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Tan Z, Lo DYK, Narasimhalu K. Neurophysiological findings in conus medullaris infarction-a case report and systematic review of the literature. Acta Neurol Belg 2024; 124:1323-1333. [PMID: 38656476 DOI: 10.1007/s13760-024-02553-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/07/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Conus medullaris infarction (CMI) is a rare vascular phenomenon that has been scarcely reported in the literature. While previous studies have described the clinical and radiological features of CMI, little attention has been paid to its associated neurophysiological findings. METHODS We present a case of idiopathic CMI and its neurophysiological findings, then present our findings from a systematic review of other reports of CMI with neurophysiological features found via PubMed search. RESULTS Nine articles describing ten cases of CMI with associated neurophysiological data were found, in addition to our case. Out of all 11 cases, 7 cases (64%) had absent F-waves on the first nerve conduction study (NCS) performed as early as 4 h after onset, 5 of whom demonstrated reappearance of F-waves on subsequent follow-up NCS. Seven patients (64%) had diminished compound muscle action potentials (CMAPs), which was usually detectable on NCS performed between day 8 and day 18 of onset. None of them showed recovery of CMAPs in follow-up studies. Four patients (36%) had absent H-reflexes and two patients (18%) had sensory abnormalities. Electromyography (EMG) was reported in seven patients (64%), showing reduced recruitment as early as day 1 of onset, and denervation potentials as early as 4 weeks after onset. CONCLUSION Absent F-waves and diminished CMAPs are the most common NCS abnormalities in CMI. Absent F-waves are detectable very early but tend to recover on subsequent NCS, while diminished CMAPs are detectable later but do not seem to resolve. Further research to determine the utility of neurophysiological studies in CMI diagnosis and prognostication is needed.
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Affiliation(s)
- Zhibin Tan
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), 20 College Road, Singapore, 169856, Singapore.
- Neuroscience Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Duke-NUS Medical School, Singapore, Singapore.
| | - Daryl Yin Keong Lo
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), 20 College Road, Singapore, 169856, Singapore
| | - Kaavya Narasimhalu
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), 20 College Road, Singapore, 169856, Singapore
- Neuroscience Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Duke-NUS Medical School, Singapore, Singapore
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Yoshida K, Niimi Y, Kamamoto D, Fukumura M, Imai R, Nagoshi N, Akiyama T. Targeted embolisation for coexisting conus medullaris arteriovenous malformation and cauda equina arteriovenous fistulas with a varix on a shared drainer †. Br J Neurosurg 2023; 37:1200-1205. [PMID: 33034527 DOI: 10.1080/02688697.2020.1830948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The coexistence of vascular malformations in the conus medullaris and cauda equina has been rarely reported, and the complex angioarchitecture in multiple arteriovenous lesions remains poorly understood. CASE DESCRIPTION A 17-year-old woman presented with a sudden-onset, stepwise worsening of weakness and pain in the bilateral legs. Angiography revealed conus medullaris arteriovenous malformation and cauda equina arteriovenous fistulas. One of the drainers was shared between the coexisting lesions and harboured a varix. Targeted embolisation of a fistulous point in the conus lesion was performed with precaution to prevent occluding the common drainage route, which led to symptom improvement with angiographical diminishment of the varix. CONCLUSIONS Recognising that communications between drainers can be observed in multiple spinal arteriovenous lesions is important in facilitating a safe embolisation. Cautious assessment of angiogram with fusion images of cone-beam computed tomography and volumetric T2 magnetic resonance imaging can help in establishing the diagnosis and treatment strategy.
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Affiliation(s)
- Keisuke Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Dai Kamamoto
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Mariko Fukumura
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryotaro Imai
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takenori Akiyama
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
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Zhang QY, Xu LY, Wang ML, Cao H, Ji XF. Spontaneous conus infarction with "snake-eye appearance" on magnetic resonance imaging: A case report and literature review. World J Clin Cases 2023; 11:2074-2083. [PMID: 36998945 PMCID: PMC10044943 DOI: 10.12998/wjcc.v11.i9.2074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/27/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Infarction of the conus medullaris is a rare form of spinal cord infarction. The first symptom is usually acute non-characteristic lumbar pain, followed by lower limb pain, saddle numbness, fecal incontinence, and sexual dysfunction. Spontaneous conus infarction with "snake-eye appearance" on magnetic resonance imaging has rarely been reported.
