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Jadhav AP. Vascular Myelopathies. Continuum (Minneap Minn) 2024; 30:160-179. [PMID: 38330477 DOI: 10.1212/con.0000000000001378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Vascular injuries of the spinal cord are less common than those involving the brain; however, they can be equally devastating. This article discusses the diagnosis and management of ischemic and hemorrhagic vascular disorders of the spinal cord. LATEST DEVELOPMENTS Clinical suspicion remains the mainstay for recognizing vascular myelopathies, yet diagnoses are often delayed and challenging in part because of their rarity and atypical manifestations. Noninvasive imaging such as CT and MRI continues to improve in spatial resolution and diagnostic precision; however, catheter-based spinal angiography remains the gold standard for defining the spinal angioarchitecture. In addition to hemorrhagic and ischemic disease, the contribution of venous dysfunction is increasingly appreciated and informs treatment strategies in conditions such as intracranial hypotension. ESSENTIAL POINTS Vascular disorders of the spine manifest in variable and often atypical ways, which may lead to delayed diagnosis. Increased awareness of these conditions is critical for early recognition and treatment. The goal of treatment is to minimize long-term morbidity and mortality.
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Simon D. Severe Mimic of Transverse Myelitis - Spontaneous Non-Traumatic Intramedullary Hematomyelia: A Case Report. Neurohospitalist 2024; 14:83-86. [PMID: 38235023 PMCID: PMC10790618 DOI: 10.1177/19418744231196931] [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: 01/19/2024] Open
Abstract
Spinal cord hemorrhage remains an uncommon vascular pathology with no standard approach to treatment. Intramedullary hematomyelia is the rarest subtype and has only been described in case reports, making it a diagnosis easier to miss. A 55-year-old male with history of polysubstance abuse presented for abrupt onset non-traumatic back pain that progressed over several days evolving into paraplegia, sensory loss up to the T3 dermatome, and incontinence of bowel and bladder. His MRI imaging of the cervical and thoracic spine was concerning for a T1 and T2 hyperintense lesion extending from the internal medulla to the upper thoracic spine causing edema. The initial differential diagnosis, based on history and progressive neurologic decline, included a longitudinally extensive transverse mellitus of unclear etiology. He received high dose steroids and plasma exchange without any clinical improvement. An extensive autoimmune, inflammatory, infectious, and demyelinating workup via serum and CSF analysis was unremarkable. He was transferred to a tertiary facility, where repeat MRI spinal imaging included GRE sequences that was significant for increased susceptibility. MRA imaging of the spine was completed showing no vascular malformation. Overall, the diagnosis of hematomyelia was felt to be most likely. Despite aggressive inpatient rehabilitation, the patient remains paraplegic and requires long term management consistent with severe spinal cord injury. This case highlights the importance of recognizing vascular syndromes as a cause of acute myelopathy, understanding the imaging findings of blood breakdown products on MRI, and the desperate need for successful therapeutic strategies to combat a potentially devastating neurologic process.
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Affiliation(s)
- Devin Simon
- Department of Neurology and Ophthalmology, Michigan State University, Lansing, MI, USA
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Oliveira DS, Sousa L. Off-label tenecteplase use in spinal cord ischemia. Acta Neurol Belg 2023; 123:2409-2412. [PMID: 36892749 DOI: 10.1007/s13760-023-02228-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Affiliation(s)
- Daniela Santos Oliveira
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Rua Dr. Cândido Pinho, nº 5, 4520-220, Santa Maria da Feira, Portugal.
| | - Luísa Sousa
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Rua Dr. Cândido Pinho, nº 5, 4520-220, Santa Maria da Feira, Portugal
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Ezzeldin M, Hill C, Kerro A, Percenti E, Delora A, Santos J, Saei H, Greco L, Ezzeldin R, El-Ghanem M, Alderazi Y, Kim Y, Poitevint C, Mir O. A Comparative Study of Hemorrhagic Conversion Patterns After Stroke Thrombolysis With Alteplase Versus Tenecteplase. Cureus 2023; 15:e46889. [PMID: 37859677 PMCID: PMC10584357 DOI: 10.7759/cureus.46889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND PURPOSE Tenecteplase is the thrombolytic drug of choice for acute ischemic stroke (AIS) as it has unique pharmacologic properties, along with results demonstrating its non-inferiority compared to alteplase. However, there are contradictory data concerning the risk of intracranial hemorrhage. The purpose of the study was to report the rate and patterns of symptomatic intracranial hemorrhage (sICH) in AIS patients after thrombolysis with tenecteplase compared to alteplase. METHODS This is a retrospective cohort study with data collected 90 days before and after the change from alteplase to tenecteplase from 15 Texas stroke centers. The primary endpoint is the incidence of sICH according to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) and European Cooperative Acute Stroke Study III (ECASS-3) criteria. The secondary endpoints are the radiographic pattern of hemorrhagic conversion according to the Heidelberg bleeding classification (HBC). RESULTS A total of 431 patients were eligible for thrombolytic therapy. Half of the cohort received alteplase (n=216), and the other half received tenecteplase (n=215). The average age of the alteplase group was 62.94 years old (SD=15.12) and 64.45 years old (SD=14.51) for the tenecteplase group. Seven patients in the alteplase group (3.2%) and 14 (6.5%) in the tenecteplase group had sICH, with an odds ratio of 1.44 (95% CI 0.60-3.43; P=0.41). An increased National Institutes of Health Stroke Scale (NIHSS) score on arrival (1.06; 95% CI 1.0004-1.131; P=0.04) was a statistically significant predictor of sICH. Tenecteplase was associated with a statistically significant increase in HBC-3 (P=0.040) over alteplase. CONCLUSIONS Compared with alteplase, our study revealed a higher rate of sICH with tenecteplase that was not statistically significant and a higher rate of HBC-3 hemorrhages that was statistically significant. The proposed mechanism of bleeding is hemorrhagic conversion in clinically silent infarcts and contusions underlying the lesions. Further studies are needed to confirm our findings and determine predictive risk factors.
