Tag: Indocyanine green videoangiography

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The value of intraoperative indocyanine green angiography in microvascular decompression for hemifacial spasm to avoid brainstem ischemia

Acta Neurochirurgica (2023) 165:747–755

Despite being rarely reported, ischemic insults resulting from compromising small brainstem perforators following microvascular decompression (MVD) remain a potential devastating complication. To avoid this complication, we have been using indocyanine green (ICG) angiography intraoperatively to check the flow within the small brainstem perforators. We aim to evaluate the safety and usefulness of ICG videoangiography in MVD.

Methods We extracted retrospective data of patients who received ICG videoangiography from our prospectively maintained database for microvascular decompression. We noted relevant data including demographics, offending vessels, operative technique, outcome, and complications.

Results Out of the 438 patients, 15 patients with a mean age (SD) of 53 ± 10.5 years underwent intraoperative ICG angiography. Male:female was 1:1.14. The mean disease duration prior to surgery was 7.7 ± 5.3 years. The mean follow-up (SD) was 50.7 ± 42.0 months. In 14 patients, the offending vessel was an artery, and in one patient, a vein. Intraoperative readjustment of the Teflon pledget or sling was required in 20% (3/15) of the cases. No patient had any sort of brainstem ischemia. Eighty percent of the patients (12/15) experienced complete resolution of the spasms. 86.7% (13/15) of the patients reported a satisfactory outcome with marked improvement of the spasms. Three patients experienced slight hearing affection after surgery, which improved in two patients later. There was no facial or lower cranial nerve affection.

Conclusion Intraoperative ICG is a safe tool for evaluating the flow within the brain stem perforators and avoiding brainstem ischemia in MVD for hemifacial spasm.

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Endoscope- versus microscope-integrated near-infrared indocyanine green videoangiography in aneurysm surgery

J Neurosurg 131:1413–1422, 2019

The quality of surgical treatment of intracranial aneurysms is determined by complete aneurysm occlusion while preserving blood flow in the parent, branching, and perforating arteries. For a few years, there has been a nearly noninvasive and cost-effective technique for intraoperative flow evaluation: microscope-integrated indocyanine green videoangiography (mICG-VA). This method allows for real-time information about blood flow in the aneurysm and the involved vessels, but its limitations are seen in the evaluation of structures located in the depth of the surgical field, especially through small craniotomies. To compensate for these drawbacks, an endoscope-integrated ICG-VA (eICG-VA) was developed. The objective of the present study was to assess the use of eICG-VA in comparison with mICG-VA for intraoperative blood flow evaluation.

METHODS In the period between January 2011 and January 2015, 216 patients with a total of 248 intracranial saccular aneurysms were surgically treated in the Department of Neurosurgery of Saarland University Medical Center in Homburg/Saar, Germany. During 95 surgeries in 88 patients with a total of 108 aneurysms, intraoperative evaluation was performed with both eICG-VA and mICG-VA. After clipping, evaluation of complete aneurysm occlusion and flow in the parent, branching, and perforating arteries was performed using both methods. Intraoperative applicability of each technique was compared with the other and with postoperative digital subtraction angiography as a standard evaluation technique.

RESULTS Evaluation of completeness of aneurysm occlusion and of flow in the parent, branching, and perforating arteries was more successful with eICG-VA than with mICG-VA, especially for aneurysm neck assessment (88.9% vs 69.4%). For 63.9% of the aneurysms (n = 69), both methods were equivalent, but in 30.6% of the cases (n = 33), the eICG-VA provided better results for evaluating the post-clipping situation. In 4.6% of these aneurysms (n = 5), the information given by the additional endoscope considerably changed the surgical procedure. Thus, one residual aneurysm (0.9%), two neck remnants (1.9%), and two branch occlusions (1.9%) could be prevented. Nevertheless, two incomplete aneurysm occlusions (1.9%) and six neck remnants (5.6%) were revealed by postoperative digital subtraction angiography.

CONCLUSIONS Endoscope-integrated ICG-VA seems to be an improvement that might increase the quality of aneurysm surgery by providing additional information. It offers higher illumination, magnification, and an extended viewing angle. Its main advantage is its ability to assess deep-seated aneurysms, especially through small craniotomies, but further studies are required.

