Treatment of painful vertebral hemangioma with alcohol, cement or both

Treatment of painful vertebral hemangioma with alcohol, cement or both Poster No.: C-0746 Congress: ECR 2012 Type: Scientific Exhibit Authors: M. Zauner, S. PEREZ, A. Marin; Sabadell/ES Keywords: Haemangioma, Vertebroplasty, Fluoroscopy, CT, Neuroradiology spine, Musculoskeletal spine, Interventional non-vascular DOI: 10.1594/ecr2012/C-0746 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 18

Purpose Hemangiomas are benign tumors of vascular origin with scant malignant metaplasia, although they sometimes exhibit aggressive behavior. Vertebral hemangiomas are found in 11% of autopsies. Vertebral hemangiomas are found most frequently in the thoracic spine, followed by the lumbar spine. Only 1% of vertebral hemangiomas give rise to symptoms, causing pain or diverse neurologic symptoms, including paraplegia, but they rarely result in compression fractures. Page 2 of 18

Images for this section: Fig. 4: Different hemangiomas as seen by CT Page 3 of 18

Fig. 5: Type I Hemangioma. Note T1w hyperintensity and hypointensity on IR indicating mainly fat struma. Page 4 of 18

Fig. 6: Type II hemangioma. Note T1w hyposignal and hypersignal on IR because of mainly vascular structure. Note slightly epidural extension. Page 5 of 18

Methods and Materials Hemangiomas are classified into two types, which are practically indistinguishable on CT but can be differentiated according to their signal intensity on MRI. Type I hemangiomas are hyperintense on T1-weighted images and hypointense in STIR images due to the predominance of stromal fat; type I hemangiomas are hardly ever aggressive and rarely extend beyond the vertebral body. Type II hemangiomas are hypointense on T1-weighted images and markedly hyperintense on STIR images due to the preponderance of the vascular component over the fatty component; type II hemangiomas occasionally exhibit aggressive behavior, extending beyond the vertebral body and developing a soft-tissue component. Occasionally, type II hemangiomas are located completely outside the vertebra. The treatment of hemangiomas is controversial. Treatment options for painful or aggressive hemangiomas include: 1) transarterial embolization (generally as a preliminary step prior to surgery) 2) surgery (resection with bone reinforcement and prosthesis) 3) radiotherapy (delayed effect) 4) alcohol ablation and/or cement vertebroplasty. We use only percutaneous treatment for painful hemangiomas (in the absence of other conditions that might be responsible for the pain) and for hemangiomas with an aggressive, extravertebral component. Percutaneous treatment is minimally invasive and achieves rapid clinical improvement. We use CT fluoroscopy (Siemens Volume Zoom) to guide all percutaneous procedures on the spine. We have classified the hemangiomas according to the indication for treatment: painful hemangiomas (those without an extravertebral component) or aggressive hemangiomas (those with an extravertebral component). To date we have treated a total of 20 patients (mean age, 54.1 years; age range 26-80), of whom 13 were women; 17 had painful hemangiomas and 6 had aggressive hemangiomas. Table 1 shows the distribution of the hemangiomas according to the vertebrae affected. The efficacy of intravertebral injection of both absolute alcohol and polymethylmethacrylate (PMMA) for treating both painful and aggressive hemangiomas is well established. However, there are no uniform criteria that limit the use of alcohol alone or combined alcohol-pmma treatment, so we decided to establish our own protocol. Our protocol calls for alcohol ablation alone in patients under 60 years of age with painful hemangiomas that involve less than 50% of the vertebral body and for combined alcoholpmma treatment in patients over 60 years of age with painful hemangiomas, in all patients Page 6 of 18

with aggressive hemangiomas, and in all patients with painful hemangiomas that involve more than 50% of the vertebral body. The procedure (see Figures 7-10): 1) We place the patient in the prone position, administer neuroleptanalgesia, and perform a CT study to locate the lesion, determine its extension, and plan the approach. 2) We place a 13G trocar in the center of the most anterior part of the lesion. 3) We perform vertebrography to identify the vascular behavior of the hemangioma and we repeat the vertebrography two minutes later to evaluate the degree of contrast retention (Figures: 8 and 9). 4) We proceed to rapidly inject a mixture of 50% alcohol and 50% iodinated contrast agent; if necessary, we repeat the injection (up to a limit of 10 cc of absolute alcohol). 5) In patients in whom the protocol calls for combined alcohol-pmma treatment, we then proceed to inject the PMMA using the same technique that we use for vertebroplasty. 6) At the end of the procedure, we obtain a control helical CT image to evaluate the retention of the contrast agent or the distribution of the PMMA. 7) Three months after the procedure, we do a follow-up MRI examination and administer a personal questionnaire that includes a visual analogue scale (see Figures 11-12 at Results). Page 7 of 18

