Anterior spinal artery

In blockade of the anterior spinal artery, ischemia of the medial medulla may occur with contralateral hemiparesis, ipsilateral tongue weakness and contralateral loss of posterior column sensation (Ho and Meyer 1981). 

Vertebral arteries vary in size and symmetry, where mostly the left vertebral artery is the dominant one. The coincidence of vertebral fenestrations and aneurysms is well known. The anterior spinal artery receives tiny vessels from the vertebral arteries which are physiologically not depicted by MRA due to their size. The posterior inferior cerebellar artery (PICA) as the largest, most important and most variable cerebellar artery however, under normal conditions it is constantly depictable with TOF and CE-MRA. 

Medullary infarcts can be medial, lateral or combined (Fig. 14.6). The medial territory is supplied by penetrating vessels from the anterior spinal artery and the distal vertebral artery. The lateral territory main arterial supply comes from penetrating arteries from the distal vertebral artery and the posterior inferior cerebellar artery. The small posterior territory is supplied by the posterior spinal artery and the posterior inferior cerebellar artery. Medial... 

Fig. 17.2. a Superficial arteries of the spinal cord. X-ray film of an injected specimen in a.p. view. The anterior spinal artery system is visible on the ventral surface of the cord, b Intrinsic spinal cord arteries. X-ray microangiogram of a transverse section (lumbar enlargement). The sulcal or central artery within the anterior fissure (arrow) is dominant. Note the posterior and posterolateral spinal arteries at both sides of the posterior root entry zone (arrowheads). AST, anterior spinal artery... 

Those spinal radicular arteries that are radiculo-medullary arteries, supplying nerve root, pial plexus and medulla, branch in a very typical way to form the anterior spinal artery. The ascending branch continues the direction of the radicular artery in the midline of the anterior surface. The descending branch, being the larger one at thoracolumbar levels, forms a hairpin curve as soon as it reaches the midline at the entrance of the anterior fissure (Fig. 17.3). The artery runs above the vein. The maximum diameter of a spinal radiculomedullary artery or the anterior... 

Fig. 17.3. Selective spinal DSA in a 59-year-old woman, p.a. projection. Injection of the 12th left thoracic segmental artery. Filling of the radiculomedullary arteries T12 and T10 on the left side (arrows) and the anterior spinal artery system. Collateral filling of the right-sided segmental arteries via retrocorpo-ral anastomoses (arrowheads). These extradural anastomoses can compensate for focal vessel occlusions at the level of the radicular artery...

AVMs of the perimedullary fistula type are direct AV shunts that are located on the ventral or dorsal surface of the spinal cord or the conus medullaris, usually in the thoracolumbar area, occasionally thoracic, and rarely cervical. Their location thus is intradural, intra- or extramedullary. They are always supplied by spinal cord vessels, either by the anterior spinal artery (ventrally) or by a posterolateral artery (dorsally), depending on their location. They drain into spinal cord veins (Fig. 17.12). Drainage may even ascend up to the foramen magnum or into the posterior fossa. 

Even if spatial and contrast resolution of these imaging modalities will increase in the future, it might be difficult to differentiate the artery from the vein on the anterior surface of the cord. The anterior spinal artery and vein run very close together. The branching of a radicular artery or vein has a very similar hairpin-configuration, and the level at which a segmental in- or outflow occurs cannot be predicted in a given case. 

Selective spinal DSA has a better spatial resolution and plays a main role in the exclusion of spinal vascular malformations. In selected cases affection of the radicular artery and occlusion of the anterior spinal artery system can be demonstrated as well as collateral supply even in the later course of the ischemia (Mull et al. 2002). Thus, spinal DSA helps to identify pathologic vascular conditions in spinal cord ischemia. The main indication remains to exclude a spinal vascular malformation. Angiographic information about the acute phase of spinal cord ischemia is not yet available. 

Haddad MC, Aabed al-Thagafi MY, Djurberg H (1996) MRI of spinal cord and vertebral body infarction in the anterior spinal artery syndrome. Neuroradiology 38 161-162 HasslerW, Thron A, Grote EH (1989) Hemodynamics of spinal dural arteriovenous fistulas. An intraoperative study. JNeu-rosurg 70 360-370... 

Rosenblum B, Oldfield EH, Doppman JL, Di Chiro G (1987) Spinal arteriovenous malformations a comparison of dural arteriovenous fistulas and intradural AVM s in 81 patients. J Neurosurg 67 795-802 Rosenkranz M, Grzyska U, Niesen W, Fuchs K, Schummer W, Weiller C, Rother J (2004) Anterior spinal artery syndrome following periradicular cervical nerve root therapy. J Neurol 251 229-231... 

