ICG videoangiography Microsurgical Anatomy of Perforators The Efficacy of ICG Videoangiography and Neuroendoscopy Hiroharu Kataoka, M.D., Ph.D

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1 IG videoangiography Microsurgical natomy of Perforators The Efficacy of IG Videoangiography and Neuroendoscopy Hiroharu Kataoka, M.D., Ph.D. 1, and Koji IIhara, M.D., Ph.D. 2 1 Department of Neurosurgery, National erebral and ardiovascular enter, 2 Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University The anatomy of perforating arteries is quite important in microneurosurgery, because any blood flow insufficiency in the perforating arteries can cause serious neurological deficits. Especially in aneurysm clipping, surgeons must be aware of the anatomical variation of the perforators related to the aneurysm. For example, the anterior choroidal artery sometimes arises from the aneurysm itself or it may also arise as 2 4 independent vessels. Lenticulostriate arteries usually arise from the posterior aspect of the M1 segment, but also from the M1 M2 bifurcation or the M2 segment. Hypothalamic arteries originate from the posterior aspect of the anterior communicating artery and are ordinarily difficult to confirm by the pterional approach. To preserve perforator blood flows, surgeons must first identify all of the perforators around an aneurysm. Neuroendoscopy helps us in this task by allowing us to observe the blind area of the microscope. lso, clips must be placed in such a way as to spare the blood flow of the perforators. fter clipping, the patency of the perforators is confirmed by Doppler ultrasonography, indocyanine green IG videoangiography and motor evoked potential MEP monitoring. s each of these intraoperative monitoring methods may yield a false negative result on its own, the combination of multiple modalities is mandatory for avoiding neurological complications due to perforator injury. Received July 10, 2014 accepted July 24, 2014 Key words perforator, neuroendoscopy, IG videoangiography, intracranial aneurysm, clipping Jpn J Neurosurg Tokyo , mm ddress reprint requests to Hiroharu Kataoka, M.D., Ph.D., Department of Neurosurgery, National erebral and ardiovascular enter, Fujishirodai, Suita shi, Osaka , Japan

from the anterior aspect and from the inferior aspect displaying a left anterior choroidal artery ch aneurysm.

, D Intraoperative photographs in the left pterional approach.

These perforators were dissected from the aneurysm, and the aneurysm was occluded by fenestrated clips with the clip blades passing beneath

は脳動脈瘤クリッピング術に必要な穿通枝の外科解剖 1 前脈絡叢動脈 anterior choroidal artery ch を実際の術中所見をもとに解説するとともに術中モニ ch は側頭葉内側面視索外側膝状体外側部

2 E D Fig. 1 case of an anterior choroidal artery aneurysm associated with multiple anterior choroidal arteries, Preoperative 3D cerebral angiograms from the anterior aspect and from the inferior aspect displaying a left anterior choroidal artery ch aneurysm. single ch arrow originating at the proximal neck of the aneurysm was visualized in the angiograms., D Intraoperative photographs in the left pterional approach. In addition to the main trunk of the ch large arrow, small perforators arrow adhered to the aneurysm. These perforators were dissected from the aneurysm, and the aneurysm was occluded by fenestrated clips with the clip blades passing beneath the perforators D. E IG videoangiogram confirming the patency of all the perforators. は脳動脈瘤クリッピング術に必要な穿通枝の外科解剖 1 前脈絡叢動脈 anterior choroidal artery ch を実際の術中所見をもとに解説するとともに術中モニ ch は側頭葉内側面視索外側膝状体外側部異の種々のパターンを認識しておく必要がある本稿で淡蒼球大脳脚中 1 3 内包後脚の後方 2 3 視床の一タリングの注意点についても述べる部などを栄養しその血流障害は bbie 症候群に代表さ脳動脈瘤クリッピング術の際に重要な穿通枝と外科解剖れる対側の片麻痺感覚障害半盲などの重篤な神経学的後遺症を生じる19 20 ch は通常後交通動脈分岐部から内頚動脈分岐部の間の内頚動脈の外側壁から分岐脳動脈瘤クリッピング術の際に注意すべき穿通枝は動するが19 内側壁から分岐するもの8 後交通動脈より脈瘤の部位ごとに異なるが特に臨床的に重要なのはも近位部から分岐するもの9 16 中大脳動脈から分岐す前脈絡叢動脈レンズ核線条体動脈視床下部動脈であるもの10 後交通動脈から分岐するもの17 19 などの変異るが報告されている通常の位置に ch が認められない場合にはこのような変異の可能性を考えなくてはならないまた ch のうち 70 は 1 本の主幹動脈として起始してから複数の枝に分岐するが 30 は起始部から Jpn J Neurosurg VOL. 24 NO

arises Preoperative 3D cerebral angiogram displaying a right anterior choroidal artery

, Intraoperative findings of the microscope and of the endoscope before clipping.

itself. D F Intraoperative findings after clipping.

