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Spinal Cord Infarction

Spinal Cord Stroke

Spinal cord infarction is a rare vascular-occlusive disorder of the spinal cord that constitutes only 1% of reported strokes. It is characterized by myelopathy and sensory loss, although atypical symptoms occur.


Presentation

Spinal cord infarction (SCI) is an ailment that is precipitated by the occlusion of one of the arteries of the spinal vasculature, leading to variable clinical features depending on the affected vessel. Resultant local ischemia of the spinal cord leads to the acute onset of myelopathy [1]. The latter is characterized by sensory and motor deficits below the lesion. Diagnosis of SCI is clinical, and although the condition is abrupt, it may be partially diminished and delayed due to the continued circulation provided by collateral vessels [2]. Individuals who suffer from SCI may have risk factors such as trauma, coagulopathies or prior aortic surgery, although a significant number of cases have no identifiable etiology [3] [4].

One of the most common symptoms is back pain, which occurs in up to 70% of cases [5]. The general findings reported, however, are neurological, and may include loss of fine touch and proprioception (commonly in anterior spinal artery infarcts), vibration, pain and temperature perception. Motor disturbances and flaccid paralysis have also been described. In addition, muscle weakness and loss of reflexes are often experienced [6]. Features of Brown-Sequard syndrome are also documented [7].

Individuals may also present with loss of sphincter tone as well as complaints consistent with a neurogenic bladder. Hyperreflexia may follow initial symptoms, and a positive Babinski reflex may be elicited.

SCI shares feature with other neuropathies and myopathies such as Guillain-Barré syndrome, thus making the diagnosis more difficult [1].

Retrosternal Chest Pain
  • To reduce the risk of hypotensive sequelae such as spinal cord infarction, blood pressure should be closely monitored in elderly patients presenting with retrosternal chest pain who are treated with short-acting oral antihypertensive agent, particularly[ncbi.nlm.nih.gov]
Back Pain
  • SUMMARY OF BACKGROUND DATA: Diagnostic and therapeutic image-guided nerve root injection is commonly performed in the management of low back pain and sciatica.[ncbi.nlm.nih.gov]
  • Ten days after a trivial strike to the neck and back, he had sudden back pain, weakness of the upper and lower extremities, developed dyspnea and became unconscious.[ncbi.nlm.nih.gov]
  • We describe a 65-year-old man who presented with sudden paraplegia and back pain of 4-days duration with sensory loss below the umbilicus and bilateral scalp necrosis.[ncbi.nlm.nih.gov]
  • Symptoms, which generally appear within minutes or a few hours of the infarction, may include intermittent sharp or burning back pain, aching pain down through the legs, weakness in the legs, paralysis, loss of deep tendon reflexes, loss of pain and temperature[ninds.nih.gov]
  • They may also be caused due to aortic atherosclerosis, dissecting aortic aneurysm (chest or back pain with diminished pulses in legs), or hypotension from any cause.[sci-recovery.org]
Spine Pain
  • ., Eagle, Idaho, 2001 Selected Publications Calantoni A (2016), The Utilization of Long Term Care for Herniated Lumbar Discs with Chiropractic for the Management of Mechanical Spine Pain.[bridesburgchiro.com]
Hyperreflexia
  • Hyperreflexia may follow initial symptoms, and a positive Babinski reflex may be elicited. SCI shares feature with other neuropathies and myopathies such as Guillain-Barré syndrome, thus making the diagnosis more difficult.[symptoma.com]
  • 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]
  • Initial areflexia changes to hyperreflexia with the presence of Babinski signs.[aibolita.com]
  • Within days, flaccid limbs become spastic and hyporeflexia (underactive nerve responses) turns into hyperreflexia (overactive nerve responses) and extensor plantar nerve responses.[en.wikipedia.org]
Radiculomyelopathy
  • Rivista di Neuroradiologia 17(3):277–281 Google Scholar Thron A, Koenig E, Pfeiffer P, Rossberg C (1987) Dural vascular anomalies of the spine-an important cause of progressive radiculomyelopathy.[link.springer.com]
Cognitive Deficit
  • Cerebral infarction patients often have cognitive deficits, whereas cognitive deficits are rare among spinal cord infarction patients and probably do not differ from those in other hospitalized patients with equally serious conditions.[karger.com]
Urinary Incontinence
  • A catheter may be necessary for patients with urinary incontinence. Definition Spinal cord infarction is a stroke either within the spinal cord or the arteries that supply it.[ninds.nih.gov]
  • Catheterisation may be required if the patiemt has urinary incontinence. 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]
  • When the arteria radicularis magna is affected the patient progresses to fecal and urinary incontinence, as well as motor deficit [ 9 ].[jneuro.com]

Workup

The aim of imaging modalities and laboratory studies is to demonstrate the presence of a spinal cord infarction, and also to rule out alternative etiologies of symptoms such as hypercoagulability and stroke due to cardiac emboli.

