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Saffarini L, Aboelkher R, Sabobeh N, Abdelfattah T, Naji M. Spinal Cord Infarction: Access Site Complication of Femoral Artery Percutaneous Coronary Intervention. Cureus 2024; 16:e60666. [PMID: 38899271 PMCID: PMC11186398 DOI: 10.7759/cureus.60666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Spinal cord infarction (SCI) is an uncommon vascular syndrome that leads to neurologic abnormalities with multiple implicated causes. Percutaneous coronary intervention (PCI) is a non-surgical invasive procedure used to relieve an arterial occlusion or narrowing that causes ischemia to the heart. This is usually performed by different methods and different arterial access sites. Here, we present a case of a patient who developed bilateral lower limb weakness eight days after a femoral artery PCI and was diagnosed with SCI. This case report aims to document a rare complication and highlight the most important demographic, investigation, management, risk factors, and prognosis data available in the literature.
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Jadhav AP. Vascular Myelopathies. Continuum (Minneap Minn) 2024; 30:160-179. [PMID: 38330477 DOI: 10.1212/con.0000000000001378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Vascular injuries of the spinal cord are less common than those involving the brain; however, they can be equally devastating. This article discusses the diagnosis and management of ischemic and hemorrhagic vascular disorders of the spinal cord. LATEST DEVELOPMENTS Clinical suspicion remains the mainstay for recognizing vascular myelopathies, yet diagnoses are often delayed and challenging in part because of their rarity and atypical manifestations. Noninvasive imaging such as CT and MRI continues to improve in spatial resolution and diagnostic precision; however, catheter-based spinal angiography remains the gold standard for defining the spinal angioarchitecture. In addition to hemorrhagic and ischemic disease, the contribution of venous dysfunction is increasingly appreciated and informs treatment strategies in conditions such as intracranial hypotension. ESSENTIAL POINTS Vascular disorders of the spine manifest in variable and often atypical ways, which may lead to delayed diagnosis. Increased awareness of these conditions is critical for early recognition and treatment. The goal of treatment is to minimize long-term morbidity and mortality.
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Kwak SY, Boudier-Revéret M, Chang MC. Differential diagnosis of suddenly developed motor weakness in bilateral lower extremities of a 79-year-old male patient. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2023; 40:457-460. [PMID: 36617703 PMCID: PMC10626293 DOI: 10.12701/jyms.2022.00787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/01/2022] [Accepted: 11/05/2022] [Indexed: 06/17/2023]
Affiliation(s)
- Seong Yeob Kwak
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
| | - Mathieu Boudier-Revéret
- Department of Physical Medicine and Rehabilitation, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
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Zhang QY, Xu LY, Wang ML, Cao H, Ji XF. Spontaneous conus infarction with "snake-eye appearance" on magnetic resonance imaging: A case report and literature review. World J Clin Cases 2023; 11:2074-2083. [PMID: 36998945 PMCID: PMC10044943 DOI: 10.12998/wjcc.v11.i9.2074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/27/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Infarction of the conus medullaris is a rare form of spinal cord infarction. The first symptom is usually acute non-characteristic lumbar pain, followed by lower limb pain, saddle numbness, fecal incontinence, and sexual dysfunction. Spontaneous conus infarction with "snake-eye appearance" on magnetic resonance imaging has rarely been reported.
CASE SUMMARY We report a 79-year-old male patient with spontaneous conus infarction who had acute lower extremity pain and dysuria as the first symptoms. He did not have any recent history of aortic surgery and trauma. Magnetic resonance imaging revealed a rare "snake-eye appearance." In addition, we reviewed the literature on 23 similar cases and summarized the clinical features and magnetic resonance manifestations of common diseases related to the "snake-eye sign" to explore the etiology, imaging findings, and prognosis of spontaneous conus infarction.
CONCLUSION We conclude that acute onset of conus medullaris syndrome combined with "snake-eye appearance" should be strongly suspected as conus medullaris infarction caused by anterior spinal artery ischemia. This special imaging manifestation is helpful in the early diagnosis and treatment of conus infarction.
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Affiliation(s)
- Qiao-Yu Zhang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
- Department of Neurology, Nanchuan People's Hospital Affiliated to Chongqing Medical University, Chongqing 408400, China
| | - Lin-Ying Xu
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Ming-Li Wang
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Hua Cao
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Xiao-Fei Ji
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
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Puente-Hernandez M, Rivero-de-Aguilar A, Varela-Lema L. Cancer-associated spinal cord infarction: A systematic review and analysis of survival predictors. J Neurol Sci 2023; 446:120580. [PMID: 36764185 DOI: 10.1016/j.jns.2023.120580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/09/2022] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The association between spinal cord infarction (SCI) and cancer is an infrequent condition but requires an accurate diagnosis to establish the appropriate treatment. Clinical features and prognosis of cancer-associated SCI have never been assessed. The aim of this systematic review is to describe the characteristics and outcomes of patients with cancer-associated SCI. Illustratively, a case of ovarian cancer-related SCI is presented. MATERIAL AND METHODS Two authors independently analysed three different bibliographic databases looking for cancer-associated SCI case reports and case series. Data regarding age, sex, cardiovascular risk factors (CVRF), history of known cancer, infarction localization, spinal cord syndrome, Zalewski criteria classification, mechanism of ischemia, diagnostic tests, treatment and functional outcome were registered. A statistical analysis was carried out to identify factors related to mortality and survival time. RESULTS A total of 48 articles met the inclusion criteria and 52 patients were identified. The median age was 62 years. The most frequent neoplasm was intravascular large B-cell lymphoma. The median survival time was 17.4 weeks and the cumulative probability of survival at 12 months was 16.3%. In the group of deceased patients there was a higher proportion of malignant neoplasms than in those who survived (94.7% vs. 5.3%, p < 0.01). There were no statistically significant differences in terms of mortality or survival time depending on age, previously known cancer or CVRF. CONCLUSION Cancer-associated SCI entails a poor outcome. Mortality is increased in patients with malignant neoplasm. No other prognosis factors could be identified.
