Spontaneous Spinal Cord Infarction Research Articles

Spontaneous spinal cord infarction: a systematic review

Background and objectivesSpontaneous spinal cord infarction (SCInf) is a rare condition resulting in acute neurological impairment. Consensus on diagnostic criteria is lacking, which may present a challenge for the physician....

Brown sequard syndrome secondary to spontaneous spinal cord infarction

Brown sequard syndrome secondary to spontaneous spinal cord infarction

Long-term Outcomes Following Periprocedural and Spontaneous Spinal Cord Infarctions: A Population-Based Cohort Study.

Spinal cord infarction (SCInf) is a rare condition where consensus regarding diagnostic criteria is lacking and mis- or delayed diagnosis can be detrimental. The aim of this study was to describe baseline findings and predictors of long-term functional outcome in a population-based cohort of patients with SCInf. All adult patients (≥18 years) treated at the Spinal Cord Injury Unit of the study center, between 2006-2019, and discharged with a G95 diagnosis ("other and unspecified disease of the spinal cord") were screened for inclusion. The diagnostic criteria proposed by Zalewski et al. were retrospectively applied to evaluate the certainty of the SCInf diagnosis. 270 patients were screened and 57 were included in the study, of whom 30 had a spontaneous and 27 had a periprocedural SCInf. The median American Spinal Cord Injury Association Impairment Scale (AIS) on admission was C, which at median follow-up of 2.1 years had improved to D (p=0.002). Compared to periprocedural cases, spontaneous SCInf showed significantly better admission-AIS (median AIS D vs. B, p<0.001), fewer multilevel SCInf (27% vs. 59%, p=0.029), shorter hospital stay (median 22 vs. 44 days, p<0.001), as well as better AIS (median AIS D vs. C, p<0.001) and ambulatory status on long-term follow-up (66% vs. 1%, p<0.001). Regression analyses revealed that spontaneous SCInfs (OR=5.91 [1.92-18.1], p=0.002) and more favorable admission-AIS (OR=33.6 [7.72-146], p<0.001) were significant predictors of more favorable AIS at follow-up, with admission-AIS demonstrating independent predictive ability (OR=35.9 [8.05-160], p<0.001). SCInf is a rare neurological emergency lacking specific management guidelines. While the presumptive diagnosis is based on the typical presentation and clinical findings, T2-weighted and diffusion-weighted MRI were the most useful diagnostic tools in establishing a definitive diagnosis. Our data shows that spontaneous SCInf mostly affected a single spinal cord segment while periprocedural cases were more extensive, had poorer AIS on admission, poorer ambulatory function, and longer hospital stays. Regardless of the etiology, significant neurological improvements were seen at long-term follow-up, highlighting the importance of active rehabilitation.

Spontaneous spinal cord infarction in a 10-year-old Japanese girl.

Spontaneous spinal cord infarction in a 10-year-old Japanese girl.

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.

Serum Neurofilament to Magnetic Resonance Imaging Lesion Area Ratio Differentiates Spinal Cord Infarction From Acute Myelitis.

The diagnosis of spontaneous spinal cord infarction (SCI) is limited by the lack of diagnostic biomarkers and MRI features that often overlap with those of other myelopathies, especially acute myelitis. We investigated whether the ratio between serum neurofilament light chain levels and MRI T2-lesion area (neurofilament light chain/area ratio-NAR) differentiates SCI from acute myelitis of similar severity. We retrospectively identified Mayo Clinic patients (January 1, 2000-December 31, 2019) with (1) SCI, (2) AQP4 (aquaporin 4)-IgG or MOG (myelin oligodendrocyte glycoprotein)-IgG-associated myelitis at disease clinical presentation, or (3) idiopathic transverse myelitis from a previously identified population-based cohort of patients seronegative for AQP4-IgG and MOG-IgG. Serum neurofilament light chain levels (pg/mL) were assessed at the Verona University (SIMOA, Quanterix) in a blinded fashion on available stored samples obtained ≤3 months from myelopathy presentation. For each patient, the largest spinal cord lesion area (mm2) was manually outlined by 2 independent raters on sagittal T2-weighted MRI images, and the mean value was used to determine NAR (pg/[mL·mm2]). Forty-eight patients were included SCI, 20 (definite, 11; probable, 6; possible, 3); acute myelitis, 28 (AQP4-IgG-associated, 17; MOG-IgG-associated, 5; idiopathic transverse myelitis, 6). The median expanded disability status scale score (range) at myelopathy nadir were 7.75 (2-8.5) and 5.5 (2-8), respectively. Serum neurofilament light chain levels (median [range] pg/mL) in patients with SCI (188 [14.3-2793.4]) were significantly higher compared with patients with AQP4-IgG-associated myelitis (37 [0.8-6942.9]), MOG-IgG-associated myelitis (45.8 [4-283.8]), and idiopathic transverse myelitis (15.6 [0.9-217.8]); P=0.01. NAR showed the highest accuracy for identification of SCI versus acute myelitis with values ≥0.35 pg/(mL·mm2) yielding 86% specificity and 95% sensitivity (area under the curve=0.93). The positive and negative likelihood ratios were 6.67 and 0.06, respectively. NAR remained independently associated with SCI after adjusting for age, gender, immunotherapy before sampling, and days from myelopathy symptoms onset to sampling (P=0.0007). NAR is a novel and promising clinical biomarker for differentiation of SCI from acute myelitis.

