Nontraumatic spinal cord ischaemic syndrome

Spinal Cord Infarction: Clinical and Neuroradiological Clues of a Rare Stroke Subtype

Spinal cord infarction (SCI) of arterial origin is a rare vascular event, and its incidence is probably underestimated. There are no strong epidemiological data, and the diagnostic pathway is complex and sometimes incomplete. Furthermore, many cases may be misdiagnosed as other forms of acute and subacute myelopathies. The focus of this review is the clinical and neuroradiological issues in diagnosing SCI and their respective reliability in a clinical setting. The new proposed diagnostic criteria of SCI, although not covering all aspects, highlight the need for a comprehensive approach, including even atypical cases, as the lack of cord compression on Magnetic Resonance Imaging (MRI) is the only mandatory feature for diagnosis. Some MRI features are supportive of the diagnosis, particularly when the anterior spinal artery territory is involved and diffusion-weighted imaging (DWI) is used. Several etiologies can be considered, considering traditional vascular risk factors and diseases affecting the aorta and its main branches, yet a significant proportion of cases remain without a definite etiology. The strongest predictor of SCI diagnosis is a clinical variable, i.e., a time to nadir of severe deficits < 12 h.

Case report: Combined transcutaneous spinal cord stimulation and physical therapy on recovery of neurological function after spinal cord infarction

The case of a 37-year-old woman who suffered from spinal cord infarction (SI), resulting in a complete spinal cord injury (AIS A, neurological level T10), and autonomic dysfunction is presented. This study aimed to assess the effect of transcutaneous Spinal Cord Electrical Stimulation (tSCS) on improving motor, sensory, and autonomic function after SI. During the first 8 months, tSCS was applied alone, then, physical therapy (PT) was included in the sessions (tSCS+PT), until completion of 20 months. Compared to baseline, at 20 months, an increase in ISNCSCI motor (50 vs. 57) and sensory scores (light touch, 72 vs. 82; pinprick, 71 vs. 92) were observed. Neurogenic Bladder Symptoms Score (NBSS) changed from 27 at baseline to 17 at 20 months. ISAFSCI scores in sacral autonomic function improved from 0 pts (absent function) to 1 pt. (altered function) indicating better sphincter control. EMG recordings during volitional movements, including overground stepping with 80% of body weight support showed activity in gluteus medialis, tensor fascia latae, sartorius, rectus femoris, biceps femoris, tibialis anterior, and gastrocnemius medialis, indicating a partial reversion of paralysis. RMS analysis indicated higher activity during "tSCS on" compared to "tSCS off" during overground stepping in bilateral rectus femoris (p < 0.001) and gastrocnemius medialis (p < 0.01); and unilateral biceps femoris, and tibialis anterior (p < 0.001). As this is the first report on the use of tSCS in the case of SI, future studies in a case series are warranted.

Idiopathic cervical cord infarction in a young girl presenting with acute neck pain and flaccid paralysis: a case report

INTRODUCTION

Spinal cord infarction (SCI) is a rare disease representing nearly 1% of all strokes with a wide variety of symptoms at presentation. SCI diagnosis is very challenging owing to its low incidence and the variety of symptoms, and could be misdiagnosed with neuromyelitis optica spectrum disorders (NMOSD).

CASE PRESENTATION

We describe the case of an 18-year-old girl who presented to the emergency department with acute neck pain and flaccid paralysis of the left upper and lower extremities. Few hours later, she developed apnea and was endotracheally intubated. Brain MRI was normal but spinal cord MRI revealed non-enhancing longitudinal abnormal high T2 signal intensity extending from C1 to C5. The patient underwent steroid therapy with methylprednisolone (1 g daily for 7 consecutive days) combined with physiotherapy. She was extubated after 3 weeks and discharged after 30 days of hospitalization with a muscle force of 4/5 in her left extremities.

