Spinal cord infarction (ischemic stroke)
Before vertebral arteries unite to form the basilar artery, they give branches to the uppermost part of the cervical spinal cord and give rise to one anterior and two posterior spinal arteries. Anterior and posterior spinal artery are lying longitudinally throughout the spinal cord arteries, which provide anastomoses. Anterior and posterior spinal artery's arterial blood supply from different levels and distribute it among the spinal cord proper arteries.
Anterior spinal artery (a. spinalis anterior) comes in the form of a single continuous vascular trunk on the spinal cord front surface (in the ventral median fissure) and downwards to the terminal cone. Then, it makes a loop towards the spinal cord posterior part (lumbar level), then connected with the posterior spinal arteries (a. spinales posterior).
Spinal cord supplied from one anterior spinal and two posterior spinal artery.
Posterior spinal artery descend in spinal cord posterolateral sulcus near the exit of the posterior nerve roots. Posterior spinal artery does not exist like a continuous individual vessels, they forms a small arteries anastomoses, where arterial blood can circulate in opposite directions. Sometimes the posterior inferior cerebellar artery provide arterial blood through the branches in to the posterior spinal arteries.
In addition to arterial inflows from the vertebral arteries basin, the anterior and posterior spinal arteries receive blood from:
- radicular arteries extending from one or both vertebral arteries on the neck level,
- thyrocostocervical trunk of the subclavian artery,
- segmental intercostal and lumbar arteries (below the level of the Th3 vertebral body).
After birth, each segment of the spinal cord has a pair of radicular arteries. Later remains the only 5-8 radicular arteries, going along with the anterior roots to the anterior spinal artery, and 4-8 arteries going along with the posterior roots to the posterior spinal arteries at irregular intervals. Anterior radicular artery is larger than the posterior. The biggest radicular arteries is called great radicular artery (of Adamkiewicz, arteria radicularis magna). Great radicular artery (of Adamkiewicz) usually accompanies right or left L2 nerve root on his way to the anterior spinal artery. Segmental spinal artery (atrophy after the human's initial development period) not completely disappear. They supply blood to the nerve roots, spinal ganglions and the dura mater.
1 - vertebral artery, 2 - anterior radicular artery C4-C5, 3 - anterior radicular artery of C6-C8, 4 - costocervical trunk, 5 - thyrocervical trunk, 6 - common carotid artery, 7 - brachiocephalic trunk, 8 - aorta, 9 - anterior vertebral artery, 10 - posterior intercostal artery Th4-Th6, 11 - great radicular artery (of Adamkiewicz), 12 - posterior intercostal artery Th9-L1.
Anterior spinal artery gives sulcocommissural (sulcocomissurales) and envelopes (circumflexae) branches through small intervals. Approximately 200 sulcocommissural branches extend horizontally through the spinal cord ventral median fissure (fissura mediana anterior), diverge in front of the anterior commissure (commissura alba) like a fan on both sides and supply blood to almost all of the gray matter and white matter surrounding rim, including a portion of the front cords. Envelopes branches give anastomoses with the same branches from the posterior spinal arteries, forming vascular crown (vasocorona). Its anterior branches supply the spinal cord anterolateral and lateral cords, including most part of the lateral pyramidal tract. The main neural structures, supplying by posterior spinal artery, are posterior cords and dorsal horn's apical parts.
Spinal cords capillaries, which form the groups in gray matter, corresponding to the neurons columns render blood in the veins of the spinal cord. Most of these veins extends radially towards the spinal cord periphery. Located close to the spinal cord center along the vein initially diverge and run parallel to the central channel before leaving the spinal cord in depth of dorsal or ventral median fissure. On the surface of the spinal cord veins form a plexus, that give blood into the longitudinal winding collectors veins, anterior and posterior spinal veins. Posterior cerebrospinal collector vein larger, it grows in size toward the spinal cord lower levels. From cerebrospinal collectors veins blood flowing through the central and posterior radicular veins (from 5 to 11 on each of the spinal cord side) into the internal vertebral venous plexus (plexus venosus vertebralis internus).
