Anterior Spinal Artery Infarction Research Articles

A confounding pediatric spinal cord injury: Anterior, central, or both?

Pediatric spinal cord injury (SCI) most commonly affects the cervical region. Central cord syndrome most often occurs in the lower cervical injury due to hyperextension injury, while anterior cord syndrome is primarily due to vascular infarction after hyperextension injury. An unusual case of a pediatric patient who physically presented with central cord syndrome but radiologically had evidence of anterior spinal artery syndrome is described. A two-year-old male presented after a fall from three feet with flaccid upper extremities and dysesthesias but maintained functional strength in bilateral lower extremities. Although his clinical presentation was that of central cord syndrome, he was found to have an anterior spinal artery infarct spanning from C2-T3 with a ligamentous injury at C3 and an incidental finding of Chiari I malformation on MRI. Given the negative evaluation for a cardiac or hematologic source of embolus and normal angiography, it was theorized that compression of vertebral arteries by previously undiagnosed Chiari I malformation in the setting of trauma could have made the patient more vulnerable to this complication. During inpatient rehabilitation, he regained scapular movement and shoulder flexion. However, he regained distal movement in supination, wrist extension, and finger flexion instead of the more usual proximal-to-distal motor recovery observed in SCI. While he had a relative sparing of strength in his legs, he had impaired proprioception and balance, leading to gait impairment. This case highlights the complexity of pediatric cervical SCI diagnosis and prognostication. While classic SCI subtypes are well described, many pediatric and adult patients will present and recover in unexpected ways. All with SCI should be evaluated thoroughly for common etiologies and transitioned to rehabilitation therapies to assist in recovery.

A Case of Acute Anterior Spinal Artery Infarction Masquerading as Acute Transverse Myelitis (P8-5.028)

A Case of Acute Anterior Spinal Artery Infarction Masquerading as Acute Transverse Myelitis (P8-5.028)

Anterior spinal artery infarction: study of a case in the neurology department of the CHU Ignace Deen in Conakry

Introduction: Spinal cord infarction corresponds to all the clinical manifestations secondary to ischemia of part or all of the spinal cord, whether sudden or progressive. It is a rare condition with a difficult diagnosis affecting only 1.2% of patients admitted to the neurovascular pathologies department. It is most frequently located in the territory of the anterior spinal artery (66.7%). Observation: 43-year-old patient with a lifestyle of repeatedly carrying heavy weights on the head, presenting with neck pain radiating to the upper limbs and tetra paresis. The clinic is characterized by anterior spinal artery syndrome, a lesional and sublesional syndrome and the spinal MRI revealed an extensive T2 hyper signal localized at the level of the anterior horn producing the characteristic appearance of snake eyes evoking an infarction in the territory of the anterior spinal artery. Conclusion: It is a diagnosis which remains difficult and is based on the comparison of clinical and para-clinical data.

Spinal Cord Ischemia in a Young Patient Following Strenuous Exercise (P6-5.027)

