Picket-Fence Technique in Surgical Treatment of Cerebral Aneurysms and Role of Intraoperative Videoangiography in Aneurysm Surgery

<i>Background and Objectives</i>: To evaluate factors affecting aneurysm rupture, present our surgical experience with intracranial aneurysms, specifically using the picket-fence clipping technique for giant aneurysms, and highlight the complementary roles of sodium fluorescein (Na-Fl) and indocyanine green (ICG) videoangiography in enhancing surgical precision and patient outcomes. <i>Materials and Methods</i>: We retrospectively analyzed 47 patients who underwent microsurgical clipping of intracranial aneurysms with intraoperative Na-Fl and ICG videoangiography between September 2015 and February 2024. We assessed relationships between patient comorbidities, family history of subarachnoid hemorrhage (SAH), smoking history, aneurysm location and size, and SAH occurrence. Concordance between intraoperative videoangiography and postoperative digital subtraction angiography (DSA) for detecting residual aneurysms was also evaluated. <i>Results</i>: Of the 47 patients (31 female, 16 male; mean age 51.78 ± 11.16 years), 11 (23.4%) presented with SAH. The most common aneurysm location was the middle cerebral artery (MCA) (68.1%). Hypertension and smoking history were significantly higher in the hemorrhage group (<i>p</i> < 0.05). Aneurysm size and anterior communicating artery (AComA) location were also significantly associated with hemorrhage (<i>p</i> < 0.05). Aneurysm size demonstrated significant discriminative power for hemorrhage [AUC: 0.884 (0.827-0.941)], with a cutoff of 7.1 mm yielding 90.9% sensitivity and 94.4% specificity. Five giant MCA aneurysms were treated with the picket-fence technique, with intraoperative ICG and Na-Fl confirming parent artery patency and complete aneurysm occlusion, subsequently confirmed by postoperative DSA. Small remnants were detected in 2 cases (4.26%) on postoperative DSA, both in distal ACA aneurysms, which were also detected by intraoperative videoangiography. <i>Conclusions</i>: Hypertension, smoking history, aneurysm size, and location were important predictors of aneurysm rupture. Intraoperative ICG and Na-Fl videoangiography provide real-time, high-resolution visualization crucial for complex intracranial aneurysm surgery, including the picket-fence technique for giant aneurysms. Their complementary use enhances surgical safety, guides intraoperative decision-making, and contributes to improved outcomes in challenging cases.