Intraoperative angiography with indocyanine green, an aid in the diagnosis and treatment of obscure digestive tract bleeding, a case report.

Lower digestive tract bleeding occurs distal to the angle of Treitz. While many cases remit spontaneously; some pose a diagnostic challenge for surgeons. We present the case of a 68-year-old man with unexplained digestive tract bleeding. Despite various diagnostic efforts, the source remained unknown. Faced with the challenge of persistent bleeding and hemodynamic instability, surgery became necessary. During the procedure, intraoperative angiography with indocyanine green was used to facilitate the identification of the bleeding site, revealing a gastrointestinal stromal tumor in the small bowel. Resection was performed with favorable outcomes. Indocyanine green staining has become popular for locating intestinal bleeding during emergency surgeries, aiding surgeons in making precise decisions.

Application of indocyanine green fluorescence angiography in evaluating blood flow in rotator cuff tears: a preliminary study.

BACKGROUND: The relationship between the degree of vascularization at the edge of a torn rotator cuff tendon and cuff healing remains unclear. The purpose of this study was to employ indocyanine green (ICG) fluorescence angiography to evaluate the blood flow at the edge of a torn rotator cuff tendon under the subacromial view. METHODS: Thirteen shoulders of 13 patients who underwent arthroscopic repair of full-thickness rotator cuff tears were included in this prospective study. Viewing from the posterolateral portal, ICG at 0.2 mg/kg body weight was intravenously administered, and the blood flow was recorded. After resecting the poorly vascularized torn edge of the tendon, ICG administration was repeated at the same volume. The fluorescence intensity and perfusion time of the tendon blood flow were evaluated using video analysis and modeling tools. Cuff integrity was evaluated using magnetic resonance imaging at 6 months postoperatively. Patients were divided into healed and retear groups, and the differences in the degree of blood flow were evaluated. RESULTS: ICG fluorescence angiography could visualize the blood flow in the rotator cuff tendon, and the torn edge of the tendon with poor blood flow was resected. The overall retear rate was 23.1% (3/13). Based on quantitative analysis, the fluorescence intensity factors were significantly lower in the retear group than in the healed group before tendon débridement. The retear rate in the high blood flow group was 0% (0/7), while that in the low blood flow group was 50.0% (3/6). CONCLUSIONS: ICG fluorescence angiography may play a role in the future of shoulder arthroscopy. Further study is needed to determine the effect of blood flow on tendon healing.

Mid-term Outcomes of Image-Guided Surgical Thromboembolectomy and Routine Intraoperative Angiography for Native Vessel Acute Lower-Limb-Threatening Ischemia.

BACKGROUND: Standard balloon-catheter thromboembolectomy (TE) is an established effective treatment for acute lower-limb ischemia (ALI) with recognized limitations when there is an underlying arterial lesion or thromboembolism of the infrapopliteal arteries. The aim of this study was to evaluate the efficacy and safety of image-guided surgical TE combined with routine intraoperative completion angiography in the treatment of ALI patients. METHODS: Between September 2020 and August 2022, this prospective study included all consecutive adult patients presenting to a tertiary center with unilateral ALI of Rutherford class II due to thromboembolic occlusion of native arteries who underwent image-guided surgical TE and routine completion intraoperative angiography. Adjunctive endovascular techniques (hybrid revascularization) including plain balloon angioplasty (PTA)±stenting or on-table lysis were used if underlying arterial lesions or residual thrombosis were detected on the intraoperative angiography, respectively. The primary outcome measures included technical success and 30-day major amputation rate. Perioperative complications, 1-year primary and secondary patency, limb salvage, mortality, and amputation-free survival rates were endorsed as secondary outcome measures. RESULTS: Image-guided surgical thrombectomy was done for 109 ALI patients (109 limbs), provisionally diagnosed as embolic (57 patients, 52.3%) or thrombotic (52 patients, 47.7%) arterial occlusion. Thromboembolectomy without adjunctive endovascular treatment was done in 38 patients (34.86%), whereas 71 patients (65.14%) required adjunctive PTA±stenting of underlying arterial lesions (60, 55.05%) or on-table lysis±PTA of residual thrombosis (11, 10.09%). The overall technical success rate was 92.66%. At 30 days, amputation and mortality rates were 3.67% and 5.5%, respectively. None of the patients had thrombectomy-induced arterial injuries. One-year follow-up data were available for 81 patients (74.3%). The Kaplan-Meier estimate of the 12-month primary and secondary patency, limb salvage, and amputation-free survival rates was 76.5%±0.04, 91.5%±0.03, 90.6±0.03, and 91.4±0.03%, respectively. CONCLUSIONS: Image-guided TE combined with routine intraoperative angiography is a safe and effective technique for surgical TE in acute lower-limb ischemia patients with the advantage of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. CLINICAL IMPACT: The present study has confirmed the safety and effectiveness of image-guided thromboembolectomy combined with routine use of intraoperative angiography during surgical treatment of acute lower limb ischemia in terms of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. This technique also facilitates selective passage of Fogarty balloon catheter into infrapopliteal arteries from the femoral approach which is traditionally done by exploration of the popliteal trifurcation or tibial arteries under regional or general anesthesia. Using this technique can guide the operating surgeon for adequate balloon manipulation and inflation to avoid iatrogenic vessel injury.

