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The Squeezing Maneuver in Microsurgical Clipping of Intracranial Aneurysms Assisted by Indocyanine Green Videoangiography

Della Puppa, Alessandro MD*; Rustemi, Oriela MD*; Rossetto, Marta MD*; Gioffrè, Giorgio MD*; Munari, Marina MD; Charbel, Fady T. MD§; Scienza, Renato MD*

doi: 10.1227/NEU.0000000000000334
Operative Nuances

BACKGROUND: Indocyanine green videoangiography (ICGV) is becoming routine in intracranial aneurysm surgery to assess intraoperatively both sac obliteration and vessel patency after clipping. However, ICGV-derived data have been reported to be misleading at times. We recently noted that a simple intraoperative maneuver, the “squeezing maneuver,” allows the detection of deceptive ICGV data on aneurysm exclusion and allows potential clip repositioning. The squeezing maneuver is based on a gentle pinch of the dome of a clipped aneurysm when ICGV documents its apparent exclusion.

OBJECTIVE: To present the surgical findings and the clinical outcome of this squeezing maneuver.

METHODS: Data from 23 consecutive patients affected by intracranial aneurysms who underwent the squeezing maneuver were analyzed retrospectively. The clip was repositioned in all cases when the dyeing of the sac was visualized after the maneuver.

RESULTS: In 22% of patients, after an initial ICGV showing the aneurysm exclusion after clipping, the squeezing maneuver caused the prompt dyeing of the sac; in all cases, the clip was consequently repositioned. A calcification/atheroma of the wall/neck was predictive of a positive maneuver (P = .001). The aneurysm exclusion rate at postoperative radiological findings was 100%.

CONCLUSION: With the limits of our small series, the squeezing maneuver appears helpful in the intraoperative detection of misleading ICGV data, mostly when dealing with aneurysms with atheromatic and calcified walls.

ABBREVIATIONS: DSA, digital subtraction angiography

ICG, indocyanine green

ICGV, indocyanine green videoangiography

*Department of Neurosurgery and

Department of Anaesthesiology, Padua University Hospital, Padua, Italy;

§Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois

Correspondence: Alessandro Della Puppa, MD, Department of Neurosurgery, Padua University Hospital, Azienda Ospedaliera di Padova, Via Giustiniani, 2-35128, Padova, Italy. E-mail:

Received December 20, 2013

Accepted February 12, 2014

© 2014 by Lippincott Williams & Wilkins, Inc.
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