Bilbao Christopher J, Bhalla Tarun, Dalal Shamsher, Patel Hiren, Dehdashti Amir R
Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, 4190 City Avenue, Philadelphia, PA, 19131, USA,
Acta Neurochir (Wien). 2015 Mar;157(3):351-9. doi: 10.1007/s00701-014-2287-2. Epub 2014 Dec 10.
The potential utility of intraoperative microscope-integrated indocyanine green (ICG) fluorescence angiography in the surgery of brain arteriovenous malformations (AVMs) and evaluation of the completeness of resection is debatable. Postoperative catheter angiography is considered the gold standard. We evaluated the value of ICG and intraoperative catheter angiography in this setting.
Between January 2009 and July 2013, 37 patients with brain AVMs underwent surgical resection of their vascular lesions. ICG videoangiography and an intraoperative catheter angiography were performed in 32 cases, and a routine postoperative angiogram was performed within 48 h to 2 weeks after surgery. The usefulness of ICG findings and the ability to confirm total resection and to identify residual nidus or persistent shunt were assessed and compared to intraoperative and postoperative digital subtraction angiography, respectively.
There were 7 grade 1, 11 grade 2, 11 grade 3 and 3 grade 4 Spetzler-Martin classification AVMs. ICG angiography helped to distinguish AVM vessels in 26 patients. In 31 patients, it demonstrated that there was no residual shunting. In one patient, a residual AVM was identified and further resected. Intraoperative catheter angiography detected two additional small residuals that were missed by ICG angiography, both deep in the surgical cavity. Further resection of the AVM was performed, and total resection was confirmed by a repeat intraoperative angiogram. Postoperative angiography in a patient with a grade 4 lesion revealed one additional small deep residual AVM nidus with persistent late shunting missed on both ICG and intraoperative angiography. Overall ICG angiography missed three out of four residual AVMs after initial resection, while the intraoperative angiogram missed one.
Although ICG angiography is a helpful adjunct in the surgery of some brain AVMs, 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.
术中显微镜集成吲哚菁绿（ICG）荧光血管造影在脑动静脉畸形（AVM）手术及评估切除完整性方面的潜在效用存在争议。术后导管血管造影被视为金标准。我们评估了ICG及术中导管血管造影在此情况下的价值。
2009年1月至2013年7月，37例脑AVM患者接受了血管病变的手术切除。32例患者进行了ICG视频血管造影及术中导管血管造影，并在术后48小时至2周内进行了常规术后血管造影。评估ICG检查结果的有用性以及确认完全切除和识别残留病灶或持续性分流的能力，并分别与术中及术后数字减影血管造影进行比较。
有7例1级、11例2级、11例3级和3例4级斯佩茨勒-马丁分级的AVM。ICG血管造影帮助26例患者区分了AVM血管。31例患者中，显示无残留分流。1例患者中，识别出残留AVM并进一步切除。术中导管血管造影检测到另外两个ICG血管造影遗漏的小残留，均位于手术腔深部。对AVM进行了进一步切除，并通过重复术中血管造影确认了完全切除。1例4级病变患者的术后血管造影显示，在ICG和术中血管造影中均遗漏了一个额外的小深部残留AVM病灶及持续性晚期分流。总体而言，ICG血管造影在初次切除后遗漏了四分之三的残留AVM，而术中血管造影遗漏了一个。
尽管ICG血管造影在某些脑AVM手术中是一种有用的辅助手段，但其在检测残留AVM病灶或分流方面的检出率较低，尤其是对于深部病变和高级别AVM。ICG血管造影不应作为唯一和/或可靠的技术。脑AVM手术必须进行高分辨率术后血管造影，它仍然是可靠确认AVM完全切除的最佳检查。
