A rare case of spinal cord and posterior circulation infarction after bronchial artery embolization

A rare case of spinal cord and posterior circulation infarction after bronchial artery embolization | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A rare case of spinal cord and posterior circulation infarction after bronchial artery embolization Tao Xiang, Ming Cheng, Yangling Wu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6153049/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Bronchial artery embolization (BAE) is a first-line therapy for massive hemoptysis. However, spinal cord and posterior circulation infarction are rare but severe complications. Case Presentation: A 56-year-old male with bronchiectasis presented with recurrent hemoptysis (>500 mL/24h). BAEwas performed using microspheres (500-900μm). Postoperatively, he developed paraplegia, urinary retention, and posterior circulation infarctions (right occipital lobe and left cerebellum).Despite rehabilitation, lower limb motor and sensory deficits persisted at 2-year follow-up. Conclusion: This case highlights the risk of dual spinal and cerebral infarction post-BAE. Interventional radiologists must meticulously avoid embolizing spinal collaterals and monitor injection pressure to prevent reflux. Preoperative spinal artery mapping (e.g., Wada test) may reduce complications. Bronchial artery embolization Spinal cord infarction Posterior circulation infarction Hemoptysis Complications Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction There are numerous potential causes of hemoptysis, a dangerous and potentially fatal disorder. According to a prior study, individuals with hemoptysis had a hospital death rate between 8.7–10.1%[ 1 ]. First-line therapy for hemoptysis that has been well-documented is bronchial artery embolization[ 2 , 3 ]. There have been reports of discomfort, myocardial infarction, spinal cord infarction, and posterior circulation infarction following this surgery[ 4 , 5 ]. The most dangerous side effect is spinal cord infarction, which might result in permanently lost function. During bronchial artery embolization, we observed a case with concomitant spinal cord and posterior circulatory infarction, which had not previously been reported. Case Presentation A 56-year-old male with a history of smoking was admitted to hospital with coughing hemoptysis. His hemoptysis in the previous 24 hours exceeded 500ml. Computed Tomography(CT) scans showed scattered ground glass density plaques in both lungs, as well as left and right bronchi and intratracheal flocculation lesions. (Fig. 1). On the second day after admission, the patient experienced massive hemoptysis again despite anti-infection and medical hemostasis treatment. Following an evaluation, the patient received bronchial arteriography and embolization. The right femoral artery was punctured and a 5F catheter was inserted into the aortic arch and bronchial artery under local anesthetic. Angiography revealed two bronchial arteries in the left lung and one in the right lung. The artery arteries were twisted, and the wall was rough. At the distal end of the bronchial artery branch opening, embolization was performed with 500-700um and 700-900um embolization microspheres. The patient developed weakness in both lower limbs immediately after surgery, accompanied by dizziness, urine retention, and decreased sensation below the nipple level. Neurological examination showed that the patient's cognition and language were normal, the fingernose test and the rotation test were negative, the superficial sensation (pain, temperature and touch) below the level of the nipple disappeared, the deep sensation disappeared, the lower limb muscle strength was grade 0, the bilateral tendon reflex disappeared, and the bilateral pathological signs were negative. Head Magnetic Resonance Imaging(MRI)showed a patchy acute infarction in the left cerebellar hemisphere and a spotty acute infarction in the right occipital lobe (Fig. 2 , Figuer3), and thoracolumbar MRI revealed long, lamellar T2 signal shadow in the thoracolumbar spinal cord (approximately thoracolumbar 10-lumbar 1 vertebral level) with unknown nature (Fig. 4 ). The patient was diagnosed with spinal cord injury, according to the American Spinal Cord Injury Association grading criteria, the patient's spinal cord injury level was T10 and the degree was grade A, that is, complete spinal cord injury. Based on the head MRI findings, it was also diagnosed as acute cerebral infarction in the right occipital lobe and left cerebellum. The patient underwent a comprehensive treatment regimen that included pharmacological interventions with medications such as hormones and mannitol. These were administered to alleviate spinal edema, promote vasodilation, and enhance