DOI: 10.1148/rg.235025031
(Radiographics. 2003;23:1215-1225.)
© RSNA, 2003
MR Angiography and CT Angiography of the Artery of Adamkiewicz: Noninvasive Preoperative Assessment of Thoracoabdominal Aortic Aneurysm1
Kunihiro Yoshioka, MD,
Hiroyuki Niinuma, MD,
Atsushi Ohira, MD,
Kazuhiro Nasu, MD,
Tomoko Kawakami, MD,
Makoto Sasaki, MD and
Kouhei Kawazoe, MD
1 From the Department of Radiology (K.Y., M.S.), the Second Department of Internal Medicine (H.N., A.O., K.N., T.K.), and the Department of Cardiovascular Surgery (K.K.), Memorial Heart Center, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate 020-8505, Japan. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received February 19, 2002; revision requested March 20; final revision received February 1, 2003; accepted February 11. Address correspondence to K.Y. (e-mail: kyoshi@iwate-med.ac.jp).
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Abstract
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It is important to identify the artery of Adamkiewicz in patients with thoracoabdominal aortic aneurysm to aid in surgical planning and to prevent postoperative paraplegia or paraparesis. However, the artery of Adamkiewicz is difficult to visualize and impossible or very dangerous to evaluate with selective intercostal or lumbar angiography. The feasibility, advantages, and limitations of magnetic resonance (MR) angiography and computed tomographic (CT) angiography in the preoperative assessment of the artery of Adamkiewicz were evaluated in 30 patients with thoracoabdominal aortic aneurysm. Initial results indicate that MR angiography and CT angiography are safe, effective, noninvasive procedures that allow clear visualization of the artery of Adamkiewicz by providing detailed depiction of the vascular anatomy from the aorta to the anterior spinal artery. However, further studies will be needed to assess the efficacy of these modalities in decreasing surgical risk.
© RSNA, 2003
Index Terms: Aneurysm, aortic, 943.73, 981.73 • Arteries, Adamkiewicz, 373.12116, 373.12142, 373.92 • Arteries, CT, 373.12116 • Arteries, MR, 373.12142 • Computed tomography (CT), angiography, 373.12116 • Magnetic resonance (MR), vascular studies, 373.12142
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Introduction
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Surgery for thoracoabdominal aortic aneurysm sometimes leads to paraparesis or paraplegia (1,2). Patients who undergo graft replacement of thoracoabdominal aortic aneurysms are still at risk for ischemic spinal cord injury, and paraplegia occurs in 5%–10% of cases (1,3–5). These critical complications are caused by occlusion of the anterior spinal artery (6,7). In the thoracolumbar region, the arterial feeding vessel of the anterior spinal artery is the great anterior radiculomedullary artery, also known as the artery of Adamkiewicz, which was first described by A. Adamkiewicz in 1882 (8). Griepp et al (9) reported that the risk of paraplegia decreased with reimplantation of intercostal arteries that at the time of surgery were monitored for change in evoked potential of the spinal cord (9). This is the main reason for identifying the artery of Adamkiewicz preoperatively.
Identification of the artery of Adamkiewicz in patients with thoracoabdominal aortic aneurysm is important for surgical planning and for prevention of postoperative paraplegia or paraparesis. However, the artery of Adamkiewicz is difficult to visualize and impossible or very dangerous to evaluate with selective intercostal or lumbar angiography.
In this article, we describe the patients and procedures involved in a study of 30 patients with thoracoabdominal aortic aneurysm; the normal anatomy of the artery of Adamkiewicz; and magnetic resonance (MR) angiography and computed tomographic (CT) angiography in terms of imaging technique, data processing, advantages and limitations, and clinical applications.
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Patients and Procedures
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Between April 1998 and August 2001, 30 patients (25 men, 5 women; age range, 45–78 years; mean age, 64 years) with thoracoabdominal aortic aneurysm and descending aortic aneurysm underwent gadolinium-enhanced MR angiography followed by multi–detector row CT angiography to investigate the artery of Adamkiewicz in preoperative evaluation of the blood supply of the spinal cord. The underlying aortic disease was a dissecting thoracic aortic aneurysm in 10 patients and a true thoracic aortic aneurysm in 20 patients (Crawford classification type I in five patients, type II in two, type III in three, type IV in six, and descending aortic aneurysm with abdominal aortic aneurysm in four).
