Spinal cord infarction with multiple etiologic factors

Sildenafil-induced spinal cord infarction: a case report

Spinal cord infarction is a rare condition, accounting for only a small percentage of strokes. It can be classified into cervical and thoracolumbar infarctions, with various factors contributing to its occurrence. Sildenafil, a phosphodiesterase type 5 inhibitor commonly used for erectile dysfunction, has been associated with cardiovascular side effects, including transient hypotension. In this case report, we present the unusual occurrence of spinal cord infarction in a 65-year-old man who had self-administered high doses of sildenafil without a doctor's prescription. The patient experienced severe radicular pain in the lumbar region and subsequent weakness in the lower limbs. Evaluation revealed an anterior spinal cord infarction in the thoracic region, confirmed by MRI imaging. After excluding other potential causes, it was concluded that the intake of sildenafil likely led to systemic hypotension, resulting in spinal cord infarction. This case highlights the importance of considering sildenafil as a possible contributor to spinal cord infarction, particularly when used at high doses. Further studies are needed to better understand the relationship between sildenafil and vascular complications, including spinal cord infarction.

Critical illness-associated weakness and related motor disorders

Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.

Acute aortic occlusion leading to spinal cord ischemia in a 73-year-old: A case report

Background

Cauda equina syndrome (CES) is typically caused by a compressive etiology from a herniated disk, tumor, or fracture of the spine compressing the thecal sac. Here, we report a CES mimic - acute aortic occlusion (AAO), a rare disease that is associated with high morbidity and mortality. AAO can compromise spinal cord blood supply and leads to spinal cord ischemia.

Case Description

Our patient presented with an acute onset of bilateral lower extremity pain and weakness with bowel/bladder incontinence, a constellation of symptoms concerning for CES. However, on initial imaging, there was no compression of his thecal sac to explain his symptomology. Further, investigation revealed an AAO. The patient underwent an emergent aortic thrombectomy with resolution of symptoms.

Conclusion

AAO can mimic CES and should be considered in one's differential diagnosis when imaging is negative for any spinal compressive etiologies.

Fibrocartilagenous embolism case series: is it a zebra?

INTRODUCTION

There have been 30 clinically suspected cases and 41 histopathologically confirmed cases of fibrocartilaginous embolism (FCE) reported in the literature. FCE often has a poor prognosis and is estimated to represent 5.5% of spinal cord infarctions, but may be more common than initially presumed given underdiagnosis due to its vague clinical presentation.

CASE PRESENTATION

We report two cases, a 15-year-old male and a 15-year-old female, whose clinical history, examination, and imaging findings were consistent with spinal cord infarction secondary to FCE.

DISCUSSION

These cases were unique given our patients' neurologic improvement; however, the commonly held assumption of poor prognosis may in part be fueled by the preferential case ascertainment via biopsy on autopsy. These cases highlight the importance of recognizing rare causes of spinal cord pathology and considering FCE in the differential diagnosis of acute myelopathy.

Spinal cord infarction in a young patient with methamphetamine abuse

We report a case of a 20-year-old man who was diagnosed with spontaneous spinal cord infarction after abusing methamphetamine for a year. He presented with sudden onset of bilateral upper and lower limb weakness. His MRI spine showed a long segment of high signal intensity seen predominantly in the anterior spinal cord from medulla to mid thoracic level as well as a pencil-like hyperintensity seen postcontrast suggestive of spinal cord ischaemia or infarct. Thus, he was empirically treated for presumed anterior spinal cord infarction. He then developed autonomic dysfunction and went into respiratory distress, which required invasive mechanical ventilation support. Subsequently, he developed cardiac arrythmia with supraventricular tachycardiac followed by asystole and succumbed to illness on day 9 despite maximal resuscitative efforts. This case report illustrates a rare spinal cord infarction caused by methamphetamine intoxication and the importance of identifying and treating it early.

The casual association of cervical spinal cord ischemia and axonal degeneration in second motor neuron following subarachnoid hemorrhage: Experimental study

AIM

Muscle abnormalities after spinal cord ischemia caused by subarachnoid hemorrhage (SAH) have not been explored for degenerative variations in the soma of second motor neurons of the spinal cord gray matter. This study aimed to investigate histopathological alterations in the gray matter and the role of peripheral nerves in SAH.

