On a Crusade
Date: June 7, 2013
Identifying and treating spinal vascular malformations—including arteriovenous malformations (AVMs) and fistulas—is a race against time. Without prompt attention, symptoms (including numbness and tingling in the extremities, limb weakness, bladder and bowel incontinence, and sexual dysfunction) can become permanent.
The challenge is that these conditions can be very difficult to accurately diagnose.
One reason many patients aren’t treated quickly enough, say neurosurgeon Rafael Tamargo and interventional neuroradiologist Philippe Gailloud, is that these conditions are rare, affecting only a fraction of a percent of the population. “Most doctors, even neurologists and neurosurgeons, will only see a handful of spinal vascular malformations in their entire careers,” says Tamargo.
Adding to the difficulty is the fact that the symptoms tend to mimic other, more common conditions, such as herniated discs, spinal stenosis, multiple sclerosis, or transverse myelitis.
Getting patients headed toward the right diagnosis can also be delayed by the difficulty in imaging these conditions, says Gailloud. Spinal arteriovenous fistulas often aren’t visible on MRIs, and the ones that show up on scans require a shrewd radiologist to spot them.
Definitively diagnosing these problems requires a spinal angiogram, Gailloud says. However, he says, doctors often eschew this specialized imaging technique because of its fearsome reputation. Spinal angiograms differ from the more common ones done in the brain to diagnose aneurysms and other vascular conditions, which require injecting a contrast agent into only a handful of blood vessels. By contrast, spinal angiograms require injections in a couple of arteries at most spinal levels, adding up to 30 or more.
When this technique was invented in the late 1960s, it was blamed for spinal infarctions and a host of other serious complications. Although they still carry a bad reputation, spinal angiograms have become much safer with decades of experience. At Hopkins, Gailloud and his colleagues perform two or three of these procedures each week. They recently published a paper in which they described tracking the complications of spinal angiograms on a series of 350 patients. “There were no significant complications,” he says. “It turns out to be a very safe procedure.”
Once they diagnose a spinal vascular malformation, Tamargo says, he, Gailloud and their colleagues formulate a treatment plan individualized for each patient. Most can be treated endovascularly, he says, by embolizing their problematic blood vessels with coils or glue. For those whose anatomy or conditions don’t allow endovascular treatment, surgery is the next best option.
When spinal vascular malformations are diagnosed in time, Gailloud adds, endovascular treatments or surgery can often cure the condition. That early diagnosis remains a key part of their efforts to treat these problems, he says. To make sure patients have the best outcomes, he and Tamargo strive to see patients the day after every inquiry they receive on these conditions.
“Our goal is to have the lesions recognized earlier so patients have a better chance of a significant recovery,” Gailloud says. “It’s a crusade for us. The quicker we can address their problems, the better the outcome will be.” CB