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Normal Anatomy
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The most important arterial feeding vessel of the thoracolumbar spinal cord is the great anterior radiculomedullary artery (artery of Adamkiewicz) (10,11). This artery supplies the lower one-third of the spinal cord, originating in the left intercostal or lumbar artery in 68%–73% of cases and at the level of the 9th–12th intercostal artery in 62%–75% (12–17). The anatomic course of the artery of Adamkiewicz is as follows: The intercostal or lumbar arteries that arise from the descending aorta (Fig 1a) (18) divide into an anterior branch, which runs along the costal groove, and a posterior branch, which courses to the spine. The posterior branch subdivides into the radiculomedullary artery, the muscular branch, and the dorsal somatic branch. The radiculomedullary artery further subdivides into anterior and posterior radiculomedullary arteries, which accompany the anterior and posterior nerve roots, respectively (Fig 1b) (18). The artery of Adamkiewicz is the most dominant anterior radiculomedullary artery, with a diameter of 0.8–1.3 mm. The distal portion of this artery, together with the anterior spinal artery, form a characteristic "hairpin" turn.
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Figure 1a. Drawings illustrate the arteries of the spinal cord and spine. (a) The thoracolumbar segment of the spinal cord is vascularized by branches of the thoracoabdominal aorta via the intercostal and lumbar arteries. (b) The intercostal or lumbar artery arises from the aorta and divides into anterior and posterior branches. The posterior branch subdivides into the radiculomedullary artery, the muscular branch, and the dorsal somatic branch. The radiculomedullary artery further subdivides into the anterior and posterior radiculomedullary arteries. (Fig 1 reprinted, with permission, from reference 18.)
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Figure 1b. Drawings illustrate the arteries of the spinal cord and spine. (a) The thoracolumbar segment of the spinal cord is vascularized by branches of the thoracoabdominal aorta via the intercostal and lumbar arteries. (b) The intercostal or lumbar artery arises from the aorta and divides into anterior and posterior branches. The posterior branch subdivides into the radiculomedullary artery, the muscular branch, and the dorsal somatic branch. The radiculomedullary artery further subdivides into the anterior and posterior radiculomedullary arteries. (Fig 1 reprinted, with permission, from reference 18.)
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Imaging Technique
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MR Angiography
We performed MR angiography with a 1.5-T superconducting imager (Signa; GE Medical Systems, Milwaukee, Wis) and 8.3 operating system software, along with a phased-array coil for the spine to optimize signal detection.
First, localization imaging with a wide field of view (480 x 480 mm) was performed in coronal, sagittal, and transverse orientations. Next, a gadolinium-enhanced MR angiographic sequence was performed according to the method described by Prince (19), with some modification. We used a three-dimensional (3D) fast spoiled gradient-echo sequence with a chemical shift–selective fat-suppression technique. The original sequence used by Prince (19) was a fast spoiled gradient-echo sequence without fat suppression but with out-of-phase echo time. MR angiography with the Signa system usually consists of a 3D fast spoiled gradient-echo sequence with a spectral inversion at lipid (SPECIAL) sequence for fat suppression. We used the chemical shift–selective technique because it is more effective than a SPECIAL sequence for fat suppression and has less susceptibility than a SPECIAL sequence so that a long repetition time is required. Subtraction technique was not used in this method. Imaging parameters were as follows: 50–60-mm section thickness with 50–60 partitions (1-mm partition thickness), 0.5-mm reconstruction interval with the zero-filling interpolation technique, 20-msec repetition time, 2.2-msec echo time, 40° flip angle, 32-Hz acquisition bandwidth, 168 x 240-mm field of view, and a 384 x 512 matrix. The resulting pixel size was 0.47 x 0.44 mm. The section orientation was sagittal, allowing coverage of the area from the seventh thoracic vertebra to the second lumbar vertebra. Acquisition time was 5–6 minutes. With this pulse sequence, k space was acquired in the standard sequential linear fashion. We selected sequential order for sampling the k space so that half-acquisition time could become a center of k space.
A 22-gauge plastic intravenous catheter was placed in an antecubital vein. A total of 0.2 mmol/kg of body weight of gadopentetate dimeglumine (Magnevist; Schering, Berlin, Germany) was administered at a rate of 0.2 mL/sec with a power injector (Sonicshot 50; Nemotokyorindou, Tokyo, Japan), which was then flushed with 20 mL of normal saline solution, also at 0.2 mL/sec. Injection was initiated 60–70 seconds before half-acquisition time so that the contrast material reached the target site (descending aorta) within this time delay.
CT Angiography
We performed CT angiography with a four-channel multi–detector row helical CT scanner (Aquilion; Toshiba, Tokyo, Japan). Scanning parameters were as follows: 120 kV, 300 mA, 1-mm section thickness, 3.5 pitch, and 0.5-second rotation speed. Scanning was performed from the seventh thoracic vertebra to the second lumbar vertebra (location was determined with use of a scout digital radiograph).
