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Treatment of vertebral hemangioma : what the interventional radiologist can do ?

Hatem Rajhi .MD Department of Radiology and Interventional Radiology- Charles Nicolle Hospital Tunis -Tunisia. Treatment of vertebral hemangioma : what the interventional radiologist can do ? .

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Treatment of vertebral hemangioma : what the interventional radiologist can do ?

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  1. HatemRajhi .MD Department of Radiology and Interventional Radiology- Charles Nicolle Hospital Tunis -Tunisia Treatment of vertebral hemangioma : what the interventional radiologist can do ?

  2. To illustrate through a series of observations documented therapeutic methods in the interventional treatment of vertebral hemangiomas PURPOSE

  3. VertebralHémangioma (VH) • The most common benign tumor of the spine• Multiple in 25% of cases• Peak incidence: 40-60 years• Slow-growing lesion• benign vascular dysplasia          capillary          Cavernous (most common)         or Venous INTRODUCTION (Picture takenfromwebsite:www.back.com/causes-tumors-benign.html)

  4. When to treat a spinal hemangioma?  Usually asymptomatic, discovered incidentally.  Only 0.9% to 1.2% of cases become symptomatic:Aggressive Hemangioma           Local pain, Radiological aggressiveness Neurologic deficit INTRODUCTION

  5. Background: Semiology of vertebral HemangiomaRadiographic findings Vertical striations and trabeculations “Honeycomb” appearence. CT axial image “Polka dot” appearance of the involved vertebra MRI increased signal on T1- and T2 weighted images (intralesional fat)

  6. Spine level between T3 to T10• Involvement of the entire vertebral body• Extension to the posterior arch• Discontinuous cortical bone • Lyticappearence• Paraspinal or intra ductal expansion• Low signal intensity on T1-weighted images • Intense enhancement after contrast injection Signs of aggressiveness on imaging of Vertebral Hemangioma

  7. CASE N°1 A 18 years old patient 09/08/2007  Neurological dysfunction due to spinal cord compression.Radiographic findings: aggressive vertebral hemangioma T310/08/2007bilateral T3 laminectomyFollow-up: worsening paraparesisImmediate revision surgery: epidural hematoma evacuation

  8. Significant improvement of motor deficit. • Histologic diagnose: capillary hemangioma

  9. April 2009 (20 months later) • High back pain • Spastic paraparesis • Bilateral Babinski signs

  10. MRI sequences a,b,csagittale T2-weighted images d : sagittale T1 weighted images withcontrast injection e : axial T1 weighted image withcontrast injection a b c d e Is there an explanation for the current neurological symptoms  ?

  11. What could be proposed?A. Reoperation B. TransarterialEmbolization C. Surgery with preoperative embolization D. vertebroplasty E. Radiotherapy

  12. What could be proposed?A. Reoperation B. TransarterialEmbolization • C. Surgery with preoperative embolization D. vertebroplasty E. Radiotherapy

  13. What arterial branches to explore?A. The celiac trunk and superior mesenteric artery B. The dorsal intercostal arteriesC. The lumbar arteriesD. The thoracic and abdominal aorta

  14. What arterial branches to explore? • The celiac trunk and superior mesenteric artery  • B. The dorsal intercostal arteries C. The lumbar arteries D. The thoracic and abdominal aorta

  15. Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

  16. Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

  17. Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

  18. Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

  19. Which embolic agent to use ? A. Coils B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

  20. Which embolic agent to use ? A. Coils • B. Embospheres C. Curaspon D. Ethanol E. Biological Glue

  21. The anterior spinal artery was identified in T10 left. Is there a risk of embolization of T3.A. yesB. noC. Distrust

  22. The anterior spinal artery was identified in T10 left. Is there a risk of embolization of T3. • A. Yes B. No • C. Distrust

  23. Embolization Right T4 Right T5

  24. Selective angiography of the pedicle of the left T3intercostal artery We can embolize at this level? A. Yes B. No

  25. Selective angiography of the pedicle of the left T3intercostal artery We can embolize at this level? A. Yes • B. No

  26. Surgical resection is limited because of: A. The involvement of the anterior archB. The epidural extensionC. The involvement of the posterior arch

  27. Surgical resection is limited because of: A. The involvement of the anterior arch • B. The epidural extension • C. The involvement of the posterior arch

  28. What can we do ?A. Surgery as part of the angioma was embolizedB. VertebroplastyC. Sclerotherapy  with Absolute ethanol D. There is no other treatmentE. There is another alternative ?

  29. What can we do ?A. Surgery as part of the angioma was embolizedB. VertebroplastyC. Sclerotherapy  with Absolute ethanol D. There is no other treatment • E. There is another alternative?

  30. What does this alternative ?A. radiofrequency ablationB. direct embolization ?

  31. What does this alternative ?A. Radiofrequency ablation • B.Direct embolization ?

  32. Which embolic agent to use ? A. Ethanol B. Coils C. Embospheres D. Biological Glue

  33. Which embolic agent to use ? A. Ethanol B. Coils C. Embospheres • D. Biological glue

  34. Which type of radiographic guidance ? A. Fluoroscopy B. CT scanner C. Ultrasonography

  35. Which type of radiographic guidance ? A. Fluoroscopy • B. CT scanner C. Ultrasonography

  36. Sclerotherapy with Glubran 2 by direct puncture under CT guidance

  37. Sclerotherapy with Glubran 2 by direct puncture under CT guidance

  38. Sclerotherapy with Glubran 2 by direct puncture under CT guidance

  39. Sclerotherapy with Glubran 2 by direct puncture under CT guidance

  40. Sclerotherapy with Glubran 2 by direct puncture under CT guidance

  41. Is surgery indicated ? A. Yes B. No

  42. Is surgery indicated ? • A. Yes B. No

  43. What time limits ? A. In 7 dayssothat the inflammation decreases B. In one month C. Within 48 hours of embolization D. The time limits is not important

  44. What time limits ? A. In 7 dayssothat the inflammation decreases B. In one month • C. Within 48 hours of embolization D. The time limits is not important

  45. Surgery should include : • T 3 Laminectomy • T 3 Vertebrectomy C. Laminectomy and osteosynthesis D. Osteosynthesis

  46. Surgeryshouldinclude: A. T 3 Laminectomy B. T 3 Vertebrectomy • C. Laminectomy and osteosynthesis D. Osteosynthesis

  47. Osteosynthesis T1 to T6

  48. Favorable evolution with recovery of motor function of lower extremities. • Is the treatmentachieved? • A . Yes • B . No

  49. Favorable evolution with recovery of motor function of lower extremities. • Is the treatmentachieved? • A . Yes • B . No

  50. To treat vertebral body of T3 must be associate : A. Surgery by anterior approachB. PercutaneousVertebroplastyC. Sclerotherapy with Glubran 2 under CT guidance

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