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Abu Mayyala W, Abu Aqeel N, Jobran AW, Shaheen F, Abdulrazzak M, Alhroub Y. Fibrocartilaginous embolism: a rare cause of cervical spine infarction. Ann Med Surg (Lond) 2024; 86:3165-3168. [PMID: 38694385 PMCID: PMC11060198 DOI: 10.1097/ms9.0000000000002005] [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] [Received: 01/22/2024] [Accepted: 03/16/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction and importance One of the uncommon causes of ischaemic myelopathy is fibrocartilaginous embolisation, which results from the intersomatic disc nucleus pulposus becoming embolised into the spinal vasculature during Valsalva-like manoeuvres. Case presentation A 29-year-old female patient presented to the authors' emergency department with general weakness, dizziness, and an inability to move her right hand after a minor trauma. These symptoms deteriorated suddenly until the patient became quadriplegic. The clinical picture and MRI led to a diagnosis of fibrocartilaginous embolism. Clinical discussion Fibrocartilaginous embolism is a rare cause of spine infarction. There is still little understanding of the underlying cause of FCE. Most cases occur sporadically in people without a family history of the disease, such as the authors' case, and diagnosis is based on imaging of the spinal cord and ruling out other causes of a blockage in the vascular system within the spinal cord, infectious and inflammatory causes. Conclusion When a practitioner suspects that a patient may have fibrocartilaginous embolism (FCE), they should take the patient's history and do a neurological examination. An MRI is required since it is thought to be the most accurate method of diagnosing FCE.
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Affiliation(s)
- Widad Abu Mayyala
- Faculty of medicine, Palestine Polytechnic University, Hebron, Palestine
| | - Nawras Abu Aqeel
- Faculty of medicine, Palestine Polytechnic University, Hebron, Palestine
| | | | - Farah Shaheen
- Faculty of medicine, Palestine Polytechnic University, Hebron, Palestine
| | | | - Yousef Alhroub
- Neurosurgery department, Hebron Governmental Hospital, Hebron, Palestine
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Kubota T, Hosaka T, Ando D, Ikeda K, Izumi R, Misu T, Warita H, Aoki M. Spinal Cord Infarction in an Adolescent with Protein S Deficiency: A Case Report and Literature Review. Intern Med 2023; 62:2415-2418. [PMID: 36631088 PMCID: PMC10484774 DOI: 10.2169/internalmedicine.0153-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 11/24/2022] [Indexed: 01/13/2023] Open
Abstract
Protein S deficiency causes spinal cord infarction in rare cases. We herein report the first case of severe cervicothoracic cord infarction in an adolescent with protein S deficiency. A 16-year-old boy presented with neck pain, four-limb paralysis, and numbness. Magnetic resonance imaging revealed spinal artery infarction in the C4 to Th4 area. Protein S antigen and activity were decreased. The patient was diagnosed with protein S deficiency-associated cervicothoracic cord infarction, which was treated with anticoagulation. Protein S deficiency should be considered as a potential cause of spinal cord infarction in young healthy patients and should be appropriately treated with anticoagulation.
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Affiliation(s)
| | | | - Daisuke Ando
- Department of Neurology, Tohoku University Hospital, Japan
| | - Kensuke Ikeda
- Department of Neurology, Tohoku University Hospital, Japan
| | - Rumiko Izumi
- Department of Neurology, Tohoku University Hospital, Japan
| | - Tatsuro Misu
- Department of Neurology, Tohoku University Hospital, Japan
| | - Hitoshi Warita
- Department of Neurology, Tohoku University Hospital, Japan
| | - Masashi Aoki
- Department of Neurology, Tohoku University Graduate School of Medicine, Japan
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3
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Heckman CA, Miller DJ, Kremer KM, Martinez ML, Jea AH. An ischemic myelopathy case series: Flaccid paraplegia following a spike ball save and numbness while walking normally. Brain Circ 2023; 9:107-111. [PMID: 37576578 PMCID: PMC10419739 DOI: 10.4103/bc.bc_80_22] [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: 10/19/2022] [Revised: 02/11/2023] [Accepted: 02/24/2023] [Indexed: 08/15/2023] Open
Abstract
Spinal cord infarctions in children are rare and early magnetic resonance imaging studies are often negative. A high clinical suspicion must be maintained to identify stroke and initiate workup for underlying etiology to suggest appropriate treatment. We present two cases of spinal cord infarction without major preceding trauma. The first was caused by disc herniation and external impingement of a radiculomedullary artery and the second was due to fibrocartilaginous embolism with classic imaging findings of ventral and dorsal cord infarctions, respectively. These cases were treated conservatively with diagnostic workup and aspirin, though additional treatments which can be considered with prompt diagnosis are also explored in our discussion. Both cases recovered the ability to ambulate independently within months. Case 1 is attending college and ambulates campus with a single-point cane. Case 2 ambulates independently, though has some difficulty with proprioception of the feet so uses wheelchairs for long-distance ambulation.
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Affiliation(s)
- Caroline A. Heckman
- Undergraduate, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Derryl J. Miller
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kelly M. Kremer
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, United States
| | - Mesha L. Martinez
- Department of Clinical Radiology and Imaging Sciences, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrew H. Jea
- Pediatric Neurosurgery, Oklahoma University, Oklahoma Children’s Hospital, Oklahoma, United States
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4
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Holanda ACD, Nunes MF, Medeiros FLD, Melo ESD. "Owl's eyes" sign in acute spinal cord infarction in newborn submitted to aortoplasty. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1184. [PMID: 36577420 PMCID: PMC9797264 DOI: 10.1055/s-0042-1758392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Arthur Cesario de Holanda
- Universidade Federal de Pernambuco, Hospital das Clínicas, Unidade de Neurologia e Neurocirurgia, Recife PE, Brazil.
| | | | | | - Eduardo Sousa de Melo
- Universidade Federal de Pernambuco, Hospital das Clínicas, Unidade de Neurologia e Neurocirurgia, Recife PE, Brazil.,Universidade Federal de Pernambuco, Centro de Ciências Médicas, Recife PE, Brazil.,Address for correspondence Eduardo Sousa de Melo
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Fu W, Church J, Garton H, Geiger J, Newman E. Pre-operative lumbar drain placement: A technique for minimizing ischemic spinal cord injury during neuroblastoma resection. J Pediatr Surg 2022; 57:1443-1445. [PMID: 34903356 DOI: 10.1016/j.jpedsurg.2021.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Whitney Fu
- Department of Surgery, Michigan Medicine, 1500 East Medicine Center Drive, 2920 Taubman Center, SPC 5331, Ann Arbor, MI 48109, United States.