CASE SUMMARY We report a 79-year-old male patient with spontaneous conus infarction who had acute lower extremity pain and dysuria as the first symptoms. He did not have any recent history of aortic surgery and trauma. Magnetic resonance imaging revealed a rare "snake-eye appearance." In addition, we reviewed the literature on 23 similar cases and summarized the clinical features and magnetic resonance manifestations of common diseases related to the "snake-eye sign" to explore the etiology, imaging findings, and prognosis of spontaneous conus infarction.
CONCLUSION We conclude that acute onset of conus medullaris syndrome combined with "snake-eye appearance" should be strongly suspected as conus medullaris infarction caused by anterior spinal artery ischemia. This special imaging manifestation is helpful in the early diagnosis and treatment of conus infarction.
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Affiliation(s)
- Qiao-Yu Zhang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
- Department of Neurology, Nanchuan People's Hospital Affiliated to Chongqing Medical University, Chongqing 408400, China
| | - Lin-Ying Xu
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Ming-Li Wang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Hua Cao
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Xiao-Fei Ji
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
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Chou D, Narsinh K. Editorial. The relevance of the artery of Adamkiewicz in the 21st century. J Neurosurg Spine 2023; 38:230-231. [PMID: 36152328 DOI: 10.3171/2022.6.spine22532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Dean Chou
- 1Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York; and
| | - Kazim Narsinh
- 2Department of Radiology, University of California, San Francisco, California
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Alvernia JE, Simon E, Khandelwal K, Ramos CD, Perkins E, Kim P, Mertens P, Messina R, Luzardo G, Diaz O. Anatomical study of the thoracolumbar radiculomedullary arteries, including the Adamkiewicz artery and supporting radiculomedullary arteries. J Neurosurg Spine 2023; 38:233-241. [PMID: 36152330 DOI: 10.3171/2022.5.spine2214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this paper was to identify and characterize all the segmental radiculomedullary arteries (RMAs) that supply the thoracic and lumbar spinal cord. METHODS All RMAs from T4 to L5 were studied systematically in 25 cadaveric specimens. The RMA with the greatest diameter in each specimen was termed the artery of Adamkiewicz (AKA). Other supporting RMAs were also identified and characterized. RESULTS A total of 27 AKAs were found in 25 specimens. Twenty-two AKAs (81%) originated from a left thoracic or a left lumbar radicular branch, and 5 (19%) arose from the right. Two specimens (8%) had two AKAs each: one specimen with two AKAs on the left side and the other specimen with one AKA on each side. Eight cadaveric specimens (32%) had 10 additional RMAs; among those, a single additional RMA was found in 6 specimens (75%), and 2 additional RMAs were found in each of the remaining 2 specimens (25%). Of those specimens with a single additional RMA, the supporting RMA was ipsilateral to the AKA in 5 specimens (83%) and contralateral in only 1 specimen (17%). The specimens containing 2 additional RMAs were all (100%) ipsilateral to their respective AKAs. CONCLUSIONS The segmental RMAs supplying the thoracic and lumbar spinal cord can be unilateral, bilateral, or multiple. Multiple AKAs or additional RMAs supplying a single anterior spinal artery are common and should be considered when dealing with the spinal cord at the thoracolumbar level.