circulation. Additionally, neurotrophic support was provided. Complementary to the drug therapy, the patient also received rehabilitative treatments, which encompassed acupuncture, electrical stimulation, and therapeutic exercises, aimed at facilitating recovery and functional improvement. Within two weeks, the patient's dizziness had fully resolved, and there were no signs of ataxia or motor sensory disturbances in the upper limbs. Advanced brain functions, including speech and cognitive abilities, remained intact without any observed deficits. However, persistent sequelae from the spinal cord injury continued to affect the patient, with issues persisting in the motor function of both lower limbs, sensory perception below the navel, and urinary and bowel functions. Unfortunately, these conditions showed no improvement even two years following surgical intervention. Discussion and Conclusions Massive hemoptysis is one of the common acute and critical diseases. The etiology of hemoptysis is complex. It can not only be caused by respiratory diseases, such as bronchiectasis, tuberculosis, lung cancer and pulmonary vascular malformation inflammation, but also by circulatory system and systemic system diseases, Such as mitral stenosis, acute left heart failure, congenital heart disease, leukemia, thrombocytopenic purpura, diffuse intravascular coagulation, immune system diseases, and so on[ 1 ]. Most of the bleeding sites in patients with massive hemoptysis come from bronchial artery, and some also come from subclavian artery branch intercostal artery, etc., and a few come from pulmonary artery branch. The main cause of massive hemoptysis in this patient is bronchiectasis. At present, bronchial artery embolization has become the preferred method for the clinical treatment of massive hemoptysis with various causes[ 2 , 7 ]. With the gradual perfection and maturity of equipment technology and embolization methods, serious complications after embolization have gradually decreased. However, spinal cord injury and posterior circulation infarction are the most serious complications of bronchial artery embolization, especially spinal cord injury, which may cause serious consequences to patients once it occurs. After surgery, the patient developed spinal cord injury and infarction in the occipital lobe and cerebellar hemisphere. The symptoms of cerebral infarction were not significant and quickly recovered, but permanent spinal cord injury remained. Bronchial artery is a vegetative artery with bronchial wall and lung stent structure. It originates from the anterior lateral wall of thoracic aorta at the level of thoracic 5 and thoracic 6 vertebrae [ 8 ]. 90% of the originating locations and numbers of bronchial arteries are in the following 4 situations: 2 branches on the left side, 1 branch on the right (L2R1), 1 branch on the left side, 1 branch on the right (R1L1), and 2 branches on the right side, 1 branch on the left side and the left side together. The left bronchial artery mainly originates from the thoracic aorta, the left intercostal artery, and the right bronchial artery mainly originates from the right intercostal artery, the thoracic aorta, and the right subclavian artery [ 10 ]. Because the right bronchial artery is often homologous with the right intercostal artery, Cauldusell calls it the intercostal bronchial artery. Clinical right bronchial arteriography accompanied by intercostal artery imaging is at risk for a transverse spinal cord injury. There are two sources of blood supply to the spinal cord: the anterior and posterior spinal arteries from the vertebral arteries; The second is the spinal branch from segmental arteries, such as the subclavian artery, intercostal artery, lumbar artery, lateral sacral artery, etc. [ 11 ]. The anterior spinal artery originates from the intracranial portion of the lateral vertebral artery and supplies the anterior 2/3 area of the spinal cord transection. The posterior spinal artery originates from the intracranial part of the ipsilateral vertebral artery and mainly supplies the posterior 1/3 of the spinal cross section. Segmental arteries anastomosed with anterior spinal artery and posterior spinal artery respectively to form arterial coronary surrounding the spinal cord. This coronary artery ring divided small branches to supply the surface structure of the spinal cord, and sent small perforating branches into the spinal cord to supply blood to the peripheral part of the spinal cord parenchyma. According to the characteristics of spinal artery distribution, the segment with the least sufficient circulation was usually located at the junction of two adjacent root artery distribution areas, and T4 and T10 were the most prone to blood insufficiency [ 13 ]. The mechanism of spinal cord injury in this patient