Role of intraoperative indocyanine green video-angiography to identify small, posterior fossa arteriovenous malformations mimicking cavernous angiomas. Technical report and review of the literature on common features of these cerebral vascular malformations.
OBJECTIVE
To illustrate the usefulness of intraoperative indocyanine green videoangiography (ICG-VA) to identify the nidus and feeders of a small cerebellar AVM resembling a cavernous hemangioma. To review the unique features regarding the overlay between these two vascular malformations and to highlight the importance to identify with ICG-VA, and treat accordingly, the arterial and venous vessels of the AVM.


METHODS
A 36-year old man presented with bilateral cerebellar hemorrhage. MRI was equivocal in showing an underlying vascular malformation but angiography demonstrated a small, Spetzler-Martin grade I AVM. Surgical resection of the AVM with the aid of intraoperative ICG-VA was performed. After hematoma evacuation, pre-resection ICG-VA did not reveal tortuous arterial and venous vessels in keeping with a typical AVM but rather an unusual blackberry-like image resembling a cavernous hemangioma, with tiny surrounding vessels. Such intraoperative appearance, which could also be the consequence of a "leakage" of fluorescent dye from the nidal pathological vessels, with absent blood-brain barrier, into the surrounding parenchymal pathological capillary network, is important to be recognized as an unusual AVM appearance.


RESULTS
Post-resection ICG-VA confirmed the AVM removal, as also shown by postoperative and 3-month follow-up DSAs.


CONCLUSIONS
Despite technical limitations associated with ICG-VA in post-hemorrhage AVMs, this case together with the intraoperative video, demonstrates the useful role of ICG-VA in identifying small AVMs with peculiar features.
Neurosurgery Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123, Catania, Italy. Electronic address: giuseppebarbagal@hotmail.com.
Giuseppe M V
GM
Barbagallo
Neurosurgery Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123, Catania, Italy.
Francesco
F
Certo
Department G.F. Ingrassia, Section of Anatomic Pathology, University of Catania, via Santa Sofia 78, 95123 Catania, Italy.
Rosario
R
Caltabiano
Radiology Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123 Catania, Italy.
Ignazio
I
Chiaramonte
Neurosurgery Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123, Catania, Italy.
Vincenzo
V
Albanese
Institute of Neurosurgery, Catholic University of Rome, Italy.
Massimiliano
M
Visocchi
D000328:Adult; D001932:Brain Neoplasms / Q000000981:diagnostic imaging; D002533:Cerebral Angiography / Q000379:methods; D004396:Coloring Agents; D003388:Cranial Fossa, Posterior / Q000002:abnormalities*; D003399:Craniotomy; D003937:Diagnosis, Differential; D006392:Hemangioma, Cavernous / Q000000981:diagnostic imaging; D006801:Humans; D007208:Indocyanine Green; D002538:Intracranial Arteriovenous Malformations / Q000000981:diagnostic imaging* / Q000601:surgery; D008297:Male; D020535:Video-Assisted Surgery / Q000379:methods*
D004396:Coloring Agents; D007208:Indocyanine Green
Angiography; Arterio-venous malformation; Hemorrhage; Indocyanine green videoangiography; Posterior fossa; Vascular malformation