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Affiliation(s)
- Jorge E Alvernia
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
- 2Brain and Spine Associates, Monroe, Louisiana
| | - Emile Simon
- 3Department of Neurosurgery, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Bron, France
- 4Laboratory of Anatomy, Faculty of Medicine Lyon Est, Claude Bernard University Lyon 1, Lyon, France
| | | | - Cara D Ramos
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
| | - Eddie Perkins
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
| | - Patrick Kim
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
| | - Patrick Mertens
- 3Department of Neurosurgery, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Bron, France
- 4Laboratory of Anatomy, Faculty of Medicine Lyon Est, Claude Bernard University Lyon 1, Lyon, France
| | - Raffaella Messina
- 5Division of Neurosurgery University "Aldo Moro" of Bari, Italy; and
| | - Gustavo Luzardo
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
| | - Orlando Diaz
- 6Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
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Iampreechakul P, Liengudom A, Lertbutsayanukul P, Siriwimonmas S, Pongpech S. Remote Intramedullary Hemorrhage in the Thoracic Spinal Cord Secondary to a Perimedullary Arteriovenous Fistula of the Distal End of Conus Medullaris Mimicking Filum Terminale Arteriovenous Fistula: A Case Report. Asian J Neurosurg 2022; 17:88-94. [PMID: 35873833 PMCID: PMC9298594 DOI: 10.1055/s-0042-1748791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Perimedullary arteriovenous fistulas (PMAVFs) of the conus medullaris are rare and usually manifest with progressive myelopathy secondary to venous congestion resulting from retrograde arterialization of the draining vein into the spinal cord. We present a rare case of conus PMAVF presenting with remote intramedullary spinal cord hemorrhage in the thoracic cord. A 37-year-old woman was transferred to our institute due to sudden severe pain in the left lower leg and weakness of the lower extremities following progressive paresthesia of the lower extremities. Magnetic resonance imaging of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T6 with intramedullary hemorrhage at the level of T8–9 on the left side of the spinal cord. There were abnormal serpiginous intradural flow voids along the anterior surface of the spinal cord extending from the level of L2 to the lower cervical with venous varix at the level of T8–9, probably being the source of hemorrhage. Spinal angiography confirmed conus PMAVF at the distal end of the conus medullaris supplied by the sulco-commissural artery arising from the enlarged anterior spinal artery originating from the left T11 intercostal artery with cranial drainage through the dilated anterior spinal vein into the tortuous perimedullary veins up to the lower cervical level. The patient underwent successful endovascular treatment with N-butyl cyanoacrylate and had gradually improved until being ability to walk independently without residual pain of the left lower leg. We speculated that an increased venous flow into a varix may be considered an important risk factor of hemorrhage.
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Affiliation(s)
| | - Anusak Liengudom
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | | | | | - Sirintara Pongpech
- Division of Interventional Neuroradiology, Department of Radiology, Ramathibodi Hospital Medical School, Mahidol University, Bangkok, Thailand
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Koyanagi I, Chiba Y, Imamura H, Osanai T. Intradural lumbar radicular arteriovenous malformation mimicking perimedullary arteriovenous malformation of the conus medullaris: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2021; 2:CASE21551. [PMID: 36060427 PMCID: PMC9435550 DOI: 10.3171/case21551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/07/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Intradural radicular arteriovenous malformation (AVM) of the cauda equina is a rare entity of spinal AVMs. Because of the specific arterial supply of the conus medullaris and cauda equina, AVMs in this area sometimes present with confusing radiological features. OBSERVATIONS The authors reported a rare case of intradural radicular AVM arising from the lumbar posterior root. The patient presented with urinary symptoms with multiple flow void around the conus medullaris, as shown on magnetic resonance imaging. Digital subtraction angiography demonstrated arteriovenous shunt at the left side of the conus medullaris fed by the anterior spinal artery via anastomotic channel to the posterior spinal artery and rich perimedullary drainers. There was another arteriovenous shunt at the L3 level from the left L4 radicular artery. Preoperative diagnosis was perimedullary AVM with radicular arteriovenous fistula. Direct surgery with indocyanine green angiography revealed that the actual arteriovenous shunt was located at the left L4 posterior root. The AVM was successfully treated by coagulation of feeding branches. LESSONS Unilateral arteriovenous shunt fed by either posterior or anterior spinal artery at the conus medullaris may include AVM of the cauda equina despite abundant perimedullary venous drainage. Careful pre- and intraoperative diagnostic imaging is necessary for appropriate treatment.
