Evaluation of the Utility of Indocyanine Green Video Angiography in Cerebral Arteriovenous Malformation Surgery

Abstract

Objective: To assess the utility of intraoperative indocyanine green video angiography (ICG-VA) during microsurgical resection of arteriovenous malformations (AVMs). Methods: Data of the 24 patients, who were surgically treated for AVM using intraoperative ICG-VA, were reviewed retrospectively. Postoperative digital subtraction angiography (DSA) was performed in all patients before they regained consciousness and became fully awake, and the results were compared with those obtained with intraoperative ICG-VA. A scheduled DSA was performed in all patients in the third, sixth, and 12th postoperative months as well. Results: Authors retrospectively analyzed the records of intraoperative ICG-VA application of all 24 patients. Though the exposures were limited and the image qualities were poor at higher magnification on the surgical microscope within deep surgical fields, the AVM niduses, feeding arteries, draining veins, and their relations to normal vasculature were observed precisely with ICG-VA in all the procedures. Furthermore, the visualization was not qualified enough to identify these pathological vascular structures accurately before evacuating and irrigating the layer of blood clots that obscure the view in patients who presented with hemorrhage. In a patient in our series, a residual nidus in the tail of the caudate nucleus was detected with immediate postoperative DSA which was not revealed by terminal assessment with final intraoperative ICG-VA. Conclusions: Intraoperative ICG-VA is particularly effective in the identification of the feeder, nidus, and drainer and in the assessment of the flow dynamics of the nidus in cerebral AVM surgery. It may be a quick and safe technique for intraoperative imaging of the angioarchitecture of superficial AVMs, but it may be less helpful for deep-seated lesions. Furthermore, this method alone may not be useful in the identification of residual disease or improvement of the clinical outcomes. DSA has remained the gold standard for confirming AVM obliteration. Despite the technical limitations associated with ICG-VA, a combination of intraoperative ICG-VA and immediate postoperative DSA may advance the safety and efficacy of AVM surgery. © 2022 Elsevier Inc.