Artikel
Indocyanin-green-videoangiography in spinal dural AV-fistula: a new pooling technique for improved visualization
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Veröffentlicht: | 8. Juni 2016 |
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Objective: Intra-operative indocyanine green videoangiography (ICG-VAG) is a useful tool in cerebral vascular surgery. In spinal procedures like dural arteriovenous (AV-) fistula, the use of ICG-VAG is limited due to a lower perfusion pressure in the spinal vasculature. Therefore, we developed a new pooling technique with an adapted workflow to improve intraoperative visualization of spinal vascular malformations.
Method: Patients operated on a spinal AV-fistula using ICG-VAG and a microscope-integrated infra-red sensitive monochrome video camera (OPMI Pentero) were prospectively included. We applied a new modification of the established workflow for ICG-VAG. During a period of 100% oxygenation and breathing arrest, ICG was administered intravenously (10mg per dose, Pulsion Medical Systems). Case records, clinical data, pre-/postoperative magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) were analyzed. Clinical outcome was assigned by the modified Aminoff-Logue Scale (ALS), McCormick score and modified Rankin scale (mRS).
Results: Eleven patients (8 male, 3 female) aged 68 years (range: 44-84 years) and an average course of disease of 15 months (range: 2-48 months) were analyzed. Symptoms were basically lower limb numbness, weakness, ataxia and urinary/ defecation dysfunction. Two patients had unsuccessful endovascular therapy before surgery. The optimized, inverted workflow resulted in considerable pooling of fluorescence signal in the supplying feeder of the AV-fistula in all cases. Through this the imaging quality was remarkably improved compared to standard protocols. Complete obliteration was confirmed in eleven patients by post-operative DSA. However, in one patient a remaining small feeder, which was hidden under a fascicle, was not identified during the operation and had to be reoperated. No adverse reactions after ICG administration were seen. After 2.2-16 months of follow-up, ALS was significantly decreased in all patients, McCormick score was improved in 9 patients and remained stable in 2 patients and mRS was decreased in 8 patients and remained stable in 3 patients.
Conclusions: We conclude that ICG-VAG is a useful adjunct in the surgical treatment of spinal dural AV-fistula since it is a simple, real-time, non-invasive, radiation-free technique with good image resolution. Procedure modification in terms of ICG pooling enabled us to detect more easily the pathological vascular architecture in patients harboring spinal AV-fistula.