MR Angiography of the Great Anterior Radiculomedullary Artery (Adamkiewicz Artery) Validated by Digital Subtraction Angiography
R.J. Nijenhuisa,b,
M. Mullc,
J.T. Wilminkb,
A.K. Thronc and
W.H. Backesb
a Department of Surgery, Maastricht University Hospital, Maastricht, The Netherlands
b Department of Radiology, Maastricht University Hospital, Maastricht, The Netherlands
c Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
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Fig 1. Postmortem spinal cord specimen of the anterior cord surface, on which both the superficial spinal cord arteries and veins are shown. The great anterior radiculomedullary artery (ie, the Adamkiewicz artery [AKA]) (white arrow) and anterior spinal artery (ASA) (white arrowheads) are displayed on the right side of the image. The anterior median vein (AMV) (black arrowheads) as well as the great anterior radiculomedullary vein (GARV) (black arrow) are displayed on the left side. Note the close anatomic relation between the AMV and ASA as well as the similarity in the configuration of the AKA and GARV, respectively. Clotted blood is present in the veins and ASA. No blood is present in the AKA (white appearance) because of the preparation process. (Used with permission.)
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Fig 2. Coronal digital subtraction angiography (DSA) projection (A) and multiplanar reformatted contrast-enhanced MR angiography (CE-MRA) of the early phase (B) and late phase (C) in a 57-year-old male patient (case 3) with a spinal arteriovenous malformation (diagnosed on the basis of DSA). On the DSA projection image (A), the supplying segmental artery (SA) (asterisk), the great anterior radiculomedullary artery, (ie, the Adamkiewicz artery [AKA]) (large white arrow), and the anterior spinal artery (ASA) (white arrowheads) are shown. The CE-MRA of the early phase (B) shows the supplying SA (asterisk) and the AKA (large white arrow). Regarding the anterior midline enhancement in the early phase (B) above as well as below the connection of the AKA with the ASA, this is most likely to be enhancement of both the ASA (white arrowheads) and the anterior median vein (AMV) (black arrowheads). The late phase CE-MRA (C) shows diminished signal intensity of the AKA (large white arrow), in contrast to the anterior midline enhancement, which is clearly increased compared with the early phase (B) because of increased venous enhancement. The midline enhancement seen in the late phase (C) is most likely to be a combination of AMV (black arrowheads) and ASA (white arrowheads) enhancement. Furthermore, there is enhancement of the venous plexus (small black arrows) in the late phase (C) that is not seen in the early-phase CE-MRA image (B). Note that the cephalad enhancement above the connection of the AKA with the ASA is depicted only in the CE-MRA images (B and C), and not in the DSA image (A). Note also that the AKA appears enlarged in the DSA as well as the CE-MRA examination.
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Fig 3. Coronal digital subtraction angiography (DSA) projection (A) and multiplanar reformatted contrast-enhanced MR angiography (CE-MRA) of the early phase (B) and late phase (C and D) in a 43-year-old female patient (case 12) with no spinal arteriovenous malformations. On the DSA projection image (A), the supplying segmental artery (SA) (asterisk), the great anterior radiculomedullary artery (ie, the Adamkiewicz artery [AKA]) (large white arrow), and the anterior spinal artery (ASA) (white arrowhead) are shown. The CE-MRA of the early phase (B) shows the supplying SA (asterisk) and the AKA (large white arrow). Regarding the anterior midline enhancement in the early phase (B) above as well as below the connection of the AKA with the ASA, this is most likely to be the combined enhancement of the ASA (white arrowheads) as well as the anterior median vein (AMV) (black arrowheads). The late phase CE-MRA (C) shows diminished signal intensity of the AKA (large white arrowhead) in contrast to the anterior midline enhancement, which is clearly increased compared with the early phase (B) because of increased venous enhancement. The midline enhancement seen in the late phase (C and D) is most likely to be a combination of AMV (black arrowheads) and ASA (white arrowheads) enhancement. In addition, the great anterior radiculomedullary vein (GARV) (large black arrow) is displayed in the late phase of the CE-MRA (D). Note that the signal intensity of the GARV and midline enhancement is equal (D). Furthermore, there is enhancement of the venous plexus (small black arrows) in the late phase (C and D) that is not seen in the early-phase CE-MRA image (B). Furthermore, note that the cephalad enhancement above the connection of the AKA with the ASA is depicted only in the CE-MRA images (B and C), and not in the DSA image (A).
