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Thread: Great idea!

  1. #21
    Quote Originally Posted by keps
    Is an AVM similar to spontaneous spinal extradural haematoma, or are they totally different?
    I know how bad the pain can be from a bleed. Mine was so enormous, I actually started stabbing my hand with a needle to take my mind off it(and failed), I also tried to burn my chest with a hot water bottle I happened to have. I know all that sounds ridiculous, but the pain was absolutely phenomenal, and I was utterly desperate.
    Keps, a frequent manifestation of spinal AVM is a history of pain. It is often one of the first signs of ischemia, before paralysis. An acute episode is often associated with hemorrhage.

    I was involved in some of the earliest studies of embolization therapies of AVM in the early 1980's, evaluating somatosensory evoked potential monitoring. In these cases, I have seen many cases where embolization partly reversed sensory loss and paralysis, even after many years. For example, we did an Israeli athlete who had been paralyzed for several years and, over several weeks, he walked out of the hospital.

    I have been hearing people talking about the superiority of surgical approaches to AVMs versus embolization. From my experience, I am surprised by these stories. The man that I worked with is Alejandro Berenstein and I consider him to be the best and most experienced interventional radiologist. With careful planning and monitoring, the number of patients who get worse from the embolization is small, probably less than 5%. A sizable proportion of patients get better, on the order of 60% or greater.

    One thing that Alex Berenstein did was to stage the embolization. He often will not do it all in one sitting but will go back and do it over 4-5 procedures over several weeks, allowing the blood flow to redistribute after embolizing one vessel and then going back in again to more in stages. It is possible that in centers that have less experience, they try to do too much at a time.

    Wise.

  2. #22
    Senior Member
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    Quote Originally Posted by Wise Young
    I have been hearing people talking about the superiority of surgical approaches to AVMs versus embolization. From my experience, I am surprised by these stories. The man that I worked with is Alejandro Berenstein and I consider him to be the best and most experienced interventional radiologist. With careful planning and monitoring, the number of patients who get worse from the embolization is small, probably less than 5%. A sizable proportion of patients get better, on the order of 60% or greater.
    Wise. I’m not arguing this. In all my reading and discussions with doctors for treating avm’s they all recommend embolization. They did it with me and they also tried to do it in steps. But when embolization is not possible for a complete removal I understand from my reading and the doctors involved in my case that surgery is a last option. This is if the avm finally will paralyze a person left untreated. I also understand that surgery on this field has developed a lot the last years, meaning that it is less risky then before.

    I have also read about the “window of opportunity”, as I understand that this means is; if you get the symptoms caused by an avm like loss of sensation and functions the “window of opportunity” means that sensation and functions lost the last half year are most likely to recover if treated by embolization. Sensation and functions lost before this half year are more difficult to recover. Thanks Leif.

  3. #23
    I agree with your description of surgery as the last option. I oppose the attempts to establish a "therapeutic window" for AVM's because it is not based on strong data. It also gives false sense of security for delaying therapy and, at the same time, may deny therapy to some patients who are beyond the therapeutic window but who might benefit from interventional neuroradiology or neurosurgery. Unnecessary rules sometimes come back to haunt us.

    I have seen patients benefit from embolization many years after their initial symptoms and discovery, including reversal of symptoms. In the 1980's, because the outcome from surgical treatment of AVM was uniformly poor, most neurosurgeons would delay operation on AVMs until significant symptoms developed. With the advent of interventional neuroradiology, not only were AVMs discovered earlier but the threshold for intervention became lower, i.e. pain or transient neurological loss.

    Common sense tell us that it would is important to eliminate the AVM before it ruptures or otherwise causes injury to the spinal cord. This is the advice that neurosurgeons give to their patients regarding aneurysms which is another vascular malformation with similar risks as AVMs.

    Neurosurgeons have three distinct disadvantages when approaching an AVM surgically, compared to an interventional radiologist approaching the AVM through a blood vessel. First, the neurosurgeon does not have the luxury of going back multiple times and staging the procedure. Second, the neurosurgeon can only approach the AVM from the surface. Third, surgery is often associated with hemorrhage. Even a small leak of blood can cause vasoconstriction that would shift flow into the shunt, initiating a cascade of events leading to a worsening of the ischemia for an already borderline perfused tissue.

