Spinal cord ischemia after resection of thoracoabdominal aortic aneurysms: MR findings in 24 patients

MR images of the thoracic spinal cord were made in 24 patients who developed signs and symptoms of spinal cord ischemia or infarction following surgery for a thoracoabdominal aortic aneurysm. Findings consisted primarily of four different patterns of signal abnormalities in the distribution of the anterior spinal artery. These abnormalities were identified as types A-D, depending on the degree of involvement of the gray matter and surrounding white matter. We found good correlation between the distribution of the signal abnormalities in the cord, the severity of the neurologic deficits, and the clinical outcome. MR is the imaging method of choice for diagnosing spinal cord ischemia or infarction. A thorough knowledge of the spinal cord arterial territories is crucial for characterizing ischemic MR signal abnormalities and for differentiating them from other causes of myelopathy.     

Spinal cord ischemia after resection of thoracoabdominal aortic aneurysms: MR findings in 24 patients

MR images of the thoracic spinal cord were made in 24 patients who developed signs and symptoms of spinal cord ischemia or infarction following surgery for a thoracoabdominal aortic aneurysm. Findings consisted primarily of four different patterns of signal abnormalities in the distribution of the anterior spinal artery. These abnormalities were identified as types A-D, depending on the degree of involvement of the gray matter and surrounding white matter. We found good correlation between the distribution of the signal abnormalities in the cord, the severity of the neurologic deficits, and the clinical outcome. MR is the imaging method of choice for diagnosing spinal cord ischemia or infarction. A thorough knowledge of the spinal cord arterial territories is crucial for characterizing ischemic MR signal abnormalities and for differentiating them from other causes of myelopathy.     

Spinal cord infarction complicating acute aortic syndrome: about 2 cases

Spinal cord infarction is an uncommon but devastating disorder caused by various conditions. It remains however a rare neurological complication in acute aortic injuries. In this context, aortic dissection is the most frequent etiological factor. Acute aortic intra mural hematoma and atheromatous penetrating ulcer remain exceptional. We encountered two cases of spinal cord infarction associated with acute aortic intra mural hematoma in one case and atheromatous penetrating ulcer in the other case that presented without typical severe pain. Thus, acute aortic injuries should be considered a cause of spinal cord infarction even if there is little or no pain.     

Spinal cord vascularity. I. Extraspinal sources of spinal cord arteries in man.

The arrangement of extraspinal sources of the spinal cord arterial supply in man is more complicated than previously described, especially with regard to the origin and branching of the aortic segmental arteries. The fact that other arteries in the neck than the vertebral artery, such as the costo-cervical trunk and the ascending cervical artery may contribute to the supply of the cervical cord is confirmed, and also the occurrence of two or more spinal branches from different sources entering the same intervertebral foramen. Frequent occurrence of two or more segmental arteries arising from a common stem and variations in the branching of the subcostal arteries were found; their functional significance on the spinal cord circulation is not known. The fact that no significant anterior root artery was ever seen at the level of the vascular anomaly suggests that the anomaly is of no clinical importance. Nevertheless, obstruction of a common stem entail the risk of spinal cord infarction due to involvement of an important posterior root artery. On the other hand, the spinal cord seems to be fairly well protected against ischaemic injury following limited interference with the extraspinal arteries due to a profuse supply of intra- and extraspinal collaterals.     

A ruptured dissecting aneurysm of the anterior radiculomedullary artery caused by vertebral angiography

We report here a 54-year-old man with an aneurysm arising on a cervical anterior radiculomedullary artery. The aneurysm ruptured just after vertebral angiography for a vascular anomaly of the brain, and it appeared to be fusiform, with thrombosis following angiography. Considering the sequential radiological studies and clinical course, it was assumed to be a dissecting aneurysm caused by the angiography. MRI showed severe swelling of the cervical spinal cord and an infarct in the territory of the anterior spinal artery. The mechanism of this rare complication is discussed. Received: 29 March 1999 Accepted: 18 August 1999     

Spinal cord watershed infarction: Novel findings on magnetic resonance imaging

Spinal cord watershed ischemia is a rare phenomenon often associated with cardiac arrest, prolonged hypotension, and atherosclerotic disease. It can manifest as central necrosis with peripheral sparing in the transverse axis, and central lesion with rostral and caudal sparing in the longitudinal axis. Few reports provide detailed imaging findings of spinal cord watershed ischemia lesions. We present a patient who experienced watershed infarcts of the brain and spinal cord following prolonged hypotension due to blood loss after an aortic aneurysm repair. The patient experienced loss of neurologic function of the lower extremities and left arm that did not recover following spinal cord ischemia protocol. MRI revealed spinal cord watershed ischemia in both the longitudinal and axial planes with the point of maximal T2 signal hyperintensity in the central cord at T10-T11. Unique findings included zones of central maximal T2 signal hyperintensity with peripheral sparing, and moderate T2 intensity representing partial ischemia between regions of maximal T2 intensity unaffected peripheral regions. Thoracoabdominal computed tomography angiogram revealed extensive intraluminal thrombus and bilateral spinal artery occlusion from T8 to L2 and bilateral severe renal artery stenosis. T7 and L3 spinal arteries were patent. We suspect preexisting atherosclerotic disease played a significant role in the development of widespread watershed lesions following prolonged hypotension and resulted in a clinical and imaging presentation distinct from that seen with isolated anterior spinal artery occlusion. Our unique MRI findings portray a rarely documented pattern of spinal cord watershed ischemia and prompt questions about the role of anatomic idiosyncrasies and preexisting vascular disease in the development of spinal cord watershed ischemia.     

