Identifying the artery of Adamkiewicz (AoA) is essential for minimizing the risk of spinal cord ischemia that can result from injury or displacement during aortopexy. A pre-operative CT angiogram (CTA) is commonly requested; however, locating the artery can be challenging due to its small size and variable course. To enhance the visualization of the artery of Adamkiewicz, it is effective to increase the tube current while maintaining a low kV of 70 and raising the Hounsfield unit (HU) trigger threshold. This method adheres to the As Low As Reasonably Achievable (ALARA) principle, ensuring a reliably diagnostic study.

A filum terminale arteriovenous fistula fed by the left L1 artery of adamkiewicz: a case report and updated systematic review of 71 cases.

Photon-counting computed tomography (PCCT) is a new imaging technology that has advanced diagnostic imaging by offering improved spatial and contrast resolution as well as novel spectral imaging capabilities. Unlike conventional CT, which uses energy-integrating detectors, PCCT employs photon-counting detectors that directly measure individual photon energies, enabling applications such as virtual monochromatic imaging (VMI) and material decomposition. These innovations allow for artifact reduction, better visualization of fine anatomic structures, and improved diagnostic accuracy, all while reducing radiation dose. This review explores select applications of PCCT in neuroimaging, focusing on the brain, temporal bone, and spine. In the brain, we discuss how PCCT demonstrates superior performance for evaluating aneurysms, metallic prostheses, and vessel stenosis, offering enhanced visualization of vascular structures and minimizing artifacts. For temporal bone imaging, we review assessment of both complex anatomy and potentially subtle pathologies such as otosclerosis, as well as visualization of implants like cochlear devices and their intricate components. In spinal imaging, we explore how PCCT improves precise detection of causes of cerebrospinal fluid leaks, improves localization of tiny vessels such as the artery of Adamkiewicz and spinal dural arteriovenous fistulas, and reduces metal artifacts associated with postoperative hardware. PCCT addresses limitations of conventional CT while unlocking new diagnostic possibilities across neuroimaging applications. As clinical adoption of PCCT grows, ongoing research and development will refine imaging protocols and expand its utility. The accumulating evidence underscores PCCT's transformative potential to improve diagnostic confidence in neuroimaging and beyond.

Anatomical variations in nerves are common and can significantly impact ultrasound-guided regional anesthesia. They directly influence needle trajectory, local anesthetic spread, and block efficacy, contributing to procedural failure or complications. However, the literature specifically addressing the clinical implications of neural variations for regional anesthesia remains limited. This narrative review synthesizes evidence on three key aspects: (1) variations of common peripheral nerves and their clinical significance in regional anesthesia (including the terminal branches of the trigeminal nerve, suprascapular nerve, phrenic nerve, lumbar plexus, saphenous nerve, obturator nerve, and sciatic nerve); (2) variations of major vessels relevant to regional anesthesia and their clinical significance in regional anesthesia (including the Adamkiewicz artery and vertebral artery); (3) variations of the spine and spinal nerve roots and their clinical significance in regional anesthesia. This review systematically synthesizes current evidence on these anatomical variations and introduces practical resources, including regional ultrasound guidance and tables correlating specific variants with technical modifications, to enhance ultrasound recognition and clinical decision-making, thereby serving as a valuable reference for clinicians.

Photon counting detector CT is a relatively new technology that is becoming increasingly prevalent. In recent years, photon counting CT has been shown to have benefits in numerous neuroradiologic clinical applications, including temporal bone imaging, detection of spinal CSF leaks, and CT angiography of the head, neck, and spine. New uses for photon counting detector CT continue to emerge, capitalizing on the high spatial resolution and other advantages of this technology to improve patient care. One potential application in the spine is the detection and localization of the artery of Adamkiewicz, which provides the dominant supply to the inferior portion of the anterior spinal artery. Localization of this artery is sometimes desired prior to surgeries requiring ligation of the foraminal neurovascular complex. Traditional energy integrating detector CT is useful but imperfect for detection of this relatively small and transiently opacifying vessel. The improved spatial resolution and spectral information obtained with photon counting CT may help improve detection of the artery of Adamkiewicz. In this clinical report, we outline a protocol for imaging the artery of Adamkiewicz with photon counting detector CT and describe a comparative analysis of three different reconstruction techniques in six consecutive patients who underwent this exam. We found that an intermediate sharp vascular kernel (Bv60) reconstructed with a low energy threshold outperformed other conditions, including a sharper kernel and a low keV virtual monoenergetic reconstruction.ABBREVIATIONS: AKA = artery of Adamkiewicz or great radiculomedullary artery; CNR = contrast-to-noise ratio; EID = energy integrating detector; PCD = photon counting detector QIR = quantum iterative reconstruction; T3D = low energy threshold; UHR = ultra-high resolution.