The patency of the ch was confirmed by IG videoangiography E.

The aneurysmal wall near the origin of ch asterisk was thickened.

3 I N * D E F Fig. 2 case of an anterior choroidal artery aneurysm from which an anterior choroidal artery arises Preoperative 3D cerebral angiogram displaying a right anterior choroidal artery ch aneurysm. The ch arrow arose from the dome of the aneurysm., Intraoperative findings of the microscope and of the endoscope before clipping. n endoscopic view clearly demonstrated that the ch arrow originated from the aneurysm itself. D F Intraoperative findings after clipping. lipping was performed as the origin of ch was spared D. The patency of the ch was confirmed by IG videoangiography E. Neuroendoscopy demonstrated that the origin of the ch was not kinked F. The aneurysmal wall near the origin of ch asterisk was thickened digital subtraction angiography DS 1 74 DS Fig. 1 proximal neck ch Fig. 1 Pterional approach DS ch distal Fig. 1 dome / blade Fig. 1D E ch ch neck dome Friedman 6 dome 44 ch Fig. 2 ch Fig. 2 2 lenticulostriate artery LS LS LS medial group middle group lateral group 3 14 M1 lateral group M1 2 M

20 LS M1 short M1 11 dome / free Fig. 3 ch DS lateral group M1 2 M2 dome N M1 3 hypothalamic artery Hypothalamic artery co 1 6 0.1 0.

upper projecting aneurysm arising from the bifurcation of the M1 and the orbitofrontal artery.

4 20 LS M1 short M1 11 dome / free Fig. 3 ch DS lateral group M1 2 M2 dome N M1 3 hypothalamic artery Hypothalamic artery co mm 21 Yasargil co co / hypothalamic artery pterional approach interhemispheric approach Hypothalamic artery DS Fig. 4 Orbitofrontal artery Fig. 3 case of a middle cerebral artery aneurysm with short M1 segment Preoperative anteroposterior and 3D cerebral angiograms displaying an upper projecting aneurysm arising from the bifurcation of the M1 and the orbitofrontal artery. The lenticulostriate artery LS arrow was visualized at the proximal neck of the aneurysm. Intraoperative finding after neck clipping. Some LSs originated from the sclerotic neck of the aneurysm arrows. The clip was placed to avoid the sclerotic neck. Fig. 2 5 dome kink Jpn J Neurosurg VOL. 24 NO

N 2 2 Fig. 4 case of a superoposterior projecting anterior communicating aneurysm preoperative 3D cerebral angiogram from the posterior aspect.

n intraoperative photograph in the interhemispheric approach after tentative clipping.

5 N 2 2 Fig. 4 case of a superoposterior projecting anterior communicating aneurysm preoperative 3D cerebral angiogram from the posterior aspect. The aneurysm projected superoposteriorly from the left 1 2 junction. The hypothalamic artery arrow was visualized at the proximal neck of the aneurysm. n intraoperative photograph in the interhemispheric approach after tentative clipping. In addition to the main trunk of the hypothalamic artery large arrow, its small branch arrow was confirmed and separated from the aneurysm. indocyanine green videoangiography IG V motor evoked potential MEP 22 IG V IG V 110 IG V IG V IG V 2 24 IG V FLOW 800 arl Zeiss Jena Germany Fig. 5 MEP modality modality pitfall 1 variation 2 3D DS 3 / llcock JM, Drake G Postoperative angiography in cases of ruptured intracranial aneurysm. J Neurosurg ,

200 verage intensity 100 0 5 10 15 20 25 Time sec 200 verage intensity 100 D E F 0 5 10 15 20 25 Time sec Fig.

right anterior choroidal artery ch aneurysm was occluded using a straight clip while sparing the origin of the ch arrow arising from the aneurysm itself.

of the ch was delayed. D F Microscopic view D, IG V E and time intensity curves on FLOW 800 F after the adjustment of the clip.

The time intensity curve of the ch green line was almost identical to that of I red line F.

