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Spine
Vascular anatomy of the spinal cord
Alejandro Santillan, Veronica Nacarino, Edward Greenberg, Howard A Riina,
Y Pierre Gobin, Athos Patsalides
Division of Interventional
Neuroradiology, Department of
Neurological Surgery, New York
Presbyterian Hospital, Weill
Cornell Medical Center, New
York, New York, USA
Correspondence to
Dr A Santillan, 525 E 68th St,
Division of Interventional
Neuroradiology, Department of
Neurological Surgery, New York
Presbyterian Hospital/Weill
Cornell Medical Center, New
York, NY 10065, USA;
[email protected]
Received 5 March 2011
Accepted 7 March 2011
Published Online First
2 May 2011
ABSTRACT
In this article, a detailed description of the normal arterial
supply and venous drainage of the spinal cord is
provided, and the role of catheter angiography and MR
angiography in depicting the vascular anatomy of the
spinal cord is discussed.
INTRODUCTION
Improvements in endovascular and microsurgical
techniques have resulted in more effective treatments for many vascular lesions of the spinal cord.
A thorough knowledge of the vascular anatomy of
the spine and spinal cord is a prerequisite for
understanding the pathophysiology of spinal
vascular lesions and is necessary for planning safe
surgical and endovascular interventions. This
knowledge is also important for the treatment of
thoracoabdominal aortic aneurysms and for percutaneous spinal procedures. Even though digital
subtraction angiography remains the gold standard
for spinal vascular imaging, MR angiography
(MRA) has gained widespread acceptance in the
detection of large vascular structures, such as the
artery of Adamkiewicz, and has demonstrated
promise in detecting vascular abnormalities of the
spinal cord.
ARTERIAL BLOOD SUPPLY
Arterial supply to the spinal column and spinal cord
Segmental arteries
The arterial supply to the spinal column, paraspinal
muscles, dura, nerve roots and spinal cord derives
from the segmental arteries. The segmental arteries
in the thoracic and upper lumbar spine originate in
pairs from the posterior aspect of the descending
aorta adjacent to the spinal column. The segmental
arteries in the thoracic spine include the posterior
intercostal arteries (nine pairs) and subcostal
arteries (one pair); there are typically four pairs of
lumbar segmental arteries arising from the
descending aorta, corresponding to the top four
lumbar vertebrae (figure 1). Above T3, several
segmental arteries may arise from a common origin,
termed the supreme intercostal artery. The supreme
intercostal artery, also called superior intercostal
artery, is commonly a branch of the costocervical
trunk or the aortic arch, and rarely from the
vertebral artery. It provides supply to the upper
thoracic region. Below T3, there is typically one
pair of segmental arteries at each level which
supply all of the dorsolateral tissues of a single
metamere, except the spinal cord. There are
extensive anastomoses between segmental arteries
with important connections both above and below
a given level, as well as contralaterally. The
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descending aorta is situated to the left of the spinal
column in the upper thoracic levels and descends
anteromedially to become just slightly left of
midline by the lumbar region, before bifurcating
into the common iliac arteries at the lower level of
the fourth lumbar vertebra. The segmental arteries
originate from the aspect of the descending aorta
adjacent to the spinal column. Thus the left
segmental arteries originate from the posterior
aspect of the aorta in both the thoracic and lumbar
spine but the right segmental arteries originate
from the medial aspect of the aorta in the upper
thoracic spine and the posterior aspect of the aorta
in the lower lumbar spine. There is some variability
in the craniocaudal location of the ostia of the
segmental arteries. In the upper thoracic spine, the
segmental arteries originate about two vertebral
levels caudal to the level they supply and therefore
have a marked upward course. In the lower thoracic
and upper lumbar spine, the segmental arteries
originate just below the corresponding vertebral
level, and therefore these arteries tend to have
a short upward course. In the lower lumbar spine,
the ostia of the segmental arteries are generally
located at the level of the center of the third and
fourth lumbar vertebrae, respectively.1 It is important to remember that the segmental arteries are
named by the level they supply and not by the level
from which they originate. When performing
catheter angiography of the spine, one can correctly
identify the level of a given segmental artery by
identifying the (hemi) vertebral blush evident after
injection of contrast material or through the use of
bony landmarks (figures 5A and 11B). In the
thoracic spine, each segmental artery can be named
according to the rib under which it courses.
