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.

Fig. 1

Left-sided, thoracic ganglioneuroma in a 5-year-old girl (patient 5). (a) Coronar and (b) sagittal magnetic resonance (MR) images. The tumor is located from T6 to T8. (c) Coronar and (d) sagittal images of selective spinal angiography. The origin of the artery of Adamkiewicz at level L1 is on the left. (e) Clamshell incision for tumor resection. (f) Paravertebrally located tumor. (g) Situs after tumor resection.

Fig. 2

Left-sided, paravertebral local relapse of hepatocellular carcinoma in an 18-year-old girl (patient 4). (a) Coronar and (b) axial MR images. The tumor is located from T12 to L2. (c) Coronar and (d) sagittal images of selective spinal angiography. The origin of the artery of Adamkiewicz is at level L1 on the left. Surgery was abandoned, and proton beam therapy was performed.

Fig. 3

Left-sided, thoracic neuroblastoma in a 6-year-old boy (patient 6). (a) Coronar and (b) axial magnetic resonance (MR) images. The tumor is located from T7 to T10. (c) Coronar and (d) sagittal images of selective spinal angiography. The origin of the artery of Adamkiewicz is at level T9 on the left. Surgery was abandoned, and external irradiation was performed.