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Gharios M, Stenimahitis V, El-Hajj VG, Mahdi OA, Fletcher-Sandersjöö A, Jabbour P, Andersson M, Hultling C, Elmi-Terander A, Edström E. Spontaneous spinal cord infarction: a systematic review. BMJ Neurol Open 2024; 6:e000754. [PMID: 38818241 PMCID: PMC11138300 DOI: 10.1136/bmjno-2024-000754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024] Open
Abstract
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.
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Affiliation(s)
- Maria Gharios
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Vasilios Stenimahitis
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Rehabilitation, Furuhöjden Rehab Hospital, Täby, Sweden
| | | | - Omar Ali Mahdi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Magnus Andersson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Claes Hultling
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Capio Spine Center Stockholm, Löwenströmska Hospital, Upplands-Väsby, Sweden
- Department of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Erik Edström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Capio Spine Center Stockholm, Löwenströmska Hospital, Upplands-Väsby, Sweden
- Department of Medical Sciences, Örebro University, Örebro, Sweden
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2
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Fournel J, Hermier M, Martin A, Gamondès D, Tommasino E, Broussolle T, Morgado A, Baassiri W, Cotton F, Berthezène Y, Bani-Sadr A. It Looks Like a Spinal Cord Tumor but It Is Not. Cancers (Basel) 2024; 16:1004. [PMID: 38473365 DOI: 10.3390/cancers16051004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
Differentiating neoplastic from non-neoplastic spinal cord pathologies may be challenging due to overlapping clinical and radiological features. Spinal cord tumors, which comprise only 2-4% of central nervous system tumors, are rarer than non-tumoral myelopathies of inflammatory, vascular, or infectious origins. The risk of neurological deterioration and the high rate of false negatives or misdiagnoses associated with spinal cord biopsies require a cautious approach. Facing a spinal cord lesion, prioritizing more common non-surgical myelopathies in differential diagnoses is essential. A comprehensive radiological diagnostic approach is mandatory to identify spinal cord tumor mimics. The diagnostic process involves a multi-step approach: detecting lesions primarily using MRI techniques, precise localization of lesions, assessing lesion signal intensity characteristics, and searching for potentially associated anomalies at spinal cord and cerebral MRI. This review aims to delineate the radiological diagnostic approach for spinal cord lesions that may mimic tumors and briefly highlight the primary pathologies behind these lesions.
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Affiliation(s)
- Julien Fournel
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Marc Hermier
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Anna Martin
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Delphine Gamondès
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Emanuele Tommasino
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Théo Broussolle
- Department of Spine and Spinal Cord Neurosurgery, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Alexis Morgado
- Department of Spine and Spinal Cord Neurosurgery, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Wassim Baassiri
- Department of Spine and Spinal Cord Neurosurgery, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Francois Cotton
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, 7 Avenue Jean Capelle, 69100 Villeurbanne, France
- Department of Radiology, South Lyon Hospital, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495 Pierre-Bénite, France
| | - Yves Berthezène
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, 7 Avenue Jean Capelle, 69100 Villeurbanne, France
| | - Alexandre Bani-Sadr
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, 7 Avenue Jean Capelle, 69100 Villeurbanne, France
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3
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Kwak SY, Boudier-Revéret M, Chang MC. Differential diagnosis of suddenly developed motor weakness in bilateral lower extremities of a 79-year-old male patient. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2023; 40:457-460. [PMID: 36617703 PMCID: PMC10626293 DOI: 10.12701/jyms.2022.00787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/01/2022] [Accepted: 11/05/2022] [Indexed: 06/17/2023]
Affiliation(s)
- Seong Yeob Kwak
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
| | - Mathieu Boudier-Revéret
- Department of Physical Medicine and Rehabilitation, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
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4
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Panesar H, Conry A, Finocchi V, Desai C, Bracewell RM. Posterior spinal artery infarct. Pract Neurol 2023; 23:160-163. [PMID: 36863868 DOI: 10.1136/pn-2021-003336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 03/04/2023]
Abstract
Posterior spinal artery syndrome has a variable presentation and often poses a clinical challenge. We describe an acute posterior spinal artery syndrome in a man in his 60s with vascular risk factors, who presented with altered sensation in the left arm and left side of his torso but with normal tone, strength and deep tendon reflexes. MR imaging showed a left paracentral T2 hyperintense area affecting the posterior spinal cord at the level of C1. Diffusion-weighted MRI (DWI) showed high signal intensity in the same location. He was medically managed as having ischaemic stroke and made a good recovery. Three-month MRI follow-up showed a persisting T2 lesion but the DWI changes had resolved, consistent with the time course for infarction. Posterior spinal artery stroke has a variable presentation and is probably under-recognised clinically, requiring careful attention to MR imaging for its diagnosis.
