The Role of Angiographic Imaging in the Treatment of Spinal Vascular Malformations

Spinal vascular malformations (SVMs) are rare and heterogeneous lesions that may lead to progressive neurological decline or hemorrhage, posing significant challenges for management due to their complex angioarchitecture and proximity to critical neural structures. This review examines the role of angiographic imaging modalities used intraoperatively and postoperatively in guiding treatment, confirming therapeutic success, and informing follow-up strategies. We summarize evidence on two-dimensional digital subtraction angiography (2D DSA), indocyanine green videoangiography (ICG-VAG), and emerging adjunctive techniques. 2D DSA remains the reference standard, offering superior temporal and spatial resolution for real-time visualization of vascular anatomy, catheter navigation, and embolic delivery, though its invasive nature, radiation exposure, and two-dimensional projection limit long-term applicability. ICG-VAG provides a complementary, non-ionizing method for intraoperative fluorescence imaging, aiding in shunt localization and venous preservation, although its restricted field of view and limited capacity for quantitative analysis reduce its standalone value. Advances in quantitative angiographic metrics, patient-specific hemodynamic modeling, and artificial intelligence-driven image analysis are anticipated to enhance diagnostic accuracy and reproducibility. The development of standardized multimodal protocols will be crucial for optimizing patient-centered treatment of these complex and rare lesions.