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Affiliation(s)
- Izumi Koyanagi
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Hokkaido, Japan; and
| | - Yasuhiro Chiba
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Hokkaido, Japan; and
| | - Hiroyuki Imamura
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Hokkaido, Japan; and
| | - Toshiya Osanai
- Department of Neurosurgery, Hokkaido University, Hokkaido, Sapporo, Japan
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Iampreechakul P, Liengudom A, Lertbutsayanukul P, Siriwimonmas S, Pongpech S. Remote Intramedullary Hemorrhage in the Thoracic Spinal Cord Secondary to a Perimedullary Arteriovenous Fistula of the Distal End of Conus Medullaris Mimicking Filum Terminale Arteriovenous Fistula. Asian J Neurosurg 2021; 16:638-644. [PMID: 34660387 PMCID: PMC8477807 DOI: 10.4103/ajns.ajns_185_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/31/2021] [Accepted: 06/15/2021] [Indexed: 11/04/2022] Open
Abstract
Perimedullary arteriovenous fistulas (PMAVFs) of the conus medullaris are rare and usually manifest with progressive myelopathy secondary to venous congestion resulting from retrograde arterialization of the draining vein into the spinal cord. We present a rare case of conus PMAVF presenting with remote intramedullary spinal cord hemorrhage in the thoracic cord. A 37-year-old woman was transferred to our institute due to sudden severe pain in the left lower leg and weakness of the lower extremities following progressive paresthesia of the lower extremities. Magnetic resonance imaging of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T6 with intramedullary hemorrhage at the level of T8–9 on the left side of the spinal cord. There were abnormal serpiginous intradural flow voids along the anterior surface of the spinal cord extending from the level of L2 to the lower cervical with venous varix at the level of T8–9, probably being the source of hemorrhage. Spinal angiography confirmed conus PMAVF at the distal end of the conus medullaris supplied by the sulco-commissural artery arising from the enlarged anterior spinal artery originating from the left T11 intercostal artery with cranial drainage through the dilated anterior spinal vein into the tortuous perimedullary veins up to the lower cervical level. The patient underwent successful endovascular treatment with N-butyl cyanoacrylate and had gradually improved until being ability to walk independently without residual pain of the left lower leg. We speculated that an increased venous flow into a varix may be considered an important risk factor of hemorrhage.
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Affiliation(s)
| | - Anusak Liengudom
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | | | | | - Sirintara Pongpech
- Department of Radiology, Division of Interventional Neuroradiology, Ramathibodi Hospital Medical School, Mahidol University, Bangkok, Thailand
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Scheer M, Griesler B, Ottlik E, Strauss C, Mawrin C, Kunze C, Prell J, Rampp S, Simmermacher S, Illert J, Kielstein H, Scheller C. Variability in the distance from the end of the gray matter to the end of the conus medullaris: a case-triggered histological investigation. J Neurosurg Spine 2021; 35:446-453. [PMID: 34359036 DOI: 10.3171/2020.12.spine201890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The background for this investigation was the dramatic course of a 14-year-old girl with a spontaneous hemorrhage in the area of the conus medullaris resulting in a complete cross-sectional syndrome with bladder and bowel dysfunction. Despite immediate surgical treatment, the patient showed close to no postoperative improvement. Subsequent histopathological examination of the removed masses revealed a cavernoma. To better understand the link between the site and symptoms of conus medullaris lesions, the authors performed a literature search and then histological examination of the conus medullaris of 18 cadaveric specimens from body donors. METHODS After a literature search regarding the histological features of the structure of the conus medullaris did not lead to satisfying results, the authors performed histological examination of the conus medullaris in 18 cadaveric specimens from body donors. The largest (a) and smallest (b) diameters of the conus medullaris were measured, noting individual variations in the distance from the caudal ending of the gray matter to the macroscopically visible end of the conus medullaris. Correlations of these differences with sex, body height, gray matter transverse diameter, and cross-sectional area at the end of the gray matter were analyzed. RESULTS Gray matter displayed in the form of a butterfly figure was found along almost the entire length of the conus medullaris. The specific slide containing the end of the gray matter was noted. The distance between the caudal ending of the gray matter in the conus and the macroscopical end of the conus medullaris was defined as the gray matter to cone termination (GMCT) distance. There were great individual variations in the distance from the caudal ending of the gray matter to the macroscopically visible end of the conus medullaris. Analysis of the correlations of these differences with sex, body height, gray matter transverse diameter, and cross-sectional area at the end of the gray matter showed no significant sex-specific differences in the GMCT distance. Patient body height and transverse diameter at the end of the gray matter were found to be correlated positively with the GMCT distance. Moreover, greater height also correlated positively with the cross-sectional area at the end of the gray matter. CONCLUSIONS This report is, to the authors' knowledge, the first published description of the histological structure of the conus medullaris and can serve as the basis for a better understanding of neurological deficits in patients with a conus medullaris syndrome. Findings that gray matter can be detected far into the conus medullaris, with large individual differences in the endpoint of the gray matter, are important for operative care of intramedullary masses and vascular malformations in this area. It is therefore important to use electrophysiological monitoring during these operations.
