Artikel
Intraoperative indocyanine green microscope-integrated videoangiography for obliteration of a recurrent conus arteriovenous malformation – case report and review
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Veröffentlicht: | 16. September 2010 |
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Objective: Spinal arteriovenous malformations (SAVMs) are a heterogeneous group of vascular anomalies that can render a devastating neurological outcome for the patient if not correctly diagnosed and properly treated. Advancements in non-invasive imaging and optimal use of spinal digital subtraction angiography (DSA) have facilitated accurate diagnosis and choice of treatment. Successful microsurgical treatment is dependent on the neurosurgeon's ability to identify vessels and to confirm the nidus obliteration during surgery. Intraoperative non invasive imaging techniques enhancing this ability are of a tremendous value in reducing procedural risk exposure.
The authors describe the microsurgical occlusion of an intramedullary AVM facilitated by the intraoperative application of indocyanine green (ICG) fluorescent microscope based videoangiography and review the current literature on the use of this technique during surgery of SAVMs. Though there are numerous reports of ICG applications during cerebrovascular procedures, there are few reports about the usage of this technique during surgery of spinal dural arteriovenous fistulas and no described applications in the treatment of intramedullary AVMs.
Methods: The 39-year-old female patient had a history of SAVM of the conus, treated with open surgery twelve years ago. She presented with a new progressive debilitating left side lower-extremity weakness over the last six months. DSA and MR findings revealed an intramedullary AVM at the T-12 level with feeders from the left L1 artery. Unfavourable anatomy precluded endovascular embolization. The patient subsequently underwent surgery. Intraoperative ICG microscope based videoangiography was used as a stand alone imaging technique to identify the arterialized veins and nidus, and to confirm obliteration of the fistulous connection and restoration of normal blood flow.
Results: The ICG applications were fast and uncomplicated and provided real-time information about intra- and perimedullary vascular anatomy and flow with a high spatial resolution that was of important value to intraoperative decision making. The patient’s condition improved rapidly and the postoperative and follow up imaging half a year later confirmed successful obliteration of the AVM.
Conclusions: This case clearly demonstrates the value of intraoperative ICG angiography in the microsurgical treatment of SAVMs, supporting its use as a stand alone technique during surgery of these lesions.