Confirmation of blood flow in perforating arteries using fluorescein cerebral angiography during aneurysm surgery

Restricted access

Object

The authors performed fluorescein cerebral angiography in patients after aneurysm clip placement to confirm the patency of the parent artery, perforating artery, and other arteries around the aneurysm.

Methods

Twenty-three patients who underwent aneurysm surgery were studied. Aneurysms were located in the internal carotid artery in 12 patients, middle cerebral artery in six, anterior cerebral artery in three, basilar artery bifurcation in one, and junction of the vertebral artery (VA) and posterior inferior cerebellar artery in one. After aneurysm clip placement, the target arteries were illuminated using a beam from a blue light-emitting diode atop a 7-mm diameter pencil-type probe. In all patients, after intravenous administration of 5 ml of 10% fluorescein sodium, fluorescence in the vessels was clearly observed through a microscope and recorded on videotape.

Results

The excellent image quality and spatial resolution of the fluorescein angiography procedure facilitated intra-operative real-time assessment of the patency of the perforating arteries and branches near the aneurysm, including: 12 posterior communicating arteries; 12 anterior choroidal arteries; four lenticulostriate arteries; three recurrent arteries of Heubner; three hypothalamic arteries; one ophthalmic artery; one perforating artery arising from the VA; and one posterior thalamoperforating artery. All 23 patients experienced an uneventful postoperative course without clinical symptoms of perforating artery occlusion.

Conclusions

Because the fluorescein angiography procedure described here allows intraoperative confirmation of the patency of perforating arteries located deep inside the surgical field, it can be practically used for preventing unexpected cerebral infarction during aneurysm surgery.

Abbreviations used in this paper:AChA = anterior choroidal artery; ACoA = anterior communicating artery; BA = basilar artery; ICA = internal carotid artery; LED = light-emitting diode; LSA = lenticulostriate artery; MACC = median artery of corpus callosum; MCA = middle cerebral artery; PCoA = posterior communicating artery; PICA = posterior inferior cerebellar artery; VA = vertebral artery.

Article Information

Address reprint requests to: Namio Kodama, M.D., Ph.D., Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima 960-1295, Japan. email: nkodama@fmu.ac.jp.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Illustration and photographs showing the setup for intraoperative fluorescein cerebral angiography. The pencil-type probe with a blue LED at its tip (A) is held by hand over the operative field. The perforating artery is illuminated by the probe's excitatory beam (B). After the intravenous administration of 5 ml of 10% fluorescein sodium, the increase of fluorescence in the perforating artery is observed under a microscope through a barrier filter (C) that facilitates the collection of only fluorescein sodium–induced fluorescence. The barrier filter can be inserted into and removed from the light axis of a microscope by moving the tab (black arrow) by 90° (white arrow).

  • View in gallery

    Illustration and intraoperative photographs showing clip application to the neck of an ACoA aneurysm (An) performed using a conventional microscope (A and B) and using fluorescein cerebral angiography (C and D). After insertion of the barrier filter into the light pathway of the microscope, the surgical field became yellowish (C) compared with the original image (B). Fluorescein cerebral angiography shows fluorescence within the bilateral A2 segment of the anterior cerebral artery (A2) and the hypothalamic artery (HThA) (D). Fluorescence from the aneurysm could not be observed. A1 = A1 segment of the anterior cerebral artery; Lt. = left; Rt. = right.

  • View in gallery

    Illustration and intraoperative photographs showing clip application to the neck of an ACoA aneurysm. After clip placement (A and B), fluorescence from the MACC and the hypothalamic artery could not be visualized (C). Repositioning the clip to release the occlusion of these vessels allowed us to confirm their patency afterwards (D).

  • View in gallery

    Intraoperative photographs and illustration showing clip application to the necks of the left ICA–PCoA and ICA–AChA aneurysms. After clip placement (A and B), the patency of the AChA was confirmed using fluorescein cerebral angiography (C). The ICA–PCoA aneurysm is covered with cotton and is not visible.

  • View in gallery

    Intraoperative photographs and illustration of clip application to the neck of a left MCA bifurcation aneurysm. After clip placement (A and B), the patency of the lateral frontoorbital artery (LFOA) and LSA was confirmed using fluorescein cerebral angiography (C). M1 and M2 = M1 and M2 segments of the MCA.

References

  • 1

    Baker DW: Pulsed ultrasonic Doppler blood-flow sensing. IEEE Trans Sonics Ultrasonics 17:1701851970

  • 2

    Chiang VLGailloud PMurphy KJRigamonti DTamargo RJ: Routine intraoperative angiography during aneurysm surgery. J Neurosurg 96:9889922002

    • Search Google Scholar
    • Export Citation
  • 3

    Feindel WYamamoto YLHodge CP: Red cerebral veins and the cerebral steal syndrome. Evidence from fluorescein angiography and microregional blood flow by radioisotopes during excision of an angioma. J Neurosurg 35:1671791971

    • Search Google Scholar
    • Export Citation
  • 4

    Friberg TRExamination of the retina: principles of fluorescein angiography. Albert DMJakobiec FA: Principles and Practice of Ophthalmology ed 2PhiladelphiaWB Saunders2000. 3:18421862

