# Indocyanine Green and Fluorescein Videoangiography for the Assessment of Collateral Circulation in Posterior Circulation Aneurysm Clipping: A Case Report and Review

## TL;DR

This case report shows how fluorescent imaging helps surgeons treat complex brain aneurysms by assessing blood flow in real time, avoiding unnecessary procedures.

## Contribution

Demonstrates the clinical utility of ICG and FL-VAG in guiding posterior circulation aneurysm surgery.

## Key findings

- Intraoperative ICG and FL-VAG confirmed sufficient collateral flow, avoiding the need for a bypass.
- Postoperative imaging showed preserved circulation without ischemic damage.
- Fluorescent imaging improved surgical precision and patient outcomes.

## Abstract

Microsurgical treatment of posterior circulation aneurysms remains challenging due to their deep location, complex anatomical exposure, and close proximity to critical neurovascular structures. Ensuring adequate collateral circulation is paramount for preventing ischemic complications. Indocyanine Green (ICG) and Fluorescein Video Angiography (FL-VAG) have emerged as effective intraoperative tools for assessing cerebral perfusion and guiding surgical decision-making.

We report the case of a 29-year-old male presenting with a thunderclap headache, nausea, and vomiting, subsequently diagnosed with a fusiform aneurysm at the P2-P3 junction of the left posterior cerebral artery. The patient underwent a subtemporal approach with partial posterior petrosectomy for aneurysm clipping and remodeling. Initially, an STA-P3 and PITA-P3 bypass were considered; however, intraoperative ICG and FL-VAG confirmed sufficient retrograde collateral flow, allowing the bypass procedure to be avoided. Postoperative imaging demonstrated patent circulation in the occipitotemporal region without ischemic compromise.

This case highlights the crucial role of intraoperative fluorescence imaging in refining surgical strategies for complex aneurysm clipping. ICG and FL-VAG enhance surgical precision by providing real-time perfusion assessment, reducing the need for additional vascular interventions, and improving patient outcomes.