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Fig 4. Coronal digital subtraction angiography (DSA) projection (A) and multiplanar reformatted contrast-enhanced MR angiography (CE-MRA) of the early phase (B) and late phase (C and D) in a 55-year-old male patient (case 8) with a spinal dural arteriovenous fistula (diagnosed on the basis of DSA). On the DSA projection image (A) the supplying segmental artery (SA) (asterisk), the great anterior radiculomedullary artery (ie, the Adamkiewicz artery [AKA]) (large white arrow), and the anterior spinal artery (ASA) (white arrowhead) are shown. The CE-MRA of the early phase (B) shows the supplying SA (asterisk) and the AKA (large white arrow). Regarding the anterior midline enhancement in the early phase (B) above as well as below the connection of the AKA with the ASA, this is most likely to be enhancement of both the ASA (white arrowheads) and the anterior median vein (AMV) (black arrowheads). The late-phase CE-MRA (C) shows diminished signal intensity of the AKA (large white arrow), in contrast to the anterior midline enhancement, which is clearly increased compared with the early phase (B) as a result of increased venous enhancement. The midline enhancement seen in the late phase (C and D) is most likely to be a combination of AMV (black arrowheads) and ASA (white arrowheads) enhancement. In addition, the great anterior radiculomedullary vein (GARV) (large black arrow) is displayed in the late phase of the CE-MRA (D). Note that the signal intensity of the GARV and midline enhancement is equal (D). Furthermore, there is enhancement of the venous plexus (small black arrows) in the late phase (C and D), which is not seen in the early phase CE-MRA image (B). Note that the cephalad enhancement above the connection of the AKA with the ASA is only depicted on the CE-MRA images (B and C), and not in the DSA image (A). Note that there is more background enhancement in the CE-MRA images.
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Fig 5. Coronal digital subtraction angiography (DSA) projection (A) and multiplanar reformatted contrast-enhanced MR angiography (CE-MRA) of the early phase (B) and late phase (C and D) in a 73-year-old male patient (case 13) with a spinal dural arteriovenous fistula (diagnosed on the basis of DSA). On the DSA projection image (A) the supplying segmental artery (SA) (asterisk), the great anterior radiculomedullary artery (ie, the Adamkiewicz artery [AKA]) (large arrow), and the anterior spinal artery (ASA) are shown. The CE-MRA of the early phase (B) shows the supplying SA (asterisk) and the AKA (large white arrow). Regarding the anterior midline enhancement in the early phase (B) above as well as below the connection of the AKA with the ASA, this is most likely to be enhancement of both the ASA (white arrowheads) as well as the anterior median vein (AMV) (black arrowheads). The late phase CE-MRA (C) shows diminished signal intensity of the AKA (large white arrow), in contrast to the anterior midline enhancement, which is clearly increased compared with the early phase (B) as a result of increased venous enhancement. The midline enhancement in the late phase (C) below the connection of the AKA with the ASA is most likely to be a combination of AMV (black arrowheads) and ASA (white arrowheads) enhancement. In addition, the great anterior radiculomedullary vein (GARV) (large black arrow) is displayed in the late phase of the CE-MRA (D). Furthermore, there is enhancement of the venous plexus (small black arrows) in the late phase, which is not seen in the early-phase CE-MRA image (B). Note that the cephalad enhancement above the connection of the AKA with the ASA is depicted only in the late phase CE-MRA (C) and is therefore most likely to correspond to enhancement of the AMV (black arrowhead) only.
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Fig 6. Coronal digital subtraction angiography (DSA) projection (A) and multiplanar reformatted contrast-enhanced MR angiography (CE-MRA) of the early phase (B and C) and late phase (D) of a 43-year-old female patient (case 11) with a perimedullary arteriovenous malformation of the fistulous type (diagnosed on the basis of DSA). On the DSA projection image (A), the supplying segmental artery (SA) (asterisk), the great anterior radiculomedullary artery (ie, the Adamkiewicz artery [AKA]) (large white arrow), and the anterior spinal artery (ASA) (white arrowheads) are shown. The SA (asterisk) connecting to the AKA (large arrow) is falsely identified in the early phase CE-MRA (B) because of an erroneously created curved multiplanar reformation resulting from the many entangled vessels. Retrospectively, the correct SA (asterisk) supplying the AKA (large white arrows) was identified in the early-phase CE-MRA (C). The cephalad enhancement above the connection of the AKA (large white arrows) with the ASA is depicted only in the late phase CE-MRA image (D), and therefore is most likely to represent the anterior median vein (black arrowhead). In addition, there is enhancement of the venous plexus (small black arrows) in the late-phase CE-MRA image (D) that is not seen in the early phase CE-MRA image (B and C). Note the strong enhancement of the dilated and arterialized veins on the CE-MRA images, which is due to the nonselective manner of contrast administration. Furthermore, the AKA appears enlarged in the DSA as well as the CE-MRA examination.
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