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

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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Anterior Spinal Cord Syndrome is a Complication Following Embolisation of Bleeding Intercostal Artery in Penetrating Trauma: A Case Report

10.21203/rs.3.rs-73539/v1 ◽

2020 ◽

Author(s):

Tovi Vo ◽

Daniel Harris ◽

Ngee Foo ◽

Daniel Eillis

Keyword(s):

Spinal Cord ◽

Trauma Patient ◽

Penetrating Trauma ◽

Intercostal Artery ◽

Spinal Cord Infarction ◽

Contrast Extravasation ◽

Transcatheter Arterial Embolisation ◽

Arterial Embolisation ◽

Artery Of Adamkiewicz ◽

The Right

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

The Spine Journal ◽

10.1016/j.spinee.2016.02.010 ◽

2016 ◽

Vol 16 (9) ◽

pp. e603-e604 ◽

Cited By ~ 1

Author(s):

David Phillips ◽

Sanjay S. Dhall ◽

Alina Uzelac ◽

Jason F. Talbott

Keyword(s):

Spinal Cord ◽

Gunshot Wound ◽

Spinal Cord Infarction ◽

Artery Of Adamkiewicz

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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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Spinal Neoplasm in Dogs

Acta Scientiae Veterinariae ◽

10.22456/1679-9216.81302 ◽

2018 ◽

Vol 44 (1) ◽

pp. 10

Author(s):

Larissa Garbelini Valentim ◽

Rogério Anderson Marcasso ◽

Ana Paula Frederico Loureiro Bracarense ◽

Mônica Vicky Bahr Arias

Keyword(s):

Spinal Cord ◽

Complete Blood Count ◽

Histopathological Examination ◽

Clinical Signs ◽

Neurological Dysfunction ◽

Spinal Tumors ◽

Spinal Instability ◽

Presumptive Diagnosis ◽

Cord Injury ◽

Thoracolumbar Region

Background: Various diseases can cause spinal cord disorders in dogs including neoplasia of the nervous system, which are more common in mature and older animals. Some breeds, as brachycephalics, are more predisposed for certain types of tumors. Spinal neoplasia can be categorized as primary or secondary tumors, and still can be grouped in extradural, intradural/extramedullary or intramedullary. The aim of this study was to investigate the signalment, neurological syndrome, type and source of the mass, presence of metastases, and clinical outcomes in 28 dogs diagnosed with spinal tumors.Materials, Methods & Results: This study included 28 dogs, and in 20 cases, spinal neoplasia was confirmed by necropsy, biopsy, histopathology, and immunohistochemistry. In the other eight animals, the presumptive diagnosis was based on clinical and neurological signs and by observing changes in plain radiographs of the spine, chest radiographs, and myelography. The location of the lesion was established as cervical, cervicothoracic, thoracolumbar, or lumbosacral, and the lesion was determined to be multifocal when clinical signs appeared in more than one location. Spinal cord injury was additionally classified as unilateral, bilateral, symmetrical, or asymmetrical. The following complementary examinations were performed based on the clinical suspicion, indications, and availability of the owner: complete blood count, serum biochemical profile, urinalysis, spinal radiography, cerebrospinal fluid analysis (CSF), myelography, abdominal ultrasound, thoracic X-ray to determine metastases, and Computed Tomography. CSF was collected and analyzed in seven animals, and pleocytosis with a predominance of lymphocytes was found in two cases. Decompression and exploratory surgeries were performed in six dogs to confirm the suspected diagnosis and collect tissues for histopathology. The final diagnosis was made by histopathological examination of the tissue obtained by excisional biopsy or necropsy after the death of the animal or euthanasia. In eight cases, the neoplasia type could not be confirmed as the owner did not provide consent to perform exploratory surgery or necropsy. The dogs most affected were poodles (17.85%) and boxers (17.85%), between the ages of 5 and 10 years, and 67.85% of the cases were female dogs. The thoracolumbar region was the most affected (50%). Metastatic spinal tumors predominated; especially those originating in the mammary gland (38.46%) and on the skin (34.61%), and among the primary neoplasms, meningiomas predominated. The clinical course in relation to the onset of symptoms of neurological dysfunction, until death or euthanasia, ranged from 1-170 days, with an average 42 days of survival.Discussion: The results differ from previous studies, in which the number of male and female dogs with neoplasms in the CNS was the same, as in the present study female dogs were more affected. Unlike other studies, metastatic spinal tumors predominated. After the diagnosis, the survival was short and this may be due to the fact that most dogs in this study already had more than one system affected, and consequently showed significant changes related to systemic metastases during the onset of the neurological symptoms. The surgical treatment presented variable results, and the results observed after surgical resection of neoplasms vary due to the location in relation to the spinal cord, neoplasm type, severity of the clinical signs, and possibility of removal along with margin without causing spinal instability. In dogs with spinal disorders, the veterinary practitioner should suspect cancer, especially if there is a history of excision of neoplasms in other systems.

