16 year old boy from Africa used to have recurrent sudden back and neck pain. It was thought to be muscular and proper diagnosis could not be made. The pain was persistent for over 2 years as he left it unnoticed. With the age the condition is thought to be rare. The patient had lost control over his bowel, numbness in the body and sensory loss when he came for consultation. He was immediately taken for diagnosis and treatment. With the use of high-resolution MRI, the spinal AVM was confirmed. Further, spinal angiography was performed to study the lesion in details by inserting a small catheter through the leg blood vessels. After detecting the abnormal connection between the arteries and the veins, material known as glue was injected into the blood vessels which solidify immediately after coming in contact with the blood and the abnormal connections and leakage spots were closed permanently.
This was a complex procedure which used image guidance technique to also check if the normal blood vessels were injured. This procedure is known as endovascular embolization, a minimally invasive procedure to reduce the risk of any complications like hemorrhage. After the procedure, the patient was able to resume normal activities from very next day.
What is Spinal AVM?
Spinal Cord arteriovenous malformation (SCAVM) is a relatively rare disease.Normally the oxygen rich blood enters the spinal cord through arteries which further branch into smaller blood capillaries and the oxygen is utilized. Veins carry the oxygen depleted blood away from spinal cord to other parts of the body. When the blood directly passes from the arteries to the veins, bypassing the capillaries, the condition is known as spinal AVM.
AVM happens when there is a wrong connection between the arteries and veins and leads to swelling of blood vessels and there is always a danger of bleeding in these blood vessels.
This disturbance of flow in blood deprives the surrounding cells of vital oxygen and causes cells in your spinal tissue to rapture, deteriorate, bleeding in spinal cord or die. Timely diagnosis and treatment can prevent the spinal cord from permanent damage.
Spinal AVM – though rare, more common in children
Spinal AVMs can occur at any age, but more than 80% present between age 20 and 60 years. More rarely younger persons may present due to this rare lesions.
What are the symptoms?
If left unnoticed the condition only worsens over time with elevated back pain, sensory loss and weakening of leg muscles. The patient may feel numbness, weakness, loss of bowel control. Depending on the severity and location the symptoms may vary. Random pain throughout the body and burning sensations are usually the marked symptoms. It is thus advised to immediately consult a neurosurgeon in case the symptoms persist, as delay in diagnosis may lead to worsen the complications.
How it is treated?
High-resolution MRI is very useful in diagnosis of presence of spinal AVM. Thereafter the lesion is study in detail by spinal angiography. In this procedure, a small tube (catheter) is sent through leg blood vessel and injection is done in spinal arteries to detect the location of abnormal connection between artery and vein
In order to close the wrong connection, a very fine (less than 1mm thick) tube known as microcatheter is taken to the site of wrong connection and material known as ‘glue’ is injected into the blood vessels. The material solidifies as soon as it comes in contact with the blood and closes the abnormal connection or leakage spot permanently. After the procedure the tubes (catheters) are withdrawn. This procedure is done with the use of image guidance technique, to avoid any injury to normal blood vessels. This procedure is known as endovascular embolization, a minimally invasive procedure to reduce the risk of any complications like hemorrhage. After the procedure patient can resume normal activities from very next day.
Other option is to perform an AVM surgery. The surgery is intended to remove the AVM from the surrounding tissues. The surgery being complicated, highly skilled and expertise in neurosurgeon is required. Because of less risk and quick recovery, embolization is preferred in most of these cases.
62 y.o. lady had sudden onset of paralysis of left side of the body with difficulty in speech. She was immediately bought to the Medanta, The Medicity hospital where she was found to be suffering from acute stroke leading to complete left side paralysis. His immediate CT revealed that found that her major blood vessel in brain was occluded which was causing damage to her brain. Specialized imaging (CT based brain blood flow imaging) revealed that although some tissue was already dead, there was significant part of his brain which could still be revived by restoring the blood supply. However if this was not done soon, those brain cells were likely to die in very short while. She was treated by intra-arterial thrombolysis. Through the leg artery a very small tube (microcatheter) was placed in the blocked brain vessel and clot dissolving drugs were given to open it up. She started to recover immediately and was completely all right in next 24 hours. She has now recovered complete power in left arm and leg with no difficulty in speech and living a normal life.
Patients with acute ischaemic stroke or paralytic attacks usually face a life of dependancy with a huge psychological, social and financial burden. Acute stroke happens due to blockage of blood supply. Although some brain cells die immediately, there is usually a part of brain which can still be revived if the blood supply is restored in next few hours. This can be done by giving thrombolytic drugs (Intravenous thrombolysis) which act as clot busters and open up the blockage in the arteries. This can result in reversal of stroke and better recovery. Direct delivery of drugs in the blocked artery (Intra-arterial or endovascular) therapy can be more effective when clot is large or when IV therapy cannot be given. This is done by placing a catheter (a small tube) from one of the leg blood vessels in to the blocked vessel followed by injection of blockage (clot) dissolving drugs. Many mechanical devices are also available which can be used to extract clot from the brain to open the blood vessel. This selective (intra-arterial) treatment can be given at least up to 8-hours after the brain attack. First such case of mechanical recnalization using penumbra device in North India was done in Medanta, The Medicity. Recently first case of direct stenting to open up a blocked vessel was performed in the hospital. All patients of stroke are immediately assessed with CT angiography and perfusion (brain blood flow) imaging using 256 slice CT scan to detect patients which have brain which can be revived and can benefit with immediate treatment. We are the only centre in North India to use such technology as a part of protocol.
Patient a 43 year old male working in an insurance company suddenly became unconscious at work. He was taken to a nearby hospital which revealed brain haemorrhage. He was shifted to Medanta, The Medicity. Brain Angiography revealed a swollen blood vessel (aneurysm) which had burst to cause the bleeding. He was at high risk of repeat haemorrhage and immediate repair of the leaking blood vessel was needed to safe his life. This procedure was done by endovascular means through his leg blood vessel. A very small tube (microcatheter) was placed in to the swollen damaged blood vessel and the bleeding point was closed using platinum coils (coiling). Patient has made almost complete recovery and has gone back to his routine life.
Aneurysms are focal swelling of blood vessels, which can burst and cause bleeding in brain. It is accepted that about 3% to 5% of the population harbour an intracranial aneurysm and one in every 20 strokes is caused by rupture of intracranial aneurysm. The aneurysm disease commonly strikes at prime of one's life at age of 40-50 yrs. Although it is less common then some other forms of stroke, because the disease strikes a fairly young age and is often fatal the loss of productive life years is similar to that for cerebral infarction or intracerebral hemorrhage. Many patients (up to 30%) do not survive initial bleeding. Even the patients who survive more than 50% of patients do not survive even for a month because the aneurysm bleeds again. Even the patients who survive the initial bleeding, more than 50% of patients do not survive even for a month because the aneurysm bleeds again. Open surgery "clipping" has been the conventional method of aneurysm treatment but has high chances of trauma to normal brain parenchyma. By endovascular method a microcatheter (a very thin tube) is placed into the brain aneurysms through the leg blood vessel. Then the aneurysm is occluded by using specialized coils. This procedure known as "coiling" has advantage of minimal injury to normal brain and leading to better outcomes. Studies have shown that patient recovery is much better with coiling rather than clipping. Medanta The Medicity has developed a dedicated brain aneurysm program and more than 90% of brain aneurysms are treated by endovascular means with very good clinical outcomes.