<h3>Objective:</h3> NA <h3>Background:</h3> Spinal infarcts in the setting of anatomical variants with absent arteries of Lazorthes and Adamkiewicz are rare and seldom reported. <h3>Design/Methods:</h3> We report a healthy twenty-two-year-old man who presented after severe neck pain following strenuous weight lifting, with bilateral arm followed by leg weakness, and respiratory failure requiring intubation. Initial exam was significant for absent movement in the arms and decreased movement in the left &gt; right leg, a C3 sensory level, and hyporeflexia. MRI cervical/thoracic/lumbar spine with and without gadolinium revealed an extensive, thin, anterior, non-enhancing T2 hyperintensity from the craniocervical junction to T7. CSF analysis was unremarkable. He was started on steroids and plasmapheresis for possible NMOSD though anterior spinal artery infarct was high in the differential. Repeat MRI was DWI positive with ADC correlate. A spinal angiogram revealed the absence of intracranial vertebral artery, PICA, a. of Lazorthes, and a. of Adamkiewicz. Steroids and plasmapheresis were discontinued after anti-MOG and NMO antibodies were negative. <h3>Results:</h3> This patient’s presentation exemplifies the challenge of determining whether the underlying etiology is demyelinating versus ischemic. Given that the patient’s symptoms developed in the setting of strenuous weight lifting, the diagnosis of spinal cord infarct is likely. The most probable mechanism is dissection and occlusion of the vertebral artery with subsequent occlusion of the anterior spinal artery. The anatomic variants seen in the spinal angiogram may have worsened the presentation due to fewer collaterals present. Another mechanism which was considered, although less likely, was fibrocartilaginous embolism. During the hospital course the patient regained motor function in the legs and some function in the arms but continued to require mechanical ventilation. <h3>Conclusions:</h3> Acute intramedullary ischemia should be considered in younger patients without vascular risk factors if the clinical presentation and diagnostic work-up are suggestive, even when a thrombus or dissection is not seen on angiogram. <b>Disclosure:</b> Dr. Bellara has nothing to disclose. Dr. Sacks has nothing to disclose. Dr. Choi has nothing to disclose. Dr. Chernyak has nothing to disclose. Dr. Jacoby has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alexion. Dr. Jacoby has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Argenx. Dr. Jacoby has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for N/A. The institution of Dr. Jacoby has received research support from ABPN. Dr. Levine has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for MEDLINK. Dr. Levine has received personal compensation in the range of $50,000-$99,999 for serving as an Expert Witness for Law Firms. The institution of Dr. Levine has received research support from NIH.

Abstract Number ‐ 219: Spinal cord infarct in young: Fibrocartilaginous Embolism with Occlusion of Anterior Spinal Artery

Introduction Spinal cord infarctions are rare and account for fewer than 1% of all strokes. Diagnosis is usually established by clinical symptoms of sudden onset paraplegia and sensory dysfunction along with radiographic evidence of a non‐enhancing, diffusion‐restricted T2 hyperintense lesion on spinal cord MRI. We describe an interesting case of anterior spinal artery infarct from suspected fibrocartilaginous embolus from intervertebral disc. Methods Case report. Demographics and clinical history were obtained by chart review. MRI and cerebral angiogram images were reviewed and compared to radiology reports. Results 21‐year‐old female with no prior medical history presented with sudden onset headache, bilateral arm tingling, and neck stiffness that rapidly progressed within the hour to quadriplegia with numbness below the T2 sensory level. She continued to worsen, developed respiratory failure and required intubation. MRI of the cervical cord revealed a longitudinally extensive, non‐enhancing, diffusion‐restricted lesion extending from the bilateral medial medulla to the ventral spinal cord at C5/6 vertebral level. Cerebral and spinal digital subtraction angiography was notable for non‐opacification of the cervical anterior spinal artery. She had extensive work up for dissection, vasculitis, hypercoagulable state, autoimmune conditions that were all negative. However, there was a diminished T2 signal in her C5‐6 intervertebral disc with subtle loss of intervertebral disc space concerning for disc compression, likely related to her job requiring intensive heavy lifting. It was surmised that she developed a ventral cervical cord infarct secondary to fibrocartilaginous embolization and occlusion of anterior spinal artery, from recent mechanical compression of her C5‐6 disc. Cases of spinal cord infarcts following mechanical trigger, such as heavy lifting or falls, with histopathological confirmation of fibrocartilaginous material in the vasculature postmortem are well reported. It is postulated as a mechanism of spinal cord infarct in young patients that compressive forces on the intra‐vertebral body trigger embolization of nucleus pulposus material through persistent nuclear anastomoses to the spinal circulation. Conclusions Ischemic infarct should be considered in the differential diagnosis for sudden onset of symptoms localizable to spinal cord, especially when spinal MRI shows restricted diffusion in a vascular distribution. Demonstrating non‐opacification of the anterior spinal artery on digital subtraction angiography confirms the diagnosis. In case of negative work up for spinal cord infarct, the presence of an abnormal signal in the intervertebral disc on MRI may suggest fibrocartilaginous embolism as a mechanism of infarction in young patients.

Spontaneous spinal cord infarction in Austria: a two-center comparative study.

