Gunshot wound causing anterior spinal cord infarction due to injury to the artery of Adamkiewicz

Abstract Background:Transcatheter arterial embolisation of intercostal vessels is a minimally invasive procedure that is increasingly being used in the management of haemothorax in the trauma patient, however significant complications – such as spinal ischaemia can occur. We present a rare case of paralysis in a patient following embolisation of the intercostal arteries due to bleeding from penetrating trauma.Case presentation:A 46-year-old male presented to the Emergency department with two stab wounds to the right posterior chest. Computed tomography scan of the chest revealed active contrast extravasation from the right 9th intercostal artery. Selective embolisation of the right 9th intercostal artery using Gelfoam® and coils as well as further embolisation of the 7th, 8th and 10th intercostal arteries was performed. Unfortunately due to ongoing bleeding and hypotension, the patient subsequently required emergency surgery that revealed two penetrating injuries to the right inferior lobe of the lung. After the patient was extubated, he was found to have bilateral motor from the level of L4 and below and sensory deficits from L2 and below. Magnetic resonance imaging of the spine showed spinal cord infarction at the level of T11 and T12 that was thought to be secondary to the embolisation of the intercostal arteries inadvertently affecting the artery of Adamkiewicz.Conclusions:Transcatheter arterial embolisation has an established roll in haemostasis of the trauma patient – particularly in intercostal arteries for the management of haemothorax. Although extremely rare, spinal complications from this procedure can be significantly life changing for the patient. The variable anatomy of the artery of Adamkiewicz should be carefully considered on a case-by-base basis in the stable trauma patient and balance of risk versus benefit be determined if the artery is unable to be identified on pre-procedure angiography.

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Spinal Cord Infarction from an Unstable Aortic Plaque

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100011215 ◽

2011 ◽

Vol 38 (1) ◽

pp. 145-146

Author(s):

Jamsheed A. Desai ◽

Nicola Gambarotta

Keyword(s):

Spinal Cord ◽

Conus Medullaris ◽

Acute Onset ◽

Spinal Cord Infarction ◽

Sensory Level ◽

Aortic Plaque ◽

Artery Of Adamkiewicz ◽

Magnetic Resonance Imaging Mri ◽

T2 Hyperintensity ◽

The Right

A 78 year-old woman presented with acute onset low back pain with radiation into the right T12-L2 dermatomes, progressive flaccid paraparesis, urinary incontinence and bilateral lower extremity paresthesias. Examination revealed flaccid paraparesis, and a T12 sensory level to pin with intact vibration and proprioception. Magnetic resonance imaging (MRI) (Figure 1) of the spinal cord demonstrated T2 hyperintensity and restricted diffusion from T12 to the conus medullaris. Computed tomogram (CT) aortogram (Figure 2) highlighted an ulcerated plaque and thrombus at the approximate level of the artery of Adamkiewicz. These findings were consistent with a spinal cord infarct of the cord from T12-L2. The patient was treated with Clopidogrel and IV heparin (x two days) and was transferred for spinal cord rehabilitation.

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Malignant Melanotic Schwannian Tumor Presenting with Spinal Cord Infarction Due to Occlusion of the Artery of Adamkiewicz: Case Report and Review of the Literature

World Neurosurgery ◽

10.1016/j.wneu.2019.04.267 ◽

2019 ◽

Vol 128 ◽

pp. 422-425

Author(s):

Orel Zaninovich ◽

Wyatt Ramey ◽

Jordan Eldersveld ◽

Willard S. Kasoff

Keyword(s):

Spinal Cord ◽

Case Report ◽

Spinal Cord Infarction ◽

Review Of The Literature ◽

Artery Of Adamkiewicz

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The angiosome territories of the spinal cord: exploring the issue of preoperative spinal angiography

Journal of Neurosurgery Spine ◽

10.3171/spi/2008/8/4/352 ◽

2008 ◽

Vol 8 (4) ◽

pp. 352-364 ◽

Cited By ~ 14

Author(s):

Michael K.-Y. Hong ◽

Matthew K.-H. Hong ◽

Wei-Ren Pan ◽

David Wallace ◽

Mark W. Ashton ◽

...

