Sulcal artery syndrome: A Three-patient series and review of literature

[A case of high cervical cord infarction presenting with cardiopulmonary arrest due to respiratory dysfunction]

A 46-year-old man with neck pain and impaired physical mobility called for emergency medical services. The patient was able to communicate with the emergency medical team upon their arrival. However, he went into cardiopulmonary arrest 5 minutes later. Cardiopulmonary resuscitation was immediately performed, and the patient was admitted to our hospital with a Glasgow Coma Scale score of E1V1M1. His respiratory rate was 5 breaths/minute and his partial pressure of carbon dioxide in arterial blood (PaCO2) was 127 ‍mmHg, necessitating intubation and ventilation. His consciousness improved as the PaCO2 level decreased. However, he was unable to be weaned off the ventilator and breathe independently. Neurological examination revealed flaccid quadriplegia, pain sensation up to the C5 level, absence of deep tendon reflexes, indifferent plantar responses, and absence of the rectoanal inhibitory reflex. Magnetic resonance imaging showed a hyperintense lesion with slight enlargement of the anterior two-thirds of the spinal cord at the C2-C4 level on both T2-weighted and diffusion-weighted images, consistent with a diagnosis of spinal cord infarction. Although the quadriplegia and sensory loss partially improved, the patient was unable to be weaned from the ventilator. Cervical cord infarction of the anterior spinal artery can cause rapid respiratory failure leading to cardiopulmonary arrest. Therefore, cervical cord infarction should be included as a differential diagnosis when examining patients after cardiopulmonary resuscitation.

Functional Anatomy of the Spinal Cord

Localization of lesions in the spinal cord requires knowledge of the functional anatomy of gray and white matter tracts. Using decussation points for white matter tracts can help determine lesion level. Pathologies can affect gray and white matter tracts in distinct ways and pattern recognition can help narrow down the differential diagnosis.

Clip Ligation and Disconnection of a Ruptured Ventral Subaxial Cervical Isolated Spinal Aneurysm Using Tailored Access Osteotomies: An Operative Technique

BACKGROUND

Isolated spinal aneurysms (iSAs) are lesions of the spinal vasculature with no associated vascular malformation with difficult management paradigms limited by safe access.

OBJECTIVE

To describe a case of an irregular fusiform ruptured distal subaxial cervical spine iSA with a complex angioarchitecture intimately associated with the ventral pial plexus (VPP), treated using open clip ligation and disconnection.

METHODS

A 51-year-old woman presented with complete spinal cord injury with a C8 sensory level and ventral subarachnoid hemorrhage at the C6-T1 vertebral levels. After emergent anterior evacuation and fusion, angiography revealed a small iSA around the VPP. A total laminectomy spanning C5 to T3 was completed, and bilateral C7 pedicle resections were performed. A temporary clip was placed from the left for proximal control, and a permanent clip was placed across the dome of the distal vessel for disconnection. The dura was then closed, and a cervicothoracic fusion completed.

RESULTS

Postoperative angiography confirmed iSA disconnection and obliteration with anterior spinal artery preservation. The patient had intermittent numbness in the right C8 dermatome. On postoperative day 1, she regained proprioception in the right foot and movement in the lower extremities on command. On postoperative day 3, she regained full sensation and voluntary movement in both lower extremities.

CONCLUSION

iSA is a rare and morbid condition with nonstandardized guidelines regarding management. We promote the concept of using tailored osteotomies to establish safe corridors for the open treatment of difficult subaxial cervical ventral lesions not amenable to transarterial treatment. Multidisciplinary collaboration is promising, and further investigation is highly warranted.

Isolated Infarctions of the Conus Medullaris: Clinical Features and Outcomes

OBJECTIVE

This study aims to describe the clinical features and outcomes of patients with isolated infarctions of the conus medullaris, and to identify factors associated with poor functional outcomes.

MATERIALS AND METHODS

We performed a systematic review and retrospective analysis on the clinical characteristics and outcomes of patients with isolated conus medullaris infarctions reported in literature over the past 30 years.

RESULTS

We analyzed a total of 19 cases; 18 identified in literature from January 1991 to June 2021, together with our patient. Their median age was 56 years (range 28-79), with twice as many females as males. Pain was prominent at onset (15/19, 79%), only a third had vascular risk factors (7/19, 37%), and half had no significant preceding activities or events (9/19, 47%). Almost all experienced paraplegia or paraparesis (16/19, 84%), in which upper motor neuron features were rare (3/19, 16%). The underlying cause was unknown in half (10/19, 53%). Functional outcomes appeared fair, with nearly half being capable of unassisted ambulation (9/11, 82%). Patients with vascular risk factors (67% vs 13%, p = 0.024) or with identified underlying causes (78% vs 13%, p = 0.007) were less likely to walk unassisted.

CONCLUSION

Isolated conus medullaris but should be considered in patients with acute cauda equina syndrome, especially in females. Patients with vascular risk factors, or with known causes of infarction, are less likely to walk unassisted. DWI sequences should be included in conventional MRI sequences when evaluating patients with acute cauda equina syndrome.