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Background Proximal arterial control is critical for safe and effective microsurgical clipping of ophthalmic segment aneurysms (OSAs). Traditionally, this is achieved via neck dissection and temporary clamping of the cervical internal carotid artery (ICA). Advances in endovascular technology have introduced temporary balloon occlusion (TBO) as a potentially less invasive alternative. This study aims to assess the utility of TBO during microsurgical clipping of OSAs. Methods A retrospective review was conducted of all patients at a single institution who underwent microsurgical OSA clipping with planned TBO. Patient demographics, presentation, aneurysm morphology, occlusion outcomes, complications, recurrence, and functional outcomes based on modified Rankin score (mRS) at follow-up were evaluated. Patients who underwent balloon inflation for proximal control (+ TBO) were compared with those who did not (-TBO). Results A total of 34 patients with 35 OSAs were included. A temporary balloon guide catheter was successfully navigated to the cervical carotid in all cases. TBO was performed in 19 patients (20 aneurysms) during aneurysm clipping. Aneurysm sizes ranged from 2.8 to 18.0 mm (mean: 6.7 mm), with neck sizes ranging from 1.6 to 8.1 mm (mean: 4.2 mm). The + TBO group had a significantly higher proportion of wide-necked aneurysms (> 4 mm) compared to the -TBO group (55.0% vs. 26.7%; p = 0.008) and more frequently required anterior clinoidectomy (84.2% vs. 46.7%; p = 0.020). Complete or near-complete (< 2 mm remnant) aneurysm occlusion was achieved in all cases. There was one complication (2.9%) with permanent sequela and median mRS at follow-up was 0. There were no significant differences in complication rates or functional outcomes between the + TBO and -TBO groups. Conclusion Endovascular-assisted TBO is a safe and effective minimally invasive alternative to open neck dissection for achieving proximal control during OSA clipping. TBO may be particularly advantageous for managing wide-neck aneurysms.

BACKGROUND AND IMPORTANCE:Iatrogenic internal carotid artery (ICA) injuries during endoscopic endonasal approach (EEA) surgeries are associated with a high morbidity and mortality, with few acceptable methods described for repair. CLINICAL PRESENTATION:A 13-year-old girl with a large anterior and central skull base osteoblastoma incurred an iatrogenic cavernous ICA injury during a staged EEA approach. Intraoperative angiogram was performed with balloon-assisted EEA primary microsurgical repair of the lacerated ICA. CONCLUSION:By integrating current techniques commonly used in open aneurysm surgeries and in endovascular procedures, we developed a rapid, safe technique to repair an EEA-associated iatrogenic ICA injury. ABBREVIATIONS:EEA, endoscopic endonasal approachICA, internal carotid artery

Abstract BACKGROUND Digital subtraction angiography (DSA) is the gold standard for vascular imaging, but is not easily integrated into a continuous microsurgical environment. Other available modalities for intraoperative vascular assessment have their own limitations. OBJECTIVE To investigate multispectral fluorescence (MFL), a new technology based on indocyanine green (ICG) fluorescence, which may provide advantages over current intraoperative imaging modalities. METHODS Cadaveric intracranial aneurysm models and turkey wing bypasses were created and tested with white light and micro-Doppler ultrasound, indocyanine green videoangiography (ICG-VA), MFL, and DSA in conditions mimicking surgery. Assessments with these modalities were scored by 7 neurosurgeons. RESULTS DSA was significantly better than other modalities in evaluating the vasculature (P < .0001), but was significantly less ergonomic and efficient (P < .0001). MFL and ICG-VA were not significantly different from each other. Both were significantly better than white light/micro-Doppler ultrasound in assessing occlusion and patency (P ≤ .011), and both were better than DSA in ergonomics and efficiency (P < .0001). CONCLUSION MFL performs similarly to ICG-VA in a laboratory setting. Further study will be required to determine whether it compares favorably in the operating room. While DSA is the standard for cerebrovascular visualization, MFL and ICG are significantly more ergonomic and efficient.

Abstract BACKGROUND: Intraoperative angiography is routinely utilized for aneurysms and arteriovenous malformations (AVMs) to verify complete occlusion and resection. Surgery for spinal and posterior fossa neurovascular lesions is usually performed in prone position. Intraoperative angiography in the prone position is challenging and there is no standardized protocol for this procedure. OBJECTIVE: To describe our experience with intraoperative angiography in the prone and lateral positions, using upper extremity arterial access. METHODS: We reviewed our experience with intraoperative angiography in the prone position between 2014 and 2015, where vascular access was obtained via the upper extremity arteries. Patients were treated in a hybrid endovascular operating room. High cervical and intracranial lesions were studied via brachial or radial access. All accesses were obtained using ultrasonographic guidance and a small caliber arterial sheath (4F). RESULTS: Five patients were treated in the prone and lateral positions using brachial/radial artery access. Patients harbored cerebellar AVM, lateral medullary AVM, cervical arteriovenous fistula (AVF), tentorial dural AVF, and tentorial-incisural dural AVF. Patients were positioned prone (n = 2), semiprone (n = 2), and lateral (n = 1) for the surgery. Three patients were treated via right brachial artery access. Two patients were treated via radial arteries access. All patients tolerated the procedures without technical or clinical complications. Intraoperative angiography verified complete occlusion and resection in all cases prior to surgical closure. CONCLUSIONS: Intraoperative angiography in the prone and lateral positions using upper extremity access is an important adjunct. Brachial or radial access can be obtained safely and provides comfortable and quick approaches.