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Affiliation(s)
- Harrypal Panesar
- Radiology, Nobles Hospital, Douglas, Isle of Man
- Radiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Aoife Conry
- Medicine, Nobles Hospital, Braddan, Isle of Man
| | | | - Chaitya Desai
- Radiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Robert Martyn Bracewell
- Bangor University, Bangor, UK
- Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
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5
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Tan YJ, Manohararaj N. Isolated Infarctions of the Conus Medullaris: Clinical Features and Outcomes. J Stroke Cerebrovasc Dis 2021; 30:106055. [PMID: 34433121 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/02/2021] [Accepted: 08/05/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- You-Jiang Tan
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore.
| | - Nijanth Manohararaj
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
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6
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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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7
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Agarwal V, Shah LM, Parsons MS, Boulter DJ, Cassidy RC, Hutchins TA, Jamlik-Omari Johnson, Kendi AT, Khan MA, Liebeskind DS, Moritani T, Ortiz AO, Reitman C, Shah VN, Snyder LA, Timpone VM, Corey AS. ACR Appropriateness Criteria® Myelopathy: 2021 Update. J Am Coll Radiol 2021; 18:S73-S82. [PMID: 33958120 DOI: 10.1016/j.jacr.2021.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 01/22/2023]
Abstract
Myelopathy is a clinical diagnosis with localization of the neurological findings to the spinal cord, rather than the brain or the peripheral nervous system, and then to a particular segment of the spinal cord. Myelopathy can be the result of primary intrinsic disorders of the spinal cord or from secondary conditions, which result in extrinsic compression of the spinal cord. While the causes of myelopathy may be multiple, the acuity of presentation and symptom onset frame a practical approach to the differential diagnosis. Imaging plays a crucial role in the evaluation of myelopathy with MRI the preferred modality. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Vikas Agarwal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, Vice Chair of Education, Department of Radiology, University of Pittsburgh Medical Center, Program Director, Neuroradiology Fellowship, University of Pittsburgh Medical Center.
| | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah, Chair, Committee on Appropriateness Criteria, Co-Chair, Neurological Imaging Panel, member of the ACR Commission on Neuroradiology
| | - Matthew S Parsons
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | | | - R Carter Cassidy
- UK Healthcare Spine and Total Joint Service, Lexington, Kentucky, American Academy of Orthopaedic Surgeons, Evidence Based Guideline Committee, North American Spine Society
| | | | | | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Director of Nuclear Medicine Therapies, Mayo Clinic Rochester
| | | | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California, American Academy of Neurology, President of SVIN
| | | | | | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina, North American Spine Society
| | - Vinil N Shah
- University of California San Francisco, San Francisco, California
| | - Laura A Snyder
- Barrow Neurological Institute, Phoenix, Arizona, Neurosurgery expert
| | - Vincent M Timpone
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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8
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Sulcal artery syndrome: A Three-patient series and review of literature. J Clin Neurosci 2021; 88:47-51. [PMID: 33992202 DOI: 10.1016/j.jocn.2021.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/03/2021] [Accepted: 03/11/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study aims to describe the clinical characteristics of patients with sulcal artery syndrome, and between those with vertebral artery dissection against those without. METHODS We report three cases of sulcal artery syndrome without vertebral artery dissection, performed a systematic review and retrospective analysis of the characteristics of patients with sulcal artery syndrome in available literature, and compared the clinical features of those with vertebral artery dissection against those without. RESULTS We report 3 patients with sulcal artery syndrome, and analysed them with 17 other cases identified in literature between January 1990 till April 2020. The mean age was 47 years (range 10-80), with twice as many males as females. Pain at onset was a prominent feature (17/18, 94.4%). Preceding trauma occurred in less than half (7/18, 38.9%). Most had cervical cord infarctions (18/20, 90%), often over the high cervical cord (16/18, 88.9%). Good functional recovery (mRS 0-2) was observed in 86.7% (13/15). While vertebral artery dissection was the leading aetiology (11/20, 55.5%), about half of the cases were due to other causes. Cervical cord involvement was significantly associated with vertebral artery dissection (p = 0.026). CONCLUSION Sulcal artery syndrome should be suspected in patients with acute hemicord syndrome, especially in males with cervical cord involvement or pain at onset. High cervical cord involvement was strongly suggestive of underlying vertebral artery dissection. Additionally, DWI sequences are useful when evaluating acute myelopathies, and its inclusion in conventional MRI sequences is supported in prevailing literature.