Segmental arteries in the lower lumbar and sacral
region originate from branches of the internal iliac
artery (mainly the iliolumbar and lateral sacral
arteries) and the median sacral artery (branch of the
aorta at the level of the bifurcation), providing
arterial supply to the L5 vertebra and the sacrum.
The segmental arteries travel posteriorly (on the
left) or posterolaterally (on the right) along the
surface of the vertebral bodies, providing short
branches to supply the anterior and lateral vertebral
bodies. They divide into three major trunks: (i)
lateral or ventral (posterior intercostal or lumbar
artery), (ii) middle or dorsal (muscular and cutaneous branches) and (iii) medial or spinal. The
spinal trunk of each segmental artery enters the
spinal canal at the intervertebral foramen and
divides into: (a) anterior and posterior spinal canal
arteries (called retro-corporeal and pre-laminar
arteries, respectively) that supply the vertebral and
ligamentous structures and, to a lesser extent, the
dura mater, and (b) a radicular artery that supplies
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the dura and nerve root at each level, but not necessarily the
spinal cord (figure 2). The radicular arteries that supply the dura
and nerve roots and dura are named radiculoradial or radiculomeningeal arteries and exist at almost every spinal level.2
At several levels, the radicular artery gives branches that
follow the anterior and/or posterior nerve roots to supply the
spinal cord. Such branches are termed the radiculomedullary
arteries, with the medullary suffix denoting their supply to the
spinal cord. Therefore, the arterial supply to the spinal cord
originates from only a few of the segmental arteries. The radiculomedullary arteries are further divided into anterior and
posterior radiculomedullary arteries based on whether they
supply the anterior or posterior spinal arteries, respectively
(figure 2). The average number of anterior radiculomedullary
arteries is 6 (range 2e14)3 4 whereas the number of posterior
radiculomedullary arteries varies from 11 to 16.5
The arterial supply to the cervical spinal cord varies considerably among individuals. Based on embryonic development,
feeding arteries to the cervical spinal cord are derived from the
vertebral arteries, the deep and ascending cervical arteries (from
the costocervical and thyrocervical trunks, respectively) and to
a lesser degree from the ascending pharyngeal and occipital
arteries. Therefore, all of these arteries need to be meticulously
explored for complete angiographic evaluation of the vascular
supply to the cervical cord.
Superficial arterial system of the spinal cord
At the surface of the cord, two arterial systems can be described:
(1) the longitudinal arterial trunks that extend along the long
axis of the spinal cord and are constituted by the anterior spinal
artery and two posterior (or posterolateral) spinal arteries and
(2) the pial plexus that covers the periphery of the spinal cord.
Longitudinal arterial trunks
Anterior spinal artery
Figure 1 (1) Basilar artery; (2) vertebral artery; (3) anterior spinal artery; (4)
posterior spinal arteries; (5) anterior radiculomedullary artery; (6) ascending
cervical artery; (7) deep cervical artery; (8) subclavian artery; (9) posterior
radiculomedullary artery; (10) segmental arteries (posterior intercostal
arteries); (11) great anterior radiculomedullary artery or artery of
Adamkiewicz; (12) segmental arteries (lumbar arteries); (13) rami cruciantes.
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The anterior spinal artery (ASA) is typically formed at the level
of the foramen magnum by the confluence of descending
branches of the intracranial segments of the vertebral arteries
(figure 6). Descending feeders of equal size from each vertebral
artery are rather uncommon as one side is usually dominant.
Descending branches from both vertebral arteries may join at
the C2e4 level, or the smaller of the two branches may end
separately as a centrally located artery.5 The anterior spinal
artery (ASA) travels along the anterior sulcus of the spinal cord
and descends (with variable interruptions) to the conus medullaris. Although the ASA has variable caliber (diameter
0.2e0.8 mm)5, it is thinnest in the thoracic cord and thickest in
the region of the conus. Due to its long course, the ASA requires
additional arterial supply via anterior radiculomedullary arteries
in order to maintain adequate blood flow to the entire spinal
cord. As a result, the ASA should not be thought of as a single
straight artery but rather as a consecutive series of anastomotic
vascular loops.6 Blood supply to the ASA via radiculomedullary
arteries originates from three major regions: cervicothoracic,
midthoracic and thoracolumbar. Because of the opposing flow
from adjacent ascending and descending radicular branches that
supply the ASA, watershed areas exist at the border of each
region, especially in the upper thoracic region. The ASA supplies
the anterior two-thirds of the spinal cord tissue (including the
anterior horns, and the spinothalamic and corticospinal tracts)
by central and pial branches.
