Endovascular Treatment of Vascular and Nonvascular Diseases of the Spine

  • Shahram Rahimi
  • Ali Shaibani
  • Ajay K. Wakhloo


In general, the following entities have been listed under spinal vascular disease: Hemangioblastomas, Cavernous malformation/angioma, Spinal aneurysms, Arteriovenous fistulae, Arteriovenous malformations. With regard to vascular lesions of the vertebral bodies, aneurysmal bone cysts and vertebral hemangiomas also can be mentioned. Many different classification schemes have been suggested over the last three decades. The newest proposed classification for spinal vascular lesions is by Spetzler et al.1 The authors list the most prevalent classification scheme for arteriovenous fistulae and malformations along with the new classification and the angiographic/anatomic classification (Table 14.1).


Arteriovenous Fistula Aneurysmal Bone Cyst Hereditary Hemorrhagic Telangiectasia Venous Hypertension Cavernous Malformation 


  1. 1.
    Spetzler RF, Detwiler PW, Riina HA, Porter RW. Modified classification of spinal cord vascular lesions. J Neurosurg 2002;96(2 Suppl):145-156.PubMedGoogle Scholar
  2. 2.
    Zhang H, He M, Mao B. Thoracic spine extradural arteriovenous fistula: case report and review of the literature. Surg Neurol 2006;66 Suppl 1:S18-S23; discussion S23-S24.CrossRefPubMedGoogle Scholar
  3. 3.
    Chul Suh D, Gon Choi C, Bo Sung K, Kim K-K, Chul Rhim S. Spinal osseous epidural arteriovenous fistula with multiple small arterial feeders converging to a round fistular nidus as a target of venous approach. AJNR 2004;25(1):69-73.PubMedGoogle Scholar
  4. 4.
    Oldfield EH, Bennett A III, Chen MY, Doppman JL. Successful management of spinal dural arteriovenous fistulas undetected by arteriography. J Neurosurg 2002;96(Suppl 2):220-229.PubMedGoogle Scholar
  5. 5.
    Eskandar, EN, Borges LF, Budzik RF Jr, Putman CM, Ogilvy CS. Spinal dural arteriovenous fistulas: experience with endovascular and surgical therapy. J Neurosurg 2002;96(Suppl 2):162-167.PubMedGoogle Scholar
  6. 6.
    Niimi Y, Berenstein A. Endovascular treatment of spinal vascular malformations. Neurosurg Clin North Am 1999;10(1):47-70.Google Scholar
  7. 7.
    Van Dijk JM, Ter Brugge KG, Willinsky RA, Farb RI, Wallace MC. Multidisciplinary management of spinal dural arteriovenous fistulas. Stroke 2002;33:1578-1583.CrossRefPubMedGoogle Scholar
  8. 8.
    Atkinson JLD, Miller GM, Krauss WE, Marsh WR, Piepgras DG, Atkinson PP, Brown RD Jr, Lane JI. Clinical and radiographic features of dural arteriovenous fistula, a treatable cause of myelopathy. Mayo Clin Proc 2001;76:120-130.CrossRefGoogle Scholar
  9. 9.
    Veznedaroglu E, Nelson PK, Jabbour PM, Rosenwasser RH. Endovascular treatment of spinal cord arteriovenous malformations. Neurosurgery 2006;59(5 Suppl 3):S202-S209; discussion S3-S13.PubMedGoogle Scholar
  10. 10.
    Bostroem A, Thron A, Hans FJ, Krings T. Spinal vascular malformations - typical and atypical findings. Zentralbl Neurochir 2007;68(4):205-213.CrossRefPubMedGoogle Scholar
  11. 11.
    Rohany M, Shaibani A, Arafat O, Walker MT, Russell EJ, Batjer HH, Getch CC. Spinal arteriovenous malformations associated with Klippel-Trenaunay-Weber syndrome: a literature search and report of two cases. AJNR Am J Neuroradiol 2007;28(3):584-589.PubMedGoogle Scholar
  12. 12.
    Oran I, Parildar M, Derbent A. Treatment of slow-flow (type I) perimedullary spinal arteriovenous fistulas with special reference to embolization. AJNR Am J Neuroradiol 2005;26(10):2582-2586.PubMedGoogle Scholar
  13. 13.
