Selective Spinal Arteriography Research Articles

Introduction: Spinal Vascular Malformations

From the earliest observations of spinal vascular malformations, successful management has been challenging. Initially the challenges were diagnosing, understanding, and treating these lesions. They were originally considered all to be the same, or at least to be a single general type, of disease. With the introduction of selective spinal arteriography in the 1960s and more recently with the introduction and widespread use of MR imaging, the initial challenge of diagnosing spinal vascular malformations was overcome, and significant progress has been made in understanding their anatomy as well as the pathophysiology that underlies the myelopathy commonly associated with them. The anatomical features defined by selective arteriography and the observations permitted with the operating microscope ultimately led to distinctions between the major categories of the vascular lesions affecting the spinal cord; these distinctions were based on the lesions' anatomy, epidemiology, and the mechanism of spinal cord injury.

Endovascular surgery for vascular malformations of the spinal cord

Since the introduction of modern selective spinal arteriography, catheter-based endovascular surgery has evolved as an important modality for the management of spinal vascular malformations. The endovascular therapy functions either as an adjunct to open surgery or as the primary treatment of choice. This article reviews the current status of endovascular surgery for spinal cord vascular malformations with particular emphasis on its technical aspects.

Postmyelographic computerized tomographic scan in the differential diagnosis of radiculomeningeal arteriovenous malformation: Technical note

The differential diagnosis of radiculomeningeal arteriovenous malformation (AVM) includes spinal intramedullary tumor and spinal cord myelitis. In making the diagnosis of radiculomeningeal AVM, clinical features of the history and magnetic resonance (MR) imaging findings are important initially, followed by selective spinal arteriography with or without myelography to confirm the diagnosis. The differential diagnosis, however, is not always easy. We encountered five radiculomeningeal AVM and 14 intramedullary thoracolumbar tumors that were accurately diagnosed preoperatively. We performed postmyelographic computerized tomography (CT) in all five patients with radiculomeningeal AVM and five patients with intramedullary thoracolumbar tumors that were not able to exclude radiculomeningeal AVM with only MR imaging. In all our patients with radiculomeningeal AVM, postmyelographic CT demonstrated the dilated coronal venous plexus on the dorsal aspect of the spinal cord in contrast with a single swelling of the spinal cord in the patients with intramedullary tumor. We believe that this finding is useful when the serpentine dilated coronal venous plexus is not clearly identified on myelogram and selective spinal arteriography is not apparently indicated.

Vertebral hemangiomas: fat content as a sign of aggressiveness.

Thirty-two vertebral hemangiomas (VHs) were evaluated with nonenhanced computed tomography (CT), T1-weighted magnetic resonance (MR) imaging, CT enhanced with contrast material, and selective spinal arteriography. The stroma between the osseous trabeculae was found to correspond to either fatty tissue or soft tissue or both. All 11 asymptomatic VHs showed complete fatty stroma at CT and increased signal intensity at MR imaging. In contrast, all four compressive VHs had soft-tissue attenuation at CT. Three compressive VHs showed low signal intensity on MR images. Predominantly fatty stroma at CT and increased signal intensity at MR imaging were associated with normal or only slightly increased vascularization at selective spinal arteriography or contrast-enhanced CT, while soft-tissue stroma at CT and low signal intensity at MR imaging were associated with distinct hypervascularization. The authors' experience suggests that fatty VHs may represent inactive forms of VH, while soft-tissue content at CT and low signal intensity at MR imaging may indicate a more active vascular lesion with potential to compress the spinal cord. CT and MR imaging may be especially valuable for evaluating patients with clinical signs or symptoms of uncertain origin and findings compatible with VH at plain radiography.

