1/22/2020

European Course on Spine Radiology European Course on Spine Radiology

The Normal Spine:
I have no conflict of interest
Vascular Anatomy to disclosure
Pedro Vilela Pedro Vilela

Rome, 22-25 January 2020 Rome, 22-25 January 2020

European Course on Spine Radiology European Course on Spine Radiology

The Normal Spine: Vascular Anatomy The Normal Spine: Vascular Anatomy
Arterial anatomy Arterial anatomy
spinal cord spinal cord
nerve / dura nerve / dura from: Surg. Neuroang.
Lasjaunias P et al.
spine (bone, soft tissue) spine (bone, soft tissue)
Venous anatomy Venous anatomy
spinal cord spinal cord
nerve / dura nerve / dura
spine (bone, soft tissue) spine (bone, soft tissue)
Metameric organization Metameric organization

Clinical Case Clinical Case

C7

T2

Male 63 y-old. Acute thoracic pain followed by flaccid paraparesis European Course on Spine Radiology Rome 2020 Male 63 y-old. Acute thoracic pain followed by flaccid paraparesis European Course on Spine Radiology Rome 2020
 1/22/2020

Clinical Case The Normal Spine: Vascular Anatomy

• Spinal Cord
ASA

• Origin of the arterial supply: Segmental arteries

• Cervical area
Vertebral arteries (ASA)/ PICA (PSA)
Tirocervical trunk Anterior (ascending) cervical art.
ASA Costocervical trunk  Deep cervical art./Intercostal sup art.
Ascending pharyngeal / Occipital art.

C7 • Dorsal area: Intercostal arts.

• Lumbar area: Lumbar arts.

T2

• Sacral arteries do not supply the spinal cord (only the sacral nerves) From Amato A et al 2015

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A, Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,
ter Brugge K European Course on Spine Radiology Rome 2020 ter Brugge K European Course on Spine Radiology Rome 2020

The Normal Spine: Vascular Anatomy The Normal Spine: Vascular Anatomy
• Spinal Cord • Spinal Cord
Anterior spinal artery (ASA) Anterior spinal artery (ASA)
Desegmentation and • Origin: CV junction (vertebral branches
Metameric stage Longitudinal fusion
middle line fusion distal to the PICA origin)

• Course: anterior median fissure

• Contribution from: segmental arteries
Artery of (cervical dorsal, lumbosacral segments)
Adamkiewicz
• Termination: filum terminale

• Supplies: sulco-commisural arteries

2/3 anterior spinal cord; central spinal cord
from: neuroangio.org (grey and white matter) from: Surg. Neuroang.
Nerve  Regression of the radicular arteries Lasjaunias P et al.
myelomeric segment spinal cord arterial supply From: Taterra D et al 2019

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A, Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,
ter Brugge K European Course on Spine Radiology Rome 2020 ter Brugge K European Course on Spine Radiology Rome 2020

The Normal Spine: Vascular Anatomy The Normal Spine: Vascular Anatomy
• Spinal Cord • Spinal Cord
Anterior spinal artery (ASA) Anterior spinal artery (ASA)

• Radiculo-Medullary arteries • Radiculo-Medullary arteries

• Origin: ventral branch of the radicular artery • Origin: ventral branch of the radicular artery
• Number and origin unpredictable • Number and origin unpredictable from: Surg. Neuroang.
• Major: • Major: Lasjaunias P et al.
• Artery of Adamkiewicz (AKA) • Artery of Adamkiewicz (AKA)
• major blood supply to the anterior thoracolumbar • major blood supply to the anterior thoracolumbar
spinal cord from T8 to the conus medullaris spinal cord from T8 to the conus medullaris
More common origin: D9-L2 (left >right) More common origin: D9-L2 (left >right)

• SulcoCommissural arteries • SulcoCommissural arteries

• Topography: subpial (more deep than the vein) – • Topography: subpial (more deep than the vein) –
penetrate in the central sulcus and branch to supply the penetrate in the central sulcus and branch to supply the
spinal cord tissue From Amato A et al 2015 spinal cord tissue

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A, Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,
ter Brugge K European Course on Spine Radiology Rome 2020 ter Brugge K European Course on Spine Radiology Rome 2020
 1/22/2020

The Normal Spine: Vascular Anatomy The Normal Spine: Vascular Anatomy
• Spinal Cord from: Surg. Neuroang.
Lasjaunias P et al.
• Spinal Cord from: Surg. Neuroang.
Lasjaunias P et al.
Posterior spinal axis (PSA)
Posterior spinal axis – pial network (PSA)
• Radiculo-Pial arteries
• Origin: CV junction (vertebral branches / extradural PICA)
Origin: dorsal (more common) or ventral branch of the radicular artery
Number and origin unpredictable (higher number than radiculo-medullary)
• Course: dorsolateral subpial space  arterial pial network (vasa corona) D

