[A case of high cervical cord infarction presenting with cardiopulmonary arrest due to respiratory dysfunction]

A 46-year-old man with neck pain and impaired physical mobility called for emergency medical services. The patient was able to communicate with the emergency medical team upon their arrival. However, he went into cardiopulmonary arrest 5 minutes later. Cardiopulmonary resuscitation was immediately performed, and the patient was admitted to our hospital with a Glasgow Coma Scale score of E1V1M1. His respiratory rate was 5 breaths/minute and his partial pressure of carbon dioxide in arterial blood (PaCO2) was 127 ‍mmHg, necessitating intubation and ventilation. His consciousness improved as the PaCO2 level decreased. However, he was unable to be weaned off the ventilator and breathe independently. Neurological examination revealed flaccid quadriplegia, pain sensation up to the C5 level, absence of deep tendon reflexes, indifferent plantar responses, and absence of the rectoanal inhibitory reflex. Magnetic resonance imaging showed a hyperintense lesion with slight enlargement of the anterior two-thirds of the spinal cord at the C2-C4 level on both T2-weighted and diffusion-weighted images, consistent with a diagnosis of spinal cord infarction. Although the quadriplegia and sensory loss partially improved, the patient was unable to be weaned from the ventilator. Cervical cord infarction of the anterior spinal artery can cause rapid respiratory failure leading to cardiopulmonary arrest. Therefore, cervical cord infarction should be included as a differential diagnosis when examining patients after cardiopulmonary resuscitation.

[Diagnostic capabilities of spinal MR angiography and spinal MR tractography in a patient with motor neuron disease]

Motor neuron diseases (MND) include two main forms - amyotrophic lateral sclerosis (ALS) and spinal muscular atrophy (SMA). A certain part of these diseases is hereditary, while etiology of sporadic cases remains unknown. Both entities are known to develop because of motoneurons damage. Difference between them lies in the state of the descending pyramidal pathways. The pyramidal pathways in SMA are intact, as brain pyramidal neurons are not affected, thus pathology of SMA is restricted to anterior horns of spinal cord. Meanwhile, most forms of ALS arise due to loss of both cerebral and spinal motoneurons, which, in addition to anterior horn lesion, leads to pyramidal descending pathways damage either in brain or in spinal cord. While pathological distinction between these two entities is clear and definite, the clinical difference remains obscure. We present the case of 41-year old patient with MND, in whom spinal MR tractography has revealed lateral columns to be intact that proves the utility of spinal MR tractography in differential diagnosis between ALS and SMA. Given that ischemic diseases of the spinal cord often occur with a clinical picture of MND, we also examined this patient using spinal MRI angiography, revealing a pronounced narrowing and tortuosity of the spinal arteries, complicated by occlusion of the right twelve intercostal artery.

Intraoperative identification of the lateral spinal artery in a case of craniocervical junction dural arteriovenous fistula surgically obliterated

BACKGROUND

The formation of a dural arteriovenous fistula (DAVF) at the craniocervical junction is rare. Such a fistula can be fed by the branches of the vertebral and external carotid arteries. The lateral spinal artery can branch from the vertebral artery. The feeders of a DAVF at the craniocervical junction are often diagnosed on preoperative angiography, and there is little reported evidence on the intraoperative diagnosis of the lateral spinal artery.

CASE DESCRIPTION

An 84-year-old man presented with motor weakness and sensory disturbance of the lower extremities. Edematous changes in the medulla oblongata and cervical spinal cord were observed on magnetic resonance imaging. Cerebral angiography revealed a DAVF fed by a branch of the vertebral artery, with a shunting point located in the dura of the right condyle; the main drain was the anterior spinal vein. The DAVF drain was surgically obliterated to prevent hemorrhagic events and improve neurological symptoms. Intraoperatively, an artery branching from the feeder of the DAVF was identified and preserved. The patient had a good postoperative course, and the neurological symptoms were ameliorated. Follow-up cerebral angiography revealed proximal branching of the lateral spinal artery from the feeding artery of the DAVF.

CONCLUSION

A lateral spinal artery was identified intraoperatively while a DAVF at the craniocervical junction was obliterated. This suggests that preoperative imaging should be carefully reviewed, and endovascular procedures should consider such possibilities to avoid adverse ischemic outcomes.

