it cotain short detail about spinal av malformation with angiographic images

1. Spinal angiography-Normal vascular
anatomy and Spinal AV malformations-
Neurovascular management
DR BHAVIN J PATEL
DM NEUROLOGY RESIDENT
MBS HOSPITAL

2. Index…..
Spinal vascular anatomy
Spinal AV Malformations:- Classification
Pathophysiology
Clinical presentation
Neuroimaging of spinal AVM
Treatment
Spinal angiography:- Indication
Procedure
Complications
Stereotactic spinal radiosurgery(SSR)

3. Spinal vascular anatomy
Vascular anatomy of spinal cord is very complex.
Difficult to study due to small caliber of vessels.
Understanding this complex anatomy is essential for safe surgical
and endovascular intervention

4. Arterial supply of spinal cord
Anterior spinal artery:-
Arises from the fusion of a contribution from each of the vertebral arteries
Supplies the ventral 2/3 of the cord
 The anterior spinal axis in the anterior commissure of the spinal cord gives rise to
perforators throughout its length.
Paired posterior spinal arteries:-
Run the length of the spine
 supply the posterior 1/3 of the cord

5. Arterial supply of spinal cord
Segmental artery:-
A dorsal ramus of the segmental artery enters the intervertebral foramen and
gives rise to 3 branches:
1. Dural branch: to dura
2. Radicular branch: to nerve root
3. Medullary branch: Augments the flow to the anterior spinal artery
 Somewhere between T8 & L2, especially on the left: the medullary branch does not
involute and becomes the artery of Adamkiewicz

7. Venous Drainage
Coronal venous plexus:
 A plexus on the cord surface
 Formed by coalescence and anastomosis of radial veins
Epidural venous plexus:
At segmental levels, medullary veins leave the coronal plexus and exit the
intervertebral foramen to join the epidural plexus
The plexus communicates with the venous sinuses of the cranial dura
 It drains into the ascending lumbar veins and the azygous venous system

9. MODIFIED CLASSIFICATION OF SPINAL
CORD VASCULAR LESIONS
1. NEOPLASTIC VASCULAR LESION
• Hemangioblastoma
• Cavernous malformation
2. SPINA L ANEURYSM
3. AVF : Extradural
Intradural :-Ventral (Small/Medium/Large shunt)
Dorsal (Single/Multiple feeder)
4 AVM
• EXTRADURAL-INTRADURAL
• INTRADURAL
• CONUS MEDULLARIS

10. Spinal Cord Vascular Malformations
Definition:- Spinal arteriovenous malformation (AVM) is an
abnormal tangle of arteries and veins in which the arteries feed
directly into the veins with abnormal intervening capillary bed
AV fistula (AVF): direct communication between artery & vein
AV malformations (AVMs): multiple complex communications

11. Spinal Cord Vascular Malformations
Rare cause of neurologic dysfunction
 5% of all intraspinal pathology
 Occur throughout the spine
 Affect any age group, majority: 30-50
O`Toole and McCormick. Chapter 83: Vascular Malformations of the Spinal Cord.
Rothman-Simeone The Spine. 5th Edition

12. Classification of AVM
Loacalization:- Axial
Longitudinal
Vascular supply:- Feeding artery
Draining vein
Structural features:- Glomus or compact AVM
Diffuse AVM
AV fistula
Hemodynamic features:- High, Moderate or Low grade flow

13. Classification: Anson, Spetzler(1992)
Type 1:Dural AV Fistula(DAVF) located between a dural branch of the
spinal ramus of a radicular artery and an intradural medullary vein
Type 2 : Intramedullary glomus malformation with a compact nidus
within the substance of the spinal cord
Type 3: Juvenile or combined AVMs –extensive AVM often extending
to the vertebra or paraspinal tissues.

14. Classification: Anson, Spetzler(1992)
Type 4 : Intradural perimedullary arteriovenous fistula
A – simple fistula fed by a single arterial branch.
B – Intermediate sized fistula with multiple dilated arterial feeders
C – Large perimedullary fistula with multiple giant arterial feeders.

15. Type I (Dural AV Fistula)
Most common type
60% of spinal AVF/AVM
 Results in dilated arterialized coronal
venous plexus
Most commonly occur at thoracolumbar
levels, usually between T5 and L3

16. Type II (Glomus AVMs)
Tightly packed nidus of dysmorphic
arteries and veins in direct
communication w/o capillary bed
Typically lie in the anterior half of the
spinal cord
 Usually at the cervicothoracic junction

17. Type 3 (Juvenile type)
These lesions are fed by multiple
enlarged medullary arteries via the
anterior and posterolateral spinal arteries
The nidus also has intervening
neural tissue.
These may frequently involve
vertebrae and paraspinal tissues .