There are 2e3 anterior radiculomedullary arteries in the
cervical region. The most important supply to the cervical ASA
is usually located between the C4 and C8 levels of the spinal
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Figure 2 (1) Posterior spinal arteries; (2) anterior spinal artery;
(3) great anterior radiculomedullary artery or artery of Adamkiewicz;
(4) medial musculocutaneous branch; (5) lateral musculocutaneous
branch; (6) posterior radiculomedullary artery; (7) retrocorporeal arteries;
(8) spinal branch; (9) posterior (dorsal) branch; (10) anterior (ventral)
branch; (11) left segmental artery (posterior intercostal artery); (12) right
segmental artery (posterior intercostal artery); (13) aorta.
cord and is termed the artery of cervical enlargement7 (figure 8).
It is more often a branch of the deep cervical artery and usually
accompanies the C6 nerve root. There are also numerous
secondary ASA contributors arising from the vertebral arteries.
These branches are usually small in caliber; however, one of the
vertebral arteries usually has a large, angiographically detectable
branch, at or near C3. According to Djindjan, other small
contributors may arise from the costocervical trunk, thyrocervical trunk and, to a lesser extent, the ascending cervical artery.
The ascending cervical artery usually supplies branches to the
midcervical cord (C4eC6), and the deep cervical artery supplies
the segmental arteries at C7 and C8.4 The radiculomedullary
arteries (feeder arteries) branch in a ‘Y’ or ‘T’ shape in the
Figure 4 (1) Anterior median vein; (2) right deep cervical vein; (3) left
deep cervical vein; (4) right vertebral vein; (5) left vertebral vein;
(6) subclavian vein; (7) internal jugular vein; (8) left brachiocephalic vein;
(9) superior vena cava; (10) accessory hemiazygos vein; (11) intercostal
veins; (12) posterior radiculomedullary vein; (13) anterior radiculomedullary vein; (14) azygos vein; (15) hemiazygos vein; (16) lumbar veins;
(17) vein of the filum terminale.
Figure 3 (1) Posterior spinal arteries; (2) anterior spinal artery;
(3) spinal branch; (4) anterior radiculomedullary artery; (5) posterior
radiculomedullary artery; (6) central (sulcal) arteries; (7) vasocorona.
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cervical region. Duplication of the ASA is frequent in the cervical
region (figure 7).
The segmental levels that give rise to anterior radiculomedullary arteries in the thoracic and lumbar region are
variable and unpredictable. Small radicular arteries that are
difficult to visualize angiographically supply the spinal cord
in the upper and mid-thoracic region. The most important
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Figure 5 (A, B) Selective catheter spinal angiography (frontal view)
depicts the typical ‘hairpin’ ascending branch of the artery of
Adamkiewicz (arrow) which supplies the anterior spinal artery
(arrowheads). The hemivertebral blush is noted in (A), confirming the
midline position of the anterior spinal artery.
anterior radiculomedullary arterydand the one most easily
recognized in angiographydis the artery radiculomedullaris
magna, also known as the artery of Adamkiewicz (AKA). It has
a diameter of 0.5e1.0 mm5 and almost always arises in the
thoracolumbar region, between T8 and L2 in 75% of cases.6 8e10
It has, however, been identified as superiorly as T5 and as inferiorly as L4.4 In 80% of cases, it is found in the left side. The AKA
forms the classic ‘hairpin’ loop when it reaches the ASA
and gives off a thin ascending branch and a larger descending
branch (figures 2, 5A, 5B and 9). Portions of the thoracic
and upper lumbar spinal cord are extremely vulnerable to
ischemic compromise as there is minimal collateral supply to
the spinal cord inferior to the junction of the AKA and ASA.
Additional feeders to the ASA below the level of the AKA
are rarely found, and the ASA maintains a large caliber until the
end of the conus. Even though the ASA continues caudally
past the conus as an insignificant branch to the filum terminale,
the more important, functional continuations of the ASA are
the ‘rami cruciantes’ that surround the conus and provide
robust anastomoses with the posterior spinal arteries (PSAs)
(figure 1).