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

A woman in her 30s with a left posterior mediastinal tumor incidentally found on a chest computed tomography (CT) was referred to our hospital. Chest CT revealed a dumbbell-shaped tumor of 37 mm in diameter located on the paravertebral region at the left Th9/10 level. The tumor extended into the Th9 intervertebral foramen, but did not extend into the spinal canal. Three dimensional (3D)-CT showed the artery of Adamkiewicz (AKA) with a hair-pin turn from the 11th left intercostal artery. We performed surgical treatment. First, the nerve root was dissected by the posterior approach. Next, the tumor was resected by thoracoscopic surgery. The postoperative pathological diagnosis was neurinoma. In surgical resection of posterior mediastinal tumors (especially on the left side) located between the eighth thoracic vertebra and the first lumbar vertebra, it is considered important to identify AKA preoperatively in order to prevent postoperative paraplegia.

Spinal epidural arteriovenous fistulas (SEAVFs) with intradural reflux are rare but important vascular lesions that may cause progressive myelopathy due to spinal cord venous hypertension. Although traditionally managed by means of arterial embolization or surgical disconnection, these approaches can pose risks, particularly when critical vascular structures, such as the artery of Adamkiewicz, originate in close proximity to the fistulous site. We report the case of a patient in their 60s who presented with progressive paraparesis over approximately 1year, ultimately attributed to an SEAVF located adjacent to the right L1-L2 neural foramen, with radiculo-perimedullary reflux. The artery of Adamkiewicz was visualized with its origin near the shunt site, rendering arterial embolization unsafe and prompting selection of a purely transvenous endovascular approach. Venous access was obtained via the azygos system, and a microcatheter was navigated through the epidural venous pouch to reach a cranially directed draining vein extending toward the perimedullary venous system, which was then embolized using detachable platinum coils. The procedure achieved complete occlusion of the targeted vein, with early neurological improvement and significant reduction in spinal cord edema on follow-up imaging. This case supports the feasibility, safety, and efficacy of transvenous embolization for SEAVFs and underscores its expanding role in the treatment of complex spinal vascular lesions.

Complete resection of spinal cord tumors in the thoracic region requires precise preservation of critical vascular structures such as the Adamkiewicz artery. This report highlights the utility of narrow band imaging (NBI) in achieving complete schwannoma removal, while preserving vascular integrity. A 72-year-old male presented with left lower extremity weakness persisting for four months. He experienced difficulty cycling uphill and was forced to walk in a forward-bent posture. MRI revealed a dumbbell-shaped mass extending from the intradural space at Th12/L1 into the paravertebral region, resulting in the diagnosis of schwannoma arising from the left Th12 nerve root. Preoperative computed tomography angiography indicated proximity of the Adamkiewicz artery to the tumor. Intraoperatively, NBI facilitated identification and preservation of the Adamkiewicz artery during tumor removal. Postoperatively, the patient's muscle strength improved, and he resumed normal walking without forward bending posture. NBI is a valuable adjunct for visualizing critical vascular structures intraoperatively, ensuring safe and effective tumor resection.

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.

Exclusion of long aortic segments in the treatment of endovascular thoracoabdominal aortic aneurysms is associated with a higher risk of spinal cord ischemia. We present the successful implantation of a branch stent graft with perfusion of the great Adamkiewicz artery to diminish risk of paraplegia. An 81-year-old man was diagnosed with a perirenal aneurysm of the abdominal aorta (64 mm). Imaging examination revealed an Adamkiewicz artery with a diameter of 4.5 mm. Endovascular treatment was conducted using a customized branched stent graft with an additional branch to the Adamkiewicz artery, with access via the right femoral artery and the left axillary artery. After embolization of the inferior mesenteric artery, a stent graft was implanted, maintaining patency of the renal arteries, Adamkiewicz artery and visceral vessels. This case demonstrates the effectiveness of personalized stent grafts adapted to the patient's anatomy. The stent graft used, with a branch to the Adamkiewicz artery, allowed the aneurysm to be excluded from the circulation while maintaining spinal cord perfusion. In our opinion, such a solution should be considered in cases of extensive aortic aneurysms involving the large Adamkiewicz artery treated with branched endovascular aneurysm repair.Clinical ImpactPresented case illustrates the potential of customized stent-grafts, which can be adapted to the patient's anatomy. Spinal cord ischemia remains a significant complication of endovascular repair of aortic aneurysms. A prosthesis providing adequate perfusion of the Adamkiewicz artery may prove an additional method of preventing paraplegia. There is a paucity of literature on the repair of aortic aneurysms with the implantation of branched stent grafts with a branch into the Adamkiewicz artery, which serves to highlight the innovation of our treatment. The presented case offers new insights into the prevention of paraplegia with branched endovascular aneurysm repair procedures.