MRA of the Adamkiewicz artery: a preoperative study for thoracic aortic aneurysm

PURPOSE: The purpose of this work was to investigate the ability of MR angiography (MRA) to visualize the Adamkiewicz artery (AKA) as a preoperative study of thoracic aortic aneurysm to prevent ischemic injury of the spinal cord. METHOD: Twenty-six patients scheduled for surgical or endovascular stent-graft repair of thoracic aortic aneurysm were studied with a three-dimensional contrast MRA. Data acquisition was repeated two times following injection of Gd-DTPA. Source images were processed with multiplanar reconstruction and maximum intensity projection. RESULTS: The AKA was identified in 69% (18/26). In three patients, selective angiography of the intercostal artery confirmed the AKA at the same level and side predicted by MRA. The anterior spinal artery and the anterior medullary vein were observed in 50% (13/26) and 65% (17/26), respectively. CONCLUSION: Contrast MRA is a promising technique to visualize the AKA noninvasively as a preoperative evaluation of thoracic aortic aneurysms.     

Spinal cord infarction: MR imaging and clinical features in 16 cases

Spinal cord infarctions are rare and due to heterogeneous etiologies. The aim of the study was to analyze the MR imaging findings and evaluate their correlations with clinical symptoms in ischemic spinal cord lesions. MR images and clinical features of 16 patients (11 male, 5 female) with typical sudden onset of neurological deficits caused by spinal cord ischemia were evaluated. MR imaging was performed within 2 h to 14 days after the initial neurological symptoms. Eight patients had follow-up examinations including contrast-enhanced MR imaging. MR abnormalities were best demonstrated on sagittal T2-weighted images, with "pencil-like" hyperintensities (16/16) and cord enlargement (9/16). Axial T2-weighted images showed bilateral (13/16) and unilateral (3/16) hyperintensities according, in 15 patients, to anterior spinal artery (ASA) territory, with three of them located particularly in the spinal sulcal artery territory. In one patient only the posterior spinal artery (PSA) territory was involved. Spinal cord was affected at the cervical level (especially C2-C3) in seven patients, at the upper thoracic level (T3-T5) in two patients and at the thoracolumbar region including the conus medullaris (T10-L1) in seven patients. Presumed etiologies were vascular surgery (3 patients), infrarenal aortic aneurysm (1 patient), bilateral vertebral artery dissection (1 patient), hypotension (1 patient), spine operation (1 patient), excessive cocaine misuse (1 patient) and cardioembolic vertebral artery occlusion (1 patient); six of seven patients with unclear etiologies had vascular risk factors such as hypertension, diabetes and cigarette smoking. MR imaging is therefore useful in detecting spinal cord infarction, with axial T2-weighted images showing hyperintensities in the ASA territory in 15 of 16 patients. Contrary to the presumed spinal cord watershed at the lower cervical and upper thoracic level, and despite numerous central arteries in the cervical cord, our data suggest a high ischemic vulnerability of the cervical spinal cord at level C2-C3.     

Aortic pathology revealed by MRI in patients with clinical suspicion of spinal disease

In five patients with clinical suspicion of spinal disease, MRI of the spine revealed unexpected aortic pathology explaining the symptoms. No significant intraspinal pathology was found on MRI. However, in one patient with clinical suspicion of spinal stenosis, an aortic occlusion was detected on MR images of the spine. The lower extremity ischaemia, caused by the occlusion, was responsible for the symptoms. In another patient a paravertebral haematoma from a ruptured aortic aneurysm resulted in spinal nerve compression, thought before MRI to be caused by a spinal tumour. In three patients aortic aneurysm or dissection resulted in spinal cord ischaemia with symptoms mimicking those of compressive spinal disease. Thus, if MRI of the spine does not provide an explanation for the patient's symptoms, examination of the aorta is recommended.     

Case report 582

A patient with Marfan syndrome presented with enlargement of lumbosacral spinal canal with a bulky meningocele, and a fusiform aneurysm of the ascending aorta. In Marfan syndrome, the presence of a meningocele is extremely rare, but 60% of the patients develop cardio-vascular complications (a frequent cause of death). MRI is the imaging technique of choice for the diagnosis of meningocele and aortic aneurysm.     

Neurologic injury after endovascular stent-graft and bilateral internal iliac artery embolization for infrarenal abdominal aortic aneurysm

The authors report a rare neurologic complication after the implantation of a bifurcated stent-graft for abdominal aortic aneurysm. The stent-graft was extended to both external iliac arteries after embolization of both internal iliac arteries. The patient subsequently had weakness and numbness of both lower limbs with bowel and bladder incontinence. He probably had ischemic injury to the nerve roots or the lumbosacral plexus, which was related to extensive occlusion of their supplying arteries. The mechanism of spinal cord and neurologic ischemia after aortic stent-graft implantation is discussed.     