Figure 6 Selective left vertebral artery catheter angiogram (frontal
view) shows the anterior spinal artery (arrowheads) originating from the
left vertebral artery (arrow).
PSA system can be thought of as a ‘ladder-like’ longitudinal
network comprised of two trunks coursing on either side of the
spinal cord, medial to the posterior root entry zone.6 Eleven to
16 feeders contribute to the PSA at various levels through the
spine. The largest posterior radiculomedullary artery often
enters below the level of the AKA.5
Throughout its course, each PSA gives off branches that
supply the posterior third of the spinal cord, including the
posterior columns, dorsal gray matter and superficial dorsal
aspect of the lateral columns of the spinal cord.
Pial plexus
Besides the direct connections between the ASA and PSAs at the
conus medullaris, there is an extensive arterial network on the
entire surface of the spinal cord formed by effective anastomoses
Posterior spinal arteries
The two PSAs (diameter <0.5 mm) also originate at the level of
the foramen magnum by branches of the ipsilateral vertebral or
posterior inferior cerebellar arteries. The PSAs travel along the
right and left posterolateral surface of the spinal cord (hence the
alternative term posterolateral spinal arteries), receiving supply
at various levels from the posterior radiculomedullary arteries
(figures 3 and 11A, B). The system of posterior spinal arteries is
discontinuous, and sometimes a PSA may cross over to the
contralateral side to supply the contralateral spinal cord. The
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Figure 7 Detailed view from a reconstructed image from rotational
catheter angiogram of the left vertebral artery in a patient with
subarachnoid hemorrhage shows an anterior spinal artery aneurysm
(arrow) and duplication of the same artery (arrowheads). The duplication
represents an anatomic variant.
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Figure 8 Selective right vertebral artery catheter angiogram (frontal
view) demonstrates the artery of cervical enlargement (arrow) supplying
the anterior spinal artery (arrowheads).
between the ASAs and PSAs. This superficial rich anastomotic
network is termed the pial plexus and has been visualized on
micro angiograms of the spinal cord.5 This network, which may
also be referred to as the ‘vasocorona’, consists of transverse and
oblique branches from the ASAs and PSAs and is responsible for
supplying the periphery of the spinal cord (figure 3).
Intrinsic arterial system
The spinal cord parenchyma is supplied by the intrinsic arterial
system, which is subdivided into a central (centrifugal) system
and a peripheral (centripetal or vasocorona) system. The central
system is comprised of the central arteries, also referred to as
sulcal or sulcocommisural arteries, which originate from the
ASAs and travel into the anterior median fissure (figure 3). After
penetrating into the cord either on the left or right, they branch
centrifugally, mainly within the gray matter. The peripheral
system (vasocorona; diameter 0.1e0.2 mm)4 consists of small
perforators (rami perforantes) that originate from the pial plexus
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Figure 9 Selective spinal angiogram in a patient with arteriovenous
malformation of the spinal cord (thick arrow), demonstrates a common
feeder for the anterior (thin arrows) and left posterior spinal
(arrowheads) arteries.
and vascularizes the periphery of the spinal cord. These small
perforators course into the white matter centripetally. The
territory supplied by the central arteries (diameter
0.06e0.40 mm)4 vascularizes the majority of the gray matter.
The ASA also supplies the ventral half of the outer white matter
tracts through its contribution to the vasocorona. As a result,
the ASA supplies approximately two-thirds of the cross
sectional area of the spinal cord (anterior commissure, anterior
horns, Clarke’s nucleus, anterior portions of the fasciculi
cuneatus and gracilis, corticospinal and spinothalamic tracts).
The PSAs distribute blood to the dorsal third of the spinal cord,
contributing to the apex of the posterior horns. The corticospinal pathways are nourished by both systems.
VENOUS DRAINAGE
Just as the arterial system can be divided into intrinsic and
extrinsic systems, the venous system of the spinal cord is also
composed of intrinsic and extrinsic (superficial) systems. The
venous system, like the arterial system, is extremely variable in
its anatomy although the variability of the anatomy of the
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spinal cord venous drainage is even greater than the arterial
supply (figure 4).