It is known that acute and chronic disorders of spinal blood circulation in clinical practice are almost always accompanied by significant risks of complications and gross residual phenomena that significantly affect the patient’s quality of life in the long term. Spinal blood circulation disorders are acute or chronic disorders caused by pathology of the vessels that provide blood supply to the spinal cord. Arterial blood supply to the spinal cord is provided from several sources. The spinal cord is supplied by branches of the following arteries: vertebral artery, ascending cervical artery, deep cervical artery, posterior intercostal arteries, lumbar and median sacral arteries, iliolumbar artery and lateral sacral arteries. In many cases, the Adamkiewicz artery, which is found in over 80 % of people, plays a significant role in ensuring blood supply to the spinal cord. This artery arises from the spinal branch (r. spinalis) of the dorsal branch (r.dorsalis) of the posterior intercostal, or subcostal, or lumbar arteries (all of these arteries arise from the descending aorta). The Adamkiewicz artery, independently and through the anterior spinal artery (after merging with it), supplies blood to the lower part of the spinal cord. Circulatory disorders in the Adamkiewicz artery can lead to severe (often irreversible) neurological consequences, including spinal cord ischemia syndrome, similar to anterior spinal artery syndrome, or spinal stroke. In addition to the above sources of blood supply to the spinal cord, some non-permanent additional arteries are also described, one of the most important of which is the Desproges-Gotteron artery. It arises from the internal iliac artery or one of its branches (usually on one side), enters the spinal canal along with the roots of the fifth lumbar or first sacral nerve and supplies blood to the conus medullaris.

Aortic dissection with neurological symptoms is a usual presentation and rare condition. It poses a major diagnostic challenge due to the risk of misdiagnosis and worse prognosis (functional or vital). We present the clinical case of a 53-year-old female patient admitted for chest pain and sudden onset paraplegia in cardiology department. Her medical history included hypertension and diabetes mellitus. Physical examination showed paraplegia associated to anesthesia of legs and painless back. BP: 120/60 mmHG. Cariopulmonary auscultation was normal. Pulses presents. Chest X-ray revealed mediastinal widening. Cardiac ultrasound revealed an intimal tear of aortic dissection and severe aortic insufficiency. Chest CT angiography showed a Stanford type A aortic dissection with left renal infarction. Spinal cord MRI was not available. In the absence of a cardiac surgery center, the patient died one month later from trophic and infectious complications. Paraplegia leads to aortic dissection when there is no pain in the back and occurs suddenly. Hypertension is the common cause in subafrica. Early diagnosis and management prevent death.

Does Computed Tomography Angiography for the Adamkiewicz Artery Add Value Over Standard Scanning in Thoracic Endovascular Aortic Repair Planning?

Abstract There are increasing number of clinical cases with physician-modified endograft (PMEG) endograft for urgent reconstruction of large pararenal aneurysms to reduce the perioperative complication risks of fragile patients, but the risk of spinal cord ischemia due to the coverage of longer segment of thoracic aorta is relatively high.We demonstrate an expedited endovascular treatment of an 88 mm pararenal aneurysm by performing a 4-vessel fenestrated endovascular aortic repair. A prominent Adamkiewicz artery, ectatic supraceliac aortic segment, median arcuate ligament compression of the celiac artery and severe tortuosity of the common iliac arteries made the endovascular repair more challenging. A PMEG was implanted with simultaneous deployment technique to achieve a short proximal landing zone to preserve the Adamkiewicz artery.The proper risk assessment and preparation of the patient based on the clinical evaluation and procedure planning is essential for the clinical success of PMEG in urgent indication.

Microanastomotic Primary Repair of Artery of Adamkiewicz Transection With Artery of Adamkiewicz to Artery of Adamkiewicz Intraspinal Anastomosis: 2-Dimensional Operative Video.