may be that the embolization agent causes segmental arterial embolization and blood circulation disturbance through the intercostal artery homologous to the bronchial artery. Meanwhile, the patient was complicated with cerebral infarction in the right occipital lobe and the left cerebellar cerebellum during treatment, and the responsible vessels were the posterior cerebral artery and the anterior superior cerebellar artery, which were posterior circulation infarction. We speculate that the possible mechanism is that the microcatheter may not be deep enough into the bronchial artery, and the injection pressure during embolization is relatively high, which causes gelatin sponge particles to regress through the bronchial artery to the aorta and reach the vertebrobasilar artery system, causing embolization of the posterior cerebral artery and the anterior cerebellar artery. The possibility of embolic particles entering the posterior circulation through the collateral between the bronchi and vertebral arteries is also not ruled out. At the same time, we cannot rule out the possibility of atherosclerotic plaque entering the vertebral artery during surgery, but this possibility is unlikely because the patient is relatively young and has complications from spinal cord injury after surgery. Interventional radiologists performing BAE should be careful to avoid complications of spinal cord injury and posterior circulation infarction, especially brain stem ischemic lesions, due to their poor severity and prognosis. The embolization process should be carried out under the close supervision of DSA, and the catheter should be placed at sufficient depth within the bronchial artery to avoid embolization of other parts caused by embolization into common stem vessels such as intercostal artery and rhizomedullary artery. The pressure of the embolic agent injection should also be appropriate, the speed should be slow, and should not be forced, so as to avoid the occurrence of reflux, resulting in ectopic embolism. Prior to the use of Wada test in bronchial artery embolization, it has been suggested that Wada test combined with evoked potential may provide a repeatable and reversible method to assess the risk of spinal infarction prior to embolization surgery. In order to avoid the occurrence of serious complications of spinal cord injury due to the abnormal origin of the anterior spinal artery, the reflux of fine or invisible spinal artery supplying vessels or embolic substances [ 14 , 15 ]. Abbreviations BAE Bronchial Artery Embolization CT Computed Tomography MRI Magnetic Resonance Imaging Declarations Ethics approval and consent to participate All procedures in this study were approved by the Ethics Committees of Chengdu Jinniu District People’s Hospital. Consent to publish Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials All data and material supporting our findings are contained within the manuscript. Competing interests Tao Xiang, Ming Cheng and Yangling Wu declare that they have no conflict of interest. Funding This article was funded by Chengdu Health Commission (Item No.2024151) Authors' contributions TX and YLW participated in the design of this research. TX, MC, and YLW collected and analyzed the raw clinical data. TX and MC carried out computational studies and wrote the manuscript. All authors have read and approved the final manuscript. Acknowledgement We are grateful to the patient and her family who kindly consented to join the study. Clinical trial number: not applicable References Abdulmalak C,Cottenet J,Beltramo G et al. Haemoptysis in adults: a 5-year study using the French nationwide hospital administrative database.[J]. Eur Respir J. (2015), 46: 503-11. doi: 10.1183/09031936.00218214 Davidson K,Shojaee S. Managing Massive Hemoptysis.[J] . Chest . (2020), 157: 77-88. doi: 10.1016/j.chest.2019.07.012 Kathuria H,Hollingsworth HM,Vilvendhan R et al.Management of life-threatening hemoptysis.[J] . J Intensive Care . (2020), 8: 23. doi: 10.1186/s40560-020-00441-8 Hoffman M,Gerding JP,Zuckerman JB.Stroke and myocardial infarction following bronchial artery embolization in a cystic fibrosis patient.[J] . J Cyst Fibros . (2017), 16: 161-162. doi: 10.1016/j.jcf.2016.11.007 Ishikawa H,Ohbe H,Omachi N et al.Spinal Cord Infarction after Bronchial Artery Embolization for Hemoptysis: A Nationwide Observational Study in Japan.[J] . Radiology.( 2021), 298: 673-679. doi: 10.1148/radiol.2021202500 Park JH,Kim DS,Kwon JS et al.Posterior circulation stroke after bronchial artery embolization.[J] . Neurol Sci. (2012), 33: 923-6. doi: 10.1007/s10072-011-0855-2 Panda A, Bhalla AS, Goyal A.Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol . (2017),23(4):307-317. doi: 10.5152/dir.2017.16454 Cauldwell EW,Siekert RG.The bronchial arteries; an anatomic study of 150 human cadavers.