DOI: 10.1148/radiol.2231010513
(Radiology 2002;223:39-45.)
© RSNA, 2002
Demonstration of the Artery of Adamkiewicz at Multi– Detector Row Helical CT1
Kei Takase, MD,
Yoshihiro Sawamura, MD,
Kazumasa Igarashi, RT,
Yoshihiro Chiba, RT,
Kenichi Haga, MD,
Haruo Saito, MD and
Shoki Takahashi, MD
1 From the Departments of Radiology (K.T., K.I., Y.C., K.H.) and Cardiovascular Surgery (Y.S.), Ishinomaki Redcross Hospital, 1-7-10 Yoshino, Ishinomaki, Miyagi 986-8522, Japan; and Department of Radiology, Tohoku University School of Medicine, Sendai, Japan (H.S., S.T.). From the 2000 RSNA scientific assembly. Received February 23, 2001; revision requested April 12; revision received July 6; accepted August 15. Address correspondence to K.T. (e-mail: kytakase@mb.infoweb.ne.jp).
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ABSTRACT
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PURPOSE: To assess the ability of multi–detector row helical computed tomography (CT) to depict the artery of Adamkiewicz.
MATERIALS AND METHODS: Seventy patients with vascular diseases underwent multi–detector row helical CT of the entire aorta and iliac arteries. The artery of Adamkiewicz was examined on multiplanar and curved planar reformation images and on cine-mode displays. The visualization of the artery of Adamkiewicz, as well as its branching level and side of origin, was investigated.
RESULTS: In 63 (90%) of the 70 patients, at least a single artery of Adamkiewicz was clearly visualized from the intervertebral foramen to the hairpin-shaped union with the anterior spinal artery. Two arteries of Adamkiewicz were identified in 15 (24%) of 63 patients. Fifty-five arteries of Adamkiewicz (71%) originated from the left side. Seventy-two (92%) originated between T8 and L1. Neither the intercostal vein nor the posterior spinal vein were visualized in 57 of 63 patients. Continuity of the entire length, starting from the stem of the intercostal or lumbar artery and proceeding to the artery of Adamkiewicz and finally to the anterior spinal artery, was traceable on cine-mode displays or on curved planar reformation images in 20 of 63 patients.
CONCLUSION: Multi–detector row helical CT depicts the artery of Adamkiewicz in a high percentage of patients.
Supplemental material: radiology.rsnajnls.org/cgi/content/full/2231010513/DC1.
© RSNA, 2002
Index terms: Arteries, CT, 373.12115 • Arteries, spinal, 373.12115, 373.92
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INTRODUCTION
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The accurate localization of the artery of Adamkiewicz is important in planning the surgical and/or interventional radiologic treatment not only of spinal lesions, including cord tumors and vascular malformations, but also of thoracoabdominal aneurysms. Preoperative information on the location of the artery of Adamkiewicz may help reduce the risk of postoperative ischemic spinal complications or paraplegia (1,2). The usefulness of locating the artery of Adamkiewicz at conventional angiography has been reported (3–6). However, selective spinal angiography is time consuming, can be technically difficult to perform, and may be hazardous, particularly in patients with vascular diseases, in whom complications of spinal angiography have been described (3,5). Noninvasive detection of the artery of Adamkiewicz with magnetic resonance (MR) imaging was recently reported by Yamada et al (7,8). However, the detection rate never exceeded 69%, which may not be satisfactory. On the other hand, multi–detector row helical computed tomography (CT), a recently developed imaging technique, enables examinations that cover an extensive range in the craniocaudal direction with thin collimation in a short time interval. As a result, thin blood vessels that extend craniocaudally may be easily visualized. The purpose of our study was to assess the ability of multi–detector row helical CT to depict the artery of Adamkiewicz.
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MATERIALS AND METHODS
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The ability of multi–detector row helical CT to depict the artery of Adamkiewicz was retrospectively evaluated in 70 patients. The branching level and side of origin of the arteries of Adamkiewicz were also assessed. Informed consent was obtained from all patients before they underwent CT examination. We used our standard CT protocol for evaluation of the thoracoabdominal aorta in this study. Our institutional review board did not require its approval for this study.
The study included 70 consecutive patients (54 men and 16 women; age range, 43–86 years; average age, 68.4 years) with a presumptive diagnosis of thoracoabdominal vascular disease who underwent helical CT of the aorta over a range that covered the thoracoabdominal aorta and the iliac arteries between November 1999 and October 2000. Twenty of these patients had abdominal aortic aneurysm, 16 had thoracic aortic aneurysm, 19 had aortic dissection, and 15 had atherosclerosis and were suspected of having aortic aneurysm due to the presence of a tortuous aorta. Seventeen patients had previously undergone aortic graft replacement outside a level between the T5 and L2 vertebrae.
The CT scanner used was an Aquilion multi–detector row helical CT scanner (Toshiba, Tokyo, Japan). Scans were obtained with the following parameters: 0.5 seconds per rotation, 2-mm collimation, and 14-mm/sec table increment (pitch, 3.5). Patients were requested to hold their breath for approximately 40 seconds during scanning after inhalation of oxygen. When patients could not hold their breath for the entire scanning time, they were instructed to breathe shallowly after holding their breath for as long as possible.
