# Selection of Recipient Vessels in Double-Barrel STA-MCA Bypass Surgery with the Assistance of Intraoperative ICG Fluorescence: A Case Report and Review of the Literature

## TL;DR

This case report shows how intraoperative ICG fluorescence can help choose the best blood vessels for a brain bypass surgery in patients with blocked arteries.

## Contribution

The paper demonstrates the novel use of ICG fluorescence for real-time perfusion assessment to guide recipient vessel selection in double-barrel STA-MCA bypass.

## Key findings

- ICG-VA visualizes relative cortical perfusion delay during bypass surgery.
- Qualitative ICG-VA supports intraoperative decision-making without invasive imaging.
- Postoperative angiography confirmed graft patency and neurological stability in the patient.

## Abstract

What are the main findings?
Intraoperative indocyanine green video angiography (ICG-VA) visualizes relative cortical perfusion delay in steno-occlusive disease during STA-MCA bypass surgery.This case report demonstrates the application of ICG-VA for recipient vessel selection in double-barrel STA-MCA bypass.

Intraoperative indocyanine green video angiography (ICG-VA) visualizes relative cortical perfusion delay in steno-occlusive disease during STA-MCA bypass surgery.

This case report demonstrates the application of ICG-VA for recipient vessel selection in double-barrel STA-MCA bypass.

What are the implications of the main findings?
Perfusion-oriented assessment may complement conventional anatomical criteria during flow-augmentation bypass.Qualitative real-time fluorescence imaging may support intraoperative decision-making without additional invasive imaging.

Perfusion-oriented assessment may complement conventional anatomical criteria during flow-augmentation bypass.

Qualitative real-time fluorescence imaging may support intraoperative decision-making without additional invasive imaging.

Background/Objectives: Selection of the optimal recipient artery in superficial temporal artery to middle cerebral artery (STA–MCA) extracranial–intracranial bypass surgery is essential to ensure adequate cerebral perfusion. Various pre- and intraoperative tools for target vessel selection have been proposed. Indocyanine green fluorescence video angiography (ICG-VA) enables real-time visualization of cerebral hemodynamics, facilitating recipient vessel selection and anastomotic evaluation. Here, we review the literature and present the use of qualitative ICG-VA to support intraoperative decision-making during double-barrel (DB) STA–MCA bypass surgery. Case description: We report the case of a 68-year-old patient with bilateral steno-occlusive cerebrovascular disease, who developed progressive hemodynamic compromise of the left hemisphere after prior right-sided STA-MCA bypass. Preoperative imaging demonstrated impaired perfusion and posterior-to-anterior leptomeningeal collateralization from the posterior cerebral artery. During the left-sided DB bypass surgery, intravenous ICG-VA was used to assess relative cortical perfusion. Two superficial M4 branches with the most pronounced perfusion delay were selected as recipients based on the ICG-VA and anatomical criteria. Postoperative angiography confirmed graft patency. At short-term follow-up, the patient remained neurologically stable, with complete regression of preoperative symptoms. Conclusions: This case illustrates the application of qualitative ICG-VA for perfusion-oriented recipient vessel selection in DB STA-MCA bypass for steno-occlusive disease. Real-time perfusion assessment may complement conventional anatomical criteria for recipient vessel selection in flow-augmentation procedures. Further studies incorporating quantitative hemodynamic analysis are warranted.