Intraoperative dynamic assessment of the posterior communicating artery and its branches by indocyanine green videoangiography
A 47-year-old female presented with headache. CT angiography and a four-vessel angiogram revealed a PComA–PCA junction aneurysm on the right hemisphere and P1 segment aneurysm on the left side [Figure and ]. The patient elected to undergo coil embolization of both aneurysms. Although the right-sided P1–PComA junction aneurysm was successfully coiled the left-sided P1 aneurysm was not amenable to safe coiling due to its broad neck involving the P1 posterior thalamoperforating artery. Therefore, the patient underwent a cranio-orbital approach for the clipping of the left P1 aneurysm. After wide splitting of the arachnoid cisterns, the ICA, PComA, PCA and basilar bifurcation were all exposed. The aneurysm was originating from the P1 segment of the PCA in relation to the P1 perforating artery. The tethered PComA was obstructing the view of the aneurysm neck and origin of the P1 perforator. Preclipping ICG-VA was performed to lay out the vasculature. Although few clip options were exercised, it was felt that without dividing the PComA, safe clipping would not be possible. As such, a temporary clip was placed along the distal P1 vessel and then ICG-VA performed to ensure that there was flow through the PComA perforators. After this was confirmed, the distal portion of the PComA was divided. The aneurysm was then dissected free and good clip purchase was provided. Postclipping ICG-VA revealed no flow through the aneurysm dome and persistent flow in the P1 perforator and rest of the P1 (see video, , which demonstrates the surgery, 3 min 18 s, and 97.5 MB). The patient refused to undergo postoperative arterial DSA, so intravenous-DSA was performed and revealed the total obliteration of the aneurysm [Figure and ]. The postoperative course was uneventful and the patient was discharged home in stable and neurologically intact condition.