Visualization of the spinal cord in the form of magnetic resonance imaging (MRI) scanning may show abnormalities such as the 'owl eye' sign, seen in anterior spinal artery (ASA) involvement [5]. Nevertheless, up to 45% of patients have undetectable changes on MRI while in the acute stages. Additional signs include vertebral body infarction, which may become apparent earlier than SCI [8]. The importance of MRI is emphasized in its ability to exclude conditions such as atriovenous malformations, space occupying lesions and infection [9]. Diffusion-weighted imaging and T2 weighted imaging may be able to detect early infarctions, although artifacts are common in the former [10]. Signs of cord ischemia seen in T2 weighted images include local swelling and hyperintense lesions [1] [2] [10]. Brain abnormalities may also be visible after some hours.

Spinal angiogram to eliminate vascular malformations as the cause may be attempted in young patients, however, this procedure is available at highly specialized institutions and carries a risk of worsening the ischemia.

Cerebrospinal fluid (CSF) analysis can rule out both bacterial and viral infections such as human immunodeficiency virus, herpes simplex virus, Epstein-Barr virus, and syphilis. Polymerase chain reaction and serology are among the tests performed. Screening for autoimmune causes uses both CSF and serum analysis, measuring erythrocyte sedimentation rate, antinuclear antibody, and complement.

Hyperviscosity
  • CONCLUSIONS: Polycythemia vera creates a high risk of systemic thrombosis due to hyperviscosity and platelet activation.[ncbi.nlm.nih.gov]
Streptococcus Pneumoniae
  • Abstract We report a male with spinal cord infarction and tetraplegia after Streptococcus pneumoniae meningitis. He was subsequently found to have both a Chiari I malformation and factor V Leiden mutation.[ncbi.nlm.nih.gov]
Ischemic Changes
  • Magnetic resonance imaging showed contrast-enhanced and high-intensity lesions in the mid and lower thoracic cord, which were consistent with ischemic changes within the spinal cord and in the T4 vertebral body.[ncbi.nlm.nih.gov]

Treatment

  • This case report suggests that the relative hypotension of autoregulatory failure induced by treatment of malignant hypertension may give rise to these neurologic complications.[ncbi.nlm.nih.gov]
  • There are few reports in the pediatric literature characterizing etiology, diagnosis, treatment, and prognosis.[ncbi.nlm.nih.gov]
  • […] loss in bilateral T4-L1 levels and the left lower limb at two hours after treatment.[ncbi.nlm.nih.gov]
  • OUTCOMES: The patient's condition was stable when he discharged from the hospital after 20 days of treatment.[ncbi.nlm.nih.gov]
  • RESULTS: The patient underwent hyperbaric oxygen treatment.[ncbi.nlm.nih.gov]

Prognosis

  • There are few reports in the pediatric literature characterizing etiology, diagnosis, treatment, and prognosis.[ncbi.nlm.nih.gov]
  • Here, we report a case of SCI in diabetic pregnancy, properly diagnosed, promptly treated, and a good prognosis achieved.[ncbi.nlm.nih.gov]
  • Definition Treatment Prognosis Clinical Trials Organizations Publications Definition Spinal cord infarction is a stroke either within the spinal cord or the arteries that supply it.[ninds.nih.gov]
  • In this paper, we present a case report of a subject having presented an isolated motor deficit of the lower limbs and a favorable prognosis, suggesting selective involvement of the anterior horns of the spinal cord subsequent to surgical repair of an[ncbi.nlm.nih.gov]
  • This case highlights the importance of recognizing rare causes of spinal cord pathology and considering infarction in the differential diagnosis of acute myelopathy because management and prognosis varies.[ncbi.nlm.nih.gov]

Etiology

  • Nine patients (40.9%) had probable etiologies, while 13 were cryptogenic (59.1%). The primary etiologies were aortic diseases. Hypertension was the most common vascular risk factor (50%).[ncbi.nlm.nih.gov]
  • We consider their presentation, etiology, and treatment course to provide other emergency department physicians with the ability to better identify and evaluate these patients.[ncbi.nlm.nih.gov]
  • Individuals who suffer from SCI may have risk factors such as trauma, coagulopathies or prior aortic surgery, although a significant number of cases have no identifiable etiology.[symptoma.com]
  • Several etiological factors, each one able to affect blood flow in the spinal cord and cause infarction, might have been present in our patient, including generalized degenerative atherosclerotic vascular disease, secondary polycythemia resulting from[ncbi.nlm.nih.gov]
  • Abstract Spinal cord infarction is a rare entity of varying etiology although most often associated with atherosclerotic aortic disease.[ncbi.nlm.nih.gov]