18. Type 4 (Perimedullary AV
fistulas)
Consist of direct AVF located on the cord and
fed directly by arteries supplying the cord
8-19 % of spinal AVM.
Most common location of SCAVFs in
the lower thoracic or lumbar region

19. Pathophysiology
Vascular steal mechanism
Dysmorphic vessels susceptible to hemorrhage
Mass effect: myelopathy or radiculopathy
Venous congestion and hypertension(VENOUS HYPERTENSIVE
MYELOPATHY)

20. Clinical presentation
Characteristic DAVF SCAVM PMAVF
Age of presentation 4-5th decade 2-3rd decade 2-4th decade
Sex Male predominace Minimal male
predominance
No sex predilection
Origin Acquired Congenital Congenital
Symptom onset Gradual Acute Gradual(2/3)
Acute(1/3)
MC presentation Chronic pregressive
myelopathy
Acute medullary syndrome Chronic progressive
myelopathy
Claudication pain Common Not present May occur
Bowel and bladder
involvement
Late Early Late
Haemorrhage Never bleeds Common Occur in 1/3 pt
Bruit over spinal cord No 10% No
Foix alajouanine syndrome Rapid progression-
pregnancy,trauma, excercise
----

21. NeuroImaging of
DAVF
MRI:-
Conus and lumbar enlargement of the cord are
almost uniformly affected
Hallmark of diagnosis:- dilated pial veins of
cord, most commonly along dorsal surface flow
voids
May show contrast enhancement
Ischemia and venous infarct can occur

22. Angiography of DAVF
AVF shunt below or medial to the
pedicle .
The draining vein is almost 10
times larger than feeding artery.
The arterial flow is slow .

23. Imaging of SCAVM
Flow voids :-enlarged arterial feeding vessels
Intramedullary nidus
 Recent / remote intramedullary hemorraghe
 T2W Hyperintensity : gliosis, edema, infarction
 Draining veins :
• Flow voids
• Mass effect
• Thrombosis
 Intramedullary contrast enhancement

24. Angiography of SCAVM

25. Imaging of PMAVF
Flow voids - enlarged feeding and
draining vessels of SCAVF.
 Intrinsic cord signal abnormality and
evidence of hemorrhage may also be
present.
 Abnormal enhancement of the cord
may be present.

26. Angiography of PMAVF

27. Treatment
1. Surgical approach
2. Endovascular approach
3. Combined
4. Stereotactic spinal radiosurgery(SSR)
Mode of treatment depend on type and location of AVM.

28. Treatment of DAVF
Goal of treatment:- permanent elimination of venous congestion
Simple interruption of the AvF produces permanent resolution of
venous congestion and improvement of myelopathy
The extreme tortuosity and sinuous course of the feeding arteries
that made catheterization difficult; and an extremely low-flow fistula
made surgery a favorable option in these patients

29. Treatment of SCAVM
Goal of treatment:-To suppress the risk of hemorrhage & arrest progression
of neurological deficit
Should be pursued aggressively because of the poor outcomes in untreated
patients
Method of choice :- embolization
Surgical resection can be done in glomus type.

30. Treatment of PMAVF
Type 1:-surgery > embolization
Type 2:- dorsal surface:- embolization= surgery
ventral surface:- embolization > surgery
Type 3:- Embolization (curative or pre op) > surgery

31. Treatment summary

32. Indication of surgery
Embolization of the tributaries threatens to occlude the arteries feeding
the spinal cord.
Selective spinal angiography does not identify all of the tributaries
Diameter is too small
Failure of endovascular treatment.