Peri-procedure efficacy and safety of one-stop hybrid surgery for the treatment of brain arteriovenous malformations: A single-center preliminary experience.

Background: Some deficiencies and shortcomings in treatment strategies of brain arteriovenous malformation (bAVM) remain. It is worth exploring whether the one-stop hybrid surgical platform can play a positive role in the treatment of bAVM. Objective: This study investigated short clinical and angiographic results of one-stop hybrid surgery for the treatment of bAVM. Methods: All patients with bAVM treated with one-stop hybrid surgery were reviewed from February 2017 to December 2021. Data including demographic information, clinical conditions, characteristics of AVM, procedure details, and clinical and angiographic results were collected. Result: In total, 150 cerebral bAVM patients received one-stop hybrid surgery; among them, 122 received surgical resection assisted by intraoperative DSA, and 28 were treated with combination surgical resection and endovascular embolization. Complete angiographic obliteration of the AVM was achieved in 136 patients (90.7%), and procedure-related death and neurological deficit rates were 7.3%. Of all relevant variables, logistic regression analysis showed that the Spetzler & Martin (S&M) score was the only factor related to the cure rate (P < 0.001) and endpoint complication rate (P = 0.007). Conclusions: In our preliminary experience, one-stop hybrid surgery for the treatment of brain AVMs achieves a high angiographic total occlusion rate, with acceptable peri-procedure morbidity and mortality. For S&M 4 and 5 lesions, more cases and further study are needed to investigate the effects and safety of hybrid surgery.

Intraoperative Angiogram Using C-Arm Fluoroscopy and Direct Common Carotid Artery Puncture During Surgical Treatment of Paraclinoid Aneurysms.

BACKGROUND: Intraoperative angiography (IOA) has been shown to be a useful adjunct in surgical treatment of cerebral aneurysms. However, its use can be limited by hybrid operating room availability. On the other hand, the use of C-arm fluoroscopy can add challenges to IOA during navigation of the aortic arch and selection of the great vessels. We aimed to describe a simple method of IOA that can be applied during surgery of paraclinoid aneurysms and can be performed in a normal operating room without the need to navigate the aortic arch. METHODS: In patients undergoing surgery for paraclinoid aneurysms with need for cervical carotid artery exposure, IOA was performed using a single plane C-arm fluoroscopy unit after direct puncture of the carotid artery. RESULTS: Five patients were included: 2 with subarachnoid hemorrhage, 2 with unruptured aneurysm and history of subarachnoid hemorrhage, and 1 with unruptured aneurysm. There were 2 internal carotid blister aneurysms, 2 ophthalmic artery aneurysms, and 1 superior hypophyseal artery aneurysm. IOA was performed using direct carotid puncture through the neck incision required for proximal control. In all cases, intraoperative images were of sufficient quality to determine the completeness of aneurysm occlusion as well as parent and branching vessel patency. There were no postoperative infarctions and no complications related to IOA. CONCLUSIONS: IOA using direct carotid puncture can be performed in a standard operating room with the use of a C-arm, eliminating the need to catheterize the great vessels of the aortic arch.