• Contribution: segmental arteries (cervical dorsal, lumbosacral segments) • Arterial pial network (vasa corona)
Topography: subpial L
• Termination: conus medularis basket
Arterial pial network with transversal anastomosis – vasa corona)
Radial perforators to the spinal cord white matter
• Supplies: 1/3 posterior spinal cord; superficial spinal cord (white matter only) There are major longitudinal (mainstream) axis (“posterior spinal art.”)
3 areas: Dorsal (D); Lateral (L) (Ventral (V) – originates from ASA)
V

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A, Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,
ter Brugge K European Course on Spine Radiology Rome 2020 ter Brugge K European Course on Spine Radiology Rome 2020

The Normal Spine: Vascular Anatomy Clinical Case

• Spinal Cord
Brain stem perforators
Direct anteromedial
“sulcal vessels”

Circumferential “pial network”

anterolateral (short) / posterolateral (long)
from: Surg. Neuroang. Lasjaunias P et al.

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,

ter Brugge K European Course on Spine Radiology Rome 2020 European Course on Spine Radiology Rome 2020

Clinical Case Clinical Case

European Course on Spine Radiology Rome 2020 AVF of the filum terminale artery European Course on Spine Radiology Rome 2020
 1/22/2020

Clinical Case Clinical Case

From Giordan et al 2017

From Martirosyan N et al. 2015 from: Surg. Neuroang. Lasjaunias P et al.

AVF of the filum terminale artery European Course on Spine Radiology Rome 2020 Basket and filum terminale artery (ASA) European Course on Spine Radiology Rome 2020

Clinical Case Clinical Case

Male 64 years/old. Long lasting (more than 1 year) of progressive Male 64 years/old. Long lasting (more than 1 year) of progressive
paraparesis, impotence and urinary dysfunction European Course on Spine Radiology Rome 2020 paraparesis, impotence and urinary dysfunction European Course on Spine Radiology Rome 2020

Clinical Case Clinical Case

Sacral arterial supply:
• Median Sacral Artery
• Origin
• Aorta “continuation” of the aorta at the
caudal end / bifurcation (more
common); L5 or L4 segmental arteries
L5
• Lateral Sacral Arteries
• Origin: proximal internal iliac arteries M S
(posterior division)
• Generally there are 2 in each side
(superior S1-S2/ inferior S3-S5)
From: Taterra D et al 2019

Dural AVF European Course on Spine Radiology Rome 2020 Sacral arteries European Course on Spine Radiology Rome 2020
 1/22/2020

Clinical Case The Normal Spine: Vascular Anatomy

Sacral arterial supply: • Radicular arteries
Features
• Median Sacral Artery • Follow the segmental spine nerve
RP
• Origin • Division: anterior and posterior br.
• Aorta “continuation” of the aorta at the • Anterior: larger
caudal end / bifurcation (more • Posterior: smaller
common); L5 or L4 segmental arteries ASA RM
Types (accordingly to the supply)
• Lateral Sacral Arteries • Meningo-radicular  nerve root + dura
• Origin: proximal internal iliac arteries
(posterior division)
• Radiculo-Pial  nerve root + dura + posterior arterial axis
• Generally there are 2 in each side
(superior S1-S2/ inferior S3-S5)
From: Taterra D et al 2019 from: neuroangio.org • Radiculo-Medullary  nerve root + dura + anterior arterial axis
from: Surg. Neuroang. Lasjaunias P et al.

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,

Sacral arteries European Course on Spine Radiology Rome 2020 ter Brugge K European Course on Spine Radiology Rome 2020

The Normal Spine: Vascular Anatomy Clinical Case

• Radicular arteries

Vascular
compartment

C7

T2
from Gregg L et al AJNR 2016

Male 57 years/old Subacute paraparesis with urinary dysfunction

European Course on Spine Radiology Rome 2020 and acute lumbar pain European Course on Spine Radiology Rome 2020

Clinical Case Clinical Case

C7 C7

T2 T2

Male 57 years/old Subacute paraparesis with urinary dysfunction Male 57 years/old Subacute paraparesis with urinary dysfunction
and acute lumbar pain European Course on Spine Radiology Rome 2020 and acute lumbar pain European Course on Spine Radiology Rome 2020
 1/22/2020

Clinical Case The Normal Spine: Vascular Anatomy

• Segmental arteries
Supply:

Spinal cord,
Spinal nerve,
Dura,
Bone,
Muscles
C7 Joints, ligaments

T2
Share the same arterial supply
from: Surg. Neuroang. Lasjaunias P et al.