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Petrosal Meningiomas: Factors Affecting Outcome and the Role of Intraoperative Multimodal Assistance to Microsurgery

Neurosurgery, Volume 84, Issue 6, June 2019, Pages 1313–1324

Petrous meningiomas (PMs) represent a subset of posterior fossa tumors accounting for ∼8% of all intracranial meningiomas. Surgical treatment of PMs is challenging because of their relationships with vital neurovascular structures of the cerebellopontine angle.

OBJECTIVE: To investigate independent pre- and intraoperative predictors of PM surgery outcome.

METHODS:We reviewed the surgical and outcome data of patients who underwent microsurgical resection of PMs from 1997 to 2016. From 2007 onward, a multimodal intraoperative protocol consisting of intraoperative neuromonitoring (IONM), endoscopy, and indocyanine green (ICG) videoangiography was applied. Outcome variables included extent of resection, Karnofsky performance status (KPS), overall survival, and progression-free survival (PFS).

RESULTS: A total of 54 patients were included. Independent predictors of gross total resection (GTR) included retromeatal location (P < .0175; odds ratio [OR] 4.05), absence of brainstem compression (P < .02; OR 3.55), and histological WHO grade I (P < .001; OR 3.47). Nongiant size (P < .012; OR 4.38), and WHO grade I (P < .0001; OR 7.7) were independent predictors of stable or improved KPS. The use of multimodal intraoperative tools to assist surgery independently predicted GTR (P < .002; OR 6.8) and good KPS (P < .018; OR 4.23). Nongiant size (P = .01) and WHO grade I (P = .002) were significantly associated with increased PFS.

CONCLUSION: Notwithstanding the limitations of a retrospective study, our results suggest that support of microsurgery by a combination of IONM, endoscopy, and ICG videoangiography may improve patient outcome in PM surgery.

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The role of microscope-integrated near-infrared indocyanine green videoangiography in the surgical treatment of intracranial dural arteriovenous fistulas

The role of microscope-integrated near-infrared indocyanine green videoangiography in the surgical treatment of intracranial dural arteriovenous fistulas

J Neurosurg 122:876–882, 2015

The successful treatment of an intracranial dural arteriovenous fistula (dAVF) requires complete obliteration of blood flow through the fistulous point. Surgical ligation is often used along with endovascular techniques. Digital subtraction angiography (DSA) can be used to confirm fistula obliteration; however, this technique can be cumbersome intraoperatively and difficult to correlate anatomically with the surgical field. Near-infrared indocyanine green (ICG) videoangiography has been described as a complementary tool for this purpose.

Methods The authors examined intracranial dAVF cases in which microscope-integrated intraoperative ICG videoangiography was used to identify and/or confirm obliteration of the dAVF during surgery. Retrospective evaluation of all intracranial dAVF cases treated with surgical ligation over a 10-year period at the Barrow Neurological Institute (n = 47) revealed 28 cases in which ICG videoangiography was used. The results were compared with findings on preoperative and intraoperative or postoperative DSA.

Results ICG videoangiography successfully confirmed the fistulous point intraoperatively in 96% (22/23) of the cases. It also revealed complete obliteration of fistulas, comparable to intraoperative or postoperative DSA, in 91% (21/23) of the cases. The false-negative rate of ICG was 8.7% (2/23), which is similar to the false-negative rate of intraoperative DSA alone (10.5% [2/19]).

Conclusions Microscope-based ICG videoangiography provides real-time information about the intraoperative anatomy of dAVFs. In addition, it can confirm complete obliteration of a fistula. This technique may be useful during dAVF surgery as an independent form of angiography or as an adjunct to intraoperative or postoperative DSA.

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Comparison of indocyanine green fluorescent angiography to digital subtraction angiography in brain arteriovenous malformation surgery

ICG and AVM

Acta Neurochir (2015) 157:351–359

The potential utility of intraoperative microscope-integrated indocyanine green (ICG) fluorescence angiography in the surgery of brain arteriovenous malformations (AVMs) and evaluation of the completeness of resection is debatable. Postoperative catheter angiography is considered the gold standard. We evaluated the value of ICG and intraoperative catheter angiography in this setting.

