Centers of Excellence in Interventional Cardiology and Radiology

INTERVENTIONAL NEURORADIOLOGY

Spinal arteriovenous malformation

The procedure performed by team of specialists from abroad!

Our center has saved the lives of over 4,500 patients in the last 4 years

The most modern equipped angiography room , an exceptional medical team

We have the most famous abroad specialists! Team from Romania, Israel, Greece and Germany!

Only 24 hours hospitalization

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Generalities

What are arteriovenous malformations (AVM)?

Arteriovenous malformation (AVM) is an abnormal, fragile connection between arteries and veins, bypassing the capillary system. This vascular anomaly is widely known because of its occurrence in the central nervous system, but can appear in any location. Although many AVMs are asymptomatic, they can cause intense pain or bleeding or lead to other serious medical problems, especially those affecting the spinal cord, because of the increase risk of bleeding and compresing phenomens, causing neurologic events.

Spinal AVM may be located within the parenchyma ( intramedullary), the surface of the spinal cord (pial), the epidural space (epidural), or they may have a more complex anatomy with both intramedullary and extramedullary components without respect to tissue boundaries. This abnormal connection between arteries and veins may be associated with myelopathy (sensory and motor deficits, bladder and bowel dysfunction), radicular pain or deficit, back pain, or spinal column deformity, venous hypertension.

Spinal AVM receive blood suply from at least one branch of anterior spinal artery ( wich is the principal blood supplier for the spinal cord – two-thirds of the spinal cord), whereas the posterior spinal artery supply

the dorsal one-third of the spinal cord.

Wath is the cause of spinal AVM ?

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It is not known why these abnormalities happen or what causes them. It is believed some people are probably born (i.e. it is congenital or inherited) with a predisposition or tendency to form this abnormality and at some stage in life it develops. It is not known what triggers this.

Symptoms

Symptoms include progressive neurological symptoms, causing major complications like hemorrhage or spinal cord infarction. This can in turn result in a sudden or gradual loss of movement of limbs, such as temporary or permanent paralysis, abnormal sensations such as tingling, “pins and needles”, or a complete loss of feeling in the limbs, intense pain. There may also be a loss of urinary bladder or bowel control.

If untreated, AVM can progress to a severe disability and although rare, can result in death.

Untreated, these abnormalities leads to progressive lesions, wich may be permanent and may have severe medical and social impact ( permanent paralysis, family dependence).

Diagnosis

Diagnosis is settled using imaging studies: angio-computer tomography, angio-magnetic resonance imagistic, aniography.

Despite the advances of noninvasive vascular imaging, conventional catheter spinal angiography remains the definitive test for the diagnosis and classification of spinal arteriovenous lesions due to its superior spatial resolution and image quality. Performing spinal angiography with the patient under general anesthesia improves the quality of the study because the patient remains comfortable during a potentially long study and apnea can be used to reduce motion artifacts when evaluating the thoracic spine.

Spinal angiography should also be used to evaluate the venous hypertension (in this severe venous hypertension venous drainage is prolonged or absent).

Indications

As we pointed above, AVM may lead to severe, progressive neurological events.

Treatment consists either of surgery, either of embolisation (interventional treatment).

Embolisation is a minimally-invasive procedure, which enables the injection of medical grade “glue”, special tiny coils, or sand like particles directly into the abnormal connection or ‘site’ to block off the abnormal blood vessel connection.

Treatment planning for spinal vascular arteriovenous lesions is based on the hemodynamics of the lesion, location in the axial and longitudinal plane, and the angioarchitecture. An important consideration before any intervention is a patient’s preoperative neurologic status. As with all inherent disease processes of the

spinal cord, postoperative function is highly related to preoperative presentation, and maximum functional results are obtained in patients treated early before advanced deterioration. Partial results can still be obtained in patients with severe neurologic impairment.

Embolization is the treatment of choice for many arteriovenous anomalies. However, surgery continues to play a key role, and a multidisciplinary approach is essential.

Embolization plays an important role in the management of intramedullary spinal AVMs either as a primary treatment or as an adjunct to surgery, decreasing the risc associated with surgery:

can be curative

even if it is not cured, embolisation can stabilise the AVM to lessen the chances of future stroke or haemorrhage, reduce or reverse (fully or partially) current symptoms such as abnormal sensation, weakness of limbs or incontinence (loss of control of the urinary bladder or bowel)

can reduce AVM dimensions so the surgery may be performed

can be palliative and should be targeted to relieving symptoms

Procedure

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To decrease the risk of vascular injury to the spinal cord, one must clearly define the vascular anatomy before any attempt at embolization. More arterial anastomoses exist in the posterior spinal artery (PSA), suggesting that the possibility for sufficient collateral circulation is higher after occlusion of the PSA rather than the anterior spinal artery, therefore, occlusion of this arterie carries a significant risk for spinal cord ischemia.

Interventional treatment, also know as “embolisation” is a minim invasive tehnique, which enables the injection of medical grade “glue” or sand like particles, or special tiny coils (coils can only achieve proximal embolization, which may lead to the development of collateral flow to the nidus while preventing safe access for future embolizations ), directly into the abnormal connection or ‘site’ to block off the abnormal blood vessel connection.