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,

Bone and spinal cord infarct European Course on Spine Radiology Rome 2020 ter Brugge K European Course on Spine Radiology Rome 2020

The Normal Spine: Vascular Anatomy European Course on Spine Radiology

• Segmental arteries The Normal Spine: Vascular Anatomy
Arterial anatomy summary
Supply:
Segmental
Spinal cord, artery
Spinal nerve,
Dura, Vertebral
Bone, Deep cervical
Ascend cervical
Muscles Occipital/Asc Pha
Joints, ligaments

Intercostal
Lumbar
Share the same arterial supply Sacral

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A, from: Surg. Neuroang. Lasjaunias P et al.
ter Brugge K European Course on Spine Radiology Rome 2020

European Course on Spine Radiology European Course on Spine Radiology

The Normal Spine: Vascular Anatomy The Normal Spine: Vascular Anatomy
Arterial anatomy summary Arterial anatomy summary
Segmental Cervical
C1-C2 Proatlantal I and II (Occipital, Vertebral, Deep cervical
Segmental Vertebral body (bone branches)
artery art.) artery
C3-C4 Deep cervical, Vertebral art.
C5-C6 Ascending (anterior) cervical, Vertebral art.
C7 Vertebral art.
Vertebral C8 Costocervical art
Vertebral
Deep cervical Deep cervical
Ascend cervical Dorsal T1-T2/T5 Superior/Supreme intercostal art Ascend cervical
(Costocervical art) Occipital/Asc Pha
Occipital/Asc Pha T3-T12 Intercostal arteries (posterior)

Lumbar L1-L4 Lumbar arteries

L5 Median sacral art.
Intercostal Intercostal
Lumbar Sacral S1-S5 Sacral arteries Lumbar
Sacral S1-S2 Superior lateral sacral art Sacral
S3-S5 Inferior lateral sacral
from: Surg. Neuroang. Lasjaunias P et al. from: Surg. Neuroang. Lasjaunias P et al.
 1/22/2020

European Course on Spine Radiology European Course on Spine Radiology

The Normal Spine: Vascular Anatomy The Normal Spine: Vascular Anatomy
Arterial anatomy summary Arterial anatomy summary
Segmental Intercostal / Lumbar branch (lateral branch) Segmental Spinous process branch
artery artery

Vertebral Vertebral
Deep cervical Deep cervical
Ascend cervical Ascend cervical
Occipital/Asc Pha Occipital/Asc Pha

Intercostal Intercostal
Lumbar Lumbar
Sacral Sacral

from: Surg. Neuroang. Lasjaunias P et al. from: Surg. Neuroang. Lasjaunias P et al.

European Course on Spine Radiology European Course on Spine Radiology

The Normal Spine: Vascular Anatomy The Normal Spine: Vascular Anatomy
Arterial anatomy summary Arterial anatomy
Segmental spinal cord from: Surg. Neuroang.
Radicular artery  Anterior / Posterior br. Lasjaunias P et al.
artery nerve / dura
Vertebral spine (bone, soft tissue)
Deep cervical Nerve
Ascend cervical Dura
Venous anatomy
RM
Occipital/Asc Pha
RP
Spinal cord spinal cord
nerve / dura
Intercostal Meningo-radicular
Lumbar Radiculo-pial spine (bone, soft tissue)
Sacral Radiculo-medullary
Metameric organization
from: Surg. Neuroang. Lasjaunias P et al.

The Normal Spine: Vascular Anatomy The Normal Spine: Vascular Anatomy
•Spine venous anatomy •Spine venous anatomy
Intrinsic spinal Medial Spinal veins
cord venous
Longitudinal venous collectors
drainage
Anterior (ventral)
subpial topography
Radial veins

Superficial pial Posterior (dorsal)
venous network
 subarachnoid topography
Sulcal veins more visible
(ventral and dorsal) from: Surg.
from: Surg. Neuroang. Neuroang.
Lasjaunias P et al. Lasjaunias P et al.

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A, Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,
ter Brugge K European Course on Spine Radiology Rome 2020 ter Brugge K European Course on Spine Radiology Rome 2020
 1/22/2020

Clinical Case Clinical Case

C7

T2

Male 56 years/old. Recurrent syncope, gait ataxia, and upper limbs weakness Male 56 years/old. Recurrent syncope, gait ataxia, and upper limbs weakness
Asymmetric tetraparesis, lower (XI, XII) cranial nerve palsies, European Course on Spine Radiology Rome 2020 Asymmetric tetraparesis, lower (XI, XII) cranial nerve palsies, European Course on Spine Radiology Rome 2020

Clinical Case Clinical Case

Lateral
BVRosenthal mesencephalic
Vein
(anastomosis between BVR – Petrous Vein)

Peduncular veins

Petrous
Vein

Anteromedial
medullar / pontine /
Anterolateral pontomesencephalic
(Olivar; Lateral medullary) vein Marginal / Occipital
medullar
veins
Sinus

Dural AVF w/spine venous reflux European Course on Spine Radiology Rome 2020 Dural AVF w/spine venous reflux Spinal cord veins

