Selective intra-arterial indocyanine green video angiography in a hybrid operating theatre for a ruptured arteriovenous malformation involving Broca’s area

Brain arteriovenous malformations (bAVMs) located in functionally critical regions are challenging for neurosurgeons. Multidisciplinary discussions are essential to determine the best treatment strategy. We describe the minimally invasive surgical treatment of a ruptured pseudoaneurysm in a bAVM located in Broca's area using selective intra-arterial indocyanine green (SIA-ICG) video angiography in the hybrid operating theatre. The patient presented a large intracerebral haematoma caused by an intranidal pseudoaneurysm. As an endovascular treatment was considered unsafe, a multidisciplinary approach was pursued: in the hybrid operating theatre, a SIA-ICG video angiography combined with a 4k-3D exoscope was used to visualise the feeding vessels and pseudoaneurysm, which was clipped without damaging surrounding tissue. Postoperatively, the patient was referred for Gamma Knife radiosurgery. To our knowledge, this is the first case of SIA-ICG injection in a hybrid-OR to treat a functionally critical ruptured AVM, combining advanced technologies to improve patient safety and treatment effectiveness.