Intraoperative angiography imaging correlates with wound complications following soft tissue sarcoma resection.

For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in these patients. A consecutive series of patients with soft tissue sarcoma of the extremities or pelvis who received neoadjuvant radiation and a subsequent radical resection received intraoperative ICGA with the SPY PHI device (Stryker Inc.) at the time of closure. Retrospective analysis of fluorescence signal along multiple points of the wound length was performed and quantified. The primary endpoint was wound complication, defined as delayed wound healing or wound dehiscence, within 3 months of surgery. Fourteen patients with preoperative irradiated soft tissue sarcoma were consecutively imaged. There were six patients with wound complications classified as "aseptic" in five cases. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. During the inflow phase, a mean ratio of normal of 0.62 maximized the area under the curve (AUC = 0.90) for predicting wound complications with a sensitivity of 100% and specificity of 77.4%. During the peak phase, a mean ratio of normal of 0.55 maximized the AUC (0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity of 100%. Intraoperative use of ICGA may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis.

Intraoperative angiography for visceral arteries originating from false lumen.

A 70-year-old man had an acute type B aortic dissection 9 years before his admission. The last enhanced computed tomography that was performed revealed an aneurysm that extended from the ascending aorta to the aortic arch, associated with a chronic aortic dissection, which extended from the aortic arch to the left external iliac artery. His visceral arteries originated from the false lumen. We performed a total arch replacement with a frozen elephant trunk in the hybrid operating room. Immediately after the circulatory arrest termination, using intraoperative angiography, we verified that the blood supply to the visceral arteries was patent.

Intraoperative Identification of the Shunt Point of Spinal Arteriovenous Malformations by a Selective Arterial Injection of Saline to Subtract Signals of Indocyanine Green: Technical Note.

BACKGROUND: It is crucial to identify a shunt point for spinal arteriovenous malformation (AVM) treatment. For this purpose, some intraoperative supports have been reported-intravenous injection of indocyanine green (ICG), selective arterial injection of ICG, and selective arterial injection of saline with a high frame rate digital camera. However, there are difficulties in accurately identifying the shunt point, especially if the lesion has multiple feeders. The aim of this technical note was to report a novel method, selective arterial injection of saline to subtract signals of ICG, to precisely identify perimedullary arteriovenous fistula shunt points having multiple feeding arteries. METHODS: After exposing the lesion, a 4-F catheter was cannulated into the origins of the segmental artery. ICG was injected intravenously as a first step, and then heparinized saline solution was flushed from the catheter. RESULTS: Compared with other methods, this method could identify the exact shunt point and was effective for certain shunt point obliterations. CONCLUSIONS: Despite having similar invasiveness, selective arterial injection of saline to subtract signals of ICG is superior to previously described techniques, such as selective arterial injection of ICG. Therefore, it will be useful in spinal arteriovenous malformation surgical treatment.

The value of intraoperative angiography in the time of indocyanine green videoangiography in the treatment of cerebrovascular lesions: Efficacy, workflow, risk-benefit and cost analysis A prospective study.