    Bao Y, Ling F. Classification and therapeutic modalities of spinal vascular malformations in 80 patients. Neurosurgery 1997;40(1):75-81.CrossRefPubMedGoogle Scholar
  14. 14.
    Hodes JE, Merland JJ, Casasco A, Houdart E, Reizine D. Spinal vascular malformations: endovascular therapy. Neurosurg Clin North Am 1999;10(1):139-152.Google Scholar
  15. 15.
    Mourier KL, Gobin YP, George B, Lot G, Merland JJ. Intradural perimedullary arteriovenous fistulae: results of surgical and endovascular treatment in a series of 35 cases. Neurosurgery 1993;32(6):885-891.CrossRefPubMedGoogle Scholar
  16. 16.
    Rodesch G,Hurth M, Alvarez H et al. Spinal cord intradural arteriovenous fistulae: anatomic, clinical, and therapeutic considerations in a series of 32 consecutive patients seen between 1981 and 2000 with emphasis on endovascular therapy. Neurosurgery 2005;57(5):973-983; discussion 973-983.CrossRefPubMedGoogle Scholar
  17. 17.
    Rodesch G, Hurth M, Alvarez H, Tadié M, Lasjaunias P. Classification of spinal cord arteriovenous shunts: proposal for a reappraisal. Neurosurgery 2002;15(2):374-380.CrossRefGoogle Scholar
  18. 18.
    Ricolfi F, Gobin YP, Aymard A, Brunelle F, Gaston A, Merland JJ. Giant perimedullary arteriovenous fistulas of the spine: clinical and radiologic features and endovascular treatment. AJNR Am J Neuroradiol 1997;18:677-687.PubMedGoogle Scholar
  19. 19.
    Aletich VA, Debrun GM, Koenigsberg R, Ausman JI, Charbel F, Dujovny M. Arteriovenous malformation nidus catheterization with hydrophilic wire and flow-directed catheter. AJNR Am J Neuroradiol 1997;18:929-935.PubMedGoogle Scholar
  20. 20.
    Touho H, Monobe T, Ohnishi H, Karasawa J. Treatment of type II perimedullary arteriovenous fistulas by intraoperative transvenous embolization: case report. Surg Neurol 1995;43(5):491-496.CrossRefPubMedGoogle Scholar
  21. 21.
    Spetzler RF, Zabramski JM, Flom RA. Management of juvenile spinal AVMs by embolization and operative excision. Case report. J Neurosurg 1989;60:238-247.Google Scholar
  22. 22.
    Kim LJ, Spetzler RF. Classification and surgical management of spinal arteriovenous lesions: arteriovenous fistulae and arteriovenous malformations. Neurosurgery 2006;59(5 Suppl 3):S195-S201; discussion S3-S13.PubMedGoogle Scholar
  23. 23.
    Aminoff M, Logue V. Clinical features of spinal vascular malformations. Brain 1974;97:197-210.CrossRefPubMedGoogle Scholar
  24. 24.
    Djindjian R. Clinical symptomatology and natural history of arteriovenous malformations of the spinal cord: a study of the clinical aspects and prognosis based on 150 cases. In Pia H, Djindjian R (eds): Spinal Angiomas: Advances in Diagnosis and Therapy. Berlin: Springer, 1978.Google Scholar
  25. 25.
    Chen CC, Wang CM, Chu NK, Wu KPH, Tang SFT, Wong AMK. Spinal cord arteriovenous malformation presenting as chest pain in a child. Spinal Cord 2008;46:456-458.CrossRefPubMedGoogle Scholar
  26. 26.
    Biondi A, Merland JJ, Reizine D, Aymard A, Hodes JE, Lecoz P, Rey A. Embolization with particles in thoracic intramedullary arteriovenous malformations: long-term angiographic and clinical results. Radiology 1990;177:651-658.PubMedGoogle Scholar
  27. 27.
    Biondi A, Merland JJ, Hodes JE, Pruvo JD, Reizine D. Aneurysms of spinal arteries associated with intramedullary arteriovenous malformations. I. Angiographic and clinical aspects. AJNR Am J Neuroradiol 1992;13:913-922.PubMedGoogle Scholar
  28. 28.
