Endovascular treatment |
Embolization of a DAVF in the head or the spine with glue, coils and/or particles
With this information we would like to clarify the treatment of a dural arteriovenous fistula (DAVF) in the head or spine and give you some guidelines and advice to heal faster.
The DAVF in the brain or spine
A dural arteriovenous malformation (DAVF) can occur in the head or the spine. The disorder consists of an acquired malformation of the vascular system in the hard meninges (the dura) located where there is an abnormal short circuit between arteries and veins. Typically, there is a direct connection between the artery and vein. The result is that the blood pressure in the veins is much higher than normal. The resulting symptoms are:
- Pulsatile tinnitus (the heartbeat is heard on the side of the DAVF)
- Pressure on the eyes
- Loss of function of the spinal cord (numbness / weakness of the legs)
The diagnosis of DAVF is not easy. Most patients are sent long after their initial symptoms to us. Treatment is usually embolization, but sometimes a surgical operation or irradiation. In our team every patient with a DAVF is discussed individually, and the treatment or combination of treatments with the lowest risk and most optimal result is proposed.
Before the treatment
- It is important to inform the doctor or nurse on the following:
- Allergies, especially contrast allergy
- Medication use
- Use of medication should be consulted with your physician. Especially important to discuss is the use of blood thinners (aspirin, Ascal, Asaflow, Plavix, Clopidigrel, Ticlid, Marevan, Warfarin, fraxiparin, etc).
- If you are contrast allergic, you should be premedicated. Generally, you need to take a Medrol 35mg tablet the evening before the examination.
- You need to be sober for the treatment. This means that from midnight the day before the examination you should no longer eat or drink. On the day of the study, only take the necessary medication with a little water.
Illness or foreclosure
Ordinarily, your doctor or you yourself made an appointment for the examination. If due to any reason you are unable to pass the examination, kindly get in touch with the radiology department. This can be done via the telephone 03 821 3803. Please make a new appointment, if possible.
During the treatment you have to lie perfectly still. This requires that you be completely put to sleep (general anesthesia). This is done by a specialist doctor (anesthesiologist). In order to undergo the narcosis as safe as possible you might get an appointment for a consultation with the anesthesiologist in the period prior to the treatment. It is also possible that you should undergo some additional studies (eg EKG, blood test, heart or lung examination, ...).
Because of the anesthesia, you should be sober for at least 6 hours, but usually longer. Often alongside an intravenous drip, a urinary catheter is inserted during anesthesia.
You are at least 2 to 3 days (sometimes longer) in the hospital. This is usually on the ward A4 (4th floor) at the neurosurgery department. On the morning of the admittance you need to be sober (last meal taken before midnight). You check in at the central reception area of the hospital, then you will be referred to the ward. There, you will received by a nurse who can arrange all the practical issues. At the ward there is a attending physician present.
The embolization of a DAVF is performed by specialized interventional neuroradiologists on the angiography room of the radiology department. Usually, the treatment is performed under general anesthesia, but in some cases in a awake patient. After the anesthesiologist has put you to sleep, a thin catheter (small tube) is placed from the femoral artery (usually right) in one of the head and neck arteries (or intercostal/lumbar arteries in case of a spinal DAVF). Through this catheter an even thinner tube (micro catheter) is then guided very carefully nearby or preferably in the DAVF. Subsequently the DAVF is gradually occluded with Onyx® (special glue) under constant X-ray guidance until the malformation is closed or partly closed. Sometimes coils or particles (very small balls) are used to close the affected blood vessels.
After treatment, the catheters are removed and the hole in the femoral artery is closed with a special plug (Angioseal ®). This Angioseal® is naturally degraded by the body in about 2 to 3 months. During this period caution should be exercised with any re-puncture of the groin.
After the treatment
The patient wakes up in the angio room or in the recovery room (recovery, PACU or recovery room). The patient is constantly monitored. The puncture site in the groin is regularly controlled. If everything goes well, the patient will be transported to the ward. Sometimes it is necessary to be monitored on the medium care (MC) or intensive care unit (ICU). The patient has strict bed rest until the next day. To prevent a bleeding at the puncture site (groin) the patients has to keep his/her right leg immobile for at least 4 hours and needs to lie on his/her back. Try not to use the abdominal muscles (no coughing or sneezing, no toilet, ….). Depending on the condition of the patient he/she stays for 2 or 3 days in the hospital with a recovery in about a week. After this period, the patient can return to normal daily (work- and sport) activities, provided that the doctor gives his permission.
Frequently patients have headache. This can be treated with pain medication. Typically in Onyx® embolizations a strong odor will be smelled due to the glue.
It is not allowed to drive a car the days after a treatment. Also, the patient needs to be cautious with sports, lifting and labour.
At hospital discharge you get instructions for medication and an appointment for a consultation at the neurovascular consultation (approximately 6 weeks after treatment).
Pain, discomfort and risks
During the treatment you will be under general anesthesia and feel nothing. You should inform the nurse or doctor if you have pain. Afterwards the puncture site in the groin can be sore. Seldom a bleeding can also occur in the groin at the puncture site. Rarely, allergic reactions (redness, rashes, swelling, hoarseness, chest tightness, …) or adverse effects on the kidneys (especially in people with preexisting poorer kidney function) can occur because of the use of contrast and / or medication.
Sometimes serious complications of the embolization can occur due to glue deposition in normal instead of pathologic vessels or a bleeding caused by the DAVF. Sometimes an emergency operation by the neurosurgeon is necessary.
The specific (serious) risks of the treatment (thrombosis of brain vessels, bleeding) and possible consequences will be discussed before the procedure by the treating physicians.
Possible problems the first days…
Should one or more of the following symptoms occur the first days to weeks after the treatment, you immediately contact us: sudden onset headache (worse than before), progressive drowsiness, paralysis or other dysfunctions, bleeding in the groin. You call the general number of the hospital 03-8213000 and ask for one of the doctors of our team.
If you have any further questions, please feel free to contact your treating physician, neurosurgeon, specialist nurse or interventional neuroradiologist via the telephone number of the department of angiography of the UZA (03-821 3803).