A 20-gauge plastic intravenous catheter was placed in an antecubital vein. The line was then connected to a power injector (Autoenhance A-250, Nemotokyorindou). A total of 2.5 mL/kg of body weight of high-osmolarity iopamidol (Iopamiron, Schering; iodine, 370 mg/mL) was administered at a rate of 3 mL/sec with a power injector, which was then flushed with 30 mL of normal saline solution, also at 3 mL/sec. The scan delay was set with an automatic triggering system (Surestart, Toshiba). Continuous low-dose fluoroscopy (120 kV, 50 mA) performed at the level of the descending aorta was initiated 10 seconds after the start of contrast material injection. The attenuation value of a round, 1-cm-diameter region of interest in the descending aorta at the level of the seventh thoracic vertebra was measured three times per second. When this value reached a preset threshold (an absolute attenuation value of 130 HU) three consecutive times, helical CT began automatically.
Data Processing
All MR angiographic and CT angiographic data were transferred to a workstation (Advantage Windows 3.1, GE Medical Systems) and displayed as multiplanar reformatted (MPR) and maximum-intensity-projection (MIP) images. Selected CT angiograms were transferred to another workstation (Zio M900; Ziosoft, Tokyo, Japan) for 3D display (volume rendering). At both modalities, 1-mm-thick MPR images were obtained at 1-mm intervals. Section thickness for the MIP images was 2–28 mm to ensure the longest possible time for vessel visualization.
Some oblique MPR images with nearly coronal orientations were obtained to compensate for the curvature of the spinal cord. If a vessel was determined or suspected to run from the dorsal branch of the intercostal or lumbar artery to the anterior surface of the spinal cord, some oblique axial and coronal MPR images were obtained to track the continuity between the aorta and the anterior spinal artery. In some cases, curved MPR images were obtained along the vessels of interest (aorta, intercostal or lumbar artery, radiculomedullary artery, artery of Adamkiewicz, anterior spinal artery); partial MIP images were created from a small volume of MR and CT images to show the longest possible continuity in a single plane and to avoid "contaminating" the other arteries.
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Identification of the Artery of Adamkiewicz
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The artery of Adamkiewicz and the anterior spinal artery were evaluated by two experienced radiologists, each working separately and using the processed images. The criteria for identifying the artery of Adamkiewicz were as follows: (a) The vessel ascended to the anterior midsagittal surface of the spinal cord from the radiculomedullary artery, which usually arises from the dorsal branch of the intercostal or lumbar artery; or (b) there was observed continuity of the aorta, intercostal or lumbar artery, radiculomedullary artery, and anterior radiculomedullary artery, which feeds the anterior spinal artery with a characteristic hairpin turn that connects the artery of Adamkiewicz with the anterior spinal artery.
The quality of CT angiograms may change with section thickness. Figure 2 shows the qualitative difference between an MR angiogram and a CT angiogram and between CT angiograms with a section thickness of 2 mm and 1 mm, respectively. The quality of images with a 1-mm section thickness is better than that of images with a 2-mm section thickness. The radiculomedullary artery could be identified just beneath the vertebra on the CT angiogram with a 1-mm section thickness (Fig 2c).
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Figure 2a. Differences in image quality owing to modality and section thickness. (a) Oblique coronal MPR image from MR angiography shows that the artery of Adamkiewicz originates from the radiculomedullary artery at the level of the left 10th-11th intercostal artery. (b, c) Oblique coronal MPR images from CT angiography with a 2-mm (b) and 1-mm (c) section thickness show the artery of Adamkiewicz. The radiculomedullary artery is seen just beneath the vertebra in c (arrow).
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Figure 2b. Differences in image quality owing to modality and section thickness. (a) Oblique coronal MPR image from MR angiography shows that the artery of Adamkiewicz originates from the radiculomedullary artery at the level of the left 10th-11th intercostal artery. (b, c) Oblique coronal MPR images from CT angiography with a 2-mm (b) and 1-mm (c) section thickness show the artery of Adamkiewicz. The radiculomedullary artery is seen just beneath the vertebra in c (arrow).
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Figure 2c. Differences in image quality owing to modality and section thickness. (a) Oblique coronal MPR image from MR angiography shows that the artery of Adamkiewicz originates from the radiculomedullary artery at the level of the left 10th-11th intercostal artery. (b, c) Oblique coronal MPR images from CT angiography with a 2-mm (b) and 1-mm (c) section thickness show the artery of Adamkiewicz. The radiculomedullary artery is seen just beneath the vertebra in c (arrow).
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The branching level of the artery of Adamkiewicz was determined on the basis of the anatomic level of the intercostal or lumbar artery that was seen branching from the artery of Adamkiewicz. The anatomic level of the intercostal artery was defined as the level of the rib below which the intercostal artery ran. Because the intercostal or lumbar artery usually turned in a cranial direction immediately after branching from the descending aorta, we did not determine its branching level on the basis of the level of the vertebra from which it arose.
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Results
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All of the patients gave informed consent for MR angiography and CT angiography, and all examinations were completed without incident.
