Intraoperative indocyanine green angiography for obliteration of a spinal dural arteriovenous fistula

Case report

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Spinal dural arteriovenous fistulas (DAVFs) are the most common type of spinal arteriovenous malformation and are an important, underdiagnosed cause of progressive myelopathy and morbidity in patients with spine disorders. Successful microsurgical management of these lesions is dependent on the surgeon's ability to identify vessels of the fistula and to confirm its successful obliteration postintervention. Indocyanine green (ICG) fluorescent angiography is an emerging tool for delineating intraoperative vascular anatomy, and it has significant potential utility in the treatment of vascular disease in the spine.

The authors present the case of a 76-year-old man with progressive and debilitating bilateral lower-extremity weakness and numbness on exertion, in whom a left T-8 spinal DAVF was diagnosed based on results of conventional spinal angiography. Unfavorable anatomy based on angiographic findings precluded endovascular embolization of the fistula, and the patient subsequently underwent T7–9 bilateral laminectomies for microsurgical clip occlusion. Intraoperative ICG fluorescent angiography was used before clip placement to identify the arterialized veins of the fistula, and after clip placement to confirm obliteration of the fistulous connection and restoration of normal blood flow.

Intraoperative ICG angiography serves an important role in the microsurgical treatment of DAVF. It can be used to map the anatomy of the fistula in real time during surgery and to verify fistula obliteration rapidly after clip placement. This report adds to the growing body of literature demonstrating the importance of ICG angiography in vascular neurosurgery of the spine.

Abbreviations used in this paper: AVM = arteriovenous malformation; DAVF = dural arteriovenous fistula; DS = digital subtraction; ICG = indocyanine green; MEP = motor evoked potential; SSEP = somatosensory evoked potential.

Article Information

Address correspondence to: Rafael J. Tamargo, M.D., Department of Neurosurgery, The Johns Hopkins Hospital, Meyer 8–181, 600 North Wolfe Street, Baltimore, Maryland 21287. email: rtamarg@jhmi.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    A: Sagittal T1-weighted thoracic MR imaging study obtained after addition of contrast material revealing diffuse enhancement in the thoracic spinal cord, particularly the T7–9 levels, as labeled. B: Preoperative spinal DS angiography study acquired after injection of ICG in the left T-8 radicular artery, demonstrating the DAVF and the contribution to the posterior spinal artery (arrows).

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    A: Intraoperative photograph showing the DAVF and its arterialized veins. Arrows identify a superior projecting vessel with questionable fistula involvement. B: Intraoperative ICG angiography study (arterial phase) clearly demonstrating the arterialized veins of the fistula, including involvement of the superior projecting vessel mentioned in A (arrows). C: Intraoperative photograph showing temporary clips applied at the suspected fistula point. D and E: Intraoperative ICG angiography study obtained after clip placement, demonstrating obliteration of the fistula. The abnormal arterialized vessels no longer fill during the arterial phase (D) of the ICG injection, but they do fill during the normal venous phase (E). In panel E, the venous phase is confirmed by ICG signal in the contralateral normal spinal veins (arrows). F: Intraoperative photograph showing permanent clip configuration prior to dural closure.

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    Intraoperative spinal DS angiography study. Injection of the left T-8 radicular artery demonstrates obliteration of the DAVF.

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