DISCUSSION

Idiopathic SCI in adolescence is a rare but often devastating disorder with unknown pathophysiology, however, some specific conditions in adolescent such as mechanical stresses on the immature spine can be considered as risk factors for SCI development. Early diagnosis and treatment can improve outcomes in SCI.

Spontaneous spinal cord infarction: a systematic review

Background and objectives

Spontaneous spinal cord infarction (SCInf) is a rare condition resulting in acute neurological impairment. Consensus on diagnostic criteria is lacking, which may present a challenge for the physician. This review aims to analyse the current literature on spontaneous SCInf, focusing on epidemiology, the diagnostic process, treatment strategies and neurological outcomes.

Methods

The study was performed in accordance with a previously published protocol. PubMed, Web of Science and Embase were searched using the keywords 'spontaneous', 'spinal cord', 'infarction' and 'ischaemic'. The eligibility of studies was evaluated in two steps by multiple reviewers. Data from eligible studies were extracted and systematically analysed.

Results

440 patients from 33 studies were included in this systematic review. Analysis of vascular risk factors showed that hypertension was present in 40%, followed by smoking in 30%, dyslipidaemia in 29% and diabetes in 16%. The severity of symptoms at admission according to the American Spinal Injury Association (ASIA) Impairment Scale was score A 19%, score B14%, score C36% and score D32%. The mean follow-up period was 34.8 (±12.2) months. ASIA score at follow-up showed score A 11%, score B 3%, score C 16%, score D 67% and score E 2%. The overall mortality during the follow-up period was 5%. When used, MRI with diffusion-weighted imaging (DWI) supported the diagnosis in 81% of cases. At follow-up, 71% of the patients were able to walk with or without walking aids.

Conclusion

The findings suggest a significant role for vascular risk factors in the pathophysiology of spontaneous SCInf. In the diagnostic workup, the use of DWI along with an MRI may help in confirming the diagnosis. The findings at follow-up suggest that neurological recovery is to be expected, with the majority of patients regaining ambulation. This systematic review highlights gaps in the literature and underscores the necessity for further research to establish diagnostic criteria and treatment guidelines.

Fibrocartilaginous embolism after mountain cycling: a case report with clinical and radiological follow-up and almost complete recovery

Introduction

Fibrocartilaginous embolism (FCE) is a rare spinal cord infarction due to embolism of fibrocartilaginous material with consecutive arterial infarction of the anterior spinal artery. Physical activity with increased axial pressure is the underlying mechanism of the retrograde migration of primarily nucleus pulposus material into the arterial system of the spinal cord. The initial severity of the clinical symptoms is supposed to be a prognostic predictor of recovery and so far, no specific treatment recommendation exists.

Methods

We present a case of spinal cord infarction due to FCE after long and sporty mountain cycling (during 6 hours and 2500 altitude difference) with detailed clinical and radiological follow-up.

Results

The clinical and radiological follow-up at month 4 showed an unexpected almost complete recovery despite the extensive initial clinical impairment.

Conclusion

Mountain cycling has not yet been described as a specific trigger of FCE with spinal cord infarction. Further observation is necessary to show if the prolonged bent posture and core muscle imbalance in cycling, in addition to the Valsalva manoeuvre during physical effort, may contribute to FCE. It is unknown if prognosis of spinal cord infarction due to FCE differs from other causes of spinal ischaemia and if anticoagulation treatment presents a therapeutic option.

Vascular Myelopathies

There are many vascular disorders that can affect the spinal cord, and their prevalence and etiology are highly influenced by age, sex, and risk factors. This article reviews the embryology and anatomy of the spinal cord, as well as several vascular conditions, describing their clinical and imaging presentation, emphasizing the different imaging modalities' contributions to increasing specificity and better defining the most appropriate therapy strategy for improving the patient's prognosis.