A Case of Coil Embolization for a Ruptured Anterior Spinal Artery Aneurysm Associated with Bilateral Vertebral Artery Occlusion

Anterior spinal artery (ASA) aneurysms are rare, and the majority are associated with vascular lesions such as arteriovenous malformations, moyamoya disease, and aortic stenosis. Herein, we report a case of a ruptured anterior spinal artery aneurysm caused by bilateral vertebral artery (VA) occlusion, which was treated by coil embolization. An 83-year-old man was found collapsed at home, and was brought in by emergency. His consciousness level was I-1 on the Japan Coma Scale, and there were no symptoms such as paralysis in the extremities. Computed tomography showed Fisher 3 subarachnoid hemorrhage, while magnetic resonance angiography showed an aneurysm in the right VA. Digital subtraction angiography showed bilateral VA occlusion, and an aneurysm was found on the dilated ASA as a collateral circulation. Coil embolization was performed after confirmation of no hemodynamic problems. No postoperative adverse events were observed. Coil embolization may be an effective treatment for ruptured aneurysms of the ASA.

[A case of sudden-onset transverse myelopathy suspected to be caused by fibrocartilaginous embolism]

A 44-year-old male was admitted to our hospital because of sudden weakness and sensory loss in both legs following left scapular pain. He had a history of lower back pain but no vascular risk factors. Neurological examination on admission revealed flaccid paraplegia, a loss of both pinprick and vibratory sensations below the Th6 level, and bladder and rectal disturbances. Tendon reflexes were absent in both lower limbs. Diffusion-weighted imaging performed 5 hours after onset revealed an extensive high-intensity lesion at the Th2-6 spine levels, accompanied by a vague high intensity on T₂-weighted images. CT angiography showed no abnormalities of the aorta or the artery of Adamkiewicz. Laboratory test results were normal and there was no evidence of coagulopathy. Autoantibodies, including anti-aquaporin-4 and anti-myelin oligodendrocyte glycoprotein antibodies, were negative. The cerebrospinal fluid test was normal. The lesion had expanded to the whole thoracic cord and was markedly swollen on T₂-weighted imaging at 5 days after onset. Immunotherapies, including intravenous methylprednisolone pulse therapy and plasma exchange, were ineffective. Although there was no evidence of any source of embolism, we found degenerative calcified changes in the fibrocartilage of the intervertebral discs, with Schmorl's nodes in the thoracic spines. We clinically diagnosed the patient with spinal cord infarction caused by fibrocartilaginous embolism. He developed deep vein thrombosis and was treated with edoxaban. His neurological symptoms did not improve during 55 days of hospitalization. In a case with sudden-onset myelopathy, fibrocartilaginous embolism should be considered.

Extirpation of a Ruptured Anterior Spinal Artery Aneurysm Accompanied by Dural Arteriovenous Fistula at the Craniovertebral Junction via a Posterolateral Approach: The Management of Extradural Venous Congestion

Objective  This study was aimed to discuss how to control extradural venous congestion with an increased pressure in cases of arteriovenous shunt disease of the craniovertebral junction.

Design  The study is presented through an operative video.

Results  A 77-year-old patient with subarachnoid hemorrhage had a dural arteriovenous fistula located at the C1–C2 level. Left vertebral angiography showed a fistula between the left C2 radiculomeningeal muscular artery and perivertebral plexus. Furthermore, right vertebral angiography showed a ruptured aneurysm at the aberrant branch of the anterior spinal artery originating from the contralateral vertebral artery (VA), possibly formed because of the concurrently increased pressure of the perimedullary veins. Aneurysm extirpation was planned through a posterolateral approach. To reduce venous bleeding during the approach, preoperative embolization of the radiculomeningeal muscular artery was performed. During surgery, the suboccipital triangle was exposed following layer-by-layer dissection of the suboccipital muscles ( Figs. 1 and 2 ). Subperiosteal dissection of the paravertebral plexus surrounding the VA around the C1 lamina was effective to avoid venous bleeding. A bloodless operative field was achieved, and key anatomical structures, such as the C2 nerve root, feeder, and V3 portion of the left VA, were clearly identified. With a sufficient amount of lateral exposure, the ruptured anterior spinal artery aneurysm was successfully extirpated with bipolar coagulation. The patient was discharged with no neurologic deficit.

