A systematic review on COVID-19 and spinal strokes, the end of an era.

Treatment for arteriovenous fistulas located at the craniocervical junction involving the pial feeder aneurysm is challenging. When a direct aneurysm manipulation is not feasible, shunt interception to achieve flow reduction is a considerable option. However, a potential risk for remnant or recurrence of aneurysm may exist due to residual minor shunt flow from small vessels that are undetectable using conventional digital subtraction angiography. A 44-year-old Asian man presented with sudden-onset left occipital headache, right thermoanesthesia, and left hemiparesis due to hematomyelia of the cervical spine. Digital subtraction angiography revealed epidural arteriovenous fistula with aneurysmal formation on the anterior spinal artery. As a direct approach to the aneurysm was difficult, the anterior spinal artery was intercepted from the fistula. During surgery, an endoscope-integrated indocyanine green videoangiography allows a clear visualization of abnormal small vessels that were not fully evaluated using digital subtraction angiography. Although the aneurysm blood flow was remnant, shunt interception was confirmed through endoscopic findings of disappearance of blood flow to these small vessels, leading to subsequent aneurysm obliteration. In the treatment of dural arteriovenous fistulas with anterior spinal artery aneurysm, a more precise assessment of small vessels and their occlusion is possible through the use of an endoscope-integrated indocyanine green videoangiography.

Introduction Spinal cord infarction resulting from perforator occlusion and ischemia after Pipeline Embolization Devices (PEDs) deployment in the posterior circulation is a feared complication with devastating consequences. However, only 2 case reports described such occurrences, one involving the posterior spinal artery (PSA) after basilar artery aneurysm embolization and the other involving the anterior spinal artery (ASA) after embolization of a posterior inferior cerebellar artery (PICA) dissecting aneurysm. We present the first reported case of ASA syndrome after embolization of the V4 segment of the vertebral artery (VA), with a unique unilateral presentation. Case Description A 72‐year‐old right‐handed woman with a previous history of a stroke without any residual deficits underwent elective pipeline stent placement for an incidental, unruptured right V4 segment VA aneurysm originating at the origin of the right PICA (Figure 1A). The patient was premedicated with aspirin 81 mg daily and ticagrelor 90 mg twice daily for one week preoperatively. The initial procedure was uneventful, and the Pipeline Shield® (Medtronic) was deployed across the neck of the aneurysm. Several hours postoperatively, the patient developed acute onset right‐sided weakness affecting the right arm and leg; neurological examination revealed 4/5 strength in the right upper limb and 3/5 in the right lower limb. Per unit protocol was followed, and subsequent images were done, including CT head and CT‐angiogram of the head and neck, which were normal. Due to the new evolving symptoms, the patient was taken to the angiography suite where distal foreshortening of the stent was noted (Figure 1B). The decision was made to place a second stent to cover the aneurysm neck proximally and the procedure was performed successfully. Postoperatively, the patient had complete resolution of the symptoms and was transferred to the neurocritical intensive care unit. Later the same day, the patient experienced recurrent right‐sided weakness. Neurological examination revealed persistent hemiparesis without cranial nerve involvement. Repeat neuroimages revealed no acute intracranial bleeding with complete patency of the devices deployed. Despite continued dual antiplatelet therapy and blood pressure augmentation, her deficits remained unchanged. Subsequent MRI demonstrated a right anterolateral spinal cord infarct (Figure 1C), consistent with perforator‐related ischemia. Conclusion To our knowledge, this case is the first reported ASA syndrome after flow diversion of a V4 vertebral artery aneurysm. Spinal cord infarction, although rare, should be recognized as a potential complication of posterior circulation PED deployment. Awareness of its possible unilateral presentation may facilitate timely diagnosis and management. image

BackgroundVertebral artery dissecting aneurysms (VADAs) pose therapeutic challenges when the posterior inferior cerebellar artery (PICA), anterior spinal artery (ASA), or dominant vertebral artery (VA) is involved.ObjectivesTo describe anatomical factors, treatment strategies, and clinical outcomes after endovascular therapy for VADAs.MethodsWe retrospectively reviewed prospectively collected data (January 2013-April 2025) on adults treated endovascularly for intradural VADAs. The primary outcome was 12-month modified Rankin Scale (mRS ≤ 2).ResultsNineteen patients (9 women, median age ≈52 years) were included. Most aneurysms were fusiform (12/19, 63.2%), and 8/19 (42.1%) presented ruptured. Flow diversion was the predominant treatment (12/19, 63.2%). At 12 months, 15/19 patients (78.9%) achieved a favorable mRS, while 4/19 (21.1%) were dependent or dead. Complications occurred in 4/19 (22.2%), most commonly ischemic events. Angiographic occlusion improved over time, with complete occlusion in 8/9 (88.9%) at 6 months and 3/5 (60.0%) at 12 months. Outcomes were favorable across anatomical subgroups, with no consistent differences by PICA or ASA involvement or VA dominance.ConclusionsOptimal VADA management relies on anatomy: parent-artery occlusion suits nondominant VAs with contralateral and PICA collaterals, while branch-preserving flow diversion (often with adjunctive coils at the PICA origin) is preferred for dominant-side or PICA/ASA-related dissections.