| | - Joseph Church
- Department of Surgery, Division of Pediatric Surgery, Michigan Medicine, Ann Arbor, MI, United States; Division of Pediatric General and Thoracic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Hugh Garton
- Department of Neurosurgery, Michigan Medicine, Ann Arbor, MI, United States
| | - James Geiger
- Department of Surgery, Division of Pediatric Surgery, Michigan Medicine, Ann Arbor, MI, United States
| | - Erika Newman
- Department of Surgery, Division of Pediatric Surgery, Michigan Medicine, Ann Arbor, MI, United States
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Kim TH. Delayed Post-Traumatic Spinal Cord Infarction with Quadriplegia: A Case Report. JOURNAL OF TRAUMA AND INJURY 2021. [DOI: 10.20408/jti.2021.0004] [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] Open
Abstract
Traumatic spinal cord infarction is a rare condition that causes serious paralysis. The regulation of spinal cord blood flow in injured spinal cords remains unknown. Spinal cord infarction or ischemia has been reported after cardiovascular interventions, scoliosis correction, or profound hypotension. In this case, a 52-year-old man revisited the emergency center with motor and sensory abnormalities in all four extremities 56 hours after a motor vehicle collision. Despite the clinical presentation and imaging examination, there were no specific findings on the patient’s first visit to the trauma center. Cervical spine computed tomography angiography showed a narrow vertebral artery, and diffusion-weighted imaging revealed spinal cord infarction from C3 to C5 with high signal intensity. It should be kept in mind that delayed-onset spinal cord infarction may occur in minor or major trauma patients as a result of head and neck injuries.
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Bravar G, Luchesa Smith A, Siddiqui A, Lim M. Acute Myelopathy in Childhood. CHILDREN (BASEL, SWITZERLAND) 2021; 8:1055. [PMID: 34828768 PMCID: PMC8618498 DOI: 10.3390/children8111055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/04/2021] [Accepted: 11/11/2021] [Indexed: 12/13/2022]
Abstract
Acute myelopathy presenting in childhood can be clinically classified based on the location of injury (with resulting spinal syndrome) or the cause (broadly traumatic or non-traumatic). Types of nontraumatic myelopathy include ischaemic, infectious, inflammatory, nutritional, and metabolic causes, some of which may be part of a systemic illness such as systemic lupus erythematosus or a demyelinating disease such as multiple sclerosis. Nonaccidental injury is an important consideration in cases of traumatic myelopathy, which may often be associated with other injuries. Assessment should include neuroimaging of the brain and spinal cord, with further investigations targeted based on the most likely differential diagnoses; for example, a child with suspected demyelinating disease may require specialist cerebrospinal fluid and serological testing. Management also will differ based on the cause of the myelopathy, with several of these treatments more efficacious with earlier initiation, necessitating prompt recognition, diagnosis, and treatment of children presenting with symptoms of a myelopathy. Important components of holistic care may include physiotherapy and occupational therapy, with multidisciplinary team involvement as required (for example psychological support or specialist bowel and bladder teams).
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Affiliation(s)
- Giulia Bravar
- Department of Paediatrics, Hospital Santa Maria della Misericordia, 33100 Udine, Italy;
| | | | - Ata Siddiqui
- Children’s Neurosciences, Evelina London Children’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London SE1 7EH, UK;
- Department of Neuroradiology, King’s College Hospital, London SE5 9RS, UK
| | - Ming Lim
- Children’s Neurosciences, Evelina London Children’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London SE1 7EH, UK;
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London SE5 9NU, UK
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Abstract
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.
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Affiliation(s)
- Maria Khoueiry
- Department of Neurology, American University Medical Center, Beirut, Lebanon
| | - Hussein Moussa
- Department of Neurology, American University Medical Center, Beirut, Lebanon
| | - Raja Sawaya
- Department of Neurology, American University Medical Center, Beirut, Lebanon,Correspondence to: Raja Sawaya, Clinical Neurophysiology Laboratory, AmericanUniversity Medical Center, POB: 113 - 6044 / C-27, Beirut, Lebanon; Ph: 00-961-3347377.
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9
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Lim J, Hamouda ES, Fortier MV, Thomas T. Antecedent Minor Trauma and Hyperacute Presentations in Childhood Transverse Myelitis. J Child Neurol 2021; 36:1034-1041. [PMID: 34353149 DOI: 10.1177/08830738211025856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Fibrocartilaginous embolism and spinal cord infarction may resemble transverse myelitis with antecedent minor trauma (sporting activity or minor falls) or with hyperacute (<12-hour) presentation. METHODS Diagnostic criteria for fibrocartilaginous embolism and spinal cord infarction were applied to a 10-year (2007-2016) cohort of children aged 1 month to 16 years with transverse myelitis and clinical, laboratory, neuroimaging, and outcome data compared between those with and without antecedent minor trauma. RESULTS Thirty-two children of median age 8.9 (range 2.7-15.8) years were included; 19 (59%) were female. Falls at home, school, or play (6 children, 60%), swimming (2, 20%), physical education (1, 10%), and caning (1, 10%) were antecedent events in 10 (31%) children. Six (19%) had hyperacute presentations. One patient met spinal cord infarction criteria; none had fibrocartilaginous embolism. Children with transverse myelitis and antecedent minor trauma had single, short spinal cord lesions (median 3 vertebral bodies) but without a specific neuroimaging lesion pattern. None had intervertebral disc abnormalities or brain involvement and were negative for myelin oligodendrocyte and aquaporin 4 antibodies. Twenty-five (86%) of 29 had cerebrospinal fluid inflammation, and 30 (94%) received immunotherapy. Thirty (97%) were followed for a median of 3.6 (0.1-10.2) years, with good outcome (modified Rankin Scale score 0-1) in the majority (80%). Four (75%) with hyperacute presentation had a good outcome (modified Rankin Scale score 0-1), but the patient with spinal cord infarction was the most disabled (modified Rankin Scale score 4). CONCLUSION Minor trauma or hyperacute presentations does not always indicate fibrocartilaginous embolism or spinal cord infarction. Children with minor trauma preceding transverse myelitis have a distinct clinicoradiologic syndrome, with good outcome following immunotherapy.
