Indocyanine green video angiography for arteriovenous malformation [Neurosurgery Wiki]

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=====Indocyanine green video angiography for arteriovenous malformation=====
The role of [[indocyanine green videoangiography]] (ICG-VA) in the [[resection]] of [[vascular malformation]]s has been largely described.

Wang et al. evaluated the application of [[intraoperative ultrasound]] (IOU) combined with [[indocyanine green videoangiography for arteriovenous malformation]] and concluded that it can identify the boundary of AVM, detect deep vessels, and discriminate between feeding arteries and draining veins, reducing operation difficulty, decreasing mortality and disability rate, and increasing the rate of complete excision
((Wang H, Ye ZP, Huang ZC, Luo L, Chen C, Guo Y. Intraoperative Ultrasonography 
Combined with Indocyanine Green Video-Angiography in Patients with Cerebral
Arteriovenous Malformations. J Neuroimaging. 2015 Mar 19. doi: 10.1111/jon.12232.
[Epub ahead of print] PubMed PMID: 25800700.)).

Intraarterial [[injection]] was feasible and useful to distinguish [[feeder]]s from normal [[artery]] and to observe changes in flow dynamics. Intraarterial injection of ICG had better phase contrast than intra-venous injection of ICG and better spatial resolution than [[digital subtraction angiography]]. 
Therefore, this technique can be helpful in [[arteriovenous malformation]] (AVM) surgery
((Kono K, Uka A, Mori M, Haga S, Hamada Y, Nagata S. Intra-arterial injection of indocyanine green in cerebral arteriovenous malformation surgery. Turk Neurosurg. 2013;23(5):676-9. doi: 10.5137/1019-5149.JTN.6420-12.0. PubMed PMID: 24101318.)).

The utility of ICG-VA before dural opening (transdural ICG-VA) proved an efficient tool that allows optimising the exposure of the malformation, performing a safe dural opening and identifying dural vascular connections of the lesion
((Della Puppa A, Rustemi O, Gioffrè G, Causin F, Scienza R. Transdural indocyanine green video-angiography of vascular malformations. Acta Neurochir (Wien). 2014 Sep;156(9):1761-7. doi: 10.1007/s00701-014-2164-z. Epub 2014 Jul 19.PubMed PMID: 25034506.)).

ICG videoangiography is a quick and safe method of intraoperatively mapping the angioarchitecture of superficial AVMs, but it is less helpful for deep-seated lesions. This modality alone does not improve the identification of residual disease or clinical outcomes. Surgeon experience with extensive study of preoperative vascular imaging is paramount to achieving acceptable clinical outcomes. Formal angiography remains the gold standard for the evaluation of AVM obliteration
((Zaidi HA, Abla AA, Nakaji P, Chowdhry SA, Albuquerque FC, Spetzler RF.
Indocyanine green angiography in the surgical management of cerebral
arteriovenous malformations: lessons learned in 130 consecutive cases.
Neurosurgery. 2014 Jun;10 Suppl 2:246-51; discussion 251. doi:
10.1227/NEU.0000000000000318. PubMed PMID: 24535264.
)).

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
((Bilbao CJ, Bhalla T, Dalal S, Patel H, Dehdashti AR. Comparison of indocyanine
green fluorescent angiography to digital subtraction angiography in brain
arteriovenous malformation surgery. Acta Neurochir (Wien). 2015 Mar;157(3):351-9.
doi: 10.1007/s00701-014-2287-2. Epub 2014 Dec 10. PubMed PMID: 25488175.)).

It plays a role to identify small, posterior fossa arteriovenous malformations mimicking cavernous angiomas
((Barbagallo GM, Certo F, Caltabiano R, Chiaramonte I, Albanese V, Visocchi M.
Role of intraoperative indocyanine green video-angiography to identify small,
posterior fossa arteriovenous malformations mimicking cavernous angiomas.
Technical report and review of the literature on common features of these
cerebral vascular malformations. Clin Neurol Neurosurg. 2015 Jul 26;138:45-51.
doi: 10.1016/j.clineuro.2015.07.016. [Epub ahead of print] Review. PubMed PMID:
26276727.
)).

===== Retrospective cohort studies =====
In a [[retrospective cohort study]], Yang et al. from The First Affiliated Hospital of Soochow University (Suzhou, Jiangsu) and Beijing Tiantan Hospital, Capital Medical University (Beijing, China), published in [[World Neurosurgery]],
evaluated the safety and effectiveness of combining intraoperative [[indocyanine green video angiography]] (ICG-VA) with [[FLOW800]] and [[multimodal]] fusion [[neuronavigation]] in the microsurgical resection of brain [[arteriovenous malformation]]s (AVMs).

The combined use of ICG-VA, FLOW800, and multimodal neuro-navigation was associated with:

Reduced intraoperative [[blood loss]]

Improved functional outcomes

Lower rates of postoperative [[complications]] and [[reoperation]]

→ Enhancing both the safety and efficacy of AVM microsurgery.

((Yang X, Tao X, Meng J, You W, Gu F, Li J, Tian Z, Wang Z. [[Intraoperative]] ICG-VA with [[FLOW800]] and multimodal fusion neuro-[[navigation]] for the [[resection]] of [[arteriovenous malformation]] with reduced [[blood loss]]. World Neurosurg. 2025 Jun 18:124193. doi: 10.1016/j.wneu.2025.124193. Epub ahead of print. PMID: 40541664.))
----
A flashy mix of fluorescence imaging, hemodynamic mapping, and navigation overlays is presented as a major leap forward in AVM surgery. Ninety patients, split into two groups. Outcomes like hemoglobin drop and mRS are tracked. Sounds solid. Until you actually read it.

⚠️ Fatal Methodological Flaws
Retrospective Bias Parade:
No randomization. No matching. No controls for AVM grade, eloquence, or preoperative hemorrhage. The groups may as well be different species.

Selection Bias in Disguise:
Surgeons probably chose to use the "combined approach" in cases where they already expected better outcomes. That’s not innovation — it’s cherry-picking.

The Repetition Problem:
Results are stated twice, almost copy-pasted, a red flag for editorial padding and weak analysis.

Outcomes Without Depth:
Hemoglobin drop is statistically significant? Great. But was the surgical time longer? Were AVMs larger in one group? Were there intraoperative conversions? You’ll never know — because they didn’t ask.

💡 Technological Fanfare ≠ Scientific Rigor
FLOW800 is useful — but not new. ICG-VA has been around for two decades. Multimodal navigation is standard in many centers.
What this paper calls a "combined approach" is what high-volume centers consider routine. Wrapping these tools together doesn’t create a paradigm shift. It creates a PowerPoint slide.

💬 What It Should Have Been
A prospective, stratified study with AVM grading, eloquence mapping, and independent radiological adjudication.
Instead, we got a glorified before-and-after comparison with soft endpoints and flashy tools.

🧠 Final Verdict
This article is a sales pitch disguised as science — useful to tech vendors, not to evidence-based neurosurgeons.
It recycles known tools and rebrands them as revolution — with no real control, no blinding, and no humility.

Publishable? Maybe. Transformative? Not even close.