Selective arteriography of arteriovenous aneurysms of spinal cord.

Abstract

Myelography is not entirely satisfactory for the preoperative diagnosis of spinal cord vascular malformations. The linear, serpiginous filling defects first described by Guillain and Alajouanine (1) are by no means constant or pathognomonic findings. Lombardi and Migliavacca (2) reported positive myelographic findings in 15 out of 18 spinal angiomas, Teng and Papatheodorou (3) in 6 out of 12 cases, and Verbiest and Calliauw (4) in only 3 of their 12 cases. Iodophendylate (Pantopaque) myelography may also lead to false-positive diagnoses, e.g., vascular malformations in cases of tumor or other lesions with dilated vessels. Nor is gas myelography of any use in the diagnosis of these malformations (5). Prior Investigatioks The diagnostic inadequacies in handling the spinal cord vascular malformations spurred this investigation. We believe, however, that some knowledge of the normal anatomy of the spinal cord vascularization is indispensable for a better understanding of the pathologic anatomy of the lesions. The data which follow were obtained from the literature (23–28). These articles, particularly the excellent review by Tureen (23), include extensive reports of the classical work of Duret (29), Adam-kiewicz (30, 31), and Kadyi (32). The arteries supplying the spinal cord may be divided into two markedly different systems, the anterior and the posterior. The anterior arterial chain (anterior median spinal artery) extends without interruption along the entire anterior surface of the spinal cord, beginning at the junction of the two anterior spinal branches of the vertebral artery and extending to the filum terminale. In the cervical area this long anastomotic channel sometimes may be paired (13 times out of 28 spinal cords according to Perese and Fracasso (33)). Besides the anterior spinal rami from the intracranial portion of the vertebral artery, the following arteries contribute to the anterior arterial chain of the spinal cord (Fig. 1): anterior radicular arteries originating from spinal branches of the cervical vertebral artery and of other subclavian branches (deep cervical and ascending cervical) for the cervical cord; anterior radicular arteries originating from spinal rami of subclavian branches (superior intercostal) and of aortic intercostals for the upper and middle part of the thoracic cord; great anterior radicular or great anterior medullary artery or artery of Adamkiewicz for the inferior part of the thoracic and the lumbar cord with its enlargement, conus, and filum terminale. The origin of the important artery of Adamkiewicz may vary from spinal branches of the eighth intercostal to the fourth lumbar, most frequently from the left. This vessel reaches, after a long course upward, the anterior aspect of the spinal cord, always above the lumbar enlargement, and in the anterior median fissure divides into a thin ascending and a much larger descending branch which swings with a sharp “hairpin” bend to course downward on the midline.