6 200 verage intensity Time sec 200 verage intensity 100 D E F Time sec Fig. 5 case in which FLOW 800 was useful in detecting the blood flow insufficiency of perforators Microscopic view, IG videoangiogram IG V and time intensity curves on FLOW 800 after the first clipping. right anterior choroidal artery ch aneurysm was occluded using a straight clip while sparing the origin of the ch arrow arising from the aneurysm itself. lthough IG V showed fluorescence in the ch, the maximum intensity of the time intensity curve of the ch green line was lower than that of the internal carotid artery I red line and the time to peak of the ch was delayed. D F Microscopic view D, IG V E and time intensity curves on FLOW 800 F after the adjustment of the clip. The clip was replaced away from the aneurysmal neck, and a curved clip was added to a small thin walled portion on the near side D. The time intensity curve of the ch green line was almost identical to that of I red line F. 2 aplan JM, Sankey E, Yang W, Radvany MG, olby GP, oon L, Tamargo RJ, Huang J Impact of indocyanine green videoangiography on rate of clip adjustments following intraoperative angiography. Neurosurgery , Dashti R, Laakso, Niemelä M, Porras M, Hernesniemi J Microscope integrated near infrared indocyanine green videoangiography during surgery of intracranial aneurysms the Helsinki experience. Surg Neurol , Fischer G, Stadie, Oertel JM Near infrared indocyanine green videoangiography versus microvascular Doppler sonography in aneurysm surgery. cta Neurochir Wien , Fischer G, Oertel J, Perneczky Endoscopy in aneurysm surgery. Neurosurgery 70 2 Suppl Operative discussion , Friedman J, Pichelmann M, Piepgras DG, tkinson JL, Maher O, Meyer F, Hansen KK Ischemic complications of surgery for anterior choroidal artery aneurysms. J Neurosurg , Friedman W, Kaplan L, Day L, Sypert GW, urran MT Evoked potential monitoring during aneurysm operation observations after fifty cases. Neurosurgery , Hammers R, Hacein ey L, Origitano T nomalous medial origin of the anterior choroidal artery with associated aneurysm. J Neurol Sci , Hara N, Koike T, kiyama K, Toyama M nomalous origin of anterior choroidal artery. Neuroradiology 31 88, Herman LH, Fernando OU, Gurdjian ES The anterior choroidal artery an anatomical study of its area of distribution. nat Rec , Iwama T, Yoshimura S, Kaku Y, Sakai N onsiderations in the surgical treatment of superior wall type aneurysm at the proximal M1 segment of the middle cerebral artery. cta Neurochir Wien discussion 972, Kivisaari RP, Porras M, Ohman J, Siironen J, Ishii K, Hernesniemi J Routine cerebral angiography after surgery for saccular aneurysms is it worth it? Neurosurgery , Macdonald RL, Wallace M, Kestle JR Role of angiography following aneurysm surgery. J Neurosurg , Jpn J Neurosurg VOL. 24 NO

7 14 Marinković SV, Kovacević MS, Marinković JM Perforating branches of the middle cerebral artery. Microsurgical anatomy of their extracerebral segments. J Neurosurg , Meyer, Urbach H, Schaller, aslam M, Nordblom J, Schramm J Immediate postoperative angiography after aneurysm clipping implications for quality control and guidance of further management. Zentralbl Neurochir , Nomura M, Kida S, Kita D, Hasegawa M, Matsui O, Yamashita J nomalous origin of anterior choroidal artery associated with an aneurysm. cta Neurochir Wien , Otomo E The anterior choroidal artery. rch Neurol , Raabe, Nakaji P, eck J, Kim LJ, Hsu FP, Kamerman JD, Seifert V, Spetzler RF Prospective evaluation of surgical microscope integrated intraoperative near infrared indocyanine green videoangiography during aneurysm surgery. J Neurosurg , Rhoton L Jr, Fujii K, Fradd Microsurgical anatomy of the anterior choroidal artery. Surg Neurol , Rosner SS, Rhoton L Jr, Ono M, arry M Microsurgical anatomy of the anterior perforating arteries. J Neurosurg , Serizawa T, Saeki N, Yamaura Microsurgical anatomy and clinical significance of the anterior communicating artery and its perforating branches. Neurosurgery discussion , Suzuki K, Kodama N, Sasaki T, Matsumoto M, Konno Y, Sakuma J, Oinuma M, Murakawa M Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery. J Neurosurg , Wang S, Liu L, Zhao Y, Zhang D, Yang M, Zhao J Evaluation of surgical microscope integrated intraoperative near infrared indocyanine green videoangiography during aneurysm surgery. Neurosurg Rev , Washington W, Zipfel GJ, hicoine MR, Derdeyn P, Rich KM, Moran J, ross DT, Dacey RG Jr omparing indocyanine green videoangiography to the gold standard of intraoperative digital subtraction angiography used in aneurysm surgery. J Neurosurg , Yasargil MG Operative anatomy. in Yasargil MG ed Microneurosurgery. Volume I Microsurgical natomy of the asal isterns and Vessels of the rain, Diagnostic Studies, General Operative Techniques onsiderations of the Intracranial neurysms. Stuttgart, Thieme Verlag, 1984, pp IG videoangiography 2 4 M1 M1 2 M2 pterional approach IG

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