Long-segment spinal cord infarction complicated with multiple cerebral infarctions: a case report

Background

Spinal cord infarction is a rare disorder, constituting only 1% to 2% of all neurological vascular emergencies (making it less frequent than ischaemic brain injury); however, it is severe. A case of long-segment spinal cord infarction complicated with multiple cerebral infarctions has not been reported to date.

Case presentation

Here, we describe one such case: a patient with spinal cord infarction from the cervical 7 (C7) to thoracic 6 (T6) vertebrae, along with anterior spinal artery syndrome and complicated by multiple cerebral infarctions. A 65-year-old farmer experienced sudden onset of severe pain in his chest, back and upper limbs while unloading heavy objects. Subsequently, both his lower limbs became weak and hypoaesthetic, and he was unable to walk. Spinal magnetic resonance imaging (MRI) revealed equal T1 and long T2 signals centred on the anterior horn of the spinal cord. The axial slice of these signals was shaped like an owl’s eye. After receiving drug treatment and active rehabilitation treatment, the patient’s ability to walk was restored.

Conclusions

Long-segment spinal cord infarction is rare and can be complicated with cerebral infarction. The specific aetiology is worth exploring.

Spinal cord infarction in a young adult: What is the culprit?

Context: Non-traumatic spinal cord infarction in the young adult is usually associated with a single or multiple genetic mutations. There are certain gene mutations that are more commonly associated with spinal cord infarctions. Homozygous or heterozygous mutations, and single mutations or polymorphism, do not seem to determine the probability of spinal cord infarction.Findings: We add another case of spinal cord infarction in a young adult to the few reported in the literature, and discuss the value of genetic studies and genetic counseling.Conclusion: Non-traumatic spinal cord infarction is usually caused by a genetic mutation. Early recognition of this entity and definition of the mutation will limit unnecessary and invasive procedures and allows early rehabilitation, preventive measures for complications and genetic counseling.

Pediatric spinal cord infarct: a rare cause of a rare disorder, (wo)man in barrel syndrome

The "man in barrel syndrome" is a condition which resembles the aspect of patient being constrained in a barrel in which patient presents with bilateral upper limb weakness. It has classically been attributed to supratentorial lesions in watershed zones. We present such a case in a 12-year-old child who presented with bibrachial weakness and was noted to have cervical cord infarct on imaging. Spinal cord infarct is a rare cause of this syndrome, and until now only 20 cases have been described in which cervical cord infarct led to this presentation, all of them being adults. We describe first case report of bibrachial diplegia due to cord infarct in a child. Our case adds to the limited literature of cervical cord ischemia as a cause of "(wo) man in barrel syndrome" and re-iterates the fact that imaging of cervical cord should be considered while evaluating these cases.

Acute Myelopathy: Vascular and Infectious Diseases

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.

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.

Acute spontaneous spinal cord infarction: Utilisation of hyperbaric oxygen treatment, cerebrospinal fluid drainage and pentoxifylline

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.

Hyperacute extensive spinal cord infarction and negative spine magnetic resonance imaging: a case report and review of the literature

RATIONALE

Spinal cord infarction (SCI) accounts for only 1% to 2% of all ischemic strokes and 5% to 8% of acute myelopathies. Magnetic resonance imaging (MRI) holds a role in ruling out non-ischemic etiologies, but the diagnostic accuracy of this procedure may be low in confirming the diagnosis, even when extensive cord lesions are present. Indeed, T2 changes on MRI can develop over hours to days, thus accounting for the low sensitivity in the hyperacute setting (ie, within 6 hours from symptom onset). For these reasons, SCI remains a clinical diagnosis. Despite extensive diagnostic work-up, up to 20% to 40% of SCI cases are classified as cryptogenic. Here, we describe a case of cryptogenic longitudinally extensive transverse myelopathy due to SCI, with negative MRI and diffusion-weighted imaging at 9 hours after symptom onset.

PATIENT CONCERNS

A 51-year-old woman presented to our Emergency Department with acute severe abdominal pain, nausea, vomiting, sudden-onset of bilateral leg weakness with diffuse sensory loss, and paresthesias on the trunk and legs.

