Ask Dr. Z

For the case that follows, I came up with the following: right subclavian 36225-RT, right vertebral 36226-RT(delete 36225), right thyrocervical 36217-RT/75774-RT, right costocervical 36217-59RT/75774-59RT, left subclavian 36225-LT, left vertebral 36226-59LT (delete 36225), left ascending cervical 36216-LT/75705, left thyrocervical 36216-59LT/75774-59LT, left costocervical 36216-59LT/75774-59, and right and left bronchial 36216-50/75705-50.

INDICATIONS/COMMENTS: Upper thoracic possible intradural/subarachnoid hemorrhage to rule out AVM. HISTORY: Acute onset of the upper thoracic spine pain and chest pain. Cardiac workup has been negative. Questionable findings on total spine MRI. Please evaluate for vascular malformation in the upper thoracic spine. PROCEDURE: The risks and benefits were discussed with and accepted by the patient. The right groin was prepared and draped using maximum barrier sterile technique. Dermal and subcutaneous local anesthesia was given with 1% lidocaine. Moderate sedation was administered under my direct observation using continuous oximetric and hemodynamic monitoring. The patient received small titrated doses of Versed and Fentanyl, remained hemodynamically stable, and maintained oxygen saturation levels comparable to preprocedure levels. Total time of conscious sedation was 120 minutes. Catheter tip was placed in the right subclavian artery, contrast injected and images obtained over the upper chest and neck. Catheter tip was subsequently placed in the right vertebral artery, right thyrocervical trunk, and right costocervical trunk. At these locations, contrast was injected and images obtained over the right shoulder, neck, and upper thoracic spine. The catheter was placed into the left subclavian artery. Contrast was injected and images obtained over the neck and upper chest and shoulder. The catheter was subsequently placed into the left vertebral artery, left acsending cervical artery which had a separate origin from the left subclavian artery, the left thyrocervical trunk, and the left costocervical trunk. Then we made numerous catheter exchanges and placed a catheter tip in left and right bronchial arteries and numerous intercostal arteries in the upper thoracic and middle thoracic aorta. Catheter tip was removed and hemostasis was obtained with an Angio-Seal. RESULT: The anterior spinal artery is well identified in the cervical spine and upper thoracic spine down to the T2 or T3 level. It is very small with no nidus or early venous filling identified. In the middle and lower thoracic spine, I believe we can identify radiculomedullary branches but we never identify the anterior spinal artery. The anterior spinal artery is a direct continuation of radicular medullary branches, so that vessel must be very small. No abnormal blush or enhancement is identified in the paravertebral regions. CONCLUSION: 1. No significant abnormality.