significant logistics and result in increased morbidity and mortality. Adenosine is a suitable alternative for inducing a temporary flow arrest, causing a short period of controlled hypotension. Its rapid onset and offset property along with low incidence of adverse events makes it an ideal agent in this regard. We present here a review on its use, contraindications, safety profile, and future applications.

Use of a New Indocyanine Green Pooling Technique for Improved Visualization of Spinal Dural AV Fistula: A Single-Center Case Series

Intraoperative indocyanine green video angiography (ICG-VAG) is a useful tool in cerebral vascular surgery. In spinal procedures such as dural arteriovenous (AV) fistula, use of ICG-VAG is limited due to lower perfusion pressure. Therefore, we developed a new pooling technique with adapted workflow to improve intraoperative visualization. Patients operated on spinal dural AV fistulas using ICG-VAG were prospectively included. A new workflow for ICG-VAG was applied: 1) temporary clip placement at the suspected fistula point, 2) ICG administration during 100% oxygenation, 3) ICG pooling proximal of temporary clip, 4) clip removal/observation of vascular filling. Case records, clinical data, magnetic resonance imaging, digital subtraction angiography (DSA), and clinical outcome were analyzed retrospectively. A total of 11 patients (median age 68 years, average course of disease 15 months) were included. Optimized, inverted workflow resulted in considerable pooling of ICG in the supplying feeder of the AV fistula in all cases. Complete obliteration was confirmed in 10 of 11 patients by postoperative DSA. However, 1 patient had an additional, preoperative radiologically undetected small feeder that enlarged until postoperative DSA and made successful reoperation necessary. After the median follow-up of 33.2 months, the Aminoff-Logue scale was decreased in all patients, and the McCormick score (modified Rankin score) was improved in 9 (8) patients and remained stable in 2 (3) patients. Procedure modification in terms of ICG pooling enabled us to detect more easily the pathologic vascular architecture. ICG-VAG is a useful adjunct in the surgical treatment of spinal dural AV fistula because it is a real-time, noninvasive, and radiation-free technique with adequate image resolution.

Individualization of microsurgical tactics during clipping cerebral arterial aneurysms

Objective — to determinate clinical and anatomical options of influence of strategy and tactics of microsurgical treatment cerebral arterial aneurysms (AA) to increase the effectiveness of clipping surgery.&#x0D; Materials and methods. A retrospective analysis of the results of a comprehensive clinical and instrumental examination of 437 adult patients who were operated by clipping cerebral AA, which were on screening and treatment in the department of «Institute of Neurosurgery named after acad.&#x0D; A.P. Romodanov NAMS of Ukraine» in the period from 2009 to 2018 (results of treat of AA distal part anterior cerebral artery (ACA) were analyzed for the period from 1998 to 2015). Men were 235 (53.8 %), women — 202 (46.2 %). In all age groups men dominated. All patients performed a comprehensive clinical and instrumental study in accordance with the supplement to the Order of the Ministry of Health of Ukraine No. 317 dated 13.06.2008. The code for ICD-10: І60.1. Survey results for unification were evaluated according to international scales and classifications.&#x0D; Results. Often, AA was affected by the complex anterior communicating artery (145 (33.2 %)), bifurcation of the M1–M2-segment of the middle cerebral artery (112 (25.6 %)), C5–C6-segments of the internal carotid artery (98 (22.4%)), A2–A5-segments of ACA (79 (18.1 %)). AA of the basilar bifurcation were only 3 (0.7 %) cases. Clinically, cerebral AA was found after ruptured in 382 (87.6 %). Most of AAs were «berry»-type of shape — 364 (83.3 %). Complex AA was detected in 73 (16.7 %) patients. Extended basal craniotomy was used in 46 (10.5 %) cases, pterional craniotomy — in 323 (73.9 %), and other accesses — in 68 (15.6 %). The technique of simple clinging of aneurysms was used in 273 (57.4 %) cases, multiple clipping with clip reconstruction — in 148 (39.0 %), other methods — in 16 (3.6 %). Temporary clip proximally before final dissection was performed in 319 (73.0 %) patients, «pilot» clipping — 76 (17.4%), without proximal control — 42 (9.6 %).&#x0D; Conclusions. When choosing the appropriate strategy and tactics of the microsurgical devascularization of cerebral AA should take into account clinical manifestations and features of the course of the disease. The choice of the optimal microsurgical corridor and AA clinging technique depends on the anatomic-topographic and hemodynamic parameters of AA and the affected arterial segment cerebral artery.

Indocyanine Green Videoangiography in the Surgical Treatment of Spinal Dural Arterovenous Fistula: A Useful Application

Indocyanine green videoangiography (ICG-V) is used with increasing frequency in neurovascular surgery. ICG-V use in spinal dural arteriovenous fistulas (DAVFs) allows visualization of the hemodynamics of the fistula and to confirm its exclusion after ligation of the feeder. Here, we illustrate how ICG-V is useful for centering the surgical exposure during mini-invasive approaches to spinal DAVFs. An overweight 66-year-old woman with progressive paraparesis and sphincter disturbances underwent treatment for a spinal DAVF fed by the left T6 radicular artery. After intraoperative fluoroscopy, T6 hemilaminectomy was performed. Because of slight misplacement of the bone opening, the feeder was not visible at the dural opening. We placed a temporary clip on a perimedullary arterialized vein and performed ICG-V while removing the clip. Reviewing the video clip and analyzing the direction of ICG flow inside the perimedullary venous plexus allowed us to locate the fistula with respect to the bone window and to extend the laminectomy in the correct direction. IGC-V can be helpful in mini-invasive approaches to spinal DAVFs to recalibrate the bone opening after misplacement of the initial hemilaminectomy.