Conclusion  Controlling extradural venous congestion is essential to obtain a clear operative field in cases of arteriovenous shunt disease at the craniovertebral junction.

The link to the video can be found at: https://youtu.be/fCT69WtAQbo .

Transvenous embolization for craniocervical junction epidural arteriovenous fistula with a pial feeder aneurysm

Arteriovenous fistulas at the craniocervical junction are rare vascular malformations with frequent hemorrhagic presentations, which may have a concurrent pial feeder aneurysm. A 65-year-old man presented with subarachnoid hemorrhage and angiography showed an epidural arteriovenous fistula at the C-2 level with an anterior spinal feeder aneurysm without perimedullary venous drainage. Transarterial coil embolization of the ruptured aneurysm and partial Onyx embolization of the shunt led to thrombosis of the aneurysm. However, three years later angiography showed an increased shunt flow and recurrence of the aneurysm. Transvenous embolization of the shunt using coils and Onyx yielded complete obliteration of the shunt, thus leading to occlusion of the aneurysm. This case demonstrates that partial transarterial embolization of arteriovenous fistula leaves a risk of rebleeding, whereas complete obliteration of the shunt with a transvenous approach can lead to disappearance of the flow-related aneurysm without embolization of the aneurysm itself.

Clipping of an anterior spinal artery aneurysm using an endoscopic fluorescence imaging system for craniocervical junction epidural arteriovenous fistula: technical note

The authors report the case of a 78-year-old man with a craniocervical junction epidural arteriovenous fistula who presented with subarachnoid hemorrhage from a ruptured anterior spinal artery (ASA) aneurysm. Because endovascular embolization was difficult, a posterolateral approach was chosen and a novel endoscopic fluorescence imaging system was utilized to clip the aneurysm. The fluorescence imaging system provided clear and magnified views of the ventral spinal cord simultaneously with the endoscope-integrated indocyanine green videoangiography, which helped safely obliterate the ASA aneurysm. With the aid of this novel imaging system, surgeons can appreciate and manipulate complex vascular pathologies of the ventral spinal cord through a posterolateral approach, even when the lesion is closely related to the ASA.

Cervical Cord Infarction Caused by Dissection of the Intracranial Segment of the Vertebral Artery

Cervical cord infarction is uncommon but has been increasingly reported as a complication of vertebral artery dissection (VAD). A 54-year-old woman presented with neck pain and neurological deficit following sudden neck movement. Radiological findings suggested cervical cord infarction in the anterior spinal artery territory at the C5-C6 vertebral level and dissection of the intracranial segment of the right vertebral artery. Cervical cord infarction due to VAD is usually caused by dissection of its extracranial segment. The present case indicates that dissection of the intracranial segment of the vertebral artery can also cause cervical cord infarction.

Fusiform vertebral artery aneurysms involving the posterior inferior cerebellar artery origin associated with the sole angiographic anterior spinal artery origin: technical case report and treatment paradigm proposal

Fusiform aneurysms of the vertebral artery (VA) involving the posterior inferior cerebellar artery (PICA) origin are uncommon and challenging. The anterior spinal artery (ASA) commonly originates from a unilateral ramus just distal to the PICA. Occlusion of an unpaired ASA can result in bilateral medial medullary syndrome. The authors propose a treatment paradigm for ASA preservation based on the artery's proximity to fusiform VA aneurysms, and they present 3 representative cases. In the first case, they performed a V3-PICA bypass using an interposition graft and then performed endovascular coil embolization of the parent VA. A complete occlusion of the aneurysm and VA was complicated by ASA thrombosis. The subsequent cases were treated with PICA-PICA bypass and subsequent endovascular embolization of the VA. Filling of the sole angiographic ASA remote from the aneurysm was preserved in both cases. The anatomy of the ASA is the most critical determinant of treatment recommendations for fusiform VA aneurysms involving PICA. When the ASA originates from the aneurysm, proximal occlusion with or without a PICA bypass is suggested. In cases in which the ASA is removed from the aneurysm, the authors recommend revascularization followed by endovascular sacrifice. When the aneurysm is immediately adjacent to the ASA, revascularization and open trapping should be considered.

