Endoscopic Indocyanine Green Angiography for Endonasal Aneurysm Clipping

Introduction: Indocyanine green (ICG) video angiography is a useful tool, used routinely during microsurgical aneurysm clipping. The endoscopic endonasal approach (EEA) for aneurysm clipping has been described as a viable option for rare, select cases. No reports currently exist on EEA and ICG near-infrared endoscopic angiography during aneurysm clipping.

Objective: The main goal of this report is to describe the conceptual application and technical nuances of these operations.

Methods: We present two patients with intracranial aneurysms arising from the proximal anterior inferior cerebellar artery (AICA) and from the supraclinoid segment of bilateral internal carotid arteries (ICAs) (bilateral aneurysms) which were successfully clipped through an EEA with the use of intraoperative ICG angiography.

Results: Case 1 was a 52-year-old asymptomatic female with a strong family history of ruptured intracranial aneurysms and incidental bilateral ICA aneurysms found on MRI screening and confirmed with digital subtraction angiography. An endoscopic endonasal transsellar bilateral transcavernous and transplanum approach was performed to clip the aneurysms with the use of intraoperative ICG angiography. Complete occlusion of the aneurysms and patency of the adjacent vasculature was achieved. Case 2 was a 54-year-old female who suffered an acute, severe headache and presented to the emergency department as a Hunt-Hess Grade 3 secondary to a dissecting pseudoaneurysm of the right proximal AICA. After a right frontal external ventricular drain was placed an endoscopic endonasal transclival approach was used to clip the pseudoaneurysm with the use of intraoperative ICG angiography. Patency of the adjacent vasculature and proximal AICA and obliteration of the pseudoaneurysm was confirmed with intraoperative angiography.

Conclusion: The EEA can be a safe and effective way to clip rare, well-selected aneurysms when done by skull base teams with extensive experience with the EEA. The use of ICG during endoscopic endonasal aneurysm surgery may help improve the surgical outcomes in the same way it has for microscopic surgery.

No conflict of interest has been declared by the author(s).