Endoscope-Assisted Microneurosurgery for Intracranial Aneurysms

Abstract

Background: The endovascular techniques has widely changed the treatment of intracranial aneurysms. However surgery still represent the best therapeutic option in case of broad-based and complex lesions. The combined use of endoscopic and microsurgical techniques (EAM) may improve surgical results.Objective: The purpose of our study is to evaluate the advantages and limits of EAM for intracranial aneurysms.Methods: Between January 2002 and December 2012, 173 patients, harboring 206 aneurysms were surgically treated in our department with the EAM technique. One hundred and fifty-seven aneurysms were located in the anterior circulation and 49 were in the posterior circulation. Standard tailored approaches, based on skull base surgery principles, were chosen. The use of the endoscope included three steps: initial inspection, true operative time, and final inspection. For each procedure, an intraoperative video and an evaluation schedule were prepared, to report surgeons’ opinions about the technique itself. In the first cases, we always used the endoscope during surgical procedures in order to get an adequate surgical training. Afterwards we became aware in selecting cases in which to apply the endoscopy, as we started to become familiar with its advantages and limits.Results: After clipping, all patients were undergone postoperative cerebral angiography. No surgical mortality related to EAM were observed. Complications directly related to endoscopic procedures were rare.Conclusion: Our retrospective study suggests that endoscopic efficacy for aneurysms is only scarcely influenced by the preoperative clinical condition (Hunt–Hess grade), surgical timing, presence of blood in the cisterns (Fisher grade) and/or hydrocephalus. However the most important factors contributing to the efficacy of EAM are determined by the anatomical locations and sizes of the lesions. Furthermore, the advantages are especially evident using dedicated scopes and holders, after an adequate surgical training to increase the learning curve.

Endoscopic Endonasal Transclival Approach versus Dual Transorbital Port Technique for Clip Application to the Posterior Circulation: A Cadaveric Anatomical and Cerebral Circulation Simulation Study

“…A current challenge with clipping aneurysms is acute morbidity and mortality due to surgical complexity and invasiveness (►Table 1). 9,12,14,15,[33][34][35][36][37] Endoscopic approaches provide a novel way to reach and clip posterior circulation aneurysms. 17 The ETA was superior to the TONES as demonstrated in this study when there is a high-riding basilar apex above the posterior clinoid.…”

A Journey into the Technical Evolution of Neuroendoscopy

“…The use of angled eyepiece telescopes (Figure 8) allows the surgeon to have the endoscope in the microneurosurgical field, without interfering with the maneuverability of the surgical tools. "Picture in picture" endoscopic and microscopic images, or viewed on small liquid crystal display screens placed above the binocular head of the microscope, allows the surgeon to obtain a simultaneous vision of the different images and angles of view (31).…”

The Clinical Importance of Perforator Preservation in Intracranial Aneurysm Surgery: An Overview with a Review of the Literature

“…Since Apuzzo et al adopted the side-angled rigid endoscope for surgery, 58 its usefulness has been reported in compensating for the shortcomings of the direct microscope. 7 8 9 59 60 61 62 63 64 In summary, the advantages of the neuroendoscope are as follows: (1) increased light intensity while approaching an object, (2) clear depiction of details in close-up positions, and (3) extended viewing angles. 65 66 The position of the clip blades in relation to perforating branches in the vicinity of the aneurysm neck can be assessed endoscopically in selected cases.…”