Methods Between January 2009 and July 2013, 37 patients with brain AVMs underwent surgical resection of their vascular lesions. ICG videoangiography and an intraoperative catheter angiography were performed in 32 cases, and a routine postoperative angiogram was performed within 48 h to 2 weeks after surgery. The usefulness of ICG findings and the ability to confirm total resection and to identify residual nidus or persistent shunt were assessed and compared to intraoperative and postoperative digital subtraction angiography, respectively.

Results There were 7 grade 1, 11 grade 2, 11 grade 3 and 3 grade 4 Spetzler-Martin classification AVMs. ICG angiography helped to distinguish AVM vessels in 26 patients. In 31 patients, it demonstrated that there was no residual shunting. In one patient, a residual AVMwas identified and further resected. Intraoperative catheter angiography detected two additional small residuals that were missed by ICG angiography, both deep in the surgical cavity. Further resection of the AVM was performed, and total resection was confirmed by a repeat intraoperative angiogram. Postoperative angiography in a patient with a grade 4 lesion revealed one additional small deep residual AVM nidus with persistent late shunting missed on both ICG and intraoperative angiography. Overall ICG angiography missed three out of four residual AVMs after initial resection, while the intraoperative angiogram missed one.

Conclusion Although ICG angiography is a helpful adjunct in the surgery of some brain AVMs, it’s yield in detecting residual AVM nidus or shunt is low, especially for deepseated lesions and higher grade AVMs. ICG angiography should not be used as a sole and/or reliable technique. Highresolution postoperative angiography must be performed in brain AVM surgery and remains the best test to confidently confirm complete AVM resection.

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The “Squeezing Maneuver” in Microsurgical Clipping of Intracranial Aneurysms Assisted by Indocyanine Green Videoangiography

The “Squeezing Maneuver” in Microsurgical Clipping of Intracranial Aneurysms Assisted by Indocyanine Green Videoangiography

Operative Neurosurgery 10:208–213, 2014

Indocyanine green videoangiography (ICGV) is becoming routine in intracranial aneurysm surgery to assess intraoperatively both sac obliteration and vessel patency after clipping. However, ICGV-derived data have been reported to be misleading at times. We recently noted that a simple intraoperative maneuver, the “squeezing maneuver,” allows the detection of deceptive ICGV data on aneurysm exclusion and allows potential clip repositioning. The squeezing maneuver is based on a gentle pinch of the dome of a clipped aneurysm when ICGV documents its apparent exclusion.

OBJECTIVE: To present the surgical findings and the clinical outcome of this squeezing maneuver.

METHODS: Data from 23 consecutive patients affected by intracranial aneurysms who underwent the squeezing maneuver were analyzed retrospectively. The clip was repositioned in all cases when the dyeing of the sac was visualized after the maneuver.

RESULTS: In 22% of patients, after an initial ICGV showing the aneurysm exclusion after clipping, the squeezing maneuver caused the prompt dyeing of the sac; in all cases, the clip was consequently repositioned. A calcification/atheroma of the wall/neck was predictive of a positive maneuver (P = .001). The aneurysm exclusion rate at postoperative radiological findings was 100%.

CONCLUSION: With the limits of our small series, the squeezing maneuver appears helpful in the intraoperative detection of misleading ICGV data, mostly when dealing with aneurysms with atheromatic and calcified walls.

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Indocyanine green videoangiography (ICGV)-guided surgery of parasagittal meningiomas occluding the superior sagittal sinus (SSS)

ICG meningioma

Acta Neurochir (2013) 155:415–420

Maximal safe resection is the goal of correct surgical treatment of parasagittal meningiomas, and it is intimately related to the venous anatomy both near and directly involved by the tumor. Indocyanine green videoangiography (ICGV) has already been advocated as an intra-operative resourceful technique in brain tumor surgery for the identification of vessels. The aim of this study was to investigate the role of ICGV in surgery of parasagittal meningiomas occluding the superior sagittal sinus (SSS).

Method In this study, we prospectively analyzed clinical, radiological and intra-operative findings of patients affected by parasagittal meningioma occluding the SSS, who underwent ICGVassisted-surgery. Radiological diagnosis of complete SSS occlusion was pre-operatively established in all cases. ICGV was performed before dural opening, before and during tumor resection, at the end of the procedure.