Keyword(s):

Spinal Cord ◽

Collateral Circulation ◽

Vascular Occlusion ◽

Senior Author ◽

Spinal Tumors ◽

Spinal Cord Infarction ◽

Spinal Angiography ◽

Oxide Mixture ◽

Thoracolumbar Region ◽

Artery Of Adamkiewicz

Object The angiosome concept has been the subject of extensive research by the senior author (G.I.T.), but its specific applicability to the spinal cord was hitherto unknown. The aim of this study was to see if the spinal cord vasculature followed the angiosome concept and to review the usefulness of preoperative spinal angiography in surgery for spinal disorders. Spinal cord infarction and permanent paraplegia may result from inadvertent interruption of the artery of Adamkiewicz. Spinal angiography, which may enable avoidance of this catastrophic complication, is still not commonly used. Methods Two fresh cadavers were injected with a gelatin–lead oxide mixture for detailed comparative study of spinal cord vasculature. One cadaver had insignificant vascular disease, whereas the other had extensive aortic atherosclerosis, presenting a unique opportunity for study. After removal from each cadaver, radiographs of the spinal cords were obtained, then photographed, and the vascular territories of the cords were defined. Results Four angiosome territories were defined: vertebral, subclavian, posterior intercostal, and lumbar. These vascular territories were joined longitudinally by true anastomotic channels along the anterior and posterior spinal cord. Anastomosis between the anterior and posterior vasculature was poor in the thoracolumbar region. The anterior cord relied on fewer feeder arteries than the posterior, and the anterior thoracolumbar cord depended on the artery of Adamkiewicz for its supply. In chronic aortic disease with intercostal artery occlusion at multiple levels, a rich collateral circulation supporting the spinal cord was found. Conclusions The arterial supply of the spinal cord follows the angiosome concept. The atherosclerotic specimen supports the suggestion that the blood supply is able to adapt to gradual vascular occlusion through development of a collateral circulation. Nevertheless, the spinal cord is susceptible to ischemia when faced with acute vascular occlusion. This includes inadvertent interruption of the artery of Adamkiewicz. The authors recommend the use of preoperative spinal angiography to prevent possible paraplegia in removal of thoracolumbar spinal tumors.

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Microsurgical Management of a Spinal Dural Arteriovenous Fistula With Shared Blood Supply to the Artery of Adamkiewicz: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy293 ◽

2018 ◽

Vol 16 (6) ◽

pp. E174-E175 ◽

Cited By ~ 1

Author(s):

C Michael Cawley ◽

Brian M Howard ◽

Daniel L Barrow

Keyword(s):

Spinal Cord ◽

Lower Extremity ◽

Arteriovenous Fistula ◽

Blood Supply ◽

Dural Arteriovenous Fistula ◽

Spinal Cord Infarction ◽

Thoracic Myelopathy ◽

Spinal Dural Arteriovenous Fistula ◽

Lower Extremity Weakness ◽

Artery Of Adamkiewicz

Abstract The presented case is of a 65-yr-old gentleman referred for thoracic myelopathy. He developed bilateral, nondermatomal foot dysesthesia 14 mo prior to presentation, which progressed to numbness below the L3 level. He reported progressive gait instability, bilateral lower extremity weakness, and required a cane for ambulation. He subsequently developed urinary incontinence, while bowel function was spared. The neurological examination upon presentation revealed lower extremity strength was reduced to 4/5 in all major muscle groups bilaterally, while sensation and proprioception were reduced below the L3 level. Patellar and Achilles reflexes were not elicited and clonus was absent. Gait was unsteady and slow. The patient was not able to perform heel, toe and tandem gait. MRI revealed abnormal T2 hyper-intense signal and spinal cord expansion from T6 through the conus medullaris. Angiography revealed a dural arteriovenous fistula (dAVF) originating from the left T9 radicomedullary pedicle, which also supplied the Artery of Adamkiewicz (AoA). The patient underwent T8-10 laminectomies. Prior to disconnection of the fistula, an aneurysm clip was applied to the fistulous point and an indocyanine green video angiogram was completed to show that the fistula no longer opacified, but that the AoA remained patent, which was later confirmed with angiography. As of discharge, the patient's motor exam had improved substantially, though his sensory deficits persisted. This case demonstrates that surgical disconnection is requisite in the treatment of spinal dAVF that have a shared blood supply with the AoA, as embolization risks spinal cord infarction. The patient consented to presentation of this case in a de-identified fashion.

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