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Affiliation(s)
- Jocelyn Lim
- Neurology Service, Department of Paediatric Medicine, 37579KK Women's and Children's Hospital, Singapore
| | - Ehab Shaban Hamouda
- Department of Radiology, Children and Adolescent Services, 200462Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Marielle Valerie Fortier
- Department of Diagnostic & Interventional Imaging, 37579KK Women's and Children's Hospital, Singapore
| | - Terrence Thomas
- Neurology Service, Department of Paediatric Medicine, 37579KK Women's and Children's Hospital, Singapore
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10
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Sarkaki A, Rashidi M, Ranjbaran M, Asareh Zadegan Dezfuli A, Shabaninejad Z, Behzad E, Adelipour M. Therapeutic Effects of Resveratrol on Ischemia-Reperfusion Injury in the Nervous System. Neurochem Res 2021; 46:3085-3102. [PMID: 34365594 DOI: 10.1007/s11064-021-03412-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 01/07/2023]
Abstract
Resveratrol is a phenol compound produced by some plants in response to pathogens, infection, or physical injury. It is well-known that resveratrol has antioxidant and protective roles in damages potentially caused by cancer or other serious disorders. Thus, it is considered as a candidate agent for the prevention and treatment of human diseases. Evidence has confirmed other bioactive impacts of resveratrol, including cardioprotective, anti-tumorigenic, anti-inflammatory, phytoestrogenic, and neuroprotective effects. Ischemia-reperfusion (IR) can result in various disorders, comprising myocardial infarction, stroke, and peripheral vascular disease, which may continue to induce debilitating conditions and even mortality. In virtue of chronic ischemia or hypoxia, cells switch to anaerobic metabolism, giving rise to some dysfunctions in mitochondria. As the result of lactate accumulation, adenosine triphosphate levels and pH decline in cells. This condition leads cells to apoptosis, necrosis, and autophagy. However, restoring oxygen level upon reperfusion after ischemia by producing reactive oxygen species is an outcome of mitochondrial dysfunction. Considering the neuroprotective effect of resveratrol and neuronal injury that comes from IR, we focused on the mechanism(s) involved in IR injury in the nervous system and also on the functions of resveratrol in the protection, inhibition, and treatment of this injury.
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Affiliation(s)
- Alireza Sarkaki
- Department of Physiology, School of Medicine, Persian Gulf Physiology Research Center, Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mojtaba Rashidi
- Department of Biochemistry, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mina Ranjbaran
- Department of Physiology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Aram Asareh Zadegan Dezfuli
- Department of Microbiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Zahra Shabaninejad
- Department of Nanotechnology, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Ebrahim Behzad
- Neurology Department, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Adelipour
- Department of Biochemistry, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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de Brito Chagas J, Cancelinha C, Pais RP, Costa C. Spinal cord ischaemic injury while playing in a playground. BMJ Case Rep 2021; 14:14/7/e242155. [PMID: 34226254 DOI: 10.1136/bcr-2021-242155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Spinal cord ischaemia is a rare condition in children in which imaging diagnosis can be difficult and treatment guidelines are not well established. We describe a case of a previously healthy 13-year-old girl admitted to the emergency department with an acute flaccid paralysis of the lower limbs, abdominal and dorsal pain, and bladder dysfunction. A few hours earlier, she had been playing on a swing with hyperextension and an arched back position. Spinal cord MRI was normal in the first hours, but ischaemic signs were described in a second examination performed some hours later. We discuss the extensive investigation for differential diagnosis and the management of this case.
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Affiliation(s)
- Joana de Brito Chagas
- Paediatric Medical Service, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Candida Cancelinha
- Paediatric Medical Service, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Paediatric University Clinic, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Rui Pedro Pais
- Medical Imaging Service, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carmen Costa
- Neuropaediatric Unit, Child Development Centre, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Vijay CS, Nield TR, Nield LS. Paraplegia After Basketball Play: A Case of Spinal Cord Infarction Secondary to Fibrocartilaginous Embolization. Pediatr Emerg Care 2021; 37:e401-e403. [PMID: 30399067 DOI: 10.1097/pec.0000000000001666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Pediatric emergency medicine providers must be astute at generating the differential diagnosis and performing the appropriate evaluation to promptly determine the underlying cause of new onset paraplegia. Spinal cord infarction (SCI) is a potential etiology of paraplegia in children, and fibrocartilaginous embolization is a rare underlying cause of SCI. We present an illustrative case of SCI secondary to fibrocartilaginous embolization in an otherwise healthy adolescent who developed symptoms of spinal cord dysfunction after basketball play.
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Affiliation(s)
- Chickajajur S Vijay
- From the Department of Pediatrics, Section of Hospital Medicine, West Virginia University School of Medicine
| | - Timothy R Nield
- From the Department of Pediatrics, Section of Hospital Medicine, West Virginia University School of Medicine
| | - Linda S Nield
- Departments of Medical Education and Pediatrics, Section of General Pediatrics, West Virginia University School of Medicine, Morgantown, WV
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Putzeys CC, Batra M, Maertens P, Sharma K. A Curious Case of Progressive Respiratory Failure Due to Anterior Spinal Cord Infarction in an Adolescent Boy: A Case Report and Review of the Literature. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1731397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractClinical features of cervical spontaneous spinal cord infarctions (SSCIs) remain poorly described in the literature. The goal of this article was to improve recognition of cervical SSCI, a rare but life-threatening condition. We presented a 15-year-old adolescent male patient who developed neck pain with weakness and numbness in all four limbs half an hour after returning from a hike in the late afternoon. The next morning, he was brought to the emergency room due to persistent weakness, vomiting, and progressive respiratory distress. He was promptly intubated for airway protection. Pupils were 2 mm, sluggishly reactive, and all four extremities were flaccid. He was found to have anterior spinal cord syndrome. Light touch (brush) was normal down to the posterior aspect of shoulders. Cervical magnetic resonance imaging (MRI) showed increased T2/short-tau inversion recovery and decreased T1 signal of the anterior spinal cord from C3 to C7. Four days later, MRI of the spinal cord showed restricted diffusion of anterior spinal cord consistent with radicular artery territory infarction. The work-ups for infection, thrombosis, and cardioembolism were all negative. Three months later, he still had incomplete Brown-Séquard's syndrome, as position sense was preserved. There was in addition bilateral loss of pain and temperature sensations below the clavicles. MRI showed cervical myelomalacia most severe between C3 and C5. Furthermore, MRI showed changes in C3–C4 intervertebral disc, consistent with a fibrocartilaginous embolism via retrograde arterial route into the anterior spinal artery. This article demonstrates the importance of recognizing subtle clinical clues leading to cervical SSCI diagnosis.
