Anterior spinal artery syndrome (ASAS) is a very rare condition which occurs following infarction of the anterior two-third of the spinal cord supplied by the anterior spinal artery. The cause of the infarction can be either iatrogenic or secondary to diseases. Common etiologies include mediastinal surgeries [1] [2], diabetes with atherosclerosis [3], diseases of the aorta [4], hematological disorders (sickle cell, polycythemia), cervical spine injury or spondylosis [5] [6] [7], infections (tuberculosis, N.meningitidis) [8] [9] [10], drugs (cocaine) [11], vasculitis, and idiopathic.

The common clinical presentation of ASAS is sudden onset, severe, pain along the spinal nerve roots radiating to the lower limbs with quadriparesis due to corticospinal tract involvement. The myelopathy can be associated with impaired bladder, bowel and sexual function depending upon the level at which the spinal cord is affected. Pain, as well as, temperature sensation are lost below the level of the infarction as the lateral spinothalamic tract is affected while the posterior column vibration and position sense are preserved. Orthostatic hypotension may be present due to autonomic dysfunction. Occasionally the spinal cord gray matter may be involved, preferentially with the preservation of sensory, bladder and bowel functions.

• Lower Extremity Pain

  The patient started complaining of spasmodic lower extremity pain and general weakness. She was unable to flex her knees upon request. [anesthesiology.pubs.asahq.org]

• Edema of Lower Extremity

  A 51-year-old woman with a history of breast cancer developed pulmonary edema and lower extremity paraplegia with preservation of proprioception as the initial manifestation of abdominal aortic thrombosis. [ncbi.nlm.nih.gov]

• Acute Intermittent Porphyria

  61 Koch M...Seifert CL 26386968 2016 24 A Clinical Perspective and Definition of Spinal Cord Injury. 61 Kretzer RM 27015067 2016 25 Guillain Barré Syndrome, Systemic Lupus Erythematosus and Acute Intermittent Porphyria – A Deadly Trio. 61 Patil AD...Passidhi [malacards.org]

• Chest Pain Radiating to the Back

  This was preceded by a two weeks' history of severe, sharp, lancinating, tearing left parasternal chest pain radiating to the back. [ncbi.nlm.nih.gov]

• Protein S Deficiency

  Individuals with protein S deficiency have an 8-fold increased risk of thrombosis. [ncbi.nlm.nih.gov]

  Conditions such as protein C or protein S deficiency can contribute or increase the risk of having thromboembolic events develop [ 5 Harris R.E. Reimer K.A. Crain B.J. Becsey D.D. Oldham Jr, H.N. [annalsthoracicsurgery.org]

  S deficiency. ( 11292220 ) Ramelli G.P....Ozdoba C. 2001 47 Anterior spinal artery syndrome after aortic surgery in a child. ( 11377109 ) Servais L.J....Dan B. 2001 48 A cervical anterior spinal artery syndrome after diagnostic blockade of the right [malacards.org]

• Back Pain

  Abstract Reported here is a 37-yr-old professional diving instructor who had developed complaints of back pain and weakness in the lower extremities after diving. [ncbi.nlm.nih.gov]

  Losses of pain and temperature sensation while vibration and position sense are preserved. Radiating back pain which is localized to the area of infarct.. [sci-recovery.org]

• Bilateral Arm Weakness

  Neurologic examination months later revealed man-in-the-barrel syndrome characterized by bilateral arm weakness and atrophy but preserved leg strength (video at Neurology.org/cp ). [cp.neurology.org]

• Hyperreflexia

  Detrusor hyperreflexia was noted in 8 patients, a normal bladder in 1 and detrusor areflexia in 1. External urethral sphincter electromyography revealed detrusor-sphincter dyssynergia in 4 patients and normal findings in 6. [ncbi.nlm.nih.gov]

  At first the lower limb paralysis was flaccid and areflexic but after several weeks spasticity, hyperreflexia, and Babinski signs appeared. After an initial period of incontinence bowel and bladder control was regained. [lksom.temple.edu]

  Initially areflexia is present due to spinal shock but, hyperreflexia and spasticity appear later The most common form is anterior spinal artery syndrome. [sci-recovery.org]

  The acute stages are characterized by flaccidity and loss of deep tendon reflexes; spasticity and hyperreflexia develop over ensuing days and weeks. [oatext.com]

• Flaccid Paralysis of the Lower Extremity

  Postoperative neurologic examination disclosed flaccid paralysis of the lower extremities and sphincter incontinence. [ncbi.nlm.nih.gov]

  Anterior spinal artery syndrome manifests as flaccid paralysis of the lower extremities and bowel and bladder dysfunction with sparing of proprioception and sensation, due to the selective ischemia to the anterior portion of the cord. [openanesthesia.org]

  Postoperative Course Flaccid paralysis of the lower extremities and sphincter incontinence was observed after the surgery. [journals.lww.com]

• Flail Arm

  arm syndrome Dinesh C. [neurologyindia.com]

ASAS should be suspected in any adult or child presenting with acute onset painful quadriparesis with preservation of posterior column sensations. History may indicate the etiology but a thorough physical and neurological examination are vital for diagnosis of the condition as well a to detect the level and extent of the neurological deficits. Routine laboratory tests such as complete blood count with differential, serum blood glucose, erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA) levels, complement assay, nuclear antibody assays, serum lipids, serum electrolytes, and serology for syphilis should be ordered. An infectious etiology is indicated by leukocytosis while inflammatory markers may be elevated in infections as well as vasculitis. Besides diabetes, it is important to exclude coagulation disorders with tests like activated partial thromboplastin time, antiphospholipid antibody titer, protein C and protein S levels and platelet count [12] [13]. Cerebrospinal fluid analysis (CSF) is performed to look for infectious and autoimmune conditions while blood and CSF polymerase chain reaction (PCR) may be required to exclude viral etiologies.