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Affiliation(s)
| | - Alejandro Rivero-de-Aguilar
- Department of Neurology, University Hospital of the Canary Islands, carretera Ofra S/N, La Laguna, Tenerife, Spain
| | - Leonor Varela-Lema
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Praza do Obradoiro, Santiago de Compostela, A Coruña, Spain; Consortium for Biomedical Research in Respiratory Diseases (CIBER de Enfermedades Respiratorias/CibeRes), Av. de Monforte de Lemos 3-5, Madrid, Spain
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Chen F, Wang D, Jiang Y, Ma H, Li X, Wang H. Dexmedetomidine postconditioning alleviates spinal cord ischemia-reperfusion injury in rats via inhibiting neutrophil infiltration, microglia activation, reactive gliosis and CXCL13/CXCR5 axis activation. Int J Neurosci 2023; 133:1-12. [PMID: 33499703 DOI: 10.1080/00207454.2021.1881089] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Spinal cord ischemia-reperfusion (I/R) injury is an unresolved complication and its mechanisms are still not completely understood. Here, we studied the neuroprotective effects of dexmedetomidine (DEX) postconditioning against spinal cord I/R injury in rats and explored the possible mechanisms. MATERIALS AND METHODS In the study, rats were randomly divided into five groups: sham group, I/R group, DEX0.5 group, DEX2.5 group, and DEX5 group. I/R injury was induced in experimental rats; 0.5 μg/kg, 2.5 μg/kg, 5 μg/kg DEX were intravenously injected upon reperfusion respectively. Neurological function, histological assessment, and the disruption of blood-spinal cord barrier (BSCB) were evaluated via the BBB scoring, hematoxylin and eosin staining, Evans Blue (EB) extravasation and spinal cord edema, respectively. Neutrophil infiltration was evaluated via Myeloperoxidase (MPO) activity. Microglia activation and reactive gliosis was evaluated via ionized calcium-binding adapter molecule-1(IBA-1) and glial fibrillary acidic protein (GFAP) immunofluorescence, respectively. The expression of C-X-C motif ligand 13 (CXCL13), C-X-C chemokine receptor type 5(CXCR5), caspase-3 was determined by western blotting. The expression levels of interleukin 6(IL-6), tumor necrosis factor-α(TNF-α), IL-1β were determined by ELISA assay. RESULTS DEX postconditioning preserved neurological assessment scores, improved histological assessment scores, attenuated BSCB leakage after spinal cord I/R injury. Neutrophil infiltration, microglia activation and reactive gliosis were also inhibited by DEX postconditioning. The expression of CXCL13, CXCR5, caspase-3, IL-6, TNF-α, IL-1β were reduced by DEX postconditioning. CONCLUSIONS DEX postconditioning alleviated spinal cord I/R injury, which might be mediated via inhibition of neutrophil infiltration, microglia activation, reactive gliosis and CXCL13/CXCR5 axis activation.
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Affiliation(s)
- Fengshou Chen
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Dan Wang
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yanhua Jiang
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Hong Ma
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xiaoqian Li
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - He Wang
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
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Umalkar GN, Chavan G, Kantode VV, Wanjari MB. A Sporadic Case of a 22-Year-Old Female With Spinal Cord Infarction (SCI) Complicated by SS Pattern Sickle Cell Disease (SCD): A Rare Case Report. Cureus 2022; 14:e30334. [DOI: 10.7759/cureus.30334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/15/2022] [Indexed: 11/05/2022] Open
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8
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Nagaratnam SA, Lee RLK, Sturm J. Fibrocartilaginous embolism: an under-recognised cause of young spinal stroke. Pract Neurol 2022; 22:practneurol-2021-003322. [PMID: 35501140 DOI: 10.1136/practneurol-2021-003322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2022] [Indexed: 01/14/2023]
Abstract
Fibrocartilaginous embolism is a rarely reported cause of spinal cord infarction. Seemingly innocuous activities may be associated with nucleus pulposus material embolising to the spinal cord vasculature. We describe a 36-year-old woman presenting with bilateral arm paraesthesia and chest pain that evolved into an acute cord syndrome. Initial MR scan of spine showed central spinal cord T2-weighted hyperintensity over several vertebral levels, suggesting transverse myelitis. Repeat MR scan after her symptoms persisted showed an acute cord infarction from a presumed fibrocartilaginous embolus. Clinicians should consider fibrocartilaginous embolism in patients presenting with an acute cord syndrome with supportive radiological findings.