Intrinsic venous system
Although the intrinsic veins draining the spinal cord are divided
into sulcal (central) and radial (peripheral) veins, the areas
drained by them do not correspond to the areas harbored by the
central and peripheral arterial systems. The sulcal veins collect
blood from both halves of the medial aspects of the anterior
horns, anterior gray commissure and white matter of the anterior funniculus. The radial veins arise from the capillaries near
the periphery of the gray matter of the lateral horns, and from
the dorsal nucleus of Clark or from the white matter. They are
directed outward towards the surface of the spinal cord where
they form a venous ring and eventually drain into the superficial
venous system, which consists of longitudinal veins in median
and paramedian locations with numerous anastomoses and
a rich collateral network.
Superficial (extrinsic) venous system
At the level of the spinal pia matter, blood is accumulated in the
anterior and posterior spinal veins. The anterior median spinal
vein accompanies the ASA (diameter 0.4e1.5 mm),5 is most
prominent in the lumbosacral segment and typically continues
along the filum terminale to the end of the dural sac as
a terminal vein (vein of the filum terminale) (figure 12). The
anterior median vein receives drainage from the sulcal veins and
the veins of the ventral fissure. There may be as many as three
posterior spinal veins,4 with the posterior median vein being the
most constant and of the greatest caliber. The other posterior
spinal veins are located posterolaterally, accompany each PSA
and are called posterolateral spinal veins. The posterior spinal
veins receive blood supply from the radial veins of the dorsal
spinal cord. There is high variability of the superficial veins along
the posterior surface of the cord and it is important to recognize
that secondary networks of superficial veins often replace or
complement the longitudinal veins.
The anterior and posterior median spinal veins drain into the
radiculomedullary veins, which accompany the anterior or
posterior spinal nerve root. Numerous anterior and posterior
radiculomedullary veins drain the spinal cord. These radiculomedullary veins drain into the paravertebral and intervertebral plexuses, which communicate with the pelvic venous
plexuses. There are usually 8e14 anterior radiculomedullary
veins11 but there may be as many as 20.12 The number of
posterior radiculomedullary veins draining the spinal cords is
5e10.5 The great anterior radiculomedullary vein (GARV,
diameter 1.5e2.0 mm), the largest vein draining the anterior
thoracolumbar spinal cord, is easily mistaken for the AKA due its
spatial course and location seen by MRA or angiography during
the venous phase. The junction of a radiculomedullary vein with
a median vein (anterior or posterior) is described as a ‘coathook’
configuration because of its more obtuse angulation, compared
with the more acute ‘hairpin’ configuration of the AKA.13 The
GARV usually accompanies the corresponding anterior or
posterior nerve roots between T11 and L3. The posterior median
spinal veins can be easily recognized on radiological images by
the irregular tortuous courses and large caliber (<2 mm).5 The
anterior median spinal vein and the three (usually) longitudinal
posterior medial spinal veins communicate with the internal
vertebral (epidural) venous plexus via the anterior and posterior
radiculomedullary veins.
A functional valve at the level of the dura that consists of an
oblique, zigzag course of the vein coupled with a narrowed
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lumen prevents reflux from the epidural veins into the intradural
veins. Groen and colleagues14 separated the vertebral venous
plexus (Batson’s plexus) into three intercommunicating divisions: (i) the internal vertebral venous plexus (anterior and
posterior) which passes superiorly within the vertebral canal
through the foramen magnum to freely anastomose with the
intracranial venous system; (ii) the external vertebral venous
plexus (anterior and posterior) which surround the vertebral
column and (iii) the basivertebral veins which run horizontally
within the vertebra. The vertebral venous plexus is a valveless
system along the length of the spinal cord. The external vertebral venous plexus connects to the internal vertebral venous
plexus via the intervertebral veins. These intervertebral veins
empty into segmental veins that drain into the ascending
lumbar and azygos venous systems. The three azygos vessels in
the thoracic spine are the azygos on the right and the hemiazygos and accessory hemiazygos on the left. All three drain into
the superior vena cava (figure 4).
