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

## TL;DR

This case report describes the successful use of microscope-integrated ICG videoangiography in a rare pediatric spinal vascular malformation surgery.

## Contribution

The paper presents the first reported use of intraoperative ICG videoangiography in pediatric spinal dural arteriovenous fistula surgery.

## Key findings

- Intraoperative ICG videoangiography successfully localized and confirmed obliteration of the fistula in a pediatric SDAVF case.
- No complications from ICG administration were observed, and postoperative imaging confirmed complete closure.
- The technique may reduce the need for postoperative DSA and associated radiation risks in children.

## 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.