Application Of Intraoperative Indocyanine Green Angiography During Anterior Communicating Aneurysm Surgery

Objective:By analyzing the indocyanine green fluorescence angiography during the anterior communicating aneurysm surgery to observe whether the aneurysms were clipped entirely,the parent artery were stenosis and the perforating arteries were involved.And combined with the clinical information after the operations and the intraoperative and postoperative imagings were explored in the patients to investigate the clinical value of ICG.Methods:In this paper,we collected the clinical data of 20 patients with anterior communicating artery aneurysm,who came to the Neurosurgery Department of the First Hospital of Jilin University from March 2008 to March 2009.In these patients,12 cases were male and 8 females,aged from 35 to 65, and the average age was 49.1 years old.All of them were suffering from spontaneous subarachnoid hemorrhage(SAH),diagnosed by preoperative CT, CTA,and(or) DSA.All the aneurysms were single,located in the anterior communicating artery.Preoperative Hunt-Hess grade:Ⅰgrade with 2 cases,Ⅱgrade with six cases,Ⅲgrade with 10 cases,Ⅳgrade with 2 cases.Fisher Grade:Ⅰgrade with 2 cases,Ⅱgrade with 11 cases,Ⅲgrade with 7 cases.The interval time between onset and microsurgical treatment:13 cases less than 3 days,other 7 cases were 10 to 14 days.Before the surgerical operations,we confirmed that the patients were non-allergy,non-iodine,dye or contrast agent allergy history,women with no pregnancy.Before the surgerical operations,we explained to the patients and they agreed to use the ICG angiography during their operations and signed the informed consent form.We used the German-based Zeiss OPMI Pentero microscope during the surgerical operations. In all the patients,we chosed the side of which the anterior cerebral artery blood were advantage pterional flank.We separated the lateral cleft,cleared hematocele in the surgical field.After we were satisfied with the anatomical structure,one aneurysm clip was used to clip the neck of the aneurysm.Before and after the aneurysms were clipped,we went on ICG fluorescein angiography respectively.The usual dose of ICG were 0.2～0.5mg/kg,the largest not more than 5mg/kg.The conventional use for adults were 25mg ICG solubling in 5ml sterile distilled water.Then,the solution was injected from the median cubital vein rapidly.Before the angiography,we adjusted the microscope to a suitable view angle,focal length and magnification,got a satisfied surgerical view.The microscope was switched to the fluorescence microscope angiography mode.Then,we observed the ICG fluorescein angiography of the aneurysms,the parent artery and its perforating artery,including whether the aneurysms were clipped entirely,the parent artery were stenosis and the perforating artery were involved.Results:We went on ICG fluorescein angiography 42 times in the 20 patients,and we were basically satisfied with the results.The arteries were enhanced in 15～20 seconds after the contrast agents were injected,and the effective time was 1～2 minutes.We could observe the arterial phase,capillary and venous phase during the period.There were 20 times of ICG fluorescein angiography before the aneurysms were clipped.We could observe the aneurysms and the parent arteries,and 2 to 4 perforating arteries could be observed around the aneurysms.There were 22 times of ICG fluorescein angiography after the aneurysms were clipped.In one cases,a perforating artery was confirmed to be occlusion by ICG angiography after the aneurysm was clipped.We adjusted the aneurysm clip in time and went on another ICG angiography.This time,the perforating artery was revealed to be recanalization.In another case,we were not satisfied with the results becase the view was blocked by the aneurysm clip.After adjusting for observation point of view and once again after the angiography,we confirmed that the aneurysm was clipped completely.The other 18 patients' angiography showed that the aneurysms were clipped entirely,parent arteries were not contained in narrow, and no perforating arteries were occlusion.Intraoperative use of ICG fluorescence contrast agent adverse reaction did not appear.In one case,of which the intraoperative angiography showed nothing positive,the patient showed a weakness of the limb muscle strength at the right side,and after 15 days,the limb muscle strength was gradeⅢ.The head CT of the patient showed that there was an infarcted area located at the head of the left caudate nucleus,and the size of infarction is about 1cm~2,considering that the most possibility was one perforating artery involved.One case of the patients died due to a serious cerebral vasospasm.There were nothing special in the other patients and no significant abnormal clinical manifestations,did not appear improper clipping complications.When the 20 patients discharged from the hospital,the GOS score showed:17 patients were 5,1 patient was 4,1 patient was 3,1 patient was 1,and the rate of patients with good prognosis was 90%.Conclusion.Intraoperative ICG fluorescence angiography is simple, offering the surgery-related information to the surgery in time,and the risk is low. The angiography effective are good,and it can clearly show whether the aneurysm is completely occluded,the parent artery stenosis and the perforating artery occlusion.However,the view of ICG fluorescence angiography is easily blocked by other objects.And it's difficult to show the vasculars out of the surgery field.And it be better to conjunction with other monitoring tools.