    Biondi A, Merland JJ, Hodes JE, Aymard A, Reizine D. Aneurysms of spinal arteries associated with intramedullary arteriovenous malformations. II. Results of AVM endovascular treatment and hemodynamic consideration. AJNR Am J Neuroradiol 1992;13:923-931.Google Scholar
  29. 29.
    Cullen S, Krings T, Ozanne A, Alvarez H, Rodesch G, Lasjaunias P. Diagnosis and endovascular treatment of pediatric spinal arteriovenous shunts. Neuroimaging Clin N Am 2007;17(2):207-221.CrossRefPubMedGoogle Scholar
  30. 30.
    Sinclair J, Chang SD, Gibbs IC, Adler Jr JR. Multisession CyberKnife radiosurgery for intramedullary spinal cord arteriovenous malformations. Neurosurgery 2006;58(6):1081-1089; discussion 1081-1089.CrossRefPubMedGoogle Scholar
  31. 31.
    Kocak A, Ates O, Cayli S, Sara K. Isolated posterior spinal artery aneurysm. Br J Neurosurg 2006;20(4):241-244.CrossRefPubMedGoogle Scholar
  32. 32.
    Gonzalez LF, Zabramski JM, Tabrizi P, Wallace RC, Massand MG, Spetzler RF. Spontaneous spinal subarachnoid hemorrhage secondary to spinal aneurysms: diagnosis and treatment paradigm. Neurosurgery 2005;57(6):1127-1131; discussion 1127-1131.CrossRefPubMedGoogle Scholar
  33. 33.
    Maraire JN, Awad IA. Cavernous malformations: natural history and indications for treatment. In Batjer HH (eds): Cerebrovascular Disease. Philadelphia: Lippincott-Raven, 1997:669-677.Google Scholar
  34. 34.
    Canavero S, Pagni CA, Duca S, Bradac GB. Spinal intramedullary cavernous angiomas: a literature metaanalysis. Surg Neurol 1994;41:381-388.CrossRefPubMedGoogle Scholar
  35. 35.
    Krings T, Mull M, Gilsbach JM, Thron A. Spinal vascular malformations. Eur Radiol 2005;15(2):267-278.CrossRefPubMedGoogle Scholar
  36. 36.
    Mocco J, Laufer I, Mack WJ, Winfree CJ, Libien J, Connolly Jr ES. An extramedullary foramen magnum cavernous malformation presenting with acute subarachnoid hemorrhage: case report and literature review. Neurosurgery 2005;56(2):E410; discussion E410.CrossRefPubMedGoogle Scholar
  37. 37.
    Minh NH. Cervicothoracic spinal epidural cavernous hemangioma: case report and review of the literature. Surg Neurol 2005;64(1):83-85; discussion 85.CrossRefPubMedGoogle Scholar
  38. 38.
    Sze G. Neoplastic disease of the spine and spinal cord. In: Atlas SW (ed): Magnetic Resonance Imaging of the Brain and Spine. Philadelphia: Lippincott-Raven, 1996:1377-1379.Google Scholar
  39. 39.
    Steinmetz MP, Claybrooks R, Krishnaney A, Prayson RA, Benzel EC. Surgical management of osseous hemangioblastoma of the thoracic spine: technical case report. Neurosurgery 2005;57(4 Suppl):E405; discussion E405.CrossRefPubMedGoogle Scholar
  40. 40.
    Eskridge JM, McAuliffe W, Harris B, Kim DK, Scott J, Winn HR. Preoperative endovascular embolization of craniospinal hemangioblastomas. AJNR Am J Neuroradiol 1996;17:525-531.PubMedGoogle Scholar
  41. 41.
    Tampieri D, Leblanc R, Ter Brugge KG. Pre-operative embolization of brain and spinal hemangioblastomas. Neurosurgery 1993;33(3):502-504.CrossRefPubMedGoogle Scholar
  42. 42.
    Pia H, Djindjian M. Spinal Angiomas: Advances in Diagnosis and Therapy. New York: Springer, 1978.Google Scholar
  43. 43.
    Krings T, Chng SM, Ozanne A, Alvarez H, Rodesch G. Lasjaunias PL. Hereditary hemorrhagic telangiectasia in children: endovascular treatment of neurovascular malformations: results in 31 patients. Neuroradiology 2005;47(12):946-954.CrossRefPubMedGoogle Scholar
  44. 44.