1 - arachnoid, 2 - dura, 3 - posterior external vertebral venous plexus, 4 - posterior spinal vein, 5 - posterior central vein, 6 - posterolateral spinal veins, 7 - sulcocommissural vein, 8 - commissural vein, 9 - periosteum, 10 - anterior and posterior radicular veins, 11 - anterior internal cerebro-spinal venous plexus, 12 - intervertebral vein, 13 - vertebral veins, 14 - anterior external cerebrospinal venous plexus, 15 - vertebrobasilar vein, 16 - anterior spinal vein.
The internal vertebral venous plexus, surrounded by loose connective and adipose tissue, located in subdural space and is an analogue of the brainís dural venous sinuses. This venous plexus through the foramen magnum those communicated with the skull basis sinuses. The outflow of venous blood happens by the intervertebral veins through the intervertebral foramen. By intervertebral veins blood enters into the external vertebral venous plexus (plexus venosus vertebralis externus). This plexus, among others, supplies venous blood into the azygos vein, which is connects the upper and lower vena cava on spine's right side.
Anterior and posterior spinal artery usually not susceptible to atherosclerosis. Anterior and posterior spinal artery may be affected by arteritis or embolism. Most often, patientís spinal cord infarction is results of ischemia in existing remote artery occlusions. Thrombosis or aortic dissection cause spinal infarction due to occlusion of the radicular artery and termination of direct arterial blood flow to the anterior and posterior spinal artery. Infarction (ischemic stroke) usually develops in the zone of the adjacent blood supply of the spinal cord thoracic levels between the major spinal branches of the aorta, the artery of Adamkiewicz below and anterior spinal artery above.
Causes of spinal cord ischemia and stroke:
- stenosis of intersegmental artery (ISA) ostia
- compression of the ISA or its branches by anterior, lateral or posterior disc herniation
- diaphragmatic crus syndrome
Spinal cord Infarction can occur in patients with systemic arteritis, immune responses with serum disease and after contrast agent intravascular injection. During intravascular contrasting, the spinal cord infarction harbinger severe back pain. It has occurs in a patient during contrast agent intravascular injection.
Causes of spinal cord ischemia and stroke: stenosis or compression of the intersegmental artery (ISA) by disc herniation, diaphragmatic crus syndrome.
Spinal cords infarction caused by herniated disc's microscopic fragments, which contents is the nucleus pulposus, may develop in patients after a slight injury, often obtained it under sporting. At the same time, patients reported severe local pain, alternating rapidly coming paraplegic syndrome and transverse spinal cord lesions, developing in several minutes or an hour. In small intramedullary vessels and often within the adjacent vertebral bodies bone marrow is detect pulposus tissue. The path of its penetration from the disc material in to the bone marrow and from there to the spinal cord is still unclear. This condition should be suspected in young patients with transverse spinal cord injury syndromes in an accident.
Depending on the patient's spinal artery occlusion level will be manifests motor and sensory disorders.
Clinical manifestations of anterior spinal artery lesions usually occur suddenly in a patient, like apoplexy. In some patients with anterior spinal artery occlusion, the same symptoms grow for 1-3 days, which makes difficult for correct diagnosis. A sudden, usually by thrombus, cervical anterior spinal artery's occlusion causes the patient's sensitivity disorder in the form of severe pain and paresthesia. After sensitivity disorder in patients develops a hand muscles flaccid paralysis (peripheral type) and a leg muscles spastic paraparesis (central type) due spinal cord pyramidal tract involvement in lesion site.
On MRI visible acute spinal cord ischemia resulting from compression fracture with displacement of the vertebral bodies during its osteoporosis.
Similarly occurs the bladder and bowel dysfunction, and decreased pain and temperature sensitivity on the anterior spinal artery's occlusion segmental level. In this case, in a patient usually kept proprioceptive and tactile sensitivity. Anhidrosis on the paralyzed body parts can lead to an increase in body temperature, especially in case of environment's high temperature, that simulates infection's symptom in a patient.
One or both posterior spinal arteries occlusion in patients is extremely rare in clinical practice. Resulting spinal infarct involves a spinal cord posterior tract and a horns, as well as partially pyramidal lateral tract. Below the spinal cord infarction level in a patient identified sensitivity disorder (anesthesia and analgesia), spastic paresis and reflectory muscle disorder.
If you have any questions on the diagnosis or treatment of spinal cord infarction (ischemic stroke), you can ask them to our neurosurgeon or neurologist: (499) 130–08–09
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