Embolization of spinal intramedullary arteriovenous malformations using the liquid embolic agent, Onyx: a single-center experience in a series of 17 patients

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Object

The aim of this study was to analyze the endovascular treatment results of using the Onyx liquid embolic system for spinal intramedullary arteriovenous malformations (AVMs).

Methods

The clinical and radiological records of 17 patients with symptomatic spinal intramedullary AVMs treated exclusively by embolization with Onyx between 1999 and 2003 were retrospectively reviewed. There were 12 females and five males in the patient series (mean age 29 years). Four of these AVMs were located in the cervical spine, eight in the thoracic spine, and five in the lumbar spine. The clinical presentation of these AVMs included upper motor neuron signs and symptoms, and hemorrhage was the initial presentation in 12 patients. Neurological and functional evaluation was performed before and after treatment with Onyx in all patients.

Results

Thirteen patients underwent a single endovascular treatment and four patients underwent two endovascular treatments (average 1.23 sessions per patient). Intraprocedural complications occurred on two occasions without neurological consequences. The mean follow-up duration was 24.3 months. Angiographic outcomes included total AVM obliteration in six patients (37.5%), subtotal obliteration in five patients (31.25%), and partial obliteration in five patients (31.25%). Improvement in neurological and/or functional status was noted in 14 patients, resulting in an 82% rate of overall good clinical outcome.

Conclusions

Embolization using the Onyx system is a promising treatment method for spinal vascular malformations, even for challenging intramedullary AVMs. Larger studies with longer follow-up durations will further enhance our knowledge on the safety and efficacy of this relatively new liquid embolic agent.

Abbreviations used in this paper:ASA = anterior spinal artery; ASIA = American Spinal Injury Association; AVF = arteriovenous fistula; AVM = arteriovenous malformation; DMSO = dimethyl sulfoxide; DS = digital subtraction; FIM = Functional Independence Measure; MR = magnetic resonance; NBCA = N-butyl cyanoacrylate; PSA = posterior spinal artery.

Article Information

Address correspondence to: Rufus A. Corkill, Department of Neuroradiology, Level 1, West Wing, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, United Kingdom. email: racorkill@hotmail.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 3. Images showing a cervical spinal intramedullary AVM presenting with hemorrhage. A: Sagittal T2-weighted MR image revealing the intramedullary AVM and its related hemorrhage, cord expansion, and edema between C2 and C7. B: Lateral projection of a DS angiogram showing the wedged intranidal microcatheter position after super-selective catheterization. C: Lateral projection of a DS angiogram showing the slow injection of Onyx into the AVM nidus with some venous penetration. D: Frontal projection of a DS angiogram through the left ascending cervical angiogram after embolization using Onyx, showing no residual nidal filling.

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    Case 8. Images of a thoracic intramedullary AVM. A: Oblique projection of a DS angiogram showing the AVM fed via the right supreme intercostal artery. B: Three-dimensional time-of-flight MR angiogram with contrast enhancement showing the AVM. C: Oblique projection of a DS angiogram showing partial embolization after two subsequent injections of Onyx.

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    Case 13. Images showing a thoracic intramedullary AVM. A: Digital subtraction angiogram through a left T-8 injection. B: Superselective catheterization (through the anterior spinal axis) of a sulcal artery into the AVM nidus. C: Postembolization angiogram obtained after a slow injection of Onyx into the AVM nidus.

References

  • 1

    Aminoff MJLogue V: The prognosis of patients with spinal vascular malformations. Brain 97:2112181974

  • 2

    Bao YHLing F: Classification and therapeutic modalities of spinal vascular malformations in 80 patients. Neurosurgery 40:75811997

    • Search Google Scholar
    • Export Citation
  • 3

    Berenstein ALasjaunias P: Surgical Neuroangiography: Endovascular Treatment of Spine and Spinal Cord BerlinSpringer-Verlag1992. Vol 5:

    • Search Google Scholar
    • Export Citation
  • 4

    Biondi AMerland JJHodes JEAymard AReizine D: Aneurysms of spinal arteries associated with intramedullary arteri-ovenous malformations. Results of AVM endovascular treatment and hemodynamic considerations. AJNR Am J Neuroradiol 13:9239311992

    • Search Google Scholar
    • Export Citation
  • 5

    Chaloupka JCHuddle DCAlderman JFink SHammond RVinters HV: A reexamination of the angiotoxicity of superselective injection of DMSO in the swine rete embolization model. AJNR Am J Neuroradiol 20:4014101999

    • Search Google Scholar
    • Export Citation
  • 6

    Detwiler PWPorter RWSpetzler RF: Spinal arteriovenous malformations. Neurosurg Clin N Am 10:891001999

  • 7

    Di Chiro GDoppman JOmmaya AK: Selective arteriography of arteriovenous aneurysms of the spinal cord. Radiology 88:106510771967

  • 8

    Ditunno JF Jr: Functional assessment measures in CNS trauma. J Neurotrauma 9:1 SupplS301S3051992

  • 9

    Ditunno JF JrYoung WDonovan WHCreasey G: The international standards booklet for neurological and functional classification of spinal cord injury. American Spinal Injury Association Paraplegia 32:70801994

