Clinical Neurology and Neurosurgery 115 (2013) 870–878 Contents lists available at SciVerse ScienceDirect Clinical Neurology and Neurosurgery j o ur nal hom epage: www.elsevier.com/locate/clineuro How reliable and accurate is indocyanine green video angiography in the evaluation of aneurysm obliteration? Erkin Özgiray, Erinc ¸ Aktüre, Nirav Patel, Christopher Baggott, Melih Bozkurt, David Niemann, Mustafa K. Bas ¸ kaya * Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53792, USA a r t i c l e i n f o Article history: Received 11 April 2012 Received in revised form 27 June 2012 Accepted 12 August 2012 Available online 7 September 2012 Keywords: Clipping ICG video angiography Indocyanine green Intracranial aneurysms a b s t r a c t Introduction: Indocyanine green video angiography (ICG-VA) has been recently introduced into neurovas- cular surgery and gained a role in assessing vessel patency and obliteration of intracranial aneurysms (IA) after clipping. Although its correlation with intra-postoperative angiography was demonstrated in previ- ous studies, difficulties in evaluating aneurysm obliteration have not been reported. We report reliability and accuracy of ICG-VA in 109 clipped aneurysms with attention given to five cases in which ICG-VA evaluation resulted in false indication that aneurysms were secure in terms of complete obliteration. Materials and methods: A retrospective chart review was performed of IAs surgically treated by a sin- gle surgeon from January 2009. In all cases, aneurysm obliteration was confirmed by a combination of microdoppler ultrasonography (MUSG), ICG-VA, and post-operative angiography. Results: ICG-VA appropriately assessed vessel patency and aneurysm obliteration in 93.5% of aneurysms clipped. In four cases (3.6%), puncturing the dome of the aneurysm after satisfactory clipping revealed persistent flow within the aneurysm despite ICG-VA showing no flow after clipping. In one case (0.9%), ICG-VA showed persistent flow within the aneurysm and MUSG did not, and puncture of the dome confirmed no flow within the aneurysm. In one case (0.9%), ICG-VA failed to demonstrate residual neck. Conclusion: ICG-VA is a simple and safe procedure and an important adjunct to microsurgical clipping of aneurysm. Although ICG-VA assesses vessel patency and obliteration of aneurysms in most cases, applying the principles of microsurgery in aneurysm clipping remains a main tool for obtaining the complete obliteration of aneurysm along with preservation of the normal vasculature. © 2012 Elsevier B.V. All rights reserved. 1. Introduction Despite advances in alternative treatments such as coiling or stenting, microsurgical clipping should be considered as the defini- tive and durable treatment for intracranial aneurysms (IA’s) [1–6]. Optimal treatment of aneurysms by clipping must be accom- plished without a remnant, while preserving the parent artery and its branches. These goals can be achieved by careful microsurgi- cal techniques and intraoperative adjuncts such as microdoppler ultrasonography (MUSG), intraoperative conventional catheter angiography, and indocyanine green videoangiography (ICG-VA). Since ICG-VA has been introduced into the neurosurgical armamen- tarium in 2003, it has found common usage in daily neurovascular surgery [3,7–16]. Recent studies have assessed its comparability with intraoperative angiogram and reported corresponding results * Corresponding author at: Department of Neurological Surgery, University of Wisconsin, School of Medicine, CSC K4/822, 600 Highland Avenue, Madison, WI 53792, USA. Tel.: +1 608 262 7303; fax: +1 608 263 1728. E-mail address: m.baskaya@neurosurgery.wisc.edu (M.K. Bas ¸ kaya). in 90–98% of cases. Almost all of the studies published to date focused on ICG-VA’s reliability in assessing residual aneurysm or perforating artery occlusion, with the exception of a case report by Mery et al. [5]. They reported two cases in which ICG-VA showed no filling of the aneurysm, giving the indication of complete oblit- eration, while puncturing the dome revealed persistent flow. In this study, we report our experience with ICG-VA in 109 aneurysms, and we discuss in details the patients in whom ICG- VA revealed false indication that aneurysms were secure in terms of complete obliteration. 2. Materials and methods This study was performed retrospectively in the Department of Neurological Surgery, University of Wisconsin-Madison after obtaining the approval by our Institutional Review Board. 2.1. Patient population Between January 2009 and July 2011, 92 patients (mean age 54.2) harboring 117 aneurysms were operated on by a single 0303-8467/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.clineuro.2012.08.027