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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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DIFFERENTIAL SIGNS IN THE DIAGNOSIS OF CONSTRICTIVE MYELOPATHY AND SPINAL NEOPLASMS IN THE THORACOLUMBAR REGION

Scientific Notes Kazan Bauman State Academy of Veterinary Medicine ◽

10.31588/2413-4201-1883-246-2-283-287 ◽

2021 ◽

Vol 246 (2) ◽

pp. 283-287

Author(s):

I.R. Yunsi ◽

◽

T.A. Bykovskaya ◽

Keyword(s):

Spinal Cord ◽

Differential Diagnosis ◽

Spinal Column ◽

Spinal Tumors ◽

Spinal Neoplasms ◽

Intramedullary Tumors ◽

Thoracolumbar Region ◽

Intradural Extramedullary ◽

Vertebral Bodies ◽

Extradural Space

Neoplasms of the spinal column and spinal cord, depending on their localization relative to the spinal cord and its membranes, are classified into extradural, intradural extramedullary and intramedullary. Extradural tumors are located outside the dura mater. This category includes tumors of the vertebral bodies and tumors lying in the extradural space of the spinal canal. Intradural extramedullary tumors are found within the dura but outside the spinal parenchyma. Intramedullary tumors originate within the spinal cord and are the rarest group of spinal tumors. The aim of the study is to determine the criteria for the differential diagnosis of studied pathology.

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Republished: Ruptured aneurysm of the artery of Adamkiewicz: is conservative management the standard of treatment in the current era?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013194.rep ◽

2018 ◽

Vol 10 (8) ◽

pp. e22-e22 ◽

Cited By ~ 3

Author(s):

Pedro Aguilar-Salinas ◽

Jussie Lima ◽

Leonardo B C Brasiliense ◽

Ricardo A Hanel ◽

Eric Sauvageau

Keyword(s):

Spinal Cord ◽

Conservative Management ◽

Collateral Circulation ◽

Fusiform Aneurysm ◽

Spontaneous Thrombosis ◽

Complete Occlusion ◽

Artery Of Adamkiewicz ◽

Spinal Subarachnoid Hemorrhage ◽

Case Basis

Spinal aneurysms are rare lesions, and their natural history is not well known. In particular, aneurysms arising from the artery of Adamkiewicz (AA) are an extremely rare phenomenon, and given the lack of solid evidence its management remains unclear. We present the case of a 54-year-old woman with spinal subarachnoid hemorrhage. A spinal angiogram demonstrated a fusiform aneurysm arising from the AA. Based on the location, the absence of evident collateral circulation to the anterior spinal artery, and the available literature supporting spontaneous thrombosis, we opted for conservative management. Fifteen days after the diagnosis, a spinal angiogram demonstrated complete occlusion of the aneurysm with no visualization of the AA. At 10-month follow-up, the patient was able to walk without assistance. Management should be done on a case-by-case basis with the goal of preserving spinal cord perfusion. Similar to previous articles, our report reinforces conservative management as a valid strategy.

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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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