Results Five patients were included in our study. In all cases, ICGV guided dural opening, tumor resection, and venous management. The venous collateral pathway was easily identified and preserved in all cases. Radical resection was achieved in four cases. Surgery was uneventful in all cases.

Conclusions Despite the small number of patients, our study shows that ICG videoangiography could play a crucial role in guiding surgery of parasagittal meningioma occluding the SSS. Further studies are needed to define the role of this technique on functional and oncological outcome of these patients.

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Selective-Targeted Extra-Intracranial Bypass Surgery in Complex Middle Cerebral Artery Aneurysms: Correctly Identifying the Recipient Artery Using Indocyanine Green Videoangiography

Neurosurgery 71[ONS Suppl 2]:ons274–ons285, 2012

Treatment of complex middle cerebral artery (MCA) aneurysms often requires vessel sacrifice or prolonged temporary occlusion with extra- to intracranial (EC-IC) bypass to preserve perfusion. A crucial surgical step is the identification of the bypass recipient artery matching the distal territory of the involved vessel.

OBJECTIVE: To report about the feasibility and efficiency of an indocyanine green videoangiography (ICG-VA) assisted technique for identification of cortical recipient vessels to perform selective-targeted EC-IC bypass.

METHODS: The proposed technique is based on the analysis of differences in the timing of filling of M4 vessels seen on serial ICG-VAs. A delayed fluorescence can be visualized either primarily on a baseline ICG-VA or secondarily on an ICG-VA performed during temporary occlusion of the involved MCA branch. M4 branches presenting delayed fluorescence represent suitable bypass recipient arteries. We report 7 consecutive patients treated for complex MCA aneurysms with selective-targeted EC-IC bypass.

RESULTS: Application of the proposed technique permitted the correct identification of recipient arteries (cortical branches of the involved MCA segment) in all patients. The cortex distal to the occlusion filled concomitantly on ICG-VA at the end of surgery. All patients underwent successful treatment of the aneurysm, including a cortical bypass. There were no ischemic complications, and a favorable clinical outcome was achieved in all patients (modified Rankin Scale at follow-up # modified Rankin Scale preoperative).

CONCLUSION: The proposed ICG-VA-based technique enables reliable and accurate identification of the cortical recipient artery and eliminates the risk of erroneous revascularization of noninvolved territories.

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Selective-Targeted Extra-Intracranial Bypass Surgery in Complex Middle Cerebral Artery Aneurysms: Correctly Identifying the Recipient Artery Using Indocyanine Green Videoangiography

Neurosurgery 71[ONS Suppl 2]:ons274–ons285, 2012

Treatment of complex middle cerebral artery (MCA) aneurysms often requires vessel sacrifice or prolonged temporary occlusion with extra- to intracranial (EC-IC) bypass to preserve perfusion. A crucial surgical step is the identification of the bypass recipient artery matching the distal territory of the involved vessel.

OBJECTIVE: To report about the feasibility and efficiency of an indocyanine green videoangiography (ICG-VA) assisted technique for identification of cortical recipient vessels to perform selective-targeted EC-IC bypass.

METHODS: The proposed technique is based on the analysis of differences in the timing of filling of M4 vessels seen on serial ICG-VAs. A delayed fluorescence can be visualized either primarily on a baseline ICG-VA or secondarily on an ICG-VA performed during temporary occlusion of the involved MCA branch. M4 branches presenting delayed fluorescence represent suitable bypass recipient arteries. We report 7 consecutive patients treated for complex MCA aneurysms with selective-targeted EC-IC bypass.

RESULTS: Application of the proposed technique permitted the correct identification of recipient arteries (cortical branches of the involved MCA segment) in all patients. The cortex distal to the occlusion filled concomitantly on ICG-VA at the end of surgery. All patients underwent successful treatment of the aneurysm, including a cortical bypass. There were no ischemic complications, and a favorable clinical outcome was achieved in all patients (modified Rankin Scale at follow-up # modified Rankin Scale preoperative).

