• Christopher J Bilbao, Tarun Bhalla, Shamsher Dalal, Hiren Patel, and Amir R Dehdashti.
• Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, 4190 City Avenue, Philadelphia, PA, 19131, USA, christopher.bilbao@gmail.com.
• Acta Neurochir (Wien). 2015 Mar 1;157(3):351-9.

BackgroundThe 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.MethodsBetween 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.ResultsThere 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.ConclusionAlthough 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.

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