MR angiography of the Adamkiewicz artery and anterior radiculomedullary vein: postmortem validation

SUMMARY: Spinal cord arteries and veins are difficult to visualize and distinguish by MR angiographic techniques because of their small sizes, similar spatial course, and close vascular anatomy. Contrast-enhanced MR angiography was demonstrated to dynamically resolve the Adamkiewicz artery from the anterior radiculomedullary vein in the thoracolumbar spinal cord. The location of the Adamkiewicz artery and the anterior radiculomedullary vein could be validated in the postmortem specimen of a thoracoabdominal aortic aneurysm patient.     

Ruptured intracranial aneurysm associated with isolated aortic arch interruption

Interruption of the aortic arch is a very rare congenital defect consisting of discontinuity between the ascending and descending aorta. Few patients survive to adulthood, due to effective collateral arterial flow to the descending aorta. An intracranial aneurysm is reported in only one patient with aortic arch interruption. We report a 16-year-old boy with an isolated aortic arch interruption and a ruptured anterior communicating artery aneurysm. Received: 30 November 1999 Accepted: 31 January 2000     

MRI in presumed cervical anterior spinal artery territory infarcts

WE report the MRI findings in two patients with presumed cervical spinal cord infarcts in the anterior spinal artery territory. MRI revealed abnormal signal intensities and/or band-like enhancement in the anterior two-thirds of the cervical spinal cord, corresponding to the vascular territory of the anterior spinal artery. Clinically there was an anterior spinal cord syndrome.     

MR imaging and angiography of cerebral venous angiomas associated with brain tumors

Summary Cervical spinal cord lesions in the anterior spinal artery syndrome were delineated on magnetic resonance images (MRI) in four patients. The lesion was always seen anteriorly in the cervical cord. On T2-weighted images, the lesions appeared hyperintense relative to the normal spinal cord, while on T1-weighted images, two chronic lesions appeared hypointense, with local atrophy of the cord. In one case, repeated T1-weighted images showed no signal abnormality 4 days after the ictus, but the lesion became hypointense 18 days later, when contrast enhancement was also recognized after injection of Gd-DTPA; this sequence of intensity changes was similar to that of cerebral infarction. The extent of the lesion seen MRI correlated closely with neurological findings in all cases. Although the findings may not be specific, MRI is now the modality of choice for confirming the diagnosis in patients suspected of having an anterior spinal artery syndrome.     

Idiopathic dural herniation of the thoracic spinal cord

Symptomatic anterior or anterolateral dural herniation of the spinal cord is rare, and not uncommonly misdiagnosed, both clinically and radiologically. We present four patients with a radiological diagnosis of herniation of the thoracic spinal cord, and review the current literature. All affected patients have been adults, typically presenting with long-standing, unexplained sensory symptoms and eventually developing a Brown-Séquard syndrome, with or without motor changes. Herniation occurs in the upper or midthoracic region, between the T2 and T8 levels.     

Syphilitic aneurysm of descending thoracic aorta causing vertebral body erosion and spastic paraparesis

Bone erosion from a syphilitic aortic aneurysm is uncommon, having been reported in only a few cases. Vertebral body erosion by a syphilitic aortic aneurysm is rarely associated with neurological deficits. We report a case of a syphilitic aneurysm of the descending thoracic aorta with associated vertebral body erosion and spinal cord compression causing spastic paraparesis.     

Migrating subdural hematoma without subarachnoid hemorrhage in the case of a patient with a ruptured aneurysm in the intrasellar anterior communicating artery

Acute spontaneous subdural hematoma without the presence of a subarachnoid hemorrhage as a result of a ruptured aneurysm is rare. We present the case of a patient with an aneurysm of the intrasellar anterior communicating artery that caused hemorrhage solely into the subdural space. The hemorrhage then migrated down the spinal canal. Our case is unique because all these 3 rare processes occurred in a single patient. Identification of the cause of this type of hemorrhage in a timely fashion is crucial to the management of such a patient.     

Aortic dissection with concurrent abdominal aortic aneurysm: computed tomography diagnosis

Thoracic aortic dissection in association with preexisting abdominal aortic aneurysm is rare. An illustrative case is presented in which an additional complication of contained aortic rupture and renal infarction occurred. Computed tomography was the primary diagnostic modality.     

Spinaler Infarkt

Infarction of the spinal cord can cause a variety of symptoms and neurological deficits because of the complex vascular supply of the myelon. The most common leading symptom is distal paresis ranging from paraparesis to tetraplegia caused by arterial ischemia or infarction of the myelon. Venous infarction, however, cannot always be distinguished from arterial infarction based on the symptoms alone.Modern imaging techniques, such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA) assist in preoperative planning of aortic operations to reliably identify not only the most important vascular structure supplying the spinal cord, the artery of Adamkiewicz, but also other pathologies such as tumors or infectious disorders. In contrast to CT, MRI can reliably depict infarction of the spinal cord.