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

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

3. INTRODUCTION Vertebral Hémangioma (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
(Picture taken from website:

4. INTRODUCTION
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

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

7. CASE N°1
A 18 years old patient
09/08/2007  Neurological dysfunction due to spinal cord compression. Radiographic findings: aggressive vertebral hemangioma T3 10/08/2007 bilateral T3 laminectomy  Follow-up: worsening paraparesis Immediate 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. Is there an explanation for the current neurological symptoms ?
MRI sequences
a,b,c sagittale T2-weighted images
d : sagittale T1 weighted images with contrast injection
e : axial T1 weighted image with contrast injection
a b c d e
Is there an explanation for the current neurological symptoms  ?

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

12. What could be proposed? A. Reoperation
B. Transarterial Embolization
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 arteries C. The lumbar arteries D. 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
The anterior spinal artery was identified in T10 left. Is there a risk of embolization of T3. A. yes B. no C. 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 T3 intercostal artery
We can embolize at this level?
A. Yes
B. No

25. Selective angiography of the pedicle of the left T3 intercostal artery
We can embolize at this level?
A. Yes
B. No

26. Surgical resection is limited because of:
A. The involvement of the anterior arch B. The epidural extension C. 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 embolized B
What can we do ? A. Surgery as part of the angioma was embolized B. Vertebroplasty C. Sclerotherapy  with Absolute ethanol D. There is no other treatment E. There is another alternative ?

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

30. What does this alternative. A. radiofrequency ablation B
What does this alternative ? A. radiofrequency ablation B. 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 days so that 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 days so that 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. Surgery should include:
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 treatment achieved ?
A . Yes
B . No

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

50. To treat vertebral body of T3 must be associate :
A. Surgery by anterior approach B. Percutaneous Vertebroplasty C. Sclerotherapy with Glubran 2 under CT guidance

51. To treat vertebral body of T3 must be associate :
A. Surgery by anterior approach
B. Percutaneous Vertebroplasty
C. Sclerotherapy with Glubran 2 under CT guidance

52. Percutaneous Vertebroplasty

53. Significant improvement with gait recovery actually walking without  cane

54. PERCUTANEOUS VERTEBROPLASTY

55. PERCUTANEOUS VERTEBROPLASTY
Percutaneous injection of acrylic cement in
a pathologic vertebral body 
Double effet:
Pain relief
Vertebral stabilization

56. PERCUTANEOUS VERTEBROPLASTY
Patient preparation
Systematic radiological assessment: X-ray + CT + MRI
Anesthesia consultation before the procedure.
Search for contraindications
Informed consent obtained from the patient

57. Absolute Contraindications
- Pregnancy; - coagulation disorders; - Contraindications to anesthesia and prolonged
 prone position; - Allergy to PMMA; - Systemic or local infections; - Spinal cord compression with neurological
deficit

58. Relative Contraindications
- Pedicles fracture
Vertebral body collapse with retropulsion of fracture fragment causing spinal canal compromise
Severe vertebral body collapse

59. Technique
Fluoroscopic C-arm
Guidance
CT guidance
General anesthesia
or local analgesia with or without conscious sedation

60. Equipment
Bone cement :PMMA Bone Needles 11 G cm (thoracic spine)  cm (lumbar spine) Surgical hammer Combination pliers

61. Cement preparation
Methylmethacrylate powder is mixed with methylmethacrylate monomer liquid.
Metallic powder is added to PMMA in order to enhance the visibility of the cement.
The preparation is mixed until it
becomes like toothpaste
Cement volume vary between 2 and 10 ml

62. Cement injection
Transpedicular approach
Unipedicular
or Bipedicular

63. Cement injection Postero lateral approach - pedicular lysis
- osteosynthesis

64. Incidents Vascular leakage of cement - the operator should adjust
the needle direction
- or stop the injection
immediately.
Risk of Pulmonary embolism

65. Spinal canal and epidural extravasation of cement
Incidents
Spinal canal and epidural extravasation of cement
- Low risk < 1 %
- Associated with vertebral fracture:
Pedicles
posterior wall
posterior arch

