Flash fluorescence with indocyanine green videoangiography to identify the recipient artery for bypass with distal middle cerebral artery aneurysms: operative technique

Document Type

Article

Abstract

BACKGROUND: Distal middle cerebral artery (MCA) aneurysms frequently have nonsaccular morphology that necessitates trapping and bypass. Bypasses can be difficult because efferent arteries lie deep in the opercular cleft and may not be easily identifiable. OBJECTIVE: We introduce the "flash fluorescence" technique, which uses videoangiography with indocyanine green (ICG) dye to identify an appropriate recipient artery on the cortical surface for the bypass, enabling a more superficial and easier anastomosis. METHODS: Flash fluorescence requires 3 steps: (1) temporary clip occlusion of the involved afferent artery; (2) videoangiography demonstrating fluorescence in uninvolved arteries on the cortical surface; and (3) removal of the temporary clip with flash fluorescence in the involved efferent arteries on the cortical surface, thereby identifying a recipient. Alternatively, temporary clips can occlude uninvolved arteries, and videoangiography will demonstrate initial fluorescence in efferent arteries during temporary occlusion and flash fluorescence in uninvolved arteries during reperfusion. RESULTS: From a consecutive series of 604 MCA aneurysms treated microsurgically, 22 (3.6%) were distal aneurysms and 11 required a bypass. The flash fluorescence technique was used in 3 patients to select the recipient artery for 2 superficial temporal artery-to-MCA bypasses and 1 MCA-MCA bypass. The correct recipient was selected in all cases. CONCLUSION: The flash fluorescence technique provides quick, reliable localization of an appropriate recipient artery for bypass when revascularization is needed for a distal MCA aneurysm. This technique eliminates the need for extensive dissection of the efferent artery and enables a superficial recipient site that makes the anastomosis safer, faster, and less demanding.

Medical Subject Headings

Adolescent; Adult; Cerebral Revascularization (instrumentation, methods); Female; Fluorescein Angiography (methods); Humans; Indocyanine Green; Intracranial Aneurysm (diagnosis, surgery); Male; Middle Aged; Prospective Studies; Retrospective Studies; Video-Assisted Surgery (methods); Young Adult

Publication Date

8-16-2011

Publication Title

Neurosurgery

E-ISSN

1524-4040

Volume

70

Issue

2 Suppl Operative

First Page

209

Last Page

20

PubMed ID

21841520

Digital Object Identifier (DOI)

10.1227/NEU.0b013e31823158f3

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