Microscope-Integrated Indocyanine Green Videoangiography in Pediatric Spinal Dural Arteriovenous Fistula (SDAVF) Surgery: A Case Report on an Extremely Rare Vascular Malformation

Abstract

Spinal dural arteriovenous fistulas (SDAVFs) are exceptionally rare, acquired vascular malformations of the spinal cord, mostly affecting middle-aged to elderly men and typically presenting with progressive myelopathy. Given the diagnostic and therapeutic challenges of SDAVFs in children, we evaluated the feasibility and effectiveness of microscope-integrated indocyanine green (ICG) videoangiography as an intraoperative adjunct. While ICG use is well-documented in the surgical management of cranial aneurysms and adult spinal vascular malformations, its application in spinal arteriovenous malformations (AVM) in children remains limited and poorly characterized, and to date, its use in pediatric SDAVFs, especially, has not been reported. We present an exceptionally rare case of a pediatric SDAVF in a nine-year-old male patient who exhibited progressive, high-grade paraparesis and gait disturbances. The microsurgical disconnection of the fistula was performed at our institution. Intraoperative microscope-integrated ICG videoangiography was employed to localize the fistulous point at the Th7 level and to confirm the complete obliteration of the arteriovenous shunt in real time. No intraoperative or postoperative complications related to ICG administration were observed. Postoperative digital subtraction angiography (DSA) confirmed complete fistula closure. No recurrence or delayed complications were noted during a 70-month follow-up period. The results of this case report underscore the safety and effectiveness of intraoperative microscope-integrated ICG videoangiography for localizing and confirming the obliteration of pediatric SDAVF. This technique offers a promising alternative to routine postoperative DSA, reducing radiation exposure-associated risks in the pediatric population. Further studies on larger cohorts are warranted to validate these findings and standardize the use of ICG in pediatric spinal vascular surgery.

Keywords: intraoperative indocyanine green; microscope; pediatric; spinal angiography; spinal dural arteriovenous fistulas.

Figure 1. Sagittal T2-weighted MRI (A and B).

In image A, a hyperintense intramedullary signal alteration from T7 to T12 represents edema (white arrow). In image B, the multiple flow voids in the dorsal subarachnoid space are distributed over almost the entire thoracic cord length, complying with pathological distended vessels (white arrow). MRI: magnetic resonance imaging

Figure 2. Preoperative (A and B) and postoperative (C) spinal DSA from the left side at the level T7.

Image A shows the fistula located caudal of the T7 pedicle. The shunting zone is denoted by the white arrow. The main supply to the shunt is derived from the radiculomeningeal artery originating from the injected segmental artery. There is a marked alteration of the caliber of the vessels at the fistula site as the exact position of the shunt. In image B, contrast media highlights the dilated dorsal pial venous plexus, revealing cephalad-directed venous blood flow (white arrow). In image C, the arteriovenous shunt has been successfully occluded, indicating a complete cure. DSA: digital subtraction angiography

Figure 3. An intraoperative screenshot of the situs.

The black arrows show the dilated dorsal pial venous plexus. The arteriovenous shunt is interrupted by an AVM clip (white arrow). AVM: arteriovenous malformation

Figure 4. An intraoperative post-ICG injection screenshot of the intradural space after supplying intravenous ICG.

The ICG videoangiography shows the dilated pial venous plexus and also the point of fistula (white arrows). ICG: indocyanine green