33. Mode of surgery
DAVF :- Microsurgical resection of fistula
SCAVM :- Occlusion of feeding vessels + removal of nidus+
myelecotomy
PMAVF:- Surgical resection of fistula + removal of dilated veins(
sometime)

34. Complications
 Open surgical ligation or resection
Infection of meninges (meningitis)
Cerebrospinal fluid leak
Wound dehiscence
Skin infection or cellulitis

35. Complications
 Open surgical ligation or resection
Bleeding
Injury to nervous tissue, causing paralysis, bladder or bowel
dysfunction, or sexual dysfunction
Chronic pain syndromes

36. Embolization
Indication:-
Occlude only the feeding vessels
Combined AVM and intervertebral AVM
AVMs with a pronounced blood flow

37. Embolic agents
Particulate materials
Poly vinyl alcohol(150-250micro)
Gelfoam
Sponge microparticulate
Balloon occlusion or Coils
Liquid agents
N-butyl cyanoacrylate
Ethylene vinyl alcohol copolymer(ONYX)

38. Embolic agents
Biondi et al:-
Embolization with particles
Total cases-35
outcome
Improved 63%
Unchanged 26%
Worse 11%
Rufus A. Corkill, et al:-
 Embolization with liquid embolic agent
 Total cases-17
 outcome
 total obliteration 6 patients (37.5%),
 subtotal obliteration 5 patients (31.25%),
 partial obliteration 5 patients (31.25%).
 Improvement 14 patients (82%).

39. Complications
Endovascular technique
Femoral hematoma
Pseudoaneurysms and thrombosis
Arterial dissection
Thrombosis of epidural veins and neurologic loss
Spinal cord infarction

40. Complications
The cause of the initial neurological deterioration following embolization
Edema in the spinal cord following occlusion of the nidus and thrombosis
Occlusion of the ASA due to reflux
Direct toxic effect of DMSO
Thrombosis of the spinal veins
JNeurosurg (Spine 2) 93:304–308, 2000

41. Spinal angiography
Gold standard for imaging spinal vasculature
Non invasive imaging fails to provide:-
 Precise information regarding flow patterns and collateral flow
Precise location of vascular anomaly

42. Indications
Diagnostic:-
Evaluation of chronic myelopathy( to r/o DAVF)
Pt with spinal intramedullary or subarachnoid haemorrage
Spinal cord ischemia
Planning for neurointervational procedure.

43. Indications
Therapeutic:-
Embolization for spinal AVM or Vascular tumour.
Intraoperative assistance in spinal coed surgery
Follow up imaging after treatment

44. Pre procedure evaluation
Brief neurological exam
History of iodinated contrast reactions.
Femoral pulse, as well as the dorsalis pedis and posterior
tibialis pulses should be examined
Serum creatinine level and coagulation parameters
Medications

45. Procedure
NPO for 6 hours
General anesthesia
Femoral sheath insertion:-
Rapid exchange of catheters and less potential for trauma to the
arteriotomy site
Radial, brachial or axial artery catheterization

46. Procedure
Selective or complete spinal angiography
Continuous saline flush
Contrast ingestion:- Hand injection
Mechanical injection
Frame rate:- 1-2 per second

47. Contrast agent
 Non ionic contrast iodixanol ( lower osmolality and better tolerance)
1. Diagnostic angiogram: Omnipaque ® , 300 mg I/mL, or Visipaque TM 320
mg I/mL.
2. Neurointerventional procedure: Omnipaque ® , 240 mg I/mL or Visipaque TM
270 mg I/mL.
Patients with normal renal function can tolerate up to 400–800 mL of
Omnipaque and 300 mg I/mL without adverse effects

50. Video on spinal angiography

51. Complications
Neurological(2.2%):-
Cerebral or spinal cord ischemia:-
•Vessel wall dissection
• Embolic occlusion due to glue or air
• Atherosclerotic plaque

52. Complications
Non neurological:-
Retroperitoneal hematoma(0.4%)
 Allergic reactions(0.1%)
 Femoral artery pseudoaneurysm,(0.03%)
 Thromboembolism of the lower extremity,
 Nephropathy,
 Pulmonary embolism.

53. Stereotactic Spinal Radiosurgery
Favorable obliteration outcomes for cerebral AVM,
SSR in the treatment of intramedullary lesions remains in its infancy
Literature on SSR for intramedullary spinal lesions remains limited
Proper spinal cord dosing in SSR has yet to be clarified
Potential for radiation-induced myelopathy

57. References
Asian Journal of Neurosurgery ,Vol. 11, Issue 2, April-June 2016
Practical Neuroangiography, 3rd edition , Pearse morris
 Handbook of Cerebrovascular Disease and Neurointerventional Technique,
M.R. Harrigan, J.P. Deveikis
Kalani MA et al. Stereotactic radiosurgery for intramedullary spinal
arteriovenous malformations. J Clin Neurosci (2016)
JNeurosurg (Spine 2) 93:304–308, 2000
Chapter 83: Vascular Malformations of the Spinal Cord. Rothman-Simeone The
Spine. 5th Edition
Uptodate.com

58. Thank you