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

Background: 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. Research question: 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. Methods: 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. Results: 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. Conclusion: 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.