Background:Spinal cord infarction (SCI) is a neurological emergency associated with high rates of persistent neurological deficits. Knowledge about this rare but potentially treatable condition needs to be expanded.Objective:To describe the characteristics of spontaneous SCI in a large retrospective series of patients treated at two tertiary care centers in Austria.Methods:We performed a descriptive and comparative analysis of spontaneous SCI treated at the University Hospitals of Salzburg and Graz between the years 2000 and 2020. The analysis included pre- and in-hospital procedures, clinical presentation, etiology, diagnostic certainty, reperfusion therapy, and functional outcome at discharge.Results:We identified 88 cases, 61% were ascertained in the second half of the study period. The median age was 65.5 years [interquartile range (IQR) = 56–74], 51.1% were women. Anterior spinal artery infarction was the predominant syndrome (82.9%). Demographics, vascular comorbidities, and clinical presentation did not differ between the centers. The most frequent etiology and level of diagnostic certainty were distinct, with atherosclerosis (50%) and definite SCI (42%), and unknown (52.5%) and probable SCI (60%) as front runners in Salzburg and Graz, respectively. Patients arrived after a median of 258.5 min (IQR = 110–528) at the emergency room. The first magnetic resonance imaging (MRI) of the spinal cord was performed after a median of 148 min (IQR = 90–312) from admission and was diagnostic for SCI in 45%. Two patients received intravenous thrombolysis (2.2%). The outcome was poor in 37/77 (48%).Conclusion:Demographics, clinical syndromes, and quality benchmarks for spontaneous SCI were consistent at two Austrian tertiary care centers. Our findings provide the foundation for establishing standards for pre- and in-hospital care to improve outcomes.

Pediatric spinal cord infarction following a minor trauma: a case report.

Pediatric spinal cord infarction is a rare entity that presents a diagnostic challenge at the emergency department. Ischemic spinal cord infarction can occur in the setting of trauma, cardiovascular malformation, or postoperatively. We report a case of anterior spinal artery infarction following seemingly minor trauma in an otherwise healthy 14-year-old male. A 14-year-old male presented with unprovoked sudden-onset stabbing back pain earlier that day. The patient then demonstrated bilateral lower extremities weakness while at the emergency department. After extensive diagnostic workup, the patient was diagnosed with anterior spinal artery territory infarction involving the thoracic spinal cord. Minor trauma to the thoracic spinal cord was detected on imaging and was believed to be the culprit of this event. Given the rarity of spinal cord ischemia, a high index of suspicion and extensive workup of patients presenting with clinical weakness are needed for accurate diagnosis and to avoid the eventual poor outcome. With so few reports in the literature regarding spinal cord ischemia in the pediatric population, accurate diagnosis is often delayed until after irreversible events have already taken place. Our case report of anterior spinal artery distribution thoracic cord infarct following a minor trauma was diagnosed by axial thin-slice DWI MRI with an otherwise negative workup.

Sulcal artery syndrome presenting as an incomplete Brown–Sequard syndrome – Report of an unusual case and review of the literature

Sulcal arteries perfuse the anterior two-thirds of the spinal cord, and spinal cord infarction as a result of sulcal artery occlusion is rare. Most reported cases are associated with vertebral artery dissection, and commonly involve the cervical spinal cord. A 74-year-old man presented with sudden onset weakness and numbness after a brief bout of abdominal pain. Further investigations concluded that this was sulcal artery syndrome. We report a case of sulcal artery syndrome affecting the thoracic spinal cord presenting as Brown–Sequard syndrome. Sulcal artery syndrome usually has good prognoses, unlike anterior spinal artery infarction.

Monoparesis Post Bronchial Artery Embolization: Clinicoradiological Discordance in Anterior Spinal Artery Infarct—Case Report and Review of Literature

AbstractBronchial artery embolization (BAE) is an established minimally invasive treatment for massive or recurrent haemoptysis. Anterior spinal artery (ASA) infarct is an uncommon but serious complication of the procedure. The interventional radiologist doing these procedures must be well versed with the bronchial artery anatomy, its variations, and its relation with ASA to avoid this dreaded complication. The authors report a case in which the patient developed monoparesis and mild transient autonomic dysfunction post BAE but magnetic resonance imaging of spine showed diffuse symmetric cord involvement in ASA territory from D1–D4 level.