Rationale:This case report describes a rare instance of concurrent acute cerebellar and spinal cord infarction caused by right vertebral artery occlusion, providing dynamic angiographic visualization of the collateral circulation.Patient concerns:A 69-year-old male with hypertension and diabetes presented with thunderclap occipital headaches, left-dominant limb hypesthesia, and mild bladder dysfunction.Diagnoses:Brain magnetic resonance imaging revealed an acute right cerebellar infarction in the posterior inferior cerebellar artery (PICA) territory. Cervical magnetic resonance imaging demonstrated bilateral anterior horn hyperintensity (“owl’s eye” sign) at C2 to C4, consistent with spinal cord infarction. Digital subtraction angiography confirmed atherosclerotic occlusion at the right vertebral artery origin, with collateral circulation via the deep cervical artery. Cerebrospinal fluid analysis showed elevated protein (0.679 g/L) without pleocytosis or autoantibodies (AQP4/MOG/MBP), excluding inflammatory/demyelinating etiologies.Interventions:The patient was treated with antiplatelet therapy (aspirin) and statins (rosuvastatin).Outcomes:The patient’s symptoms significantly improved within 2 weeks (headache Visual Analog Scale score decreased from 8 to 2).Lessons:This is the first reported case combining acute cerebellar (PICA territory) and cervical spinal cord (C2–C4) infarction, with digital subtraction angiography visualization of collateral circulation via the deep cervical artery. It underscores vertebral artery occlusion as a rare yet critical cause of dual cerebellar–spinal infarction, mediated by hemodynamic compromise in both PICA and anterior spinal artery territories.

The median medullary perforators, a group of perforator vessels arising from the vertebrobasilar junction, remain underrecognized. There is scarce knowledge regarding their clinical significanceand relevance in foramen magnum surgery. This study elucidates the anatomy of these perforators and their clinical and surgical relevance, in analogy to the well-known vital basilar tip perforators. We highlight their potential contribution to selective pyramidal infarct or ischemia during foramen magnum tumor resection, and rarely their implication in isolated ischemic strokes of the medullary pyramid.The anatomical study included six formalin-fixed cadaver specimens with latex, India ink, ICG, and gadolinium-injected brainstem vessels. The intrinsic distribution of the median medullary perforators was visualized grossly, histologically, and by micro-MRI. We also reviewed ten operative videos of ventral foramen magnum meningioma cases to assess intraoperative identification and preservation of these vessels. One unique clinical case with pure bilateral pyramidal ischemia manifesting as dense quadriplegia was readdressed.Gross inspection showed various origins of these perforators, mainly from the lower basilar segment and the junction of the vertebral arteries, which coursed towards the caecum and anterior median fissure. Injection of the isolated vertebrobasilar junction with India ink, ICG, and contrast revealed short vessels that supplied the pyramids exclusively, and longer perforators coursing medially.Distinct short perforators were identified predominantly supplying the pyramids, arising from the vertebral artery distal to, and separate from, the anterior spinal artery. Intraoperative video confirmed the presence of the median medullary perforators and their potential in causing grave isolated pyramidal ischemia.

The authors present the case of a type IVc filum terminale arteriovenous fistula in a female patient in her 40s, who presented with lower abdominal pain, back pain, and lower extremity weakness. MRI showed an intradural mass with serpiginous vessels. Spinal angiography revealed a type IVc perimedullary fistula primarily fed by the anterior spinal artery with a giant venous varix. Because of anatomical factors, endovascular embolization was not feasible, and surgical ligation was performed via laminectomy at L1–3. The fistula seen within the filum terminale was successfully clipped, with no further venous outflow on angiography. The patient recovered with complete symptom improvement.The video can be found here: https://stream.cadmore.media/r10.3171/2025.7.FOCVID2536

Adamkiewicz artery visualisation using iterative model-based reconstruction in low-dose computed tomograpyhy (CT) angiography.