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Affiliation(s)
| | - Bruno Griesler
- 2Institute of Anatomy and Cell Biology, Medical Faculty, and
| | | | | | | | - Christian Kunze
- 3Department of Radiology, Martin Luther University Halle-Wittenberg, Halle; and
| | | | | | | | | | - Heike Kielstein
- 2Institute of Anatomy and Cell Biology, Medical Faculty, and
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Tan YJ, Manohararaj N. Isolated Infarctions of the Conus Medullaris: Clinical Features and Outcomes. J Stroke Cerebrovasc Dis 2021; 30:106055. [PMID: 34433121 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/02/2021] [Accepted: 08/05/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study aims to describe the clinical features and outcomes of patients with isolated infarctions of the conus medullaris, and to identify factors associated with poor functional outcomes. MATERIALS AND METHODS We performed a systematic review and retrospective analysis on the clinical characteristics and outcomes of patients with isolated conus medullaris infarctions reported in literature over the past 30 years. RESULTS We analyzed a total of 19 cases; 18 identified in literature from January 1991 to June 2021, together with our patient. Their median age was 56 years (range 28-79), with twice as many females as males. Pain was prominent at onset (15/19, 79%), only a third had vascular risk factors (7/19, 37%), and half had no significant preceding activities or events (9/19, 47%). Almost all experienced paraplegia or paraparesis (16/19, 84%), in which upper motor neuron features were rare (3/19, 16%). The underlying cause was unknown in half (10/19, 53%). Functional outcomes appeared fair, with nearly half being capable of unassisted ambulation (9/11, 82%). Patients with vascular risk factors (67% vs 13%, p = 0.024) or with identified underlying causes (78% vs 13%, p = 0.007) were less likely to walk unassisted. CONCLUSION Isolated conus medullaris but should be considered in patients with acute cauda equina syndrome, especially in females. Patients with vascular risk factors, or with known causes of infarction, are less likely to walk unassisted. DWI sequences should be included in conventional MRI sequences when evaluating patients with acute cauda equina syndrome.
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Affiliation(s)
- You-Jiang Tan
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore.
| | - Nijanth Manohararaj
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
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Iampreechakul P, Yaisarn N, Wangtanaphat K, Lertbutsayanukul P, Siriwimonmas S, Techataweewan N. Filum Terminale Arteriovenous Fistula with Additional Arterial Supply by the Posterior Spinal Artery: A Report of Two Cases. Asian J Neurosurg 2021; 16:423-430. [PMID: 34268179 PMCID: PMC8244683 DOI: 10.4103/ajns.ajns_528_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 06/05/2021] [Accepted: 06/26/2021] [Indexed: 11/18/2022] Open
Abstract
Filum terminale arteriovenous fistulas (FTAVFs) are rare and usually supplied by the artery of the filum terminale, distal termination of the anterior spinal artery (ASA). These fistulas may also supply from the lateral sacral artery (LSA) arising from the internal iliac artery and/or middle sacral artery. Additional supply by the posterior spinal artery (PSA) has never been mentioned before. The authors describe two middle-aged men harboring FTAVFs manifested with progressive myelopathy and bowel/bladder dysfunction. The first fistula was supplied by the ASA with additional supply by the dilated PSA connecting with the ASA. Another fistula was supplied by the LSA and the PSA communicating with the ASA. The first case was successfully treated by endovascular treatment with N-butyl cyanoacrylate through the enlarged PSA, whereas the second case was surgically treated by direct obliteration of the fistula. Both patients had good neurological outcome.