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9
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Cheng SJ, Tsai PH, Lee YT, Li YT, Chung HW, Chen CY. Diffusion Tensor Imaging of the Spinal Cord. Magn Reson Imaging Clin N Am 2021; 29:195-204. [PMID: 33902903 DOI: 10.1016/j.mric.2021.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Spinal cord often is regarded as one of the last territories in the central nervous system where diffusion tensor imaging (DTI) can be used to probe white matter architecture. This article reviews current progress in spinal cord DTI, starting with anatomic properties and technical challenges that make spinal cord DTI a difficult task. Several possibilities offered by advanced pulse sequences that might overcome the difficulties are addressed, with associated trade-offs and limitations. Potential clinical assistance also is discussed in various spinal cord pathologies, such as myelopathy due to external compression, spinal cord tumors, acute ischemia, traumatic injury, and so forth.
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Affiliation(s)
- Sho-Jen Cheng
- Department of Medical Imaging, Taipei Medical University Hospital, 252 Wu-Hsing Street, Taipei 110, Taiwan
| | - Ping-Huei Tsai
- Department of Medical Imaging and Radiological Sciences, Chung-Shan Medical University, No.110, Sec.1, Jianguo N. Road, Taichung 40201, Taiwan
| | - Yun-Ting Lee
- Translational Imaging Research Center, Taipei Medical University Hospital, 252 Wu-Hsing Street, Taipei 110, Taiwan
| | - Yi-Tien Li
- Translational Imaging Research Center, Taipei Medical University Hospital, 252 Wu-Hsing Street, Taipei 110, Taiwan
| | - Hsiao-Wen Chung
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, No.1, Sec.4, Roosevelt Road, Taipei 10617, Taiwan; Department of Electrical Engineering, National Taiwan University, No.1, Sec.4, Roosevelt Road, Taipei 10617, Taiwan.
| | - Cheng-Yu Chen
- Department of Medical Imaging, Taipei Medical University Hospital, 252 Wu-Hsing Street, Taipei 110, Taiwan; Translational Imaging Research Center, Taipei Medical University Hospital, 252 Wu-Hsing Street, Taipei 110, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, Taipei 110, Taiwan
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10
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Fisher O, Benson RA, Wayte S, Kimani PK, Hutchinson C, Imray CHE. Multimodal analysis of the effects of dexamethasone on high-altitude cerebral oedema: protocol for a pilot study. Trials 2019; 20:604. [PMID: 31651350 PMCID: PMC6813976 DOI: 10.1186/s13063-019-3681-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/25/2019] [Indexed: 11/17/2022] Open
Abstract
Background Acute mountain sickness (AMS) is a cluster of symptoms that commonly occur in those ascending to high altitudes. Symptoms can include headaches, nausea, insomnia and fatigue. Exposure to high altitude can also lead to high-altitude cerebral oedema (HACE), which is a potential cause of death whilst mountaineering. Generally, AMS precedes the development of HACE. Historical studies have demonstrated the effectiveness of regular dexamethasone administration in reducing the symptoms of AMS. However, the mechanism by which dexamethasone works to reduce symptoms AMS remains poorly understood. Further studies, simulating altitude using hypoxic tents, have characterised the effect of prolonged exposure to normobaric hypoxia on cerebral oedema and blood flow using MRI. This randomised trial assesses the effect of dexamethasone on hypoxia-induced cerebral oedema in healthy adult volunteers. Methods/design D4H is a double-blind placebo-controlled randomised trial assessing the effect of dexamethasone on hypoxia-induced cerebral oedema. In total, 20 volunteers were randomised in pairs to receive either 8.25 mg dexamethasone or normal saline placebo intravenously after 8 h of hypoxia with an FiO2 of 12%. Serial MRI images of the brain and spinal cord were obtained at hours 0, 7, 11, 22 and 26 of the study along with serum and urinary markers to correlate with the severity of cerebral oedema and the effect of the intervention. Discussion MRI has been used to identify changes in cerebral vasculature in the development of AMS and HACE. Dexamethasone is effective at reducing the symptoms of AMS; however, the mechanism of this effect is unknown. If this study demonstrates a clear objective benefit of dexamethasone in this setting, future studies may be able to demonstrate that dexamethasone is an effective therapy for oedema associated with brain and spinal cord ischaemia beyond AMS. Trial registration Clinicaltrials.gov, NCT03341676. Registered on 14 November 2017.