[J] . Surg Gynecol Obstet.( 1948), 86: 395-412. Gade J,Norgaard MA,Andersen CB et al.The porcine bronchial artery: surgical and angiographic anatomy.[J] . J Anat.( 1999): 241-7. doi: 10.1046/j.1469-7580.1999.19420241.x Morita Y,Takase K,Ichikawa H et al.Bronchial artery anatomy: preoperative 3D simulation with multidetector CT.[J] . Radiology. (2010), 255: 934-43. doi: 10.1148/radiol.10081220 Gailloud P.Spinal Vascular Anatomy.[J]. Neuroimaging Clin N Am. ( 2019), 29: 615-633. doi:10.1016/j.nic.2019.07.007 Da Ros V,Picchi E,Ferrazzoli V et al.Spinal vascular lesions: anatomy, imaging techniques and treatment.[J] . Eur J Radiol Open . (2021), 8: 100369. doi: 10.1016/j.ejro.2021.100369 Hashmi SS,van Staalduinen EK,Massoud TF.Anatomy of the Spinal Cord, Coverings, and Nerves.[J] . Neuroimaging Clin N Am. (2022), 32: 903-914. doi:10.1016/j.nic.2022.07.025 Doppman JL, Girton M, Oldfield EH.Spinal Wada test. Radiology .（1986), 161(1):319-21. doi:10.1148/radiology.161.2.3763894 Perchik JD,Perchik JE.The Spinal Wada Test: Adapting a Neurointerventional Technique for Bronchial Artery Embolization.[J] . Cardiovasc Intervent Radiol . (2020), 43: 1731-1732. doi:10.1007/s00270-020-02603-5 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 Apr, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviews received at journal 13 Apr, 2025 Reviewers agreed at journal 13 Apr, 2025 Reviews received at journal 06 Apr, 2025 Reviewers agreed at journal 06 Apr, 2025 Reviewers invited by journal 06 Apr, 2025 Editor invited by journal 13 Mar, 2025 Editor assigned by journal 12 Mar, 2025 Submission checks completed at journal 12 Mar, 2025 First submitted to journal 04 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6153049","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":428196644,"identity":"6d0ad9b6-1cc0-483b-9ad0-9da1d0af589c","order_by":0,"name":"Tao Xiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYBACAwhlw8PP30CSloQ0GckZB0jTctjGoCGBSC3mEskPP7z9cZ7HgOEA44ePOURosZyRZiw5J+E2jzlzA7PkzG3EOOxGgoE0D1CLZcMBNmZe4rSkf/7Nk3COx+BAAtFacsyAthwgQYtlz5syyzlpyTySMw42E+cXc/b0zTfe2NjZ8/M3H/zwkRgtYMADJhkbiFUP1zIKRsEoGAWjAAcAAI3vNP18H/kvAAAAAElFTkSuQmCC","orcid":"","institution":"Chengdu Jinniu District People’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tao","middleName":"","lastName":"Xiang","suffix":""},{"id":428196647,"identity":"8f9d0926-c9b5-4bf1-9096-dddd24d0f7e8","order_by":1,"name":"Ming Cheng","email":"","orcid":"","institution":"Chengdu Jinniu District People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"Cheng","suffix":""},{"id":428196648,"identity":"f851540f-af7e-43bb-b022-0c457da7f475","order_by":2,"name":"Yangling Wu","email":"","orcid":"","institution":"Chengdu Jinniu District People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yangling","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2025-03-04 09:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6153049/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6153049/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78672811,"identity":"ea5a398f-f1eb-4daf-ad9b-7d39dadaf920","added_by":"auto","created_at":"2025-03-17 13:00:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":439108,"visible":true,"origin":"","legend":"\u003cp\u003eChest CT scan showed scattered ground glass density patches in both lungs and flocculent lesions in the left and right bronchi and trachea.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6153049/v1/dd19478a1490c1fb9f4aa5d8.png"},{"id":78671714,"identity":"7be8442b-a5be-42ac-8d69-95baae7da748","added_by":"auto","created_at":"2025-03-17 12:44:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":176621,"visible":true,"origin":"","legend":"\u003cp\u003eMRI performed 1 day after the clinical presentation. A Hyper intense lesions are seen in left the left cerebellar hemisphere on diffusion-weighted image.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6153049/v1/46e1c8b3e311f10c07485f0d.png"},{"id":78671718,"identity":"6ecb1864-d2cf-4894-8abe-b29837f08426","added_by":"auto","created_at":"2025-03-17 12:44:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":218568,"visible":true,"origin":"","legend":"\u003cp\u003eMRI performed 1 day after the clinical presentation. Diffusion-weighted imaging shows a punctate hyperintensity lesion in the right occipital lobe.