Acute spontaneous spinal cord infarction: Utilisation of hyperbaric oxygen treatment, cerebrospinal fluid drainage and pentoxifylline.

Spinal cord infarction (SCI) is a potentially devastating disorder presenting with an acute anterior spinal artery syndrome, accounting for an estimated 1% of stroke presentations. Aetiologies include aortic surgical complications, systemic hypotension, fibrocartilaginous embolism and vascular malformations. Diagnosis is clinical combined with restriction on diffusion-weighted magnetic resonance imaging (MRI). There are no treatment guidelines for non-perioperative cases although there is limited literature regarding potential therapies, including hyperbaric oxygen treatment (HBOT) and cerebrospinal fluid (CSF) drainage. We describe 13 cases of acute SCI, five receiving HBOT, and three also receiving pentoxifylline and drainage of lumbar CSF. Data for all patients with MRI-proven SCI at Fiona Stanley Hospital from 2014-2019 were reviewed. Thirteen patients, median age 57 years (31-74), 54% female, were identified. Aetiologies: two fibrocartilaginous emboli; seven likely atherosclerotic; two thromboembolic; two cryptogenic. All presented with flaccid paraplegia except one with Brown-Sequard syndrome. Levels ranged from C4 to T11. Five patients received HBOT within a median time of 40 hours from symptom onset, with an average 15 treatments (10-20). Three of these received triple therapy (HBOT, pentoxifylline, CSF drainage) and had median Medical Research Council manual muscle testing power of 5, median modified Rankin Score (mRS) of 1 and American Spinal Injury Association (ASIA) score of D on discharge, compared with 2 power, mRS 3.5 and ASIA B in those who did not. SCI can be severely disabling. Triple therapy with pentoxifylline, CSF drainage and HBOT may reduce disability and further prospective trials are required.

Spinal Cord Infarction: A Single Center Experience and the Usefulness of Evoked Potential as an Early Diagnostic Tool.

Background: Spinal cord infarction (SCI) is a rare disease and its early diagnosis is challenging. Here, we described the clinical features and imaging findings of SCI, and assessed the results of evoked potential (EP) studies to elucidate their diagnostic role in the early stage of SCI.Methods: We retrospectively analyzed 14 patients who had spontaneous SCI. The demographic, neurological, and temporal profiles of the SCI patients were identified. We reviewed the imaging findings and assessed the changes in them over time. To review EP, central motor conduction time (CMCT) and somatosensory evoked potential (SEP) values were obtained. We also enrolled 15 patients with transverse myelitis (TM), and compared the clinical, radiological and electrophysiological features between SCI and TM patients.Results: The ages of the SCI patients ranged from 54 to 73 years. Nine patients (64.3%) showed nadir deficits within 6 h. The most common type of clinical visit was via the emergency center. Nine patients (64.3%) presented with peri-onset focal pain. The median initial modified Rankin scale score was 3. For 9 patients (64.3%), initial T2 imaging findings were negative, but subsequent diffusion weighed imaging (DWI) showed diffusion restriction. Vertebral body infarction was observed in 5 patients (35.7%). EP data were available for 10 SCI patients. All 8 patients who had their CMCT measured showed abnormalities. Among them, motor evoked potentials were not evoked in 6 patients at all. SEP was measured in 10 patients, and 9 of them showed abnormalities; one of them showed no SEP response. For 5 patients, the EP studies were done prior to DWI, and all the patients showed definite abnormalities. The abnormalities in the EP findings of the SCI patients were more profound than those of the TM patients, even though the duration from the onset to the start of the study was much shorter for SCI patients.Conclusion: SCI can be diagnosed based on typical clinical manifestations and appropriate imaging studies. Our study also indicates that immediate sensory and motor EP study can have an adjuvant diagnostic role in the hyperacute stage of SCI, and can improve the accuracy of diagnosis.