The artery of Adamkiewicz was successfully visualized in 20 of 30 patients (66.7%) at MR angiography and in 24 of 30 patients (80%) at CT angiography. Continuity of the aorta, intercostal artery, radiculomedullary artery, artery of Adamkiewicz, and anterior spinal artery was depicted in 17 of the 20 patients (85%) at MR angiography and in 15 of the 24 patients (62.5%) at CT angiography. The artery of Adamkiewicz could be identified in 27 of 30 patients (90%) at MR angiography or CT angiography and was identified on the basis of continuity from the aorta to the anterior spinal artery in 19 of 30 patients (63.3%) (Table).
The patients were divided into two groups: those with a dissecting aneurysm (group D) (n = 10) and those with a true aneurysm (group T) (n = 20). In group D, the artery of Adamkiewicz was depicted in seven of 10 patients (70%) at MR angiography, but continuity was observed in only five of these seven patients (71.4%) and was seen to originate at the level of the left seventh intercostal artery in one case, the left 10th intercostal artery in two, the left 11th intercostal artery in one, and the right ninth intercostal artery in one. The artery of Adamkiewicz was depicted in four of 10 patients (40%) at CT angiography, but continuity was observed in only one of these patients (25%). In group T, the artery of Adamkiewicz was depicted in 13 of 20 patients (65%) at MR angiography, and continuity was observed in 12 of these 13 patients (92.3%). The artery of Adamkiewicz was depicted in all 20 patients (100%) with CT angiography, but continuity was observed in only 14 patients (70%). In these 14 cases, the artery of Adamkiewicz was seen to originate at the level of the left eighth intercostal artery in two cases, the left ninth intercostal artery in six, the left 10th intercostal artery in two, the left 11th intercostal artery in two, the right ninth intercostal artery in one, and the right 10th intercostal artery in one (Table). In four cases, the collateral vessels were depicted with MR angiography.
Thus, the artery of Adamkiewicz was detected on the basis of continuity from the aorta to the anterior spinal artery in 17 of 30 patients (56.6%) with MR angiography and in 15 of 30 patients (50%) with CT angiography. There was no difference between the two methods of detection of the artery of Adamkiewicz, and no examination was corrupted by motion artifact.
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Clinical Application
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Continuity of the Artery of Adamkiewicz with the Aorta
The artery of Adamkiewicz used to be identified with conventional selective angiography (17,20,21). However, MR angiography and CT angiography also have the potential to demonstrate the vessels of interest—the intercostal or lumbar artery, anterior and posterior branches, radiculomedullary artery, and anterior radiculomedullary artery from the aorta to the anterior spinal artery—in their entirety. Thus, the artery of Adamkiewicz can be identified on the basis of continuity from the aorta to the anterior spinal artery.
The images shown in Figure 3 were obtained according to prescribed methods and anatomic considerations and clearly depict the vessels of interest. Figure 4 shows the precise continuity of these vessels. Therefore, we suggest that the artery of Adamkiewicz can be identified with MR angiography and CT angiography without conventional selective angiography.
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Figure 3a. True thoracoabdominal aortic aneurysm in a 63-year-old woman. (a) Oblique coronal MPR image from MR angiography shows the artery of Adamkiewicz (arrow), which branches from the left ninth radiculomedullary artery (arrowheads). The anterior spinal artery is continuous with the artery of Adamkiewicz, creating a hairpin turn. (b) Axial partial MPR image from MR angiography demonstrates continuity between the aorta (Ao) and the radiculomedullary artery (arrowhead). The anterior (a) and muscular (m) branches are also visualized. (c) Oblique coronal MPR image from CT angiography shows the artery of Adamkiewicz (arrow) and the radiculomedullary artery (arrowhead). (d) Oblique axial MPR image from CT angiography shows the proximal portion of the left ninth intercostal artery (arrow). (e) Oblique axial MPR image from CT angiography shows the radiculomedullary artery (arrowheads). The anterior branch (a) is also visualized.
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Figure 3b. True thoracoabdominal aortic aneurysm in a 63-year-old woman. (a) Oblique coronal MPR image from MR angiography shows the artery of Adamkiewicz (arrow), which branches from the left ninth radiculomedullary artery (arrowheads). The anterior spinal artery is continuous with the artery of Adamkiewicz, creating a hairpin turn. (b) Axial partial MPR image from MR angiography demonstrates continuity between the aorta (Ao) and the radiculomedullary artery (arrowhead). The anterior (a) and muscular (m) branches are also visualized. (c) Oblique coronal MPR image from CT angiography shows the artery of Adamkiewicz (arrow) and the radiculomedullary artery (arrowhead). (d) Oblique axial MPR image from CT angiography shows the proximal portion of the left ninth intercostal artery (arrow). (e) Oblique axial MPR image from CT angiography shows the radiculomedullary artery (arrowheads). The anterior branch (a) is also visualized.