Before scanning was started, 100 mL of a contrast material containing 300 mg of iodine per milliliter (iopamidol, Iopamiron; Schering, Berlin, Germany) was injected into an antecubital vein at a rate of 3.5 mL/sec. In the first 23 patients in our series, the scan delay after the start of the injection was 32 seconds; in the remaining 47 patients in our series, the scan delay was set by means of an automatic triggering system (SureStart; Toshiba). In these 47 patients, continuous low-dose fluoroscopy (120 kV, 50 mA) at the level of the ascending aorta was initiated 10 seconds after the start of the injection of contrast material. A circular region of interest in the ascending aorta was measured three times per second. When the attenuation value reached a pre-set threshold (an absolute attenuation value of 85 HU) in three consecutive sampling points, helical scanning automatically began.
Transverse sections were reconstructed with a 2-mm section thickness at 1-mm intervals. For evaluation of the artery of Adamkiewicz, the reconstruction field of view was set to the area around the aorta and spine.
Images were processed at a stand-alone workstation (Zio M900; Amin, Tokyo, Japan). Volume-rendered images of the entire aorta were routinely generated. Multiplanar reformation (MPR) images, including oblique coronal images with craniocaudal angulations and curved planar reformation images, were reconstructed to confer the greatest possible likelihood that the anterior spinal artery and/or the artery of Adamkiewicz was included on the scans.
We used a cine-mode display, in which multiple original transverse sections and MPR images can be observed by scrolling the images on the workstation as if pages were being turned over. With this method, the artery of Adamkiewicz and the anterior spinal artery were identified according to the following criteria: (a) In the absence of venous contrast material enhancement or in the presence of only slight venous enhancement, a single enhanced vessel observed on the midline ventral surface of the spinal cord was considered to be the anterior spinal artery. Particular attention was given to the determination that no substantial enhancement of a vessel on the midline dorsal surface of the spinal cord was present; such a vessel could possibly be a spinal vein. (b) An enhanced vessel entering the spinal canal through the intervertebral foramen and joining the anterior spinal artery at the tip of a typical hairpin curve was considered to be the artery of Adamkiewicz.
We evaluated the following points: (a) the level and the side from which the artery of Adamkiewicz originated; (b) the continuity of the artery of Adamkiewicz with the anterior spinal artery, the intercostal or lumbar artery, its posterior branch, and the aorta; and (c) the visualization of surrounding venous structures, such as the epidural vertebral venous plexus, the lateral longitudinal vertebral veins, the intercostal veins, and the azygos vein. The level of the intercostal or lumbar artery from which the artery of Adamkiewicz arose was defined as the level of the intervertebral foramen through which the artery of Adamkiewicz entered the spinal canal. According to the definition of Koshino et al (9), we considered that radiculomedullary arteries arising from the fifth thoracic through the second lumbar levels were arteries of Adamkiewicz.
The images were evaluated by two radiologists (K.T. and K.H.), each of whom had more than 10 years of experience. In the case of disagreement as to the evaluation, final consensus was reached through interobserver discussion.
The total examination time, including time for patient preparation, was less than 10 minutes. Volume-rendered images that excluded bony structures were routinely generated within 10 minutes by two well-experienced radiologic technologists (K.I. and Y.C.). Image processing at the workstation to generate oblique coronal MPR images with craniocaudal angulation took about 2 minutes, and observation of the cine-mode display was generally completed within 5 minutes. An additional 10 minutes were required for a well-experienced radiologist (K.T.) to generate curved reformation images.
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RESULTS
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In 63 (90%) of 70 patients, the artery of Adamkiewicz was clearly delineated within the bony spinal canal, enabling determination of both the level and the side of origin of the artery. The entire course of the artery of Adamkiewicz was not visible on single images because the artery has an oblique anteromediosuperior course from its origin from the posterior branch of the intercostal artery or lumbar artery to the ventral aspect of the spinal cord and finally to the junction with the anterior spinal artery. However, the course of the artery of Adamkiewicz from the intervertebral foramen to its junction with the anterior spinal artery was traceable on contiguous transverse images in all of the 63 patients.
Furthermore, with cine-mode display (Movies 1, 2 [radiology.rsnajnls.org/cgi/content/full/2231010513/DC1]) of multiple transverse and/or oblique coronal MPR images or a single curved planar reformation image, the full length of the arterial course, starting from the stem of the intercostal artery or lumbar artery and then its posterior branch, proceeding to the artery of Adamkiewicz, and continuing as far as the anterior spinal artery, was traceable in 20 of 63 patients (Figs 1, 2). In the remaining 43 patients, the continuity between the posterior branch of the intercostal artery or lumbar artery and the artery of Adamkiewicz was partially obscured at the intervertebral foramen because of proximity to bone.