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Affiliation(s)
- O Fisher
- University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK. .,University of Warwick, Coventry, UK.
| | - R A Benson
- University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.,University of Birmingham, Birmingham, UK
| | - S Wayte
- University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | | | - C Hutchinson
- University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.,University of Warwick, Coventry, UK
| | - C H E Imray
- University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.,University of Warwick, Coventry, UK
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11
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Jankovic J, Rey Bataillard V, Mercier N, Bonvin C, Michel P. Acute ischemic myelopathy treated with intravenous thrombolysis: Four new cases and literature review. Int J Stroke 2019; 14:893-897. [DOI: 10.1177/1747493019851289] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Intravenous thrombolysis is a well-established treatment of ischemic stroke within 4.5 h. However, its effectiveness in acute ischemic myelopathy is unknown. Purpose We describe a series of four acute ischemic myelopathy patients treated with intravenous thrombolysis within 4.5 h and review the current literature to explore this treatment feasibility, potential safety, and efficacy. Methods We reviewed all routinely collected clinical, radiological, and follow-up data of patients with a final acute ischemic myelopathy diagnosis who received acute intravenous thrombolysis in our stroke network. We also reviewed thrombolyzed acute ischemic myelopathy patients in the literature. Results Four patients (three women) aged 57 to 83 years presented with acute uni- or bilateral extremity paresis, considered initially as cerebral strokes in two of them. After excluding contraindications by brain imaging in three, spinal computed tomography in one and confirmation of acute ischemic myelopathy on spinal magnetic resonance imaging in one patient, intravenous thrombolysis was administered at 135, 190, 240, and 245 min accordingly. Subacute diffusion-weighted imaging-magnetic resonance imaging confirmed acute ischemic myelopathy in all but one patient. Favorable outcome was achieved in two patients rapidly and in three patients at three-month follow-up. We identified seven other thrombolyzed acute ischemic myelopathy patients in the literature, who showed variable recovery and no hemorrhagic complications. Conclusions With appropriate acute imaging, intravenous thrombolysis after acute ischemic myelopathy is feasible and potentially safe within 4.5 h. Given the potential of benefit of thrombolysis in acute ischemic myelopathy, this treatment warrants further efficacy and safety studies.
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Affiliation(s)
- Jeremy Jankovic
- Oncology Service, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Noëlle Mercier
- Neurology Service, Rehabilitation Institute of Lavigny, Lavigny, Switzerland
| | | | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
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12
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Spinal Cord Infarction. Neuroradiology 2019. [DOI: 10.1016/b978-0-323-44549-8.00031-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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Abstract
Acute low back pain, defined as less than 6 weeks in duration, does not require imaging in the absence of "red flags" that may indicate a cause, such as fracture, infection, or malignancy. When imaging is indicated, it is important to rule out a host of abnormalities that may be responsible for the pain and any associated symptoms. A common mnemonic VINDICATE can help ensure a thorough consideration of the possible causes.
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Affiliation(s)
- Scott M Johnson
- Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East, Room 1A71, Salt Lake City, UT 84132, USA
| | - Lubdha M Shah
- Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East, Room 1A71, Salt Lake City, UT 84132, USA.