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Figure 3c. True thoracoabdominal aortic aneurysm in a 63-year-old woman. (a) Oblique coronal MPR image from MR angiography shows the artery of Adamkiewicz (arrow), which branches from the left ninth radiculomedullary artery (arrowheads). The anterior spinal artery is continuous with the artery of Adamkiewicz, creating a hairpin turn. (b) Axial partial MPR image from MR angiography demonstrates continuity between the aorta (Ao) and the radiculomedullary artery (arrowhead). The anterior (a) and muscular (m) branches are also visualized. (c) Oblique coronal MPR image from CT angiography shows the artery of Adamkiewicz (arrow) and the radiculomedullary artery (arrowhead). (d) Oblique axial MPR image from CT angiography shows the proximal portion of the left ninth intercostal artery (arrow). (e) Oblique axial MPR image from CT angiography shows the radiculomedullary artery (arrowheads). The anterior branch (a) is also visualized.
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Figure 3d. True thoracoabdominal aortic aneurysm in a 63-year-old woman. (a) Oblique coronal MPR image from MR angiography shows the artery of Adamkiewicz (arrow), which branches from the left ninth radiculomedullary artery (arrowheads). The anterior spinal artery is continuous with the artery of Adamkiewicz, creating a hairpin turn. (b) Axial partial MPR image from MR angiography demonstrates continuity between the aorta (Ao) and the radiculomedullary artery (arrowhead). The anterior (a) and muscular (m) branches are also visualized. (c) Oblique coronal MPR image from CT angiography shows the artery of Adamkiewicz (arrow) and the radiculomedullary artery (arrowhead). (d) Oblique axial MPR image from CT angiography shows the proximal portion of the left ninth intercostal artery (arrow). (e) Oblique axial MPR image from CT angiography shows the radiculomedullary artery (arrowheads). The anterior branch (a) is also visualized.
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Figure 3e. True thoracoabdominal aortic aneurysm in a 63-year-old woman. (a) Oblique coronal MPR image from MR angiography shows the artery of Adamkiewicz (arrow), which branches from the left ninth radiculomedullary artery (arrowheads). The anterior spinal artery is continuous with the artery of Adamkiewicz, creating a hairpin turn. (b) Axial partial MPR image from MR angiography demonstrates continuity between the aorta (Ao) and the radiculomedullary artery (arrowhead). The anterior (a) and muscular (m) branches are also visualized. (c) Oblique coronal MPR image from CT angiography shows the artery of Adamkiewicz (arrow) and the radiculomedullary artery (arrowhead). (d) Oblique axial MPR image from CT angiography shows the proximal portion of the left ninth intercostal artery (arrow). (e) Oblique axial MPR image from CT angiography shows the radiculomedullary artery (arrowheads). The anterior branch (a) is also visualized.
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Figure 4a. True thoracoabdominal aortic aneurysm in a 78-year-old man. (a-c) Oblique axial MPR images from CT angiography show the left ninth intercostal artery (arrow in a and b) and the radiculomedullary artery (arrowhead in c). (d) Planning image for the curved MPR image (cf e). (e) Curved MPR image from CT angiography clearly shows continuity of the aorta, intercostal artery, radiculomedullary artery, artery of Adamkiewicz (arrow), and anterior spinal artery.
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Figure 4b. True thoracoabdominal aortic aneurysm in a 78-year-old man. (a-c) Oblique axial MPR images from CT angiography show the left ninth intercostal artery (arrow in a and b) and the radiculomedullary artery (arrowhead in c). (d) Planning image for the curved MPR image (cf e). (e) Curved MPR image from CT angiography clearly shows continuity of the aorta, intercostal artery, radiculomedullary artery, artery of Adamkiewicz (arrow), and anterior spinal artery.
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Figure 4c. True thoracoabdominal aortic aneurysm in a 78-year-old man. (a-c) Oblique axial MPR images from CT angiography show the left ninth intercostal artery (arrow in a and b) and the radiculomedullary artery (arrowhead in c). (d) Planning image for the curved MPR image (cf e). (e) Curved MPR image from CT angiography clearly shows continuity of the aorta, intercostal artery, radiculomedullary artery, artery of Adamkiewicz (arrow), and anterior spinal artery.
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Figure 4d. True thoracoabdominal aortic aneurysm in a 78-year-old man. (a-c) Oblique axial MPR images from CT angiography show the left ninth intercostal artery (arrow in a and b) and the radiculomedullary artery (arrowhead in c). (d) Planning image for the curved MPR image (cf e). (e) Curved MPR image from CT angiography clearly shows continuity of the aorta, intercostal artery, radiculomedullary artery, artery of Adamkiewicz (arrow), and anterior spinal artery.