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Figure 1a. CT images obtained in a 74-year-old man with abdominal aortic and bilateral iliac aneurysms. (a) Volume-rendered image shows the abdominal aortic aneurysm (large arrow) and the iliac aneurysms (small arrows). (b) Oblique coronal MPR image with a craniocaudal angulation shows the artery of Adamkiewicz (arrow) originating from the left intercostal artery and joining the anterior spinal artery (arrowheads). The letters C, D, E, and F correspond to the levels at which the images in c-f were obtained. (c-f) Consecutive transverse images show the continuity of the intercostal artery (large curved arrow in e), its posterior branch (small curved arrow in e), and the artery of Adamkiewicz (solid straight arrow) with the anterior spinal artery (arrowhead) on the cine-mode display. Neither any distinct vessel along the dorsal surface of the spinal cord nor the azygos vein (open arrow) is enhanced. (g, h) Curved planar reformation image (h) of the area along the left ninth intercostal artery (the red line in g is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (large curved arrow in h), its posterior branch (small curved arrow in h), and the artery of Adamkiewicz (straight arrow in h) with the anterior spinal artery (arrowheads in h). Note the characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery. (i) Curved planar reformation image of the area along the ventral aspect of the spinal cord delineates the long craniocaudal extent of the anterior spinal artery (arrowheads).
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Figure 1b. CT images obtained in a 74-year-old man with abdominal aortic and bilateral iliac aneurysms. (a) Volume-rendered image shows the abdominal aortic aneurysm (large arrow) and the iliac aneurysms (small arrows). (b) Oblique coronal MPR image with a craniocaudal angulation shows the artery of Adamkiewicz (arrow) originating from the left intercostal artery and joining the anterior spinal artery (arrowheads). The letters C, D, E, and F correspond to the levels at which the images in c-f were obtained. (c-f) Consecutive transverse images show the continuity of the intercostal artery (large curved arrow in e), its posterior branch (small curved arrow in e), and the artery of Adamkiewicz (solid straight arrow) with the anterior spinal artery (arrowhead) on the cine-mode display. Neither any distinct vessel along the dorsal surface of the spinal cord nor the azygos vein (open arrow) is enhanced. (g, h) Curved planar reformation image (h) of the area along the left ninth intercostal artery (the red line in g is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (large curved arrow in h), its posterior branch (small curved arrow in h), and the artery of Adamkiewicz (straight arrow in h) with the anterior spinal artery (arrowheads in h). Note the characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery. (i) Curved planar reformation image of the area along the ventral aspect of the spinal cord delineates the long craniocaudal extent of the anterior spinal artery (arrowheads).
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Figure 1c. CT images obtained in a 74-year-old man with abdominal aortic and bilateral iliac aneurysms. (a) Volume-rendered image shows the abdominal aortic aneurysm (large arrow) and the iliac aneurysms (small arrows). (b) Oblique coronal MPR image with a craniocaudal angulation shows the artery of Adamkiewicz (arrow) originating from the left intercostal artery and joining the anterior spinal artery (arrowheads). The letters C, D, E, and F correspond to the levels at which the images in c-f were obtained. (c-f) Consecutive transverse images show the continuity of the intercostal artery (large curved arrow in e), its posterior branch (small curved arrow in e), and the artery of Adamkiewicz (solid straight arrow) with the anterior spinal artery (arrowhead) on the cine-mode display. Neither any distinct vessel along the dorsal surface of the spinal cord nor the azygos vein (open arrow) is enhanced. (g, h) Curved planar reformation image (h) of the area along the left ninth intercostal artery (the red line in g is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (large curved arrow in h), its posterior branch (small curved arrow in h), and the artery of Adamkiewicz (straight arrow in h) with the anterior spinal artery (arrowheads in h). Note the characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery. (i) Curved planar reformation image of the area along the ventral aspect of the spinal cord delineates the long craniocaudal extent of the anterior spinal artery (arrowheads).
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Figure 1d. CT images obtained in a 74-year-old man with abdominal aortic and bilateral iliac aneurysms. (a) Volume-rendered image shows the abdominal aortic aneurysm (large arrow) and the iliac aneurysms (small arrows). (b) Oblique coronal MPR image with a craniocaudal angulation shows the artery of Adamkiewicz (arrow) originating from the left intercostal artery and joining the anterior spinal artery (arrowheads). The letters C, D, E, and F correspond to the levels at which the images in c-f were obtained. (c-f) Consecutive transverse images show the continuity of the intercostal artery (large curved arrow in e), its posterior branch (small curved arrow in e), and the artery of Adamkiewicz (solid straight arrow) with the anterior spinal artery (arrowhead) on the cine-mode display. Neither any distinct vessel along the dorsal surface of the spinal cord nor the azygos vein (open arrow) is enhanced. (g, h) Curved planar reformation image (h) of the area along the left ninth intercostal artery (the red line in g is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (large curved arrow in h), its posterior branch (small curved arrow in h), and the artery of Adamkiewicz (straight arrow in h) with the anterior spinal artery (arrowheads in h). Note the characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery. (i) Curved planar reformation image of the area along the ventral aspect of the spinal cord delineates the long craniocaudal extent of the anterior spinal artery (arrowheads).
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Figure 1e. CT images obtained in a 74-year-old man with abdominal aortic and bilateral iliac aneurysms. (a) Volume-rendered image shows the abdominal aortic aneurysm (large arrow) and the iliac aneurysms (small arrows). (b) Oblique coronal MPR image with a craniocaudal angulation shows the artery of Adamkiewicz (arrow) originating from the left intercostal artery and joining the anterior spinal artery (arrowheads). The letters C, D, E, and F correspond to the levels at which the images in c-f were obtained. (c-f) Consecutive transverse images show the continuity of the intercostal artery (large curved arrow in e), its posterior branch (small curved arrow in e), and the artery of Adamkiewicz (solid straight arrow) with the anterior spinal artery (arrowhead) on the cine-mode display. Neither any distinct vessel along the dorsal surface of the spinal cord nor the azygos vein (open arrow) is enhanced. (g, h) Curved planar reformation image (h) of the area along the left ninth intercostal artery (the red line in g is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (large curved arrow in h), its posterior branch (small curved arrow in h), and the artery of Adamkiewicz (straight arrow in h) with the anterior spinal artery (arrowheads in h). Note the characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery. (i) Curved planar reformation image of the area along the ventral aspect of the spinal cord delineates the long craniocaudal extent of the anterior spinal artery (arrowheads).