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6153049/v1/d4965e84f0e78b1c2b10376f.png"},{"id":78671998,"identity":"752ef6c7-b43a-43cc-afce-8000418221e6","added_by":"auto","created_at":"2025-03-17 12:52:39","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":242840,"visible":true,"origin":"","legend":"\u003cp\u003eThoracolumbar MRI revealed long T2 signal shadow in the thoracolumbar spinal cord (approximately thoracolumbar 10 - lumbar 1 vertebral level)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6153049/v1/cc1f103c850a96ba50c6280a.png"},{"id":78672825,"identity":"0df31699-0746-4060-a8d7-bf22bb70b321","added_by":"auto","created_at":"2025-03-17 13:00:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1658970,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6153049/v1/fff41a9e-00b7-4560-80c5-1275fcde96a1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA rare case of spinal cord and posterior circulation infarction after bronchial artery embolization\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere are numerous potential causes of hemoptysis, a dangerous and potentially fatal disorder. According to a prior study, individuals with hemoptysis had a hospital death rate between 8.7\u0026ndash;10.1%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. First-line therapy for hemoptysis that has been well-documented is bronchial artery embolization[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. There have been reports of discomfort, myocardial infarction, spinal cord infarction, and posterior circulation infarction following this surgery[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The most dangerous side effect is spinal cord infarction, which might result in permanently lost function. During bronchial artery embolization, we observed a case with concomitant spinal cord and posterior circulatory infarction, which had not previously been reported.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 56-year-old male with a history of smoking was admitted to hospital with coughing hemoptysis. His hemoptysis in the previous 24 hours exceeded 500ml. Computed Tomography(CT) scans showed scattered ground glass density plaques in both lungs, as well as left and right bronchi and intratracheal flocculation lesions. (Fig.\u0026nbsp;1). On the second day after admission, the patient experienced massive hemoptysis again despite anti-infection and medical hemostasis treatment. Following an evaluation, the patient received bronchial arteriography and embolization. The right femoral artery was punctured and a 5F catheter was inserted into the aortic arch and bronchial artery under local anesthetic. Angiography revealed two bronchial arteries in the left lung and one in the right lung. The artery arteries were twisted, and the wall was rough.\u003c/p\u003e \u003cp\u003eAt the distal end of the bronchial artery branch opening, embolization was performed with 500-700um and 700-900um embolization microspheres. The patient developed weakness in both lower limbs immediately after surgery, accompanied by dizziness, urine retention, and decreased sensation below the nipple level. Neurological examination showed that the patient's cognition and language were normal, the fingernose test and the rotation test were negative, the superficial sensation (pain, temperature and touch) below the level of the nipple disappeared, the deep sensation disappeared, the lower limb muscle strength was grade 0, the bilateral tendon reflex disappeared, and the bilateral pathological signs were negative. Head Magnetic Resonance Imaging(MRI)showed a patchy acute infarction in the left cerebellar hemisphere and a spotty acute infarction in the right occipital lobe (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Figuer3), and thoracolumbar MRI revealed long, lamellar T2 signal shadow in the thoracolumbar spinal cord (approximately thoracolumbar 10-lumbar 1 vertebral level) with unknown nature (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The patient was diagnosed with spinal cord injury, according to the American Spinal Cord Injury Association grading criteria, the patient's spinal cord injury level was T10 and the degree was grade A, that is, complete spinal cord injury. Based on the head MRI findings, it was also diagnosed as acute cerebral infarction in the right occipital lobe and left cerebellum. The patient underwent a comprehensive treatment regimen that included pharmacological interventions with medications such as hormones and mannitol. These were administered to alleviate spinal edema, promote vasodilation, and enhance circulation. Additionally, neurotrophic support was provided. Complementary to the drug therapy, the patient also received rehabilitative treatments, which encompassed acupuncture, electrical stimulation, and therapeutic exercises, aimed at facilitating recovery and functional improvement. Within two weeks, the patient's dizziness had fully resolved, and there were no signs of ataxia or motor sensory disturbances in the upper limbs. Advanced brain functions, including speech and cognitive abilities, remained intact without any observed deficits. However, persistent sequelae from the spinal cord injury continued to affect the patient, with issues persisting in the motor function of both lower limbs, sensory perception below the navel, and urinary and bowel functions. Unfortunately, these conditions showed no improvement even two years following surgical intervention.