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Affiliation(s)
| | | | - Jonathan Sturm
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
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Pikija S, Kunz AB, Nardone R, Enzinger C, Pfaff JA, Trinka E, Seifert-Held T, Sellner J. Spontaneous spinal cord infarction in Austria: a two-center comparative study. Ther Adv Neurol Disord 2022; 15:17562864221076321. [PMID: 35299778 PMCID: PMC8921761 DOI: 10.1177/17562864221076321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/07/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Spinal cord infarction (SCI) is a neurological emergency associated with high rates of persistent neurological deficits. Knowledge about this rare but potentially treatable condition needs to be expanded. Objective: To describe the characteristics of spontaneous SCI in a large retrospective series of patients treated at two tertiary care centers in Austria. Methods: We performed a descriptive and comparative analysis of spontaneous SCI treated at the University Hospitals of Salzburg and Graz between the years 2000 and 2020. The analysis included pre- and in-hospital procedures, clinical presentation, etiology, diagnostic certainty, reperfusion therapy, and functional outcome at discharge. Results: We identified 88 cases, 61% were ascertained in the second half of the study period. The median age was 65.5 years [interquartile range (IQR) = 56–74], 51.1% were women. Anterior spinal artery infarction was the predominant syndrome (82.9%). Demographics, vascular comorbidities, and clinical presentation did not differ between the centers. The most frequent etiology and level of diagnostic certainty were distinct, with atherosclerosis (50%) and definite SCI (42%), and unknown (52.5%) and probable SCI (60%) as front runners in Salzburg and Graz, respectively. Patients arrived after a median of 258.5 min (IQR = 110–528) at the emergency room. The first magnetic resonance imaging (MRI) of the spinal cord was performed after a median of 148 min (IQR = 90–312) from admission and was diagnostic for SCI in 45%. Two patients received intravenous thrombolysis (2.2%). The outcome was poor in 37/77 (48%). Conclusion: Demographics, clinical syndromes, and quality benchmarks for spontaneous SCI were consistent at two Austrian tertiary care centers. Our findings provide the foundation for establishing standards for pre- and in-hospital care to improve outcomes.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Alexander B. Kunz
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria
| | - Raffaele Nardone
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy; Spinal Cord Injury and Tissue Regeneration Center, Salzburg, Austria
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Johannes A.R. Pfaff
- University Institute for Neuroradiology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria Neuroscience Institute, Christian Doppler Medical Center and Center for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | | | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstr. 67, 2130 Mistelbach, Austria
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany
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10
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Focke JK, Seitz RJ. Reversal of Acute Spinal Cord Ischemia by Intravenous Thrombolysis. Neurol Clin Pract 2022; 11:e975-e976. [PMID: 34993001 DOI: 10.1212/cpj.0000000000001097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/05/2021] [Indexed: 11/15/2022]
Abstract
Acute non-traumatic ischemic myelopathy is a devastating condition with a typically poor outcome occurring in adults, adolescents and even children [1-3]. The acute onset of paraplegia and sensory loss are suggestive of spinal ischemia with little recovery potential [1, 4, 5]. Due to the lack of sufficient data there are no standardized guidelines regarding the acute treatment of spinal ischemia. While intravenous thrombolysis is a well established and effective treatment in cerebral ischemia, its efficacy in spinal cord ischemia has not yet been proven [5]. We report the case of a young female patient with acute spinal cord ischemia in whom treatment with systemic thrombolysis lead to a complete reversal of paraplegia.
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Affiliation(s)
- Jan K Focke
- Department of Neurology, LVR-Klinikum, Düsseldorf, Heinrich-Heine-University, Germany
| | - Rüdiger J Seitz
- Department of Neurology, LVR-Klinikum, Düsseldorf, Heinrich-Heine-University, Germany
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11
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Marcellino C, Zalewski NL, Rabinstein AA. Treatment of Vascular Myelopathies. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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McEntire CR, Dowd RS, Orru' E, David C, Small JE, Cervantes-Arslanian A, Lerner DP. Acute Myelopathy: Vascular and Infectious Diseases. Neurol Clin 2021; 39:489-512. [PMID: 33896530 DOI: 10.1016/j.ncl.2021.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Vascular and infectious causes are rare but important causes of spinal cord injury. High suspicion for these processes is necessary, as symptoms may progress over hours to days, resulting in delayed presentation and diagnosis and worse outcomes. History and clinical examination findings can assist with localization of the affected vascular territory and spinal level, which will assist with focusing spinal imaging. Open and/or endovascular surgical management depends on the associated vascular abnormality. Infectious myelopathy treatment consists of targeted antimicrobial therapy when possible, infectious source control, and again, close monitoring for systemic complications.
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Affiliation(s)
- Caleb R McEntire
- Department of Neurology, Massachusetts General Hospital and Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard S Dowd
- Department of Neurosurgery, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Emanuele Orru'
- Department of Radiology, Neurointerventional Radiology Division, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Carlos David
- Department of Neurosurgery, Tufts University School of Medicine, Boston, MA 02111, USA; Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | - Juan E Small
- Department of Radiology, Neuroradiology Section, Lahey Hospital and Medical Center, Burlington, MA 01805, USA
| | | | - David P Lerner
- Division of Neurology, Lahey Hospital and Medical Center, Burlington, MA 01805, USA; Department of Neurology, Tufts University School of Medicine, Boston, MA 02111, USA.
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Spinal cord infarction: aetiology, imaging findings, and prognostic factors in a series of 41 patients. NEUROLOGÍA (ENGLISH EDITION) 2021:S2173-5808(21)00077-8. [PMID: 34130946 DOI: 10.1016/j.nrleng.2020.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/19/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Spinal cord infarction is a rare disease with a high rate of morbidity. Its diagnosis can be challenging and controversy remains regarding the best treatment. Few case series have been published. METHODS We conducted a retrospective review of cases of spinal cord infarction attended in a tertiary hospital from 1999 to 2020. Aetiology and clinical, imaging, and prognostic features were assessed. RESULTS Forty-one patients (58.5% men, mean [standard deviation] age 61 [17] years) were included in the study. Thirty-one patients (75.6%) presented vascular risk factors. Motor deficits were recorded in 39 (95.1%), pain in 20 (48.8%), sensory deficits in 33 (80.4%), and autonomic dysfunction in 24 (58.5%). MRI was performed in 37 (90.2%) patients. Diffusion-weighted images were available for 12 patients, with 10 showing diffusion restriction. The thoracic region was the most frequently affected (68.2%). Vascular imaging studies were performed in 33 patients (80.4%). The most frequent aetiologies were aortic dissection (6 cases), atherosclerosis demonstrated by vascular imaging (6 cases), fibrocartilaginous embolism (6 cases), surgery (5 cases), and hypotension (4 cases). Aetiology was undetermined in 12 patients (29.3%), although 9 of these presented vascular risk factors. At the end of the follow-up period (median, 24 months; interquartile range, 3-70), 12 patients (29.2%) were able to walk without assistance. Vascular risk factors and paraparesis were significantly associated with poorer prognosis (P < .05). DISCUSSION Spinal cord infarction may present diverse aetiologies, with the cause remaining undetermined in many patients. Long-term functional prognosis is poor, and depends on baseline characteristics and clinical presentation. MRI, and especially diffusion-weighted sequences, is useful for early diagnosis.