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Figure 1f. CT images obtained in a 74-year-old man with abdominal aortic and bilateral iliac aneurysms. (a) Volume-rendered image shows the abdominal aortic aneurysm (large arrow) and the iliac aneurysms (small arrows). (b) Oblique coronal MPR image with a craniocaudal angulation shows the artery of Adamkiewicz (arrow) originating from the left intercostal artery and joining the anterior spinal artery (arrowheads). The letters C, D, E, and F correspond to the levels at which the images in c-f were obtained. (c-f) Consecutive transverse images show the continuity of the intercostal artery (large curved arrow in e), its posterior branch (small curved arrow in e), and the artery of Adamkiewicz (solid straight arrow) with the anterior spinal artery (arrowhead) on the cine-mode display. Neither any distinct vessel along the dorsal surface of the spinal cord nor the azygos vein (open arrow) is enhanced. (g, h) Curved planar reformation image (h) of the area along the left ninth intercostal artery (the red line in g is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (large curved arrow in h), its posterior branch (small curved arrow in h), and the artery of Adamkiewicz (straight arrow in h) with the anterior spinal artery (arrowheads in h). Note the characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery. (i) Curved planar reformation image of the area along the ventral aspect of the spinal cord delineates the long craniocaudal extent of the anterior spinal artery (arrowheads).
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Figure 1g. CT images obtained in a 74-year-old man with abdominal aortic and bilateral iliac aneurysms. (a) Volume-rendered image shows the abdominal aortic aneurysm (large arrow) and the iliac aneurysms (small arrows). (b) Oblique coronal MPR image with a craniocaudal angulation shows the artery of Adamkiewicz (arrow) originating from the left intercostal artery and joining the anterior spinal artery (arrowheads). The letters C, D, E, and F correspond to the levels at which the images in c-f were obtained. (c-f) Consecutive transverse images show the continuity of the intercostal artery (large curved arrow in e), its posterior branch (small curved arrow in e), and the artery of Adamkiewicz (solid straight arrow) with the anterior spinal artery (arrowhead) on the cine-mode display. Neither any distinct vessel along the dorsal surface of the spinal cord nor the azygos vein (open arrow) is enhanced. (g, h) Curved planar reformation image (h) of the area along the left ninth intercostal artery (the red line in g is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (large curved arrow in h), its posterior branch (small curved arrow in h), and the artery of Adamkiewicz (straight arrow in h) with the anterior spinal artery (arrowheads in h). Note the characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery. (i) Curved planar reformation image of the area along the ventral aspect of the spinal cord delineates the long craniocaudal extent of the anterior spinal artery (arrowheads).
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Figure 1h. CT images obtained in a 74-year-old man with abdominal aortic and bilateral iliac aneurysms. (a) Volume-rendered image shows the abdominal aortic aneurysm (large arrow) and the iliac aneurysms (small arrows). (b) Oblique coronal MPR image with a craniocaudal angulation shows the artery of Adamkiewicz (arrow) originating from the left intercostal artery and joining the anterior spinal artery (arrowheads). The letters C, D, E, and F correspond to the levels at which the images in c-f were obtained. (c-f) Consecutive transverse images show the continuity of the intercostal artery (large curved arrow in e), its posterior branch (small curved arrow in e), and the artery of Adamkiewicz (solid straight arrow) with the anterior spinal artery (arrowhead) on the cine-mode display. Neither any distinct vessel along the dorsal surface of the spinal cord nor the azygos vein (open arrow) is enhanced. (g, h) Curved planar reformation image (h) of the area along the left ninth intercostal artery (the red line in g is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (large curved arrow in h), its posterior branch (small curved arrow in h), and the artery of Adamkiewicz (straight arrow in h) with the anterior spinal artery (arrowheads in h). Note the characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery. (i) Curved planar reformation image of the area along the ventral aspect of the spinal cord delineates the long craniocaudal extent of the anterior spinal artery (arrowheads).
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Figure 1i. CT images obtained in a 74-year-old man with abdominal aortic and bilateral iliac aneurysms. (a) Volume-rendered image shows the abdominal aortic aneurysm (large arrow) and the iliac aneurysms (small arrows). (b) Oblique coronal MPR image with a craniocaudal angulation shows the artery of Adamkiewicz (arrow) originating from the left intercostal artery and joining the anterior spinal artery (arrowheads). The letters C, D, E, and F correspond to the levels at which the images in c-f were obtained. (c-f) Consecutive transverse images show the continuity of the intercostal artery (large curved arrow in e), its posterior branch (small curved arrow in e), and the artery of Adamkiewicz (solid straight arrow) with the anterior spinal artery (arrowhead) on the cine-mode display. Neither any distinct vessel along the dorsal surface of the spinal cord nor the azygos vein (open arrow) is enhanced. (g, h) Curved planar reformation image (h) of the area along the left ninth intercostal artery (the red line in g is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (large curved arrow in h), its posterior branch (small curved arrow in h), and the artery of Adamkiewicz (straight arrow in h) with the anterior spinal artery (arrowheads in h). Note the characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery. (i) Curved planar reformation image of the area along the ventral aspect of the spinal cord delineates the long craniocaudal extent of the anterior spinal artery (arrowheads).
