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NEUROIMAGE
Year : 2011  |  Volume : 59  |  Issue : 2  |  Page : 317-318

A case of aortic coarctation presenting with quadriparesis due to dilated tortuous anterior spinal artery


1 Department of Neurosurgery, Army Hospital (Research and Referral), New Delhi, India
2 Department of Intervention Radiology, Army Hospital (Research and Referral), New Delhi, India

Date of Web Publication7-Apr-2011

Correspondence Address:
Maneet Gill
Department of Neurosurgery, Army Hospital (Research & Referral ), Street : Gurgaon Road , Dhaula Kuan, Delhi Cantt, New Delhi - 110010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.79174

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How to cite this article:
Gill M, Pathak HC, Singh P, Pathak K. A case of aortic coarctation presenting with quadriparesis due to dilated tortuous anterior spinal artery. Neurol India 2011;59:317-8

How to cite this URL:
Gill M, Pathak HC, Singh P, Pathak K. A case of aortic coarctation presenting with quadriparesis due to dilated tortuous anterior spinal artery. Neurol India [serial online] 2011 [cited 2020 Aug 9];59:317-8. Available from: http://www.neurologyindia.com/text.asp?2011/59/2/317/79174


A 30year-old male presented with sudden onset weakness of all four limbs. Clinically, he had hypotonia in all the four limbs and motor weakness was graded at 4/5. Deep tendon reflexes were bilaterally brisk and plantar response was extensor. Magnetic resonance imaging of cervical spine [Figure 1] showed multiple, well--defined, rounded areas of flow void, suggestive of blood vessels in the anterior epidural space from C5 to T3 level. Spinal digital subtraction angiography [Figure 2] did not reveal any dural arterio-venous fistula. Instead, it revealed coarctation of aorta with prominent collaterals. Computed tomography (CT) angiogram showed dilated vessels connecting the tortuous anterior spinal collateral to extra spinal channels, i.e., the vertebral and the intercostal arteries [Figure 3]. He showed gradual recovery from his neurological deficits. Surgical correction of coarctation of aorta is being planned.
Figure 1: Sagittal MRI showing flow voids from C5 to D3, reported as dural arterio-venous fistula. There are no signal changes in the spinal cord

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Figure 2: DSA showing the coarctation of aorta and the collaterals

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Figure 3: Coronal sagittal and axial reconstruction of CT angio showing the dilated tortuous anterior spinal artery and the collaterals from the vertebral and intercostal arteries

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In patients with coarctation of aorta, spinal complications are often due to aortic cross-clamping during surgery for the correction of the coarctation. However, myelopathy rarely can be the presenting feature of coarctation of aorta. [1],[2],[3] In coarctation of aorta, several mechanisms can lead to myelopathy: compression due to dilated intraspinal collaterals, [1] subarachnoid hemorrhage and its sequalae, [4] compression due to radicular artery aneurysm, [5] and spinal artery aneurysm. [6] However, myelopathy due to a sufficiently enlarged and tortuous anterior spinal artery collateral is extremely rare,; only 14 such cases have been documented in the English literature. [1],[2],[3]

The main collaterals in coarctation are through the internal mammary and the intercostal arteries. In patients with tortuous anterior spinal artery, the myelopathy is not congestive as inspinal dural arterio-venous fistulae. The mechanisms proposed by which a dilated anterior spinal artery can cause myelopathy include: (1) enlarged spinal arteries can cause compressive myelopathy given the space constraint in the tight spinal canal in the lower cervical and upper thoracic regions; (2) "aortic ,steal", [3], this mechanism probably explains the reversible nature of the neurological deficits as seen in our patient; and (3) dilated collaterals may serve as sources for clots and throw microemboli occluding the anterior spinal artery, resulting in sudden onset deficits. [7] The blood supply to the lower cervical and upper thoracic cord is rather tenuous and depends heavily on the supplementation of the anterior spinal artery by segmental radicular arteries. Between two adjacent radicular arteries, the blood flow is bidirectional, and due to the convergent nature of the flow, there are watershed areas.Detailed clinical angiographic correlation has shown that in cases of coarctation of aorta, there is reversal of flow and the blood passes from the anterior spinal artery, via huge dilated communicating extraspinal vessels to the part of aorta distal to the coarctation. It is as if the post-stenotic aorta were stealing the blood from the anterior spinal artery.

Treatment has to be individualized taking into consideration whether the neurological deficit is stable, improving or worsening. Most patients recover after the surgical correction of the coarctation and the consequent normalization of the blood flow patterns. [2],[3] Some patients also recover without the correction of the coarctation, [2] as seen in our patient. Tan et al.[1] have reported regression of symptoms after decompressive laminectomy.

 
  References Top

1.Tan KP, Ng FC, Ong PL. Paraparesis due to dilated spinal collaterals. Singapore Med J 1979;20:454-6.  Back to cited text no. 1
[PUBMED]    
2.Doppman JL, Di Chiro G, Glancy DL. Collateral circulation through dilated spinal cord arteries in aortic coarctation and extraspinal arteriovenous shunts. An arteriographic study. Clin Radiol 1969;20:192-7.  Back to cited text no. 2
[PUBMED]    
3.Kendall BE, Andrew J. Neurogenic intermittent claudication associated with aortic steal from the anterior spinal artery complicating coarctation of the aorta. J Neurosurg 1972;37:89-94.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Banna MM, Rose PG, Pearce GW. Coarctation of aorta as a cause of spinal subarachnoid haemorrhage. J Neurosurg 1973;39:761-3.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Tsutsumi K, Nagata K, Terashi H, Sato M, Hirata Y. A case of aortic coarctation presenting with Brown-Sequard syndrome due to radicular artery aneurysm. Rinsho Shinkeigaku 1998;38:625-30.  Back to cited text no. 5
[PUBMED]    
6.Hino H, Maruyama H, Inomata H. A case of spinal artery aneurysm presenting as transverse myelopathy associated with coarctation of the aorta. Rinsho Shinkeigaku 1989;29:1009-12.  Back to cited text no. 6
[PUBMED]    
7.Laguna J, Crairoto H. Spinal cord infarction secondary to occlusion of the anterior spinal artery. Arch Neurol 1973;28:134-6.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 Anterior spinal artery aneurysm in aortic stenosis of different etiology: Report of three cases
Vivek Singh,Suprava Naik,Sanjeev K Bhoi,RV Phadke
The Neuroradiology Journal. 2017; 30(2): 180
[Pubmed] | [DOI]



 

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