Thorsteinsdottir Jun, Siller Sebastian, Dorn Franziska, Briegel Josef, Tonn Jörg-Christian, Schichor Christian
Department of Neurosurgery, Ludwig-Maximilians-University, Munich, Germany.
Department of Neuroradiology, Ludwig-Maximilians-University, Munich, Germany.
World Neurosurg. 2019 May;125:e67-e73. doi: 10.1016/j.wneu.2018.12.190. Epub 2019 Jan 16.
Intraoperative indocyanine green video angiography (ICG-VAG) is a useful tool in cerebral vascular surgery. In spinal procedures such as dural arteriovenous (AV) fistula, use of ICG-VAG is limited due to lower perfusion pressure. Therefore, we developed a new pooling technique with adapted workflow to improve intraoperative visualization.
Patients operated on spinal dural AV fistulas using ICG-VAG were prospectively included. A new workflow for ICG-VAG was applied: 1) temporary clip placement at the suspected fistula point, 2) ICG administration during 100% oxygenation, 3) ICG pooling proximal of temporary clip, 4) clip removal/observation of vascular filling. Case records, clinical data, magnetic resonance imaging, digital subtraction angiography (DSA), and clinical outcome were analyzed retrospectively.
A total of 11 patients (median age 68 years, average course of disease 15 months) were included. Optimized, inverted workflow resulted in considerable pooling of ICG in the supplying feeder of the AV fistula in all cases. Complete obliteration was confirmed in 10 of 11 patients by postoperative DSA. However, 1 patient had an additional, preoperative radiologically undetected small feeder that enlarged until postoperative DSA and made successful reoperation necessary. After the median follow-up of 33.2 months, the Aminoff-Logue scale was decreased in all patients, and the McCormick score (modified Rankin score) was improved in 9 (8) patients and remained stable in 2 (3) patients.
Procedure modification in terms of ICG pooling enabled us to detect more easily the pathologic vascular architecture. ICG-VAG is a useful adjunct in the surgical treatment of spinal dural AV fistula because it is a real-time, noninvasive, and radiation-free technique with adequate image resolution.
术中吲哚菁绿视频血管造影（ICG-VAG）是脑血管手术中的一种有用工具。在诸如硬脊膜动静脉（AV）瘘等脊柱手术中，由于灌注压力较低，ICG-VAG的应用受到限制。因此，我们开发了一种新的聚集技术并调整了工作流程，以改善术中可视化效果。
前瞻性纳入使用ICG-VAG进行脊柱硬脊膜AV瘘手术的患者。应用了一种新的ICG-VAG工作流程：1）在疑似瘘口处临时夹闭；2）在100%氧合期间注入ICG；3）ICG在临时夹近端聚集；4）移除夹子/观察血管充盈情况。对病例记录、临床数据、磁共振成像、数字减影血管造影（DSA）和临床结果进行回顾性分析。
共纳入11例患者（中位年龄68岁，平均病程15个月）。优化后的反向工作流程在所有病例中均使ICG在AV瘘的供血支中大量聚集。11例患者中有10例术后DSA证实完全闭塞。然而，1例患者术前有一个放射学未检测到的额外小供血支，术后DSA显示其增大，因此需要再次成功手术。中位随访33.2个月后，所有患者的阿明诺夫-洛格量表评分均降低，9（8）例患者的麦考密克评分（改良Rankin评分）改善，2（3）例患者保持稳定。
ICG聚集方面的手术改进使我们能够更轻松地检测到病理性血管结构。ICG-VAG是脊柱硬脊膜AV瘘手术治疗中的一种有用辅助手段，因为它是一种实时、无创且无辐射的技术，图像分辨率足够。