DIAGNOSES

On neurological examination, she showed severe paraparesis and a D6 sensory level. A 3T spinal cord MRI with gadolinium performed at 9 hours after symptom onset did not detect spinal cord alterations. Due to the persistence of a clinical picture suggestive of an acute myelopathy, a 3T MRI of the spine was repeated after 72 hours showing a hyperintense "pencil-like" signal mainly involving the grey matter from T1 to T6 on T2 sequence, mildly hypointense on T1 and with restricted diffusion.

INTERVENTIONS

The patient was given salicylic acid (100 mg/d), prophylactic low-molecular-weight heparin, and began neuromotor rehabilitation.

OUTCOMES

Two months later, a follow-up neurological examination revealed a severe spastic paraparesis, no evident sensory level, and poor sphincteric control with distended bladder.

LESSONS

Regardless of its relatively low frequency in the general population, SCI should be suspected in every patient presenting with acute and progressive myelopathic symptoms, even in the absence of vascular risk factors. Thus, a clinical presentation consistent with a potential vascular syndrome involving the spinal cord overrides an initially negative MRI and should not delay timely and appropriate management.

Collateral Circulation in Spinal Cord Injury: A Comprehensive Review

Surgery is the most common cause of spinal cord ischemia; it is also caused by hemodynamic changes, which disrupt the blood flow. Direct ligation of the spinal arteries, especially the Adamkiewicz artery is involved as well. Other causes of spinal cord ischemia include arteriography procedures, thoracic surgery, epidural and rachianesthesia, foraminal infiltration, arterial dissection, systemic hypotension, emboligenic heart disease, thoracic disc herniation, and compression. Understanding the vascular anatomy of the spinal cord is essential to develop optimal strategies for preventing ischemic injuries to the spinal cord. During ischemia, a rich network of intra and paraspinal collaterals allow enough blood flow to compensate the intensity of spinal cord ischemia. In case of interruption of flow of a main artery, the collateral artery increases its flow to maintain perfusion to the tissues. Avoiding spinal cord ischemia by using collateral circulation is necessary to prevent the establishment of hypovolemia, hyperthermia and elevations in venous pressures. The objective of this narrative review is to present the current concepts of spinal collateral circulation and its role in the setting of ischemic events, affecting the vascular supply of the spinal cord.

Acute Traumatic and Ischemic Spinal Cord Injuries Have a Comparable Course of Recovery

Background. The relative rarity of ischemic compared with traumatic spinal cord injury (SCI) has limited a comparison of the outcomes of these conditions. Objective. To investigate the neurological and functional recovery of ischemic compared with traumatic acute SCI. Methods. Data were derived from the European Multicenter Study Spinal Cord Injury database. Patients with ischemic (iSCI) or traumatic SCI (tSCI), aged 18 years or older were evaluated at different time points from incidence: at about 1 month, 3 months, and 6 months. The neurological status was assessed at each time point by the International Standards for Neurological Classification of Spinal Cord Injury and the functional status by the Spinal Cord Independence Measure. Walking ability was evaluated by Walking Index for Spinal Cord Injury, 10-Meter Walk Test, and 6-Minute Walk Test. Because of the imbalances of the 2 groups in respect to size and lesion severity, a matching procedure according to age, neurological level, and severity of injury was performed. Outcomes evaluation was performed by means of a 2-way repeated-measures ANOVA. Results. The matching procedure resulted in 191 pairs. Both groups significantly improved from about 15 days after the lesion to 6 months. No differences were found in the course of neurological and functional recovery of iSCI compared with tSCI. Conclusions. This analysis from a representative cohort of participants revealed that from 15 days following the cord damage onward, the outcomes after iSCI and tSCI are comparable. This finding supports the potential enrolment of patients with acute iSCI into clinical trials from that point in time after the event and an evaluation up to 6 months afterward.

