The role of indocyanine green videoangiography (ICG-VA) in the resection of vascular malformations

The role of indocyanine green videoangiography (ICG-VA) in the resection of vascular malformations has been largely described.

Intraarterial injection was feasible and useful to distinguish feeders from normal artery and to observe changes in flow dynamics. Intra-arterial injection of ICG had better phase contrast than intra-venous injection of ICG and better spatial resolution than digital subtraction angiography. Therefore, this technique can be helpful in arteriovenous malformation (AVM) surgery 1).

The utility of ICG-VA before dural opening (transdural ICG-VA) proved an efficient tool that allows optimising the exposure of the malformation, performing a safe dural opening and identifying dural vascular connections of the lesion 2).

ICG videoangiography is a quick and safe method of intraoperatively mapping the angioarchitecture of superficial AVMs, but it is less helpful for deep-seated lesions. This modality alone does not improve the identification of residual disease or clinical outcomes. Surgeon experience with extensive study of preoperative vascular imaging is paramount to achieving acceptable clinical outcomes. Formal angiography remains the gold standard for the evaluation of AVM obliteration 3).

It’s yield in detecting residual AVM nidus or shunt is low, especially for deep-seated lesions and higher grade AVMs. ICG angiography should not be used as a sole and/or reliable technique. High-resolution postoperative angiography must be performed in brain AVM surgery and remains the best test to confidently confirm complete AVM resection 4).

1) Kono K, Uka A, Mori M, Haga S, Hamada Y, Nagata S. Intra-arterial injection of indocyanine green in cerebral arteriovenous malformation surgery. Turk Neurosurg. 2013;23(5):676-9. doi: 10.5137/1019-5149.JTN.6420-12.0. PubMed PMID: 24101318.
2) Della Puppa A, Rustemi O, Gioffrè G, Causin F, Scienza R. Transdural indocyanine green video-angiography of vascular malformations. Acta Neurochir (Wien). 2014 Sep;156(9):1761-7. doi: 10.1007/s00701-014-2164-z. Epub 2014 Jul 19.PubMed PMID: 25034506.
3) Zaidi HA, Abla AA, Nakaji P, Chowdhry SA, Albuquerque FC, Spetzler RF. Indocyanine green angiography in the surgical management of cerebral arteriovenous malformations: lessons learned in 130 consecutive cases. Neurosurgery. 2014 Jun;10 Suppl 2:246-51; discussion 251. doi: 10.1227/NEU.0000000000000318. PubMed PMID: 24535264.
4) Bilbao CJ, Bhalla T, Dalal S, Patel H, Dehdashti AR. Comparison of indocyanine green fluorescent angiography to digital subtraction angiography in brain arteriovenous malformation surgery. Acta Neurochir (Wien). 2014 Dec 10. [Epub ahead of print] PubMed PMID: 25488175.

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