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Affiliation(s)
| | - Mansi Batra
- Department of Pediatrics, University of South Alabama, Mobile, Alabama, United States
| | - Paul Maertens
- Division of Child Neurology, Department of Neurology, University of South Alabama, Mobile, Alabama, United States
| | - Kamal Sharma
- Division of Pediatric Critical Care, Department of Pediatrics, University of South Alabama, Mobile, Alabama, United States
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Fibrocartilagenous embolism case series: is it a zebra? Spinal Cord Ser Cases 2021; 7:28. [PMID: 33850104 DOI: 10.1038/s41394-021-00395-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION There have been 30 clinically suspected cases and 41 histopathologically confirmed cases of fibrocartilaginous embolism (FCE) reported in the literature. FCE often has a poor prognosis and is estimated to represent 5.5% of spinal cord infarctions, but may be more common than initially presumed given underdiagnosis due to its vague clinical presentation. CASE PRESENTATION We report two cases, a 15-year-old male and a 15-year-old female, whose clinical history, examination, and imaging findings were consistent with spinal cord infarction secondary to FCE. DISCUSSION These cases were unique given our patients' neurologic improvement; however, the commonly held assumption of poor prognosis may in part be fueled by the preferential case ascertainment via biopsy on autopsy. These cases highlight the importance of recognizing rare causes of spinal cord pathology and considering FCE in the differential diagnosis of acute myelopathy.
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Rodrigues M, Beça G, Almeida A, Natário I, Vilabril F, Pereira M, Barreto J, Dias L, Gandarez F. Spinal cord infarction in children: Can gymnastics be a cause? J Pediatr Rehabil Med 2021; 14:97-101. [PMID: 33164960 DOI: 10.3233/prm-200684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Spinal cord infarction (SCI) in children is rare and difficult to diagnose. Fibrocartilaginous embolism (FCE) is probably the underlying cause for some unexplained cases of spinal cord infarcts. Abrupt back pain followed by a progressive syndrome of myelopathy appears to be the typical presentation, with a close temporal relationship between the onset of symptoms and preceding minor trauma. Supportive care and rehabilitation are essential in the treatment of children with SCI. CASE REPORT A previously healthy 12-year-old girl who practiced acrobatic gymnastics was admitted to a rehabilitation centre 14 days after being diagnosed with an acute anterior SCI with no identified cause. Sensory modality of pin prick and light touch were impaired, with the former more significantly affected. She was not able to run and had difficulty on monopodal standing and performing motor sequencing. Additionally, she mentioned ineffective cough along with flatus incontinence and normal bladder function. After a 4-week multidisciplinary rehabilitation program her neurologic deficits improved. DISCUSSION Given the patient's age and clinical presentation, a literature review led to the consideration of FCE as the most likely definitive diagnosis. It should be recognized as a cause of SCI especially in those involved in sport activities, even if previous trauma is denied.
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Affiliation(s)
| | - Gustavo Beça
- Centro de Reabilitação do Norte, Vila Nova de Gaia, Portugal
| | - Ana Almeida
- Centro de Reabilitação do Norte, Vila Nova de Gaia, Portugal
| | - Inês Natário
- Centro de Reabilitação do Norte, Vila Nova de Gaia, Portugal
| | - Filipa Vilabril
- Serviço de Medicina Física e de Reabilitação, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | | | - José Barreto
- Serviço de Medicina Física e de Reabilitação, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - Leonor Dias
- Serviço de Neurologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Fátima Gandarez
- Centro de Reabilitação do Norte, Vila Nova de Gaia, Portugal
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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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Morshid A, Jadiry HA, Chaudhry U, Raghuram K. Pediatric spinal cord infarction following a minor trauma: a case report. Spinal Cord Ser Cases 2020; 6:95. [PMID: 33046690 DOI: 10.1038/s41394-020-00344-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/14/2020] [Accepted: 09/18/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Pediatric spinal cord infarction is a rare entity that presents a diagnostic challenge at the emergency department. Ischemic spinal cord infarction can occur in the setting of trauma, cardiovascular malformation, or postoperatively. We report a case of anterior spinal artery infarction following seemingly minor trauma in an otherwise healthy 14-year-old male. CASE PRESENTATION A 14-year-old male presented with unprovoked sudden-onset stabbing back pain earlier that day. The patient then demonstrated bilateral lower extremities weakness while at the emergency department. After extensive diagnostic workup, the patient was diagnosed with anterior spinal artery territory infarction involving the thoracic spinal cord. Minor trauma to the thoracic spinal cord was detected on imaging and was believed to be the culprit of this event. DISCUSSION Given the rarity of spinal cord ischemia, a high index of suspicion and extensive workup of patients presenting with clinical weakness are needed for accurate diagnosis and to avoid the eventual poor outcome. With so few reports in the literature regarding spinal cord ischemia in the pediatric population, accurate diagnosis is often delayed until after irreversible events have already taken place. Our case report of anterior spinal artery distribution thoracic cord infarct following a minor trauma was diagnosed by axial thin-slice DWI MRI with an otherwise negative workup.
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Affiliation(s)
- Ali Morshid
- Department of Diagnostic Radiology, The University of Texas Medical Branch, Galveston, TX, USA.
