Acute spinal cord ischemic stroke; A rare but potentially devastating stroke emergency in young healthy adults

Abstract

Introduction: Acute spinal cord infarction represents 1% of all strokes. The neurological presentation of spinal cord infarction is defined by vascular territory i.e. anterior or posterior spinal arteries. A broad spectrum of diseases can cause spinal cord infarction, most common cause is surgical repair or diseases of the thoracoabdominal aorta. MRI of the spine shows hyperintensities on T2WI, restricted diffusion on DWI and vertebral body infarction adjacent to a cord signal abnormality. Poor prognostic factors for recovery are severe impairment at presentation, female sex, advanced age, and lack of improvement in the first 24 hours. We describe clinical presentation, radiological findings and 3-month outcome of four patients who presented with ischemic spinal cord infarction. Methods: We retrospectively analysed our prospectively collected data and found four cases of spinal cord infarction for the period of May 2020 to April 2021. Total of 1,326 stroke patients (1125 i.e. 85% ischemic and 201 i.e. 15% haemorrhagic) were admitted in Hamad General Hospital. At our centre, spinal cord infarction accounts 0.30% of total stroke and 0.35% of ischemic strokes. We describe four young patients, presented with abrupt onset of focal neurologic deficit. Their MRI of the spine revealed hyperintensity signals in T2WI, restricted diffusion on DWI of spinal cord. Two patients had vertebral artery occlusion or dissection. One patient was discharged home and three patients underwent multidisciplinary rehabilitation program. Discussion: Spinal cord infarction may present with acute paraparesis or quadriparesis with devastating consequences. Blood flow to the spinal cord is influenced by perfusion pressure. The most common cause of spinal cord infarction in this case series was vertebral artery dissection or occlusion. Our case series suggests early recognition of spinal cord stroke, appropriate investigations and early treatment with further rehabilitation could improve patient outcome. Conclusion: Spinal cord infarction, a rare but devastating condition, represents 1% of all strokes but 0.3% of total strokes at our centre. Early recognition of spinal cord ischemia especially when presenting with abrupt onset focal neurological deficit, focus on underlying pathology with appropriate imaging and further investigations, secondary stroke prevention and rehabilitation are vital factors to improve neurological recovery. Future randomized trails are needed to establish the efficacy and safety of drug therapy including rt-PA in spinal cord infarction. Abbreviations: ASA: Anterior spinal artery; PSA: Posterior spinal artery; MRI: Magnetic resonance imaging; MRA: Magnetic resonance arteriogram; DWI: Diffusion weighted imaging; ICP: Intra-cranial pressure.