Innovations in the Surgery of Cerebral Aneurysms: Enhanced Visualization, Perfusion, and Function Monitoring

Abstract

Surgery of cerebral aneurysms has evolved over the years. Advances regard enhanced intraoperative visualization and monitoring of both function and perfusion. Technological assistance used in oncological or skull base surgery, such as intraoperative neurophysiological monitoring (IONM) or endoscopy, now adopt to vascular surgery. Intraoperative indocyanine green video angiography (ICG-VA) and techniques for its interpretation (squeezing maneuver; entrapment sign), endoscopes, and exoscopes increase visualization. Flow evaluation by microflow probe permits perfusion monitoring; IONM allows functional monitoring. Bypasses replace flow in complex aneurysm cases. Pre-, intra-, and postoperative imaging and flow measurement techniques help in donor selection and follow-up. Despite some progression in the aneurysm clips, the principle has not changed. Innovation and even change of principle in aneurysm exclusion might be desirable. Basic research in aneurysm wall and flow dynamics might in the future change the paradigms of cerebral aneurysm treatment.

Microsurgery for intracranial aneurysms: A qualitative survey on technical challenges and technological solutions

“…Intraoperative monitoring was not identified as a theme in our cohort despite being commonplace in many parts of the world and described by other authors, although the huge contribution made by ICG angiography is certainly reflected in other studies ( 31 , 35 ).…”

“…Notably, in the literature, the most commonly reported adverse event is intraoperative rupture (28) that may reflect Technological advances grouped by technical challenge they respond to (as percentages express the percentage of respondents citing each technological advance, these percentages do not sum to 100%). Intraoperative monitoring was not identified as a theme in our cohort despite being commonplace in many parts of the world and described by other authors, although the huge contribution made by ICG angiography is certainly reflected in other studies (31,35).…”

“…The profile of adverse events is, of course, recognised to be very different for surgery for unruptured cerebral aneurysms, which have much lower morbidity, principally due to the better condition of the brain and dramatically lower risk of intraoperative rupture (30). There is, of course, extensive literature from the leading cerebrovascular surgeons in the field describing the techniques and challenges of aneurysm surgery including advanced techniques that push the envelope of what is possible (1,(31)(32)(33)(34)(35)(36). The aim of this study was to survey a cohort of neurovascular surgeons to describe what they perceive as the principal technical challenges of aneurysm surgery, the technological advances that have been most significant, and how they expect technology to advance the field in the future.…”

Letter: Clipping of Complex Internal Cerebral Artery Terminus Aneurysm: 2-Dimensional Operative Video

“…Although single perforator dissection is possible with preoperative planning, multiple perforators visualization during aneurysm dissection and clipping may be possible only with multiple indocyanine green videoangiography. 4 Endoscopes are being used for a similar purpose. 5…”

Utilizing indocyanine green video angiography to bridge intracranial aneurysm treatment gaps in low- and middle-income countries: a mini-review

“…10 Open surgery approaches such as aneurysm wrapping and aneurysm resection, may lead to increased mortality rates and complications, while endovascular treatment options may not always be accessible due to cost and expertise constraints. 11 Additionally, intraoperative techniques like digital subtraction angiography (DSA) can be timeconsuming and entail limitations. 12 The recent emergence of ICG-VA presents a promising solution.…”