Cervical corpectomy for resection of ventral intramedullary capillary hemangioma with circumferential involvement of the anterior spinal artery: case report

There is limited evidence to suggest that anterior approaches for the resection of ventral intramedullary lesions of the cervical spinal cord may result in superior neurological outcomes compared with those following more traditional posterior approaches. To the authors' knowledge, no report of an anterior approach to resect a ventral intramedullary capillary hemangioma exists in the literature. In the following paper, the case of a 75-year-old male who presented with progressive neck and left shoulder pain, weakness of the left hand, myelopathy, and gait imbalance is reported. Postcontrast T1-weighted MRI demonstrated a homogeneously enhancing intramedullary lesion with associated severe impingement of the cervical spinal cord at C-4. Following a C-4 corpectomy, intradural exposure revealed a vascular lesion that circumferentially enveloped the anterior spinal artery. Gross-total resection of the lesion was performed, followed by reconstruction of the corpectomy defect, without neurological deterioration. Pathology was consistent with capillary hemangioma. In this instance, the anterior approach helped to avoid unnecessary neural manipulation and allowed for early identification of normal proximal and distal segments of the anterior spinal artery, which facilitated safe dissection and gross-total removal.

Predictors of Adamkiewicz artery and anterior spinal artery detection through computerized tomographic angiography

Background:

The detection of the Adamkiewicz artery and the anterior spinal artery has been associated with the ability to prevent adverse spinal cord outcomes after aortic surgical procedures. Yet, to our knowledge, no previous studies have attempted to use modern predictive models to identify the most important variables in determining artery detectability.

Aims:

To develop a model to predict the odds of visualizing the Adamkiewicz artery or anterior spinal artery in patients undergoing computerized tomographic angiography.

Methods:

We conducted a prospective, cross-sectional study. Outcomes of interest were the non-detection of the Adamkiewicz artery and anterior spinal artery, and their corresponding level of origin. Axial images were inspected in high definition in search of two dense spots characterizing the Adamkiewicz artery and anterior spinal artery. A multiplanar three-dimensional reconstruction was then performed using the OsiriX® software.

Results:

A total of 110 participants were part of this analysis. When evaluating risks for the Adamkiewicz artery being undetectable, significant factors could be classified into three broad categories: risk factors for arterial disease, established arterial disease, and obesity. Factors in the former category included metabolic syndrome, hypertension, and smoking status, while factors in the arterial disease included descending aortic aneurysm, mural thrombi, aortic aneurysm without a dissection, and aortic disease in general. In relation to anterior spinal artery not being detectable, significant risk factors included hypertension, smoking status, and metabolic syndrome, while those associated with arterial disease involved aortic disease and arterial thrombi. When evaluating the importance of individual clinical factors, the presence of higher body mass index was the single most important risk factor.

Conclusion:

Arterial disease, established arterial disease, and increased body mass index are risk factors in the detection of Adamkiewicz artery and anterior spinal artery. Specific diagnostic protocols should be in place for patients with these underlying conditions, thus enhancing the likelihood of detection when the Adamkiewicz artery is indeed present.

Etiology and treatment of amyotrophic lateral sclerosis

BACKGROUND

To date all researchers conclude that the etiology of Amyotrophic lateral sclerosis (ALS) is not known. On the contrary, since August 2009, we believe that disease is of ischemic origin in the anterior surface of the medulla oblongata.

MATERIAL AND METHOD

We present our surgical experience into 45 patients with ALS (bulbar form in 36 cases and spinal form in 9). Preoperative MRI scans revealed microinfarcts in the medulla oblongata and/or cervical cord. During surgery we found: 1) poor quality of omentum in most cases; 2) degenerative changes in the cervical spine; 3) anatomical anomalies at the V4 segments of the vertebral arteries; 4) moderate to severe atherosclerosis at both V4 segments; 5) unilateral absence or stenosis in the anterior-ventral spinal arteries (AVSAs). All patients received omentum on the anterior, lateral and posterior surface of the medulla oblongata, and in 9 cases, an additional segment at the C5-C6 level.