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Figure 4e. True thoracoabdominal aortic aneurysm in a 78-year-old man. (a-c) Oblique axial MPR images from CT angiography show the left ninth intercostal artery (arrow in a and b) and the radiculomedullary artery (arrowhead in c). (d) Planning image for the curved MPR image (cf e). (e) Curved MPR image from CT angiography clearly shows continuity of the aorta, intercostal artery, radiculomedullary artery, artery of Adamkiewicz (arrow), and anterior spinal artery.
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Demonstration of the Collateral Supply of the Artery of Adamkiewicz
It is important to investigate the collateral pathway in patients with thoracoabdominal aortic aneurysm. If the collateral vessel is identified prior to surgical repair of the thoracoabdominal aorta, fewer intercostal or lumbar arteries will require reconstruction (Fig 5) (21–23).
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Figure 5a. Dissecting thoracoabdominal aortic aneurysm in a 58-year-old woman. (a, b) On oblique coronal MPR images from MR angiography (a) and CT angiography (b), the artery of Adamkiewicz (arrow) is seen to originate from the left 11th radiculomedullary artery (arrowhead) at the level of the left 11th intercostal artery. (c) Axial MPR image from CT angiography performed at the level of the 11th intercostal artery shows the radiculomedullary artery (arrowhead). The proximal portion of the left 11th intercostal artery is not visualized. (d, e) Oblique axial MPR images from MR angiography demonstrate a patent left 10th intercostal artery (d) and occlusion of the proximal portion of the left 11th intercostal artery (arrow in e). (f, g) Oblique sagittal (f) and coronal (g) MPR images from MR angiography show occlusion of the proximal portion of the left 11th intercostal artery (arrow in f) and origination of the collateral artery from the muscular branch of the left 10th intercostal artery (arrowhead).
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Figure 5b. Dissecting thoracoabdominal aortic aneurysm in a 58-year-old woman. (a, b) On oblique coronal MPR images from MR angiography (a) and CT angiography (b), the artery of Adamkiewicz (arrow) is seen to originate from the left 11th radiculomedullary artery (arrowhead) at the level of the left 11th intercostal artery. (c) Axial MPR image from CT angiography performed at the level of the 11th intercostal artery shows the radiculomedullary artery (arrowhead). The proximal portion of the left 11th intercostal artery is not visualized. (d, e) Oblique axial MPR images from MR angiography demonstrate a patent left 10th intercostal artery (d) and occlusion of the proximal portion of the left 11th intercostal artery (arrow in e). (f, g) Oblique sagittal (f) and coronal (g) MPR images from MR angiography show occlusion of the proximal portion of the left 11th intercostal artery (arrow in f) and origination of the collateral artery from the muscular branch of the left 10th intercostal artery (arrowhead).
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Figure 5c. Dissecting thoracoabdominal aortic aneurysm in a 58-year-old woman. (a, b) On oblique coronal MPR images from MR angiography (a) and CT angiography (b), the artery of Adamkiewicz (arrow) is seen to originate from the left 11th radiculomedullary artery (arrowhead) at the level of the left 11th intercostal artery. (c) Axial MPR image from CT angiography performed at the level of the 11th intercostal artery shows the radiculomedullary artery (arrowhead). The proximal portion of the left 11th intercostal artery is not visualized. (d, e) Oblique axial MPR images from MR angiography demonstrate a patent left 10th intercostal artery (d) and occlusion of the proximal portion of the left 11th intercostal artery (arrow in e). (f, g) Oblique sagittal (f) and coronal (g) MPR images from MR angiography show occlusion of the proximal portion of the left 11th intercostal artery (arrow in f) and origination of the collateral artery from the muscular branch of the left 10th intercostal artery (arrowhead).
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Figure 5d. Dissecting thoracoabdominal aortic aneurysm in a 58-year-old woman. (a, b) On oblique coronal MPR images from MR angiography (a) and CT angiography (b), the artery of Adamkiewicz (arrow) is seen to originate from the left 11th radiculomedullary artery (arrowhead) at the level of the left 11th intercostal artery. (c) Axial MPR image from CT angiography performed at the level of the 11th intercostal artery shows the radiculomedullary artery (arrowhead). The proximal portion of the left 11th intercostal artery is not visualized. (d, e) Oblique axial MPR images from MR angiography demonstrate a patent left 10th intercostal artery (d) and occlusion of the proximal portion of the left 11th intercostal artery (arrow in e). (f, g) Oblique sagittal (f) and coronal (g) MPR images from MR angiography show occlusion of the proximal portion of the left 11th intercostal artery (arrow in f) and origination of the collateral artery from the muscular branch of the left 10th intercostal artery (arrowhead).