MATERIAL AND METHODS

Twenty-two rabbits were allocated in the control (Group I, n = 5), SHAM (Group II, n = 5), and research (Group III, n = 12) groups. Muscle weakness of the upper extremities innervated by radial nerves was evaluated at the initial day, and outcomes were recorded as control data. Re-measurements were done after injecting 0.5 ml of SF for SHAM and autolog artery blood inside craniocervical subarachnoid space for the study group. After 3 weeks, radial nerve roots, their ganglia, and segments of the spinal cord around C5-6 root entry zones were extracted bilaterally. Degenerated second motor neuron somas and the degenerated radial nerve motor axons at the intervertebral foramen were assessed.

RESULTS

The average degenerated soma intensity/mm³ at the C5-6 levels in the spinal cord was 2 ± 1/mm³, 13 ± 4/mm³, and 56 ± 10/mm³ for Groups I, II, and Group III. The average degenerated axon intensity of radial nerves was 3 ± 1/mm², 34 ± 9/mm², and 234 ± 78/mm² for Groups I, II, and III.

CONCLUSION

Gray matter ischemia in the spinal cord may lead to axonal deterioration on equal levels at the peripheral nerves with advanced SAH. Detected or undetected spinal SAH should be considered an important factor on the etiology of second motor neuron diseases.

Influence of Diabetes Mellitus on Surgical Outcomes in Patients with Cervical Myelopathy: A Prospective, Multicenter Study

Study Design

Multicenter, prospective study.

Purpose

To investigate the effects of diabetes mellitus (DM) on surgical outcomes in patients with cervical myelopathy.

Overview of Literature

To date, few studies have investigated the influence of postoperative blood glucose or glycated hemoglobin (HbA1c) levels on surgical outcomes.

Methods

The participants were patients who underwent surgery for the treatment of cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. The 61 cases were evaluated preoperatively and 1 year postoperatively using the Japanese Orthopaedic Association (JOA) scores and the JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ). The study variables included fasting blood glucose and HbA1c levels measured preoperatively and at 1 week, 4 weeks, and 1 year postoperatively; the F-wave conduction velocity, latency, rate of occurrence, and M-wave latency in the ulnar and tibial nerves were measured preoperatively and at 1 year postoperatively. The patients were divided into a group without diabetes (N group, 42 patients) and a group with diabetes (DM group, 19 patients). We then assessed the associations between the surgical outcomes and each of the study variables.

Results

JOA scores significantly improved in both groups; however, no significant between-group differences were found. There was no significant improvement in the JOACMEQ scores, which assessed cervical function, upper and lower limb function, and bladder function in both groups. We then subdivided the DM group into those with a good control of HbA1c after 1 year (DMG group, 12 patients) and those with HbA1c deterioration after 1 year (DMB group, seven patients), prior to comparing the surgical outcomes. The JOACMEQ scores for upper and lower limb function significantly improved in the DMG group (p<0.01). Compared with the DMB group, there were no significant increases in upper or lower limb function scores in the DMG group.

Conclusions

Poor glycemic control might prevent postoperative functional recovery of the spinal cord.

Spinal cord infarction at the level of ossification of the posterior longitudinal ligament

INTRODUCTION

We report a case of acute tetraplegia, without any trauma or symptoms prior to onset, who presented with ossification of the posterior longitudinal ligament (OPLL) in the cervical spine with concomitant spinal cord infarction.

CASE PRESENTATION

A 64-year-old man with a number of risk factors for vascular disease was admitted to our hospital with progressive motor weakness in the bilateral upper and lower extremities. He had initially felt numbness in his left upper extremity and had no previous neurological symptoms or trauma. The night after the initial symptoms, he developed spastic tetraplegia requiring respiratory support. Computed tomography images of the cervical spine demonstrated the segmental type of OPLL. Spinal cord compression and signal intensity changes were identified at the level of C3/4 on magnetic resonance imaging (MRI). He underwent emergency surgery consisting of posterior decompression with laminoplasty of C3-6. Despite the surgery, the patient's tetraplegia did not improve and he continued to require respirator support. There was still no improvement in his neurological status at 10 days postoperatively, and MRI demonstrated evidence of marked spinal cord infarction.

DISCUSSION

Mechanical compression of spinal arteries by OPLL and pre-existing vascular compromise had a role in the pathogenesis of spinal cord infarction. Chronic spinal compression may be characterized by 3 important factors, namely an uncommonly devastating clinical course, vascular risk factors and persistent findings on MRI, and these might lead to early diagnosis of spinal cord infarction.