RESULTS

Neurological improvement was better during the first days or weeks after surgery than in the following months or years, in all patients. However, 13 patients suffered neurological impairment in about 4 months later, due to greater deterioration of the cervical spine, by contrast, 7 patients with mild ALS have experienced neurological improvement by 80 to 100% during a follow-up of 4 and 6 years.

CONCLUSIONS

These results confirm that ALS is of ischemic origin in the intraparenchymal territory of the AVSAs and/or in anterior spinal artery caused by atherosclerosis and associated to anatomical variants in the V4 segments of the vertebral arteries. Because in contrast to this, its revascularization by means of omentum can cure (mild degree) or improve this disease.

Effect of spinal cord compression on local vascular blood flow and perfusion capacity by Alshareef M, Krishna V, Ferdous J, Aishareef A, Kindy M, Kolachalama VB, et al

Background:

Different degrees of blood flow/vascular compromise occur with anterior, posterior, or circumferential spinal cord compression/spinal cord injury (SCI). SCI is also divided into primary and secondary injury. Primary SCI refers to the original neurological damage to tissues, whereas secondary injury reflects interruption of normal blood flow leading to further inflammatory response/other local changes which contribute to additional neurological injury.

Methods:

The authors developed a quantitative “3-D finite element fluid structure interaction model” of spinal cord blood flow to better document the mechanisms of secondary ischemic damage occurring in the spinal cord anteriorly, posteriorly, or circumferentially. This included assessment of the anterior spinal artery (ASA) and five arterial branches (L1, L2, L3, R1, R2), but excluded the microvasculature.

Results:

Different locations of cord compression resulted in alternative patterns of spinal cord ischemia. Anterior spinal artery (ASA) flow was substantially reduced by direct anterior compression, but resulted in the least vascular compromise. Alternatively, posterior compression resulted in a significant and critical reduction of distal ASA blood flow and, therefore, correlated with the greatest susceptibility to acute ischemia. Counterintuitively, they concluded “at equivalent degrees of dural occlusion, the loss of branch blood flow under anterior posterior compression was intermediate to predictions for purely posterior or anterior loading.”

Conclusion:

Utilizing a computational three-dimensional model, Alshareef et al. observed that anterior cervical cord compression resulted in the least severe compromise of ASA blood flow to the spinal cord, whereas posterior cord compression/SCI maximally reduced distal ASA blood flow potentiating acute ischemia. Therefore, the latter warranted the earliest surgical intervention.

Anterior spinal and bulbar artery supply to the posterior inferior cerebellar artery revealed by a ruptured aneurysm: case report

The posterior inferior cerebellar artery (PICA) is a vessel located between the intra- and extracranial circulation. The artery is characterized by a complex embryological development and numerous anatomical variants. The authors present a case of the PICA supplied by both a hypertrophic anterior spinal artery and a hypoplastic bulbar artery. This unusual arrangement somehow completes the list of previously published variants, and the spontaneous rupture of a related aneurysm confirmed the fragility of this network. The authors discuss anatomical and treatment considerations.

Spinal Cord Blood Supply and Its Surgical Implications

The blood supply to the spine is based on a predictable segmental vascular structure at each spinal level, but true radiculomedullary arteries, which feed the dominant cord supply vessel, the anterior spinal artery, are relatively few and their locations variable. Under pathologic conditions, such as aortic stent grafting, spinal deformity surgery, or spinal tumor resection, sacrifice of a dominant radiculomedullary vessel may or may not lead to spinal cord ischemia, depending on dynamic autoregulatory or collateral mechanisms to compensate for its loss. Elucidation of the exact mechanisms for this compensation requires further study but will be aided by preoperative, intraoperative, and postoperative comparative angiography. Protocols in place at our center and others minimize the risk of spinal cord ischemia during planned radiculomedullary vessel sacrifice.