| | - Huda Al Jadiry
- Department of Diagnostic Radiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Umar Chaudhry
- Department of Diagnostic Radiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Karthikram Raghuram
- Department of Diagnostic Radiology, The University of Texas Medical Branch, Galveston, TX, USA
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Ponomarev GV, Lalayan TV, Dambinova SA, Skoromets AA. The neurotoxicity biomarkers as potential indicators of the spinal cord ischemia. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:52-57. [DOI: 10.17116/jnevro20181182152-57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mechanism of Neuroprotection Against Experimental Spinal Cord Injury by Riluzole or Methylprednisolone. Neurochem Res 2017; 44:200-213. [PMID: 29290040 DOI: 10.1007/s11064-017-2459-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/12/2017] [Accepted: 12/26/2017] [Indexed: 12/29/2022]
Abstract
Any spinal cord injury carries the potential for persistent disability affecting motor, sensory and autonomic functions. To prevent this outcome, it is highly desirable to block a chain of deleterious reactions developing in the spinal areas immediately around the primary lesion. Thus, early timing of pharmacological neuroprotection should be one major strategy whose impact may be first studied with preclinical models. Using a simple in vitro model of the rat spinal cord it is possible to mimic pathological processes like excitotoxicity that damages neurons because of excessive glutamate receptor activation due to injury, or hypoxic/dysmetabolic insult that preferentially affects glia following vascular dysfunction. While ongoing research is exploring the various components of pathways leading to cell death, current treatment principally relies on the off-label use of riluzole (RLZ) or methylprednisolone sodium succinate (MPSS). The mechanism of action of these drugs is diverse as RLZ targets mainly neurons and MPSS targets glia. Even when applied after a transient excitotoxic stimulus, RLZ can provide effective prevention of secondary excitotoxic damage to premotoneurons, although not to motoneurons that remain very vulnerable. This observation indicates persistent inability to express locomotor activity despite pharmacological treatment conferring some histological protection. MPSS can protect glia from dysmetabolic insult, yet it remains poorly effective to prevent neuronal death. In summary, it appears that these pharmacological agents can produce delayed protection for certain cell types only, and that their combined administration does not provide additional benefit. The search should continue for better, mechanism-based neuroprotective agents.
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Bar C, Cheuret E, Bessou P, Pedespan JM. Childhood idiopathic spinal cord infarction: Description of 7 cases and review of the literature. Brain Dev 2017; 39:818-827. [PMID: 28578817 DOI: 10.1016/j.braindev.2017.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/11/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Claire Bar
- Service de Neurologie Pédiatrique, Hôpital Pellegrin-Enfants, CHU de Bordeaux, France.
| | - Emmanuel Cheuret
- Service de Neurologie Pédiatrique, Hôpital des Enfants, CHU de Toulouse, France
| | - Pierre Bessou
- Service d'imagerie anténatale, de l'enfant et de la femme, Hôpital Pellegrin-Enfants, CHU de Bordeaux, France
| | - Jean-Michel Pedespan
- Service de Neurologie Pédiatrique, Hôpital Pellegrin-Enfants, CHU de Bordeaux, France
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Acute complete paraplegia of 8-year-old girl caused by spinal cord infarction following minor trauma complicated with longitudinal signal change of spinal cord. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:1432-1435. [DOI: 10.1007/s00586-017-4995-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 01/18/2017] [Accepted: 02/06/2017] [Indexed: 12/15/2022]
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Turgut AT, Turgut M. Paediatric spinal cord infarction-a review of the literature and two case reports. Childs Nerv Syst 2017; 33:211-212. [PMID: 28054102 DOI: 10.1007/s00381-016-3331-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Ahmet Tuncay Turgut
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Turgut
- Department of Neurosurgery, Adnan Menderes University Faculty of Medicine, Aydın, Turkey.
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Mathias E, Sethuraman U. Ischemic Stroke of the Spinal Cord: A Pediatric Emergency in an Otherwise Healthy Child. J Emerg Med 2016; 51:73-6. [PMID: 27131834 DOI: 10.1016/j.jemermed.2016.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 02/09/2016] [Accepted: 03/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Spinal cord infarctions in children are rare, with few cases reported in the literature. Recognition is challenging, as children's clinical presentations and underlying pathological processes differ from those of adults. Most reported cases are in children with predisposing medical conditions, but spinal cord strokes can occur in otherwise healthy individuals. CASE REPORT A 10-year-old boy with no significant medical history presented with progressive left-sided weakness and neck pain. He was diagnosed with ischemic infarction of his inferior medulla and cervical spinal cord. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ischemic stroke of the spinal cord should be considered in children with clinical weakness, even in the absence of risk factors.
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Affiliation(s)
- Emily Mathias
- Pediatric Emergency Medicine, Carman & Ann Adams Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Usha Sethuraman
- Pediatric Emergency Medicine, Carman & Ann Adams Department of Pediatrics, Wayne State University, Detroit, Michigan
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Reid S, Sell E. Case 2: Acute paralysis in a 10-year-old girl. Paediatr Child Health 2015; 20:289-90. [DOI: 10.1093/pch/20.6.289a] [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] Open
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Acute asymmetrical spinal infarct secondary to fibrocartilaginous embolism. Childs Nerv Syst 2015; 31:487-91. [PMID: 25293530 DOI: 10.1007/s00381-014-2562-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 09/18/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Spinal cord infarction is extremely rare in childhood and can result from a wide range of causes. Fibrocartilaginous embolism can give rise to spinal stroke and mimic non-vascular disease such as acute transverse myelitis. CASE We report two children who suffered an asymmetrical spinal cord infarction due to fibrocartilaginous embolism. The clinical presentation, radiological findings, and pathophysiology of fibrocartilaginous embolism are described. Each patient demonstrated marked clinical improvement after receiving extensive physical therapy and rehabilitation. One child demonstrated complete clinical recovery. The other had persistent asymmetrical foot weakness and distal sensory deficits. CONCLUSION We outline the key clinical and radiographic features that enable spinal cord infarction to be differentiated from transverse myelitis. Prognosis depends on many factors such as extent and type of injury, level of the cord affected, and age at the time of spinal cord infarction.
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Abstract
BACKGROUND AND PURPOSE This case report describes an aggressive, task-specific program for the recovery of gait in a girl with a spinal cord stroke. CASE DESCRIPTION The 11-year-old girl sustained a spinal cord stroke resulting in a T4 motor-incomplete lesion. Therapy was initiated 6 months after onset when she was not ambulating. INTERVENTION The focus of all interventions was on the restoration of gait. Locomotor treadmill training and over ground walking were the primary practice interventions. Walking was facilitated by orthoses, neuromuscular electrical stimulation, laser treatments, and strengthening. Treatment continued for 18 months. OUTCOMES At the conclusion of therapy, the client was able to walk independently in the community with a single ankle foot orthosis and reverse rolling walker. DISCUSSION The outcome was not anticipated for this client, given the type and level of her injury and the delay in starting gait training.
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28
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Three unique presentations of atraumatic spinal cord infarction in the pediatric emergency department. Pediatr Emerg Care 2014; 30:354-7. [PMID: 24786993 DOI: 10.1097/pec.0000000000000130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Nontraumatic spinal cord infarction is especially rare in children. Although diagnosis is easily made with magnetic resonance imaging, the typical presenting signs and symptoms and etiology remain elusive. Evidence-based treatment courses are not available. We assess a series of 3 unique patients with nontraumatic spinal cord infarction who presented to our emergency department over the course of 2 years. We consider their presentation, etiology, and treatment course to provide other emergency department physicians with the ability to better identify and evaluate these patients. We also note the need for further research on nontraumatic spinal cord infarction because these patients' outcomes can be quite devastating.