Abstract We present a patient who was diagnosed 20 yr prior to current presentation with a spinal arteriovenous malformation. This patient had a 10-yr history of worsening back pain (and underwent lumbar fusion), urinary dysfunction leading to 3-yr dependence on intermittent catheterization, lower extremity paresthesias and pain, and progressive weakness with multiple falls, leading to walker then wheelchair dependence for mobility. Magnetic resonance studies showed extensive thoracic cord expansion and edema with enlarged spinal cord surface veins and flow voids extending from spinal levels T6 to the conus medullaris. Partial embolization at an outside institution elicited transient symptom improvement. Repeated spinal angiogram demonstrated persistent T10 pial arteriovenous fistula (AVF) supplied by the posterior spinal artery arising from the right T11 segmental artery as well as by the anterior spinal artery from the left T10 segmental artery. Because additional embolization carried significant risk, we planned open surgery with fistula resection. Informed consent for the surgery and video recording was obtained. The patient was placed in the prone position, and a radial artery access was obtained for intraoperative angiogram. Following a posterior T9-T11 laminectomy and dural opening, a pial dissection was performed to expose the AVF. Intraoperative indocyanine green angiography was used to assist in identifying the feeders and major drainage of the AVF. Post-AVF resection, a formal intraoperative radial access spinal angiogram demonstrated complete resection of the lesion with no residual shunt or early venous drainage. The patient improved significantly and, on last follow-up, is ambulating without any assistive devices.

Blood blister-like aneurysms (BBLAs) are aneurysms from the non-branching sites of the internal carotid artery (ICA). Though rare lesions, they pose a high risk of intraoperative aneurysmal rupture. Definite treatment of these types of aneurysms has been debatable, but surgical approach is the ultimate rescue treatment. Microsuture of the intraoperative ruptured BBLA has been reported scarcely in literature, but no review of these cases has ever been reported. We here present our experience of a case of BBLA intraoperative rupture requiring microsuture of the ICA and conduct meticulous review of all similar cases.

A 69-year-old lady presented with complaints of decreased vision in left eye since one month. Best Corrected Visual Acuity (BCVA) was 6/18 in that eye. Fundus examination revealed non-central geographic atrophy and soft drusens at macula in both eyes. Temporal periphery of left eye revealed subretinal exudates with altered sub-RPE hemorrhage mimicking peripheral exudative hemorrhagic chorioretinopathy (PEHCR). Fundus Fluorescein Angiogram showed window defects at macula and blocked fluorescence at temporal periphery in left eye. However, Indocyanine green angiography (ICGA) revealed active peripheral choroidal polyps. The patient was successfully treated with intravitreal bevacizumab and ICGA-guided laser photocoagulation. 27 months after laser treatment, BCVA improved to 6/9. Rationale of consecutive anti-vascular endothelial growth factor (VEGF) treatment followed by more definitive laser photocoagulation is that anti-VEGF aids in resolution of subretinal fluid, thus making the polyp more amenable to focal laser photocoagulation which stabilizes the choroidal vasculature and prevents further leakage.

Mullins et al. [6] reported the first use of stent implantation to treat stenotic branch pulmonary arteries in 1988. In the early to mid-1990s, numerous reports confirmed its safety and efficacy, but there were limited stent and balloon designs and stent implantations were performed using relatively large delivery systems (10- to 12-Fr sheaths) [7, 8]. The general accepted patient size was limited to those weighing 12 kg or greater. Intraoperative stent implantation for branch pulmonary artery stenosis was reported in the early to mid-1990s [1-3, 5, 9]. Indications in these early reports included small patient size or difficult anatomy or patients who had additional cardiac lesions and needed surgery independent of the branch stenosis. The idea was to take advantage of the open-heart exposure provided in the operating room to permit direct access to the stenotic segment. Hence, all intraoperative stent implants were performed under direct visualization on bypass. There were no discussions on advantages over the routine percutaneous approach. Currently, with advances in stent and balloon technology as well as increased operator experience, many of those reported cases probably would have undergone cardiac catheterization for a percutaneous stent implant rather than open-heart surgery. The purpose of this report is to review the current indications, advantages, and disadvantages of intraoperative stent implantation as well as to discuss the techniques that are helpful to optimize intraoperative stent positioning. The role and advantages of intraoperative angiography will also be presented.