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.

• Coarctation of the Aorta

  Spinal cord complications following surgery for coarctation of the aorta. A study of 66 cases. J Thorac Cardiovasc Surg. 1972;64(3):368–381. [PubMed] [Google Scholar] Satran R. Spinal cord infarction. Stroke. 1988;19(4):529–532. [ncbi.nlm.nih.gov]

  Massive hemoptysis 27 years after surgery for coarctation of the aorta. J R Soc Med 2001 ; 94:640-641. Crossref, Medline, Google Scholar 27 Deffenbach ME, Charan NB, Lakshminarayan S, Butler J. [pubs.rsna.org]

• 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]

• Hypoventilation

  The sleep breathing pattern was compatible with central alveolar hypoventilation due to automatic breathing control failure caused by a lesion of the reticulospinal pathway, which normally activates ventilatory muscles during sleep. [ncbi.nlm.nih.gov]

  Martin TJSanders MH Chronic alveolar hypoventilation: a review for the clinician. Sleep.1995;18:617-634.PubMedGoogle Scholar 6. [jamanetwork.com]

• 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]

• 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]

  The following illustrates such a case: A 40 year old theatre nurse who recently had a long-haul flight woke up at 2 am complaining of back pain, chest pain and bilateral leg weakness. She was then brought to the emergency department. [oatext.com]

• 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]

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

  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]

• 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]

• 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]

• Monoplegia

  […] steal syndrome. 61 Mohassel P...Gailloud P 24195022 2013 37 Images in anesthesiology: reversible anterior spinal artery syndrome during celiac plexus block. 61 Elahi F...Lassalle CA 22710956 2013 38 Subacute anterior spinal cord ischemia with lower limb monoplegia [malacards.org]

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.

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