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Katsumata Y, Kawachi I, Kawaguchi Y, Gono T, Ichida H, Hara M, Yamanaka H. Semiquantitative measurement of aquaporin-4 antibodies as a possible surrogate marker of neuromyelitis optica spectrum disorders with systemic autoimmune diseases. Mod Rheumatol 2014. [DOI: 10.3109/s10165-011-0572-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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30
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Nordin AB, Fallon SC, Jea A, Kim ES. The use of spinal angiography in the management of posterior mediastinal tumors: case series and review of the literature. J Pediatr Surg 2013; 48:1871-7. [PMID: 24074660 DOI: 10.1016/j.jpedsurg.2013.04.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 04/18/2013] [Accepted: 04/20/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Resection of inferiorly located posterior mediastinal tumors can be complicated by their proximity to the artery of Adamkiewicz (AKA). Although uncommon, intraoperative injury to the AKA may result in paraparesis or paralysis secondary to spinal cord ischemia. The use of preoperative spinal angiography may serve as a useful adjunct to the surgeon in guiding extent of resection of the tumor to avoid injury to this critical artery. METHODS After IRB approval (H-31712), three patients, from 2008 to 2011, with lower posterior mediastinal tumors were identified. Their charts were reviewed for information concerning preoperative imaging, operative details, and postoperative neurologic complications. The literature regarding imaging of the AKA, cases of injury in pediatric patients, and recommendations for treatment after its injury were reviewed. RESULTS One patient, who did not have preoperative spinal angiography, developed transient paresis lasting 6 weeks after posterior mediastinal tumor resection. Two patients underwent preoperative spinal angiography with successful localization of the AKA. In both cases, the patients subsequently underwent posterior mediastinal tumor resection without injury to the artery and without postoperative neurologic sequelae. CONCLUSIONS Preoperative spinal angiography may serve as a useful adjunct in the evaluation of children with inferior posterior mediastinal tumors in order to delineate the relationship of the artery of Adamkiewicz to the tumor for the purpose of guiding surgical resection.
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Affiliation(s)
- Andrew B Nordin
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Edwards A, Clay ELJ, Jewells V, Adams S, Crawford RD, Redding-Lallinger R. A 19-year-old man with sickle cell disease presenting with spinal infarction: a case report. J Med Case Rep 2013; 7:210. [PMID: 23972124 PMCID: PMC3766176 DOI: 10.1186/1752-1947-7-210] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 07/27/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Vasculopathy of the large vessels commonly occurs in sickle cell disease, and as a result cerebral infarction is a well characterized complication of this condition. However, spinal infarction appears to be rare. Spinal infarct is infrequent in the non-sickle cell population as well, and accounts for only about 1 percent of all central nervous system infarcts. CASE PRESENTATION In the present work, we report the case of a 19-year-old African-American man with sickle cell disease who experienced an anterior spinal infarct and subsequent quadriplegia. He was incidentally noted to be a heterozygote for factor V Leiden. We also reviewed the literature and found two previous cases of spinal cord infarction and sickle hemoglobin. Our literature search did not demonstrate that heterozygocity for factor V Leiden plays an important role in spinal cord infarction. CONCLUSIONS The paucity of cases associated with sickle hemoglobin does not allow us to postulate any particular risk factors with sickle cell disease that might predispose patients to spinal cord infarction. Our patient's case raises the question as to whether spinal cord infarction is being missed in individuals with sickle cell disease and neurologic symptoms.
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Affiliation(s)
- April Edwards
- Departments of Internal Medicine and Pediatrics, University of North Carolina School of Medicine, 101 Manning Drive, Chapel Hill, NC 27514, USA
| | - E Leila Jerome Clay
- Departments of Pediatrics and Internal Medicine, Division of Hematology and Oncology, University of North Carolina School of Medicine, 170 Manning Drive 1185A, Physician Office Building CB#7236, Chapel Hill, NC 27599-7236, USA
- Departments of Pediatrics and Internal Medicine, Division of Hematology and Oncology, Georgia Regents University, 1120 15th Street, BH 2015, Augusta, GA 30912, USA
| | - Valerie Jewells
- Department of Radiology, University of North Carolina School of Medicine, 100 Manning Drive, Radiology CB#7510, Old Clinic Building, Chapel Hill, NC 27599-7510, USA
| | - Stacie Adams
- Department of Pediatrics, Michigan State University, GRMEP 1000 Monroe Avenue, NW, Grand Rapids, MI 49503, USA
| | - Regina D Crawford
- Department of Medicine, Division of Hematology, Duke University Medical Center, 2212 Elba Street DUMC Box 3939, Durham, NC 27705, USA
| | - Rupa Redding-Lallinger
- Departments of Pediatrics and Internal Medicine, Division of Hematology and Oncology, University of North Carolina School of Medicine, 170 Manning Drive 1185A, Physician Office Building CB#7236, Chapel Hill, NC 27599-7236, USA
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Abstract
A 17-year-old girl presented with rapidly progressive quadriparesis and ventilatory failure. The clinical findings indicated a spinal level, but the diagnosis of myelopathy was not supported by her initial spinal imaging and cerebrospinal fluid studies. She had completed treatment for Guillain-Barré syndrome before a follow-up spinal imaging study showed interval expansion and enhancement of the cervical cord.
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Affiliation(s)
- Neil R. Holland
- Monmouth Medical Center, Long Branch, NJ, Department of Neurology, Drexel University College of Medicine, Philadelphia, PA
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Steinlin M. Cerebrovascular disorders in childhood. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1053-64. [PMID: 23622311 DOI: 10.1016/b978-0-444-52910-7.00023-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cerebrovascular problems in childhood include diverse problems of vascular supply to the brain and occur with an overall frequency of from 5 to 8/100000 children/year. Signs and symptoms at manifestation are manifold. They depend not only on localization of the infarction but also on age at injury and specific risk factors. Acute arterial ischemic insult in neonates is oligosymptomatic (short-lasting seizures); hemiparesis is the most common symptom in children. Risk factors are multiple for both neonates and children, with more thromboembolic events in neonates and (infection-related) vasculopathies or cardiac problems in children. MRI (diffusion weighted) is the golden standard for diagnosis. In the absence of evidence for treatment in both groups, guidelines suggest use of platelet aggregation. There are some special indications for anticoagulation. Thrombolysis should be evaluated. Two-thirds of children and neonates face lifelong neurological and neuropsychological problems. Spinal artery ischemia presents with acute spinal symptoms, mostly paraplegia. Risk factors and prognosis are similar to cerebral insults. Sinus venous thromboses are significantly less common. Provoking factors in newborns are mainly neonatal problems, and in children infections, especially in the ENT region. For diagnosis the delta sign in CT is less sensitive than MR/MR venography. In the absence of any evidence, LMWH or heparinization for 3-6 months are recommended. Prognosis is better in children than in neonates. Deep vein thrombosis and/or young age worsen the outcome.