    • Search Google Scholar
    • Export Citation
  • 10

    Djindjian R: Arteriography of the spinal cord. AJR Am J Radiol 107:4614781969

  • 11

    Doppman JL: Arteriography of the spinal cord. Semin Roentgenol 7:2312391972

  • 12

    Hida KShirato HIsu TSeki TOnimaru RAoyama H: Focal fractionated radiotherapy for intramedullary spinal arteri-ovenous malformations: 10-year experience. J Neurosurg 99:1 Suppl34382003

    • Search Google Scholar
    • Export Citation
  • 13

    Jahan RMurayama YGobin YPDuckwiler GRVinters HVViñuela F: Embolization of arteriovenous malformations with Onyx: clinicopothalogical experience in 23 patients. Neurosurgery 48:9849972001

    • Search Google Scholar
    • Export Citation
  • 14

    Kataoka HMiyamoto SNagata IUeba THashimoto N: Venous congestion is a major cause of neurological deterioration in spinal arteriovenous malformations. Neurosurgery 48:122412302001

    • Search Google Scholar
    • Export Citation
  • 15

    Kendall BELogue V: Spinal epidural angiomatous malformations draining into intrathecal veins. Neuroradiology 13:1811891977

  • 16

    Kim LJSpetzler RF: Classification and surgical management of spinal arteriovenous lesions: arteriovenous fistulae and arteriovenous malformations. Neurosurgery 59:5 Suppl 3S195S2012006

    • Search Google Scholar
    • Export Citation
  • 17

    Krings TMull MGilsbach JMThron A: Spinal vascular malformations. Eur Radiol 15:2672782005

  • 18

    Lasjaunias P: Spinal cord vascular lesions. J Neurosurg 98:1 Suppl1171202003

  • 19

    Liu AHGobin PRiina H: Endovascular surgery for vascular malformations of the spinal cord. Oper Tech Neurosurg 6:1631702003

  • 20

    Marsh WR: Vascular lesions of the spinal cord: history and classification. Neurosurg Clin N Am 10:181999

  • 21

    Maynard FM JrBracken MBCreasey GDitunno JF JrDonovan WHDucker TB: International Standards for Neurological and Functional Classification of Spinal Cord Injury. American Spinal Injury Association Spinal Cord 35:2662741997

    • Search Google Scholar
    • Export Citation
  • 22

    Molyneux AJColey SC: Embolization of spinal cord arteriovenous malformations with an ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide (Onyx liquid embolic system). Report of two cases. J Neurosurg 93:2 Suppl3043082000

    • Search Google Scholar
    • Export Citation
  • 23

    Murayama YViñuela FUlhoa AAkiba YDuckwiler GRGobin YP: Nonadhesive liquid embolic agent for cerebral arteriovenous malformations: preliminary histopathological studies in swine rete mirabile. Neurosurgery 43:116411751998

    • Search Google Scholar
    • Export Citation
  • 24

    Prestigiacomo CJNiimi YSetton ABerenstein A: Three-dimensional rotational spinal angiography in the evaluation and treatment of vascular malformations. AJNR Am J Neuroradiol 24:142914352003

    • Search Google Scholar
    • Export Citation
  • 25

    Riché MCMelki JPMerland JJ: Embolization of spinal cord vascular malformations via the anterior spinal artery. AJNR Am J Neuroradiol 4:3783811983

    • Search Google Scholar
    • Export Citation
  • 26

    Rodesch GHurth MAlvarez HDavid PTadie MLasjaunias P: Embolization of spinal cord arteriovenous shunts: morphological and clinical follow-up and results—review of 69 consecutive cases. Neurosurgery 53:40502003

    • Search Google Scholar
    • Export Citation
  • 27

    Rodesch GHurth MAlvarez HDucot BTadie MLasjaunias P: Angio-architecture of spinal cord arteriovenous shunts at presentation. Clinical correlations in adults and children. Acta Neurochir (Wien) 146:2172272004

    • Search Google Scholar
    • Export Citation
  • 28

    Rodesch GHurth MAlvarez HTadie MLasjaunias P: Classification of spinal cord arteriovenous shunts: proposal for a reappraisal—the Bicetre experience with 155 consecutive patients treated between 1981 and 1999. Neurosurgery 51:3743802002

    • Search Google Scholar
    • Export Citation
  • 29

    Rosenblum BOldfield EHDoppman JLDi Chiro G: Spinal arteriovenous malformations: a comparison of dural arteriovenous fistulas and intradural AVMs in 81 patients. J Neurosurg 67:7958021987

    • Search Google Scholar
    • Export Citation
  • 30

    Sinclair JChang SDGibbs ICAdler JR Jr: Multisession Cyber-Knife radiosurgery for intramedullary spinal cord arteriovenous malformations. Neurosurgery 58:108110892006

    • Search Google Scholar
    • Export Citation
  • 31

    Spetzler RFDetwiler PWRiina HAPorter RW: Modified classification of spinal cord vascular lesions. J Neurosurg 96:2 Suppl1451562002

    • Search Google Scholar
    • Export Citation
  • 32

    Tai PATu YKLiu HM: Surgical treatment of spinal arteriovenous malformations: vascular anatomy and surgical outcome. J Formos Med Assoc 100:3893962001

    • Search Google Scholar
    • Export Citation
  • 33

    van Rooji WJSluzewski MBeute GN: Brain AVM embolization with Onyx. AJNR Am J Neuroradiol 28:1721782007

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