Clinical Case The Normal Spine: Vascular Anatomy

•Spine venous anatomy
Lateral
BVRosenthal mesencephalic
Vein
(anastomosis between BVR – Petrous Vein)

Peduncular veins

Petrous
Vein

Anteromedial
medullar / pontine /
Anterolateral pontomesencephalic
(Olivar; Lateral medullary) vein Marginal / Occipital From Amato A et al 2015
medullar
veins
Sinus Radicular veins - Do not follow the segmental nerve
Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,
Dural AVF w/spine venous reflux Spinal cord veins ter Brugge K European Course on Spine Radiology Rome 2020
 1/22/2020

The Normal Spine: Vascular Anatomy The Normal Spine: Vascular Anatomy
•Spine venous anatomy •Spine venous anatomy
Venous epidural plexus

Are epidural - between the periosteum

and the dura (connection between the
spinal venous plexus and the
retroclival and cavernous plexus)

Examples: cavernous; retroclival

venous plexus, venous plexus of the
foramen magnum and spinal venous
plexus from: Surg. Neuroang.
from: Surg. Neuroang. Lasjaunias P et al. From Amato A et al 2015
Lasjaunias P et al.

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A, Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,
ter Brugge K European Course on Spine Radiology Rome 2020 ter Brugge K European Course on Spine Radiology Rome 2020

Clinical Case Clinical Case

C7 C7

T2 T2

Male 26 years/old. Chronic lumbar pain European Course on Spine Radiology Rome 2020 Male 26 years/old. Chronic lumbar pain European Course on Spine Radiology Rome 2020

Clinical Case The Normal Spine: Vascular Anatomy

•Spine venous anatomy

C7

T2
“femoral” vein injection from: Surg. Neuroang. Lasjaunias P et al.

Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,

Bilateral
Male 26 iliofemoral
years/old. vein thrombosis
Chronic lumbar(collateral
pain venous drainage) European Course on Spine Radiology Rome 2020 ter Brugge K European Course on Spine Radiology Rome 2020
 1/22/2020

European Course on Spine Radiology Clinical Case

The Normal Spine: Vascular Anatomy
Arterial anatomy
spinal cord from: Surg. Neuroang.
Lasjaunias P et al.
nerve / dura
spine (bone, soft tissue)
Venous anatomy
spinal cord C7

nerve / dura
T2
spine (bone, soft tissue)
Metameric organization
Male, 16y. Reddish spot on right upper limb from birth and
vessels dilatations, with episodes of pain and edema European Course on Spine Radiology Rome 2020

Clinical Case Clinical Case

C7 C7

T2 T2

Male, 16y. Reddish spot on right upper limb from birth and
vessels dilatations, with episodes of pain and edema European Course on Spine Radiology Rome 2020 Cobb Synd: Spinal Arteriovenous Metameric Syndrome European Course on Spine Radiology Rome 2020

The Normal Spine: Vascular Anatomy European Course on Spine Radiology

• Cobb Syndrome (SAMS: Spinal Arteriovenous Metameric Syndrome) The Normal Spine: Vascular Anatomy
Arterial anatomy
• Complex of vascular malformations affecting:
• spinal cord, epidural space, vertebral body, spinal cord from: Surg. Neuroang.
Lasjaunias P et al.
• paraspinal soft tissue, muscle, subcutaneous tissue, nerve / dura
• skin
spine (bone, soft tissue)
• All components involved are derived from the Venous anatomy
same spinal metameric segment (SAMS 1- 31) spinal cord
• Diagnosis: vascular malformations affecting more
from: Surg. Neuroang. Lasjaunias P et al.
nerve / dura
than two different tissues in the same spinal metamere topography spine (bone, soft tissue)
Metameric organization
Suggested references: Surgical Neuroangiography. Lasjaunias P , Berenstein A,
ter Brugge K European Course on Spine Radiology Rome 2020
 1/22/2020

European Course on Spine Radiology European Course on Spine Radiology

The Normal Spine:
Vascular Anatomy
Pedro Vilela

Rome, 22-25 January 2020 Rome, 22-25 January 2020

Clinical Case Clinical Case

w/ GAD w/ GAD

AVF of the filum terminale artery European Course on Spine Radiology Rome 2020 AVF of the filum terminale artery European Course on Spine Radiology Rome 2020

Clinical Case Clinical Case

AP view lateral view

C7 C7

T2 T2

European Course on Spine Radiology Rome 2020 Perimedullary spinal cord AVF European Course on Spine Radiology Rome 2020
 1/22/2020

Clinical Case The Normal Spine: Vascular Anatomy

• Spinal Cord
Anterior and Posterior spinal artery

Invasive (extra osseous) hemangioma European Course on Spine Radiology Rome 2020 Refs: European Course on Spine Radiology Rome 2020