Gary Spiegel

Novel application of 3-dimensional rotational C-arm conebeam computed tomography angiography for metastatic hypervascular tumor mass in the spine.

Study Design. This is a case report. Objective. To report a 3-dimensional (3D) rotational C-arm conebeam computed tomography (CT) (DynaCT) angiography generating computed tomographic data concurrently with spinal angiographic datasets. This technology allowed 3D modeling of the anterior spinal arterial supply in juxtaposition to a hypervascular tumor mass, thus affording unprecedented guidance in presurgical planning. Summary of Background Data. An enhanced demonstration of spatial relationships between the vascular elements and their adjacent soft-tissue structures is needed to visualize the minute anterior spinal artery optimally. Methods. A 76-year-old male with a history of renal cell carcinoma metastasis to the T6 vertebra 1 year prior, presented with worsening myelopathy caused by severe spinal cord compression at T6 level, and a plan for surgical decompression was established. Because of the hypervascular nature of this renal cell carcinoma metastasis, preoperative embolization was requested to minimize blood loss during the operation. A digital subtraction angiogram identified the major arterial contribution to the tumor to also supply the radiculomedullary branch to the anterior spinal artery. To further characterize this blood supply, a rotational DynaCT angiography was performed. Results. The rotationally acquired data were processed generating volumetric CT datasets demonstrating the 3D relationships of the anterior spinal artery, the blood supply to the tumor and the adjacent soft-tissue and bony structures. A shared blood supply to both the tumor mass and the anterior spinal artery from the left T6 segmental artery was confirmed. The dual nature of this blood supply presented increased risk of ischemic spinal cord injury by possible nontarget embolization. Therefore, the embolization was deferred. Conclusion. The DynaCT angiography precisely characterized the complex blood supply of a hypervascular vertebral tumor mass in relation to a shared arterial supply to the thoracic spinal cord. The optimal visualization properly aided presurgical planning. Level of Evidence: N/A

Clinical Reasoning: A case of progressive cognitive decline reversed by middle cerebral artery stent placement

A 46-year-old right-handed African American man presented to the emergency department after a 10-minute episode of sudden-onset left-hand weakness and slurred speech. His medical history was significant for a left cerebellar stroke 6 years ago. That event occurred during a physical training exercise and was thought to be secondary to a vertebral artery dissection.1,2 He was placed on aspirin 81 mg daily. The patient had minimal residual deficits, with left face numbness and left hypoacusis. He did not smoke, drink, or use recreational drugs. There was no family history of stroke or vascular disease. On initial examination, the patient was normotensive. His mental status was intact, with a Mini-Mental State Examination (MMSE) score of 30/30. There was no apraxia, aphasia, or visual field deficit. Cranial nerve examination had normal results with the exception of left hypoacusis and left facial numbness over the V1–V3 distribution to pinprick. Funduscopic examination revealed no papilledema or vasculopathy. Motor, sensory, and cerebellar examinations were normal. Deep tendon reflexes were 2+ throughout with bilateral plantar responses. Laboratory testing including a complete blood count, serum chemistry, coagulation panel, and liver function tests were normal. EKG showed normal sinus rhythm and no evidence of left ventricular hypertrophy. MRI showed no evidence of acute intracranial abnormalities; a chronic left cerebellar infarct was seen (figure 1). CT angiography demonstrated severe bilateral middle cerebral artery (MCA) stenosis, worse on the right, as well as an absent left vertebral artery which was confirmed by conventional angiography (figure 2A). Figure 1 Initial imaging Noncontrast head CT (A) on admission demonstrating chronic left cerebellar infarct. Fluid-attenuated inversion recovery (FLAIR) MRI on admission shows no evidence of ischemic changes in the middle cerebral artery territory (B). FLAIR was also negative (C). Figure 2 Initial cerebral angiogram Angiogram on admission (A), at time of cognitive decline (B), and poststent placement (C) …