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Abstract
Vascular disorders of the spinal cord are uncommon yet under-recognized causes of myelopathy. Etiologies can be predominantly categorized into clinical and radiographic presentations of arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage. While vascular myelopathies often produce significant morbidity, recent advances in the understanding and recognition of these disorders should continue to expedite diagnosis and proper management, and ideally improve patient outcomes. This article comprehensively reviews relevant spinal cord vascular anatomy, clinical features, radiographic findings, treatment, and prognosis of vascular disorders of the spinal cord.
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Ros Castelló V, Sánchez Sánchez A, Natera Villalba E, Gómez López A, Parra P, Rodríguez Jorge F, Buisán Catevilla J, García Barragán N, Masjuan J, Corral I. Spinal cord infarction: aetiology, imaging findings, and prognostic factors in a series of 41 patients. Neurologia 2021; 38:S0213-4853(21)00002-5. [PMID: 33581950 DOI: 10.1016/j.nrl.2020.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 11/03/2020] [Accepted: 11/19/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Spinal cord infarction is a rare disease with a high rate of morbidity. Its diagnosis can be challenging and controversy remains regarding the best treatment. Few case series have been published. METHODS We conducted a retrospective review of cases of spinal cord infarction attended in a tertiary hospital from 1999 to 2020. Aetiology and clinical, imaging, and prognostic features were assessed. RESULTS Forty-one patients (58.5% men, mean [standard deviation] age 61 [17] years) were included in the study. Thirty-one patients (75.6%) presented vascular risk factors. Motor deficits were recorded in 39 (95.1%), pain in 20 (48.8%), sensory deficits in 33 (80.4%), and autonomic dysfunction in 24 (58.5%). MRI was performed in 37 (90.2%) patients. Diffusion-weighted images were available for 12 patients, with 10 showing diffusion restriction. The thoracic region was the most frequently affected (68.2%). Vascular imaging studies were performed in 33 patients (80.4%). The most frequent aetiologies were aortic dissection (6 cases), atherosclerosis demonstrated by vascular imaging (6 cases), fibrocartilaginous embolism (6 cases), surgery (5 cases), and hypotension (4 cases). Aetiology was undetermined in 12 patients (29.3%), although 9 of these presented vascular risk factors. At the end of the follow-up period (median, 24 months; interquartile range, 3-70), 12 patients (29.2%) were able to walk without assistance. Vascular risk factors and paraparesis were significantly associated with poorer prognosis (P<.05). DISCUSSION Spinal cord infarction may present diverse aetiologies, with the cause remaining undetermined in many patients. Long-term functional prognosis is poor, and depends on baseline characteristics and clinical presentation. MRI, and especially diffusion-weighted sequences, is useful for early diagnosis.
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Affiliation(s)
- V Ros Castelló
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - A Sánchez Sánchez
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - E Natera Villalba
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A Gómez López
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - P Parra
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - F Rodríguez Jorge
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Buisán Catevilla
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - N García Barragán
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Masjuan
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - I Corral
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Madrid, España
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Menezes FTL, Alencar JMD, Oliveira da Cruz A, Candeias da Silva C, Oliveira EML, Bichuetti DB. Myelopathies in patients older than 50: not to miss inflammatory etiologies. Mult Scler Relat Disord 2021; 50:102826. [PMID: 33618122 DOI: 10.1016/j.msard.2021.102826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/31/2020] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Inflammatory myelopathies are primarily associated with younger age, and there are few studies in the elderly. Longitudinally extensive spinal cord lesions (LECL) are common in inflammatory myelopathies, but when the first event occurs in older age may have a broader differential diagnosis. OBJECTIVES To identify all non-traumatic myelopathies' etiologies in patients older than 50 years in a tertiary care hospital and to evaluate characteristics that differentiate inflammatory from non-inflammatory etiologies, focusing on the late-onset (≥50 years old) longitudinally extensive spinal cord lesions (LO-LECL) group. METHODS Retrospective study of patients admitted between 2008 to 2019. Demographic, clinical, laboratory, and magnetic resonance imaging (MRI) data of all patients were analyzed to identify predictors that could more easily identify inflammatory from non-inflammatory etiologies and further identify the etiologies of LO-LECL. RESULTS One hundred and three patients 50 years or older diagnosed with non-traumatic myelopathy were included, despite the lesion extension. Five were vascular (5%), 10 spondylotic (10%), 16 other etiologies (16%), 22 inflammatory (21%) and 50 neoplastic myelopathies (49%). Among 23 LO-LECL, 3 were vascular (13%), 4 neoplastic (17%), 7 other etiologies (30%) and 9 inflammatory (39%). The inflammatory LO-LECL had the median time to nadir significantly different from the neoplastic and the other etiologies groups and had the median EDSS at last visit (3.5) significantly lower than the non-inflammatory LO-LECL (7.0-7.5). CONCLUSIONS Inflammatory etiologies are not to be disregarded in older adults with non-traumatic myelopathies. The symptoms' temporal profile is critical to differentiate inflammatory LO-LECL from other etiologies and it has better functional recovery after adequate treatment.