Vascular Disorders of the Spinal Cord

PURPOSE OF REVIEW

Prompt recognition and timely management of vascular disorders of the spinal cord can improve patient outcomes. This article provides contemporary and practical knowledge about the most common vascular myelopathies.

RECENT FINDINGS

New studies have provided additional information on the risk factors and impact of neurologic monitoring on perioperative spinal cord infarction. Additionally, recent publications have provided information on the impact of misdiagnosis, corticosteroid treatment, and postoperative prognosis in the treatment of spinal dural arteriovenous fistulas and have discussed the outcome of patients with spinal arteriovenous malformations treated with embolization, surgery, and stereotactic radiosurgery. Finally, recent studies have provided information on the natural history and postoperative prognosis of spinal cavernous malformations and on the risk factors and surgical outcome of patients with spinal epidural hematomas.

SUMMARY

Diagnostic and therapeutic challenges are inherent in managing patients with vascular disorders of the spinal cord, and clinicians should have a thorough understanding of these disorders to facilitate optimal outcomes for patients with these potentially devastating illnesses. This article begins by reviewing functional vascular anatomy and subsequently describes the fundamental characteristics of both ischemic and hemorrhagic vascular myelopathies to equip clinicians with the knowledge to avoid common pitfalls.

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 in a Patient Undergoing Veno-arterial Extracorporeal Membrane Oxygenation

Spinal cord infarction is an uncommon, but serious disorder characterized by severe motor impairment and bladder and bowel dysfunction. Spinal cord infarction is likely caused by hypoperfusion at the thoraco-lumbar spinal cord due to diverse reasons. An 81-year-old woman without motor or neurologic dysfunction presented with cardiogenic shock due to acute myocardial infarction. We performed veno-arterial extracorporeal membrane oxygenation (VA ECMO) to maintain adequate organ perfusion. Lower limb weakness was noted on day 1 of ECMO support. Although the symptom persisted, we could not carry out further evaluation because of her hemodynamic instability. After removal of ECMO, spinal magnetic resonance imaging was performed and showed a signal abnormality extending from the level of T5 to the conus medullaris. The patient underwent conservative management, but eventually experienced limb paralysis. Herein, we report a case of spinal cord infarction in a patient with myocardial infarction during VA ECMO support.

Childhood idiopathic spinal cord infarction: Description of 7 cases and review of the literature

OBJECTIVES

To describe the clinical course, neuroimaging findings and functional outcome of idiopathic spinal cord infarction (SCI) in adolescents.

METHODS

Retrospective and descriptive analyses of seven patients with idiopathic SCI and 50 additional cases from the literature were included. Data collected concerned clinical presentation, MRI findings, initial diagnosis, treatments and functional outcome at the last medical visit.

RESULTS

Mean age at presentation was 13.2years (range 13-15). All patients presented a sudden and painful acute myelopathy with <24h time to maximal symptoms manifestation. A suspected trigger related to a minor effort was reported in 3/7 cases. Six patients presented with paraplegia, one with paraparesis. All had bladder dysfunction needing catheterization. Three patients had an initial misdiagnosis. Initial MRI was considered as normal in 2 cases. In the 5 other cases, T2-weighted-MR images showed hyperintensity within the thoracolumbar spinal cord, affecting mostly the anterior spinal artery territory. Evidence for associated spinal growth dystrophy were present in 6/7 cases. Mean follow-up time was 27.4months (range 3-46): 2 patients recovered autonomous ambulation, 4 patients regained walking ability with aids and one child (the shortest follow-up) remained wheelchair-dependent. A neurogenic bladder was still reported in 6/7 children at the last visit. Complementary analyses with literature cases were consistent with the findings obtained in our cohort.