CONCLUSION: The proposed ICG-VA-based technique enables reliable and accurate identification of the cortical recipient artery and eliminates the risk of erroneous revascularization of noninvolved territories.

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The use of intraoperative near-infrared indocyanine green videoangiography in the microscopic resection of hemangioblastomas

Acta Neurochir (2012) 154:1407–1412 

The authors assessed the usefulness of intraoperative near-infrared indocyanine green videoangiography (ICG-VA) in the microscopic resection of hemangioblastomas.

Methods From January 2009 to February 2012, nine consecutive patients (seven men, two women) who underwent surgery for hemangioblastomas using intraoperative ICGVA were included in this study. Surgery was performed on four cystic cerebellar lesions with mural nodules, two solid tumors (one in the cerebellar hemisphere and one in the medulla oblongata), one spinal tumor and multiple tumors in two patients with von Hippel-Lindau disease. Of the nine patients, three were treated for recurrent tumor. The ICGinduced fluorescence images of hemangioblastomas with variable presentation were evaluated.

Results All tumors could be completely removed en bloc. Blood flow in the tumor and tumor-related vessels at the brain surface were clearly detected by ICG-VA in all cases, except one recurrent tumor where postoperative adhesive scar tissue obstructed ICG-induced fluorescence resulting in poor delineation of the blood flow patterns and tumor margins. ICG-VAwas also helpful for detecting the multiple small mural nodules within the cyst or the tumors buried under thin gliotic neural tissue despite reduced fluorescence.

Conclusion Intraoperative ICG-VA is a safe and easy modality for confirming the vascular flow patterns in hemangioblastomas. In addition, ICG-VA provided useful information for intracystic small lesions or lesions concealed under thin brain tissue in order to accomplish total resection of these tumors.

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An analysis of flow dynamics in cerebral cavernous malformation and orbital cavernous angioma using indocyanine green videoangiography

Acta Neurochir (2012) 154:1169–1175 DOI 10.1007/s00701-012-1354-9

Cerebral cavernous malformations (CCMs) are known to be vascular anomalies with low perfusion because of being angiographically occult. We attempted direct visualization of blood flow within CCMs and orbital cavernous angiomas (CAs), and analyzed flow dynamics using indocyanine green videoangiography (ICG-VAG).

Methods This series included seven CCMs and two orbital CAs. ICG-VAG was performed to visualize blood flow of the lesions before resection. Time to peak of staining was evaluated by reviewing recorded ICG-VAG.

Results In five of seven CCMs, stain was identified. CCMs were seen as avascular areas in both arterial and venous phases, and were stained gradually. Stain was maximized late after venous phase. The orbital CAs were also stained lately, but more intensely than CCMs.

Conclusions The present study directly demonstrated slow and low perfusion within CCM and orbital CA using ICGVAG. On the basis of characteristic flow dynamics of CCMs, intraoperative ICG-VAG provides useful information in microsurgical resection.

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Flash Fluorescence With Indocyanine Green Videoangiography to Identify the Recipient Artery for Bypass With Distal Middle Cerebral Artery Aneurysms

Neurosurgery 70[ONS Suppl 2]:ons209–ons220, 2012 DOI: 10.1227/NEU.0b013e31823158f3

Distal middle cerebral artery (MCA) aneurysms frequently have nonsaccular morphology that necessitates trapping and bypass. Bypasses can be difficult because efferent arteries lie deep in the opercular cleft and may not be easily identifiable.

OBJECTIVE: We introduce the “flash fluorescence” technique, which uses videoangiography with indocyanine green (ICG) dye to identify an appropriate recipient artery on the cortical surface for the bypass, enabling a more superficial and easier anastomosis.

METHODS: Flash fluorescence requires 3 steps: (1) temporary clip occlusion of the involved afferent artery; (2) videoangiography demonstrating fluorescence in uninvolved arteries on the cortical surface; and (3) removal of the temporary clip with flash fluorescence in the involved efferent arteries on the cortical surface, thereby identifying a recipient. Alternatively, temporary clips can occlude uninvolved arteries, and videoangiography will demonstrate initial fluorescence in efferent arteries during temporary occlusion and flash fluorescence in uninvolved arteries during reperfusion.

