Intraoperative indocyanine green video-angiography as an aid to the microsurgical treatment of spinal vascular malformations

Abstract

Aims and Objectives. Intra-operative Indocyanine Green (ICG) video-angiography (ICG-VA) has become an established aid to cerebrovascular surgery. We describe our experience using this technique to define angio-architecture intraoperatively in a range of spinal vascular malformations. Methods. A retrospective review of notes and imaging was carried out from a prospectively maintained database. Our series comprises 27 patients who underwent surgical treatment between September 2007 and August 2012. We carried out a retrospective review of data from a prospectively maintained database. Results. For slow-flow Type 1 fistulae the ICG videoangiogram demonstrated conclusively that the arteriovenous shunt was obliterated. This is a consideration on the rare occasions where a second fistula is present, an example of which is included in this series. ICG-VA also helps to demonstrate normal vascular anatomy and distinguish these vessels from pathology. For Type II lesions it allowed orientation to the vascular anatomy as demonstrated by the pre-operative angiogram. In one of two cases in this series it ensured to the complete extirpation of a large arteriovenous malformation (AVM). However a second Type II case demonstrated its limitations, as a diffuse intramedullary component could not be identified. Two cases were explored where digital subtraction spinal angiography was not possible and incomplete understanding of the angio-architectures of the lesions were available from Time Resolved dynamic magnetic resonance angiography and/or multi-detector CT angiography. ICG-VA provided invaluable information on alterations in arterio-venous flow that allowed diagnosis and obliteration of the arteriovenous shunts in each case. Discussion. ICG video-angiography is a time-efficient and safe alternative to intra-operative spinal angiography. It provided useful information on haemodynamic changes intraoperatively and completeness of treatment. We discuss its limitations and role in the management of these lesions.

Keywords::

• indocyanine green videoangiography
• intraoperative angiography
• spinal dural arteriovenous fistula
• spinal vascular malformation

Declaration of interest: The authors declare no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

DCW wrote the manuscript, carried out a literature review and was an operating surgeon in all cases. BZ carried out a literature review, assisted with the cross checking of data and reviewed the final manuscript. CMT reviewed the final manuscript. RWG reviewed the final manuscript and was an operating surgeon in one of the cases.