BACKGROUND AND OBJECTIVES:Spinal cord ischemia affects up to 40% of patients undergoing repair of complex thoracoabdominal aortic aneurysms (TAAAs). Preoperative identification of key segmental spinal artery contributors may guide the design of custom fenestrated graft constructs or extra-anatomic bypass. Despite the high resolution provided by diagnostic spinal angiography, it is infrequently performed. We describe the safety, feasibility, diagnostic, and treatment outcomes for a case series of spinal angiography performed before complex endovascular TAAA repair.METHODS:We retrospectively analyzed data from patients who underwent preoperative spinal angiography before endovascular repair of their aortic aneurysms between July 2022 and December 2023. All patients had previously undergone either open and/or endovascular treatment of their aortic aneurysms.RESULTS:Nine patients (mean age 64.7 ± 9.9 years) underwent spinal angiography before endovascular repair of their TAAA. The anterior spinal artery was identified in 4 (44%) cases and the posterior spinal artery in one (11%) patient. There were no complications attributed to the angiograms. Eight (89%) patients underwent subsequent endovascular aortic repair with one segmental artery (right T11) successfully incorporated into the stent construct. Two (20%) patients had unfavorable branch angles/stenosis at the segmental artery origin for stenting. One (11%) patient had symptomatic postoperative spinal ischemia.CONCLUSION:Diagnostic spinal angiography can safely help identify spinal arterial contributors in complex TAAA patients who have undergone previous aortic intervention. Given improvements in fenestrated endovascular technology and extra-anatomic bypass, there are burgeoning tools to prioritize the preservation of blood flow to the spinal cord in preoperative planning.

The association of tuberculous leptomeningitis and anterior spinal artery infarction, although rare, can result in severe neurological sequelae. Recognising tuberculosis as a potential aetiology is vital. Here we describe a case under our care. A 41-year-old man presented with acute back pain with lower limb weakness and paraesthesia. Magnetic resonance imaging (MRI) of the spine revealed a combination of spinal leptomeningitis, anterior spinal cord lesion and intradural tuberculoma. Cerebrospinal fluid (CSF) analysis revealed findings consistent with tuberculosis myelitis. Spinal tuberculosis can present as an anterior spinal artery infarct.

Spinal cord infarction secondary to Anterior Spinal Artery Syndrome is a very rare condition. It usually occurs secondary to aortic surgery, thromboembolism, aortic dissections and hypoperfusion. We present here a rare case of a 64 year old patient who presented with acute onset of quadriparesis and was found to have Anterior Spinal Artery syndrome. Initial imaging was normal while repeat imaging after forty eight hours showed features of cervical cord infarction. He was managed conservatively with intravenous corticosteroids, low molecular weight heparin and anti platelet agents and had improvement in motor power after treatment.

BACKGROUND: Ischemic spinal cord stroke is a rare condition, accounting for approximately 1% of all spinal cord strokes. The relevance of this publication is determined by the rarity of the condition, the complexity of differential diagnosis with other acute onset myelopathic syndromes, the severity of spinal stroke outcomes, and insufficient awareness among physicians regarding this condition in children. CASE DESCRIPTION: We present a clinical case of acute myelopathic syndrome in an 8-year-old child. Magnetic resonance imaging of the cervical spinal cord correlated with the clinical findings and indicated impaired circulation in anterior spinal artery at the cervical spinal level. DISCUSSION: Acute impairment of spinal cord circulation may be caused by systemic hypotension; occlusion of spinal cord-supplying vessels (traumatic, iatrogenic, thrombotic, or embolic); arterial dissection; arteriovenous malformations and fistulas; or hypercoagulable states. CONCLUSION: In pediatric patients presenting with acute myelopathic syndrome, ischemic stroke of the spinal cord should be considered in the differential diagnosis alongside inflammatory and infectious conditions, particularly in children with significant risk factors. Early recognition of acute impairment of spinal cord circulation is particularly important for timely neuroimaging, consultations with related specialists, and initiating etiotropic or symptomatic treatment upon identification of the underlying cause of acute spinal cord ischemia, as well as early rehabilitation.

