Spinal Vascular Neurointervention Dr Adam Rennie Lysholm Department

Spinal Vascular Neurointervention • Arteriovenous Shunts – Pial – Dural • Tumours – Paraspinal

Spinal angiography - technique • General anaesthetic • Selective injections of – – –

SPINAL PIAL AVS: GENERAL • RARE, ANY AGE • AVS ON OR IN CORD

SPINAL PIAL AVS: IMAGING • MRI – USUALLY FLOW VOIDS ON OR IN CORD

Goals of Treatment • Young symptomatic patient – Cure if feasible – Anatomical goal

Endovascular : liquid embolic agents Glue n-Butyl-2 Cyanoacrylate (tissue adhesive) Mixed with lipiodol ONYX

SPINAL PIAL AVS: CASE 1 • YOUNG MALE • PROGRESSIVE TETRAPARESIS • NO HISTORY

Spinal Pial AVS: Case 2 • Young male • Sudden onset of severe headache

DURAL AVS: SPINAL • USUALLY ELDERLY • DURAL ARTERY TO RADICULAR VEIN • INCREASED

SPINAL DURAL AVS • 65 YEAR OLD MAN • 2 YEARS PROGRESSIVE PARAPARESIS •

Results of endovascular treatment • Published studies recurrence rates of SDAVF – Nimi et

Our results • • • Endovascular treatment for SDAVF 1997 to 2010 With angiographic,

DIRECT LARGE A-VS PARAVERTEBRAL A-V FISTULA

PARASPINAL AVF: SUMMARY • USUALLY HIGH FLOW AVF, MAY CAUSE HEART FAILURE • TRAUMATIC

PARASPINAL AVF: CASE 1 • HEART FAILURE AS NEONATE • HEART FAILURE MEDICALLY CONTROLLED

Other conditions treated • Vessel sacrifice pre resection • Tumour embolisation

Vessel sacrifice • 60 yrs female • Left side cervical nerve sheath tumour

Balloons • Temporary inflation – Hyperform – Sceptre – Ascent • Permanent for occlusion

Tumour embolisation • Haemangiomas – Always hypervascular – May exhibit shunting – Pain/root or

Spinal Cord Tumour Case • • • Cervical haemangioblastoma Attempted pre-operative embolisation 2010 Attempted

Summary • Numerous vascular spinal interventions • Risks and benefits should be carefully considered

Contacts Neurointerventional Team: Dr Brew, Dr Robertson, Dr Solbach, Dr Rennie Dr Platts, Dr

Slides: 62

Download presentation

Spinal Vascular Neurointervention Dr Adam Rennie Lysholm Department of Neuroradiology The National Hospital of Neurology and Neurosurgery Great Ormond Street Hospital for Children

Spinal Vascular Neurointervention • Arteriovenous Shunts – Pial – Dural • Tumours – Paraspinal – Spinal Column – Cord

Spinal angiography - technique • General anaesthetic • Selective injections of – – – – Vertebral arteries Thyrocervical trunks Costocervical trunks External carotid arteries Supreme intercostal trunks (usually T 2 -T 4) (Rt) Intercosto-bronchial trunk, Intercostal and lumbar segmental arteries T 5 -L 4 Median and lateral sacral arteries • Must be meticulous / persistent • Can take hours • Complication rate 0. 5 – 2%

Rotational 3 D Catheter angiography

PIAL AVS SPINE

SPINAL PIAL AVS: GENERAL • RARE, ANY AGE • AVS ON OR IN CORD • HAEMATOMYELIA OR SPINAL SAH – Haemorrhage in >50%, more common in cervical • OFTEN GOOD RECOVERY, BUT MAY REBLEED – Re-bleed rate approx 50% • PROGRESSIVE NONHAEMORRHAGIC NEURO IMPAIRMENT – Root/back pain, weakness, sensory, impotence • NATURAL HISTORY VARIABLE – In event of recurrent haemorrhage death rate increases

SPINAL PIAL AVS: IMAGING • MRI – USUALLY FLOW VOIDS ON OR IN CORD – HAEMATOMYELIA/SAH – LOCAL CORD SIGNAL CHANGE • ANGIOGRAPHY – Supply from ASA, PSA or both – Consist of nidus or direct fistulae or combination – May have aneurysms or venous pouches • TREATMENT – ENDOVASCULAR OR SURGICAL – No role for radiotherapy