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Affiliation(s)
- Felipe Toscano Lins Menezes
- Neuroimmunogy Clinic, Neurology Discipline, Escola Paulista de Medicina - Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Jéssica Monique Dias Alencar
- Neuroimmunogy Clinic, Neurology Discipline, Escola Paulista de Medicina - Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Anisse Oliveira da Cruz
- Neuroimmunogy Clinic, Neurology Discipline, Escola Paulista de Medicina - Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Carolina Candeias da Silva
- Movement Disorders Clinic, Neurology Discipline, Escola Paulista de Medicina - Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Enedina Maria Lobato Oliveira
- Neuroimmunogy Clinic, Neurology Discipline, Escola Paulista de Medicina - Universidade Federal de São Paulo, São Paulo, Brazil.
| | - Denis Bernardi Bichuetti
- Neuroimmunogy Clinic, Neurology Discipline, Escola Paulista de Medicina - Universidade Federal de São Paulo, São Paulo, Brazil.
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17
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Abstract
PURPOSE OF REVIEW Neurologists should be able to identify clinical and neuroimaging features that distinguish vascular disorders from other causes of myelopathy. RECENT FINDINGS Although certain clinical features suggest a vascular etiology in acute and chronic myelopathy settings, accurate MRI interpretation within the clinical context is key. Recent studies have shown vascular myelopathies are frequently misdiagnosed as transverse myelitis, and recognition of this diagnostic pitfall is important. Many different vascular mechanisms can cause myelopathy; this article provides a comprehensive review that simplifies disease categories into arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage. SUMMARY It is important to recognize and manage vascular disorders of the spinal cord as significant causes of acute, subacute, and progressive myelopathy.
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18
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Eissa M, Abdelhady M, Alqatami H, Salem K, Own A, El Beltagi AH. Spinal cord infarction in a 41-year-old male patient with COVID-19. Neuroradiol J 2021; 34:245-248. [PMID: 33480310 DOI: 10.1177/1971400921988925] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) pandemic, became rapidly recognised by variable phonotypic expressions that involve most major body organs. Neurological complications of severe acute respiratory syndrome coronavirus disease are increasingly encountered in patients with COVID-19 infection, more frequently in patients with severe infection, and develop as a consequence of the neurotropic potential of this virus, secondary cytokine storm and acquired syndrome of COVID-19 coagulopathy. Spinal cord involvement after COVID-19 more commonly includes infectious transverse myelitis, para and post infection myelopathy and, rarely, spinal cord ischaemia related to increased coagulopathy with thromboembolic consequences. We herein report a COVID-19-positive patient with increased coagulopathy and vertebral artery thrombosis leading to posterior circulation and subsequent spinal cord infarction.
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Affiliation(s)
- Mamdouh Eissa
- Neuroradiology Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Hosam Alqatami
- Neuroradiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Khaled Salem
- Neuroradiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Own
- Neuroradiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed H El Beltagi
- Neuroradiology Department, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine, Qatar
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19
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Neth BJ, Hewitt AL, Edlund WS, Guerin JB, Patterson MC, Keating GF. Rapidly Progressive Paraplegia in an 11-Year-Old Girl: A Case of Spinal Cord Infarction and Expected Imaging Findings. Child Neurol Open 2021; 7:2329048X20981295. [PMID: 33426143 PMCID: PMC7758642 DOI: 10.1177/2329048x20981295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Rapidly progressive non-traumatic paraplegia in a child is uncommonly encountered in clinical practice, but is an important presentation to consider given the potential for significant morbidity. We present the case of an 11-year-old girl who was found to have hyperacute paraplegia due to spinal cord infarction. We discuss the appropriate workup, differential diagnosis in children and how this relates to adults; and describe the prognosis and current state of management options for spinal cord infarction.
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Affiliation(s)
- Bryan J Neth
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Angela L Hewitt
- Department of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Wendy S Edlund
- Department of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Julie B Guerin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Marc C Patterson
- Department of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Gesina F Keating
- Department of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
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20
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Ashton C, Banham N, Needham M. Acute spontaneous spinal cord infarction: Utilisation of hyperbaric oxygen treatment, cerebrospinal fluid drainage and pentoxifylline. Diving Hyperb Med 2020; 50:325-331. [PMID: 33325011 DOI: 10.28920/dhm50.4.325-331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/09/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Spinal cord infarction (SCI) is a potentially devastating disorder presenting with an acute anterior spinal artery syndrome, accounting for an estimated 1% of stroke presentations. Aetiologies include aortic surgical complications, systemic hypotension, fibrocartilaginous embolism and vascular malformations. Diagnosis is clinical combined with restriction on diffusion-weighted magnetic resonance imaging (MRI). There are no treatment guidelines for non-perioperative cases although there is limited literature regarding potential therapies, including hyperbaric oxygen treatment (HBOT) and cerebrospinal fluid (CSF) drainage. We describe 13 cases of acute SCI, five receiving HBOT, and three also receiving pentoxifylline and drainage of lumbar CSF. METHODS Data for all patients with MRI-proven SCI at Fiona Stanley Hospital from 2014-2019 were reviewed. RESULTS Thirteen patients, median age 57 years (31-74), 54% female, were identified. Aetiologies: two fibrocartilaginous emboli; seven likely atherosclerotic; two thromboembolic; two cryptogenic. All presented with flaccid paraplegia except one with Brown-Sequard syndrome. Levels ranged from C4 to T11. Five patients received HBOT within a median time of 40 hours from symptom onset, with an average 15 treatments (10-20). Three of these received triple therapy (HBOT, pentoxifylline, CSF drainage) and had median Medical Research Council manual muscle testing power of 5, median modified Rankin Score (mRS) of 1 and American Spinal Injury Association (ASIA) score of D on discharge, compared with 2 power, mRS 3.5 and ASIA B in those who did not. CONCLUSIONS SCI can be severely disabling. Triple therapy with pentoxifylline, CSF drainage and HBOT may reduce disability and further prospective trials are required.