    • Search Google Scholar
    • Export Citation
  • 5

    Friedman JAPichelmann MAPiepgras DGAtkinson JLDMaher COMeyer FB: Ischemic complications of surgery for anterior choroidal artery aneurysms. J Neurosurg 94:5655722001

    • Search Google Scholar
    • Export Citation
  • 6

    Friedman WAChadwick GMVerhoeven FJSMahla MDay AL: Monitoring of somatosensory evoked potentials during surgery for middle cerebral artery aneurysms. Neurosurgery 29:83881991

    • Search Google Scholar
    • Export Citation
  • 7

    Haglund MMBerger MSHochman DW: Enhanced optical imaging of human gliomas and tumor margins. Neurosurgery 38:3083171996

  • 8

    Horiuchi KSuzuki KSasaki TMatsumoto MSakuma JKonno Y: Intraoperative monitoring of blood flow insufficiency during surgery of middle cerebral artery aneurysms. J Neurosurg 103:2752832005

    • Search Google Scholar
    • Export Citation
  • 9

    Kassell NFTorner JCHaley EC JrJane JAAdams HPKongable GL: The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg 73:18361990

    • Search Google Scholar
    • Export Citation
  • 10

    Koenig TRWolff DMettler FAWagner LK: Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. AJR Am J Roentgenol 177:3112001

    • Search Google Scholar
    • Export Citation
  • 11

    Kuroiwa TKajimoto YOhta T: Development of a fluorescein operative microscope for use during malignant glioma surgery: A technical note and preliminary report. Surg Neurol 50:41491998

    • Search Google Scholar
    • Export Citation
  • 12

    Mizoi KYoshimoto T: Permissible temporary occlusion time in aneurysm surgery as evaluated by evoked potential monitoring. Neurosurgery 33:4344401993

    • Search Google Scholar
    • Export Citation
  • 13

    Raabe ABack JGerlach RZimmermann MSeifert V: Near-infrared indocyanine green video angiography: A new method for intraoperative assessment of vascular flow. Neurosurgery 52:1321392003

    • Search Google Scholar
    • Export Citation
  • 14

    Raabe ANakaji PBeck JKim LJHsu FPKKamerman JD: Prospective evaluation of surgical microscope-integrated intra-operative near-infrared indocyanine green videoangiography during aneurysm surgery. J Neurosurg 103:9829892005

    • Search Google Scholar
    • Export Citation
  • 15

    Sakuma JSuzuki KSasaki TMatsumoto MOinuma MKawakami M: Monitoring and preventing blood flow insufficiency due to clip rotation after the treatment of internal carotid artery aneurysms. J Neurosurg 100:9609622004

    • Search Google Scholar
    • Export Citation
  • 16

    Stendel RPietila TAl Hassan AASchilling ABrock M: Intraoperative microvascular Doppler ultrasonography in cerebral aneurysm surgery. J Neurol Neurosurg Psychiatry 68:29352000

    • Search Google Scholar
    • Export Citation
  • 17

    Stummer WNovotny AStepp HGoetz CBise KReulen HJ: Fluorescence-guided resection of glioblastoma multiforme by using 5-aminolevulinic acid-induced porphyrins: a prospective study in 52 consecutive patients. J Neurosurg 93:100310132000

    • Search Google Scholar
    • Export Citation
  • 18

    Suzuki KKodama NSasaki TMatsumoto MKonno YSakuma J: Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery. J Neurosurg 98:5075142003

    • Search Google Scholar
    • Export Citation
  • 19

    Suzuki KSasaki TKodama NLarge aneurysm of the internal carotid artery obliterated with seven fenestrated clips under intra-operative monitoring of anterior choroidal arterial blood flow insufficiency. Kobayashi S: Neurosurgery of Complex Vascular Lesions and Tumors New YorkThieme2005. 4246

    • Search Google Scholar
    • Export Citation
  • 20

    Tang GCawley CMDion JEBarrow DL: Intraoperative angiography during aneurysm surgery: a prospective evaluation of efficacy. J Neurosurg 96:9939992002

    • Search Google Scholar
    • Export Citation
  • 21

    Woitzik JHorn PVajkoczy PSchmiedek P: Intraoperative control of extracranial-intracranial bypass patency by near-infrared indocyanine green videoangiography. J Neurosurg 102:6926982005

    • Search Google Scholar
    • Export Citation
  • 22

    Wrobel CJMeltzer HLamond RAlksne JF: Intraoperative assessment of aneurysm clip placement by intravenous fluorescein angiography. Neurosurgery 35:9709731994

    • Search Google Scholar
    • Export Citation
  • 23

    Yannuzzi LARohrer KTTindel LJSobel RSCostanza MAShields W: Fluorescein angiography complication survey. Ophthalmology 93:6116171986

    • Search Google Scholar
    • Export Citation
  • 24

    Yaşargil MGYonas HGasser JC: Anterior choroidal artery aneurysms: their anatomy and surgical significance. Surg Neurol 9:1292381978

    • Search Google Scholar
    • Export Citation

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 208 208 25
Full Text Views 187 187 1
PDF Downloads 125 125 2
EPUB Downloads 0 0 0

PubMed

Google Scholar