Low-keV virtual monoenergetic images (VMIs) of dual-energy computed tomography (CT) enhances iodine contrast for detecting small arteries like the Adamkiewicz artery (AKA), but image noise can be problematic. Deep-learning image reconstruction (DLIR) effectively reduces noise without sacrificing image quality. To evaluate whether DLIR on low-keV VMIs of dual-energy CT scans improves the visualization of the AKA. We enrolled 29 patients who underwent CT angiography before aortic repair. VMIs obtained at 70 and 40 keV were reconstructed using hybrid iterative reconstruction (HIR), and 40 keV VMIs were reconstructed using DLIR. The image noise of the spinal cord, the maximum CT values of the anterior spinal artery (ASA), and the contrast-to-noise ratio (CNR) of the ASA were compared. The overall image quality and the delineation of the AKA were evaluated on a 4-point score (1 = poor, 4 = excellent). The mean image noise of the spinal cord was significantly lower on 40-keV DLIR than on 40-keV HIR scans; they were significantly higher than on 70-keV HIR images. The CNR of the ASA was highest on the 40-keV DLIR images among the three reconstruction images. The mean image quality scores for 40-keV DLIR and 70-keV HIR scans were comparable, and higher than of 40-keV HIR images. The mean delineation scores for 40-keV HIR and 40-keV DLIR scans were significantly higher than for 70-keV HIR images. Visualization of the AKA was significantly better on low-keV VMIs subjected to DLIR than conventional HIR images.

Identification of the Adamkiewicz artery before aortic surgery is important for preventing postoperative complications due to spinal cord ischemia. The Adamkiewicz artery is difficult to identify due to its small diameter. Nitroglycerin has a vasodilatory effect and is used clinically to improve visualization of blood vessels on coronary computed tomography (CT) angiography. We investigated whether the vasodilatory effect of nitroglycerin could improve the ability to visualize the Adamkiewicz artery. We extracted 33 cases wherein contrast-enhanced CT images were taken before and after aortic aneurysm surgery. Nitroglycerin was administered for coronary artery evaluation on the preoperative CT. However, no nitroglycerin was administered before the postoperative CT. Aortic contrast-to-noise ratio, CT value, image noise, and diameter of the Adamkiewicz artery and anterior spinal artery were measured. The depiction of the Adamkiewicz artery was graded into four grades and evaluated. These measurements were performed by two independent reviewers. In nitroglycerin-administered cases, the contrast-to-noise ratio and CT values were significantly higher (P < 0.001, P < 0.001, respectively); the Adamkiewicz artery and anterior spinal artery diameters were dilated (P = 0.005, P = 0.001, respectively). The Adamkiewicz artery score also improved significantly (P < 0.001). No significant difference was found in image noise. Nitroglycerin contributed to improving the Adamkiewicz artery's visualization.

Our goal was to evaluate postoperative patterns of collateral arteries to the spinal cord during occlusion of the segmental arteries supplying the artery of Adamkiewicz (AKA). Between April 2011 and December 2022, a total of 179 patients underwent thoraco-abdominal aortic aneurysm repair; 141 had an identifiable AKA on preoperative multidetector computed tomography scans, 40 underwent thoraco-abdominal aortic aneurysm replacement (TAAR) and 101 underwent thoracic endovascular aortic repair (TEVAR). New postoperative collateral blood pathways invisible on preoperative contrast-enhanced computed tomography scans were identified in 42 patients (10 patients who had TAAR vs 32 patients who had TEVAR) who underwent preoperative and postoperative multidetector computed tomography scanning for AKA identification. The thoracodorsal and segmental arteries were the main collateral pathways in both groups. Th9-initiated collaterals were the most common. Collaterals from the internal thoracic artery were observed in the TEVAR group but not in the TAAR group. One patient in the TEVAR group experienced postoperative paraparesis, which was not observed in the TAAR group. Postoperative paraplegia was more common in the non-Th9-origin group, but this difference was not significant. Thoracodorsal and segmental arteries may be important collateral pathways after TEVAR and TAAR. For thoracodorsal arteries, preserving the thoracodorsal muscle during the approach would be crucial; for segmental arteries, minimizing the area to be replaced or covered would be paramount. An AKA not initiated at the Th9 level poses a high risk of postoperative paraplegia.

A 63-year-old woman experienced severe, progressive back pain for a year from a T12 vertebral body tumor invading the epidural space and causing spinal cord compression (Figure ,A).Because of significant bleeding during biopsy, endovascular tumor embolization was pursued before surgical resection.Digital subtraction angiogram revealed not only bilateral T11-T12 radicular artery feeders but also the artery of Adamkiewicz's characteristic "hairpin turn" arising from the left T12 radicular artery (Figure ,B).The artery of Adamkiewicz supplies the lower two-thirds of the spinal cord through the anterior spinal artery and usually originates from the thoracic spinal levels T9-T12, more commonly on the left.Identifying the artery of Adamkiewicz is crucial in tumor embolization because its embolization could result in anterior cord ischemia and paraplegia.This patient safely underwent embolization and surgical resection without injury to the artery of Adamkiewicz.The tumor was diagnosed as chordoma.The patient remains functionally independent and currently undergoes radiotherapy.