In endovascular internal trapping for intracranial vertebral artery dissecting aneurysms (VADAs) distal to the posterior inferior cerebellar artery bifurcation, anterior spinal artery (ASA) occlusion is a serious complication although it is relatively infrequent because of the presence of collateral blood vessels. In this article, we investigated the correlation between vascular anatomy and ischemic complications of the ASA. We retrospectively evaluated 21 patients with ruptured PICA-distal type VADA treated by internal trapping at our affiliated institutions from 2008 to 2022. The parent arteries were embolized from the dilated segment to the normal vessel, with careful preservation of the perforating arteries and the ASA. Primary end points included ASA origin anatomy, ASA occlusion incidence, and ischemic complications in the medullary and spinal cord regions. The ASA originated from bilateral vertebral arteries (VAs), the contralateral VA, and the ipsilateral VA, in 7, 11, and 3 cases, respectively. Postoperative ASA occlusion was observed in 3 cases. In 2 of these cases, ischemic complications did not occur because of the presence of collateral flow from the ASA originating from the contralateral side. However, the third patient developed medullary cervical infarction because of occlusion of the ipsilateral ASA 5 hours after the treatment although the ASA had been preserved during intervention. In these 3 patients, the distance between the ASA and the distal coil end was shorter than that in nonobstructed cases. In addition, lateral medullary syndrome occurred in 1 case. Cases of distal VADA with unilateral ipsilateral bifurcation of the ASA and proximity of the dissection site to the ASA origin carry the risk of severe medullary cervical infarction despite intraoperative preservation of the ASA. In such cases, strict postoperative management including antithrombotic therapy or alternative treatment modalities such as direct surgical VA trapping by clips should be considered.

Our study aims at characterizing the intraspinal vascular perfusion territories (angiosomes) of the descending thoracic aorta in a cadaver stetting to understand the principles of blood supply to the spinal cord and to provide the anatomic basis for strategies to avoid spinal ischaemia during aorta surgery. Simulating blood flow in the descending thoracic aorta and thoracic aortic segmental arteries T3-T11 of 8 body donors were perfused with dyed liquids to label the epidural and spinal cord angiosomes. The cranial and caudal borders of the spinal cord angiosome varied substantially with a maximum extension from segment C7 to the conus medullaris. In 5 specimens, the anterior and posterior aspects differed for 1-2 segments. In 75%, the anterior spinal artery appeared to be stained along the entire spinal cord, and in 4 specimens, a voluminous Adamkiewicz artery joined its lower thoracic segments. In 3 of those specimens, this caused the spinal cord angiosome to be stained caudally towards the conus medullaris. In addition to details on the spinal cord angiosome, details on the epidural angiosome and the antero- and retrograde perfusion of the spinal nerve roots and the influence of thoracic aortic segmental artery variations are provided. Our study characterizes both intraspinal descending thoracic aorta angiosomes. It demonstrates the importance of the Adamkiewicz and the anterior spinal arteries for blood supply to the spinal cord and the nerve root fibers.

Abstract Background Spinal cord injuries (SCI), although rare in children, lead to significant morbidity and mortality. Case presentation This report describes the case of a 15-year-old male adolescent who developed SCI due to paradoxical embolism of a deep vein thrombus following strenuous exercise. He presented with bilateral upper limb weakness that progressed to severe tetraparesia, sensory deficits, and autonomic instability. Imaging revealed medullary ischemia with hypoperfusion of the anterior spinal artery. A family history of thromboembolism and obesity were noted as risk factors in the patient; however, thrombophilia screening was negative. Optimized fluid therapy was initiated for the medullary shock associated with dexamethasone and enoxaparin. As neurological recovery was incomplete, the patient was enrolled in an intensive rehabilitation program. Conclusion To the best of our knowledge, this is the first reported case of medullary ischemia due to a paradoxical embolism of a deep vein thrombus through a patent foramen ovale in an adolescent. This case highlights the need for a multidisciplinary approach to optimize long-term outcomes after medullary ischemia.

Diagnostic Dilemma: A Case of Acute Respiratory Failure From Anterior Spinal Artery Infarct Presenting as Guillain-Barré Syndrome

Rupture of an anterior spinal artery (ASA) aneurysm at its intracranial origin is an exceptionally rare cause of subarachnoid hemorrhage (SAH). We report a case of a 69- year old adult male presented with agitation and neck pain, initially without neurological deficit, which worsened to coma upon admission to our center, approximately 8h after the onset of symptoms. Computerized tomography (CT) revealed massive SAH in the basal cisterns with intraventricular extension (Fisher IV), and CT angiography identified a ruptured aneurysm at the ASA origin, with no visualization of the distal ASA. The only surgical procedure performed was external ventricular drainage due to the development of obstructive hydrocephalus, together with conservative management based on the patient's clinical status and neuroradiological findings, with a fatal outcome 17 days later. This is the first reported case of a ruptured intracranial ASA aneurysm originating directly from the ASA main stem, and highlights the challenges of managing SAH combined with catastrophic spinal cord damage.