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Affiliation(s)
- Catherine Ashton
- Neurology Department, Fiona Stanley Hospital, Murdoch, Australia.,Corresponding author: Dr Catherine Ashton, Neurology Department, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150, Australia,
| | - Neil Banham
- Department of Hyperbaric Medicine, Fiona Stanley Hospital, Murdoch, Australia
| | - Merrilee Needham
- Neurology Department, Fiona Stanley Hospital, Murdoch, Australia.,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia.,Perron Institute for Neurological and Translational Science, Nedlands, Australia.,University of Notre Dame, Fremantle, Australia
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21
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Park D, Kim BH, Lee SE, Park JK, Cho JM, Kwon HD, Lee SY. Spinal Cord Infarction: A Single Center Experience and the Usefulness of Evoked Potential as an Early Diagnostic Tool. Front Neurol 2020; 11:563553. [PMID: 33192998 PMCID: PMC7652817 DOI: 10.3389/fneur.2020.563553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/14/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Spinal cord infarction (SCI) is a rare disease and its early diagnosis is challenging. Here, we described the clinical features and imaging findings of SCI, and assessed the results of evoked potential (EP) studies to elucidate their diagnostic role in the early stage of SCI. Methods: We retrospectively analyzed 14 patients who had spontaneous SCI. The demographic, neurological, and temporal profiles of the SCI patients were identified. We reviewed the imaging findings and assessed the changes in them over time. To review EP, central motor conduction time (CMCT) and somatosensory evoked potential (SEP) values were obtained. We also enrolled 15 patients with transverse myelitis (TM), and compared the clinical, radiological and electrophysiological features between SCI and TM patients. Results: The ages of the SCI patients ranged from 54 to 73 years. Nine patients (64.3%) showed nadir deficits within 6 h. The most common type of clinical visit was via the emergency center. Nine patients (64.3%) presented with peri-onset focal pain. The median initial modified Rankin scale score was 3. For 9 patients (64.3%), initial T2 imaging findings were negative, but subsequent diffusion weighed imaging (DWI) showed diffusion restriction. Vertebral body infarction was observed in 5 patients (35.7%). EP data were available for 10 SCI patients. All 8 patients who had their CMCT measured showed abnormalities. Among them, motor evoked potentials were not evoked in 6 patients at all. SEP was measured in 10 patients, and 9 of them showed abnormalities; one of them showed no SEP response. For 5 patients, the EP studies were done prior to DWI, and all the patients showed definite abnormalities. The abnormalities in the EP findings of the SCI patients were more profound than those of the TM patients, even though the duration from the onset to the start of the study was much shorter for SCI patients. Conclusion: SCI can be diagnosed based on typical clinical manifestations and appropriate imaging studies. Our study also indicates that immediate sensory and motor EP study can have an adjuvant diagnostic role in the hyperacute stage of SCI, and can improve the accuracy of diagnosis.
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Affiliation(s)
- Dougho Park
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Byung Hee Kim
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Sang Eok Lee
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Ji Kang Park
- Department of Radiology, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Jae Man Cho
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Heum Dai Kwon
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Su Yun Lee
- Department of Neurology, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
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22
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Ghezzaz A, Cristea C, Ferradji A, Aboubekr EH, Bouhanna-Hamitouche L, Chahed S, Mahdjoubi A. Spinal cord infarction associated to retinal vein occlusion in a patient with chronic kidney disease. Neurol Int 2020; 12:8558. [PMID: 32944205 PMCID: PMC7477725 DOI: 10.4081/ni.2020.8558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 08/12/2020] [Indexed: 11/22/2022] Open
Abstract
A 70-year-old man presented to the emergency department with blood hypotension associated to a sudden paraplegia and thermalgesic analgesia. He had an history of colic and prostatic adenocarcinoma, hypertension and non-dialyzed Chronic Kidney Disease (CKD) related to an idiopathic membranous glomerulonephritis type 1 discovered 9 years ago. Magnetic resonance imaging confirmed a diagnosis of Spinal Cord Infarction (SCI). Few months later, he presented a blurred vision due to central Retinal Vein Occlusion (RVO), which was improved by Anti-VEGF therapy. This is the first reported case of a concomitance of retinal vascular event and SCI highlights the links between the central nervous system and retinal vascularization despite separate involvement of the two events in the arterial and venous systems. Additionally, CKD worsened the risk of cardiovascular incidents by induced oxidative stress, thrombophilia, chronic inflammation, and endothelial dysfunction. SCI occurrence indicates severe vascular dysfunction and elevates the risk of additional vascular disorders.