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Discussion and Conclusions","content":"\u003cp\u003eMassive hemoptysis is one of the common acute and critical diseases. The etiology of hemoptysis is complex. It can not only be caused by respiratory diseases, such as bronchiectasis, tuberculosis, lung cancer and pulmonary vascular malformation inflammation, but also by circulatory system and systemic system diseases, Such as mitral stenosis, acute left heart failure, congenital heart disease, leukemia, thrombocytopenic purpura, diffuse intravascular coagulation, immune system diseases, and so on[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Most of the bleeding sites in patients with massive hemoptysis come from bronchial artery, and some also come from subclavian artery branch intercostal artery, etc., and a few come from pulmonary artery branch. The main cause of massive hemoptysis in this patient is bronchiectasis.\u003c/p\u003e\u003cp\u003eAt present, bronchial artery embolization has become the preferred method for the clinical treatment of massive hemoptysis with various causes[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. With the gradual perfection and maturity of equipment technology and embolization methods, serious complications after embolization have gradually decreased. However, spinal cord injury and posterior circulation infarction are the most serious complications of bronchial artery embolization, especially spinal cord injury, which may cause serious consequences to patients once it occurs. After surgery, the patient developed spinal cord injury and infarction in the occipital lobe and cerebellar hemisphere. The symptoms of cerebral infarction were not significant and quickly recovered, but permanent spinal cord injury remained.\u003c/p\u003e\u003cp\u003eBronchial artery is a vegetative artery with bronchial wall and lung stent structure. It originates from the anterior lateral wall of thoracic aorta at the level of thoracic 5 and thoracic 6 vertebrae [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. 90% of the originating locations and numbers of bronchial arteries are in the following 4 situations: 2 branches on the left side, 1 branch on the right (L2R1), 1 branch on the left side, 1 branch on the right (R1L1), and 2 branches on the right side, 1 branch on the left side and the left side together. The left bronchial artery mainly originates from the thoracic aorta, the left intercostal artery, and the right bronchial artery mainly originates from the right intercostal artery, the thoracic aorta, and the right subclavian artery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Because the right bronchial artery is often homologous with the right intercostal artery, Cauldusell calls it the intercostal bronchial artery. Clinical right bronchial arteriography accompanied by intercostal artery imaging is at risk for a transverse spinal cord injury.\u003c/p\u003e\u003cp\u003eThere are two sources of blood supply to the spinal cord: the anterior and posterior spinal arteries from the vertebral arteries; The second is the spinal branch from segmental arteries, such as the subclavian artery, intercostal artery, lumbar artery, lateral sacral artery, etc. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The anterior spinal artery originates from the intracranial portion of the lateral vertebral artery and supplies the anterior 2/3 area of the spinal cord transection. The posterior spinal artery originates from the intracranial part of the ipsilateral vertebral artery and mainly supplies the posterior 1/3 of the spinal cross section. Segmental arteries anastomosed with anterior spinal artery and posterior spinal artery respectively to form arterial coronary surrounding the spinal cord. This coronary artery ring divided small branches to supply the surface structure of the spinal cord, and sent small perforating branches into the spinal cord to supply blood to the peripheral part of the spinal cord parenchyma. According to the characteristics of spinal artery distribution, the segment with the least sufficient circulation was usually located at the junction of two adjacent root artery distribution areas, and T4 and T10 were the most prone to blood insufficiency [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe mechanism of spinal cord injury in this patient may be that the embolization agent causes segmental arterial embolization and blood circulation disturbance through the intercostal artery homologous to the bronchial artery. Meanwhile, the patient was complicated with cerebral