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Affiliation(s)
| | - Naruedol Yaisarn
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
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12
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Kesserwani H. Difficulty Standing on the Tiptoes? Think of an Epiconus Syndrome: A Case Report and a Review of the Pathobiology of the Conus and Epiconus. Cureus 2021; 13:e12724. [PMID: 33614327 PMCID: PMC7883561 DOI: 10.7759/cureus.12724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The motor deficits, urogenital dysfunction and perineal numbness of the conus medullaris syndrome are well known. Less well known is the disease of the epiconus, the spinal cord immediately above the conus medullaris. The disease is quite unique with ankle plantar-flexion weakness that usually exceeds ankle dorsi-flexion weakness. The epiconus syndrome can present with both upper and lower motor neuron findings and manifest unique findings on nerve conduction/electromyography studies. Intriguingly, lumbo-sacral corticospinal tract disease can involve trans-synaptic degeneration of the anterior horn motor neurons and lead to acute denervation, as recorded with electromyography. The conus medullaris also contains Onuf’s nucleus, which controls penile erection, ejaculation, the external urethral and the external anal sphincter and is the basis of the bulbo-cavernosus reflex. Extension of a lesion from the epiconus to the conus can lead to urogenital dysfunction. We seize upon a case of an epiconus syndrome in order to outline some of these fascinating observations including the pathobiology of the conus and epiconus. In order to understand the epiconus, one must be versed with the conus medullaris.
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Perez Perez VH, Hernesniemi J, Small JE. Anatomy of the Great Posterior Radiculomedullary Artery. AJNR Am J Neuroradiol 2019; 40:2010-2015. [PMID: 31753838 PMCID: PMC6975349 DOI: 10.3174/ajnr.a6304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 09/19/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Although considerable variability exists as to the overall caliber of radiculomedullary arteries, dominant radiculomedullary arteries such as the artery of Adamkiewicz exist. The existence of a great posterior radiculomedullary artery has attracted little attention and has been a matter of debate. The aim of this anatomic study was to determine the presence or absence of the great posterior radiculomedullary artery. MATERIALS AND METHODS We performed microsurgical dissection on formaldehyde-fixed cadaveric human spinal cords. The artery of Adamkiewicz in the spinal cord specimens (n = 50) was injected with colored latex until the small-caliber arterial vessels were filled and the great posterior radiculomedullary artery was identified. The course, diameter, and location of great posterior radiculomedullary artery were documented. RESULTS A great posterior radiculomedullary artery was identified in 36 (72%) spinal cord specimens. In 11 (22%) specimens, bilateral great posterior radiculomedullary arteries were present. In 13 cases (26%), a unilateral left-sided great posterior radiculomedullary artery was identified. In 11 cases (22%), a unilateral right-sided great posterior radiculomedullary artery was identified. In 1 specimen (2%), 3 right-sided great posterior radiculomedullary arteries were noted. The average size of the great posterior radiculomedullary arteries was 0.44 mm (range, 0.120-0.678 mm on the left and 0.260-0.635 mm on the right). CONCLUSIONS A great posterior radiculomedullary artery is present in most (72%) individuals. The authors describe the microsurgical anatomy of the great posterior radiculomedullary artery with emphasis on its morphometric parameters as well as its implications for spinal cord blood supply. Variations of the arterial supply to the dorsal cord are of great importance due to their implications for ischemic events, endovascular procedures, and surgical approaches.
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Affiliation(s)
- V H Perez Perez
- From the Department of Neurosurgery (V.H.P.P.), Instituto de Ciencias Forenses, TSJ Ciudad de México, Centro Medico Siglo XXI, Mexico City, Mexico
| | - J Hernesniemi
- Department of Neurosurgery (H.J.), International Center for Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - J E Small
- Department of Radiology (J.E.S.), Neuroradiology Section, Lahey Hospital and Medical Center, Burlington, Massachusetts.