This procedure is performed using a technique similar with angiography, under general anesthesia and heparin.

A small cut (less than 1 centimetre) is made in the skin of your groin. Through this cut, the femural artery is punctured with a small needle and a catheter (long thin hollow plastic tube) is inserted into the artery.

Through this catheter a microcatheter is advanced into the radiculomedullary branch that supplies the AVM. All of this is done without having to make any additional incisions (cuts in the skin) apart from the small puncture in your groin where the catheter has entered your blood vessel system.

Through the catheter, serial angiograms are performed, checking the position of the catheter, but also the indication for interventional treatment (the initial planning of the procedure takes place before you are admitted to hospital, but the final steps in the planning process are done after seeing the images from the angiogram).

The embolisation, or blocking of the abnormal collection of blood vessels around your spinal cord, is planned after the angiogram pictures are taken and examined. The interventionist uses the pictures to work out what kind of small particles or glue to block the vessels with and how to do this most effectively.

After the embolisation, a new angiogram is performed.

When the procedure is done (either the total obstruction was achived, either there is nothing to do in this session) the catheters are removed.

Sometimes, one session of embolisation treatment may not be enough and 2 or 3 more sessions may be required to finish the treatment.

Occasionally, the treatment cannot be performed without making your symptoms much worse, and the procedure will be stopped at that point because your doctor has decided the risks outweigh the potential benefits.

Particles have the advantage of a stepwise embolization and the ability to follow the results clinically and angiographically during the procedure, but they have the serious disadvantage of long-term recanalization. Treatment with particle embolization requires annual angiographic control and additional embolization in cases of recanalization.

Liquid agents have the advantage of achieving more permanent occlusion with a very low recanalization rate, but with the concurrent risk of inadvertent embolization of normal perforating arteries that may not be visible on angiography. The liquid agent should be delivered within or as close to the nidus as possible.

Is it painful?

The doctor may use general anesthesia, so the patient will not feel any pain, and after the procedure it will received pain drugs.

How long does it take?

Typically it takes 3 to 6 hours and is performed in the cath lab.

Risks

Complications are rare and the risk is decreased because the proper preparation and the permanent surveillance.

• damage to surrounding blood vessels, organs, or other structures by instruments

• puncture site infection or bleeding or arteriovenous fistula

• pain

• gaseous embolia

• allergic reaction from the general anaesthesia

• fever

• headache

• puncture site haematoma

• very rarely, there may be internal blood loss and you may need open surgery to stitch up the puncture hole in the groin

• stroke and haemorrhage affecting the spinal cord. The risk of stroke or haemorrhage can vary from low to moderate. Very rarely, these can result in death.

The effects of a stroke or haemorrhage can vary. If they are mild, you could completely recover. If they are moderate or severe, you may be left with ongoing or permanent problems. These can include paralysis and/or incoordination (inability to coordinate normal movements such as picking up a cup, doing up buttons, imbalance when walking etc.) of one or more limbs, loss of feeling in the limbs or body, abnormal sensation in the limbs such as tingling or “pins and needles”, or loss of control of the urinary bladder or bowel. If very severe, these can result in death, but this is very rare.

Before procedure

The preop consult establishes if AVM can be treat using either the embolisation technique, either surgery. For this main, angiogram is very useful.

Preadmission will be done one day prior to the embolization.

If you are on medication, your will discuss with you whether to continue with your medication and give you full instructions. In particular, if you have diabetes, kidney or thyroid diseases, or if you are on blood thinning (anticoagulant) medication, special instructions will be provided to you.

You will have a medical check up to ensure that you are fit for the operation and for the anaesthetic, to have any necessary blood tests performed, and to give you any information or any special medication that you may need to take before the embolisation procedure. You will also need to sign a consent form to give permission to treat you. You will be asked to fast for eight hours before the procedure, generally after midnight. If you are pregnant or suspect that you are pregnant, you should notify your health care provider.

Notify your doctor if you are sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).

After procedure

This is a minimally invasive procedure so the recovery is quick.

You may be taken to the intensive care unit and you will be connected to monitors that will constantly display your electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. You will be given pain medication for incisional pain. Your doctor will instruct you to remain still, lying flat in bed for up to eight hours. This rest period allows the groin artery to heal.

You can leave the hospital after 1-2 days.

The surgical incision may be tender or sore for several days.Take a pain reliever for soreness as recommended by your doctor. You should not drive until your doctor tells you to. Other activity restrictions may apply, if needed. Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation. Check out for fever, pain or alteration at the incision plance, but also for neurologic events.

After the procedure, you will need to have follow up radiology tests such as computed tomography (CT) scans, magnetic resonance imaging (MRI) scans or angiograms to see how effective the procedure has been – usually, first time after few months (your doctor will tell you).

Important!

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Do not forget that AVMs involves a risk of hemorraghe or spinal cord infarctus, and untreated, these abnormalities leads to progressive lesions, wich may be permanent and may have severe medical and social impact.

Embolisation is a minimally invasive procedure, efficient, with a quick recovery and short hospitalison.

DOCTORS
that perform the procedure

X
Sună Mesaj