A rare case of dual origin of the left vertebral artery without convergence

A case of dual origin of the left vertebral artery was encountered in a dissection course for medical students in 2014. Two vertebral arteries were observed on the left side. One arose from the aortic arch between the origin of the left common carotid artery and the left subclavian artery, entered the transverse foramen of the 4th cervical vertebra, and coursed upward into the transverse foramen. The other arose from the left subclavian artery as expected, divided into two branches anterior to the cervical vertebrae, and entered the transverse foramina of the 6th and 7th cervical vertebrae. Both branches flowed into the anterior spinal artery. Moreover, as seen in other anomalies, 3 arterial fenestrations were observed in the cranial arteries. This case is extremely unique with respect to the following points: the 2 ipsilateral vertebral arteries did not combine to form 1 vertebral artery, the vertebral artery of subclavian artery origin entered the transverse foramen of the 7th cervical vertebra, and 3 fenestrations were observed in the intracranial arteries. This is a very suggestive case for neurosurgeons and radiologists who perform treatments involving the vertebral artery.

Microsurgical anatomy of the arterial basket of the conus medullaris

OBJECT The arterial basket of the conus medullaris (ABCM) consists of 1 or 2 arteries arising from the anterior spinal artery (ASA) and circumferentially connecting the ASA and the posterior spinal arteries (PSAs). The arterial basket can be involved in arteriovenous fistulas and arteriovenous malformations of the conus. In this article, the authors describe the microsurgical anatomy of the ABCM with emphasis on its morphometric parameters and important role in the intrinsic blood supply of the conus medullaris. METHODS The authors performed microsurgical dissections on 16 formalin-fixed human spinal cords harvested within 24 hours of death. The course, diameter, and branching angles of the arteries comprising the ABCM were then identified and measured. In addition, histological sections were obtained to identify perforating vessels arising from the ABCM. RESULTS The ASA tapers as it nears the conus medullaris (mean preconus diameter 0.7 ± 0.12 mm vs mean conus diameter 0.38 ± 0.08 mm). The ASA forms an anastomotic basket with the posterior spinal artery (PSA) via anastomotic branches. In most of the specimens (n= 13, 81.3%), bilateral arteries formed connections between the ASA and PSA. However, in the remaining specimens (n= 3, 18.7%), a unilateral right-sided anastomotic artery was identified. The mean diameter of the right ABCM branch was 0.49 ± 0.13 mm, and the mean diameter of the left branch was 0.53 ± 0.14 mm. The mean branching angles of the arteries forming the anastomotic basket were 95.9° ± 36.6° and 90° ± 34.3° for the right- and left-sided arteries, respectively. In cases of bilateral arterial anastomoses between the ASA and PSA, the mean distance between the origins of the arteries was 4.5 ± 3.3 mm. Histological analysis revealed numerous perforating vessels supplying tissue of the conus medullaris. CONCLUSIONS The ABCM is a critical anastomotic connection between the ASA and PSA, which play an important role in the intrinsic blood supply of the conus medullaris. The ABCM provides an important compensatory function in the blood supply of the spinal cord. Its involvement in conus medullaris vascular malformations makes it a critical anatomical structure.

Atypical Anterior Spinal Artery Infarction due to Left Vertebral Artery Occlusion Presenting with Bilateral Hand Weakness

Background

Infarct of the anterior spinal artery is the most common subtype of spinal cord infarct, and is characterized by bilateral motor deficits with spinothalamic sensory deficits. We experienced a case with atypical anterior-spinal-artery infarct that presented with bilateral hand weakness but without sensory deficits.

Case Report

A 29-year-old man presented with sudden neck pain and bilateral weakness of the hands. Magnetic resonance imaging (MRI) of the brain did not reveal any lesion. His motor symptoms improved rapidly except for mild weakness in his left wrist and fingers. Magnetic resonance angiography showed proximal occlusion of the left vertebral artery; a spine MRI revealed left cervical cord infarction.

Conclusions

Bilateral or unilateral hand weakness can be the sole symptom of a cervical cord infarct.

Bilateral segmental agenesis of carotid and vertebral arteries with rete mirabile and the prominent anterior and posterior spinal arteries as compensations

Agenesis of carotid or vertebrobasilar arteries with rete formation is rare. The anterior spinal artery or posterior spinal arteries supplying the posterior circulation with steno-occlusion or agenesis of bilateral vertebral arteries is also uncommon. Here, we describe a very rare case of concomitant segmental agenesis of bilateral carotid and vertebral arteries with collateral compensations from the prominent anterior spinal artery and posterior spinal arteries, as well as some transdural arterial networks which were considered a rete mirabile. We discuss its embryological and anatomic significance.