INTRODUCTION: Intraoperative digital subtraction angiography (ioDSA) allows early treatment evaluation after neurovascular procedures. However, the value and efficiency of this procedure has been discussed controversially. We have evaluated the additional value of hybrid operating room equipped with an Artis Zeego robotic c-arm regarding cost, efficiency and workflow. Furthermore, we have performed a risk-benefit analysis and compared it with indocyanine green (ICG) angiography. METHODS: For 3 consecutive years, we examined all neurovascular patients, treated in the hybrid operating theater in a risk-benefit analysis. After using microdoppler and ICG angiography for best operative result, every patient received an additional ioDSA to look for remnants or unfavorable clip placement which might lead to a change of operating strategy or results. Furthermore, a workflow-analysis reviewing operating steps, staff positioning, costs, technical errors or complications were conducted on randomly selected cases. RESULTS: 54 patients were enrolled in the risk-benefit analysis, 22 in the workflow analysis. The average duration of a cerebrovascular operation was 4 h 58 min 2 min 35 s accounted for ICG angiography, 46 min 4 s for ioDSA. Adverse events occurred during one ioDSA. In risk-benefit analysis, ioDSA was able to detect a perfusion rest in 2 out of 43 cases (4,7%) of aneurysm surgery, which could not have been visualized by ICG angiography before. In arterio-venous-malformation (AVM) surgery, one of 11 examined patients (7,7%) showed a remnant in ioDSA and resulted in additional resection. The average cost of an ioDSA in Ulm University can be estimated with 1928,00€. CONCLUSION: According to our results ioDSA associated complications are low. Relevant findings in ioDSA can potentially avoid additional intervention, however, due to the high costs and lower availability, the main advantage might lie in the treatment of selected patients with complexes neurovascular pathologies since ICG angiography is equally safe but associated with lower costs and better availability.

Laparoscopic treatment of median arcuate ligament syndrome without ganglionectomy of the celiac plexus in the hybrid operating room: Report of a case.

INTRODUCTION: Median arcuate ligament syndrome (MALS) is a rare condition in which the median arcuate ligament (MAL) causes compression of the celiac artery (CA) and plexus. Although 13-50 % of healthy population exhibit radiologic evidence of the CA compression, the majority remains asymptomatic. With or without symptoms, MALS have a risk of developing collateral circulation that leads to pancreaticoduodenal artery (PDA) aneurysms that have high risk of rupture. The treatment of MALS is the surgical release of the MAL. However, the necessity of ganglionectomy of the celiac plexus is still unclear. PRESENTATION OF CASE: A 60-year-old man with a ruptured PDA aneurysm caused by MALS was admitted to our hospital for an emergency. After treatment for the ruptured PDA aneurysm by transcatheter arterial coil embolization, he underwent elective laparoscopic MAL release in the hybrid operation room to check blood flow of the CA intraoperatively. The angiography of the CA immediately after MAL release without ganglionectomy of the celiac plexus showed the antegrade blood flow to the proper hepatic artery instead of the retrograde flow via the pancreaticoduodenal arcade. The postoperative course was uneventful and the follow-up computed tomography revealed no residual CA stenosis. DISCUSSION: Unlike symptomatic MALS, it might be enough to just release the MAL without ganglionectomy of the celiac plexus for asymptomatic MALS, especially that with the treated PDA aneurysm. CONCLUSION: Laparoscopic treatment of MALS in hybrid operating room could allow for adequate MAL release without ganglionectomy of the celiac plexus using the intraoperative angiography of the CA.

A novel fluorescent cardiac imaging system for preclinical intraoperative angiography.

BACKGROUND: Intraoperative coronary angiography can tremendously reduce early coronary bypass graft failures. Fluorescent cardiac imaging provides an advanced method for intraoperative observation and real-time quantitation of blood flow with high resolution. METHODS: We devised a system comprised of an LED light source, special filters, lenses and a detector for preclinical coronary artery angiography. The optical setup was implemented by using two achromatic doublet lenses, two positive meniscus lenses, a band-pass filter, a pinhole and a CCD sensor. The setup was optimized by Zemax software. Optical design was further challenged to obtain more parallel light beams, less diffusion and higher resolutions to levels as small as arterioles. Ex vivo rat hearts were prepared and coronary arteries were retrogradely perfused by indocyanine green (ICG). Video angiography was employed to assess blood flow and plot time-dependent fluorescence intensity curve (TIC). Quantitation of blood flow was performed by calculating either the gradient of TIC or area under curve. The correlation between blood flow and each calculated parameters was assessed and used to evaluate the quality of flow. RESULTS: High-resolution images of flow in coronary arteries were obtained as precise as 62 µm vessel diameter, by our custom-made ICG angiography system. The gradient of TIC was 3.4-6.3 s-1, while the area under curve indicated 712-1282 s values which ultimately gained correlation coefficients of 0.9938 and 0.9951 with relative blood flow, respectively. CONCLUSION: The present ICG angiography system may facilitate evaluation of blood flow in animal studies of myocardial infarction and coronary artery grafts intraoperatively.