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Affiliation(s)
- Maja Steinlin
- Neuropaediatric Department, University Children's Hospital Inselspital, Bern, Switzerland.
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Reisner A, Gary MF, Chern JJ, Grattan-Smith JD. Spinal cord infarction following minor trauma in children: fibrocartilaginous embolism as a putative cause. J Neurosurg Pediatr 2013; 11:445-50. [PMID: 23414133 DOI: 10.3171/2013.1.peds12382] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal cord infarctions following seemingly innocuous trauma in children are rare, devastating events. In the majority of these cases, the pathophysiology is enigmatic. The authors present 3 cases of pediatric spinal cord infarction that followed minor trauma. An analysis of the clinical, radiographic, and laboratory features of these cases suggests that thromboembolism of the nucleus pulposus into the spinal cord microcirculation is the likely mechanism. A review of the human and veterinary literature supports this notion. To the authors' knowledge, this is the largest pediatric series of myelopathy due to thromboembolism of the nucleus pulposus reported to date, and it is the first report of this condition occurring in an infant.
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Affiliation(s)
- Andrew Reisner
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA.
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Stettler S, El-Koussy M, Ritter B, Boltshauser E, Jeannet PY, Kolditz P, Meyer-Heim A, Steinlin M. Non-traumatic spinal cord ischaemia in childhood - clinical manifestation, neuroimaging and outcome. Eur J Paediatr Neurol 2013; 17:176-84. [PMID: 23040677 DOI: 10.1016/j.ejpn.2012.09.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 08/28/2012] [Accepted: 09/01/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Spinal cord ischaemia is rare in childhood and information on clinical presentation and outcome is scarce. METHODS This is a retrospective analysis of eight patients and 75 additional cases from the literature. Data search included: patient's age, primary manifestation, risk factors, neuroimaging and outcome. RESULTS Five female and three male patients gave consent to participate. Mean age was 12.5 years (10-15 years). Six patients presented with paraplegia; this was preceded by pain in four. Brown Sequard syndrome and quadriparesis were the two others' presenting condition. Sensation levels were thoracolumbar in seven cases. Bladder dysfunction only or bladder and bowel dysfunction were reported in eight and five patients respectively. Time to maximal symptom manifestation was <12 h in 7/8. Risk factors included surgery, minor trauma, recent infection, and thrombophilia. Mean follow-up was 3.3 years (0.25-6.3 years). Three patients remained wheelchair-dependent and three patients were ambulatory without aid. Bladder function recovered fully in five children. Most affected aspects of quality of life were physical and mental well-being and self-perception. T2-weighted-MR images showed pencil-like hyperintensity (8/8) in sagittal and H-shaped or snake-eyes-like lesion (6/8) in axial views. Analyses of all 83 patients were in congruence with the above results of the study group. CONCLUSION Spinal cord ischaemia in childhood presenting with pain, paraplegia, and bladder dysfunction has high morbidity concerning motor problems and quality of life. Acute arterial ischaemic event in children seems similar to adult events with respect to clinical presentation and, surprisingly, also in outcome.
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Affiliation(s)
- Sonja Stettler
- Department of Neuropaediatrics, University Children's Hospital Bern, Inselspital, Freiburgstrasse, 3010 Bern, Switzerland
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Inflammatory, vascular, and infectious myelopathies in children. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:999-1017. [PMID: 23622308 DOI: 10.1016/b978-0-444-52910-7.00020-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute nontraumatic myelopathies of childhood include inflammatory, infectious, and vascular etiologies. Inflammatory immune-mediated disorders of the spinal cord can be categorized as idiopathic isolated transverse myelitis, neuromyelitis optica, and multiple sclerosis. In recent years, human T-cell lymphotropic virus type 1, West Nile virus, enterovirus-71, and Lyme disease have been increasingly recognized as infectious etiologies of myelopathy, and poliomyelitis remains an important etiology in world regions where vaccination programs have not been universally available. Vascular etiologies include vasculopathies (systemic lupus erythematosus, small vessel primary angiitis of the central nervous system), arteriovenous malformations, and spinal cord infarction (fibrocartilaginous embolism, diffuse hypoxic ischemia-mediated infarction). Vascular myelopathies are less common than inflammatory and infectious myelopathies, but are more likely to lead to devastating clinical deficits. Current therapeutic strategies include acute anti-inflammatory treatment and rehabilitation. Stem cell transplantation, nerve graft implantation, and stimulation of endogenous repair mechanisms represent promising strategies for spinal cord repair.
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Bartanusz V, Ziu M, Wood LE, Caron JL. Delayed post-traumatic spinal cord infarction in an adult after minor head and neck trauma: a case report. J Med Case Rep 2012; 6:314. [PMID: 22992313 PMCID: PMC3470955 DOI: 10.1186/1752-1947-6-314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 07/23/2012] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Delayed post-traumatic spinal cord infarction is a devastating complication described in children. In adults, spinal cord ischemia after cardiovascular interventions, scoliosis correction, or profound hypotension has been reported in the literature. However, delayed spinal cord infarction after minor head trauma has not been described yet. CASE PRESENTATION We report the case of a 45-year-old Hispanic man who had a minor head trauma. He was admitted to our hospital because of paresthesias in his hands and neck pain. A radiological workup showed cervical spinal canal stenosis and chronic cervical spondylotic myelopathy. Twelve hours after admission, our patient became unresponsive and, despite full resuscitation efforts, died. The autopsy revealed spinal cord necrosis involving the entire cervical spinal cord and upper thoracic region. CONCLUSIONS This case illustrates the extreme fragility of spinal cord hemodynamics in patients with chronic cervical spinal canal stenosis, in which any further perturbations, such as cervical hyperflexion related to a minor head injury, can have catastrophic consequences. Furthermore, the delayed onset of spinal cord infarction in this case shows that meticulous maintenance of blood pressure in the acute post-traumatic period is of paramount importance, even in patients with minimal post-traumatic symptoms.
