Use of intraoperative indocyanine green angiography for feeder vessel ligation and en bloc resection of intramedullary hemangioblastoma

BACKGROUND: As vascular tumors, intramedullary hemangioblastomas are associated with significant intraoperative blood loss, making them particularly challenging clinical entities. The use of intraoperative indocyanine green or other fluorescent dyes has previously been described to avoid breaching the tumor capsule, but improved surgical outcomes may result from identifying and ligating the feeder arteries and arterialized draining veins. OBJECTIVE: To describe the use of combined preoperative angiography and intraoperative indocyanine green use for the identification of feeder arteries and arterialized draining veins to decrease blood loss in the resection of intramedullary hemangioblastomas. METHODS: A patient with cervical myelopathy secondary to a large C3 hemangioblastoma and cervicothoracic syrinx underwent a C2-3 laminoplasty with resection of the lesion. To reduce intraoperative blood loss and facilitate safe lesion resection, the vascular architecture of the lesion was defined via preoperative digital subtraction angiography and intraoperative use of indocyanine green. The latter permitted ligation of the major and minor feeding arteries and arterialized veins prior to tumor breach, allowing for facile en bloc resection of the lesion. RESULTS: The lesion was resected en bloc with minimal blood loss (approximately 100 mL) and without intraoperative neuromonitoring signal changes. The patient remained at neurological baseline throughout their stay. CONCLUSION: We present a written and media illustration of a technique for intraoperative indocyanine green use in the en bloc resection of intramedullary hemangioblastoma.