Spontaneous Posterior Spinal Cord Infarction Presenting as Sensory Disturbance with Radiating Pain

Spontaneous Posterior Spinal Cord Infarction Presenting as Sensory Disturbance with Radiating Pain

Spinal cord transient ischemic attack: Insights from a series of spontaneous spinal cord infarction.

To define the prevalence and characteristics of spinal cord transient ischemic attack (sTIA) in a large retrospective series of patients who met diagnostic criteria for spontaneous spinal cord infarction (SCI). An institution-based search tool was used to identify patients evaluated at the Mayo Clinic in Rochester, MN, from 1997 to 2017 with spontaneous SCI (n = 133). Cases were subsequently reviewed for transient myelopathic symptoms preceding infarction that were suspected ischemic in nature. We performed a descriptive analysis of patients with sTIA before SCI. Of 133 patients with a diagnosis of spontaneous SCI, we identified 4 patients (3%) who experienced sTIA before SCI. The median age at presentation was 61.5 years (range 46-75 years), 2 (50%) were women, and 3 (75%) had traditional vascular risk factors. Localization was cervical cord in 2 cases (50%) and thoracic cord in 2 cases (50%); all patients developed SCI in the same distribution as their preceding sTIA symptoms. All patients experienced recurrent sTIA before SCI. Symptoms ranged from seconds to a few minutes before returning to baseline. No patients had pain as a feature of sTIA. sTIAs are possible but rare in patients who subsequently have a SCI. Clinical features are similar to those of SCI, with rapid onset of severe myelopathic deficits, followed by prompt resolution. Vascular risk factors are common in these patients. Thus, recognition of a sTIA may represent a valuable opportunity for vascular risk factor modification and stroke prevention. However, given the rarity, physicians should explore other possible explanations when sTIA is considered.

Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria (S6.004)

Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria (S6.004)

Diagnostic Criteria Proposed for Spontaneous Spinal Cord Infarction

Diagnostic Criteria Proposed for Spontaneous Spinal Cord Infarction

Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria

Spinal cord infarction (SCI) is often disabling, and the diagnosis can be challenging without an inciting event (eg, aortic surgery). Patients with a spontaneous SCI are often misdiagnosed as having transverse myelitis. Diagnostic criteria for SCI are lacking, hindering clinical care and research. To describe the characteristics of spontaneous SCI and propose diagnostic criteria. An institution-based search tool was used to identify patients evaluated at Mayo Clinic, Rochester, Minnesota, from January 1997 to December 2017 with a spontaneous SCI. Patients provided written consent to use their records for research. Participants were 18 years and older with a diagnosis of spontaneous SCI (n = 133), and controls were selected from a database of alternative myelopathy etiologies for validation of the proposed diagnostic criteria (n = 280). A descriptive analysis of SCI was performed and used to propose diagnostic criteria, and the criteria were validated. Of 133 included patients with a spontaneous SCI, the median (interquartile range) age at presentation was 60 (52-69) years, and 101 (76%) had vascular risk factors. Rapid onset of severe deficits reaching nadir within 12 hours was typical (102 [77%]); some had a stuttering decline (31 [23%]). Sensory loss occurred in 126 patients (95%), selectively affecting pain/temperature in 49 (39%). Initial magnetic resonance imaging (MRI) spine results were normal in 30 patients (24%). Characteristic MRI T2-hyperintense patterns included owl eyes (82 [65%]) and pencil-like hyperintensity (50 [40%]); gadolinium enhancement (37 of 96 [39%]) was often linear and located in the anterior gray matter. Confirmatory MRI findings included diffusion-weighted imaging/apparent diffusion coefficient restriction (19 of 29 [67%]), adjacent dissection/occlusion (16 of 82 [20%]), and vertebral body infarction (11 [9%]). Cerebrospinal fluid showed mild inflammation in 7 of 89 patients (8%). Diagnostic criteria was proposed for definite, probable, and possible SCI of periprocedural and spontaneous onset. In the validation cohort (n = 280), 9 patients (3%) met criteria for possible SCI, and none met criteria for probable SCI. This large series of spontaneous SCIs provides clinical, laboratory, and MRI clues to SCI diagnosis. The diagnostic criteria proposed here will aid clinicians in making the correct diagnosis and ideally improve future care for patients with SCI. The validation of these criteria supports their utility in the evaluation of acute myelopathy.