RESULTS: From a consecutive series of 604 MCA aneurysms treated microsurgically, 22 (3.6%) were distal aneurysms and 11 required a bypass. The flash fluorescence technique was used in 3 patients to select the recipient artery for 2 superficial temporal artery-to-MCA bypasses and 1 MCA-MCA bypass. The correct recipient was selected in all cases.

CONCLUSION: The flash fluorescence technique provides quick, reliable localization of an appropriate recipient artery for bypass when revascularization is needed for a distal MCA aneurysm. This technique eliminates the need for extensive dissection of the efferent artery and enables a superficial recipient site that makes the anastomosis safer, faster, and less demanding.

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Enhanced analysis of intracerebral arteriovenous malformations by the intraoperative use of analytical indocyanine green videoangiography: technical note

Acta Neurochir (2011) 153:2181–2187. DOI 10.1007/s00701-011-1141-z

In cerebral arteriovenous malformations (AVMs) detailed intraoperative identification of feeding arteries, nidal vessels and draining veins is crucial for surgery.

Intraoperative imaging techniques like indocyanine green videoangiography (ICG-VAG) provide information about vessel architecture and patency, but do not allow time-dependent analysis of intravascular blood flow.

Here we report on our first experiences with analytical indocyanine green videoangiography (aICG-VAG) using FLOW 800 software as a useful tool for assessing the time-dependent intraoperative blood flow during surgical removal of cerebral AVMs. Microscope-integrated colour-encoded aICG-VAG was used for the surgical treatment of a 38-year-old woman diagnosed with an incidental AVM, Spetzler Martin grade I, of the left frontal lobe and of a 26-year-old man suffering from seizures caused by a symptomatic AVM, Spetzler Martin grade III, of the right temporal lobe. Analytical ICG-VAG visualization was intraoperatively correlated with in situ micro-Doppler investigation, as well as preoperative and postoperative digital subtraction angiography (DSA).

Analytical ICG-VAG is fast, easy to handle and integrates intuitively into surgical procedures. It allows colour-encoded visualization of blood flow distribution with high temporal and spatial resolution. Superficial major and minor feeding arteries can be clearly separated from the nidus and draining veins. Effects of stepwise vessel obliteration on velocity and direction of AVM blood flow can be objectified. High quality of visualization, however, is limited to the site of surgery. Colour-encoded aICG-VAG with FLOW 800 enables intraoperative real-time analysis of arterial and venous vessel architecture and might, therefore, increase efficacy and safety of neurovascular surgery in a selected subset of superficial AVMs.

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Use of Microscope-Integrated Near-Infrared Indocyanine Green Videoangiography in the Surgical Treatment of Spinal Dural Arteriovenous Fistulae

Neurosurgery 66:978-985, 2010 DOI: 10.1227/01.NEU.0000368108.94233.22

Identification and complete interruption of fistulae are essential but not always obvious during the surgical treatment of spinal dural arteriovenous fistulae (dAVFs). We examined cases in which we identified and confirmed surgical obliteration of a spinal dAVF with the aid of microscope-integrated near-infrared indocyanine green (ICG) videoangiography.

METHODS: ICG videoangiography was performed during 6 surgical interventions in which 6 intradural dorsal AVFs (type I) were interrupted. An operating microscope-integrated light source containing infrared excitation light illuminated the operating field and was used to visualize an intravenous bolus of ICG. The locations of fistulae, feeding arteries, and draining veins and documentation of occlusion of the fistulae were compared with findings on preoperative and postoperative digital subtraction angiography.

RESULTS: ICG videoangiography identified the fistulous point(s), feeding arteries, and draining veins in all 6 cases, as confirmed by immediate postoperative selective spinal angiography. In 1 case, intraoperative ICG ruled out an additional questionable fistula at a contiguous level suspected on the preoperative angiography.

CONCLUSION:Microscope-based ICG videoangiography is simple and provides real-time information about the precise location of spinal dAVFs. During spinal dAVF surgery, this technique can be useful as an independent form of angiography or as an adjunct to intraor postoperative digital subtraction angiography. Larger series are needed to determine whether use of this modality could reduce the need for immediate postoperative spinal angiography after obliteration of intradural dorsal AVFs.

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