Intraoperative application of a new-generation 3D IV-DSA technology in resection of a hemorrhagic cerebellar AVM.

Although intravenous digital subtraction angiography (IV-DSA), cone-beam CT, and rotational angiography are well-established technologies, using them in a single system in the hybrid operating room to acquire high-quality noninvasive 3D images is a recent development. This video demonstrates microsurgical excision of a ruptured cerebellar arteriovenous malformation (AVM) in a 66-year-old male followed by intraoperative IV-DSA acquisition using a new-generation system (Artis Icono). IV-DSA confirmed in real time that no residual remained following excision without the need to reposition the patient. To the best of the authors' knowledge, this is the first surgical video to demonstrate the simplified workflow and application of this technology in neurovascular surgery. The video can be found here: https://youtu.be/bo5ya9DQQPw.

Direct Tumoral Puncture Onyx Embolization for a Juvenile Nasopharyngeal Angiofibroma in a Hybrid Neurointerventional Suite.

This case video demonstrates a multidisciplinary approach to resection of a juvenile nasopharyngeal angiofibroma highlighting direct intratumoral onyx embolization. The patient is a 14-year-old boy who presented with a 1-month history of worsening epistaxis and nasal congestion. Preoperative magnetic resonance imaging demonstrated a 4.5 x 3 x 3 cm lobulated mass in the right pterygomaxillary space, sphenoid, and the nasopharynx adjacent to the cavernous carotid. Given the high vascularity of the lesion, intratumoral onyx embolization was undertaken, which significantly reduced intraoperative blood loss in this case. The present video demonstrates the technique for safe direct intratumoral onyx embolization and its role in significantly reducing intraoperative blood loss (Video 1). Postoperatively, the patient made an uncomplicated recovery. The patient consented to the procedure.

Application of Advanced Technology During Resection of Posterior Fossa Arteriovenous Malformations: 2 Sister Cases.

Various advanced imaging and intraoperative technologies can be used during resection of posterior fossa arteriovenous malformations (AVMs) in a hybrid neurovascular operating room. These technologies include transradial intraoperative angiography with post-processing of angiographic data for navigation (in combination with stereotactic magnetic resonance imaging) (Figure 1). Advanced semiautomated processing allows magnetic resonance imaging, computed tomography angiography, and angiography fusion for enhanced localization of the AVM. Additional useful technologies include processing of angiographic transit time to provide valuable flow data, indocyanine green angiography, fluorescein angiography, and use of a high-definition endoscope. While these technologies are potentially useful in certain circumstances, they may not be necessary in the case of relatively straightforward vascular lesions. Keeping this in mind is of particular importance, as the use of these technologies may require extended time with the patient under anesthesia. These sister cases of cerebellar AVMs illustrate the spectrum of the advanced technologies that are potentially available to surgeons during posterior fossa AVM resection (Video 1).

Intraoperative angiography with indocyanine green injection for precise localization and resection of small bowel bleeding.

AIM: Bleeding in the small bowel rarely occurs, and its treatment is challenging. Surgery is sometimes required in unstable patients; however, intraoperative identification of the bleeding site is extremely difficult. Many methods have been reported, but no standard strategy has been established yet. Here, we aimed to assess the safety and feasibility of intraoperative angiography with indocyanine green staining to accurately identify small bowel bleeding sites. METHODS: This retrospective study analyzed contrast-enhanced computed tomography images of patients (n = 8) with small bowel extravasation who underwent surgery. If extravasation or other vessel abnormalities that were potential bleeding sites were detected on intraoperative angiography, a microcatheter was placed as close as possible to the extravasation site. Laparotomy was carried out, and 3-5 mL indocyanine green was injected through the microcatheter. The green-stained segment of the small bowel was resected. RESULTS: Seven of the eight patients had positive angiographic findings and underwent bowel resection. The eighth patient had no abnormalities and hence did not undergo laparotomy. The rate of hemostatic success among the resected cases was 85.7% (six of seven cases). The resected specimens showed pathologic features in six of the seven patients (85.7%), all of whom achieved hemostasis. One patient had pneumonia and congestive heart failure that required longer hospital stay, but no mortality occurred. CONCLUSIONS: Intraoperative angiography with indocyanine green injection, followed by resection for massive small bowel bleeding is effective. This can be a therapeutic option for hemodynamically unstable patients.