Current and emerging treatment options for spinal cord ischemia

Spinal cord infarction (SCI) is a rare but disabling disorder caused by a wide spectrum of conditions. Given the lack of randomized-controlled trials, contemporary treatment concepts are adapted from guidelines for cerebral ischemia, atherosclerotic vascular disease, and acute traumatic spinal cord injury. In addition, patients with SCI are at risk for several potentially life-threatening but preventable systemic and neurologic complications. Notably, there is emerging evidence from preclinical studies for the use of neuroprotection in acute ischemic injury of the spinal cord. In this review, we discuss the current state of the art for the therapy and prevention of SCI and highlight potential emerging treatment concepts awaiting translational adoption.

Transient Ischemic Attacks of Spinal Cord due to Abdominal Aortic Aneurysm Thrombus

Thrombosis due to abdominal aortic aneurysm is a rare condition that causes high mortality. Transient ischemic attack of the spinal cord can occur as a result of trash emboli from thrombus in abdominal aortic aneurysm. This condition generally occurs during operation of abdominal aortic aneurysm; very rarely, it can also be seen in laminated abdominal aortic aneurysm. Here, we present a case of a patient presenting with bilateral lower extremity paralysis resulting from transient ischemic attack of the spinal cord due to infrarenal abdominal aortic aneurysm.

A 19-year-old man with sickle cell disease presenting with spinal infarction: a case report

INTRODUCTION

Vasculopathy of the large vessels commonly occurs in sickle cell disease, and as a result cerebral infarction is a well characterized complication of this condition. However, spinal infarction appears to be rare. Spinal infarct is infrequent in the non-sickle cell population as well, and accounts for only about 1 percent of all central nervous system infarcts.

CASE PRESENTATION

In the present work, we report the case of a 19-year-old African-American man with sickle cell disease who experienced an anterior spinal infarct and subsequent quadriplegia. He was incidentally noted to be a heterozygote for factor V Leiden. We also reviewed the literature and found two previous cases of spinal cord infarction and sickle hemoglobin. Our literature search did not demonstrate that heterozygocity for factor V Leiden plays an important role in spinal cord infarction.

CONCLUSIONS

The paucity of cases associated with sickle hemoglobin does not allow us to postulate any particular risk factors with sickle cell disease that might predispose patients to spinal cord infarction. Our patient's case raises the question as to whether spinal cord infarction is being missed in individuals with sickle cell disease and neurologic symptoms.

Spinal cord infarction in diabetic pregnancy: a case report

Spinal cord infarction (SCI) is uncommon as compared to cerebral stroke. Moreover, SCI during pregnancy is rare. Here, we report a case of SCI in diabetic pregnancy, properly diagnosed, promptly treated, and a good prognosis achieved. A 38-year-old, pregnant woman, para 1, with type 1 diabetes mellitus on insulin since 14 years of age, was admitted to our hospital for paresthesia and numbness in the lower left side of the body, with movement disturbances. On the basis of the temporal profile of the onset and the multiple resonance imaging scans, SCI was diagnosed. Steroid pulse therapy and low-dose aspirin administration was initiated. Her symptoms were improved and discharged. A repeat cesarean section was performed at 37 weeks of gestation and her postoperative course was uneventful. Her daily activities were not hindered severely, though she experienced defecation discomfort.

Lower motor neuron findings after upper motor neuron injury: insights from postoperative supplementary motor area syndrome

Hypertonia and hyperreflexia are classically described responses to upper motor neuron injury. However, acute hypotonia and areflexia with motor deficit are hallmark findings after many central nervous system insults such as acute stroke and spinal shock. Historic theories to explain these contradictory findings have implicated a number of potential mechanisms mostly relying on the loss of descending corticospinal input as the underlying etiology. Unfortunately, these simple descriptions consistently fail to adequately explain the pathophysiology and connectivity leading to acute hyporeflexia and delayed hyperreflexia that result from such insult. This article highlights the common observation of acute hyporeflexia after central nervous system insults and explores the underlying anatomy and physiology. Further, evidence for the underlying connectivity is presented and implicates the dominant role of supraspinal inhibitory influence originating in the supplementary motor area descending through the corticospinal tracts. Unlike traditional explanations, this theory more adequately explains the findings of postoperative supplementary motor area syndrome in which hyporeflexia motor deficit is observed acutely in the face of intact primary motor cortex connections to the spinal cord. Further, the proposed connectivity can be generalized to help explain other insults including stroke, atonic seizures, and spinal shock.