Epidemiology

  • A comprehensive summary of the clinical anatomy, patho-physiologic mechanisms, epidemiology, diagnosis and treatment of FCE is described, along with the conflicting opinions on its incidence and relevance after reviewing all of the related literature.[ncbi.nlm.nih.gov]
  • Patient Population: Prevalence and Epidemiology Knee // Shoulder & Elbow // Hip // Spine // Foot & Ankle // Hand & Wrist Fragility Fractures: Diagnosis and Treatment Shoulder & Elbow The Characteristics of Surgeons Performing Total Shoulder Arthroplasty[mdedge.com]
  • Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann PU: Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study.[karger.com]
Sex distribution
Age distribution

Pathophysiology

  • In the majority of these cases, the pathophysiology is enigmatic. The authors present 3 cases of pediatric spinal cord infarction that followed minor trauma.[ncbi.nlm.nih.gov]
  • Pathophysiologic mechanisms, clinical classification schemes, clinical presentations, imaging findings, and treatment modalities are considered. Recent advances in genetic and syndromic vascular pathologies of the spinal cord are also discussed.[ncbi.nlm.nih.gov]
  • The first chapter stresses the etiology and pathophysiology of childhood stroke as the basis for evaluations and treatment.[books.google.com]
  • . * A comprehensive source that thoroughly examines the neurological manifestations of stroke * A guide to highly studied topics, including stroke complications, syndromes, and stroke related psychiatric disorders * A better understanding of the pathophysiological[books.google.com]
  • Spontaneous dissecting aneurysms of the descending thoracic or upper abdominal aorta can occlude the ostia of segmental spinal arteries; atherosclerosis of the aorta and its branches, and iatrogenic ischemia from recent aortic surgery are the usual pathophysiologic[aibolita.com]

Prevention

  • Abstract Even though new prevention techniques have been developed and are being used during thoraco-abdominal aortic repairs, spinal cord infarction remains a severe and relatively frequent complication of aortic surgery.[ncbi.nlm.nih.gov]
  • This rare entity should be considered when managing patients with acute mono- or paraparesis who have a thoracoabdominal aneurysm with mural thrombi because interventions aimed at preventing further embolisms could be beneficial in these patients.[ncbi.nlm.nih.gov]
  • This case illustrates an unusual presenting symptom of spinal infarction, the need to identify multiple risk factors for spinal cord infarction, and the importance of optimal preventive therapy in patients at risk.[ncbi.nlm.nih.gov]
  • Surgical treatments include decompression and prophylactic fusion, during which intraoperative neuromonitoring is important to alert the surgical team to changes in cord function so that they can prevent or mitigate spinal cord injury.[ncbi.nlm.nih.gov]
  • Increased awareness of this injury may make it possible to recognize its early symptoms and prevent further injury. Copyright 2010 Elsevier B.V. All rights reserved.[ncbi.nlm.nih.gov]

References

Article

  1. de Seze J, Stojkovic T, Breteau G, et al. Acute myelopathies: Clinical, laboratory and outcome profiles in 79 cases. Brain. 2001;124(Pt 8):1509–1521.
  2. Weidauer S, Nichtweiss M, Lanfermann H, Zanella FE. Spinal cord infarction: MR imaging and clinical features in 16 cases. Neuroradiology. 2002;44(10):851–857.
  3. Masson C, Pruvo JP, Meder JF, et al. Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome. J Neurol Neurosurg Psychiatry. 2004;75(10):1431–1435.
  4. Nedeltchev K, Loher TJ, Stepper F, et al. Long-term outcome of acute spinal cord ischemia syndrome. Stroke. 2004;35(2):560–565.
  5. Cheng MY, Lyu RK, Chang YJ, et al. Spinal cord infarction in Chinese patients. Clinical features, risk factors, imaging and prognosis. Cerebrovasc Dis. 2008;26(5):502–508.
  6. Mascalchi M, Cosottini M, Ferrito G, Salvi F, Nencini P, Quilici N. Posterior spinal artery infarct. AJNR Am J Neuroradiol. 1998;19(2):361–363.
  7. Novy J, Carruzzo A, Maeder P, Bogousslavsky J. Spinal cord ischemia: clinical and imaging patterns, pathogenesis, and outcomes in 27 patients. Arch Neurol. 2006;63(8):1113–1120.
  8. Suzuki T, Kawaguchi S, Takebayashi T, Yokogushi K, Takada J, Yamashita T. Vertebral body ischemia in the posterior spinal artery syndrome: case report and review of the literature. Spine (Phila Pa 1976). 2003;28(13):E260–4.
  9. Bammer R, Fazekas F, Augustin M, et al. Diffusion-weighted MR imaging of the spinal cord. AJNR Am J Neuroradiol. 2000;21(3):587–591.
  10. Thurnher MM, Bammer R. Diffusion-weighted MR imaging (DWI) in spinal cord ischemia. Neuroradiology. 2006;48(11):795–801.

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Last updated: 2018-06-22 00:21