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Figure 2a. CT images obtained in a 75-year-old man with a thoracic aortic aneurysm and a small abdominal aortic aneurysm. (a, b) Curved planar reformation image (b) of the area along the right ninth intercostal artery (the red line in a is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (curved arrow in b), its posterior branch, and the artery of Adamkiewicz (straight arrow in b) with the anterior spinal artery (arrowheads in b). The characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery is clearly seen. The letters C, D, E, F, G, and H in b correspond to the levels at which the images in c-h were obtained. (c-h) Consecutive transverse images from superior to inferior show that the artery of Adamkiewicz (solid white arrow in c, black arrow in d), arising from the posterior branch of the intercostal artery (small curved arrow in e), approximates the anterior spinal artery (arrowhead) as it approaches their union. On the images obtained at a level inferior to the origin of the artery of Adamkiewicz (f-h), only the anterior spinal artery is seen on the ventral aspect of the cord. The large curved arrows indicate the right ninth intercostal artery. The posterior spinal vein and surrounding venous structures such as the azygos vein (open arrow) are not enhanced.
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Figure 2b. CT images obtained in a 75-year-old man with a thoracic aortic aneurysm and a small abdominal aortic aneurysm. (a, b) Curved planar reformation image (b) of the area along the right ninth intercostal artery (the red line in a is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (curved arrow in b), its posterior branch, and the artery of Adamkiewicz (straight arrow in b) with the anterior spinal artery (arrowheads in b). The characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery is clearly seen. The letters C, D, E, F, G, and H in b correspond to the levels at which the images in c-h were obtained. (c-h) Consecutive transverse images from superior to inferior show that the artery of Adamkiewicz (solid white arrow in c, black arrow in d), arising from the posterior branch of the intercostal artery (small curved arrow in e), approximates the anterior spinal artery (arrowhead) as it approaches their union. On the images obtained at a level inferior to the origin of the artery of Adamkiewicz (f-h), only the anterior spinal artery is seen on the ventral aspect of the cord. The large curved arrows indicate the right ninth intercostal artery. The posterior spinal vein and surrounding venous structures such as the azygos vein (open arrow) are not enhanced.
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Figure 2c. CT images obtained in a 75-year-old man with a thoracic aortic aneurysm and a small abdominal aortic aneurysm. (a, b) Curved planar reformation image (b) of the area along the right ninth intercostal artery (the red line in a is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (curved arrow in b), its posterior branch, and the artery of Adamkiewicz (straight arrow in b) with the anterior spinal artery (arrowheads in b). The characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery is clearly seen. The letters C, D, E, F, G, and H in b correspond to the levels at which the images in c-h were obtained. (c-h) Consecutive transverse images from superior to inferior show that the artery of Adamkiewicz (solid white arrow in c, black arrow in d), arising from the posterior branch of the intercostal artery (small curved arrow in e), approximates the anterior spinal artery (arrowhead) as it approaches their union. On the images obtained at a level inferior to the origin of the artery of Adamkiewicz (f-h), only the anterior spinal artery is seen on the ventral aspect of the cord. The large curved arrows indicate the right ninth intercostal artery. The posterior spinal vein and surrounding venous structures such as the azygos vein (open arrow) are not enhanced.
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Figure 2d. CT images obtained in a 75-year-old man with a thoracic aortic aneurysm and a small abdominal aortic aneurysm. (a, b) Curved planar reformation image (b) of the area along the right ninth intercostal artery (the red line in a is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (curved arrow in b), its posterior branch, and the artery of Adamkiewicz (straight arrow in b) with the anterior spinal artery (arrowheads in b). The characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery is clearly seen. The letters C, D, E, F, G, and H in b correspond to the levels at which the images in c-h were obtained. (c-h) Consecutive transverse images from superior to inferior show that the artery of Adamkiewicz (solid white arrow in c, black arrow in d), arising from the posterior branch of the intercostal artery (small curved arrow in e), approximates the anterior spinal artery (arrowhead) as it approaches their union. On the images obtained at a level inferior to the origin of the artery of Adamkiewicz (f-h), only the anterior spinal artery is seen on the ventral aspect of the cord. The large curved arrows indicate the right ninth intercostal artery. The posterior spinal vein and surrounding venous structures such as the azygos vein (open arrow) are not enhanced.