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14
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Mariano R, Flanagan EP, Weinshenker BG, Palace J. A practical approach to the diagnosis of spinal cord lesions. Pract Neurol 2018; 18:187-200. [PMID: 29500319 DOI: 10.1136/practneurol-2017-001845] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2018] [Indexed: 01/03/2023]
Abstract
Every neurologist will be familiar with the patient with atypical spinal cord disease and the challenges of taking the diagnosis forward. This is predominantly because of the limited range of possible clinical and investigation findings making most individual features non-specific. The difficulty in obtaining a tissue diagnosis further contributes and patients are often treated empirically based on local prevalence and potential for reversibility. This article focuses on improving the diagnosis of adult non-traumatic, non-compressive spinal cord disorders. It is structured to start with the clinical presentation in order to be of practical use to the clinician. We aim, by combining the onset phenotype with the subsequent course, along with imaging and laboratory features, to improve the diagnostic process.
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Affiliation(s)
- Romina Mariano
- Nuffield Department of Clinical Neuroscience, Oxford University, Oxford, UK
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jacqueline Palace
- Nuffield Department of Clinical Neuroscience, Oxford University, Oxford, UK
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15
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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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16
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Abbott AL, Silvestrini M, Topakian R, Golledge J, Brunser AM, de Borst GJ, Harbaugh RE, Doubal FN, Rundek T, Thapar A, Davies AH, Kam A, Wardlaw JM. Optimizing the Definitions of Stroke, Transient Ischemic Attack, and Infarction for Research and Application in Clinical Practice. Front Neurol 2017; 8:537. [PMID: 29104559 PMCID: PMC5654955 DOI: 10.3389/fneur.2017.00537] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/25/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Until now, stroke and transient ischemic attack (TIA) have been clinically based terms which describe the presence and duration of characteristic neurological deficits attributable to intrinsic disorders of particular arteries supplying the brain, retina, or (sometimes) the spinal cord. Further, infarction has been pathologically defined as death of neural tissue due to reduced blood supply. Recently, it has been proposed we shift to definitions of stroke and TIA determined by neuroimaging results alone and that neuroimaging findings be equated with infarction. METHODS We examined the scientific validity and clinical implications of these proposals using the existing published literature and our own experience in research and clinical practice. RESULTS We found that the proposals to change to imaging-dominant definitions, as published, are ambiguous and inconsistent. Therefore, they cannot provide the standardization required in research or its application in clinical practice. Further, we found that the proposals are scientifically incorrect because neuroimaging findings do not always correlate with the clinical status or the presence of infarction. In addition, we found that attempts to use the proposals are disrupting research, are otherwise clinically unhelpful and do not solve the problems they were proposed to solve. CONCLUSION We advise that the proposals must not be accepted. In particular, we explain why the clinical focus of the definitions of stroke and TIA should be retained with continued sub-classification of these syndromes depending neuroimaging results (with or without other information) and that infarction should remain a pathological term. We outline ways the established clinically based definitions of stroke and TIA, and use of them, may be improved to encourage better patient outcomes in the modern era.
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Affiliation(s)
- Anne L. Abbott
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- The Neurology Department, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia
| | - Alejandro M. Brunser
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana – Universidad del Desarrollo, Santiago, Chile
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Centre of Utrecht, Utrecht, Netherlands
| | - Robert E. Harbaugh
- Department of Neurosurgery, Penn State University, State College, PA, United States
| | - Fergus N. Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Department of Medicine, Elderly Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, Miami, FL, United States
| | - Ankur Thapar
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College, London, United Kingdom
| | - Alun H. Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom
| | - Anthony Kam
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, UK Dementia Research Institute at the University of Edinburgh, Edinburgh, United Kingdom
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17
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Rutman AM, Peterson DJ, Cohen WA, Mossa-Basha M. Diffusion Tensor Imaging of the Spinal Cord: Clinical Value, Investigational Applications, and Technical Limitations. Curr Probl Diagn Radiol 2017; 47:257-269. [PMID: 28869104 DOI: 10.1067/j.cpradiol.2017.07.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/18/2017] [Accepted: 07/26/2017] [Indexed: 11/22/2022]
Abstract
Although diffusion-weighted imaging (DWI) has become a mainstay in modern brain imaging, it remains less utilized in the evaluation of the spinal cord. Many studies have shown promise in using DWI and diffusion-tensor imaging (DTI) for evaluation of the spinal cord; however, application has been stalled by technical obstacles and artifacts, and questions remain regarding its clinical utility on an individual examination level. This review discusses the background, concepts, and technical aspects of DWI and DTI, specifically for imaging of the spinal cord. The clinical and investigational applications of spinal cord DTI, as well as the practical difficulties and limitations of DWI and DTI for the evaluation of the spinal cord are examined.
