Use of Indocyanine Green Fluorescence Endoscopy to Treat Concurrent Perimedullary and Dural Arteriovenous Fistulas in the Cervical Spine.
BACKGROUND
Intraoperative microscopic fluorescence angiography using indocyanine green (ICG) provides visual information on real-time blood flow. However, this method cannot be applied for lesions that are not visible under microscopic imaging because excitation light does not reach the targeted vascular structures. Endoscope-integrated ICG video-angiography has recently been advocated to compensate for this limitation. This is the first reported case of a spinal arteriovenous malformation in which endoscope-integrated ICG video-angiography was successfully used.


METHODS
We report the case of a 63-year-old man who presented with a subarachnoid hemorrhage from a spinal arteriovenous malformation at the C3 level. We chose the direct surgery option with a posterior approach to treat this lesion. Although the preoperative diagnosis was a perimedullary arteriovenous fistula (AVF) with multiple feeders, we found concurrent dural AVF and perimedullary AVFs during surgery. We introduced an endoscope and performed endoscope-integrated ICG video-angiography because it was difficult to identify the angioarchitectures of the perimedural and dural AVFs on the ventral surface of the spinal cord under microscopic view alone. Endoscope-integrated ICG video-angiography gave us clear and magnified angioarchitectures of these lesions. The fistulous point and the varix of the perimedullary AVF was coagulated and dissected under endoscopic view, and the draining vein of the dural AVF was also coagulated and dissected at the origin from the dura mater under microscopic view.


CONCLUSIONS
A posterior approach with the assistance of an endoscope and endoscope-integrated ICG video-angiography is feasible for spinal vascular diseases located ventrally.
Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai.
Akira
A
Ito
Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai; Department of Neurosurgery, Kohnan Hospital, Sendai, Japan. Electronic address: endo@nsg.med.tohoku.ac.jp.
Toshiki
T
Endo
Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai.
Tomoo
T
Inoue
Department of Neurosurgery, Kohnan Hospital, Sendai, Japan.
Hidenori
H
Endo
Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan.
Kenichi
K
Sato
Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai.
Teiji
T
Tominaga
D015901:Angiography, Digital Subtraction / Q000379:methods; D001164:Arteriovenous Fistula / Q000000981:diagnostic imaging / Q000601:surgery*; D053704:Capsule Endoscopy / Q000379:methods; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D005451:Fluorescein Angiography / Q000379:methods*; D005453:Fluorescence; D006801:Humans; D007208:Indocyanine Green / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D044583:Neuroendoscopy / Q000379:methods*; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures
D007208:Indocyanine Green
Cervical spine; Dural arteriovenous fistula; Perimedullary arteriovenous fistula; Subarachnoid hemorrhage