Giuseppe M V Barbagallo1, Francesco Certo2, Rosario Caltabiano3, Ignazio Chiaramonte4, Vincenzo Albanese2, Massimiliano Visocchi5. 1. Neurosurgery Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123, Catania, Italy. Electronic address: giuseppebarbagal@hotmail.com. 2. Neurosurgery Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123, Catania, Italy. 3. Department G.F. Ingrassia, Section of Anatomic Pathology, University of Catania, via Santa Sofia 78, 95123 Catania, Italy. 4. Radiology Department, Policlinico "G. Rodolico" University Hospital, via Santa Sofia 78, 95123 Catania, Italy. 5. Institute of Neurosurgery, Catholic University of Rome, Italy.
Abstract
OBJECTIVE: To illustrate the usefulness of intraoperative indocyanine green videoangiography (ICG-VA) to identify the nidus and feeders of a small cerebellar AVM resembling a cavernous hemangioma. To review the unique features regarding the overlay between these two vascular malformations and to highlight the importance to identify with ICG-VA, and treat accordingly, the arterial and venous vessels of the AVM. METHODS: A 36-year old man presented with bilateral cerebellar hemorrhage. MRI was equivocal in showing an underlying vascular malformation but angiography demonstrated a small, Spetzler-Martin grade I AVM. Surgical resection of the AVM with the aid of intraoperative ICG-VA was performed. After hematoma evacuation, pre-resection ICG-VA did not reveal tortuous arterial and venous vessels in keeping with a typical AVM but rather an unusual blackberry-like image resembling a cavernous hemangioma, with tiny surrounding vessels. Such intraoperative appearance, which could also be the consequence of a "leakage" of fluorescent dye from the nidal pathological vessels, with absent blood-brain barrier, into the surrounding parenchymal pathological capillary network, is important to be recognized as an unusual AVM appearance. RESULTS: Post-resection ICG-VA confirmed the AVM removal, as also shown by postoperative and 3-month follow-up DSAs. CONCLUSIONS: Despite technical limitations associated with ICG-VA in post-hemorrhage AVMs, this case together with the intraoperative video, demonstrates the useful role of ICG-VA in identifying small AVMs with peculiar features.
OBJECTIVE: To illustrate the usefulness of intraoperative indocyanine green videoangiography (ICG-VA) to identify the nidus and feeders of a small cerebellar AVM resembling a cavernous hemangioma. To review the unique features regarding the overlay between these two vascular malformations and to highlight the importance to identify with ICG-VA, and treat accordingly, the arterial and venous vessels of the AVM. METHODS: A 36-year old man presented with bilateral cerebellar hemorrhage. MRI was equivocal in showing an underlying vascular malformation but angiography demonstrated a small, Spetzler-Martin grade I AVM. Surgical resection of the AVM with the aid of intraoperative ICG-VA was performed. After hematoma evacuation, pre-resection ICG-VA did not reveal tortuous arterial and venous vessels in keeping with a typical AVM but rather an unusual blackberry-like image resembling a cavernous hemangioma, with tiny surrounding vessels. Such intraoperative appearance, which could also be the consequence of a "leakage" of fluorescent dye from the nidal pathological vessels, with absent blood-brain barrier, into the surrounding parenchymal pathological capillary network, is important to be recognized as an unusual AVM appearance. RESULTS: Post-resection ICG-VA confirmed the AVM removal, as also shown by postoperative and 3-month follow-up DSAs. CONCLUSIONS: Despite technical limitations associated with ICG-VA in post-hemorrhage AVMs, this case together with the intraoperative video, demonstrates the useful role of ICG-VA in identifying small AVMs with peculiar features.