A ruptured aneurysm arising at the leptomeningeal collateral circulation from the extracranial vertebral artery to the posterior inferior cerebellar artery associated with bilateral vertebral artery occlusion

We report an extremely rare case of a small ruptured aneurysm of the leptomeningeal collateral circulation from the vertebral artery (VA) to the posterior inferior cerebellar artery (PICA); this aneurysm was associated with bilateral VA occlusion. A 72-year-old woman with sudden headache, nausea, and subarachnoid hemorrhage (SAH) was admitted to our hospital. On admission, no evidence of cerebral signs or cranial nerve palsy was found. Computed tomography imaging showed SAH predominantly in the posterior fossa, and digital subtraction angiography revealed bilateral VA occlusion and the left VA aneurysm located proximal to the VA union. In addition, a small aneurysm was observed at the leptomeningeal collateral circulation located between the extracranial left VA and the left PICA. The patient underwent radical surgery on the day of the onset of the symptoms associated with SAH. However, the VA aneurysm was unruptured and surgically trapped. The small aneurysm arising at the leptomeningeal collateral circulation was ruptured during the surgery and was electrocoagulated; the collateral circulation was preserved, and no neurologic deficits were observed. The postoperative course was uneventful. SAH with the occlusion of major vessels should be diagnosed with utmost caution to allow preoperative neurologic and radiological assessments.

CT angiography of anterior spinal artery in cervical spondylotic myelopathy

PURPOSE

To identify anterior spinal artery (ASA) infarct or occlusion by CT angiography (CTA) in patients with cervical spondylotic myelopathy (CSM).

METHODS

Fourteen patients with CSM were performed CTA of ASA after admission. T2-weighted hyperintensity of MR image was compared with image of CTA of ASA.

RESULTS

All patients presented spinal canal sagittal diameter compression from 10 to 80% and different T2-weighted hyperintensity of MR images. No ASA infarct or occlusion was found in CSM patients.

CONCLUSION

ASA infarct or occlusion is not commonly seen in CSM patients with spinal canal sagittal diameter compression less than 80%. Pathological changes about T2-weighted hyperintensity of MR image in CSM have no close correlation with ASA infarct.

Spinal cord infarction with multiple etiologic factors

Spinal cord infarction is uncommon and usually presents with sudden onset of paralysis and sensory disturbances. A variety of causes are described, but rarely with multiple factors involved. We report a case of a 63-year-old man with a history of diabetes mellitus, hypertension, and osteoarthritis who presented with acute onset of chest pain, numbness, and weakness associated with episodic hypotension. He had incomplete tetraplegia and was areflexic without spasticity. Pain and temperature sensations were impaired below the C7 dermatome and absent below the T4 dermatome bilaterally. Proprioception and vibration sensations were diminished on the right below the C6 dermatome. Magnetic resonance imaging showed spinal cord infarction affecting C6-T3 segments, and severe cervical and lumbar spine degenerative changes. This case illustrates an unusual presenting symptom of spinal infarction, the need to identify multiple risk factors for spinal cord infarction, and the importance of optimal preventive therapy in patients at risk.

Acute spinal cord ischemia during aortography treated with intravenous thrombolytic therapy

Acute anterior spinal cord ischemia is a rare but disastrous complication of endovascular aortic procedures. Although intravenous thrombolysis with recombinant tissue plasminogen activator is an effective treatment for acute brain ischemia, its use for the treatment of spinal cord ischemia has not previously been reported. We report the case of a patient who developed anterior spinal cord ischemia during diagnostic aortography He was treated with intravenous recombinant tissue plasminogen activator within 3 hours after the onset of symptoms. The patient had a rapid neurologic improvement and was discharged from the hospital 3 days after thrombolysis, regaining his ability to walk unassisted. We propose that acute spinal cord ischemia can be treated with intravenous recombinant tissue plasminogen activator within 3 hours after the onset of symptoms, as can any other case of acute ischemic stroke.