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

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Abstract
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. 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. 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. 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 intra or 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.