infarction in the right occipital lobe and the left cerebellar cerebellum during treatment, and the responsible vessels were the posterior cerebral artery and the anterior superior cerebellar artery, which were posterior circulation infarction. We speculate that the possible mechanism is that the microcatheter may not be deep enough into the bronchial artery, and the injection pressure during embolization is relatively high, which causes gelatin sponge particles to regress through the bronchial artery to the aorta and reach the vertebrobasilar artery system, causing embolization of the posterior cerebral artery and the anterior cerebellar artery. The possibility of embolic particles entering the posterior circulation through the collateral between the bronchi and vertebral arteries is also not ruled out. At the same time, we cannot rule out the possibility of atherosclerotic plaque entering the vertebral artery during surgery, but this possibility is unlikely because the patient is relatively young and has complications from spinal cord injury after surgery.\u003c/p\u003e\u003cp\u003eInterventional radiologists performing BAE should be careful to avoid complications of spinal cord injury and posterior circulation infarction, especially brain stem ischemic lesions, due to their poor severity and prognosis. The embolization process should be carried out under the close supervision of DSA, and the catheter should be placed at sufficient depth within the bronchial artery to avoid embolization of other parts caused by embolization into common stem vessels such as intercostal artery and rhizomedullary artery. The pressure of the embolic agent injection should also be appropriate, the speed should be slow, and should not be forced, so as to avoid the occurrence of reflux, resulting in ectopic embolism. Prior to the use of Wada test in bronchial artery embolization, it has been suggested that Wada test combined with evoked potential may provide a repeatable and reversible method to assess the risk of spinal infarction prior to embolization surgery. In order to avoid the occurrence of serious complications of spinal cord injury due to the abnormal origin of the anterior spinal artery, the reflux of fine or invisible spinal artery supplying vessels or embolic substances [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBAE Bronchial Artery Embolization\u003c/p\u003e\n\u003cp\u003eCT Computed Tomography\u003c/p\u003e\n\u003cp\u003eMRI Magnetic Resonance Imaging\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures in this study were approved by the Ethics Committees of Chengdu Jinniu District People\u0026rsquo;s Hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data and material supporting our findings are contained within the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTao Xiang, Ming Cheng and Yangling Wu declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article was funded by Chengdu Health Commission (Item No.2024151)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTX and YLW participated in the design of this research. TX, MC, and YLW collected and analyzed the raw clinical data. TX and MC carried out computational studies and wrote the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the patient and her family who kindly consented to join the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: not applicable\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbdulmalak C,Cottenet J,Beltramo G et al. Haemoptysis in adults: a 5-year study using the French nationwide hospital administrative database.[J]. \u003cem\u003eEur Respir J.\u003c/em\u003e (2015), 46: 503-11. doi: 10.1183/09031936.00218214\u003c/li\u003e\n\u003cli\u003eDavidson K,Shojaee S. Managing Massive Hemoptysis.[J] .\u003cem\u003eChest\u003c/em\u003e. (2020), 157: 77-88. doi: 10.1016/j.chest.2019.07.012\u003c/li\u003e\n\u003cli\u003eKathuria H,Hollingsworth HM,Vilvendhan R et al.Management of life-threatening hemoptysis.[J] .\u003cem\u003eJ Intensive Care\u003c/em\u003e. (2020), 8: 23. doi: 10.1186/s40560-020-00441-8\u003c/li\u003e\n\u003cli\u003eHoffman M,Gerding JP,Zuckerman JB.Stroke and myocardial infarction following bronchial artery embolization in a cystic fibrosis patient.[J] .\u003cem\u003eJ Cyst Fibros\u003c/em\u003e. (2017), 16: 161-162. doi: 10.1016/j.jcf.2016.11.007 \u003c/li\u003e\n\u003cli\u003eIshikawa H,Ohbe H,Omachi N et al.Spinal Cord Infarction after Bronchial Artery Embolization for Hemoptysis: A Nationwide Observational Study in Japan.[J] .\u003cem\u003eRadiology.(\u003c/em\u003e 2021), 298: 673-679. doi: 10.1148/radiol.2021202500\u003c/li\u003e\n\u003cli\u003ePark JH,Kim DS,Kwon JS et al.Posterior circulation stroke after bronchial artery embolization.[J] .\u003cem\u003eNeurol Sci.