Goals of Treatment • Young symptomatic patient – Cure if feasible – Anatomical goal if not (aneurysm/venous pouch) • Patient with fixed deficit or transsected cord treatment indicated to prevent recurrent haemorrhage

Techniques of treatment

Flow directed microcatheters

Endovascular : liquid embolic agents Glue n-Butyl-2 Cyanoacrylate (tissue adhesive) Mixed with lipiodol ONYX EVOH (ethylene vinyl alcohol) copolymer dissolved in DMSO (dimethyl sulfoxide), suspended micronized tantalum powder

SPINAL PIAL AVS: CASE 1 • YOUNG MALE • PROGRESSIVE TETRAPARESIS • NO HISTORY OF BLEEDING

SPINAL PIAL AVS: CASE 1

SPINAL PIAL AVS: CASE 1(PRE)

SPINAL PIAL AVS: CASE 1(emb 1)

SPINAL PIAL AVS: CASE 1(emb 2)

SPINAL PIAL AVS: CASE 1(emb 4)

SPINAL PIAL AVS: CASE 1(POST)

Spinal Pial AVS: Case 2 • Young male • Sudden onset of severe headache • CT Head, CTA and cerebral angiogram

Spinal Pial AVS: Case 2

DURAL AVS SPINE

DURAL AVS: SPINAL • USUALLY ELDERLY • DURAL ARTERY TO RADICULAR VEIN • INCREASED CORD VENOUS PRESSURE CAUSES CORD OEDEMA/ISCHAEMIA • USUALLY PROGRESSIVE • TREATABLE, OFTEN DELAYED DIAGNOSIS

SPINAL DURAL AVS • 65 YEAR OLD MAN • 2 YEARS PROGRESSIVE PARAPARESIS • MORE RECENT INCONTINENCE • PREVIOUS NEGATIVE ANGIOGRAPHY/MRI

SPINAL DURAL AVS

Results of endovascular treatment • Published studies recurrence rates of SDAVF – Nimi et al. 8/35 23% – Westphal et al. 20/35 57% – Song et al. 7/25 25% – Eskander et al. 9/26 required surgery 39% – Van Dijk et al. 31/44 required surgery 71%

Our results • • • Endovascular treatment for SDAVF 1997 to 2010 With angiographic, MRI and clinical follow up 29 patients treated with endovascular approach 5/29 ultimately had surgery (17%) Improvements in disability and m. RS scores (P < 0. 05) • Improvements in microcatheters/wires and experience in liquid embolics?

DIRECT LARGE A-VS PARAVERTEBRAL A-V FISTULA

PARASPINAL AVF: SUMMARY • USUALLY HIGH FLOW AVF, MAY CAUSE HEART FAILURE • TRAUMATIC OR SPONTANEOUS • RARELY CAUSE NEUROLOGICAL DEFICIT BY VENOUS HYPERTENSION

PARASPINAL AVF: CASE 1 • HEART FAILURE AS NEONATE • HEART FAILURE MEDICALLY CONTROLLED • NO NEUROLOGICAL DEFICIT (? HAS SENSORY DISTURBANCE) • NOW AGED 5

PARASPINAL AVF: CASE 1

Other conditions treated • Vessel sacrifice pre resection • Tumour embolisation

Vessel sacrifice • 60 yrs female • Left side cervical nerve sheath tumour

Vessel sacrifice

Balloons • Temporary inflation – Hyperform – Sceptre – Ascent • Permanent for occlusion – Goldbal detachable

Vessel sacrifice

TUMOURS SPINAL

Tumour embolisation • Haemangiomas – Always hypervascular – May exhibit shunting – Pain/root or cord comp – Embolisation pre surgery • RCC metastases • GCC • ABC

Spinal Cord Tumour Case • • • Cervical haemangioblastoma Attempted pre-operative embolisation 2010 Attempted surgical excision 2010 Cyberknife Increasing weakness 2012 Reattempted embolisation and excision

Spinal Tumour Case 2010

Spinal Tumour Case 2010 2012

Spinal Tumour Case

Summary • Numerous vascular spinal interventions • Risks and benefits should be carefully considered • Performed in experienced centre!

Contacts Neurointerventional Team: Dr Brew, Dr Robertson, Dr Solbach, Dr Rennie Dr Platts, Dr Rangi, Dr Cowley Lysholm Department of Neuroradiology The National Hospital of Neurology and Neurosurgery Queen Square neurorad@uclh. nhs. uk Tel. 020 34483446