Intraoperative 3-Dimensional Rotational Angiography in Cerebrovascular Surgery: A Case Series.

OBJECTIVE: Intraoperative imaging is critical in cerebrovascular surgery to assess the technical success of the operation. This case series aimed to evaluate the safety and efficacy of 3-dimensional rotational angiogram (3D-RA) in addition to 2-dimensional intraoperative angiography (2D-IOA) during cerebrovascular surgery in the hybrid operating room. METHODS: All consecutive patients who underwent open cerebrovascular surgery and intraoperative 2D-IOA with 3D-RA in a hybrid operating room at 2 academic centers between August 2018 and December 2019 were identified from a prospectively maintained institutional database. Medical charts and operative videos including intraoperative angiography were reviewed, and clinical and angiographic outcomes assessed. RESULTS: A total of 40 cerebrovascular surgeries in 39 patients (mean age, 53 ± 13 years; 51% female) were carried out with the addition of 3D-RA to 2D-IOA in the hybrid operating room. After 3D-RA in addition to 2D-IOA, 1 (2.5%) surgical alteration occurred in an aneurysm clipping. Other procedures were not altered with the addition of 3D-RA to 2D-IOA. There were no complications from the addition of 3D-RA to 2D-IOA. CONCLUSIONS: Using a combination of 3D-RA and 2D-IOA in the hybrid operating room may enhance the likelihood of achieving an optimal result when employing microsurgical cerebrovascular surgery and avoid unanticipated incomplete outcomes, complications, and returns to the operating room. Whereas the addition of 3D-RA elucidated residual aneurysm not otherwise visualized on the 2D-IOA, in other cerebrovascular procedures studied, there was no additional value of the 3D-RA over the 2D-IOA.

Radial Arterial Access for Thoracic Intraoperative Spinal Angiography in the Prone Position.

BACKGROUND: Verification of complete occlusion or resection of neurovascular lesions is often performed using intraoperative angiography. Surgery for spinal vascular lesions such as arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs) is typically performed with the patient in the prone position, making intraoperative angiography difficult. No standardized protocol is available for intraoperative angiography during spinal surgery with the patient in the prone position. We have described our experience using radial artery access for intraoperative angiography in thoracic spinal neurovascular procedures performed with the patient in the prone position. METHODS: We reviewed the data from all patients who had undergone surgical resection of spinal vascular lesions in the prone position with radial artery vascular access for intraoperative angiography. The patients were treated in a hybrid endovascular operating room. RESULTS: A total of 4 patients were treated in the prone position using transradial artery access intraoperative angiography for confirmation of complete resection of the vascular lesions. Of the 4 patients, 2 had undergone surgery for a dural AVF, 1 for a pial AVF, and 1 for an AVM of the filum terminale. None of the patients had experienced any procedural complications. CONCLUSION: Radial artery access for intraoperative angiography during spinal neurovascular procedures in which selective catheterization of a thoracic branch is necessary is feasible, safe, and practical.

Microsurgical Resection of a Spinal Cord Pial Arteriovenous Fistula: 2-Dimensional Operative Video.

