title: Is an angiographically obliterated aneurysm always secure?
abstract: OBJECTIVE
  Conventional cerebral angiography is the standard examination used to confirm aneurysm obliteration. Intraoperative indocyanine green (ICG) video angiography has recently been introduced as a valuable tool that is comparable to catheter intraoperative angiography. Intraoperative imaging evaluation is especially useful when complex aneurysm features are present, making direct clipping challenging. The aim of these angiographic evaluations is to assess parent vessel patency and to confirm lesion obliteration. However, there have been recent reports of growth or even rupture of angiographically obliterated aneurysms.
  
  
  METHODS
  We report two patients in whom ICG video angiography falsely indicated that a clipped aneurysm was secure.
  
  
  METHODS
  Both patients underwent direct clipping of unruptured aneurysms. ICG video angiography was performed, showing absence of residual filling of the sac. After incising the aneurysm dome, slow but significant dye extravasation was demonstrated. In the first patient, this occurred as a result of incomplete clipping of a wide aneurysm neck that was difficult to visualize; in the second patient, it occurred as a result of atheroma at the neck not allowing complete closure of the clip blades. This finding prompted clip readjustment and placement of an additional reinforcing clip in the two patients, respectively.
  
  
  CONCLUSIONS
  We demonstrate false indication of aneurysm obliteration by intraoperative video angiographic evaluation using ICG. It is possible that this limitation would also apply to catheter angiography. If certainty of complete exclusion of the aneurysm through opening the dome is not achieved, long-term follow-up angiographic evaluation would be strongly advised.
authors.affiliation: Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Mery
authors.forename: Sepideh
authors.initials: S
authors.lastname: Amin-Hanjani
authors.forename: Fady T
authors.initials: FT
authors.lastname: Charbel
mesh_terms: D000368:Aged; D002533:Cerebral Angiography / Q000379:methods*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015641:Radiography, Interventional / Q000379:methods*; D017211:Treatment Failure; D016896:Treatment Outcome