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Figure 2e. CT images obtained in a 75-year-old man with a thoracic aortic aneurysm and a small abdominal aortic aneurysm. (a, b) Curved planar reformation image (b) of the area along the right ninth intercostal artery (the red line in a is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (curved arrow in b), its posterior branch, and the artery of Adamkiewicz (straight arrow in b) with the anterior spinal artery (arrowheads in b). The characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery is clearly seen. The letters C, D, E, F, G, and H in b correspond to the levels at which the images in c-h were obtained. (c-h) Consecutive transverse images from superior to inferior show that the artery of Adamkiewicz (solid white arrow in c, black arrow in d), arising from the posterior branch of the intercostal artery (small curved arrow in e), approximates the anterior spinal artery (arrowhead) as it approaches their union. On the images obtained at a level inferior to the origin of the artery of Adamkiewicz (f-h), only the anterior spinal artery is seen on the ventral aspect of the cord. The large curved arrows indicate the right ninth intercostal artery. The posterior spinal vein and surrounding venous structures such as the azygos vein (open arrow) are not enhanced.
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Figure 2f. CT images obtained in a 75-year-old man with a thoracic aortic aneurysm and a small abdominal aortic aneurysm. (a, b) Curved planar reformation image (b) of the area along the right ninth intercostal artery (the red line in a is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (curved arrow in b), its posterior branch, and the artery of Adamkiewicz (straight arrow in b) with the anterior spinal artery (arrowheads in b). The characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery is clearly seen. The letters C, D, E, F, G, and H in b correspond to the levels at which the images in c-h were obtained. (c-h) Consecutive transverse images from superior to inferior show that the artery of Adamkiewicz (solid white arrow in c, black arrow in d), arising from the posterior branch of the intercostal artery (small curved arrow in e), approximates the anterior spinal artery (arrowhead) as it approaches their union. On the images obtained at a level inferior to the origin of the artery of Adamkiewicz (f-h), only the anterior spinal artery is seen on the ventral aspect of the cord. The large curved arrows indicate the right ninth intercostal artery. The posterior spinal vein and surrounding venous structures such as the azygos vein (open arrow) are not enhanced.
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Figure 2g. CT images obtained in a 75-year-old man with a thoracic aortic aneurysm and a small abdominal aortic aneurysm. (a, b) Curved planar reformation image (b) of the area along the right ninth intercostal artery (the red line in a is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (curved arrow in b), its posterior branch, and the artery of Adamkiewicz (straight arrow in b) with the anterior spinal artery (arrowheads in b). The characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery is clearly seen. The letters C, D, E, F, G, and H in b correspond to the levels at which the images in c-h were obtained. (c-h) Consecutive transverse images from superior to inferior show that the artery of Adamkiewicz (solid white arrow in c, black arrow in d), arising from the posterior branch of the intercostal artery (small curved arrow in e), approximates the anterior spinal artery (arrowhead) as it approaches their union. On the images obtained at a level inferior to the origin of the artery of Adamkiewicz (f-h), only the anterior spinal artery is seen on the ventral aspect of the cord. The large curved arrows indicate the right ninth intercostal artery. The posterior spinal vein and surrounding venous structures such as the azygos vein (open arrow) are not enhanced.
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Figure 2h. CT images obtained in a 75-year-old man with a thoracic aortic aneurysm and a small abdominal aortic aneurysm. (a, b) Curved planar reformation image (b) of the area along the right ninth intercostal artery (the red line in a is a section plane for the curved planar reformation image) delineates the continuity of the intercostal artery (curved arrow in b), its posterior branch, and the artery of Adamkiewicz (straight arrow in b) with the anterior spinal artery (arrowheads in b). The characteristic hairpin-curve appearance of the union of the artery of Adamkiewicz and the anterior spinal artery is clearly seen. The letters C, D, E, F, G, and H in b correspond to the levels at which the images in c-h were obtained. (c-h) Consecutive transverse images from superior to inferior show that the artery of Adamkiewicz (solid white arrow in c, black arrow in d), arising from the posterior branch of the intercostal artery (small curved arrow in e), approximates the anterior spinal artery (arrowhead) as it approaches their union. On the images obtained at a level inferior to the origin of the artery of Adamkiewicz (f-h), only the anterior spinal artery is seen on the ventral aspect of the cord. The large curved arrows indicate the right ninth intercostal artery. The posterior spinal vein and surrounding venous structures such as the azygos vein (open arrow) are not enhanced.
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The level of origin of the artery of Adamkiewicz in 63 patients is shown in Figure 3. Seventy-eight arteries of Adamkiewicz were identified in 63 patients; in 15 patients (24%), two arteries of Adamkiewicz were recognized. Fifty-five (71%) arteries of Adamkiewicz originated from the left side, while 23 (29%) originated from the right side. Seventy-two (92%) originated at the level between T8 and L1. The branching levels of the two arteries of Adamkiewicz identified in 15 patients are shown in Figure 4. In one patient, a second radiculomedullary artery other than an artery of Adamkiewicz was detected at left T4. This artery was outside the area (ie, from T5 through L2) that our study concerned and therefore did not fit our definition of an artery of Adamkiewicz.
Both the aorta and the intercostal or lumbar artery were also clearly visualized in these 63 patients. The intercostal or lumbar or posterior spinal vein was not delineated in 57 of 63 patients (Figs 1, 2). In the remaining six patients, what we presumed to be a posterior spinal vein was only slightly enhanced on the midline dorsal surface of the spinal cord, while the intercostal or lumbar veins were not enhanced.