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Affiliation(s)
- Aaron M Rutman
- Department of Radiology, University of Washington, Seattle, WA.
| | | | - Wendy A Cohen
- Department of Radiology, University of Washington, Seattle, WA
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18
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Spinal Cord Infarction in the Course of a Septic Shock: About One Case and Review of the Literature. Case Rep Crit Care 2017; 2017:1571048. [PMID: 28316845 PMCID: PMC5337840 DOI: 10.1155/2017/1571048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/24/2017] [Indexed: 12/29/2022] Open
Abstract
We report the case of a patient admitted to our intensive care unit in the course of a septic shock, secondary to cholangitis. After rapid hemodynamic stabilization, antibiotherapy, and endoscopic extraction of bile ducts stones, she appeared to have developed flaccid paraplegia. The suspected diagnosis of medullar ischemia was confirmed by typical MRI findings. This case stresses the potential pathogenic role of hypotension in medullar ischemia and the place of magnetic resonance imaging (MRI) as a reliable diagnostic tool.
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19
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Diffusion-Weighted MRI and apparent diffusion coefficient value in assessment of intra-medullary spinal cord masses. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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20
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Weidauer S, Nichtweiß M, Hattingen E, Berkefeld J. Spinal cord ischemia: aetiology, clinical syndromes and imaging features. Neuroradiology 2014; 57:241-57. [PMID: 25398656 DOI: 10.1007/s00234-014-1464-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/03/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The purpose of this study was to analyse MR imaging features and lesion patterns as defined by compromised vascular territories, correlating them to different clinical syndromes and aetiological aspects. METHODS In a 19.8-year period, clinical records and magnetic resonance imaging (MRI) features of 55 consecutive patients suffering from spinal cord ischemia were evaluated. RESULTS Aetiologies of infarcts were arteriosclerosis of the aorta and vertebral arteries (23.6%), aortic surgery or interventional aneurysm repair (11%) and aortic and vertebral artery dissection (11%), and in 23.6%, aetiology remained unclear. Infarcts occurred in 38.2% at the cervical and thoracic level, respectively, and 49% of patients suffered from centromedullar syndrome caused by anterior spinal artery ischemia. MRI disclosed hyperintense pencil-like lesion pattern on T2WI in 98.2%, cord swelling in 40%, enhancement on post-contrast T1WI in 42.9% and always hyperintense signal on diffusion-weighted imaging (DWI) when acquired. CONCLUSION The most common clinical feature in spinal cord ischemia is a centromedullar syndrome, and in contrast to anterior spinal artery ischemia, infarcts in the posterior spinal artery territory are rare. The exclusively cervical location of the spinal sulcal artery syndrome seems to be a likely consequence of anterior spinal artery duplication which is observed preferentially here.
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Affiliation(s)
- Stefan Weidauer
- Department of Neurology, Sankt Katharinen Hospital, Teaching Hospital of the Goethe - University, Frankfurt / Main, Seckbacher Landstraße 65, D 60389, Frankfurt / Main, Germany,
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21
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Vargas MI, Gariani J, Sztajzel R, Barnaure-Nachbar I, Delattre BM, Lovblad KO, Dietemann JL. Spinal cord ischemia: practical imaging tips, pearls, and pitfalls. AJNR Am J Neuroradiol 2014; 36:825-30. [PMID: 25324492 DOI: 10.3174/ajnr.a4118] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Ischemia of the spinal cord is a rare entity with a poor prognosis. Brain ischemia is no longer a diagnostic challenge; on the contrary, ischemia of the spinal cord remains difficult, particularly in children. In this article, we illustrate the principal causes in children and adults, clinical presentation, different techniques for the diagnosis by MR imaging (diffusion, spinal MR angiography, and 1.5 versus 3T), pathophysiology, and differential diagnosis. We will discuss current knowledge, perspectives, and pitfalls.