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23
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Yamamoto Y, Nishimura Y, Okumura M, Otsuka Y, Oka K, Ikeuchi K, Nishimori H, Taniguchi K, Otsuka F. Intravascular lymphoma presenting as spinal cord infarction. Postgrad Med J 2020; 97:672-673. [PMID: 32796108 DOI: 10.1136/postgradmedj-2020-138602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/09/2020] [Accepted: 07/18/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Yukichika Yamamoto
- Department of General Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshito Nishimura
- Department of General Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Misa Okumura
- Department of General Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yuki Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kosuke Oka
- Department of General Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kazuhiro Ikeuchi
- Department of Hematology and Oncology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hisakazu Nishimori
- Department of Hematology and Oncology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kohei Taniguchi
- Department of Pathology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
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24
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Meng YY, Dou L, Wang CM, Kong DZ, Wei Y, Wu LS, Yang Y, Zhou HW. Spinal cord infarction presenting as Brown-Séquard syndrome from spontaneous vertebral artery dissection: a case report and literature review. BMC Neurol 2019; 19:321. [PMID: 31830940 PMCID: PMC6907223 DOI: 10.1186/s12883-019-1559-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/05/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Spinal cord infarction (SCI) is rarely caused by vertebral artery dissection (VAD), which is an important cause of posterior circulation stroke in young and middle-aged patients. We report the case of a middle-aged patient without obvious risk factors for atherosclerosis who had SCI from right VAD. CASE PRESENTATION An otherwise healthy 40-year-old man presented with acute right-sided body weakness. Six days earlier, he had experienced posterior neck pain without obvious inducement. Neurologic examination revealed a right Brown-Séquard syndrome. Magnetic resonance imaging (MRI) of the head was normal. Further, cervical spine MRI showed spinal cord infarction (SCI) on the right at the C1-C3 level. Three-dimensional high-resolution MRI (3D HR-MRI) volumetric isotropic turbo spin echo acquisition (VISTA) scan showed evidence of vertebral artery dissection (VAD). The patient was significantly relieved of symptoms and demonstrated negative imaging findings after therapy with anticoagulation (AC) and antiplatelets (AP) for 3 months. CONCLUSIONS The possibility of vertebral artery dissection (VAD) should be considered in the case of young and middle-aged patients without obvious risk factors for atherosclerosis. Furthermore the VISTA black blood sequence plays an important role in the pathological diagnosis of vertebral artery stenosis. Early correct diagnosis and active therapy are crucial to the prognosis.
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Affiliation(s)
- Yang-Yang Meng
- Department of Radiology, the First Hospital of JiLin University, Xinmin St. #71, Changchun, 130021, China
| | - Le Dou
- Department of Radiology, the First Hospital of JiLin University, Xinmin St. #71, Changchun, 130021, China
| | - Chun-Mei Wang
- Department of Radiology, the First Hospital of JiLin University, Xinmin St. #71, Changchun, 130021, China
| | - De-Zheng Kong
- Department of Radiology, the First Hospital of JiLin University, Xinmin St. #71, Changchun, 130021, China
| | - Ying Wei
- Department of Radiology, the First Hospital of JiLin University, Xinmin St. #71, Changchun, 130021, China
| | - Li-Shan Wu
- Department of Radiology, the First Hospital of JiLin University, Xinmin St. #71, Changchun, 130021, China
| | - Yi Yang
- Department of Neurology, Stroke Center, Neuroscience Center & Clinical Trail and Research Center for Stroke, the First Hospital of JiLin Universit, Xinmin St. #71, Changchun, 130021, China.
| | - Hong-Wei Zhou
- Department of Radiology, the First Hospital of JiLin University, Xinmin St. #71, Changchun, 130021, China.
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25
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Zalewski NL, Rabinstein AA, Krecke KN, Brown RD, Wijdicks EFM, Weinshenker BG, Kaufmann TJ, Morris JM, Aksamit AJ, Bartleson JD, Lanzino G, Blessing MM, Flanagan EP. Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria. JAMA Neurol 2019; 76:56-63. [PMID: 30264146 DOI: 10.1001/jamaneurol.2018.2734] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Spinal cord infarction (SCI) is often disabling, and the diagnosis can be challenging without an inciting event (eg, aortic surgery). Patients with a spontaneous SCI are often misdiagnosed as having transverse myelitis. Diagnostic criteria for SCI are lacking, hindering clinical care and research. Objective To describe the characteristics of spontaneous SCI and propose diagnostic criteria. Design, Setting, and Participants An institution-based search tool was used to identify patients evaluated at Mayo Clinic, Rochester, Minnesota, from January 1997 to December 2017 with a spontaneous SCI. Patients provided written consent to use their records for research. Participants were 18 years and older with a diagnosis of spontaneous SCI (n = 133), and controls were selected from a database of alternative myelopathy etiologies for validation of the proposed diagnostic criteria (n = 280). Main Outcomes and Measures A descriptive analysis of SCI was performed and used to propose diagnostic criteria, and the criteria were validated. Results Of 133 included patients with a spontaneous SCI, the median (interquartile range) age at presentation was 60 (52-69) years, and 101 (76%) had vascular risk factors. Rapid onset of severe deficits reaching nadir within 12 hours was typical (102 [77%]); some had a stuttering decline (31 [23%]). Sensory loss occurred in 126 patients (95%), selectively affecting pain/temperature in 49 (39%). Initial magnetic resonance imaging (MRI) spine results were normal in 30 patients (24%). Characteristic MRI T2-hyperintense patterns included owl eyes (82 [65%]) and pencil-like hyperintensity (50 [40%]); gadolinium enhancement (37 of 96 [39%]) was often linear and located in the anterior gray matter. Confirmatory MRI findings included diffusion-weighted imaging/apparent diffusion coefficient restriction (19 of 29 [67%]), adjacent dissection/occlusion (16 of 82 [20%]), and vertebral body infarction (11 [9%]). Cerebrospinal fluid showed mild inflammation in 7 of 89 patients (8%). Diagnostic criteria was proposed for definite, probable, and possible SCI of periprocedural and spontaneous onset. In the validation cohort (n = 280), 9 patients (3%) met criteria for possible SCI, and none met criteria for probable SCI. Conclusions and Relevance This large series of spontaneous SCIs provides clinical, laboratory, and MRI clues to SCI diagnosis. The diagnostic criteria proposed here will aid clinicians in making the correct diagnosis and ideally improve future care for patients with SCI. The validation of these criteria supports their utility in the evaluation of acute myelopathy.