The artery of Adamkiewicz was not delineated in seven patients. These patients had an abdominal aortic aneurysm (n = 2), aortic dissection (n = 2), atherosclerosis (n = 2), or a thoracic aortic aneurysm (n = 1). In these seven patients, enhancement of the artery of Adamkiewicz and the anterior spinal artery was poor, although the aorta and the intercostal and lumbar arteries were well enhanced. In three of these seven patients, the posterior spinal veins were visualized together with surrounding venous structures such as the epidural vertebral venous plexus, the lateral longitudinal vertebral veins, the intercostal veins, and the azygos vein (Fig 5). The enhancement of the vessel running along the midline ventral surface of the spinal cord was less than that of the posterior spinal vein (Fig 5a).
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Figure 5a. CT images obtained in a 69-year-old woman with thoracic aortic aneurysm. (a, b) Transverse images show enhancement of the posterior spinal vein (arrowhead) together with surrounding venous structures such as the epidural vertebral venous plexus (solid short straight arrows), the intercostal vein (curved arrow), and the azygos vein (open arrow). These venous structures show more intense enhancement than does the vessel (solid long straight arrow in a) along the midline ventral surface of the spinal cord. (c) Curved reformation image of the area along the dorsal surface of the cord shows the posterior spinal vein (arrowheads). (d) Oblique coronal MPR image with craniocaudal angulation shows enhancement of the lateral longitudinal vertebral veins (arrowheads) and the epidural vertebral venous plexus (arrows). Note that both kidneys show capillary staining of cortices only. An irregular intraspinal area with the attenuation of bone at the level of the upper half of the kidneys is an artifact resulting from partial volume averaging of vertebra.
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Figure 5b. CT images obtained in a 69-year-old woman with thoracic aortic aneurysm. (a, b) Transverse images show enhancement of the posterior spinal vein (arrowhead) together with surrounding venous structures such as the epidural vertebral venous plexus (solid short straight arrows), the intercostal vein (curved arrow), and the azygos vein (open arrow). These venous structures show more intense enhancement than does the vessel (solid long straight arrow in a) along the midline ventral surface of the spinal cord. (c) Curved reformation image of the area along the dorsal surface of the cord shows the posterior spinal vein (arrowheads). (d) Oblique coronal MPR image with craniocaudal angulation shows enhancement of the lateral longitudinal vertebral veins (arrowheads) and the epidural vertebral venous plexus (arrows). Note that both kidneys show capillary staining of cortices only. An irregular intraspinal area with the attenuation of bone at the level of the upper half of the kidneys is an artifact resulting from partial volume averaging of vertebra.
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Figure 5c. CT images obtained in a 69-year-old woman with thoracic aortic aneurysm. (a, b) Transverse images show enhancement of the posterior spinal vein (arrowhead) together with surrounding venous structures such as the epidural vertebral venous plexus (solid short straight arrows), the intercostal vein (curved arrow), and the azygos vein (open arrow). These venous structures show more intense enhancement than does the vessel (solid long straight arrow in a) along the midline ventral surface of the spinal cord. (c) Curved reformation image of the area along the dorsal surface of the cord shows the posterior spinal vein (arrowheads). (d) Oblique coronal MPR image with craniocaudal angulation shows enhancement of the lateral longitudinal vertebral veins (arrowheads) and the epidural vertebral venous plexus (arrows). Note that both kidneys show capillary staining of cortices only. An irregular intraspinal area with the attenuation of bone at the level of the upper half of the kidneys is an artifact resulting from partial volume averaging of vertebra.
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Figure 5d. CT images obtained in a 69-year-old woman with thoracic aortic aneurysm. (a, b) Transverse images show enhancement of the posterior spinal vein (arrowhead) together with surrounding venous structures such as the epidural vertebral venous plexus (solid short straight arrows), the intercostal vein (curved arrow), and the azygos vein (open arrow). These venous structures show more intense enhancement than does the vessel (solid long straight arrow in a) along the midline ventral surface of the spinal cord. (c) Curved reformation image of the area along the dorsal surface of the cord shows the posterior spinal vein (arrowheads). (d) Oblique coronal MPR image with craniocaudal angulation shows enhancement of the lateral longitudinal vertebral veins (arrowheads) and the epidural vertebral venous plexus (arrows). Note that both kidneys show capillary staining of cortices only. An irregular intraspinal area with the attenuation of bone at the level of the upper half of the kidneys is an artifact resulting from partial volume averaging of vertebra.
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The two radiologists were in agreement in their evaluations with regard to the visualization of the artery of Adamkiewicz and the assessment of the levels of its origin on the basis of the clarity of the images. In terms of the assessment of the continuity of the posterior branch of the intercostal artery and the artery of Adamkiewicz, their evaluations disagreed in two instances. Accordingly, a final decision in these two instances was arrived at through discussion.
No marked respiratory artifacts were noted between the lung apex and the level of L2 in any patient, although the patients were not asked to confirm whether or not they had held their breath.
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DISCUSSION
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Multi–detector row helical CT performed with a simple protocol of scanning and relatively brief postprocessing depicted the artery of Adamkiewicz with a high success rate.
Identification of the intercostal or lumbar artery from which the artery of Adamkiewicz branches is extremely important in planning surgical treatment (1,2) and interventional procedures involving the great vessels. Although the importance of preoperative selective spinal angiography has been emphasized (3–6), complications from this procedure have also been described (3,5). Furthermore, the success rate in localizing the origin of the artery of Adamkiewicz at spinal angiography has been no more than 55%–75% (3,4,6).