Anterior spinal artery infarct in a young female mimicking tranverse myelitis

SLE affects 0.1% of the population and 50-60% SLE patients can have neurological involvement. Spinal cord infarction is a rare entity with an incidence of <1% of all strokes. We hereby report a case of a young female who was diagnosed with SLE, and who developed right foot drop, and paraparesis due to anterior spinal artery infarction which had clinically mimicked transverse myelitis.

Spinal Cord Infarction: Clinical and Radiological Features

Introduction: Spinal cord infarction is an uncommon disease varying in its clinical presentation. This study describes the clinical and radiological presentation of spinal cord infarcts in 17 consecutive patients. Material and Methods: Clinical and MR imaging data of 17 patients were reviewed. Inclusion criteria were acute or subacute presentation (peak within 72 hours) and MRI showing typical signal changes on T2WI compatible with spinal cord infarct. Exclusion criteria were clinical or MRI findings suggesting other etiologies. Results: Clinical presentation included dissociative anesthesia, weakness of limbs, back or neck pain, and autonomic symptoms with symptom onset to peak time ranging from few minutes to 48 hours in patients with anterior spinal artery infarct (n = 16), and weakness and sensory loss in ipsilateral upper limb in patient with posterior spinal artery infarct (n = 1). One patient presented with “man-in-the-barrel syndrome (MIB).” MRI findings in anterior spinal artery infarcts included pencillike hyperintensities on T2 sagittal (n = 16, 100%) and “owl eye” appearance on T2 axial (n = 6, 37.5%) images. Diffusion restriction was noted in 8 cases and enhancement was noted in 2 cases. The posterior spinal artery infarct showed T2 hyperintensity in left posterior paramedian triangular distribution in cervical cord (C2-C7). Follow-up was available for 9 patients (period ranging from 15-41 months). Four patients had a favorable outcome who could walk independently, 1 patient could walk with support, and 2 patients were wheelchair bound. Two patients died. Conclusion: Spinal cord infarction is a rare but important cause of acute spinal syndrome. Typical distribution and appropriate imaging can help in timely diagnosis.

Anterior Spinal Artery Infarct Secondary to “Rotatory Atlantoaxial Subluxation” in a Pediatric Patient: A Case Report and Review of the Literature

Spinal cord infarction in children is a rare condition that is becoming more widely recognized. There are few reports in the pediatric literature characterizing etiology, diagnosis, treatment options, and prognosis of anterior spinal artery infarction following rotatory atlantoaxial subluxation. In many children, the cause of spinal cord ischemia in the absence of vertebral fracture is unknown and is often wrongly diagnosed. Imaging diagnosis of spinal cord ischemia is often difficult due to the small transverse area of the cord, cerebrospinal fluid artifact, and inadequate resolution. The prognosis depends on the level of spinal cord damage, early identification and reversal of ischemia, and follow-up with intensive physical therapy and medical support. In addition to summarizing the literature on spinal cord infarction in children following cervical trauma, this article adds to the literature another case of a child with anterior spinal artery territory infarction due to rotatory atlantoaxial subluxation, leading to kinking and occlusion of vertebral artery, which highlights the difficulties and controversies in the management of this condition.

Magnetic resonance imaging and diffusion-weighted imaging findings in posterior spinal cord infarction: Case report

Acute spinal cord ischemia (SCI) accounts for 5%e8% of all acute myelopathies [1]. In the SCI, posterior spinal artery (PSA) syndrome is much less common than in anterior spinal artery (ASA) syndrome [2], with PSA accounting for 3% of all acute SCIs and ASA syndrome accounting for 67% [3]. In 1994, Kaneki et al. provided a case report review of 27 cases of PSA syndrome in the literature [2]. Essentially, all 27 cases were diagnosed from neurological findings and the exclusion of other pathological conditions by neuroimaging. Even MRI cannot easily detect acute ischemic lesions in PSA syndrome due to their small size and changes in the signal that occur over the disease course. Diffusion-weighted imaging (DWI) is a well-established diagnostic method for acute cerebral ischemic injury [4] and is a potential tool for the detection of SCI. Among cases of SCI detected by DWI, ASA infarction was more involved than PSA infarction [5e7]. On the other hand, the proportion of PSA infarction among cases of SCI detected by DWI may be high than that among cases diagnosed by clinical sign, although there are only three reports on PSA infarction detected by DWI [5,8,9]. Here, we report clinical and imaging findings in a case of PSA infarction, including time-dependent changes of the apparent diffusion coefficient (ADC) abnormality, and propose that time

