Role of endoscopy in multi-modality monitoring during aneurysm surgery: A single center experience with 175 consecutive unruptured aneurysms

Abstract

Objective and Background:Unruptured aneurysm surgery is a challenge to all vascular neurosurgeons as the patient is asymptomatic and no even slight neurological deficits should be expected postoperatively. To this aim, multi-modality checking of the vessels during the surgery is highly recommended to assure of the patency of the parent and perforator arteries next to an aneurysm. In this paper, we present our experience in the last 1.5 years with emphasis on the role of endoscope assisted microsurgery.Methods:One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years. All patients underwent endoscope assisted microsurgery with pre- and post-clipping indocyanine green angiography. In selected cases, motor evoked potential monitoring was implemented.Results:No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively. Our illustrative cases show how endoscopy may help the surgeon to visualize hidden vessels behind and medial to an aneurysm.Conclusions:Our results indicated that multi-modality monitoring during unruptured aneurysm surgeries is associated with excellent outcome. Endoscope is able to show blind corners during aneurysm surgery which cannot be routinely observed with microscope and its application in aneurysm surgery assists the surgeon to make certain of complete neck clipping and preservation of perforating arteries around the aneurysm.

State-of-art in surgical treatment of dissecting posterior circulation intracranial aneurysms

“…Since VB IDAs pose specific anatomical proximities which increase the chance of branching vessels injury, perforators or cranial nerves during surgical procedure and indocyanine green video-angiography visualization is limited to the vessels directly observed under operating microscope [165], the application of the endoscope in deep seated aneurysm may further increase the feasibility of the procedure to minimize the retraction of brainstem, vascular, and neural structures resulting in reduced morbidity [22,115]. In patients with VA IDAs, the IX.…”

Minimally Invasive Microsurgery for Cerebral Aneurysms

“…33,34 Several case series have evaluated the usefulness of endoscopy assistance for aneurysm surgery in association with PTC. 33,37,38,40 Greater anatomic clarification was identified with endoscopy in 81.5% to 94.9% of aneurysms, but interestingly, information obtained exclusively through endoscopy was found in only 16.7% to 19.0% of aneurysms. 33,37 Clip repositioning was required in 6.9% to 11.4% of aneurysms because of incomplete neck obliteration, parent artery or perforator occlusion, and compression of surrounding neural structures.…”

“…48,49 However, several important caveats should be noted: (1) long narrow corridors restrict fine motor function at the target and may impair dissection of vessels and manipulation of the aneurysm clip; (2) depth perception is limited by the 2-dimensional view obtained through current endoscopes; (3) specifically designed endoscopic instrumentation for aneurysm surgery are not yet available; (4) management of an IOR may be problematic with significant bleeding obscuring the view of the endoscope; (5) aneurysm recurrence and retreatment will be made even more difficult with the presence of a previous aneurysm clip; (6) endoscopic surgery requires a specific skill set that involves a learning curve and a gradual transition from simple to complex skull base pathologies. 40,49 A listing of the advantages and disadvantages of purely endoscopic aneurysm surgery is provided in Table 3.…”

“…36 Subsequent clinical series have used a rigid neuro-endoscope with 0°, 30°, 70°, and 110° view angles. 33,34,[37][38][39][40] In endoscopeassisted craniotomies, the majority of the dissection and exposure is performed with the operating microscope, regardless of whether PTC or a mini-craniotomy is used. The endoscope has 3 applications during aneurysm surgery: inspection before clipping, clipping under endoscopic view, and postclipping evaluation.…”

Emprego de técnicas de neurocirurgia minimamente invasiva para o tratamento de aneurismas incidentais de circulação anterior

“…Desde então, a microcirurgia assistida por endoscopia para aneurismas cerebrais se tornou uma rotina em vários serviços, mas apenas algumas séries de casos foram publicadas descrevendo seus benefícios em cirurgias neurovasculares116,119,121,122,168 . Usualmente, o cirurgião principal tem que realizar a endoscopia através do olhar guiado do microscópio, e o assistente olha o monitor do endoscópio116 . Com objetivo de solucionar este problema, algumas companhias desenvolveram um modo de picture-inpicture para o microscópio 120 .…”