Anterior spinal cord infarction as a complication of bronchial artery embolization in the management of recurrent hemoptysis

Ramandeep Singh; Siddharth Prakash; Paramdeep Singh; Rupinderjeet Kaur; Rubal Rai

doi:10.4103/VIT.VIT_12_19

CASE REPORT

Year : 2019 | Volume : 2 | Issue : 2 | Page : 51-53

Anterior spinal cord infarction as a complication of bronchial artery embolization in the management of recurrent hemoptysis

Ramandeep Singh¹, Siddharth Prakash², Paramdeep Singh¹, Rupinderjeet Kaur³, Rubal Rai⁴
¹ Department of Radiology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
² Department of Radiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
³ Department of Medicine, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
⁴ Department of Anaesthesia, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India

Date of Submission	14-Feb-2019
Date of Decision	06-Apr-2019
Date of Acceptance	12-Apr-2019
Date of Web Publication	9-Oct-2019

Correspondence Address:
Dr. Paramdeep Singh
Department of Radiology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/VIT.VIT_12_19

Abstract

Bronchial artery embolization (BAE) is an established minimally invasive approach for the treatment of massive or recurrent hemoptysis. There are several minor complications associated with the procedure. A rare complication of the procedure is spinal cord infarction due to embolization of anterior spinal artery. A 48-year-old male patient of old pulmonary tuberculosis presented with fibrocalcified lesions in the right upper lobe on chest X-ray and recurrent hemoptysis. Angiography revealed bleeding from a branch of single right intercostobranchial trunk. The day following the procedure, the patient complained of weakness and pain in lower limbs. Magnetic resonance imaging dorsolumbar spine revealed acute spinal cord infarct from D2 to D5 vertebral levels. This case demonstrates that spinal cord ischemia may occur during BAE, despite all the precautionary measures.

Keywords: Bronchial artery, embolization, hemoptysis, infarction, spinal cord

How to cite this article:
Singh R, Prakash S, Singh P, Kaur R, Rai R. Anterior spinal cord infarction as a complication of bronchial artery embolization in the management of recurrent hemoptysis. Vasc Invest Ther 2019;2:51-3

How to cite this URL:
Singh R, Prakash S, Singh P, Kaur R, Rai R. Anterior spinal cord infarction as a complication of bronchial artery embolization in the management of recurrent hemoptysis. Vasc Invest Ther [serial online] 2019 [cited 2023 Mar 24];2:51-3. Available from: https://www.vitonline.org/text.asp?2019/2/2/51/268674

Introduction

The originating vessel in 90% cases of hemoptysis is bronchial artery. The most common underlying cause of hemoptysis in developing countries is tuberculosis. Unlike the low-pressure pulmonary arteries, the bronchial arterial circulation is a high-pressure system, contributing to just 1% of pulmonary blood supply. Owing to the dual blood supply of lungs, any chronic pathological reduction of pulmonary perfusion causes local hypoxia that causes angiogenic recruitment and bronchial artery hypertrophy.^[1],[2] These hypertrophied bronchial arteries/collaterals have friable walls due to inflammation which in turn leads to arterial leakage/rupture causing life-threatening hemoptysis. Bronchial artery embolization (BAE) is a well-established minimally invasive treatment for massive or recurrent hemoptysis. The commonly used materials for embolization are polyvinyl alcohol (PVA) particles, gel foam, and N-butyl cyanoacrylate. Spinal cord infarction is the most severe and dreadful complication of BAE, with a reported prevalence of 1.4%–6.5%.^[1],[2] We report a case of a patient of old pulmonary Koch's presenting with recurrent hemoptysis, wherein BAE was done with subsequent development of spinal cord infarction in the territory of anterior spinal artery.

Case Report

A 48-year-old male patient with a history of treated pulmonary tuberculosis presented with recurrent and massive hemoptysis for 3 days. Chest X-ray revealed fibrocalcified lesions in the right upper lobe [Figure 1]. To control his hemoptysis, the patient was taken up for angiography which revealed right bronchial artery hypervascularity. The right intercostobronchial trunk (ICBT) was catheterized with a 5F Mickelson (Cook Medical Inc.) catheter, and initial diagnostic angiography was performed with the base catheter. After that, a microcatheter was advanced using a microcatheter system through which embolization was done using 300–500 μm PVA particles (Boston Scientific). The angiogram was done after the procedure which revealed near-complete occlusion of the flow [Figure 2]a and [Figure 2]b. None of the anterior spinal artery feeders were opacified during the procedure. The patient developed acute lower limb weakness and pain. Magnetic resonance imaging of the spine revealed T2/STIR hyperintense signal at the D2–D5 levels in the anterior part of cord, indicating acute infarction in the anterior spinal artery territory [Figure 3].

