Atypical Anterior Spinal Artery Infarction due to Left Vertebral Artery Occlusion Presenting with Bilateral Hand Weakness

Man-in-the-Barrel Syndrome Secondary to Idiopathic Acute Anterior Spinal Artery Infarction

A 52-year-old female presented to our hospital with an acute history of isolated bilateral arm weakness. An MRI of the cervical spine confirmed an acute anterior spinal artery infarction. Further investigations to determine a specific etiology were unremarkable, leading to a diagnosis of idiopathic anterior spinal artery infarction consistent with Man-in-the-Barrel syndrome.

"Person-in-the-Barrel" Syndrome: A Case Report of Bilateral Arm Paresis Due to Vasculitis With a Review of Pathological Mechanisms

"Person-in-the-barrel" syndrome is a descriptive term for bilateral arm (brachial) paresis in the absence of lower extremity (crural) weakness or bulbar (medullary) weakness. This phenomenon is associated with various descriptive terms such as "distal field infarction", "flail limbs", and "cruciate paralysis". Arriving at a specific diagnosis is a fascinating exercise in anatomical localization. Strategic lesions involving the watershed zones of the motor frontal lobes and the pyramidal decussation at the cervico-medullary junction are the classic sites of injury. However, peripheral causes such as motor neuron disease, mononeuritis multiplex (vasculitis), bilateral brachial plexopathy, and critical illness myopathy have been sporadically reported and can stochastically inflict the motor nerves or muscles of the upper extremities. In this report, we present a case of vasculitis with weakness restricted to the upper extremities and also delve into the neuropathological mechanisms of "person-in-the-barrel" syndrome.

Spinal cord ischemia: aetiology, clinical syndromes and imaging features

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.