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Woodall MN, Spetzler RF. Microsurgical Treatment of Recurrent Conus Medullaris Arteriovenous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2019; 16:44. [PMID: 30011012 DOI: 10.1093/ons/opy180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 06/18/2018] [Indexed: 11/14/2022] Open
Abstract
Arteriovenous malformations (AVMs) involving the conus medullaris have a unique angioarchitecture due to their involvement of the arterial basket of the conus medullaris, which represents an arterial anastomotic network between the anterior spinal artery (ASA) and posterior spinal arteries (PSAs) at the level of the conus medullaris.1 These lesions consist of a combination of a true AVM nidus, which is usually extramedullary, and direct shunts between the ASA, PSAs, and the venous system. Patients may present with radiculopathy, myelopathy, or subarachnoid hemorrhage.2A 40-yr-old woman status post T11-L1 laminoplasty for resection of a ruptured conus AVM 6 yr prior presented with routine follow-up angiography suggestive of an arteriovenous fistula. She was counseled regarding treatment options including endovascular embolization and microsurgical ligation or resection, and she elected to proceed with surgical treatment. At the time of surgery, a recurrent AVM was noted. A 2-dimensional intraoperative video illustrates the microsurgical treatment of her recurrent conus AVM. The patient recovered well postoperatively. Spinal angiography demonstrated complete obliteration of the lesion. The patient experienced transient urinary retention that was self-limited but otherwise was without any new neurological deficit. Due to the retrospective nature of this report, informed consent was not required.Video used with permission from Barrow Neurological Institute, all rights reserved.
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Affiliation(s)
- M Neil Woodall
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Rojas S, Ortega M, RodríGuez‐Baeza A. Variable anatomic configuration of the posterior spinal arteries in humans. Clin Anat 2018; 31:1137-1143. [DOI: 10.1002/ca.23213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/03/2018] [Accepted: 05/09/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Santiago Rojas
- Unit of Human Anatomy and Embryology. Department of Morphological Sciences. Faculty of MedicineUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
| | - Marisa Ortega
- Unit of Human Anatomy and Embryology. Department of Morphological Sciences. Faculty of MedicineUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
- Institute of Legal Medicine and Forensic Sciences of Catalonia, Hospitalet de Llobregat Spain
| | - Alfonso RodríGuez‐Baeza
- Unit of Human Anatomy and Embryology. Department of Morphological Sciences. Faculty of MedicineUniversitat Autònoma de BarcelonaCerdanyola del VallèsSpain
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Rojas S, Ortega M, Rodríguez-Baeza A. Vascular configurations of anastomotic basket of conus medullaris in human spinal cord. Clin Anat 2017; 31:441-448. [PMID: 28906042 DOI: 10.1002/ca.22986] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/29/2017] [Accepted: 09/11/2017] [Indexed: 11/12/2022]
Abstract
The arterial basket of the conus medullaris is one of several anastomoses between the anterior and posterior spinal arteries. The anatomy of this structure has attracted little attention. This work sought to investigate its configuration in human spinal cords. Spinal cords from male and female cadavers (n = 32) were injected with colored latex through the intercostal, lumbar, medial sacral and the posterior trunks of the hypogastric arteries. After injection, specimens preserving the dural sac were obtained and fixed in formaldehyde solution. Finally, the spinal arteries were microdissected. In 18.75% of the specimens, the anterior spinal artery divided symmetrically and formed anastomoses with the posterior spinal arteries. In 81.25%, the branching pattern observed was asymmetrical. In 21.87% there were differences in the diameter of the anastomotic arteries, and 40.63% originated at different levels along the craniocaudal axis. Interestingly, 12.5% of the specimens presented an intraparenchymatous anastomosis that has not been described previously. True unilateral anastomosis was only observed in 6.25% of the spinal cords. The most frequent configuration of the anastomotic basket of the conus medullaris is a bilateral asymmetric anastomosis. The asymmetry of the branches could be caused by differences in their diameters or in their origins along the craniocaudal axis. Symmetrical patterns are less frequent, and unilateral anastomoses are rare. In reality, some cases of apparently unilateral anastomosis present an intramedullary course of the anastomotic artery. Clin. Anat. 31:441-448, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Santiago Rojas
- Unit of Human Anatomy and Embriology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Marisa Ortega
- Unit of Human Anatomy and Embriology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Institute of Legal Medicine of Catalonia, Barcelona, Spain
| | - Alfonso Rodríguez-Baeza
- Unit of Human Anatomy and Embriology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
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