Figure 1: Chest X-ray posteroanterior view of a 48-year-old male of diagnosed pulmonary Koch's reveals multiple small fibrocalcified lesions in the right upper lobe

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Figure 2: (a) Base catheter on angiography demonstrates right intercostobranchial trunk and its branching into intercostal arteries, radicular arteries, and right bronchial artery. (b) Angiogram depicts an area of blush in right upper lobe indicating the site of bleeding

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Figure 3: (a) Magnetic resonance imaging T2-weighted axial image showing area of high-signal intensity in anterior part of dorsal spinal cord indicative of infarct in anterior spinal arterial distribution, (b) magnetic resonance imaging T2-weighted vsagittal image showing spinal cord infarct in anterior spinal artery territory extending from D2 to D5 level

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Discussion

The bronchial arteries may originate directly from the aorta or with an intercostal artery from a common ICBT between T5 and T6 level, and many variations of origin of bronchial arteries have also been described. Anomalous bronchial arteries originating from a level other than T5–T6 from aorta and brachiocephalic, subclavian, interscostal, celiac, and phrenic arteries are seen in 8.3%–35% cases.^[3]

In addition to the spinal arteries, two more types of arteries may be visualized on angiography, namely the radicular arteries and medullary arteries. The anterior and posterior radicular arteries supply the dorsal and ventral nerve roots and are branches of the segmental arteries which in turn originate from the branches of deep cervical, intercostal, and lumbar arteries. Additional feeder arteries (medullary arteries), commonly arising from intercostal arteries, have a characteristic hairpin appearance as they course medial to the vertebral pedicle and supply the anterior spinal artery. Although radicular arteries are present at every level, only few medullary/Feeder arteries supply the anterior spinal artery. The greater anterior medullary artery, also known as the Artery of Adamkiewicz ^{More Details}, arises from aorta between T9 and T12 and reinforces the spinal cord circulation. It shows a characteristic hairpin bend on angiography. In up to 5% cases, the anterior spinal artery or artery of Adamkiewicz can originate from a bronchial artery usually on the right side. On angiography, this is seen as a small longitudinal vessel on the mid-ventral surface of the spinal cord. The regression of blood supply to the anterior spinal cord during embryogenesis and the disproportionately large area supplied by anterior spinal artery predisposes it to life-threatening ischemia during embolization. Chest pain is the most common complication, reported in 24%–91% of cases.^[4],[5] The most dreaded complication of BAE is spinal cord infarction.

Many authors are of the opinion that visualization of anterior spinal artery or spinal radicular arteries originating from the bronchial artery is an absolute contraindication for embolization. On the contrary, certain authors believe that unintentional embolization of radicular arteries does not cause spinal cord ischemia, thereby emphasizing that opacification of radicular artery is not an absolute contraindication for BAE. On visualization of origin of the anterior spinal artery from bronchial artery, careful distal embolization of that bronchial artery is recommended only if catheter can be stably placed distal to the origin of the spinal artery. However, to avoid spinal cord infarction, it is stressed upon that whenever the artery of Adamkiewicz is visualized at angiography, the embolization procedure should be abandoned.

Spinal cord injury has also been reported to be due to invisible anastomotic connections between the bronchial circulation and anterior spinal artery. These vessels have been called invisible owing to their small size, and these may become visible only after embolization of hypertrophied vessels and consequent redirection of the blood flow. Therefore, it is important that the particles used for embolization should be >350 μm as it may prevent the embolization of nonvisualized spinal feeders which are smaller than the particle size. In this case, there was nonvisualization of origin of artery of Adamkiewicz or small spinal arterial branches from the right ICBT or the right bronchial artery. However, the possibility of inadvertent embolization of the latter cannot be still ruled out as even the nonvisualization of spinal arterial branches cannot protect against spinal arterial infarction. According to the literature, in instances in which spinal cord injury resulted postembolization, branches to the spinal cord were not identified at angiography.^{[6],[7],[8],[9],[10]} We feel that intermittent angiograms, which were not performed in this case, might have helped in interval visualization of the spinal artery branches during the procedure.

Conclusion

This report reveals that spinal cord ischemia may occur during BAE despite all the precautionary measures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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