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Improved Turnaround Times | Median time to first decision: 12 days

Research ArticleNeurointervention

Neurophysiologic Monitoring and Pharmacologic Provocative Testing for Embolization of Spinal Cord Arteriovenous Malformations

Yasunari Niimi, Francesco Sala, Vedran Deletis, Avi Setton, Adauri Bueno de Camargo and Alex Berenstein
American Journal of Neuroradiology August 2004, 25 (7) 1131-1138;
Yasunari Niimi
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Francesco Sala
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Vedran Deletis
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Avi Setton
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Adauri Bueno de Camargo
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Alex Berenstein
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  • Fig 1.
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    Fig 1.

    Illustrative patient 1.

    A, Anteroposterior (AP) view of the right dorsocervical artery obtained before embolization shows a large AVM involving C5-C7 and supplied by the ASA.

    B, AP right dorsocervical angiogram obtained after second embolization shows decreased opacification of the nidus with preservation of the anterior spinal axis (arrowheads) with one remaining indirect feeder (arrows).

    C, AP right dorsocervical angiogram obtained 11 months after second embolization at the time of third embolization shows spontaneous occlusion of the anterior spinal axis (arrowhead) and the remaining indirect feeder (arrow). Note the decreased caliber of the ASA proximally and the increased diameter of the indirect supply. Compare with B.

    D, AP superselective ASA angiogram from just before the origin of the feeder shows complete occlusion of the anterior spinal axis distal to this origin. Arrowhead indicates the microcatheter tip in the anterior spinal axis. Arrows indicate the remaining feeder. Because provocative test results were negative, we embolized the malformation from this position with NBCA; symptoms did not worsen.

    E, AP right vertebral angiogram after third embolization. ASA is opacified from above, with minimal supply to the remaining nidus (arrowhead) mainly supplied by the vertebral artery branch. There is slow flow in the radiculomedullary artery from the right dorsocervical artery (arrow), which reaches the level of embolization in a later phase (not shown).

    F, Schematic illustration of the AVM in relation to the spinal cord. A indicates vertebral artery; B, radiculomedullary artery from the dorsocervical artery; C, ASA; D, feeders embolized in the first two procedures; E, feeder embolized in the third procedure; F, AVM nidus; and G, ASA segment occluded in the third embolization.

  • Fig 2.
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    Fig 2.

    Illustrative patient 2.

    A, AP right dorsocervical angiogram demonstrates a pial feeder (arrow) to the AVM originating from the radiculomedullary artery just before the origin of the anterior spinal axis.

    B–D, AP (B and C) and lateral (D) superselective angiograms of the radiculomedullary feeder in early (B) and late (C and D) phases. Arrow indicates microcatheter tip. The malformation is draining to the anterior spinal vein (arrowheads). This was not embolized, because positive provocative test results indicated supply to the normal spinal cord.

    E, Schematic shows the AVM in relation to the spinal cord. A indicates radiculomedullary artery; B, pial feeder; C, ASA; and D, AVM nidus.

Tables

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    TABLE 1:

    Summary of provocative test results

    VesselSodium AmytalLidocaine
    No. of VesselsNo. of Positive ResultsNo. of VesselsNo. of Positive Results
    ASA323378
    PSA131156
    Posterior inferior cerebellar artery1011
    Radicular artery1030
    Total4745615
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    TABLE 2:

    Summary of positive provocative test results

    Agent and VesselChangeNo. of Procedures (n = 19)
    Sodium amytal
     PSAUnilateral MEP1
     ASAUnilateral MEP2
     ASABilateral BCR, unilateral MEP1*
    Lidocaine
     PSABilateral MEP1
     PSABilateral MEP and SEP1
     PSAUnilateral MEP1
     PSAUnilateral SEP1
     PSAUnilateral MEP and BCR2
     ASAUnilateral MEP4
     ASABilateral MEP4
     PICAUnilateral MEP1
    • * MEPs and SEPs were monitored from only one leg because of previous amputation of the other leg.

    • View popup
    TABLE 3:

    Actions taken after positive provocative test results

    ActionNo.
    Aborted embolization6*
    Advanced catheter and embolization with NBCA5†
    Distal vessel protection and embolization with NBCA1
    Embolization with particles1
    Embolization with coils1
    Embolization with NBCA after negative wake-up test1
    Embolization with NBCA with less forceful injection1
    • * In two patients, the procedure was aborted after two consecutive positive results during advancement of a microcatheter.

    • † In one patient, embolization was performed by advancing a microcatheter from the proximal positions where two positive results were obtained.

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American Journal of Neuroradiology: 25 (7)
American Journal of Neuroradiology
Vol. 25, Issue 7
1 Aug 2004
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Neurophysiologic Monitoring and Pharmacologic Provocative Testing for Embolization of Spinal Cord Arteriovenous Malformations
Yasunari Niimi, Francesco Sala, Vedran Deletis, Avi Setton, Adauri Bueno de Camargo, Alex Berenstein
American Journal of Neuroradiology Aug 2004, 25 (7) 1131-1138;
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Yasunari Niimi, Francesco Sala, Vedran Deletis, Avi Setton, Adauri Bueno de Camargo, Alex Berenstein
Neurophysiologic Monitoring and Pharmacologic Provocative Testing for Embolization of Spinal Cord Arteriovenous Malformations
American Journal of Neuroradiology Aug 2004, 25 (7) 1131-1138;

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