J Cerebrovasc Endovasc Neurosurg.  2023 Mar;25(1):50-61. 10.7461/jcen.2023.E2022.08.004.

Roadmapping technique in the hybrid operating room for the microsurgical treatment of complex intracranial aneurysms

• Gómez-Amador JL
• Valencia-Ramos CG
• Sangrador-Deitos MV
• Eguiluz-Melendez A
• Guinto-Nishimura GY
• Hernández-Hernández A
• Romano-Feinholz S
• Ortega-Porcayo LA
• Velasco-Torres S
• Martínez-Manrique JJ
• Ramírez-Andrade JJ
• Zenteno-Castellanos M

• KMID: 2540807
• DOI: http://doi.org/10.7461/jcen.2023.E2022.08.004

Abstract

Objective
To describe the roadmapping technique and our three-year experience in the management of intracranial aneurysms in the hybrid operating room.
Methods
We analyzed all patients who underwent surgical clipping for cerebral aneurysms with the roadmapping technique from January 2017 to September 2019. We report demographic, clinical, and morphological variables, as well as clinical and radiological outcomes. We further describe three illustrative cases of the technique.
Results
A total of 13 patients were included, 9 of which (69.2%) presented with subarachnoid hemorrhage, with a total of 23 treated aneurysms. All patients were female, with a mean age of 47.7 years (range 31-63). All cases were anterior circulation aneurysms, the most frequent location being the ophthalmic segment of the internal carotid artery (ICA) in 11 cases (48%), followed by posterior communicating in 8 (36%), and ICA bifurcation in 2 (8%). Intraoperative clip repositioning was required in 9 aneurysms (36%) as a result of the roadmapping technique in the hybrid operating room. There were no residual aneurysms in our series, nor reported mortality.
Conclusions
The roadmapping technique in the hybrid operating room offers a complementary tool for the adequate occlusion of complex intracranial aneurysms, as it provides a real time fluoroscopic-guided clipping technique, and clip repositioning is possible in a single surgical stage, whenever a residual portion of the aneurysm is identified. This technique also provides some advantages, such as immediate vasospasm identification and treatment with intra-arterial vasodilators, balloon proximal control for certain paraclinoid aneurysms, and simultaneous endovascular treatment in selected cases during a single stage.

Keyword

Aneurysm; Angiography; Complex; Hybrid operating room; Microsurgery; Roadmapping

Figure

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  Fig. 1. Organization for the hybrid operation room involving endovascular team (ET), neurosurgery, anesthesiology and nursing teams.

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  Fig. 2. Case #8. Digital substraction angiography (DSA) preoperative images. (A) anteroposterior (AP) projection of the left carotid axis shows a giant (25 mm) ophthalmic aneurysm (green arrowhead), (B) lateral projection of the right carotid axis shows a small (3 mm) posterior communicating aneurysm (yellow arrowhead).

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  Fig. 3. Case #8. Intraoperative images. Left pterional approach: (A) Aneurysm dissection in which the aneurysm dome (green arrowhead) is dorsally projected. After opening the opticocarotid cistern, the optic nerve (ON) and internal carotid artery (ICA) can be seen. (B) After the aneurysm neck and dome are exposed, the clip blades (*) are placed around the aneurysm´s neck. (C) Intraoperative roadmapping technique in which initial clip position is guided by real-time imaging.

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  Fig. 4. Case #8. iDSA images. (A) Left ICA, AP projection, a residual ophthalmic aneurysm (black arrowhead) is observed. (B) Left ICA, AP projection, after clip repositioning: complete aneurysm occlusion with no remnant is observed. (C) Right ICA, lateral projection: complete occlusion of the posterior communicating aneurysm. ICA, internal carotid artery; AP, anteroposterior

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  Fig. 5. Case #13. Preoperative DSA images. (A) Lateral projection of the right ICA and (B) 3D DSA reconstruction in which two right-sided ophthalmic aneurysms are observed, a Barami type Ib (green arrowhead) and a type II (yellow arrowhead). Intraoperative images. (C) After opening of the opticocarotid cistern, a 90º angled fenestrated clip was allocated around the type II aneurysm´s neck, the dome has a ventral projection, and behind the ICA, out of the microscope field. (D) Roadmapping image during clip positioning. The clip blades (*) completely surround the aneurysm´s neck, while a proximal control balloon (black arrow) on the cavernous segment of the ICA is placed. Lateral iDSA projection. (E) A residual aneurysm is observed (black arrowhead). (F) Complete occlusion in control iDSA after clip repositioning is achieved. Note the relationship of the aneurysms with the ophthalmic artery (OA). DSA, digital subtraction angiography; ICA, internal carotid artery; ON, optic nerve

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