Spinal cord infarction: Clinical and imaging insights from the periprocedural setting

ObjectiveDescribe the range of procedures associated with spinal cord infarction (SCI) as a complication of a medical/surgical procedure and define clinical and imaging characteristics that could be applied to help diagnose spontaneous SCI, where the diagnosis is often less secure. MethodsWe used an institution-based search tool to identify patients evaluated at Mayo Clinic, Rochester, MN from 1997 to 2016 with a periprocedural SCI. We performed a descriptive analysis of clinical features, MRI and other laboratory findings, and outcome. ResultsSeventy-five patients were identified with SCI related to an invasive or non-invasive surgery including: aortic aneurysm repair (49%); other aortic surgery (15%); and a variety of other procedures (e.g., cardiac surgery, spinal decompression, epidural injection, angiography, nerve block, embolization, other vascular surgery, thoracic surgery) (36%). Deficits were severe (66% para/quadriplegia) and maximal at first post-procedural evaluation in 61 patients (81%). Impaired dorsal column function was common on initial examination. Imaging features included classic findings of owl eyes or anterior pencil sign on MRI (70%), but several other T2-hyperintensity patterns were also seen. Gadolinium enhancement of the SCI and/or cauda equina was also common when assessed. Six patients (10%) had an initial normal MRI despite a severe deficit. ConclusionsProcedures associated with SCI are many, and this complication does not exclusively occur following aortic surgery. The clinical and radiologic findings that we describe with periprocedural SCI may be used in future studies to help distinguish spontaneous SCI from alternate causes of acute myelopathy.

Spontaneous spinal epidural hematoma and spinal cord infarction following orthotopic liver transplantation: Case report and review of the literature

Background:Spinal epidural hematomas are rare conditions. Although the exact cause remains unknown in up to 40% of cases, anticoagulation therapy, neoplasm, thrombolytic therapy, internal jugular vein thrombosis, and prolonged Valsalva maneuvers associated with pregnancy may be contributing factors. The source of bleeding appears to be the dorsal internal vertebral venous plexus (IVVP).Case Description:A 65-year-old female patient with hepatitis C-related cirrhosis underwent orthotopic liver transplantation (OLT). The patient developed SSEH due to congestion of the IVVP in the peri-transplant period. Concurrent spinal cord infarction occurred, likely secondary to hypoperfusion during a cardiac arrest.Conclusion:This case study should increase awareness of SSEH as a complication of OLT.

Spontaneous spinal cord infarction secondary to embolism from an aortic aneurysm mimicking as cauda equina due to disc prolapse: a case report

Spinal “stroke” is an uncommon cause of paraplegia. Spinal cord infarction from unruptured aortic aneurysm is rare. When encountered it poses diagnostic challenge to the clinician due to its rarity, which may lead to incorrect or delayed diagnosis. We report a case of 62-year-old man presenting to casualty as caudaequina syndrome due to spinal cord infarction secondary to emboli from an infra renal abdominal aortic aneurysm. To the authors knowledge this is first case of its kind and has not been reported in literature. Patient had improvement in proximal motor function following repair of the aneurysm, although he remained doubly incontinent in six months follow up.

Spontaneous thoracolumbar spinal cord infarction: report of six cases.

We present a retrospective study of 6 patients with spinal cord infarction in the territory of the Adamkiewicz artery. In all patients, the clinical picture was stereotyped: sudden onset of paraplegia and bilateral radicular pain, dissociated sensory loss below the level of infarction and sphincter dysfunction. Emergency neuroradiological investigation ruled out a compressive lesion in all cases. In one patient, spinal angiography was performed and identified an occlusion of the Adamkiewicz artery. Treatment was supportive and all patients had a substantial recovery over a period of weeks.

MR Imaging of Spontaneous Spinal Cord Infarction

Magnetic resonance imaging was utilized to evaluate three women, one of whom was pregnant, with a clinical diagnosis of anterior spinal artery syndrome. In each case, development of spinal cord infarctions was spontaneous. Sagittal and axial MR images of the spine were obtained prior to and following administration of Gd-diethylenetriamine pentaacetic acid. Magnetic resonance showed no cord enlargement or signal abnormality on T1-weighted images prior to contrast medium administration. On T2-weighted images there was abnormal increase in signal intensity in the cord at levels corresponding to the neurologic deficits in all three patients. Variable contrast enhancement was demonstrated in these areas. Magnetic resonance imaging was positive, whereas CT-myelography, carried out in the two nonpregnant women, failed to demonstrate any abnormalities.