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Figure 5e. Dissecting thoracoabdominal aortic aneurysm in a 58-year-old woman. (a, b) On oblique coronal MPR images from MR angiography (a) and CT angiography (b), the artery of Adamkiewicz (arrow) is seen to originate from the left 11th radiculomedullary artery (arrowhead) at the level of the left 11th intercostal artery. (c) Axial MPR image from CT angiography performed at the level of the 11th intercostal artery shows the radiculomedullary artery (arrowhead). The proximal portion of the left 11th intercostal artery is not visualized. (d, e) Oblique axial MPR images from MR angiography demonstrate a patent left 10th intercostal artery (d) and occlusion of the proximal portion of the left 11th intercostal artery (arrow in e). (f, g) Oblique sagittal (f) and coronal (g) MPR images from MR angiography show occlusion of the proximal portion of the left 11th intercostal artery (arrow in f) and origination of the collateral artery from the muscular branch of the left 10th intercostal artery (arrowhead).
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Figure 5f. Dissecting thoracoabdominal aortic aneurysm in a 58-year-old woman. (a, b) On oblique coronal MPR images from MR angiography (a) and CT angiography (b), the artery of Adamkiewicz (arrow) is seen to originate from the left 11th radiculomedullary artery (arrowhead) at the level of the left 11th intercostal artery. (c) Axial MPR image from CT angiography performed at the level of the 11th intercostal artery shows the radiculomedullary artery (arrowhead). The proximal portion of the left 11th intercostal artery is not visualized. (d, e) Oblique axial MPR images from MR angiography demonstrate a patent left 10th intercostal artery (d) and occlusion of the proximal portion of the left 11th intercostal artery (arrow in e). (f, g) Oblique sagittal (f) and coronal (g) MPR images from MR angiography show occlusion of the proximal portion of the left 11th intercostal artery (arrow in f) and origination of the collateral artery from the muscular branch of the left 10th intercostal artery (arrowhead).
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Figure 5g. Dissecting thoracoabdominal aortic aneurysm in a 58-year-old woman. (a, b) On oblique coronal MPR images from MR angiography (a) and CT angiography (b), the artery of Adamkiewicz (arrow) is seen to originate from the left 11th radiculomedullary artery (arrowhead) at the level of the left 11th intercostal artery. (c) Axial MPR image from CT angiography performed at the level of the 11th intercostal artery shows the radiculomedullary artery (arrowhead). The proximal portion of the left 11th intercostal artery is not visualized. (d, e) Oblique axial MPR images from MR angiography demonstrate a patent left 10th intercostal artery (d) and occlusion of the proximal portion of the left 11th intercostal artery (arrow in e). (f, g) Oblique sagittal (f) and coronal (g) MPR images from MR angiography show occlusion of the proximal portion of the left 11th intercostal artery (arrow in f) and origination of the collateral artery from the muscular branch of the left 10th intercostal artery (arrowhead).
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Pre- and Postsurgical Evaluation
Because MR angiography and CT angiography are noninvasive, evaluation of the artery of Adamkiewicz and spinal arteries is easier with these modalities than with conventional angiography, both before and after surgical repair of thoracic and thoracoabdominal aortic aneurysms (Fig 6).
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Figure 6a. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). (h) Postoperative oblique sagittal MPR image from MR angiography shows dilatation of the collateral vessel between the left 9th and 10th intercostal arteries (arrow). (i, j) Postoperative axial MPR images from MR angiography show occlusion of the ninth intercostal artery (arrow in i) and a patent 10th intercostal artery (j). (k) Oblique coronal MPR image from MR angiography shows the dilated collateral vessel between the left 9th and 10th intercostal arteries (arrow). (l) Coronal MPR image from MR angiography shows a patent artery of Adamkiewicz (arrow) and anterior spinal artery.
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Figure 6b. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). (h) Postoperative oblique sagittal MPR image from MR angiography shows dilatation of the collateral vessel between the left 9th and 10th intercostal arteries (arrow). (i, j) Postoperative axial MPR images from MR angiography show occlusion of the ninth intercostal artery (arrow in i) and a patent 10th intercostal artery (j). (k) Oblique coronal MPR image from MR angiography shows the dilated collateral vessel between the left 9th and 10th intercostal arteries (arrow). (l) Coronal MPR image from MR angiography shows a patent artery of Adamkiewicz (arrow) and anterior spinal artery.
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Figure 6c. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). (h) Postoperative oblique sagittal MPR image from MR angiography shows dilatation of the collateral vessel between the left 9th and 10th intercostal arteries (arrow). (i, j) Postoperative axial MPR images from MR angiography show occlusion of the ninth intercostal artery (arrow in i) and a patent 10th intercostal artery (j). (k) Oblique coronal MPR image from MR angiography shows the dilated collateral vessel between the left 9th and 10th intercostal arteries (arrow). (l) Coronal MPR image from MR angiography shows a patent artery of Adamkiewicz (arrow) and anterior spinal artery.