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Affiliation(s)
| | | | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | - J D Bartleson
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
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26
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Kramer DC, Aguirre-Alarcon A, Yassari R, Brook AL, Kinon MD. Spinal cord ischemia/infarct after cauda equina syndrome from disc herniation - A case study and literature review. Surg Neurol Int 2019; 10:80. [PMID: 31528418 PMCID: PMC6744722 DOI: 10.25259/sni-148-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 03/21/2019] [Indexed: 11/04/2022] Open
Abstract
Background Spinal cord infarction is rare and occurs in 12/100,000; it represents 0.3%-2% of central nervous system infarcts. Here, we present a patient who developed recurrent bilateral lower extremity paraplegia secondary to spinal cord infarction 1 day after a successful L4-5 microdiscectomy in a patient who originally presented with a cauda equina syndrome. Case Description A 56-year-old patient presented with an acute cauda equina syndrome characterized by severe lower back pain, a right foot drop, saddle anesthesia, and acute urinary retention. When the lumbar magnetic resonance imaging (MRI) revealed a large right paracentral lumbar disc herniation at the L4-L5 level, the patient underwent an emergency minimally invasive right-sided L4-5 discectomy. Immediately, postoperatively, the patient regained normal function. However, 1 day later, while having a bowel movement, he immediately developed the recurrent paraplegia. The new lumbar MRI revealed acute ischemia and an infarct involving the distal conus medullaris. Further, workup was negative for a spinal cord vascular malformation, thus leaving an inflammatory postsurgical vasculitis as the primary etiology of delayed the conus medullaris infarction. Conclusions Acute neurologic deterioration after spinal surgery which does not neurologically correlate with the operative level or procedure performed should prompt the performance of follow-up MR studies of the neuraxis to rule out other etiologies, including vascular lesions versus infarctions, as causes of new neurological deficits.
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Affiliation(s)
| | | | - Reza Yassari
- Department of Neurological Surgery, NY, United States
| | - Allan L Brook
- Department of Radiology, Montefiore Medical Center, NY, United States
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27
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Matos JR, George RM, Wilson SH. It Is Not Always the Epidural: A Case Report of Anterior Spinal Artery Ischemia in a Trauma Patient. A A Pract 2018; 11:148-150. [PMID: 29634525 DOI: 10.1213/xaa.0000000000000764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Motor vehicle collisions impact millions of people annually resulting in multiinjury trauma. Anesthesiologists are consulted for rib fracture analgesia to improve respiratory mechanics and prevent intubation. This report describes a trauma patient who developed hypotension and lower extremity weakness after epidural placement for multiple rib fractures. Initially, hypotension was attributed to neuraxial sympathectomy. However, physical examination also indicated anterior spinal artery ischemia. Regional anesthesia and acute pain teams must be able to both identify contraindications and complications of regional techniques and discern when complications are not a result of regional interventions to initiate prompt management and definitive care.
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Affiliation(s)
- Jennifer R Matos
- From the Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
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28
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Lin WP, Kuan TS, Lin CI, Hsu LC, Lin YC. Spinal cord infarction during physical exertion due to polycythemia vera and aortoiliac occlusive disease: A case report. Medicine (Baltimore) 2018; 97:e12181. [PMID: 30170466 PMCID: PMC6392751 DOI: 10.1097/md.0000000000012181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Spinal cord infarction is rarely caused by hypercoagulable states. Polycythemia vera (PV) is a myeloproliferative neoplasm that can contribute to thrombotic events due to increased blood viscosity. We report a case of spinal cord infarction due to extensive aortic thrombosis caused by PV. PATIENT CONCERNS A 56-year-old man presented with acute paraplegia and urinary retention during heavy physical exertion. DIAGNOSES Imaging studies revealed spinal cord infarction at the T9 to T12 levels and aortoiliac occlusive disease. PV was diagnosed during workup for elevated hemoglobin level INTERVENTIONS:: The patient received intravenous hydration and anticoagulation for spinal cord infarction. PV was managed with phlebotomy and hydroxyurea. Courses of inpatient and outpatient rehabilitation programs were also given. OUTCOMES The patient became urinary catheter-free 5 months after disease onset, and was able to walk with walker. The American Spinal Injury Association Impairment scale also improved from C at diagnosis to D during last follow-up. LESSONS Etiologic workup is important for patients with spinal cord infarction to direct specific treatment strategies. Physical exertion may act as a trigger for infarction in patients at risk for thrombotic events, and monitoring of neurologic status during and after periods of exercise is warranted.
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Affiliation(s)
- Wei-Pin Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital
| | - Ta-Shen Kuan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C
| | - Cho-I Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital
| | - Lin-Chieh Hsu
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C
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29
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Zalewski NL, Rabinstein AA, Krecke KN, Brown RD, Wijdicks EF, Weinshenker BG, Doolittle DA, Flanagan EP. Spinal cord infarction: Clinical and imaging insights from the periprocedural setting. J Neurol Sci 2018; 388:162-167. [DOI: 10.1016/j.jns.2018.03.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/04/2018] [Accepted: 03/16/2018] [Indexed: 10/17/2022]
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