Spinal tuberculosis paraplegia associated with anterior spinal artery infarction: a very rare presentation

Introduction: Tuberculosis remains a major cause of morbidity and mortality in developing countries. Paraplegia is the most dreaded complication of spinal tuberculosis. Here we present a patient with a clinical picture consistent with spinal tuberculosis associated with anterior spinal arterial infarction presenting as paraplegia.

PTU-086 Outcomes of all surgery for ulcerative colitis over a 12-month period at a tertiary referral ibd unit

Introduction 1/4 of patients with ulcerative colitis (UC) will require surgery. We describe an audit of indications and outcomes of UC surgery at LTHT a tertiary referral centre for pouch surgery. Method Patients undergoing surgery for UC in 2013 were identified from surgical lists, IBD nurse post-op review and from histopathology database. Data were extracted from electronic records and case notes. Results 42 cases, 38 with complete dataset, 25 (59.5%) males. Mean age 42 (range 18–91), mean age at diagnosis 33 (7–68). 21 (55%) had failed >3 therapies and 15 (39%) taking oral steroids at time of surgery. 0 E1 disease, 15 (39.5%) E2, 15 (39.5%) extensive colitis (E3), 8 (21%) extent unclear. 48 procedures on 38 patients within the 12 months, 32 (67%) were elective, 16 (33%) emergency. Of 16 emergencies 11 were sub-total colectomies for acute severe disease (5 open, 6 laparoscopic), 3 EUAs, 1 rectal stump dehiscence and 1 obstructing tumour. At 12 months 23 (61%) completed pouch surgery. Of 40 colectomies 27 (67.5%) were laparoscopic. Indications: failed medical therapy 78.9% (n = 30, one low grade dysplasia), cancer 7.9% (n = 3, 1 = panproctocolectomy transverse colon carcinoma, 1 = pouch with adenocarcinoma cuff, 1 = sub-total colectomy with tumour in rectal remnant), patient choice 5.3% (n = 2), perforation 2.6% (n = 1), other 5.3% (n = 2) One death from pneumonia following emergency procedure. 11 short-term complications in 7 patients having 2-stage pouch surgery (5 wound infections, 2 anastomotic leaks, 1 ileus, 1 chest infection, 1 failure to restore continuity, 1 ureteric damage). 5 had longer-term complications (1 each for pouch dysfunction, high output stoma, strictured anastomosis, pouchitis, peri-anal pain). 7/16 having 3-stage pouch suffered one or more short-term complications (5 wound infection/dehiscence, 5 intra-abdominal complication (collection/sepsis/bleed), 2 ileus and one each of anastomotic leak, chest sepsis, VTE, rectal stump complication, AKI, confusion, pneumaturia, anterior spinal artery infarct). 7/16 patients suffered one or more longer-term complication (3 high output stoma before reversal ileostomy, anaemia n = 2 and and 1 of rectal discharge, SBO, adrenal insufficiency and retrograde ejaculation) Conclusion Leeds is a high volume surgical unit performing 23 pouch operations in 12 months compared with the median number of 4 (national IBD audit). Most were laparoscopic as recommended by the IBD service standards. Pouch surgery carries significant short and long term risks and these should be addressed carefully. We recommend that all elective UC surgical patients are discussed at the IBD MDT and ideally reviewed in the combined clinic. Disclosure of interest None Declared.

Anterior Spinal Artery Infarction Presenting with Hemiparesis

Anterior Spinal Artery Infarction Presenting with Hemiparesis

Atypical Anterior Spinal Artery Infarction due to Left Vertebral Artery Occlusion Presenting with Bilateral Hand Weakness.