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Affiliation(s)
| | - Courtney Hill
- Emergency Medicine, Hospital Corporation of America (HCA) Houston Healthcare Kingwood, Houston, USA
| | - Ali Kerro
- Neurology, Hospital Corporation of America (HCA) Houston Healthcare Conroe, Conroe, USA
| | - Eryn Percenti
- Internal Medicine, Hospital Corporation of America (HCA) Houston Healthcare Kingwood, Houston, USA
| | - Adam Delora
- Emergency Medicine, Hospital Corporation of America (HCA) Houston Healthcare Kingwood, Houston, USA
| | - Juan Santos
- Neurology, Corpus Christi Medical Center, Corpus Chrsiti, USA
| | - Hamzah Saei
- Neurology, Rio Grande Regional Hospital, McAllen, USA
- Neurology, Valley Baptist Medical Center, Harlingen, USA
| | - Lisa Greco
- Neurology, Hospital Corporation of America (HCA) Houston Healthcare Gulf Coast Division, Houston, USA
| | - Rime Ezzeldin
- Medicine, Jordan University of Science and Technology, Irbid, JOR
| | - Mohammad El-Ghanem
- Neurology, Hospital Corporation of America (HCA) Houston Healthcare Northwest, Houston, USA
| | - Yazan Alderazi
- Neuroendovascular Surgery, Hospital Corporation of America (HCA) Houston Healthcare Clear Lake, Houston, USA
| | - Yana Kim
- Neurology, Texas Stroke Institute, Plano, USA
| | | | - Osman Mir
- Neurology, Texas Stroke Institute, Plano, USA
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Kalaszi M, Donlon E, Ahmad MW, Mohamed AS, Boers P. Case report: Dueling etiologies: Longitudinally extensive spinal cord lesion mimicking spinal cord infarct with simultaneous positive Lyme serology and amphiphysin antibody. Front Neurol 2022; 13:905283. [PMID: 36176565 PMCID: PMC9513320 DOI: 10.3389/fneur.2022.905283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Longitudinally extensive spinal cord lesions are challenging diagnostic entities as they are uncommon, but various etiologies can cause them. Case report We report a case of a 55-year-old man with a past medical history of hypertension. He is an ex-smoker. He presented with chest pain, followed by right lower limb weakness, preceded by 2 weeks of constipation and voiding dysfunction. The examination revealed right lower limb mild flaccid paresis, absent reflexes, reduced anal tone, and urinary retention. His symptoms deteriorated over 24 h, and he developed severe flaccid paraparesis with impaired pinprick sensation below the T4 level. MRI spine showed an abnormal, non-enhancing signal in the anterior aspect of the spinal cord extending from the T4 level to the conus without associated edema. He was commenced on intravenous steroids and had significant improvement after one dose. The imaging was felt to be consistent with spinal cord infarction, and aspirin was started. The cerebrospinal fluid analysis showed elevated protein (0.8 mg/ml). Investigations for stroke and autoimmune pathologies were negative. The Lyme immunoblot confirmed intrathecal production of IgG to Borrelia antigens. The patient was started on ceftriaxone. The paraneoplastic screen identified amphiphysin antibodies. CT-TAP and PET-CT did not identify occult malignancy. The patient had a significant improvement over 2 months, strength was almost fully recovered, and autonomic functions returned to normal. Conclusion We describe an unusual steroid-responsive, longitudinally extensive spinal cord lesion with radiological features of spinal cord infarct and a simultaneous finding of intrathecal Lyme antibodies and serum amphiphysin antibodies.
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Thebault S, Kim W, Hadwen J, Walker GB, Drake B, Fantaneanu TA. Progressive Myelopathy With Acute Worsening After Steroids and Lumbar Puncture. Neurohospitalist 2022; 12:318-322. [PMID: 35419159 PMCID: PMC8995581 DOI: 10.1177/19418744211073389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We present the case of a 73-year-old woman with a 3-month history of non-traumatic thoracic myelopathy. Initial MRI showed a T6-conus T2 signal hyperintensity. Based on this presentation, and given a personal and family history of autoimmune disease, our patient was first managed as an inflammatory transverse myelitis. Subsequent worsening after lumbar puncture and steroids prompted re-evaluation, ultimately identifying the cause as a thoracic spinal dural AV fistula. Both investigation of possible transverse myelitis with lumbar puncture and empiric treatment with steroids may not only result in diagnostic delays but also precipitate venous infarction and irreversible harm. While the MRI often provides the initial diagnosis, clinical suspicion for this under-diagnosed cause of myelopathy should be raised in older patients with a more progressive thoracic myelopathy with worsening after lumbar puncture and/or steroids. Definitive and time-sensitive treatment by interventional neuroradiology or neurosurgery results in stabilization or improvement of disability in most cases.
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Affiliation(s)
- Simon Thebault
- Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - WooJin Kim
- Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Jeremiah Hadwen
- Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Gregory B. Walker
- Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Brian Drake
- Division of Neurosurgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Tadeu A. Fantaneanu
- Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
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Marcellino C, Zalewski NL, Rabinstein AA. Treatment of Vascular Myelopathies. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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