However, the diagnosis of ASAS can only be confirmed with a magnetic resonance (MRI) scan of the spinal cord. This can detect all the causative lesions within or outside the spinal cord [14] [15] [16] [17] [18] [19]. Ideally, it should be performed at the earliest to avoid complications such as renal failure from developing [1]. A concomitant brain MRI may be useful in identifying lesions of multiple sclerosis, sarcoid, and other infections. A computed tomography (CT) scan and plain radiography do not have a significant role in the diagnosis of ASAS. If MRI is not available then CT myelography can help to detect tumors. Spinal angiography (arteriography) may be performed to identify an arteriovenous malformation

Other supportive tests in ASAS include electromyography (EMG) and nerve conduction velocity (NCV) tests to document neurological deficits and denervation changes. They also help to differentiate ASAS from polyneuropathy.

Temporal artery biopsy is indicated only if confirmation of giant cell arteritis as the underlying etiology of ASAS is suspected.

The treatment has generally been supportive. We believe thrombolysis should be considered in the acute phase of this condition, and present a case with ASAS who experienced partial recovery after treatment given 4.5 h after symptom onset. [ncbi.nlm.nih.gov]

Diagnosis[edit] MRI Treatment[edit] Treatment is determined based on the primary cause of anterior cord syndrome. When the diagnosis of anterior cord syndrome is determined, the prognosis is unfortunate. [en.wikipedia.org]

Treatment The root cause if treatable should be addressed. The treatment in such cases would depend upon the root cause. [boneandspine.com]

Prognosis Prognosis is variable and entirely depends on the severity of damage and how early the treatment has been started. Patients seeking early treatment recover better. [sci-recovery.org]

In our opinion, CMAP could be seen a marker of prognosis for ASAS patients, and absent CMAP might forecast the bad prognosis. [ncbi.nlm.nih.gov]

Prognosis Prognosis is variable and entirely depends on the severity of damage and how early the treatment has been started. Patients seeking early treatment recover better. [sci-recovery.org]

10–15% functional recovery; if no recovery is evident and progressive after 24 hours, prognosis is poor Vibration and proprioception are typically spared because of an intact dorsal column! [amboss.com]

Treatment and prognosis Prognosis of anterior cord syndrome is worst among all other spinal cord injury syndromes 5. It is associated with high mortality and poor functional outcome in terms of poor recovery of motor power and coordination. [radiopaedia.org]

Temporal artery biopsy is indicated only if confirmation of giant cell arteritis as the underlying etiology of ASAS is suspected. [symptoma.com]

Spinal cord infarction is a well-described, but rare, etiology of myelopathy, especially in children. [ncbi.nlm.nih.gov]

Background: Spinal cord infarction is a well-described, but rare, etiology of myelopathy, especially in children. [tandfonline.com]

However, no epidemiologic studies are available because of the relatively small number of patients affected. [emedicine.com]

Thoracic (Lower) & Lumbar: 90% Sacral: 4% Cervical 3% Left > Right: 2:1 Feeding vessels Location: Often lumbar Number: Usually 1; Occasionally 2 or 3 Fistula in dorsolateral root sleeve High venous pressure in spinal cord Reduced spinal cord perfusion Epidemiology [neuromuscular.wustl.edu]

Summary Epidemiology To date, there have been more than 500 cases reported worldwide. Individuals of European and Asian descent are most often affected, with most case reports emerging from Japan. A slight male predominance has been reported. [orpha.net]

References:[11][13][14][15][16][17][18] Posterior cord syndrome Definition: injury of the posterior spinal cord affecting the posterior column (fine touch, vibration, pressure, and proprioception) Epidemiology: very rare Etiology: occlusion of the posterior [amboss.com]

Hardoon et al17 determined that the prevalence of SMI in THIN is similar to that of epidemiological studies. [bmjopen.bmj.com]

The clinical features, treatment and proposed pathophysiology for this condition are presented. [ncbi.nlm.nih.gov]

Anterior Uveitis <ul><li>Prevalence </li></ul><ul><li>Symptoms </li></ul><ul><li>Diagnostic techniques and signs </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Associated conditions </li></ul><ul><li>Management </li></ul> 3. [slideshare.net]

[…] carcinomas documented in 15% - 25% of cases ( J Clin Pathol. 2014;67:891 ) Sites Polyps affect entire gastrointestinal tract, except the esophagus Also associated with ectodermal changes including alopecia, nail atrophy and cutaneous hyperpigmentation Pathophysiology [pathologyoutlines.com]

Pathophysiological classification of human spinal cord ischemia. J Spinal Cord Med. 1997 Jan. 20(1):74-87. [Medline]. Cheng MY, Lyu RK, Chang YJ, Chen CM, Chen ST, Wai YY, et al. [emedicine.com]

For this reason avoidance of prolonged aortic cross clamp time, hypotension, and its associated low flow to the spinal cord, paying attention to prevent atheromatous embolization of Adamkiewicz artery and pelvic circulation can prevent this complication [ncbi.nlm.nih.gov]

Data Do Not Support Routine Use for Prevention In the first of two reviews, Esther S. [medscape.com]

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