    Fulbright RK, Chaloupka JC, Putman CM, Sze GK, Merriam MM, Lee GK, Fayad PB, Awad IA, White Jr RI. MR of hereditary hemorrhagic telangiectasia: prevalence and spectrum of cerebrovascular malformations. AJNR Am J Neuroradiol 1998;19:477-484.PubMedGoogle Scholar
  45. 45.
    Garcia-Monaco R, Taylor W, Rodesch G, Alvarez H, Burrows P, Coubes P, Lasjaunias P. Pial arteriovenous fistula in children as presenting manifestation of Rendu-Osler-Weber disease. AJNR Am J Neuroradiol 1995;37(1):60-64.Google Scholar
  46. 46.
    Jacob AG, Driscoll DJ, Shaughnessy WJ, Stanson AW, Clay RP, Gloviczki P. Klippel-Trenaunay syndrome: spectrum and management. Mayo Clinic Proc 1998;73(1):28-36.CrossRefPubMedGoogle Scholar
  47. 47.
    Hauck EF, Nauta HJ. Spontaneous spinal epidural arteriovenous fistulae in neurofibromatosis type-1. Surg Neurol 2006;66(2):215-221.CrossRefPubMedGoogle Scholar
  48. 48.
    Doppman, JL, Oldfield EH, Heiss JD. Symptomatic vertebral hemangiomas: treatment by means of direct intra-lesional injection of ethanol. Radiology 2000;214:341-348.PubMedGoogle Scholar
  49. 49.
    Fox MW, Onofrio BM. The natural history and management of symptomatic and asymptomatic vertebral hemangiomas. J Neurosurg 1993;78:36-45.CrossRefPubMedGoogle Scholar
  50. 50.
    Jayakumar PN, Vasudev MK, Srikanth SG. Symptomatic vertebral hemangiomas: endovascular treatment of 12 patients. Spinal Cord 1997;35:624-628.CrossRefPubMedGoogle Scholar
  51. 51.
    Yuksel M, Yuksel KZ, Tuncel D, Zencirci B, Bakaris S. Symptomatic vertebral hemangioma related to pregnancy. Emerg Radiol 2007;13(5):259-263.CrossRefPubMedGoogle Scholar
  52. 52.
    Djindjian R, Merland JJ, Djindjian M et al. Vertebral hemangiomas and metameric angiomatosis (Cobb’s Syndrome). In Nadjmi M, Piegras U, Vogelsang H (eds): Angiography of Spinal Column and Spinal Cord Tumors. Stuttgart: Georg Thieme, 1981:141.Google Scholar
  53. 53.
    Hadjipavlou A, Gaitanis I, Kakavelakis K, Katonis P. Balloon kyphoplasty as a single or as an adjunct procedure for the management of symptomatic vertebral haemangiomas. J Bone Joint Surg Br 2007;89(4):495-502.CrossRefPubMedGoogle Scholar
  54. 54.
    Reizine D, Laouiti M, Guimaraens L, Riche MC, Merland JJ. Vertebral arteriovenous fistulas - clinical presentation, angiographical appearance and endovascular treatment. A review of twenty-five cases. Ann Radiol 1985;28:425-438.PubMedGoogle Scholar
  55. 55.
    Berenstein A, Lasjaunias P. Surgical Neuro-angiography. Vol 5. Berlin: Springer, 1992:125-127.Google Scholar
  56. 56.
    Bonakdarpour A, Levy WM, Aegerter E. Primary and secondary aneurismal bone cyst: a radiological study of 75 cases. Radiology 1978;126:75-82.PubMedGoogle Scholar
  57. 57.
    Ameli NO, Abbassioun K, Saleh H, Eslamdoost A. Aneurysmal bone cysts of the spine; report of 17 cases. J Neurosurg 1985;63:685-690.CrossRefPubMedGoogle Scholar
  58. 58.
    Lichtenstein L. Aneurysmal bone cyst. A pathological entity commonly mistaken for giant-cell tumor and occasionally for hemangioma and osteogenic carcinoma. Cancer 1950;3:279-289.CrossRefGoogle Scholar
  59. 59.
    Cigala F, Sadile F. Arterial embolization of aneurysmal bone cysts in children. Bull Hosp Joint Dis 1996;54(4):261-264.Google Scholar
  60. 60.
