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Background: As there are many collateral pathways between venous systems, intraoperative venous injury rarely induces venous infarction. In some patients, however, venous injury during microsurgical manipulation may cause acute and/or delayed serious complications. Although intraoperative evaluation using indocyanine green (ICG) videoangiography is very useful, it is difficult to assess the flow direction using this technique. Method: A simple technique using temporary clips and ICG videoangiography was applied to assess the collateral venous pathway in 4 cases of surgical manipulation-related injury or occlusion of the main superficial Sylvian vein in patients with aneurysm. Results: The flow direction and collateral pathway can be easily visualized after release of temporary occlusion. Conclusions: A collateral venous pathway can be evaluated with the present simple technique described here. [ABSTRACT FROM AUTHOR]

Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were "Temporary Clip," "Temporary Clipping," "Cerebral Aneurysm," and "Aneurysm." Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use. [ABSTRACT FROM AUTHOR]

Background: Cerebral bypass remains important for the treatment of complex cerebral aneurysms including dissecting, giant, and fusiform aneurysms not amenable to endovascular treatment or simple clip ligation. For such aneurysms involving the anterior communicating artery complex or its branches, distal anterior cerebral artery (ACA) A3-A3 side-to-side bypass represents a valuable treatment option. Distal ACA in situ anastomosis is recognized to be technically demanding mainly due to the relative depth and narrowness of the interhemispheric surgical corridor and type of anastomosis., Objective: To demonstrate technical nuances of A3-A3 side-to-side in situ bypass surgery through case illustrations and operative videos., Methods: Elements of the procedure relating to positioning, approach, and anastomosis which have evolved in the operative technique of the senior author were collated based on review of clinical case material, imaging and video recordings of ACA aneurysms treated with side-to-side in situ A3-A3 bypass procedure. Technical elements were contrasted with relevant literature., Results: Nuances relative to patient positioning, selection of craniotomy variants, adjunctive intraoperative tools and microsurgical nuances of the side-to-side bypass procedure are reviewed. Three illustrative operative video cases, along with illustrations, are provided to complement the description of the nuances., Conclusion: In the light of the inherent technical difficulty, as well as the rather limited case volumes, the technical tips provided may contribute to bringing additional refinement and simplicity to the A3-A3 bypass procedure., (Copyright © 2018 by the Congress of Neurological Surgeons.)