Recipient artery localization for assist bypass in subarachnoid hemorrhage using composite three-dimensional digital subtraction angiography/digital subtraction venography and indocyanine green videoangiography: A case report

Background: In high-flow bypass (HFB) procedures for ruptured internal carotid artery (ICA) blister-like aneurysms, precise localization of the recipient artery for an assist superficial temporal artery-middle cerebral artery (STA-MCA) bypass is challenging when subarachnoid hemorrhage (SAH) is present. Case Description: A 59-year-old woman presented with SAH due to a ruptured ICA blister-like aneurysm. She underwent trapping of the ICA with HFB using the radial artery and an additional assist STA-MCA bypass. Preoperative composite images from three-dimensional digital subtraction angiography and digital subtraction venography enabled localization of the cortical recipient artery relative to identifiable veins. Intraoperative indocyanine green (ICG) videoangiography confirmed the recipient artery’s flow characteristics. Both bypasses remained patent, and postoperative MRI showed no ischemic complications. The patient was discharged with modified Rankin Scale. Conclusion: The combination of composite preoperative imaging and intraoperative ICG videoangiography allowed precise identification of the cortical recipient artery and contributed to favorable surgical outcomes.