CONCLUSION

Idiopathic SCI typically occurs in adolescence with a rapid onset and painful acute myelopathy. The MRI shows a T2-hyperintense signal within the spinal cord and provides evidence for an ischemic mechanism. Etiology remains unclear in most cases even though some specific risk factors for this age must play an important role in the pathogenesis, such as mechanical constraints on the immature spine.

Spinal Cord Infarcts: Risk Factors, Management, and Prognosis

OPINION STATEMENT

There are no standard guidelines for treatment of spinal cord ischemia due to how rare it is and the diverse etiology and presentations involved. In addition, to date, there have been no large clinical trials examining ideal pharmacologic treatment options for spinal cord infarct. In our practice, we rely on hemodynamic augmentation initiated as soon as possible. Otherwise, treatment is usually geared towards the etiology of spinal cord ischemia. For instance, spinal cord ischemia occurring after aortic aneurysmal repair may improve with CSF drainage through a lumbar catheter in the periprocedural setting. Vertebral artery dissection should be treated with antithrombotics. If no clear etiology is found and there is evidence of atherosclerosis in other vascular beds, then management is focused on risk factor modification with blood pressure and glucose control, statins, and antithrombotics.

Delayed Hospital Presentation and Neuroimaging in Non-surgical Spinal Cord Infarction

BACKGROUND

Lack of timely recognition and neuroimaging may be a barrier to reperfusion efforts in acute spinal cord infarction.

METHODS

We performed a retrospective study of patients diagnosed with acute non-surgical spinal cord infarction at our tertiary academic center from 2001 to 2015. We studied parameters associated with time from symptom onset to initial hospital presentation and magnetic resonance imaging (MRI) of the spinal cord.

RESULTS

We identified 39 patients among whom anterior spinal artery syndrome was the most frequent presentation (87.2%) and atherosclerosis the most common etiology (56.4%). Nearly, half of the patients presented to the emergency department on the same day of symptom onset (48.7%) but only nine (23.1%) within the first 6 h. Average time from symptom onset to spinal cord MRI was 3.2 days. We could not identify clinical, radiological, or outcome patterns associated with early vs. delayed presentation and imaging.

DISCUSSION

Our study found a time lag from symptom onset to hospital presentation and spinal cord MRI in patients with acute spinal cord infarction. These findings point at low clinical suspicion of spinal cord syndromes and limited recognition as a potentially treatable medical emergency.

Lipoprotein(a)-hyperlipoproteinemia as cause of chronic spinal cord ischemia resulting in progressive myelopathy - successful treatment with lipoprotein apheresis

High concentrations of lipoprotein(a) (Lp(a)) represent an important independent and causal risk factor associated with adverse outcome in atherosclerotic cardiovascular disease (CVD). Effective Lp(a) lowering drug treatment is not available. Lipoprotein apheresis (LA) has been proven to prevent cardiovascular events in patients with Lp(a)-hyperlipoproteinemia (Lp(a)-HLP) and progressive CVD. Here we present the course of a male patient with established peripheral arterial occlusive disease (PAOD) at the early age of 41 and coronary artery disease (CAD), who during follow-up developed over 2 years a progressive syndrome of cerebellar and spinal cord deficits against the background of multifactorial cardiovascular risk including positive family history of CVD. Spastic tetraplegia and dependency on wheel chair and nursing care represented the nadir of neurological deficits. All conventional risk factors including LDL-cholesterol had already been treated and after exclusion of other causes, genetically determined Lp(a)-HLP was considered as the major underlying etiologic factor of ischemic vascular disease in this patient including spinal cord ischemia with vascular myelopathy. Treatment with an intensive regimen of chronic LA over 4.5 years now was successful to stabilize PAOD and CAD and led to very impressive neurologic and overall physical rehabilitation and improvement of quality of life.

Measurement of Lp(a) concentration must be recommended to assess individual cardiovascular risk. Extracorporeal clearance of Lp(a) by LA should be considered as treatment option for select patients with progressive Lp(a)-associated ischemic syndromes.

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.