Images for this section: Table 1: Distribution of hemangiomas. Page 8 of 18

Fig. 7: Procedure. See text for explanation. Page 9 of 18

Fig. 8: Vertebrography Page 10 of 18

Fig. 9: Delayed vertebrography. Note relative poor contrast retention, indicating a high blood flow in the hemangioma. Page 11 of 18

Fig. 10: Final control. Note contrast retention in the sclerosed hemangioma. Page 12 of 18

Results We classified outcome as very good (disappearance of pain and return to normal daily activities), good (residual pain and/or limited return to normal daily activity), or unchanged (persistence of pain and/or deficit, no changes). Our patients showed no signs of neurological worsening, although pain increased temporarily. Of the 6 patients with aggressive hemangiomas, 1 was unchanged and required decompressive surgery, although less bleeding than expected was seen during surgery; the remaining 5 patients improved. All patients with painful hemangiomas improved to varying degrees and all had good or very good outcome. Several patients required two or three rounds of treatment. The small size of our sample precludes statistical analysis, although we observed a trend toward clinical improvement in a relatively short period (1-3 months). The efficacy of both alcohol ablation and intravertebral PMMA for both painful hemangiomas and aggressive hemangiomas with an extravertebral component is well established. In the absence of uniform criteria to define the use of alcohol ablation alone or combined alcohol-pmma treatment, we designed our own protocol: alcohol alone for patients under 60 years of age with hemangiomas that involve less than 50% of the vertebral body, and combined alcohol-pmma treatment for patients over 60 years of age and for patients of any age in whom the hemangioma involves more than 50% of the vertebral body or extends outside the vertebral body. These criteria are based on the observation that bone regeneration is sufficient to refill the space left by the obliterated hemangioma in young patients without osteoporosis, as long as the hemangioma is not so large that alcohol ablation weakens the vertebral body excessively and leads to a risk of collapse and fracture, whereas older patients with more or less severe osteoporosis and patients with large or aggressive hemangiomas benefit from the injection of PMMA to reinforce the weakened vertebral body and reduce the risk of collapse and fracture. Page 13 of 18

Images for this section: Fig. 11: Note clear reduction in size of the hemangioma 3 months after alcoholization. Page 14 of 18

Fig. 12: Note absence of cord compression and cord edema after combined treatment with alcoholization and vertebroplasty. Page 15 of 18

Conclusion Combined alcohol ablation-pmma vertebroplasty is efficacious for reinforcing the vertebral body in elderly patients or patients with hemangiomas bigger than 50% of the vertebral body and also reducing the epidural component of aggressive hemangiomas. Alcohol ablation alone leads to good outcome in younger patients with smaller painful hemangiomas. Page 16 of 18

References Doppman JL et al. Symptomatic vertebral hemangiomas: Treatment by means of direct intralesional injection of ethanol. Radiology 2000; 214:341-348. Chen Liang, Zhang Chun-lin, Tang Tian-si Cement vertebroplasty combined with ethanol injection in the treatment of vertebral hemangioma. Chin Med J 2007;120(13):1136-1139. Bas T, Aparisi F, Bas JL. Efficacy and safety of ethanol injections in 18 cases of vertebral hemangioma: a mean follow-up of 2 years. Spine 2001; 26: 1577-1582. McGraw JK, Heatwole EV, Strnad BT, Silber JS, Patzilk SB, Boorstein JM. Predictive value of intraosseous venography before percutaneous vertebroplasty. J Vasc Interv Radiol 2002; 13:149-153. Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie 1987;33: 166-168. Yang ZY, Zhang LJ, Chen ZX, Hu HY. Hemangioma of the vertebral column: A report on twenty-three patients with special reference to functional recovery after radiation therapy. Acta Radiol Oncol 1985; 24: 129-132. Page 17 of 18

Personal Information Martin Zauner, Senior Radiologist Section of Neuroradiology UDIAT C.D. Corporació Sanitària del Parc Taulí mail to: mzauner@tauli.cat Sandra Pérez, Radiologist Section of Neuroradiology UDIAT C.D. Corporació Sanitària del Parc Taulí spereza@tauli.cat Anna Marin, Radiologist Section of Musculoskeletal Radiology UDIAT C.D. Corporació Sanitària del Parc Taulí amarina@tauli.cat Page 18 of 18