Neuraxial anesthesia provides effective anesthesia and analgesia for surgery, but may cause neurological complications. The rate of neurological complications in China remains unclear. This study conducted a retrospective epidemiological investigation of neurological complications following neuraxial anesthesia in Guangxi, southwest China. This survey used the “Golden Data” platform to distribute questionnaires to anesthesiology departments across hospitals of varying levels in Guangxi, gathering data on neuraxial anesthesia methods and associated neurological complications from 2013 to 2022. Detailed patient information was recorded, with missing data supplemented by phone. The Adverse Event Reporting System was also utilized to verify and supplement cases, supported by peer review. The study analyzed the incidence and clinical characteristics of neurological complications after neuraxial anesthesia. A comprehensive survey was conducted across 243 hospitals, encompassing 2,723,615 cases of neuraxial anesthesia. The survey identified 1208 cases of neurological complications, with an incidence of 0.44‰, primarily occurring in patients undergoing obstetrics, gynecology, orthopedics, urology, and general surgery. The complications included transient nerve syndrome (999 cases), spinal injury (188 cases), cauda equina syndrome (13 cases), spinal hematoma (5 cases), anterior spinal artery syndrome (2 cases), and conus medullaris injury (1 case). The incidence of neurological complications associated with combined spinal-epidural anesthesia (0.53‰) was significantly higher than that of epidural anesthesia (0.21‰) and spinal anesthesia (0.35‰) (P < 0.001). Among the patients, 97.3% achieved full recovery, while 2.7% (30 cases) suffered permanent neurological damage. Although neurological complications are relatively rare, comprehensive preoperative assessment, adherence to standardized protocols, and vigilance regarding potential complications are essential.

Spinal cord infarction (SCI) of arterial origin is a rare vascular event, and its incidence is probably underestimated. There are no strong epidemiological data, and the diagnostic pathway is complex and sometimes incomplete. Furthermore, many cases may be misdiagnosed as other forms of acute and subacute myelopathies. The focus of this review is the clinical and neuroradiological issues in diagnosing SCI and their respective reliability in a clinical setting. The new proposed diagnostic criteria of SCI, although not covering all aspects, highlight the need for a comprehensive approach, including even atypical cases, as the lack of cord compression on Magnetic Resonance Imaging (MRI) is the only mandatory feature for diagnosis. Some MRI features are supportive of the diagnosis, particularly when the anterior spinal artery territory is involved and diffusion-weighted imaging (DWI) is used. Several etiologies can be considered, considering traditional vascular risk factors and diseases affecting the aorta and its main branches, yet a significant proportion of cases remain without a definite etiology. The strongest predictor of SCI diagnosis is a clinical variable, i.e., a time to nadir of severe deficits < 12 h.

Three-column osteotomy (3CO) offers substantial spinal deformity correction. Thoracic neurovascular bundle sacrifice is often required, and anterior spinal artery (ASA) perfusion can be compromised. Spinal angiography allows localization of variable ASA vascular contribution. This study's objective was to describe a series of patients who underwent preoperative spinal angiography and discuss the impact on surgical planning and execution of thoracic 3CO for deformity correction. Patients who underwent preoperative spinal angiograms and thoracic 3CO for deformity correction were reviewed. Preoperative, angiographic, and postoperative information was recorded. A literature review on preoperative spinal angiography in deformity surgery was performed. Eight patients were identified: single-level pedicle subtraction osteotomies (1), single-level vertebral column resections (2), and multilevel vertebral column resections (5). The average age was 40.0 years, and 75.0% were female. Thoracic scoliosis ranged from 0 to 105° preoperatively and 0 to 45.1° postoperatively. Thoracic kyphosis ranged from 29° to 120° preoperatively and 20.6° to 54.9° postoperatively. Twelve ASA supply vessels were identified bilaterally in 6 patients. Four patients had nontraditional ASA supply at T4 (1), T6 (1), and L2 (2), and 4 had multiple ASA feeders. Based on angiographic results, osteotomy site was changed (1), and neurovascular bundles were spared (2), a 37.5% rate of surgical plan alteration. There were no permanent neuromonitoring changes or postoperative neurologic deficits. No articles reported on using spinal angiography specifically for deformity surgery. Spinal angiography is low risk and provides critical information regarding ASA supply to potentially mitigate ischemic risk during neurovascular bundle takedown during thoracic 3CO. Further case series are warranted to evaluate the benefits in larger populations, but its clinical applications appear practical.