The Relevance of Preoperative Identification of the Adamkiewicz Artery in Posterior Mediastinal Pediatric Tumors

Abstract

Background Injury to the artery of Adamkiewicz (AKA) during surgery may lead to spinal cord ischemia and severe neurologic complications. Posterior mediastinal tumors may be adjacent to AKA, but data on preoperative visualization of AKA in children are rare. This study analyzed the importance of identifying the AKA preoperatively by spinal digital subtraction angiography (DSA) in children with posterior mediastinal tumors for therapeutic procedure. Methods Between 2002 and 2021, 36 children with posterior mediastinal tumors were evaluated for surgery at the authors’ clinic. In 10 children with left-sided or bilateral tumor located at vertebral levels T8 to L1, spinal DSA was performed during preoperative workup to assess AKA. The patient and tumor characteristics as well as the diagnostic and therapeutic procedures were analyzed. Results The median age of the 10 children at examination was 69 months (range, 16–217 months). Three of the children were younger than 2 years. The tumor entities were neuroblastoma, ganglioneuroblastoma, ganglioneuroma, local relapse of a hepatocellular carcinoma, and neurofibroma. The AKA was identified in all cases, and proximity to the tumor was detected in four patients, three of whom had their planned surgery changed to irradiation. No complications occurred during spinal DSA or surgery. Conclusions In posterior mediastinal pediatric tumors, spinal DSA is a safe and reliable method for preoperative visualization of the AKA. It can show proximity to the tumor and guide the local therapy, thereby avoiding critical intra- and postoperative situations.

Image‐defined risk factors in localized thoracic neuroblastoma and ganglioneuroma

“…In our cohort, a quarter presented with surgical complications, a comparable proportion to other published groups 15,24 . Patients with lower mediastinal tumors and/or intraspinal involvement are at high risk of injuring the spinal cord when operated 8,26–28 . In our cohort, no such complication was documented.…”

“…15,24 Patients with lower mediastinal tumors and/or intraspinal involvement are at high risk of injuring the spinal cord when operated. 8,[26][27][28] In our cohort, no such complication was documented. However, as mentioned before, tumors of the lower mediastinum present a heterogenous group.…”

Trap-Door Thoracotomy and Clamshell Thoracotomy as Surgical Approaches for Neuroblastoma and Other Thoracic Tumors in Children

“…In the clamshell group, preoperative spinal angiography identified the artery of Adamkiewicz in seven patients. It could be spared intraoperatively, preventing spinal cord ischemia [16]. Although this preoperative imaging modality has not been described in previous studies of posterior mediastinal tumor resection via trap-door or clamshell thoracotomy, we strongly recommend performing spinal angiography preoperatively and adjusting the surgical strategy accordingly.…”

“…The standard preoperative diagnostic workup consisted of cross-sectional imaging by magnetic resonance imaging (MRI) or computed tomography (CT) in all patients. It was supplemented by ultrasound for peripheral nerve involvement, cerebral angiography for cervical vascular compression, and spinal angiography for posterior mediastinal tumors to identify the artery of Adamkiewicz to avoid spinal cord ischemia [16]. Vascular encasement was defined as tumor contact with more than 50% of the vessel circumference [17].…”

Preoperative Spinal Angiography for Thoracic Neuroblastoma: Impact of Identification of the Adamkiewicz Artery on Gross Total Resection and Neurological Sequelae

“…Approximately 15-25% of neuroblastoma occur in the posterior thorax, where intraspinal extension is relatively common [2][3][4]. Posterior thoracic tumors may involve the origin of the Adamkiewicz artery (AKA), with an inherent iatrogenic risk of vascular damage and consequent spinal cord ischemia [5][6][7][8]. The AKA contributes to the vascularization of the anterior spinal artery and arises from the intercostal artery, usually between thoracic vertebral levels T9 and T12 [9].…”