    From my experience both in studies of the middle cerebral artery and observations in the operating room during embolization cases, the major cause of ischemia in AVM results from increased intravenous pressure. Blood flow across capillaries depend on the arteriovenous (AV) pressure difference. Because the AVM is dumping arterial pressure directly into the veins, venous pressure increases and therefore reduces the AV pressure difference. Most AVMs have a "penumbral zone" where there is borderline ischemia of the tissue around the AVM. This zone is at risk whenever one embolizes or operates on the AVM.

    Embolization is often difficult, particularly in high-flow AVMs. The reason is that the embolization material (whether it is beads, glue, or whatever) may get into the vein and clog up venous flow. In many cases of embolization, people get worse during the 24 hours after the embolization rather than during the procedure, due to "sludging" of venous flow. An experienced interventional radiologist has many tools to deal with this problem. For example, one is to use a coil rather than beads. One can place a coil, pass a current through it to heat up the coil to initiate clotting, and then detach the coil once clotting has started. A second option is to occlude the AVM a little at a time, going back multiple times.

    The skill of the interventional radiologist or surgeon is crucial. Speed is of the essence for interventional radiologists because when one places a catheter into the feeding artery, it occludes blood flow. If the procedure takes too long, that occlusion itself causes ischemia. So, speed is important. I have seen evoked potentials decline over a 10-20 minute period while the catheter is left in place. Likewise, it is important that the neurosurgeon really understand the 3-dimensional structure of the AVM and does meticulous surgery with a minimum of bleeding.

    It is one of the most challenging intervention/surgery that I know.

    Wise.

    Quote Originally Posted by Leif
    Wise. I’m not arguing this. In all my reading and discussions with doctors for treating avm’s they all recommend embolization. They did it with me and they also tried to do it in steps. But when embolization is not possible for a complete removal I understand from my reading and the doctors involved in my case that surgery is a last option. This is if the avm finally will paralyze a person left untreated. I also understand that surgery on this field has developed a lot the last years, meaning that it is less risky then before.

    I have also read about the “window of opportunity”, as I understand that this means is; if you get the symptoms caused by an avm like loss of sensation and functions the “window of opportunity” means that sensation and functions lost the last half year are most likely to recover if treated by embolization. Sensation and functions lost before this half year are more difficult to recover. Thanks Leif.
    Last edited by Wise Young; 08-05-2005 at 06:52 AM.

  4. #24

    Smile Spontaneous at age 25

    I was in my garage one night, I bent down to pick up my mail, and i felt a snap...within 5 minutes, i was numb/paralyzed from the neck down. Turned out to be c5/6 disc. I windered for a long time why and how the heck this could happen - i didnt even do anything!!! Strange stuff, but thankfully, I have regained almost all of my ability and most of my feeling. The abormal has become normal to me. It is nice to know that I am not alone.

  5. #25
    Quote Originally Posted by EFryer
    I was in my garage one night, I bent down to pick up my mail, and i felt a snap...within 5 minutes, i was numb/paralyzed from the neck down. Turned out to be c5/6 disc. I windered for a long time why and how the heck this could happen - i didnt even do anything!!! Strange stuff, but thankfully, I have regained almost all of my ability and most of my feeling. The abormal has become normal to me. It is nice to know that I am not alone.
    Efryer, I am glad. I presume that you had it decompressed soon. Wise.

  6. #26

    The cool part of my job...

    Those few times I was able to discharge someone after a decompression who came in paralyzed and went home walking. Those times give the surgeons a big rush too. They go strutting through the nurse's station smiling....unlike the rest of the times when they bark orders and run out without signing them....sheesh...

    I am glad to hear you are recovering well....

    Mary
    1FineSpineRN

  7. #27
    I think this forum is a great idea. I got suddenly paralysed 36 years ago, five minutes and no pain. First the doctors believed it was a spinal bleed, now they say it was most likely a spinal stroke but I don't think they find the reason. The MRI shows nothing wrong but still I am a th12 incomplete
    TH 12, 43 years post

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