66. Incidents Foraminal leakage of ciment Risk of compression
of the nerve root

67. Paravertebral cement leakage
Incidents
Paravertebral cement leakage
Intervertebral disc cement leakage
Without major complications

68. Vertebroplasty Results
The analgesic effect is immediate and complete 
in the vast majority of cases according to various studies.
The frequency of complications is highly variable 
depending on the series (1% to 13.5%) It's mostly technical incidents  without major
consequences

69. Vertebroplasty Results
H Rajhi and al in 2011: 100% improvement at least partially in the short and medium term Complete regression of pain in the medium term up 57.1% of cases

70. CASE N°2
48 year old woman treated by percutaneous vertebroplasty in 2008 for aggressive vertebral hemangioma T12 with improvement of symptoms.

71. Re-consulted in March 2011 for development of inflammatory back pain with sciatica and sphincter dysfunction.

72. a b c d e f MRI sequences a: sagittale T2 weighted image
b,c : sagittale T1 weighted images
d,e : sagittale T1 weighted images with contrast injection
f: axial T1 weighted image with contrast injection

73. What is the explanation of the recent symptoms. A. Herniated disc B
What is the explanation of the recent symptoms? A. Herniated disc B. Spondylodiscitis C. Vertebral metastasis D. Reactivation of aggressive Angioma T12 E. Osteoporotic fracture

74. What is the explanation of the recent symptoms?
A. Herniated disc
B. Spondylodiscitis
C. Vertebral metastasis
D. Reactivation of aggressive Angioma T12
E. Osteoporotic fracture

75. Which procedure could be proposed as a treatment. A. Surgery B
Which procedure could be proposed as a treatment? A. Surgery B. Arterial embolization C. Surgery with preoperative embolization D. Vertebroplasty E. Sclerotherapy with Ethanol

76. Which procedure could be proposed as a treatment?
A. Surgery B. Arterial embolization
C. Surgery with preoperative embolization D. Vertebroplasty
E. Sclerotherapy with Ethanol

77. The decision was to achieve  sclerotherapy with
ethanol injection in the anterior epidural component

78. Sclerotherapy with ethanol injection

79. Sclerotherapy with ethanol injection

80. Sclerotherapy with ethanol injection

81. Sclerotherapy with ethanol injection

82. The outcome was favorable with disappearance of sphincter dysfunction and sciatica
and improvement of the low back pain

83. Control MRI in April 2012 (1 year after sclerotherapy)

84. Control MRI in April 2012 (1 year after sclerotherapy)

85. SCLEROTHERAPY WITH ETHANOL
Direct percutaneous injection of Absolute alcohol
Induces:
Thrombosis, edema and sclerosis of the
Hemangioma
Shrinkage of the lesion with  radiculomedullary
decompression

86. SCLEROTHERAPY WITH ETHANOL
Intraosseous venography can be performed before alcohol injection
         Provides information on the route of preferential
venous drainage of the hemangioma
         Chek for risk of paravertebral and intra ductal
leakage        

87. Technique
CT guidance
Intravenous conscious sedation and analgesia

88. Technique Unipedicular Bipedicular
Transpedicular approach
Unipedicular
Bipedicular
Postero lateral apparoch
-Without significantly changing the absolute nature of the alcohol, we have made alcohol radioopaque by mixing it with contrast media

89. Incidents Potential risk of venous runoff
- Avoided by slow injection of Ethanol
Pleural complications and intercostal arteries injury
- Avoided by transpedicular approach

90. Complications Risk of collapse of the vertebral body
-Decreased by injecting a small volume of
alcohol

91. CONCLUSION
A number of methods have been used in the treatment of symptomatic and aggressive vertebral hemangioma, but none of them is optimal.
The therapeutic approach depends on the clinical context, the topography and the involvement of the lesion.
The decision is multidisciplinary

92. CONCLUSION
The interventional radiologist plays an important role:        - Knowledge of the limitations and benefits
of each Interventional procedure  Changes in products available    perfect control of techniques    Risk Measurement

93. MERCI
Thank
you