ROLE OF CATHETER ANGIOGRAPHY AND MR ANGIOGRAPHY
IN DEPICTING SPINAL VASCULAR ANATOMY
Depiction of spinal vascular anatomy, especially the AKA, is
important in the diagnosis and treatment planning of spinal
vascular lesions,15 16 presurgical planning for certain types of
spinal surgery,17 thoracoabdominal aortic aneurysms repair18
and for planning the preoperative embolization of hypervascular
spinal tumors.19
Catheter angiography
Catheter spinal angiography is the gold standard for the study of
spinal vascular anatomy. Despite significant advances in MRA,
catheter angiography remains the most sensitive and specific
modality for the diagnosis of spinal vascular lesions and localization of the AKA. The major drawbacks of catheter angiography include the small risk of major complications due to its
invasive nature, the use of ionizing radiation and the administration of iodinated contrast material. For these reasons, only
experienced practitioners should perform spinal angiography.
The individual thoracic and lumbar segmental arteries must be
selectively catheterized and evaluated. The vertebral, deep
cervical and ascending cervical arteries must be catheterized for
evaluation of the cervical cord. The internal iliac and iliolumbar
arteries must be catheterized to detect abnormalities in the
lumbosacral region. The sensitivity of spinal angiography in
detecting the AKA is very high and approaches 100%.10 20e23
MR angiography
Modern MRA techniques using contrast agent bolus injection
allow for evaluation of the arterial supply and venous drainage
of the spinal cord.24 Thus MRA provides important information
about the exact location of the AKA as well as spinal vascular
lesions, reducing the need for catheter angiography (figure 10).
Contrast enhanced MRA performed at 1.5 T has a success rate
for the detection of the AKA ranging from 67% to 100%.9 25e28
MRA of the cervical spinal cord is also feasible and useful, with
a detection rate of 96% for the ASA.29 Recently, Bley et al30
identified the AKA and ASA in 88% of patients by using 3.0 T
MRA. They also showed that the AKA and ASA can be differentiated from the GARV, even in patients with substantially
altered hemodynamics.30 Yoshioka et al28 demonstrated continuity of the aorta, intercostal artery, radiculomedullary
artery, AKA and anterior spinal artery in 85% of patients on
MRA at 1.5 T. Multiplanar reformatted images and maximum
intensity projection images are crucial for detection and analysis
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Figure 11 (A, B) Selective catheter spinal angiogram depicts a right
posterior radiculomedullary artery (arrow) supplying the posterior spinal
artery (arrowheads). The hemivertebral blush is noted in (B), confirming
the lateral position of the posterior spinal artery.
Figure 10 MR angiography of the lumbar spine shows the artery of
Adamkiewicz (arrow) that continues to the anterior spinal artery
(arrowheads).
J NeuroIntervent Surg 2012;4:67e74. doi:10.1136/neurintsurg-2011-010018
Figure 12 The late phase contrast enhanced MR angiography shows
the anterior median vein (arrow) which continues as the vein of the filum
terminale (arrowheads).
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of the AKA, drainage vein and spinal vascular malformations.9 24
25 31
Watanabe and colleagues32 reported the use of a contrast
enhanced MRA technique termed double subtraction postprocessing. By utilizing pre-contrast imaging and repeated
sequences after bolus contrast, the authors were able to subtract
the subtracted venous phase image from the subtracted arterial
dominant phase image in order to depict the AKA and differentiate it from the drainage vein. Later, Hyodoh and colleagues9
utilized this same technique to differentiate the AKA, which
was detected in 82.4% of patients, from the drainage vein, which
was detected in 78.2% of patients. As MRI continues to
improve, it is likely that in the near future it will play a major
role in the diagnosis of vascular lesions of the spinal cord.
Correction notice This article has been corrected since it was published Online First.
The section head has been amended to Spine.
13.
14.
15.
16.
17.
18.
19.
20.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
21.
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PAGE fraction trail=7.75
74
J NeuroIntervent Surg 2012;4:67e74. doi:10.1136/neurintsurg-2011-010018
Downloaded from http://jnis.bmj.com/ on May 27, 2016 - Published by group.bmj.com
Vascular anatomy of the spinal cord
Alejandro Santillan, Veronica Nacarino, Edward Greenberg, Howard A
Riina, Y Pierre Gobin and Athos Patsalides
J NeuroIntervent Surg 2012 4: 67-74 originally published online May 2,
2011
doi: 10.1136/neurintsurg-2011-010018
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