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Figure 6d. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). (h) Postoperative oblique sagittal MPR image from MR angiography shows dilatation of the collateral vessel between the left 9th and 10th intercostal arteries (arrow). (i, j) Postoperative axial MPR images from MR angiography show occlusion of the ninth intercostal artery (arrow in i) and a patent 10th intercostal artery (j). (k) Oblique coronal MPR image from MR angiography shows the dilated collateral vessel between the left 9th and 10th intercostal arteries (arrow). (l) Coronal MPR image from MR angiography shows a patent artery of Adamkiewicz (arrow) and anterior spinal artery.
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Figure 6e. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). (h) Postoperative oblique sagittal MPR image from MR angiography shows dilatation of the collateral vessel between the left 9th and 10th intercostal arteries (arrow). (i, j) Postoperative axial MPR images from MR angiography show occlusion of the ninth intercostal artery (arrow in i) and a patent 10th intercostal artery (j). (k) Oblique coronal MPR image from MR angiography shows the dilated collateral vessel between the left 9th and 10th intercostal arteries (arrow). (l) Coronal MPR image from MR angiography shows a patent artery of Adamkiewicz (arrow) and anterior spinal artery.
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Figure 6f. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). (h) Postoperative oblique sagittal MPR image from MR angiography shows dilatation of the collateral vessel between the left 9th and 10th intercostal arteries (arrow). (i, j) Postoperative axial MPR images from MR angiography show occlusion of the ninth intercostal artery (arrow in i) and a patent 10th intercostal artery (j). (k) Oblique coronal MPR image from MR angiography shows the dilated collateral vessel between the left 9th and 10th intercostal arteries (arrow). (l) Coronal MPR image from MR angiography shows a patent artery of Adamkiewicz (arrow) and anterior spinal artery.
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Figure 6g. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). (h) Postoperative oblique sagittal MPR image from MR angiography shows dilatation of the collateral vessel between the left 9th and 10th intercostal arteries (arrow). (i, j) Postoperative axial MPR images from MR angiography show occlusion of the ninth intercostal artery (arrow in i) and a patent 10th intercostal artery (j). (k) Oblique coronal MPR image from MR angiography shows the dilated collateral vessel between the left 9th and 10th intercostal arteries (arrow). (l) Coronal MPR image from MR angiography shows a patent artery of Adamkiewicz (arrow) and anterior spinal artery.
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Figure 6h. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). (h) Postoperative oblique sagittal MPR image from MR angiography shows dilatation of the collateral vessel between the left 9th and 10th intercostal arteries (arrow). (i, j) Postoperative axial MPR images from MR angiography show occlusion of the ninth intercostal artery (arrow in i) and a patent 10th intercostal artery (j). (k) Oblique coronal MPR image from MR angiography shows the dilated collateral vessel between the left 9th and 10th intercostal arteries (arrow). (l) Coronal MPR image from MR angiography shows a patent artery of Adamkiewicz (arrow) and anterior spinal artery.
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Figure 6i. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). (h) Postoperative oblique sagittal MPR image from MR angiography shows dilatation of the collateral vessel between the left 9th and 10th intercostal arteries (arrow). (i, j) Postoperative axial MPR images from MR angiography show occlusion of the ninth intercostal artery (arrow in i) and a patent 10th intercostal artery (j). (k) Oblique coronal MPR image from MR angiography shows the dilated collateral vessel between the left 9th and 10th intercostal arteries (arrow). (l) Coronal MPR image from MR angiography shows a patent artery of Adamkiewicz (arrow) and anterior spinal artery.
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Figure 6j. True thoracic aneurysm in a 74-year-old man. (a) Oblique coronal MIP image from CT angiography shows a thoracic aneurysm with a stomach-like shape. (b) Coronal MPR image from MR angiography shows the anterior spinal artery and the artery of Adamkiewicz (arrow) branching from the left ninth intercostal artery. (c) Oblique sagittal MPR image from MR angiography shows a small left ninth intercostal artery (arrow) and a small collateral vessel between the left 9th and 10th intercostal arteries (arrowhead). (d, e) Oblique partial MIP images from MR angiography show stenosis of the left ninth intercostal artery (arrow in d) and a patent left 10th intercostal artery (e). (f) Oblique coronal MPR image from MR angiography also shows the small collateral vessel (arrow) between the left 9th and 10th intercostal arteries (cf c). A graft replacement of the descending aorta from the fifth to the ninth thoracic level was successfully performed. A distal anastomosis was created just above the 10th intercostal artery. The left ninth intercostal artery was sutured, and the left 10th intercostal artery was preserved without any reconstruction of intercostal arteries. No paraplegia occurred after surgical repair. (g) Postoperative volume-rendered image from CT angiography shows a patent left 10th intercostal artery (arrow). | |
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Abstract
Introduction
