Fluorescein-Guided Surgery for Arteriovenous Malformation.

Microscopes with fluorescence modality for videoangiography (VAG) using indocyanine green or sodium fluorescein (FL) have been used in cerebrovascular surgeries as tools for brain blood flow assessment in vascular diseases, especially in brain aneurysms, extracranial-intracranial bypass, and arteriovenous malformations (AVMs). Indocyanine green-VAG is a well-documented tool frequently employed as an adjunct to microsurgery for AVM treatment. Nevertheless, it's worth noting that the use of FL-VAG has been significantly underrepresented in medical literature, with only a few studies addressing its application in this context. We report a case of a 33-year-old woman with a grade 1 frontal unruptured AVM, admitted because of recurrent headache. The AVM was exposed with a centered craniotomy (Video 1). Three FL injections were administered at different timing: 1) at the procedure's outset (before any dissection), 2) when the surgeon estimated most feeders had been disconnected, and 3) after the removal of the nidus. FL-VAG allowed visualization of the superficial AVM vessels and its draining veins. After identification and disconnection of feeding arteries, diminished blood flow was visualized and the AVM was completely removed, confirming no residual lesion by absence of FL on the surgical bed. Postoperative digital angiography showed complete removal of the AVM. FL-VAG represents a valuable adjunct in the AVM resection by facilitating the assessment of blood flow within cerebral vessels. This can be helpful to modify surgical strategies in some circumstances (e.g., selection of the main feeders vs. arteries in passage) and to save time making decisions about draining vein division and nidus removal.