\u003c/em\u003e (2012), 33: 923-6. doi: 10.1007/s10072-011-0855-2\u003c/li\u003e\n\u003cli\u003ePanda A, Bhalla AS, Goyal A.Bronchial artery embolization in hemoptysis: a systematic review. \u003cem\u003eDiagn Interv Radiol\u003c/em\u003e. (2017),23(4):307-317. doi: 10.5152/dir.2017.16454\u003c/li\u003e\n\u003cli\u003eCauldwell EW,Siekert RG.The bronchial arteries; an anatomic study of 150 human cadavers.[J] .\u003cem\u003eSurg Gynecol Obstet.(\u003c/em\u003e1948), 86: 395-412.\u003c/li\u003e\n\u003cli\u003eGade J,Norgaard MA,Andersen CB et al.The porcine bronchial artery: surgical and angiographic anatomy.[J] .\u003cem\u003eJ Anat.(\u003c/em\u003e1999): 241-7. doi: 10.1046/j.1469-7580.1999.19420241.x\u003c/li\u003e\n\u003cli\u003eMorita Y,Takase K,Ichikawa H et al.Bronchial artery anatomy: preoperative 3D simulation with multidetector CT.[J] .\u003cem\u003eRadiology. \u003c/em\u003e(2010), 255: 934-43. doi: 10.1148/radiol.10081220\u003c/li\u003e\n\u003cli\u003eGailloud P.Spinal Vascular Anatomy.[J]. \u003cem\u003eNeuroimaging Clin N Am. (\u003c/em\u003e2019), 29: 615-633. doi:10.1016/j.nic.2019.07.007\u003c/li\u003e\n\u003cli\u003eDa Ros V,Picchi E,Ferrazzoli V et al.Spinal vascular lesions: anatomy, imaging techniques and treatment.[J] .\u003cem\u003eEur J Radiol Open\u003c/em\u003e. (2021), 8: 100369. doi: 10.1016/j.ejro.2021.100369\u003c/li\u003e\n\u003cli\u003eHashmi SS,van Staalduinen EK,Massoud TF.Anatomy of the Spinal Cord, Coverings, and Nerves.[J] .\u003cem\u003eNeuroimaging Clin N Am.\u003c/em\u003e (2022), 32: 903-914. doi:10.1016/j.nic.2022.07.025 \u003c/li\u003e\n\u003cli\u003eDoppman JL, Girton M, Oldfield EH.Spinal Wada test. \u003cem\u003eRadiology\u003c/em\u003e.（1986), 161(1):319-21. doi:10.1148/radiology.161.2.3763894\u003c/li\u003e\n\u003cli\u003ePerchik JD,Perchik JE.The Spinal Wada Test: Adapting a Neurointerventional Technique for Bronchial Artery Embolization.[J] .\u003cem\u003eCardiovasc Intervent Radiol\u003c/em\u003e. (2020), 43: 1731-1732. doi:10.1007/s00270-020-02603-5\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bronchial artery embolization, Spinal cord infarction, Posterior circulation infarction, Hemoptysis, Complications","lastPublishedDoi":"10.21203/rs.3.rs-6153049/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6153049/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eBronchial artery embolization (BAE) is a first-line therapy for massive hemoptysis. However, spinal cord and posterior circulation infarction are rare but severe complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation: \u003c/strong\u003eA 56-year-old male with bronchiectasis presented with recurrent hemoptysis (\u0026gt;500 mL/24h). BAEwas performed using microspheres (500-900μm). Postoperatively, he developed paraplegia, urinary retention, and posterior circulation infarctions (right occipital lobe and left cerebellum).Despite rehabilitation, lower limb motor and sensory deficits persisted at 2-year follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eThis case highlights the risk of dual spinal and cerebral infarction post-BAE. Interventional radiologists must meticulously avoid embolizing spinal collaterals and monitor injection pressure to prevent reflux. Preoperative spinal artery mapping (e.g., Wada test) may reduce complications.\u003c/p\u003e","manuscriptTitle":"A rare case of spinal cord and posterior circulation infarction after bronchial artery embolization","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-17 12:44:34","doi":"10.21203/rs.3.rs-6153049/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-04-17T16:15:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157010231956887442768805169011224588706","date":"2025-04-17T15:28:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-13T13:31:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113337470128173942852914260002209702387","date":"2025-04-13T13:02:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-06T18:37:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310856685414670853695303414339625359380","date":"2025-04-06T18:02:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-06T17:23:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-13T07:27:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-12T06:43:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-12T06:40:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-03-04T09:24:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f90300c-28e1-4920-9757-9c933780f72d","owner":[],"postedDate":"March 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T12:44:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-17 12:44:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6153049","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6153049","identity":"rs-6153049","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}