Noninvasive visualization of the artery of Adamkiewicz with MR imaging has been reported at a single institution (7,8), but the detection rate with this method has not exceeded 69%. According to those reports, MR imaging primarily consisted of sagittal source MR images obtained with a complicated protocol in which the transverse dimension of the field of view was always just wide enough to include the vertebral body. In such a protocol, the artery of Adamkiewicz theoretically may be difficult to observe in patients with scoliosis, because the imaging field must be widened in such patients. Moreover, the imaging volume used in these studies included an area that ranged from T6 to L2 in the craniocaudal direction, thus leaving the possibility that the origin of the artery of Adamkiewicz may be outside the field of view. Indeed, the radiculomedullary artery arising at the T4 level that was revealed in one patient in this study (although it was not included in the group of arteries of Adamkiewicz) would have been missed at MR imaging.
In contrast, with the multi–detector row CT method used in our study, imaging volume had no practical restriction in the transverse direction and was easily enlarged in the craniocaudal direction with an additional several seconds of examination time. Moreover, using a simple scanning protocol, we achieved a success rate of 90% for the localization of the artery of Adamkiewicz while evaluating the entire aorta.
One of the major difficulties in this study was the differentiation of the artery of Adamkiewicz and the anterior spinal artery from spinal veins. Although conventional angiography was not performed in this study for confirmation of our findings because of safety and ethical concerns, arteries of Adamkiewicz were identifiable in 63 patients based on the following features: In consecutive transverse images, the artery of Adamkiewicz and the anterior spinal artery were visualized as two enhanced spots in the ventral aspect of the cord. Both vessels showed a characteristic relationship in which they typically neared each other as they approached their union when they coursed in an inferior to superior orientation. In the images obtained at a level inferior to the origin of the artery of Adamkiewicz, only the anterior spinal artery was seen in the ventral aspect of the cord. The posterior spinal vein, which is generally considered to be thicker than the anterior spinal vein (10,11), was not visualized on the midline dorsal surface of the spinal cord in most of the 63 patients. The veins surrounding the spine (ie, the intercostal or lumbar veins), were never visualized in any of the 63 patients. Although limited to a portion of the patients (ie, 20 patients), the full continuity of the entire length, starting from the stem of the intercostal or lumbar artery, proceeding to the artery of Adamkiewicz, and finally continuing to the anterior spinal artery, was traceable on cine-mode displays or on curved planar reformation images (Figs 1, 2).
In seven patients, the artery of Adamkiewicz was not detectable. In three of these seven patients, venous structures were dominantly enhanced. In all three patients, the posterior spinal vein, intercostal veins, and azygos vein were well enhanced, and the posterior spinal vein showed stronger enhancement than the vessel along the midline ventral surface of the spinal cord, which may have been a composite of the anterior spinal artery and vein (Fig 5). These patients may have had a faster circulation time compared with other patients. On the contrary, in the 63 patients in whom the arteries of Adamkiewicz were successfully depicted, a vessel on the midline posterior surface of the spinal cord or the posterior spinal vein was not visualized or was only slightly enhanced, and no enhancement of other surrounding venous structures was evident. These results indicate that the timing of the scan relative to the injection of contrast material may be crucial in the successful identification of the artery of Adamkiewicz. The high success rate of visualization in this study may have been related not only to fast scanning but also to optimal scan timing within the arterial phase. The latter factor was probably achieved with the automatic triggering system (SureStart; Toshiba) that was used in most patients. In the presence of aortic disease, flow velocity of the aorta is thought to be slow; this phenomenon also possibly contributed to the high success rate by extending the length of time the aorta was enhanced with contrast material.
Two arteries of Adamkiewicz were identified in 24% of our patients. This is in agreement with the results of an autopsy study by Koshino et al (9), in which two arteries of Adamkiewicz were identified in 26% of the cadavers examined. The frequency of left-sided origin of the artery of Adamkiewicz in our study (69%) also coincided with the frequency (72%) determined at autopsy by Koshino et al (9).
Multi–detector row helical CT, which permits a wide craniocaudal range to be scanned with thin collimation, has enabled the examination of the entire aorta and iliac arteries. In our study, multi–detector row helical CT also enabled visualization of the very thin artery of Adamkiewicz, which can arise from the intercostal or lumbar arteries over a wide range extending from T5 to L2, and its continuity with the anterior spinal artery. Thus, information on the entire aorta, as well as on the artery of Adamkiewicz, can simultaneously be obtained at a single examination.
In conclusion, the artery of Adamkiewicz can successfully be delineated in a large percentage of patients with use of multi–detector row helical CT scanning. This scanning method may therefore be helpful in the planning of aortic replacement surgery.
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FOOTNOTES
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Abbreviation: MPR = multiplanar reformation
Author contributions: Guarantor of integrity of entire study, K.T.; study concepts and design, K.T.; literature research, K.T., S.T.; clinical studies, K.T., K.H.; data acquisition, K.T., K.H., K.I., Y.C.; data analysis/interpretation, K.T.; manuscript preparation, K.T.; manuscript definition of intellectual content and editing, K.T., S.T.; manuscript revision/review and final version approval, all authors.
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TOP
ABSTRACT
INTRODUCTION
