J Cerebrovasc Endovasc Neurosurg.  2021 Sep;23(3):210-220. 10.7461/jcen.2021.E2020.10.003.

Intra-operative cerebral blood flow assessment by indocyanine green video-angiography after temporary arterial occlusion in aneurysm surgery and its clinical implications: a prospective study

• Dutta G
• Jagetia A
• Srivastava AK
• Singh D
• Singh H
• Chawla R
• Agarwal A
• Iqbal M
• Tandon M

• KMID: 2520880
• DOI: http://doi.org/10.7461/jcen.2021.E2020.10.003

Abstract

Objective
Indocyanine green video angiography (ICG-VA) is a routine while performing vascular surgery to assess patency of perforators, completeness of clipping and/or to assess patency of anastomosis. Its usefulness in assessing cerebral blood flow and perfusion is not well studied. This study is aimed to assess the cerebral blood flow and perfusion after temporary clipping and to correlate with the risk of ischemia.
Methods
Prospective analysis of intra-operative ICG-VA performed during temporary arterial occlusion in 38 patients from January 2014 to December 2018 was conducted. Co-relation with post-operative MR diffusion weighted imaging (MR DWI) in terms of vascular territory of interest within 48 hours of surgery was performed. Clinical outcome was assessed using modified Rankin Scale (mRS) score 1-month post-surgery.
Results
43 aneurysms in 38 patients clipped using ICG-VA were included in this study. No side effect of ICG dye was seen in any patients. The number of times temporary clips applied had a direct relationship to the delay in appearance of ICG in the surgical field which became statistically significant after application of 3rd temporary clip. Nine (23.7%) patients developed ischemia following the procedure confirmed by post-operative MR DWI and all the ischemic cases had visible decrease in ICG fluorescence post-temporary clipping.
Conclusions
No previous study had tried to assess the intraoperative cerebral blood flow and perfusion during temporary clipping of parent vessels during aneurysm surgery. The use of ICG-VA can be extended to assess perfusion in desired territory by merely assessing the degree of opacification.

Keyword

Indocyanine green; Temporary arterial occlusion; Aneurysm; Intracranial; Cerebral blood flow

Figure

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  Fig. 1. The time gap of 1 second between appearance of ICG and complete opacification of vessels when no clip was applied was increased to 3 seconds after application of 1st temporary clip that was in place for 3 min 23 seconds. ICG, indocyanine green.

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  Fig. 2. Acom artery aneurysm. (A) shows one perforator arising in the vicinity of the aneurysm visible on ICG-VA image before applying any temporary clip. (B) shows the ICG-VA image taken after removal of the 4th temporary clip that was applied for 5 min 30 sec. The perforator is not opacified anymore. ICG-VA, indocyanine green video angiography

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  Fig. 3. Right A1-A2 junction aneurysm. (A) shows the ICG-VA image before applying any temporary clip where 3 perforators arising in the vicinity of Rt ACA can be seen. (B) shows the ICG-VA image taken after removal of 3rd temporary clip that was applied for 7 min 2 second revealing only one remaining perforator. ICG-VA, indocyanine green video angiography; ACA, anterior cerebral artery.

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  Fig. 4. Single maximum mean time of temporary clip application vs post-operative ischemia.

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  Fig. 5. Total (mean) time of temporary clip application vs post-operative ischemia.

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  Fig. 6. Mean total temporary clips used vs post-operative ischemia.

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