Spiller W (1909) Thrombosis of the cervical anterior median spinal artery. I Nerv Ment Dis 36 601 Stein SC, Ommaya AK, Doppman JL, Di Chiro G (1972) Arteriovenous malformation of the cauda equina with arterial supply from branches of the internal iliac arteries. Case report. J Neurosurg 36 649-651 Stepper F, Lovblad KO (2001) Anterior spinal artery stroke demonstrated by echo-planar DWI. Eur Radiol 11 2607-2610 Suh T.H., Alexander L (1939) Vascular system of the human spinal cord. Arch Neurol Psychiat 41 659-677 Suzuki T, Kawaguchi S, Takebayashi T, Yokogushi K, Takada J, Yamashita T (2003) Vertebral body ischemia in the posterior spinal artery syndrome case report and review of the literature. Spine 28 E260-264... 

The authors suggested that the neurological deficit had been due to anterior spinal artery insnfficiency secondary to intrathecal bupivacaine and adrenahne. They questioned the use of adrenaline in patients with mnlti-organ vascular disease. 

Communications between bronchial arteries and systemic vessels are ubiquitous, and can sometimes complicate an embolization procedure. The most commonly seen communication is that of a right intercostobronchial trunk with an anterior medullary artery that contributes to the vascular supply of the spinal cord through the anterior spinal artery. The anterior medullary arteries have a characteristic hairpin configuration, and follow a course... 

Fig. 16.6. a Selective angiography of right inter-costobronchial trunk, early phase, b Selective angiography of right intercostobronchial trunk, late phase demonstrating thin arterial structure, with course parallel to vertebral column anterior spinal artery (arrowheads)... 

Because transvenous embolization is not feasible for spinal lesions, transarterial embolization with glue is the treatment of choice for a spinal DAVM with an arterial feeder that allows safe and distal catheterization and does not supply the anterior spinal artery. Glue should be pushed until it reaches the draining vein (Fig. 4.18) (Cognard et al. 1996 Song et al. 2001). Clinical outcome seems to dependent on the severity of the symptoms at the time of treatment (Nagata et al. 2006). 

The treatment of spinal DAVM by surgery is easy, safe, and effective and requires interruption of the draining vein at its dural entrance only (Anson and Spetzler 1992). Therefore, embolization of spinal DAVM should be offered only if the feeding pedicle provides a safe approach to a position close to the fistula site and it does not give rise to radiculomedullary branches supplying the anterior spinal artery. If there is a risk of reflux into the anterior spinal artery, surgery is significantly safer and should be performed. 

Lavoie P, Raymond J, Roy D, Guilbert F, Weill AJ (2007) Selective treatment of an anterior spinal artery aneurysm with endosaccular coil therapy. Case report. Neurosurg Spine 6(5) 460-464... 

Technical Considerations Catheterization of the bronchial arteries is best approached from the femoral artery. Since most patients with lung cancer are older and the aorta is tortuous and atherosclerotic, a 5-F catheter with good torque control in a shepherd s crook (reverse curve) or forward seeking configuration is recommended. A finely tapered tip catheter for access which would allow a 3-F microcatheter coaxial system is optimal to bypass the spinal artery. The use of nonionic contrast media should minimize pain and the risk of contrast media-induced complications. The digital subtraction technique is of value for the identification of the anterior spinal artery with small branches to the spinal cord. 

The arterial blood supply of the spinal cord is provided by the unpaired anterior spinal artery (ASA) and the paired posterior spinal arteries. These vessels constitute a longitudinally orientated arterial system that is interconnecting with numerous arteries entering transversely and resembling the segmental embryology of the spine (Gillilan 1958 Lasjaunias and Berenstein 1990). 

Fig. 24.1. Anatomy of feeding arteries of the spinal cord. 1 vertebral artery, 2 left subclavian artery, 3 posterior intercostal artery, 4 anterior spinal artery, 5 Adamkiewicz artery,...

Fig. 24.2. a Patient with thoracoabdominal penetrating aortic ulcer, b Transverse section at TIO, with evidence of anterior spinal artery, ASA (J) being accompanied by a second artery (Adamkiewicz artery [AKA]) (2). C Oblique coronal reforma-... 

Fig. 24.3. a Oblique coronal MIP (3 mm) for excellent depiction of anterior spinal artery, ASA (J), and AKA (2). b MIP of a curved MPR with bone removal demonstrating a general view at the segmental arteries in one image and with depiction of... 

Fig. 24.4a,b. Oblique sagittal MIP and volume rendering after manual bone removal of the spine with continuous vessel delineation from aorta to anterior spinal artery, ASA... 

Especially because GARY exhibit a comparable spatial configuration and course, challenges in identifying the AKA occur frequently when concomitant veins are already contrast enhanced at the time of data acquisition (Jaspers et al. 2007). To distinguish artery from vein, verification of continuity between the aorta, the suspected vessel, and the anterior spinal artery is certainly the most reliable criterion to aim at and is most notably documented on MIP and curved MPR. More-... 

---