MRI of cervical spinal cord infarction in a patient with sickle cell disease

We report a patient with sickle cell disease who developed spinal cord ischemia. Initial conventional magnetic resonance imaging (MRI) was unremarkable, but diffusion-weighted imaging showed restricted diffusion in the cervical spinal cord. Follow-up MRI performed 3 days later showed development of findings on conventional images that confirmed the infarction.

Spontaneous conus medullaris infarction in a 79 year-old female with cardiovascular risk factors: a case report

OBJECTIVE

To detail the case of a 79 year-old female who presented with sudden bilateral neurological deficits of the lower extremities and was later diagnosed with non-traumatic conus medullaris infarction. The purpose of this case report is to inform primary contact practitioners of the presentation, diagnosis and the associated risk factors of this condition in order to facilitate prompt management.

CLINICAL FEATURES

Spinal cord infarction presenting as low back pain with a high degree of bilateral loss of motor strength, sensation and reflexes in the lower extremities and bowel/bladder dysfunction, in a patient with previous coronary artery bypass graft surgery and renal insufficiency.

INTERVENTION AND OUTCOME

Referral to emergency within hours of symptom onset allowed for immediate assessment, management and relatively favourable partial recovery.

SUMMARY

Although rare, conus medullaris infarction is potentially devastating and requires an appropriate clinical index of suspicion for timely diagnosis, treatment and optimal neurological recovery.

Sildenafil-induced cervical spinal cord infarction

We present a patient with an acute cervical spinal cord infarction resulting from the use of sildenafil (Viagra) in combination with his hypertension medication. Symptoms were acute and rapidly progressive, and MR imaging with DWI was crucial in confirming the diagnosis.

Scholarship opportunities for trainees and clinician educators: learning outcomes from a case report writing workshop

INTRODUCTION

Publishing a case report demonstrates scholarly productivity for trainees and clinician-educators.

AIM

To assess the learning outcomes from a case report writing workshop.

SETTING

Medical students, residents, fellows and clinician-educators attending a workshop.

PROGRAM DESCRIPTION

Case report writing workshop conducted nine times at different venues.

PROGRAM EVALUATION

Before and after each workshop, participants self-rated their perceived competence to write a case report, likelihood of submitting a case report to a meeting or for publication in the next 6-12 months, and perceived career benefit of writing a case report (on a five-point Likert scale). The 214 participants were from 3 countries and 27 states or provinces; most participants were trainees (64.5 %). Self-rated competence for writing a case report improved from a mean of 2.5 to 3.5 (a 0.99 increase; 95% CI, 0.88-1.12, p < 0.001). The perceived likelihood of submitting a case report, and the perceived career benefit of writing one, also showed statistically significant improvements (p = 0.002, p = 0.001; respectively). Nine of 98 participants published a case report 16-41 months after workshop completion.

DISCUSSION

The workshop increased participants' perception that they could present or publish a case report.

Anterior spinal cord syndrome after initiation of treatment with atenolol

Anterior spinal cord syndrome is a rare condition with a variety of precipitating factors. Patients typically complain of weakness or paralysis of the extremities, often accompanied by pain, but frequently without a history of trauma. A 48-year-old man presented to the emergency department complaining of neck pain and inability to move his legs in the absence of trauma. Several hours prior he had seen his private physician and was given a dose of atenolol for elevated blood pressure. He had not previously been on medications for hypertension. His neurological examination revealed bilateral paralysis of the lower extremities. In the upper extremities he had weakness and sensory loss at the level of C6. Rectal tone was decreased and without sensation. Cervical and thoracic spine magnetic resonance imaging showed spondylotic disc disease, with disc herniation at C6-7 causing severe spinal canal stenosis. Despite i.v. methylprednisolone, pressors, and a prolonged intensive care unit course, the patient was discharged 5 weeks later with continued neurological deficits. Anterior spinal cord syndrome results from compression of the anterior spinal artery and often occurs in the absence of traumatic injury. The recognition, management, and prognosis of this condition are discussed.