We present a patient who was diagnosed 20 yr prior to current presentation with a spinal arteriovenous malformation. This patient had a 10-yr history of worsening back pain (and underwent lumbar fusion), urinary dysfunction leading to 3-yr dependence on intermittent catheterization, lower extremity paresthesias and pain, and progressive weakness with multiple falls, leading to walker then wheelchair dependence for mobility. Magnetic resonance studies showed extensive thoracic cord expansion and edema with enlarged spinal cord surface veins and flow voids extending from spinal levels T6 to the conus medullaris. Partial embolization at an outside institution elicited transient symptom improvement. Repeated spinal angiogram demonstrated persistent T10 pial arteriovenous fistula (AVF) supplied by the posterior spinal artery arising from the right T11 segmental artery as well as by the anterior spinal artery from the left T10 segmental artery. Because additional embolization carried significant risk, we planned open surgery with fistula resection. Informed consent for the surgery and video recording was obtained. The patient was placed in the prone position, and a radial artery access was obtained for intraoperative angiogram. Following a posterior T9-T11 laminectomy and dural opening, a pial dissection was performed to expose the AVF. Intraoperative indocyanine green angiography was used to assist in identifying the feeders and major drainage of the AVF. Post-AVF resection, a formal intraoperative radial access spinal angiogram demonstrated complete resection of the lesion with no residual shunt or early venous drainage. The patient improved significantly and, on last follow-up, is ambulating without any assistive devices.

Microsurgical Technique for Treatment of Perimedullary Spinal Arteriovenous Fistulae: 2-Dimensional Operative Video.

The case is of a 49-yr-old female admitted after acute onset lower cervical/upper thoracic region pain with left hemi-body hypoesthesia below the C7 level. Magnetic resonance imaging showed a spinal cord intraparenchymal hemorrhage at the C6/7 levels. Physical exam revealed hypoesthesia on the left from C7 and below with associated 3/5 wrist and finger extensor and 4/5 triceps strength on the left. The remainder of the neurological exam was normal including lower extremity strength and bowel/bladder function. A craniocervical angiogram showed a perimedullary arteriovenous fistula on the left, ventrolateral aspect of the spinal cord with a single feeding artery that originated from the thyrocervical trunk and entered through the left C6 nerve root sleeve. Venous drainage was cephalad to cortical cerebellar veins and to the suboccipital plexus. A branch of the thyrocervical trunk supplying the ventral spinal cord originated close to the fistula, which precluded endovascular embolization. The patient underwent C6-T1 laminectomies for microsurgical treatment of the fistula. This case demonstrates multiple key concepts in the surgical management of these rare lesions as follows: the ventral aspect of the cervical spinal cord can be safely approached from posterior. The venous anatomy is often confusing and intraoperative angiography utilizing both indocyanine green and conventional digital subtraction techniques are of paramount importance. Unlike arteriovenous malformations, the venous drainage can be pruned to gain visualization and trace the venous anatomy retrograde to the point of the fistula. The patient awoke from surgery at her neurological baseline. The patient consented to de-identified publication of this case.

Comprehensive review of imaging of intracranial aneurysms and angiographically negative subarachnoid hemorrhage.

Intracranial aneurysms confer the risk of subarachnoid hemorrhage (SAH), a potentially devastating condition, though most aneurysms will remain asymptomatic for the lifetime of the patient. Imaging is critical to all stages of patient care for those who harbor an unruptured intracranial aneurysm (UIA), including to establish the diagnosis, to determine therapeutic options, to undertake surveillance in patients who elect not to undergo treatment or whose aneurysm(s) portends such a low risk that treatment is not indicated, and to perform follow-up after treatment. Neuroimaging is equally as important in patients who suffer an SAH. DSA remains the reference standard for imaging of intracranial aneurysms due to its high spatial and temporal resolution. As noninvasive imaging technology, such as CTA and MRA, improves, the diagnostic accuracy of such tests continues to increasingly approximate that of DSA. In cases of angiographically negative SAH, imaging protocols are necessary not only for diagnosis but also to search for an initially occult vascular lesion, such as a thrombosed, ruptured aneurysm that might be detected in a delayed fashion. Given the crucial role of neuroimaging in all aspects of care for patients with UIAs and SAH, it is incumbent on those who care for these patients, including cerebrovascular neurosurgeons, interventional neurologists and neuroradiologists, and diagnostic radiologists and neurointensivists, to understand the role of imaging in this disease and how individual members of the multispecialty team use imaging to ensure best practices to deliver cutting-edge care to these often complex cases. This review expounds on the role of imaging in the management of UIAs and ruptured intracranial aneurysms and in the workup of angiographically negative subarachnoid hemorrhage.