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Affiliation(s)
- Viktor Bartanusz
- Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA.
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Rattihalli R, Khan A, Hussain N. A reminder of the dangers of trampolining: Spinal cord infarction secondary to hyperextension injury during trampolining. J Pediatr Neurosci 2012; 7:70-1. [PMID: 22837787 PMCID: PMC3401663 DOI: 10.4103/1817-1745.97632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rohini Rattihalli
- Department of Paediatric Neurology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
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Márquez JC, Granados AM, Castillo M. MRI of cervical spinal cord infarction in a patient with sickle cell disease. Clin Imaging 2012; 36:595-8. [PMID: 22920369 DOI: 10.1016/j.clinimag.2011.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 12/09/2011] [Indexed: 10/28/2022]
Abstract
We report a patient with sickle cell disease who developed spinal cord ischemia. Initial conventional magnetic resonance imaging (MRI) was unremarkable, but diffusion-weighted imaging showed restricted diffusion in the cervical spinal cord. Follow-up MRI performed 3 days later showed development of findings on conventional images that confirmed the infarction.
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Affiliation(s)
- Juan Camilo Márquez
- Division of Neuroradiology, Department of Radiology, University of North Carolina at Chapel Hill, NC, USA.
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Semiquantitative measurement of aquaporin-4 antibodies as a possible surrogate marker of neuromyelitis optica spectrum disorders with systemic autoimmune diseases. Mod Rheumatol 2011; 22:676-84. [PMID: 22183613 DOI: 10.1007/s10165-011-0572-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 11/21/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVES To assess the association between serum aquaporin-4 (AQP4) autoantibodies and neuromyelitis optica spectrum disorders (NMOSDs) associated with systemic autoimmune diseases. METHODS We retrospectively studied 626 hospitalized patients with systemic lupus erythematosus (SLE) or Sjögren's syndrome (SS). We collected serum samples from those patients with suspected NMOSDs (i.e., myelitis or optic neuritis) at the time of onset and thereafter. AQP4 antibodies were measured by a cell-based indirect immunofluorescence assay using AQP4-transfected HEK-293 cells in a semi-quantitative manner. RESULTS Sera from 6 patients with suspected NMOSDs and SLE (n = 3) or SS (n = 3) were evaluated. Among these, 2 patients' sera samples, i.e., 1 with SLE and 1 with SS, were positive for AQP4 antibodies. There was an inverse relationship between disease amelioration and antibody titer in one NMOSD patient, whereas the antibody titer remained high in the other NMOSD patient, whose clinical manifestations of NMOSDs did not improve despite intensive immunosuppressive treatments. CONCLUSIONS These results indicate that serum AQP4 antibodies are present in some SLE/SS patients with myelitis/optic neuritis and might be associated with clinical outcomes. The semi-quantitative measurement of the AQP4 antibody might be a possible surrogate marker in patients with NMOSDs associated with systemic autoimmune diseases.
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Kremer S, Holl N, Schmitt E, De Sèze J, Moser T, Dietemann JL. [Imaging of non-traumatic and non-tumoral cord lesions]. ACTA ACUST UNITED AC 2010; 91:969-87. [PMID: 20814389 DOI: 10.1016/s0221-0363(10)70143-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
There is a wide range of spinal cord pathologies (vascular, inflammatory, infectious, metabolic, degenerative). They present clinically as acute partial or complete cord syndromes, or chronic myelopathies (more than 4 weeks in duration). MRI examination should be undertaken with a very strict protocol. Spinal cord lesions should be evaluated with regards to their T1W and T2W signal characteristics, involvement of grey and/or white matter, axial and sagittal extension, cord volume changes, contrast uptake and associated lesions (perimedullary, radicular or brain). The correlation of MR imaging features with clinical and biological data (blood and CSF) should suggest a differential diagnosis.
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Affiliation(s)
- S Kremer
- Service de Radiologie 2, CHU de Strasbourg, Hôpital de Hautepierre, avenue Molière, 67098 Strasbourg, France.
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Kuzhandaivel A, Margaryan G, Nistri A, Mladinic M. Extensive glial apoptosis develops early after hypoxic-dysmetabolic insult to the neonatal rat spinal cord in vitro. Neuroscience 2010; 169:325-38. [DOI: 10.1016/j.neuroscience.2010.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Revised: 05/03/2010] [Accepted: 05/05/2010] [Indexed: 01/08/2023]
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Sohal AS, Sundaram M, Mallewa M, Tawil M, Kneen R. Anterior spinal artery syndrome in a girl with Down syndrome: case report and literature review. J Spinal Cord Med 2009; 32:349-54. [PMID: 19810637 PMCID: PMC2718815 DOI: 10.1080/10790268.2009.11760789] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Anterior spinal artery syndrome is an extremely rare cause of acute ischemic cord infarction in children. It is caused by hypoperfusion of the anterior spinal artery, leading to ischemia in the anterior two thirds of the spinal cord. The presentation is usually with an acute and painful myelopathy with impaired bladder and bowel control. Pain and temperature sensation below the lesion are lost, whereas vibration and position sense is intact because of the preservation of the posterior columns. METHODS Case report. RESULTS A 16-year-old girl with Down syndrome presented with urinary retention and acute complete flaccid paralysis of the legs with absent deep tendon and abdominal reflexes. Magnetic resonance imaging showed a signal abnormality in the anterior half of the thoracic cord from T5 to T12, consistent with anterior spinal artery infarction. CONCLUSIONS Pediatricians should consider anterior spinal artery syndrome in the child who presents with acute, painful myelopathy. We summarize the etiology, neurological findings and outcomes of 19 children found in the literature with anterior spinal artery syndrome.
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Affiliation(s)
- Aman Singh Sohal
- Department of Paediatric Neurology, Royal Liverpool Children's Hospital, Liverpool, United Kingdom.
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Tan K, Hammond ER, Kerr D, Nath A. Fibrocartilaginous embolism: a cause of acute ischemic myelopathy. Spinal Cord 2008; 47:643-5. [DOI: 10.1038/sc.2008.135] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Millichap JG. Spinal Cord Infarction in Children. Pediatr Neurol Briefs 2007. [DOI: 10.15844/pedneurbriefs-21-5-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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