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]

• Hemoptysis

  List the most common causes of massive hemoptysis. •. Discuss the roles of CT and bronchoscopy in the diagnosis of massive hemoptysis. •. [pubs.rsna.org]

  This is the most feared, though rare complication of bronchial artery embolization done in massive hemoptysis.[6] Anatomy[edit] The anterior portion of the spinal cord is supplied by the anterior spinal artery. [en.wikipedia.org]

  비록 흔치는 않으나 가장 위험스런상황으로 대량의 객혈(大量喀-hemoptysis)으로 인한 기관지동맥색전(氣管支動脈塞栓-bronchial artery embolization)이 된다. 치료 치료는 앞쪽척수동맥증후군을 일으키는 원인에 따라 달라지게 된다. 진단이 이루어졌다 해도 예후는 그리 좋은편은 아니라서 20%의 사망율을 보이게 되고 약간이나 거의 증상의 차도가 없는 앞쪽척수증후군은 50%까지 사망율이 나오게 된다. [m.blog.naver.com]

• 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]

  Infarction is suspected when severe back pain and characteristic deficits develop suddenly. Diagnosis of spinal cord infarction is by MRI. [merckmanuals.com]

  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]

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]

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. [casereports.bmj.com]

Treatment is focused on treating the primary cause of anterior spinal artery insufficiency and general supportive treatment and care. [radiopaedia.org]

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]

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]

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]

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]

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]

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]

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

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]

1. Sohal AS, Sundaram M, Mallewa M, et al. Anterior spinal artery syndrome in a girl with Down Syndrome: case report and literature review. J Spinal Cord Med. 2009 Jun; 32(3): 349-353
2. Brewer LA III, Fosburg RG, Mulder GA, Verska JJ. Spinal cord complications following surgery for coarctation of the aorta. A study of 66 cases. J Thorac Cardiovasc Surg. 1972;64(3):368–381.
3. Satran R. Spinal cord infarction. Stroke. 1988;19(4):529–532.
4. Sandson TA, Friedman JH. Spinal cord infarction. Report of 8 cases and review of the literature. Medicine (Baltimore). 1989;68(5):282–292.
5. Hughes JT, Brownell B. Cervical spondylosis complicated by anterior spinal artery thrombosis. Neurology.1964;14:1073–1077.
6. Schneider RC, Schemm GW. Vertebral artery insufficiency in acute and chronic spinal trauma, with special reference to the syndrome of acute central cervical spinal cord injury. J Neurosurg. 1961;18:348–360.
7. Foo D, Rossier AB, Cochran TP. Complete sensory and motor recovery from anterior spinal artery syndrome after sprain of the cervical spine. A case report. Eur Neurol. 1984;23(2):119–123.
8. Kumar R. Spinal tuberculosis: with reference to the children of northern India. Childs Nerv Syst. 2005;21(1):19–26.
9. Liblau R, Chiras J, Orssaud C, et al. Spinal infarction in the anterior spinal territory with possible relation with bilharziasis. J Rev Neurol (Paris) 1991;147(8–9):605–608.
10. O'Farrell R, Thornton J, Brennan P, et al. Spinal cord infarction and tetraplegia—rare complications of meningococcal meningitis. Br J Anaesthesiol. 2000;84(4):514–517.
11. Schreiber AL, Formal CS. Spinal cord infarction secondary to cocaine use. Am J Phys Med Rehabil. 2007;86(2):158–160.
12. Weidauer S, Nichtweiss M, Lanfermann H. Spinal cord infarction: MR imaging and clinical features in 16 cases. Neuroradiology. 2002 Oct; 44(10):851-7.
13. Luo CB, Chang FC, Teng MM. Magnetic resonance imaging as a guide in the diagnosis and follow-up of spinal cord infarction. J Chin Med Assoc. 2003 Feb; 66(2):89-95.
14. Weber P, Vogel T, Bitterling H, et al. Spinal cord infarction after operative stabilization of the thoracic spine in a patient with tuberculous spondylodiscitis and sickle cell trait. Spine. 2009 Apr 15; 34(8): E294-7.
15. Joseph G, Santosh C, Marimuthu R. Spinal cord infarction due to a self-inflicted needle stick injury. Spinal Cord. 2004 Nov; 42(11):655-8.
16. Hogan EL, Romanul FC. Spinal cord infarction occurring during insertion of aortic graft. Neurology. 1966 Jan; 16(1):67-74.
17. Ross RT. Spinal cord infarction in disease and surgery of the aorta. Can J Neurol Sci. 1985 Nov; 12(4):289-95.
18. Faivre A, Bonnel S, Leyral G, et al. Essential thrombocythemia presenting as spinal cord infarction.Presse Med. 2009 Apr 22.
19. Lyders EM, Morris PP. A Case of Spinal Cord Infarction Following Lumbar Transforaminal Epidural Steroid Injection: MR Imaging and Angiographic Findings. AJNR Am J Neuroradiol. 2009 Oct;30(9):1691-3