Vascular Malformations of the Spinal Cord and Dura

Current techniques of diagnosis and treatment allow for earlier detection, precise delineation of the vascular anatomy, and, most important, successful treatment of most patients with spinal AVMs. Magnetic resonance imaging is useful in the initial assessment of patients with progressive myelopathy but cannot replace myelography or arteriography in screening patients who may have a spinal AVM. The most common variety of spinal AVM is a dural arteriovenous fistula. Dural arteriovenous fistulas cause cord injury by producing venous congestion, and symptoms can be reversed by elimination of venous congestion of the spinal cord. Dural arteriovenous fistulas can be treated successfully by interrupting the arteriovenous fistula either in the dura or by disconnecting the dural fistula from the coronal venous plexus in the subarachnoid space. This can be done by interrupting the medullary vein that drains the arterial blood from the dural fistula into the coronal venous plexus of the spinal cord. Stripping of the engorged venous network on the surface of the spinal cord is unwarranted and may cause further cord injury. In dural arteriovenous fistulas embolization is often beneficial in patients with acute neurologic deterioration, to permit time for stabilization and improvement in spinal cord hemodynamics and in cord function before neurosurgical intervention is undertaken. Embolization also may be indicated in patients with intradural spinal AVMs in which surgery cannot be performed safely. Although embolic occlusion does not permanently occlude most intradural AVMs, it often permits stabilization of neurologic function and may be repeated later if neurologic dysfunction returns or progresses. Although the outcome after treatment is dependent on the type and location of the spinal AVM, as in most treatable neurologic disorders the functional outcome of patients with spinal AVMs is directly related to their neurologic condition at the time of treatment. Patients with minimal dysfunction, and with easily accessible AVMs, such as dural arteriovenous fistulas, have the greatest chance for useful recovery or stabilization. Since these patients represent the largest number of patients with spinal AVMs, they must be diagnosed and treated early to achieve the best possible outcome.

Current trends in surgery of the spine

This paper is based on an invited lecture given at the SICOT 87 meeting in Munich. The topics discussed include: selective spinal arteriography in the management of tumours, which enables definition of the vascular supply of the cord and of the tumour and may facilitate preoperative embolisation; MRI, which allows visualisation of both bone and soft tissue; the pathogenesis of transverse fractures of the upper sacrum; the management of malunion of fractures of the thoracolumbar spine by a three stage procedure, in which an initial posterior approach allows osteotomy and definition of the pedicle, a second anterior procedure for correction of the deformity by appropriate resection of the vertebral body, and a final posterior operation in which internal fixation is carried out using pedicular screws and plates. Operation on extradural tumours of the spine is usually palliative for metastases and aims to decompress the cord by laminectomy, stabilising the spine by osteosynthesis. Total removal of a vertebral body may be needed; percutaneous resection is being used increasingly for lumbar disc resection; the development of the Cotrel-Dubousset system and the use of long transpedicular plates allows better reduction of the deformity in scoliosis.

Subarachnoid Hemorrhage due to Spinal Tumor

An unusual case involving subarachnoid hemorrhage (SAH) associated with an ependymoma is presented. The patient, a 54-year-old male, was hospitalized because of sudden onset of severe headache and urinary retention. Cerebral angiography revealed no abnormality. An intraspinal lesion was suspected when serial lumbar punctures repeatedly yielded dark, brownish fluid. Further neuroradiological examinations (myelography, spinal computed tomography, and selective spinal arteriography) revealed an intraspinal tumor situated at L1-3. The tumor was totally removed with the aid of preoperative transcatheter embolization. Only 56 cases of SAH due to an intraspinal neoplasm have been reported. Such cases are thought to be uncommon and, in many of those reported, diagnosis was difficult. The possibility of an intraspinal tumor should be considered in SAH patients who present with minimal spinal cord or root signs. In terms of locating and characterizing the hypervascular spinal tumor in the present case, as well as selecting appropriate treatment, selective spinal arteriography was the most contributory procedure.

Selective spinal arteriography in vertebral and paravertebral disease processes (author's transl)

Selective arteriography was performed on 15 patients with vertebral and paravertebral diseases. This procedure is particularly justified if the bone changes are of possible vascular origin, if the presence of arterial involvement by neoplasm is to be determined, or if one wishes to judge the extent of intraspinal or paravertebral spread of a spinal tumour. Up to a point, angiography may indicate the histology and malignancy of a mass. In the diagnosis of vertebral and paravertebral disease, selective spinal arteriography would come into competition with computed tomography. Either procedure should only be used if conventional methods are incapable of solving the diagnostic problem.

Angiography with Amipaque.

Amipaque (metrizamide) has proved considerably less uncomfortable than Urografin 310 M in 42 patients submitted to selective or subselective external carotid, subclavian, and spinal angiography. Two out of five patients undergoing selective spinal arteriography developed transient neurological complications during the injection of Urografin 310 M. On repeat examination with Amipaque no complications were encountered.

Selective spinal arteriography

Selective spinal arteriography