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Affiliation(s)
- M I Vargas
- From the Divisions of Neuroradiology (M.I.V., I.B.-N., K.O.L.)
| | | | - R Sztajzel
- Neurology (R.S.), Geneva University Hospitals, Geneva, Switzerland
| | | | | | - K O Lovblad
- From the Divisions of Neuroradiology (M.I.V., I.B.-N., K.O.L.)
| | - J-L Dietemann
- Division of Radiology (J.-L.D.), Strasbourg University Hospitals, Strasbourg, France
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22
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Mendonça M, Correia AS, Luís A, Soares P, Calado S, Viana-Baptista M. Spinal cord infarction and patent foramen ovale: is there a link? Case Rep Neurol 2014; 6:188-92. [PMID: 25076895 PMCID: PMC4105946 DOI: 10.1159/000364900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Spinal cord infarction (SCI) is an uncommon but important cause of acute myelopathy. Nevertheless, contrary to cerebral stroke, the discussion about paradoxical embolism as a cause of cryptogenic SCI remains dubious. We describe the case of a 24-year-old woman who developed sudden-onset back pain followed by upper limb paralysis. T2-weighted MRI demonstrated hyperintense signal, extending from C5 to D1 with corresponding restricted diffusion on diffusion-weighted MRI and reduction of the apparent diffusion coefficient. Diagnostic workup, including lumbar puncture, showed no changes. Transcranial Doppler showed a right-to-left shunt with an uncountable number of microembolic signals after Valsalva maneuvers, and a patent foramen ovale (PFO) with an atrial septum aneurysm was identified. We discuss the paucity of evidence of right-to-left shunting in spinal diseases compared to cerebral events and the potential role of paradoxical embolism through PFO as a possible mechanism of SCI.
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Affiliation(s)
- Marcelo Mendonça
- Neurology Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal ; CEDOC, Faculdade de Ciências Médicas da Universidade Nova de Lisboa, Lisbon, Portugal
| | - Ana Sofia Correia
- Neurology Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal ; CEDOC, Faculdade de Ciências Médicas da Universidade Nova de Lisboa, Lisbon, Portugal
| | - Ana Luís
- Neurosurgery Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Pedro Soares
- Neuroimaging Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Sofia Calado
- Neurology Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal ; CEDOC, Faculdade de Ciências Médicas da Universidade Nova de Lisboa, Lisbon, Portugal
| | - Miguel Viana-Baptista
- Neurology Department, Hospital Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal ; CEDOC, Faculdade de Ciências Médicas da Universidade Nova de Lisboa, Lisbon, Portugal
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24
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Hsu CY, Cheng CY, Lee JD, Lee M, Huang YC, Wu CY, Hsu HL, Lin YH, Huang YC, Weng HH, Huang KL. Clinical features and outcomes of spinal cord infarction following vertebral artery dissection: a systematic review of the literature. Neurol Res 2013; 35:676-83. [DOI: 10.1179/1743132813y.0000000183] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Chia-Yu Hsu
- Department of NeurologyChang Gung Memorial Hospital, Yunlin, Taiwan
- College of MedicineChang Gung University, Taoyuan, Taiwan
| | - Chun-Yu Cheng
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of NeurosurgeryChang Gung Memorial Hospital, Chiayi, Taiwan
| | - Jiann-Der Lee
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of NeurologyChang Gung Memorial Hospital, Chiayi, Taiwan
| | - Meng Lee
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of NeurologyChang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ying-Chih Huang
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of NeurologyChang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chih-Ying Wu
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of NeurologyChang Gung Memorial Hospital, Chiayi, Taiwan
| | - Huan-Lin Hsu
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of NeurologyChang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ya-Hui Lin
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of NeurologyChang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yen-Chu Huang
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of NeurologyChang Gung Memorial Hospital, Chiayi, Taiwan
| | - Hsu-Huei Weng
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of Diagnostic RadiologyChang Gung Memorial Hospital, Chiayi, Taiwan
- Department of Respiratory Care and NursingChang Gung University of Science and Technology, Chiayi, Taiwan
- Department of PsychologyNational Chung Cheng University, Chiayi, Taiwan
| | - Kuo-Lun Huang
- College of MedicineChang Gung University, Taoyuan, Taiwan
- Department of Neurology and Stroke CenterChang Gung Memorial Hospital, Taoyuan, Taiwan
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