    Radanovic B, Šimunić S, Stojanović J, Orlić D, Potočki K, Oberman BB. Therapeutic embolization of aneurysmal bone cyst. Cardiovasc Intervent Radiol 1989;12(6):313-316.CrossRefPubMedGoogle Scholar
  61. 61.
    Broaddus WC, Grady MS, Delashaw JB, Ferguson RD, Jane JA. Preoperative super-selective arteriolar embolization: a new approach to enhance resectability of spinal tumors. Neurosurgery 1990;27:755-759.CrossRefPubMedGoogle Scholar
  62. 62.
    Gellad FE, Sadato N, Numaguchi Y, Levine AM. Vascular metastatic lesions of the spine: preoperative embolization. Radiology 1990;176:683-686.PubMedGoogle Scholar
  63. 63.
    Hilal SK, Michelsen JW. Therapeutic percutaneous embolization for extra-axial vascular lesions of the head, neck, and spine. J Neurosurg 1975;43:275-287.CrossRefPubMedGoogle Scholar
  64. 64.
    King GJ, Kostuik JP, McBroom RJ, Richardson W. Surgical management of metastatic renal carcinoma of the spine. Spine 1991;16:265-271.CrossRefPubMedGoogle Scholar
  65. 65.
    Jensen ME, Hendrix LE, Dion JE et al. Preoperative and palliative embolization of vertebral body metastases. Proceedings of the 31st Annual Meeting of the American Society of Neuroradiology. Vancouver, BC, Canada, 1993.Google Scholar
  66. 66.
    Gangi A, Kastler BA, Dietemann JL. Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy. AJNR Am J Neuroradiol 1994;15:83-86.PubMedGoogle Scholar
  67. 67.
    Chiras J, Cognard C, Rose M, Dessauge C, Martin N, Pierot L, Plouin PF. Percutaneous injection of an alcoholic embolizing emulsion as an alternative preoperative embolization for spine tumor. AJNR Am J Neuroradiol 1993;14:1113-1117.PubMedGoogle Scholar
  68. 68.
    Heiss JD, Doppman JL, Oldfield JH. Brief report: relief of spinal cord compression from vertebral hemangioma by intralesional injection of absolute ethanol. N Engl J Med 1994;331:508-511.CrossRefPubMedGoogle Scholar
  69. 69.
    Cotton A, Deramond H, Cortet B. Preoperative percutaneous injection of methyl methacrylate and n-butyl cyanoacrylate in vertebral hemangiomas. AJNR Am J Neuroradiol 1996;17:137-142.Google Scholar
  70. 70.
    Lai PH, Pan HB, Yang CF, Yeh LR, Su SS, Lee KW, Weng MJ, Wu MT, Liang HL, Chen CK. Multi-detector row computed tomography angiography in diagnosing spinal dural arteriovenous fistula: initial experience. Stroke 2005;36(7):1562-1564.CrossRefPubMedGoogle Scholar
  71. 71.
    Saraf-Lavi E, Bowen BC, Quencer RM, Sklar EML, Holz A, Falcone A, Latchaw RE, Duncan R, Wakhloo A. Detection of spinal dural arteriovenous fistula with MR imaging and contrast-enhanced MR angiography: sensitivity, specificity, and prediction of vertebral level. AJNR Am J Neuroradiol 2002;23:858-867.PubMedGoogle Scholar
  72. 72.
    Launey M, Chiras J, Bories J. Angiography of the spinal cord: venous phase. AJNR Am J Neuroradiol 1979;6:287-315.Google Scholar
  73. 73.
    Niimi Y, Sala F, Deletis V, Setton A, de Camargo AB, Berenstein A. Neurophysiologic monitoring and pharmacologic provocative testing for embolization of spinal cord arteriovenous malformations. AJNR Am J Neuroradiol 2004;25(7):1131-1138.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Shahram Rahimi
    • 1
  • Ali Shaibani
    • 2
  • Ajay K. Wakhloo
    • 3
  1. 1.Department of RadiologyNorthwestern University, Feinberg School of MedicineChicagoUSA
  2. 2.Department of Radiology and NeurosurgeryNorthwestern University, Feinberg School of MedicineChicagoUSA
  3. 3.Division of Neurointerventional Radiology, Department of RadiologyUniversity of MassachusettsWorcesterUSA

Personalised recommendations