# Hybrid operating rooms for the treatment of complex middle cerebral artery aneurysms: A technical note

## TL;DR

Hybrid operating rooms allow safer and more efficient treatment of complex brain aneurysms by combining microsurgery and endovascular techniques.

## Contribution

A novel hybrid technique using flash fluorescence and endovascular methods for treating fusiform MCA aneurysms is described.

## Key findings

- The hybrid flash-fluorescence technique successfully identified bypass recipients in three complex MCA aneurysm cases.
- This approach reduced surgical risks and operative time by avoiding large craniotomies and aneurysm manipulation.
- Hybrid operating rooms offer new treatment options for challenging neurovascular pathologies.

## Abstract

The recent emergence of hybrid operating rooms (H-OR) broadens treatment options for complex intracranial aneurysms. Combining endovascular options enabled by the H-OR with refined microsurgical techniques could provide less arduous treatment alternatives for large, distal, and fusiform MCA aneurysms.

To describe the technical nuances of a hybrid treatment consisting of microcatheter-guided flash fluorescence to enable revascularization bypass and endovascular parent vessel occlusion (PVO) in three different cases of large, distal and fusiform MCA aneurysms.

A technical report of three cases is provided. At a H-OR, after STA harvest and side-appropriate craniotomy, femoral artery access was obtained and a microcatheter was guided in the corresponding aneurysm. Indocyanine green (ICG) was injected throughout the microcatheter while running a videoangiography on the surgical microscope, allowing straight-forward identification of the appropriate vessel recipient for the revascularization bypass.

The described hybrid flash-fluorescence technique allowed straight-forward identification of the appropriate vessel recipient for the revascularization bypass in all three cases. After completion of the bypass and verification of its patency by intraoperative angiography, the aneurysms and their parent vessels were occluded endovascularly.

This hybrid treatment using modern endovascular and microsurgical techniques obviates the need for a large craniotomy, Sylvian fissure dissection and aneurysm manipulation, while reducing surgical risks and operative time in the treatment of complex fusiform MCA aneurysms. The H-OR room can result in new proficient, creative and safe treatment options of different neurovascular pathologies.

•Hybrid operating rooms broaden treatment options for complex intracranial aneurysms•Microcatheter-guided flash fluorescence enabled easier revascularization bypass•Combined with endovascular, provided new alternatives for fusiform MCA aneurysms•Further availability of hybrid operating rooms may enable new creative treatments

Hybrid operating rooms broaden treatment options for complex intracranial aneurysms

Microcatheter-guided flash fluorescence enabled easier revascularization bypass

Combined with endovascular, provided new alternatives for fusiform MCA aneurysms

Further availability of hybrid operating rooms may enable new creative treatments