BackgroundInfarct of the anterior spinal artery is the most common subtype of spinal cord infarct, and is characterized by bilateral motor deficits with spinothalamic sensory deficits. We experienced a case with atypical anterior-spinal-artery infarct that presented with bilateral hand weakness but without sensory deficits.Case ReportA 29-year-old man presented with sudden neck pain and bilateral weakness of the hands. Magnetic resonance imaging (MRI) of the brain did not reveal any lesion. His motor symptoms improved rapidly except for mild weakness in his left wrist and fingers. Magnetic resonance angiography showed proximal occlusion of the left vertebral artery; a spine MRI revealed left cervical cord infarction.ConclusionsBilateral or unilateral hand weakness can be the sole symptom of a cervical cord infarct.

CT angiography of anterior spinal artery in cervical spondylotic myelopathy.

To identify anterior spinal artery (ASA) infarct or occlusion by CT angiography (CTA) in patients with cervical spondylotic myelopathy (CSM). Fourteen patients with CSM were performed CTA of ASA after admission. T2-weighted hyperintensity of MR image was compared with image of CTA of ASA. All patients presented spinal canal sagittal diameter compression from 10 to 80% and different T2-weighted hyperintensity of MR images. No ASA infarct or occlusion was found in CSM patients. ASA infarct or occlusion is not commonly seen in CSM patients with spinal canal sagittal diameter compression less than 80%. Pathological changes about T2-weighted hyperintensity of MR image in CSM have no close correlation with ASA infarct.

Spectrum of clinicoradiological findings in spinal cord infarction: Report of three cases and review of the literature

Spinal cord infarction (SCI) often remains undiagnosed due to infrequent occurrence and lack of established diagnostic procedures. The unique pattern of blood supply explains the heterogeneity of clinical presentation. We present three cases of SCI to highlight the varied spectrum of clinicoradiological findings. The first patient had posterior spinal artery infarction, and spine imaging showed infarction of adjacent vertebral body, which is usually rare. The second patient had anterior spinal artery infarction and the cANCA titers were elevated. The third patient had a pure motor quadriparesis. Initial imaging did not show any cord infarction, but signal changes were noted on serial imaging. Fibrocartilagenous embolism (FCE) seems the most likely etiology in the first and third cases. A high index of clinical suspicion is necessary for prompt diagnosis. Sensitivity of the initial magnetic resonance imaging remains limited, necessitating serial follow-up scans. Infarction of the adjacent vertebral body is a useful confirmatory sign. Fat suppression images can delineate the marrow signal changes better. Elderly patients with vascular risk factors and degenerative discs need to avoid mechanical triggers that predispose to FCE. Younger patients with SCI will need evaluation for cardioembolic source and vasculitis.

Acute Spinal-Cord Ischemia: Evolution of MRI Findings

Background and PurposeMagnetic resonance (MR) findings in acute spinal-cord ischemia can be summarized as focal cord enlargement and hyperintensities on T2-weighted images and gadolinium enhancement, especially of the central gray matter. However, in analogy with acute brain ischemia, it is to be expected that the findings of MR imaging (MRI) may be normal in the first hours after symptom onset. We evaluated the clinical and MRI findings in a series of patients with acute spinal-cord ischemia, and tested the hypothesis that the development and course of MR abnormalities are predictable.MethodsFive patients with acute spinal-cord ischemia were admitted to our hospital over a 2-year period. Repeated MRI (1.5 T) was performed in all patients. Clinical data were retrieved from the patients' charts.ResultsFour women and one man with a median age of 52 years (range, 31-75 years) were admitted. Three patients had anterior spinal artery infarction and two patients had transverse infarctions. All patients underwent spinal MRI within 24 hours; the findings were normal in four of the five patients. After 1-2 days, T2-weighted MRI generally exhibited focal cord enlargement and hyperintensity in all patients, while spinal-cord enhancement appeared after 2-11 days.ConclusionsAcute spinal-cord ischemia may have a typical course on MRI. MRI findings are usually normal in the acute phase, but spinal cord swelling and T2 abnormality are expected after several days, while gadolinium enhancement appears even later after symptom onset. The sensitivity and specificity of MRI can be increased by repeated MRI in patients suspected of acute spinal-cord ischemia.